Background: Guideline-concordant therapies for survivors of an acute coronary syndrome (ACS) hospitalization require healthcare access, something that millions of Americans lack. Methods and Results: Using data from a prospective cohort study of over 2,000 survivors of a hospitalization for an ACS in central Massachusetts and Georgia from 2011 to 2013, the first two aims of this thesis sought to identify the post-discharge consequences for survival and health status of having: 1) financial barriers to healthcare, 2) no usual source of care, and 3) transportation barriers. We found that patients lacking a usual source of care and having a transportation barrier were more likely to have died within two years following hospital discharge compared to those without such barriers. Also, patients with financial barriers to healthcare were more likely to experience clinically meaningful declines in physical and mental health-related quality of life over the six months after hospital discharge. The third aim sought to better understand factors influencing the success of care transitions home after an unplanned hospitalization through a qualitative study of 22 patients. Participants described how adequate healthcare access, particularly having insurance and transportation to clinical appointments, facilitated the receipt of follow-up care and adherence to treatments. Conclusions: Limitations in healthcare access may contribute to poorer survival, health-related quality of life, and survival. Additional research is needed to identify interventions to improve healthcare access and test whether improved access leads to better patient outcomes.

African American women (AAW) are at a high risk for type 2 diabetes, a debilitating and potentially fatal disease for which there is no cure. The purpose of this study was to extend the research of Mosca et al. (2012) by examining the relationship between caregiver status and self-reported health status for AAW 18 years or older diagnosed with type 2 diabetes. The chronic care model (CCM) provided the theoretical framework for this study. The CCM promoted routine care for patients with chronic illnesses to migrate from acute care to proactive, planned, and risk-based protocols. A binomial logistic regression investigated the relationship between caregiver status, categorized as paid or unpaid, and self-reported health status, which was dichotomized as either good to excellent health or poor to fair health. There was a statistically significant relationship between primary caregiver status and self-reported health status among AAW diagnosed with Type 2 diabetes after controlling for age, education, and marital status (p < .004). Based on the fitted binomial logistic regression model, there were 186 cases of AAW with type 2 diabetes; having a paid caregiver was associated with a lower odds of having good to excellent health (OR = 0.294). About 12.3% of the variance in self-report health status was attributable to caregiver status. Overall, 82.6% of predictions were accurate. Nearly all participants required frequent assistance from a caregiver in the preceding 12 months. These findings suggest a critical need for healthcare service providers to educate caregivers as a means to deliver post-acute care to AAW diagnosed with type 2 diabetes, consistent with the CCM.

Health inequality conflates a huge number of economic, social, and political issues. These issues, together described as social determinants, determine a population's health through influencing health status and life expectancy. The research purpose of this study was to examine how social determinants affected the life expectancy of the women of Edo State, based on secondary data from Nigeria's 2008 demographic and health survey (NDHS). The theories that guided the study were self-efficacy beliefs of the social cognitive theory and physical self-concept of the health belief model. This quantitative cross-sectional study examined the associations between socioeconomic status, nutritional status, literacy/educational attainment, access to household sanitation facilities, and life expectancy. The dependent variables were health status and life expectancy (assessed using parity and age at first delivery). The independent variables were employment, ability to read and write, listening to the radio, type of place of residence, and persons responsible for reproductive health decisions. The analysis was based on data from 950 completed face-to-face interviews in the 2008 NDHS covering 846 households in Edo State selected using a stratified 2-stage cluster sampling design. Regression analyses showed that listening to the radio, persons responsible for decisions on reproductive health issues, employment, and type of place of residence had significant positive effects on parity and age at first delivery. Employment was the best predictor of both dependent variables. Ability to read and write had a negative relationship with the age at first delivery. The social change implications include the attainment of longer lives in Edo State, Nigeria, through effective policies on employment and education.

Human osteological and dental remains are important for reconstruction of health and disease patterns in the past, preserving information in the form of abnormal changes on bones and teeth. These changes can reflect the spread of numerous diseases and the consequences they had on the health of various historical populations and groups. Systematic investigation performed within the present thesis explored pathologies in skeletal collections from six archaeological sites from across Slovakia and Hungary, dating to the 1st and 5th centuries AP. The total sample consisted of 300 individuals that were divided among three populations: the Germanic (GS), the Roman (RS) and the Sarmatian series (SS). Pathologies were assessed macroscopically and discussed on population and individual levels. Overall, sex, age and lesion distribution frequencies were used to determine a disease pattern characteristic for a corresponding group and then compared between the series. Conditions identified during the analysis were arranged into nine main categories. The analysis revealed that the health status of GS, RS and SS was generally good, though adults from GS and RS had experienced poorer dental health. The most common lesions observed in all series, particularly in GS, were due to degenerative and dental diseases,...

There are significant differences between developed countries and developing countries in education, life style and health behaviour to identify the effects of the standard of living in both countries on social and health aspects. Information on the negative and positive aspects of every culture is essential in the overall health context to enable policy makers to improve the populations’ general health. The aim of this study was therefore to determine the health and fitness status of sport science students in Germany and Egypt and to identify any relevant differences in these two populations in order to derive possible strategies to promote health in a higher education setting in both countries. The sample of this study was selected from university students as they represent the future elite of companies, communities and countries. 193 students were selected from Germany as a developed country - females (n = 104) and males (n = 89) and 406 were selected from Egypt as a developing country - females (n = 167) and males (n = 238). Sport science students firstly filled in a health questionnaire, and then they participated in anthropometric and fitness tests. The data collection was first contucted on German sport science students at Chemnitz University of Technology in October 2009 (one week). In November 2010 the second year (third and fourth term) sport science students of Menofia University (two weeks). In the comparison between Germany and Egypt in the General health section the results showed that there are significant differences between the German group and the Egyptian group in describing their health status (p = .044) and in looking after their health (p = .000) in females. However, in the male group of both countries no significant difference was found regarding the item looking after their health (p = .370). The overall comparison between the German sample (both genders) and the Egyptian sample (both genders) show that there are significant differences in the items describing their health status (p ≤ 0.05) as well as in looking after their health care (p = .000). In the physical and mental health comparison there is no significance difference in the “chronic pain” section in German females and Egyptian females and German and Egyptian males (p ≥ 0.05), while there are significant differences in all other items (p ≤ 0.05). In the German sample comparison of both genders there are no significant differences in: “Stomach problems”, “Abdominal discomfort”, “Weight loss/weight gain/loss of appetite” whereas there are significant differences in all another items (p≤ 0.05). In the Egyptian group there are significant differences in all another items (p≤ 0.05) except for “Weight loss/weight gain/loss of appetite”. In study and university related problems between Germay and Egypt in both genders, there is no significant difference in the item “problems during study” while there are significant differences in all other items (p≤ 0.05). In the Egyptian group, both gender comparisons show no significant differences in the items: “social isolation”, and the same prospects about “working conditions”. However, there are significant differences in all another items (p≤ 0.05). In the German group in the same context no significant differences were found (p ≥ 0.05). The comparison between Germany and Egypt in the nutrition section showed significant differences in all food types (p≤ 0.05), whereas in the German group there is a significant difference between females and males (p≤ 0.05), and in the Egyptian group there is no significant difference in Healthy food consumption (p ≥ 0.05). The results in the media usage section show a significant difference regarding the media usage behaviour between the German group and the Egyptian group and in the comparison between German group of both genders, and the Egyptian group comparison of both genders where (p ≤ 0.05). Regarding the fitness tests section the results prove that there are significant differences in all tests among the German and the Egyptian group (p≤ 0.05), except in the static pull ups test between German males and Egyptian males (p ≥ 0.05). Significant correlations were found between one of the food types (unhealthy food), some between physical and mental health problems and BMI. There are significant correlations between some items of study and university related problems, and food types and blood pressure, and between fat %, VO2max, and physical activity. A significant link between bad dietary habits in regards to healthy food consumption and students’ own health assessment in Germany was found (95% CI below = 0.10, 95% top = 0.99) with OR = 0.10 and in Egypt (95% CI below = 0.35, 95% CI top = 0.92) with OR = 0.56. Another significant link between a reduced health consciousness and insufficient physical activity in Germany (95% CI below = 0.06, 95% CI top = 0.99) was proven with OR = 0.24. The key results from this study can be summarised in the following points: 1) There is a significant difference between German and Egyptian students in health parameters. 2) Egyptian students have significantly more physical and mental health problems than their German counterparts. 3) The Egyptian students present significantly more study and university related problems compared to German students. 4) The Egyptian students show a significantly higher media usage. 5) Egyptian students participate significantly less in physical activity and therefore perform significantly less well in most fitness test parameters. 6) A high correlation was found between the anthropometric data and some physical and mental health problems as well as study and university related problems and food types. Furthermore, a high correlation between VO2max and physical activity could be identified. 7) Significant link between bad dietary habits in regards to healthy food consumption and their own health assessment. 8) Significant link between a reduced health consciousness and insufficient physical activity. It is evident from this study that there are significant differences between the developed country Germany and the developing country Egypt in regards to general well-being, health problems, which in some parameters is also gender specific in Egypt, physical activity and fitness. The aim of this study was to identify these differences in order to direct future interventional studies in this area as a next step in improving the health of students in different countries. This information could potentially aid policy makers in improving the infrastructure in health care and physical activity and thereby change and/or develop society. / Es gibt signifikante Unterschiede zwischen Industrieländern und Schwellenländern bzgl. Bildung, Lebensstil und gesundheitsbezogenes Verhalten. Daher sind Informationen über die negativen und positiven Aspekte jeder Kultur im Gesundheitskontext essentiell, um Entscheidungsträger in die Lage zu versetzen die allgemeine Gesundheit der Bevölkerung zu verbessern. Die Zielsetzung dieser Studie war in diesem Zusammenhang den Gesundheits- und Fitnessstatuts von Studenten der Sportwissenschaft in Deutschland und Ägypten zu bestimmen und relevante Unterschiede in den beiden Populationen aufzudecken, um daraus mögliche Strategien abzuleiten, Gesundheit im univesitären Bereich in beiden Ländern zu fördern. Die Stichprobe für diese Studie rekrutierte sich aus Universitätsstudenten, da diese die zukünftige Elite von Firmen, Gemeinden und ganzen Ländern darstellen. 193 Studenten aus Deutschland, als Industrieland, wurden eingeschlossen – 104 weibliche und 89 männliche. Weitere 406 Studenten wurden in Ägypten, als Schwellenland, rekrutiert – wovon 167 Frauen und 238 Männer waren. Die Probanden füllten zuerst einen Gesundheitsfragebogen aus und nahmen dann an anthroprometrischen Messungen und Fitnesstests teil. Die Datenerhebing wurde zuerst an den Sportstudenten der TU-Chemnitz in Deutschland im Oktober 2009 duchgeführt. Im November 2010 wurden dann die Sportstudenten an der Menofia Univesität in Äypten getestet. Die Ergebnisse im Vergleich des Allgemeinen Gesundheitsteils zwischen Deutschland und Ägypten zeigte signifikante Unterschiede zwischen der deutschen und der ägyptischen Gruppe bzgl. des Items Beurteilung des eigenen Gesundheitszustandes (p = 0.44) und in Auf seine Gesundheit achten (p = 0.000) bei den Frauen. Allerdings konnte kein signifikanter Unterschied bei den Männern beider Länder nachgewiesen werden (p = 0.370). Der Gesamtvergleich der deustchen und der ägyptischen Stichprobe (beide Geschlechter) wiesen signifikante Unterschiede auf bzgl. der Items Beurteilung des eigenen Gesundheitszustandes (p ≤ 0.05) und auch Auf seine Gesundheit achten (p = 0.000). In der Sektion körperliche und geistige Gesundheit konnte kein signifikanter Unterschied festegestellt werden in den Items „Rücken-, Nacken- und Schulterschmerzen zwischen der ägyptischen und deutschen Population (beide Geschlechter) (p ≥ 0.05), aber dafür in allen anderen Items (p ≤ 0.05). In der deutschen Gruppe wurden keine Unterschiede gefunden bei „Magenbeschwerden/Gewichtszunahme/ Appetitlosigkeit“ – allerdings wurden signifikante Unterschiede in allen anderen Items gefunden (p ≤ 0.05) – in der ägyptischen Gruppe verhielt es sich ebenso. In der Sektion Studium und universitätsbezogene Probleme wurde zwischen Ägypten und Deutschland, auβer bei „Mangelnde praktische Relevanz des Studiums, Tests und Seminararbeiten“, in all anderen Items signifikante Unterschiede nachgewiesen (p ≤ 0.05). Der Geschlechtervergleich der ägyptischen Stichprobe zeigte keine signifikanten Unterschiede in den Items „Anonymität und Isolation an der Uni, und generelle Isolation“ wie auch „Schlechte Karriere, Arbeitslast zusätzlich zur Uni, schlechte Arbeitsbedingungen“. Jedoch sind signifikante Unterschiede zwischen den Geschlechtern in allen anderen Items zu verzeichnen (p ≤ 0.05). Dies traf jedoch nicht auf die deutsche Stichprobe zu (p ≥ 0.05). Der Vergleich zwischen den deutschen und ägyptischen Studenten in der Sektion Ernährung zeigte signifikante Unterschiede in allen Nahrungstypen (p ≤ 0.05) und zusätzlich in der deutschen Gruppe noch signifikante Unterschiede in der Ernährungsweise zwischen Män und Frauen (p ≤ 0.05). Die Ergebnisse in der Sektion Mediennutzung zeigten signifikante Unterschiede zwischen der gesamten deutschen und ägyptischen Stichprobe – wie auch innerhalb deutschen und ebenso ägyptischen Geschlechtervergleich (p ≤ 0.05). Bzgl. der Fitnessektion zeigten die Ergebnisse signifikant bessere Ergebnisse in der deutschen Kohorte im Vergleich zur Ägyptischen (p ≤ 0.05), mit der Ausnahme der „Statischen Klimmzüge“ bei den männlichen Studenten in Deutschland und Ägypten (p ≥ 0.05). Des Weiteren wurden signifikante Korrelationen gefunden zwischen dem Nahrungstypus „ungesundes Essen“ und einigen Parametern der körperlichen und geistigen Gesundheitsprobleme wie auch BMI. Es gibt ebenfalls signifikante Korrelationen zwischen weiteren Items der Sektion Studiums und universitätsbezogenen Problemen, und Nahrungstypen und Blutdruck – wie auch Körperfett %, VO2max und körperlicher Aktivität. Eine signifkante Verbindung der Wahrscheinleichtkeiten wurde zwischen schlechten Ernährungsgewohnheiten bzgl. Konsum von gesundem Essen und der Selbsteinschätzung der Gesundheit der Studenten wurde festgestellt (95% CI below = 0.10, 95% top = 0.99) mit einer OR = 0.10 und in Ägypten (95% CI below = 0.35, 95% CI top = 0.92) mit einer OR = 0.56. Ein weiterer signifikante Wechselbeziehung konnte zwischen einem reduzierten Gesundheitsbewuβtsein und unzureichender körperlicher Aktivität in Deutschland nachgewiesen werden (95% CI below = 0.06, 95% CI top = 0.99), mit einer OR = 0.24. Die Kernergebnisse dieser Studie lassen sich in folgenden Punkten zusammenfassen: 1) Es gibt eine signifikante Differenz zwischen deutschen und ägyptischen Studenten bzgl. Gesundheitsparameter. 2) Ägyptische Studenten haben signifikant mehr körperliche und mentale Gesundheitsprobleme als die deutsche Stichprobe. 3) Die ägyptischen Studenten zeigten signifikant mehr Studiums- und universitätsbezogene Probleme als die deutschen Studenten. 4) Die ägyptischen Studenten hatten einen signifikant höheren Medienkonsum als die deutsche Stichprobe. 5) Ägyptische Studenten wiesen signifikant weniger körperliche Bewegung auf als die deutschen Studenten und schnitten daher auch mit einer signifkant geringeren Leistung in den Fitnesstests ab. 6) Eine hohe Korrelation konnte nachgewiesen werden zwischen den anthropometrischen Daten und einigen körperlichen und psychischen Gesundheitsproblemen. Des Weiteren wurde erwartungsgemäβ auch eine hohe Korrelation zwischen VO2max und körperlicher Aktivität gezeigt. 7) Es gibt einen signifikantnten Zusammenhang zwischen schlechten Ernährungsgewoheiten bei dem Konsum von gesunden Nahrungsgewohnheiten bei dem Konsum von gesunden Nahrungsmitteln und der eigenen Gesundheitseinschätzung. 8) Des Weiteren gibt es einen signifikanten Zusammenhang zwischen einem reduzierten Gesundheitsbewusstsein und unzureichender körperlicnher Aktivität. Es ist durch die Ergebnisse dieser Studie evident, dass es signifikante Unterschiede zwischen Industrieländern und Schwellenländern gibt bzgl. des allgemeinen Wohlbefindens, Gesundheitsproblemen, von denen einige Parameter in der ägyptischen Population auch geschlechtsspezifisch sind, körperlicher Aktivität und Fitness. Das Ziel dieser Studie war es diese Unterschiede zu identifizieren und damit zukünftigen Interventionsstudien Anhaltspunkte zu liefern, um im nächsten Schritt die Gesundheit von Studenten in verschiedenen Ländern zu verbessern. Diese Informationen kann potentiell Entscheidungsträgern helfen, die Infrastruktur bzgl. Gesundheitsversorgung und die Rahmenbedingungen für körperlicher Aktivität zu verbessern und dadurch die Gesellschaft zum positiven zu verändern bzw. weiterzuentwickeln.

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As the US population ages, public health agencies must examine better ways to measure the impact of adverse health outcome on a population. Many reports have asserted that more adverse health events occur in Appalachia. However, few studies have assessed the quality of life and burden of disease on those residing in Appalachia. Therefore, the overall aim of this dissertation was to assess the health status, burden of disease, and quality of life in Appalachia using available data and improved health outcome assessment measures. For this dissertation, 3 secondary data sources collected by the State of Tennessee and the National Center for Health Statistics (NCHS) were used. These data were used to calculate the index of disparity and absolute and relative disparity measures within the study area of 8 Appalachian counties in upper east Tennessee. Vital statistics data for the selected area were also used to calculate Disability Adjusted Life Years (DALYs) by gender for all cause mortality and stroke mortality. The Behavior Risk Factor Surveillance System (BRFSS) data were used for prevalence data and to determine what factors impact Health Related Quality of Life (HRQOL) within the study area. The Index of disparity (ID) for all cause mortality for the study area found that disparity is greatest in stroke mortality for the study area and TN and the least for all cause mortality and the US. The highest numbers of DALYs was found in the 45-59 age group for the Appalachian study population. Finally, the mean general health status did not vary significantly by gender; however, predictors of reporting excellent to good health status did vary based on gender. Predictors of fair to poor general health status were found to be low income, having diabetes, or having had a stroke or heart attack. The results within this dissertation are intended to assist health professionals with the creation of health interventions and policy development within the Appalachian area. This dissertation proposes a more comprehensive health status monitoring system for assessing health disparity at a regional level.

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My doctoral thesis examines the broad question of the effect of some recent health policies on health and also tries to measure socioeconomic inequalities. The first essay investigates the effect of public health insurance on people with vulnerable health. The second chapter analyses the effect of the legalization of marijuana on health, while the third chapter measures socioeconomic inequalities in health. In chapter 1, I study the evolution of access to health care for individuals in vulnerable health before and after the Affordable Care Act. I define leakage of health care as the aggregation of accessibility hurdles for individuals in vulnerable health. However, "being in vulnerable health" is a linguistic concept that does not have a sharp mathematical definition. I draw on the fuzzy sets theory and assume a non-dichotomous membership function to capture the linguistic imprecision. However, the task of choosing the "right" membership function remains an issue. To circumscribe this additional issue, I use a stochastic dominance approach to test for changes in leakage. In order to establish causality, I exploit two quasi-experimental settings offered by the dependent coverage and the states in which medicaid expansion took place. In order to use these quasi-experiments in a stochastic dominance framework, I extend Athey and Imbens (2006) changes in changes approach to a bivariate setting. Using data from the National Health Interview Survey, the results from a before and after analysis show that leakages are much lower in 2015 compared to 2009 in the US. These before and after results hold irrespective of a person's sex or socio-economic status. The causal analysis shows that leakages in not having insurance and access are reduced in medicaid expansion states after the ACA. Chapter 2 analyzes the implications of these recreational marijuana legalization (RML) on Body Mass Index (BMI) and some healthy behaviours. I exploit the quasi experimental nature of marijuana legalization policy in states using changes in changes and difference in difference approaches to identify the effect of these recreational marijuana policies. Using data from the Behavioral Risk Factor Surveillance System (BRFSS), the results show that recreational marijuana legalization reduces BMI for the entire population. The effect is mainly in the mid and top part of the BMI distribution. Subgroup analysis shows that the reduced BMI resulting from RML is significant among women but not among men. For females, the effect is found both at the lower tail (being underweight) and at the upper tail (morbid obesity). While we found evidence of a reduction in being overweight for both whites and non-whites due to RML, the reduction in obesity and morbid obesity was only found for non-whites. In addition, RML reduces obesity for those below 45 years. I also found evidence that RML increases alcohol consumption, has no effect on smoking of tobacco and binge drinking but reduces the probability of doing any physical activity. The final chapter explores the measurement of socioeconomic inequality using ordinal variables. Most measures of socioeconomic inequality are developed for ratio scale variables. These measures use the mean as a reference point which is non-robust in the presence of categorical variables. This chapter extends Allison and Foster (2004) median based approach to measuring inequalities to a bivariate case and provides conditions to robustly rank any two distributions of socioeconomic inequalities in well-being or mental health. Using the Canadian Community Health Survey (CCHS), I provide robust ordering for socioeconomic inequalities in well-being and mental health for different sub-populations in 2015. The results show that there is less socioeconomic inequality in life satisfaction, happiness, mental health, and general health status among employed males and females compared to their respective unemployed groups in 2015.

My dissertation is composed of an introductory chapter followed by three independent chapters focusing on two themes: health and retirement. The last chapter concludes. After the introductory chapter, the second chapter investigates whether self reported general stress is a mediator in the relationship between socio-economic status (SES) and health. I use a six-year long panel of the Canadian Survey of Labour and Income Dynamics and employ dynamic econometric modelling techniques to study men and women who are major income earners in their families. I find little evidence that general stress is a pathway from SES to health. While the results suggest a strong negative association between stress and health for both men and women, they provide little support to the hypothesis of a significant effect of income on stress, consistent with the direction of the SES-health gradient. The third chapter studies whether self-assessed health status (SAH) contains information about future mortality and morbidity, beyond the information that is contained in standard "observable" characteristics of individuals (including pre-existing diagnosed medical conditions). Using a ten-year span of the Canadian National Population Health Survey, we find evidence that SAH does contain private information for future mortality and morbidity. Moreover, the extra information in SAH is greater at older ages. Our results suggest that a shift from defined benefit to defined contribution pension arrangements may carry with it the cost of exacerbated adverse selection in the market for annuities, especially at older ages. That would make it more difficult for older individuals to insure longevity risk. The fourth chapter looks at whether differences in early retirement pathways are associated with differences in post-retirement outcomes of health, stress and dwelling tenure. I use a 5 ample of men from the Canadian Survey of Labour and Income Dynamics, years 1996 to 2004. I find that differences in pre-retirement health indicators (such as self-assessed health and disability), as pathways to early retirement, are likely to be associated with differences in post-retirement health and stress. In addition, the results suggest that "involuntary" retirees (men who may have retired because of health and/or health related coniitions) are more likely to experience worse post-retirement outcomes (in terms of health and stress) than men who retire "voluntarily". Retirement circumstances are found to have no statistically significant effect on dwelling tenure. / Thesis / Doctor of Philosophy (PhD)