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

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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

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This study investigated the impact of the Malcolm Baldrige Health Care Criteria for Performance Excellence (HCPE) on effectiveness in health care organizational performance. The quality of health care has tremendous social and economic consequences for the United States (U.S.), including lost wages, reduced productivity, higher legal expenses, and lower confidence in the health care system. Increasing health care productivity, efficiency, effectiveness, and quality offers critical means to reducing cost and improving U.S. economic performance, which is an objective of the Affordable Care Act enacted by Congress in 2010. This study compared Malcolm Baldrige National Quality Award recipients to competitors in their geographic markets using Centers for Medicare & Medicaid Services (CMS) performance measures to determine if there was a relationship between the use of the HCPE as a business model and the performance of health care organizations. This study included an analysis comparing 34 hospitals using the HCPE as an organizational business model to 153 hospitals in their geographic markets not using the HCPE. There were 42 CMS measures classified into 2 major categories focused on (1) patient experience measures and (2) clinical processes and outcome measures. The results showed that the study-identified hospitals that used the HCPE had values representing higher performance on all 10 patient experience measures than the non-HCPE hospitals, and that 9 of the 10 measures were statistically significant. Although the group mean differences were not statistically significant, the study results showed that HCPE hospitals had performance outcomes with mean values representing higher performance than the non-HCPE hospitals in 38 of the 42 (90%) of the study measures. These results should provide leadership with confidence that the HCPE serve as a valid model to align organizational design, strategy, systems, and human capital to create long-term effectiveness in an institutionalized high performance culture. / acase@tulane.edu

In Mississippi, approximately 4,700 deaths are caused by smoking and approximately 3,500 young Mississippians begin smoking each year. Nearly 9 out of 10 smokers start smoking by age 18, and 99% start by age 26. Because of the early age of initiation, policy changes and other initiatives that affect smoking rates among youth are of particular interest, including tax increases. In 2009, Mississippi increased its state excise tax on tobacco from $.18 to $.68 per pack which was in addition to the federal tax increase to $1.0066 (an increase of $.6166 from the previous amount of $.39). This study examined the effect of Mississippi's tobacco tax increase on youth smoking initiation and tobacco consumption behavior using difference-in-difference analysis. Using the SmartTrackTM School Survey this study analyzed changes in youth who reported ever smoking and their recent consumption from the three years prior to the tax increase to the three years following it using data from the Louisiana Caring Communities Youth Survey as the control group since Louisiana did not experienced a state-level cigarette tax increase during this period. The analysis showed mixed results for a statistically significant difference in smoking initiation (ever smoked cigarettes) rates, and moderately supported the hypothesis of past 30 day youth smoking rates being reduced by the tax increase on cigarettes in Mississippi. While youth smoking rates declined significantly during the study period, the difference-in-difference analysis of youth who reported ever smoking showed only a small but statistically significant effect across all grades, but had a notable impact on 6th graders. The analysis of past 30 day use showed no short term effect on Mississippi youth in the year after the 2009 tax increase, but difference-in-difference comparisons showed a moderate and statistically significant impact on those rates the longer term. The results of this study will be of interest to scholars, policymakers, and tobacco control advocates as they make decisions about whether to increase state level taxes on cigarettes to prevent smoking initiation and curb youth tobacco use. / acase@tulane.edu

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