<p> The Internal Revenue Service (IRS) requires tax-exempt hospitals to conduct Community Health Needs Assessment (CHNA) every three years, formulate implementation strategies, and report yearly to the IRS and the public the progress of their work. The IRS CHNA incentivizes hospitals to provide programs responsive to community health needs. The purpose of this study was to examine the relationship between community benefit programs and prioritized community health needs in the context of a national IRS reporting requirement through analysis of published community benefit reports among North Carolina&rsquo;s (NC) tax-exempt hospitals. </p><p> This study employed quantitative research that analyzed longitudinal and cross-sectional data; qualitative research that reviewed published documents; and mixed-methods research that analyzed the integrated quantitative and qualitative results. The findings indicate that performing IRS-mandated CHNA did not substantially increase the alignment of community benefit programs with prioritized community health needs but did clearly highlight those needs. NC tax-exempt hospitals continue to focus on providing patient care financial assistance than population health, a strategy misaligned with community health needs. Although the hospitals are beginning to address population health and access to care concerns, their dollar expenditures in these areas paled in comparison to patient care financial assistance. If the IRS&rsquo; purpose in mandating CHNA was to spur a shift in community benefit priorities toward population health needs and away from the traditional patient care financial assistance, then, the evidence from 4 years after the requirement&rsquo;s implementation, indicates it is currently failing in North Carolina. As elucidated in the articles, their ingrained patient-level intervention perspective and desire to recover high unreimbursed costs or lost revenues for providing care to Medicare, Medicaid, and poor patients likely influence the hospitals&rsquo; community benefit programming to favor individual welfare over population health. Nevertheless, policymakers should continue to direct community benefit programs toward population health because it is a step in the right direction. Organizational change takes time and the desired results of policy interventions are usually incremental. Thus, conducting CHNA must remain a legal obligation by non-profit hospitals for maintaining their privileged tax status to facilitate organizational paradigm shift in community benefit programming toward population health programs or community building activities and away from individual welfare.</p><p>

<p> Caregivers&rsquo; compliance with polio vaccine regimens and timely receipt of the recommended 4 doses of polio vaccine are pivotal to eliminating polio. This cross sectional study, conducted in Lagos State, Nigeria, examined polio vaccine compliance and demographic attributes of caregivers&rsquo; for statistically significant associations. Using an adapted health belief model theoretical framework, 1,200 participants were recruited from well-baby clinics in 8 local government areas in Lagos State. Participants completed a brief demographic survey providing data on caregivers&rsquo; age, gender, residence (rural or urban), and their level of education as well as records from their children&rsquo;s immunization cards. Data obtained were tested for associations between caregiver&rsquo;s demographic information and their children&rsquo;s receipt of polio doses within specified timelines using chi-square and logistic regression analysis. Fisher&rsquo;s exact analysis were conducted for variables with frequencies less than 5. The only significant association recorded was between the receipt of Polio Dose A and location of caregivers&rsquo; residence: Rural dwelling caregivers were less likely to receive the first dose of polio. Results showed Polio Dose D to be the dose most likely received in an untimely manner as well as most likely missed of the 4 doses. Logistic regression analysis did not show any variable to be of greater odds in predicting completion of the 4 doses or compliance with timelines of their receipt. Study&rsquo;s results may inspire polio program planners to develop interventions that broaden the immunization coverage for rural dwellers to include nontraditional maternity locations. Positive social change will ensue by the improvement caregivers&rsquo; compliance with full polio dose receipts with timelines, maximizing immunity. </p><p>

This three-essay dissertation examines racial disparities in infant health outcomes and exposure to air pollution in Texas. It also asks whether the EPA's Risk-Screening Environmental Indicators Geographic Microdata (RSEI-GM) might be used to assess the effects of little-studied toxic air pollutants on infant health outcomes. Chapter 1 contributes to the “weathering” literature, which has shown that disparities in infant health outcomes between non-Hispanic black and non-Hispanic white women tend to widen with age. In this study, we ask whether the same patterns are observed in Texas and among Hispanic women, since other studies have focused on black and white women from other regions. We find that black and Hispanic women in Texas do “weather” earlier than white mothers with respect to rates of low birthweight and preterm birth. This differential weathering appears to be mediated by racial disparities in the distribution and response to socioeconomic risk factors, though a large gap between black and white mothers across all ages remains unexplained. Chapter 2 extends the statistical environmental justice literature by examining the distribution of toxic air pollution across infants in Texas. We find that, within Texas cities, being black or Hispanic is a significant predictor of how much pollution one is exposed to at birth. We further find that, among mothers who move between births, white mothers tend to move to significantly cleaner areas than black or Hispanic mothers. In Chapter 3, we use geocoded birth records matched to square-kilometer pollution concentration estimates from the RSEI-GM to ask whether the pollution-outcome relationships that emerge through regression analysis are similar to the effects found in previous research. If so, the RSEI-GM might be used to study the health effects of nearly 600 chemicals tracked in that dataset. We conclude, based on instability of results across various specifications and lack of correspondence to previous results, that the merged birth record-RSEI data are not appropriate for statistical epidemiology research.

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.

The theory selected as the potential framework for better explaining teenage pregnancy, among a cohort of health-insured sexually active teens, was Social Bond Theory. With this theoretical framework in mind, eight research questions were generated, with the primary focus of interest in determining the correlation between ten social bond scale scores to outcome status (deliver, abort and contracept). A 50-item survey instrument was developed for purposes of this research utilizing original and existing demographic and social bond questions. The questionnaire was adapted for use with a CATI system of telephone interviewing, pretested and finally administered to a total of 213 teenage respondents. Results from the stepwise multiple regression analysis showed that among the respondents who sustained a pregnancy, significant differences existed between the deliver and abort groups. The deliver group was more highly religious (p =.001) and more likely to have come from a family of lower socioeconomic status (p =.001) than were the respondents from the abort group. When comparing the abort and contracept respondents, the only significant difference was that the abort group was less connected with family than were the contraceptors (p =.02). For all demographic measures and all remaining social bond measures, these two groups of respondents were not significantly different. Lastly, it was determined that the young women most likely to be teenage mothers among the study respondents were those who were less hopeful about the future (p =.005), were less involved in school-related activities (p =.018), were more religious (p =.023) and were more likely to be of non-white racial/ethnic status (p =.015) than those who successfully contracepted.

<p> The democratic decentralization of government administration in Indonesia from 1999 represents the most dramatic shift in governance in that country for decades. In this dissertation I explore how health managers in one kabupaten (regency) are responding to the new political environment. Kabupaten health managers experience decentralization as incomplete, pointing to the tendency of central government to retain control of certain health programs and budgets. At the same time they face competing demands for autonomy from puskesmas (health center) heads. Building on Scott&rsquo;s (1985) idea of a &ldquo;moral economy&rdquo; I delve beneath the political tensions of competing autonomies to describe a moral landscape of underlying beliefs about how government ought to behave in the health sector. Through this analysis certain failures and contradictions in the decentralization process emerge, complicating the literature that presents decentralization as a move in the direction of &ldquo;good governance&rdquo; (Mitchell and Bossert 2010, Rondinelli and Cheema 2007, Manor 1999). </p><p> Decentralization brings to the fore the internal divisions within government, yet health workers present a united front in their engagements with the public. Under increasing pressure to achieve global public health goals such as the Millennium Development Goals, health managers engage in multiple translations in converting global health discourses into national and local health policies and in framing these policies in ways that are comprehensible and compelling to the general public. Using the lens of a &ldquo;cultural theory of state&rdquo; (Corrigan and Sayer 1985) I describe how health professionals and volunteers draw on local cultural forms in order to render global frameworks compatible with local moralities. I introduce the term &ldquo;moral pluralism&rdquo; to describe how individual health workers interrelate several moral frameworks in their health promotion work, including Islam, evidence based medicine and right to health. My conclusion is that kabupaten health managers are engaging in two balancing acts. The first is between decentralization and (re)centralization and deals with the proper way to manage health programming. The second is between global health discourses and local cultural forms and concerns the most effective way to convey public health messages in order to bring about behavior change in line with national and global public health goals. This is the first anthropological study of how government officials at different levels negotiate the process of health decentralization in the face of increasing international pressure to achieve global public health goals.</p>

The study of policy transfer has seen remarkable developments and received considerable attention in developed countries, but it has so far been ignored in the context of Libya. Thus, this research will fill a gap in the literature and further understanding of the topic of policy transfer, not only in relation to Libya but developing countries in general. This thesis aims at providing a comprehensive and systematic picture of the public health care system in Libya and, at the same time, to learn lessons from the UAE which can be transferred to the Libyan context in order to achieve a more effective health service. At the theoretical level, this research depended on the assumption that lessons can be drawn from the UAE to help build the public health system in Libya. This was achieved through the application of the framework of policy transfer. In order to build a more complete picture in relation to the success or failure of the transfer, the path dependency approach was used to explain the importance of old trajectories or how past legacy can lead to “lock-in" or decrease the ability of the lesson-drawing. Empirically it examined the public health sector in Libya as its main case study, comparing it with the UAE. Qualitative data collection methods were used, including personal interviews and official documents. With this in mind, the research aims to understand the public health care systems in the two countries and, through comparative analysis, make suggestions as to what lessons can be learned. The findings reveal that many lessons can learned from the practices of the UAE public health policy. Such experiences would help to remove the problems in public health services in Libya as well as to facilitate improvement of policies and plans. However, there are two factors, namely the legacy of the past regime and state capacity, which may hinder the success of the transfer. Furthermore, political will held by policy makers, including a desire for modernization of the public sector, could facilitate the transfer of the suggested lessons.

This paper analyzes a 2009 U.S. policy which provided short term federal subsidies for COBRA health insurance premiums. COBRA allows the recently unemployed to continue purchasing health insurance through their employment-based insurance plan for a short time period after they become unemployed. Early analysis found low take-up rates for COBRA insurance due to the exceedingly high cost of full health insurance premiums, especially for those who have just lost a steady employment income. A short term 65 percent federal subsidy for COBRA insurance was implemented as a part of the American Recovery and Reinvestment Act in 2009. Subsidy policy proposed to increase take-up rates of COBRA and to keep national insurance rates from dropping during a time of rising unemployment. This paper finds a 3.09 percentage point increase in insurance rates for the unemployed when subsidies became available in 2009. It also finds that the gains made in 2009 were lost by 2010, suggesting that subsidies may have provided temporary relief but did not represent a long-term solution for many of the unemployed. Demographic analysis within the unemployed population determines that educated, middle to upper income earning men saw the greatest increases in insurance rates during this time. My analysis affirms previous research finding that COBRA eligibility requirements do not allow the majority of the low income, uninsured to receive federal assistance for health insurance through this policy. I also provide a positive analysis for the impact of direct-purchasing federal subsidies on insurance rates.

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published_or_final_version / abstract / toc / Urban Planning and Environmental Management / Doctoral / Doctor of Philosophy