<p> Background. Norovirus disease is of great public health significance as evidenced by the health and economic burdens each year in the United States. Although norovirus disease afflicts all ages in the general population, vulnerable segments of the population include the young and elderly. Currently there is no norovirus vaccine on the market to prevent norovirus infection nor is there prescribed medical treatment other than supportive care for self-limiting symptoms. </p><p> Methods. Surveillance data on norovirus outbreaks obtained from the Centers for Disease Control National Outbreak Reporting System, school enrollment data obtained from the National Department of Education, healthcare resource utilization data obtained from the Healthcare Cost and Utilization Project, and results from published research findings were used to estimate the health and economic burdens of norovirus disease among the school age population. Decision analysis was used to model the costs and benefits of norovirus vaccination. Cost effectiveness analysis was conducted from the societal and healthcare perspectives in order to determine the incremental cost-effectiveness ratios for the alternative health strategy compared to the current standard health strategy. Univariate and multivariate analyses were conducted in order to examine uncertainty associated with parameters and assess how the uncertainty affects the outputs of the decision model. Probabilistic sensitivity analysis was conducted in order to assess and quantify the impact of varying all parameters at the same time. </p><p> Results. Norovirus results in high numbers of illnesses and high direct medical, direct non-medical and indirect costs among school age children. In terms of health burden, there were a greater number of cases requiring supportive care than any other health outcome. The cost of supportive care is relatively inexpensive until indirect costs are factored in to the total cost of one episode of norovirus illness. </p><p> The results of the present study indicated that when comparing the standard health strategy of no norovirus vaccination to that of the alternative health strategy of norovirus vaccination, vaccination was found to be optimal. The results of probabilistic sensitivity analysis indicated that the alternative health strategy was marginally cost effective. </p><p> Conclusion. The results of the present study represent the first attempt to estimate the health and economic burdens of norovirus disease among the school age population with a focus on norovirus disease spread occurring in closed (schools) environments. The study findings will illustrate the uniqueness of closed environments in perpetuating norovirus spread and the feasibility of norovirus vaccination among school age children. The results of cost-effectiveness analysis indicated vaccination was an optimal strategy but is marginally effective. </p><p> Given the numerous limitations of using passive surveillance data, future research efforts should use higher quality and more accurate sources of data in order to estimate the health and economic burdens of norovirus disease and examine the other hidden costs of norovirus outbreaks such as environmental decontamination, school closure, student and staff absenteeism and other intangible costs. In addition, future research efforts should use the findings from this and other studies that have identified high prevalence of norovirus disease among younger age groups in order to establish priority age groups for vaccination when a vaccine becomes available on the market. Clinical trials are underway and development of a norovirus vaccine is expected within the next few years. </p>

<p> This research examines three factors &ndash; macroeconomic conditions, the Deficit Reduction Act of 2005, and <i>inter-vivos</i> transfers &ndash; that influence both the availability of long-term care services and the use of these services. The first essay explores how changes in the macroeconomy, specifically the 2007-2009 &ldquo;Great Recession,&rdquo; affect the utilization of paid and unpaid long-term care services. It is theoretically unclear how long-term care use should be affected by such downturns, as an individual&rsquo;s health status, wealth, insurance coverage and access to care are all likely to change during a significant downturn such as the &ldquo;Great Recession.&rdquo; Using data from the 1998-2012 waves of the Health and Retirement Study, a survey that follows Americans over the age of 50 as they begin to transition into retirement, we estimate the effects of changes in the unemployment rate at both the national and county levels on long-term care use. We find consistent evidence that overall care use declines significantly during downturns, with additional results suggesting that these results may be driven by reductions in individual wealth and improvements in individual health status. The second essay examines how the implementation of the Deficit Reduction Act of 2005, a policy that imposed stricter regulations about how individuals could &ldquo;spend down&rdquo; their assets to become Medicaid eligible, impacts both asset transfers and long-term care use among the elderly. Using data from the 1998-2010 waves of the Health and Retirement Study, I estimate the effects of this policy using a difference-in-difference framework. Overall, individuals seem to substitute from making inter-vivos transfers to holding assets in trusts in response to the enactment of the Deficit Reduction Act. With regard to care use, individuals seem to substitute from in-home long-term care to more visits to both doctors and adult day care facilities following the DRA, an effect primarily driven by the wealthiest and youngest individuals. The third essay investigates the relationship between parent-to-child inter-vivos asset transfers and future informal care provision by that child. Using data from the 1998 &ndash; 2010 waves of the Health and Retirement Study, I am able to use the timing of the transfers and the care use to describe this relationship. The results suggest that the receipt of an inter-vivos transfer during the previous two years is strongly positively correlated with that child&rsquo;s likelihood of providing care during the previous month. In addition, I confirm a previous finding in the literature that child&rsquo;s gender, relationship to the parent and geographical proximity to the parent all significantly influence the child&rsquo;s decision to provide care.</p>

Thesis (Ph. D.)--University of Toronto, 2008. / Includes bibliographical references.

<p> Investment in addressing structural stigma and discrimination against refugees in resource-poor urban areas is both needed, and possible. The large population of refugees residing in resource-poor urban areas is likely to grow, and tensions in a number of settings are now documented. Without interventions to adequately address such tensions, both the protection needs of refugee populations and the stability of hosting countries could be affected. Through qualitative analysis of an urban refugee dataset in Uganda, this dissertation identified community-level drivers of structural stigma and discrimination as safeguarding one&rsquo;s body and property, defending status, and perpetuating exploitation. The designs of potentially successful programs to address these drivers were then identified though systematic review, and included one or more of the following: 1) the utilization of multiple intervention components; 2) direct information provision (e.g., lecture, role-play, other active engagement) or direct contact with stigmatized groups; 3) cooperative work between community members and stigmatized groups to better livelihoods; 4) popular opinion leaders who have authority to make change, and 5) traditional ceremonies valued by the communities for cleansing and healing. One such design involving an agricultural livelihood program in a resource-poor urban area of the Northeast United States was costed, utilizing a primarily bottom-up approach and a societal perspective in the collection of both financial and economic costs. The unit cost per participating family was significantly lower than government services that provide comparable nutritional support, but did not include components of working with the community to reduce stigma and discrimination. Thus, the studied program provided more services for a lower cost. In addition, it empowered stigmatized refugees to advocate for and support themselves, and engendered goodwill in the community by involving community members to work alongside refugee participants, improving upon a neglected piece of land, and providing fresh produce. Further research is needed to better measure the social and financial dividends of programs to address structural stigma and discrimination, particularly against urban refugees. Such research can only come in tandem with further investment, the imperative and potential of which are compellingly clear.</p><p>

<p> <b>Objectives:</b> This research identified the potential predictors of medication adherence and studied the impact of medication adherence on healthcare utilization and costs among elderly with diabetes who were enrolled in a State Pharmaceutical Assistance Program (SPAP). </p><p> <b>Methods:</b> Pharmaceutical Assistance Contract for Elderly (PACE) programs&rsquo; database was used to identify study population and estimate medication adherence as proportion of days covered (PDC) for 12-months post-index observation period (adherent: PDC &ge; 80%; nonadherent: PDC &lt; 80%). Healthcare utilization and costs for the study period were estimated using Pennsylvania Health Care Cost Containment Council&rsquo;s hospital inpatient discharge records. Healthcare utilization measures included all-cause, diabetes-specific, diabetes-related and diabetes-specific &amp; related number of inpatient hospital admissions and length of stay (LOS). Multiple regression analyzes were performed to determine the predictors of medication adherence and to assess the association of medication adherence with risk of hospitalization, hospital service utilization and costs. </p><p> <b>Results:</b> Among 9,497 elderly PACE enrollees with diabetes, 81% were adherent and 21% were hospitalized. Race, marital status, number of unique medications and out-of-pocket payment were the significant predictors of medication adherence. The odds of being hospitalized were higher for nonadherent patients by the factor 2.030 than adherent patients (95% CI: 1.784&ndash;2.310). After controlling for covariates, non-adherent patients had significantly a greater number of all-cause (IRR 1.2727; 95% CI 1.1937&ndash;1.3569), more diabetes-related (IRR 1.2210; 95% CI 1.0492&ndash;1.4210) and more combined diabetes-specific &amp; related (IRR 1.2106; 95% CI 1.0495&ndash;1.3965) hospital visits than adherent patients. After adjusting for covariates, LOS for non-adherent patients was longer for all-cause (IRR 1.2388; 95% CI 1.1706&ndash;1.3111), diabetes-related (IRR 1.1341; 95% CI 1.0415&ndash;1.2349) and for diabetes-specific &amp; related (IRR 1.1271; 95% CI 1.0357&ndash;1.2267) hospitalization than adherent patients. GLM models showed that medication nonadherence was associated with significant increase in all-cause hospitalization costs ($22,670 vs $16,383; p &lt; 0.0001) and diabetes-related hospitalization costs ($13,518 vs $12,634; p = 0.0003). </p><p> <b>Conclusions:</b> Medication nonadherence was associated with an increased risk of hospitalization, greater number of hospital visits, longer hospital LOS and substantial hospitalization costs among elderly SPAP beneficiaries with diabetes. Utilization of our findings to develop interventions or policies to improve medication adherence would significantly impact the US healthcare system particularly while allocating limited healthcare resources.</p><p>

The conversion of publicly owned industries and services into privately owned assets has been one of the most radical and controversial global economic trends of the past three decades. The major underlying rationale for this conversion is that public ownership is inherently economically inefficient. This point of view not only ignores the substantive evidence that disapproves this claim, but it also fails to recognize the merits of public ownership in promoting social welfare and health. Public ownership—in the form of public employment—does the latter in two ways: first, by providing employees with better and more equal benefits and working conditions than does the private sector, and second, by ensuring the smooth delivery of affordable quality social services to the public at large. This study quantitatively evaluates the impact of public employment on health at both the national and the individual level. At the national level, a cross-country sample from the 1980s shows that an increase of public sector employment was associated with a statistically and economically significant increase in life expectancy—a major indicator of population health. The association was even more prominent for middle- and low-income countries and for women. At the individual level, using logistic regression on data from a 2006 Chinese household survey, this study finds that public sector employees were statistically more likely to report good or excellent health than private sector employees. Analysis of the data reveals that much of this health premium is attributable to the fact that the public sector provides more permanent jobs than the private sector. Further, the private sector appears to have steep social class-health gradients, while such health inequality is moderate or even absent within the public sector. As a complement to the quantitative findings, this study also conducts a qualitative survey of China’s institutional and social context. It helps to further explain why the public sector in China remains a better employer after the collapse of the “iron rice bowl” system. Several policy implications emerge from this study. First, public sector employment deserves serious consideration as an instrument to promote health and health equality. Second, job security is essential for health; proposals for a more flexible and less regulated labor market are neither theoretically nor empirically justified. And last but not least, if the public sector continues its recent practice of implementing neoliberal policies, such as privatization and deregulation, its health premium over the private sector may go away.

<p>Eating disorders are now considered an epidemic among girls and women throughout the United States. This thesis suggests a study in which the acts and processes of anorexia nervosa and bulimia nervosa are positioned as a form of cultural labor undertaken by some Western women in order to embody the myth of the ideal female body. The researcher uses her own lived experience of anorexia and bulimia and her pursuit of embodying femininity in order to raise and guide the major questions concerning femininity and eating disorders in Western culture. </p><p> Keywords: eating disorders, anorexia nervosa, bulimia nervosa, pro-ana, pro-mia, femininity, western culture, autoethnography </p>

Thesis (Ph. D.)--Rutgers University, 2008. / "Graduate Program in Economics." Includes bibliographical references (p. 81-89).

This dissertation takes a retrospective look at the first decade of EPA's implementation of the Comprehensive Environmental Response, Compensation and Liability Act commonly known as Superfund. Two models are employed that reflect EPA's implementation of Superfund: a rational threats game-theoretic bargaining model and a discrete choice empirical model. The game theoretic hazardous waste bargaining model produces an elegant and simple decision rule. Using this decision rule, EPA compares the expected transaction costs incurred because of litigation against EPA's prospects for a court-ordered award. The agency enters into bargaining when the savings from avoiding litigation is equal to the court-ordered award. EPA and the coalition of responsible parties bargain about how to share site clean-up costs (mixed funding) and when successful, enter into a voluntary settlement. The discrete choice empirical analysis reveals that high transaction costs, lengthy delays in site clean-ups and limited enforcement/litigation characterize EPAs implementation of CERCLA during the decade ending in 1990. Differences in how EPA implements this legislation across EPA Regions is explored. Compared to the other Eastern EPA Regions, EPA Region 4 is less likely to litigate and more likely to use Superfund monies to clean up hazardous waste sites.

Background: This thesis focuses on the economic analyses of type‐2 diabetes complications defined as macro‐vascular (myocardial infarction, stroke, ischemic heart disease, heart failure) and micro‐vascular (amputation and eye‐related complications leading to blindness in one eye). Diabetes‐related complications are a substantial component of the overall economic, physical and psychological burden of the disease. As the efforts in treating diabetes are geared towards reducing the likelihood of complications, understanding the welfare benefits and future savings from reducing diabetes complications is paramount in determining the cost‐effectiveness of competing diabetes therapies. Aims: The thesis is divided into three essays aiming to (1) characterize changes in the health related quality of life of diabetes patients over time and assess the contributions of diabetes complications to these changes; (2) study the drivers of healthcare expenditure for people with diabetes in terms of both inpatient care and non‐inpatient resource utilization, and estimate the impacts of diabetes‐related complications on health care costs; (3) understand the role played by self‐reported quality of life in predicting mortality after controlling for clinical risk factors. Methods: This thesis uses longitudinal data to answer the questions of interest. A unifying theme across the thesis is the challenge of estimating causal parameters in a context in which there may be substantial observed and unobserved patient heterogeneity. Findings: Failing to account for patient heterogeneity, and in particular un‐measurable variation in patients’ outcomes, is likely to bias the impact of complications on quality of life and on non‐inpatient costs, as well as to confound predicted time to death. In the case of QoL, ignoring heterogeneity is likely to overestimate the impact of complications on self reported utility because the patients who will eventually experience diabetes‐related complications are already on a lower utility path compared to those who do not. In the case of both inpatient and non‐inpatient costs, patients who go on to develop complications have higher cost both pre and post complications. In the case of inpatient costs there is no evidence that unobserved patient heterogeneity matters, while in the case of non‐inpatient utilization the hypothesis of a common baseline level of utilization is rejected in the subset of patients that contribute to the FE identification. This subset however is systematically different from the sample as a whole, being predominately more likely to have complications and other causes of hospitalization. Moreover, a trade‐off occurs when we are interested in predictions; models that exploit within‐patient variation have wider confidence intervals and have thus less precision than population average models. The final substantive chapter finds that HRQoL is significantly associated with survival at the population level and that when patient specific unobserved heterogeneity is taken into account, the power of QoL to predict life expectancy increases. Neglected heterogeneity in frailty causes underestimation of both the extent of positive duration dependence and the impacts of time varying covariates.