India has experienced a period of unprecedented economic growth over the past few decades, credited with lifting millions out of poverty. The high rates of economic growth, however, have not led to commensurate improvements in human development indicators. While health outcomes, an important dimension of human development, have improved in India, the rate of improvement has been slow. Moreover, health outcomes vary substantially across different regions of India. The disparity in health outcomes will play a crucial role in India’s future development and necessitates new ways for targeting and evaluating policy programs. This report analyses regional disparities in health outcomes using sub-national development indicators at state, district and demographic zone level. The first chapter of the report provides an overview of health systems in India and creates a framework for understanding health disparity in India. The second chapter uses spatial mapping techniques to identify regional patterns of health disparity. The analysis uses district level indicators from health surveys and census data. The third chapter uses sub-national data to analyze infant mortality rates in India according to state and demographic zones. Along with regional variation the report also explores gender differentials and rural-urban divide in health outcomes. The final section of the report concludes by highlighting the findings, delineating a course for future research and suggesting policy measures necessary for achieving improved health outcomes. / text

Around 20% of America’s population lives in rural communities; however, only 9% of all physicians practice within these rural areas. Consequently, there is a consistent shortage of healthcare resources for these populations.1 To help this shortage, medical institutions should reach out to their local youth because a majority of the physicians who practice medicine in rural areas experienced their childhood in similar communities.2,3 The simulated Medicine in Action camp at Quillen College of Medicine provided an opportunity for local, rural high school students to learn more about the healthcare field in the hopes of eventually playing a role in alleviating the rural healthcare deficiencies. Twenty-one high school students from rural Appalachia with an interest in the healthcare field were recruited by the Simulated Medicine in Action camp to participate in a five-day medical simulation experience developed by the Quillen College of Medicine Center for Experiential Learning. The program employed interactive simulation platforms to provide education to students about various aspects of patient centered care, including communication skills, physical exam skills, technical skills, and integrative clinical reasoning skills. Through a lecture followed by simulation format, students exercised real world medical skills to assess, diagnose, and treat their “patients” in clinical scenarios. This format challenged the students to work as a team and provided students with the opportunity to experience the role of medical professionals. The curriculum also provided students with the opportunity to listen to a panel of physicians as well as a panel of other healthcare professionals to provide exposure to the breadth of the healthcare. Participants completed two surveys using the Likert scale: an entrance survey on the first day of camp and an exit survey on the final day. The likert scoring scale is as follows: 5=strongly agree, 4=agree, 3=neutral, 2=disagree, and 1=strongly disagree. Students responded to the following prompts in both of the entrance survey and the exit survey: (1) I have had enough exposure to the medical field to know that I am interested or not interested in the field; (2) If I decide that I want to be a physician, I believe that I am capable of achieving that goal; (3) If I decide I want to be a physician, I think I know enough about the educational process to pursue that career. Entrance survey had an average of 3.8, 4.5, and 3.7 respectfully. Exit survey had an average of 4.2, 4.7, 4.2 respectfully. Students also responded to the following prompts exclusively in the exit survey with the respected results: The Simulated Medicine in Action Camp improved my desire to pursue a career in healthcare (4.8); The Simulated Medicine in Action Camp improved my desire to become a physician (4.5); The Simulated Medicine in Action Camp improved my desire to pursue further education (4.7). Due to the upward trend and the high Likert scores in the exit survey, we conclude that using medical simulation experience with hands on opportunities and exposure to healthcare providers both clarifies and increases interest among high school students in regards to entering the healthcare field. We hope that this interest propels them into their careers where they may potentially serve their local rural community. References: 1Rosenblatt, R. A., & Hart, L. G. (2000). Physicians and rural America. The Western journal of medicine, 173(5), 348–351. doi:10.1136/ewjm.173.5.348 2Easterbrook, M., Godwin, M., Wilson, R., Hodgetts, G., Brown, G., Pong, R. and Najgebauer, E. (2019). Rural background and clinical rural rotations during medical training: effect on practice location. [online] CMAJ. Available at: http://www.cmaj.ca/content/160/8/1159.short [Accessed 18 Sep. 2019]. 3Feldman, Kymm, et al. "The difference between medical students interested in rural family medicine versus urban family or specialty medicine." Canadian Journal of Rural Medicine, vol. 13, no. 2, 2008, p. 73+. Gale Academic Onefile, Accessed 18 Sept. 2019.

This dissertation consists of three essays in Applied Econometrics that seek a better understanding of different aspects of risk and risk management tools. The first essay is about mortality risk in Virginia coal regions. With a focus on the mortality of non-malignant respiratory diseases (NMRD), I estimate the impact of living in a coal county and find that coal-mining county residency significantly increases the probability of dying from NMRD. This statistical association is accentuated by surface coal mining, high smoking rates, lower health insurance coverage, and a shortage of doctors. The second essay evaluates the cost of a price risk management tool called futures hedging. A variety of measures illustrate considerable changes in hedging costs over time. Quantile regression results show that substantial price volatility and high margin requirements are the main factors driving high hedging costs from 2007 to 2013. The third paper investigates a health risk management tool, a public health insurance program in China called New Cooperative Medical Scheme (NCMS). I apply contract theory to characterize local governments' selective incentives in NCMS benefit designs. Empirical analysis of China Health and Nutrition Survey data indicate challenges of financial sustainability of this scheme in poor regions. The NCMS plan tends to under-cover the services that are moderately predictable and negatively correlated with plan profits, such as outpatient treatments. Preventive services are generally over-provided, perhaps due to the incentive to attract healthy participants. / Doctor of Philosophy / This dissertation uses quantitative analysis to investigate three economic problems related to different aspects of risk. The first question is, what affects the respiratory health of Virginia coal mining counties' residents? Using respiratory mortality as the variable of interest, this paper finds that surface coal mining, high smoking rates, and lack of health access jointly contribute to the elevated risk of dying from respiratory diseases in our study area. The second research problem is about a price risk management tool called "hedging": purchasing contracts in the futures market to offset price movements in the cash markets. Based on historical data of corn and soybeans, I simulate the cost of hedging and find this risk management tool is not cheap, especially in 2007 to 2013. The high cost is mainly due to substantial price fluctuations in the recent decade. As a health risk management tool, health insurance is the focus of my third study. In China rural areas, a public health scheme aimed to reduce a resident's risk of suffering medical impoverishment by spreading the risk over residents in a county. County governments were relatively free to design the implementation and benefit plans. This study reveals that most New Cooperative Medical Scheme (NCMS) benefit plans are not efficient to achieve the scheme's objective. Facing high risk of fund deficits, local insurance programs in poor regions are likely to under-cover health services, such as outpatient treatments. If this scheme were allowed to charge higher prices from high-risk enrollees instead of a flat-rate premium, its efficiency might be improved.

This dissertation includes three studies, devoted to trying to understand inequality in health between people from different social groups in a democratic society. In the U.S., social inequality in health takes various forms and the key to understanding how democracy solves the problem of inequality lies in a complex set of political and social factors. I take an institutional approach and focus on examining how political and policy institutions, their administrative processes, and the policy implementation environment are linked to social inequality in health. The first essay, Whose Baby Matters More, uses a theoretical framework for evaluating heterogeneous group responses to public health policies and depicts how racial disparities in health are rooted in group heterogeneity in policy responses. The second essay, Anxious Girls and Inactive Boys, focuses on how state-level policy interventions and social capital interactively affect gender differences in health. The third essay, Responsibility for Equity, explores the link between publicness of state healthcare systems and social equity in healthcare access. In the first essay, I focus on racial disparities in infant mortality rates and pool state-level data from 1990 to 2006. The empirical analysis suggests that enhancing the capacity of state healthcare systems is critical to improving population health. Blacks and whites, nevertheless, exhibit different responses to the same policy. Racial disparities could be reduced only when policy interventions generate more relative benefits for Blacks. In the second essay, I find that social capital conditions the effect of public health policies with regard to managing childhood obesity. There are gender differences, moreover, in health outcomes and behavioral responses to state and local-level obesity policies. In the third essay, I find that different institutional factors exhibit different impact on inequality in healthcare access. While public finance resources may reduce inequality in healthcare access, public ownership and the public healthcare workforce do not have significant association with inequality in healthcare access. State Medicaid eligibility rules exhibit moderate impact on inequality in healthcare access.

In the US, the incidence and mortality rates of prostate cancer (PCa) are higher among African American men compared to European American men. Obesity is an important risk factor of PCa. Obesity is known to alter the gene expression profiles in prostate tumors. This study evaluates the impact of obesity and the expression of obesity-related genes on the progression of PCa in African American men. The primary outcome of interest is biochemical recurrence (BCR) of PCa. There were 48 African American prostate cancer patients in the study. The tissue samples included 42 normal tissues, 40 Prostate Intraepithelial Neoplasia (PIN) and 45 tumor tissues (127 tissue samples in total). We assembled 99 obesity-related genes and determined the levels of their expression in the three types of tissue samples using Nanostring Technologies. An ANOVA test was used to compare the means for gene expression among normal, PIN and tumor tissue samples. Unconditional logistic regression models were used to calculate odds ratios (ORs) and their respective 95% confidence intervals (95% CIs) to determine the association between obesity and BCR as well as gene expression and BCR. Results were regarded as statistically significant if p-values were less than 0.05. A Kaplan Meier Curve was constructed to depict the survival time and time to event (BCR) among obese and non-obese African American prostate cancer patients. Patients were followed up from the date of first surgery to the date of biochemical recurrence or date of last follow-up. Statistical analysis was done with SAS 9.4 software. Forty-three obesity-related genes were statistically significantly associated with biochemical recurrence. There was no association between obesity and biochemical recurrence (BCR) in obese African American men compared to non-obese African American men (OR= 2.03, 95% CI = 0.22 - 18.77, p-value= 0.53). Twenty genes showed an upward trend in gene expression among normal, PIN and tumor tissue samples including ADIPOR1, AKRIC4, ALOX12, ALOX15, CRYBB2, EIF5A, ERG, GNPDA2, HNF1B, HSD3B1, KLK4, LEP, MC4R, MTCH2, PCSK1, PIK3CB, SLC2A2, STAT1, SULT1A1, YY1. The probability of survival (not having BCR) is lower in obese African American men compared to non-obese African American men as indicted in the Kaplan Meier curve. In other words, the probability of developing BCR is higher in obese African American men compared to non-obese African American men. We did not find a significant association between obesity and biochemical recurrence. However, we elucidated some obesity-related genes that could explain PCa carcinogenesis. Further studies are needed to determine functional significance of these selected obesity-related genes and the role they play in encouraging PCa progression in African American men.

Background: Obesity has been generally understudied in Asian Americans. It is important to identify subgroups of Asian Americans at high risk of obesity to help develop targeted interventions for those subgroups. This study aimed to examine the disparities in obesity among Asians (i.e., Chinese, Filipino, Japanese, Korean, and Vietnamese) living in California. Methods: A sample of Adult Americans in California (n = 47,970) including Asian American adults (n = 3810) aged 18 years or older were obtained from the 2013–2014 California Health Interview Survey (the U.S. nation’s largest state cross-sectional health survey). Body mass index was calculated using self-reported height and weight. Weight status was determined using the WHO Asian BMI cut points in 4 categories: < 18.5 kg/m2 (underweight), 18.5–22.9 kg/m2 (normal weight), 23–27.5 kg/m2 (overweight), and ≥ 27.5 kg/m2 (obese). Multiple logistic regression analyses were used to estimate odds ratio (OR) and 95% confidence interval (CI) after adjustment for covariates. Results: Overall, the prevalence of Asians was 23.3% for obesity and 40.0% for overweight. The obesity prevalence was higher in Asians who were males, aged 45–64 years old, had higher family income, were current smokers, never got married, had lower education level, had an insufficient level of physical activity, and had more frequent consumption of fast foods. After adjusting for other factors, compared to Whites, being Hispanics and Blacks were associated with higher odds of obesity (OR = 1.47, 95%CI = 1.31–1.65; OR = 2.04, 95%CI = 1.65–2.53, respectively); being Chinese, Korean, and Vietnamese were associated with lower odds of obesity (OR = 0.28, 95%CI = 0.18–0.45; OR = 0.14, 95%CI = 0.04–0.46; OR = 0.28, 95%CI = 0.14–0.58, respectively). Compared to Chinese, being Japanese and Filipino were associated with higher odds of obesity (OR = 2.75, 95%CI = 1.52–4.95; OR = 2.90, 95%CI = 1.87–4.49, respectively). Conclusions: The prevalence of adult obesity was high among Asian Americans in California. Ethnic/racial disparities in obesity among Asian Americans in California were observed in 2013–2014. Compared to Whites, being Chinese, Korean, Vietnamese were associated with lower odds of obesity. Among Asians, compared to Chinese, being Japanese and being Filipino were associated with higher odds of obesity. These findings can help design better interventions to reduce racial and ethnic disparities in obesity, especially for Asian Americans.

Purpose of review This article describes methodological challenges, gaps, and opportunities in US transgender health research. Recent findings Lack of large prospective observational studies and intervention trials, limited data on risks and benefits of sex affirmation (e.g., hormones and surgical interventions), and inconsistent use of definitions across studies hinder evidence-based care for transgender people. Systematic high-quality observational and interventiontesting studies may be carried out using several approaches, including general population-based, health systems-based, clinic-based, venue-based, and hybrid designs. Each of these approaches has its strength and limitations; however, harmonization of research efforts is needed. Ongoing development of evidencebased clinical recommendations will benefit from a series of observational and intervention studies aimed at identification, recruitment, and follow-up of transgender people of different ages, from different racial, ethnic, and socioeconomic backgrounds and with diverse gender identities. Summary Transgender health research faces challenges that include standardization of lexicon, agreed upon population definitions, study design, sampling, measurement, outcome ascertainment, and sample size. Application of existing and new methods is needed to fill existing gaps, increase the scientific rigor and reach of transgender health research, and inform evidence-based prevention and care for this underserved population.

The choice to breastfeed a baby is a woman's concern with impact reaching beyond each individual mother and child to longer term health and mental health outcomes for society. The U.S. government has made increasing breastfeeding rates one of its major public health goals for 2010. Breastfeeding is a health disparity issue with mothers who are poor, young, less educated or Black less likely to breastfeed. This project examined impacts of sexual perceptions of breastfeeding, social support, and work on breastfeeding choices made by a sample of low income mothers. A cross-sectional survey design was employed to examine potential barriers to breastfeeding experienced by a random sample of mothers served by the federal nutrition support program WIC (Women, Infants, and Children) in a geographically central region of Virginia. WIC is the federal nutrition support program for low income pregnant women, infants, and young children. A survey questionnaire was completed through structured interviews or mailed questionnaires with WIC participant mothers with a baby between 6 and 18 months of age. Both breastfeeding and formula feeding mothers were included in the sample. One hundred and forty mothers identified their infant feeding choices in their babies' first six months. They answered questions about positive and negative breastfeeding experiences related to social support, work, and their attitudes regarding public breastfeeding and sexual perceptions of breastfeeding. The creation of a scale to measure sexual perceptions of breastfeeding is a primary contribution of the study. Social support, work, and sexual perception variables as well as demographic variables were used in logistic and linear regression models to explain mothers' breastfeeding initiation and breastfeeding duration choices. Further, mothers also expressed their perspectives on breastfeeding choices and experiences in their own words through open-ended questions in the survey/interview.Results of the study found that social and professional support, discomfort with public breastfeeding, time spent away from baby for work, not being married or partnered, and possessing a lower level of education did constrain the initiation and/or duration of breastfeeding for this low income sample of mothers. Qualitative data added description of mothers' experiences with these breastfeeding constraints.

The Anderson and Aday access framework (1974) is utilized to investigate the association of individual and community level, predisposing, socio-demographic, and enabling factors, on potential and realized access to coronary heart disease (CHD) preventive care. The cross-sectional study is based on a sample of adults age 18-85 from the Medical Expenditure Panel Survey (MEPS) who were identified with CHD risk or who had a CHD diagnosis.Variables from the MEPS and the Area Resource File (ARF) are used to test logistic regression models for dependent variables measuring primary and secondary CHD preventive care services. The primary preventive care measures include blood cholesterol testing, blood pressure checks, and, diet, exercise and smoking cessation counseling. The secondary preventive measures include beta-blocker reciept after myocardial infarction (MI) and statin drug use for the treatment of high blood cholesterol.Being uninsured is associated with a reduced likelihood of receiving primary CHD preventive care. Overall study results indicated gender and race are more consistent predictors of the receipt of CHD preventive care services than individual enabling or community characteristics. Women had a greater likelihood of receiving primaryCHD preventive care services than men. Hispanics are less likely than Caucasians to receive primary CHD preventive care services, except for blood cholesterol testing for which they are more likely to receive. Blacks are more likely than Caucasians to have blood cholesterol testing, but are no less likely to receive the other primary CHD preventive care measures. Blacks demonstrate a lower likelihood of receiving secondary CHD preventive care than Caucasians, specifically beta-blocker post myocardial infarction indicating that disparities in secondary CHD preventive care persist for segments of the study population. Persons over 75 years of age are less likely to receive primary CHD preventive care services as well as the secondary preventive measure ofstatin use for high blood cholesterol.Community level factors did not improve the logistic regression model for the receipt of CHD preventive care, yet, when predicting potential access for preventive services, persons from a higher percent Hispanic or black community were less likely to have a usual source of care.

Many lesbian, gay, bisexual, and transgender (LGBT) individuals report experiencing discrimination in their health care that leads to avoidance of regular appointments with providers. Lack of regular primary care can delay diagnoses of preventable conditions and increase patient risks for chronic disease complications. A systematic review of the literature was conducted to understand LGBT cultural competencies for nursing and other health care providers. The Cochrane Handbook for Systematic Reviews and Melnyk's levels of evidence framed this systematic literature review. Articles for inclusion were limited to those published in English between 2008 and 2018. Keywords used in the literature search included LGBT health disparity, LGBT cultural competency orientation, and nursing LGBT education. The search yielded 70 article results, which were further reduced to 12 articles by critically analyzing the applicability of the literature to the practice-related questions and removing duplicate articles. Five articles met the criteria for Levels III-IV (case-control or cohort), 6 met the criteria for Level II (randomized control trials), and 1 was Level 1 (systematic review). The analysis of evidence demonstrated the importance of providing education to nurses and other health care providers regarding LGBT cultural competency. Recommendations are offered for best practice strategies regarding the inclusion of LGBT cultural competencies in nursing orientation modules. Application of the findings may lead to positive social change if knowledgeable health care providers engage the LGBT population in primary care leading to improved health care outcomes.