<p> The United States (US) is plagued by a high-cost health care system producing lower than desired patient quality outcomes. In 2012, the Patient Protection and Affordable Care Act was enacted to financially incentivize cost-effective models of care that improve the health of US citizens. One emerging solution is engaging patients with chronic conditions in self-management practices. </p><p> Guided by Krieger's Eco-Social Theory, this study used semi-structured interviews, scales and a questionnaire to detect factors that facilitate patient activation of self-management in patients with type 2 diabetes. Managed and unmanaged participants were equally represented in the study sample. White participants and participants from two American Indian tribes located in Northeast Wisconsin were included in this study. Findings indicated the establishment of routine behavior and the ability to identify healthy alternatives when routines were disrupted support patient activation of self-management. Experiencing success such as weight loss was also identified as a factor in facilitating patient activation. Social roles and responsibilities challenged unmanaged patients. </p><p> The study concluded that community, culture and environment have both a negative and positive influence on patient activation of self-management of type 2 diabetes. The current epidemics of obesity and diabetes create an apathetic response to the type 2-diabetes diagnosis that affects subsequent treatment and self-management in the communities studied. Aspects of local cultures such as unhealthy regional and tribal foods, lack of options for menu items low in carbohydrates and sugar in restaurants, high consumption of soda and alcohol and holidays/tribal events provide significant challenges for unmanaged patients. Workplace policies surrounding health insurance premiums had an impact on attendance at educational events but not on sustaining self-management behaviors. Positive aspects of the workplace include the imposition of structure and routine and the emotional support of colleagues. Warm seasons were also found to activate self-management by providing an opportunity for outdoor exercise and healthier modes of food preparation. </p><p> Consistent with a previous study, high rates of childhood trauma were found among the study groups. However, findings did not support the hypothesis that levels of childhood trauma were linked to self-management. While some evidence of historical grief and loss along with associated symptoms was found among the American Indian populations, there was no correlation between managed condition and level of grief and loss. Further examination of the connection between childhood and historical trauma to the current obesity and diabetic epidemics in these communities is recommended. Recommendations for changes to public health and health care policy are included.</p>

<p> The Kingdom of Jordan is one of the world's most water poor countries suffering from physical water scarcity, a growing population, regional instability, poor water infrastructure, inefficient water sector management and high water misuse. Through conducting a content analysis of 73 USAID reports, focusing on water demand management, this paper aims to understand how water demand is managed in the Kingdom, in addition to understanding the role of international aid in transforming Jordan's water sector. A greater understanding of the crisis and actions taken to mitigate the impacts were revealed by examining specific water polices and laws, the role of government structures and water sectors, and implemented projects. It was found that Jordan has taken significant efforts to sustainably manage water resources and to address growing water demand. Reallocating water among various sectors, reducing non-revenue water, and decentralizing water provision are key priorities outlined in the Kingdom's water strategy.</p>

<p> Immigrant communities in Massachusetts Gateway Cities face a number of economic and social challenges that can be difficult to understand or quantify through traditional research methods. This thesis explores the use of sentiment analysis of microblogging data as an alternative method for assessing well-being of immigrant communities, with a focus on Portuguese speaking immigrants. I collected Tweets from four key cities in Massachusetts and analyzed them using two sentiment lexicons, one in Portuguese and one in English. I compared results between languages as well as correlated with a number of traditional indicators of well-being gathered from U.S. Census data. I found that the results from the English analysis were overall more positive than those from the Portuguese analysis, but most differences were not statistically significant. I also found some correlations between the demographic data and the sentiment analysis results with promising implications for further research. </p>

The Health Care Finance Administration is challenged with improving enrollment into the alternative managed health care system called Medicare+Choice. The current Medicare cohort is knowledgeable about where to obtain information about Medicare+Choice, but they cannot recall the terminology or comprehend the concepts of the program. This study attempts to improve older adult recall and comprehension of Medicare managed care written text, with the goal of improving their attitude toward Medicare managed care. Older adults (n = 49) from a community located in the Southwest were randomly assigned to one of three study conditions. Analysis of Variance, Tukey HSD, and correlation analysis were conducted on questionnaire responses measuring for recall, comprehension and attitude. An "Elderspeak Process" improved older adult recall of specific terms, words, and phrases about Medicare and Medicare managed care. Medicare managed care organizations can use the process to simplify information about their managed care programs to knowledgeable older adults.

The relationship between perpetrator and target, as a factor in school peer sexual harassment, has been particularly neglected (Stein, 1999). This relationship spans nonromantic and romantic interest between peers. This paper focuses on peer relationship, as a dimension of overlap and intersection between peer school sexual harassment and dating violence. My project is a qualitative interview-study of the sexual harassment experiences of eighteen 13 to 20-year-olds, particularly where there is romantic interest involved between harasser and target. The study's findings show school sexual harassment and teen dating violence to overlap and intersect in the areas of behavior (physical or nonphysical), relationship (romantic or nonromantic), and location (more private to more public places at or away from school). Important contextual information about school sexual harassment revealed by the data includes: (1) school sexual harassment occurring in all peer relationships, including dating and ex-dating relationships, (2) patterns of school sexual harassment behavior that resemble obsessive control in stalking and dating violence, (3) the protracted or violent nature of the harassment (like dating violence), and (4) the high levels of upset and injury experienced by the target (similar to dating violence). My results suggest that peer relationship context is critical to understanding significant aspects of peer sexual harassment, including the power and gender dynamics which underlie the behaviors, and to revealing its similarities and overlap with dating violence.

This dissertation analyzes the social history and current struggles of Analco and Santa Cecilia, two Chinantec peasant localities of Oaxaca, Mexico, which experienced the boom and bust years of coffee agriculture subject to the vagaries of the global market for this cash crop. It examines the last twenty-five years of State interventions toward the Indian peasantry, focusing especially on current neoliberal economic and social policies, to reveal how they have affected local well-being and livelihood strategies. In the course of describing food security and nutrition, I show how Analqueno and Cecilieno men, women and children have coped with major changes in Mexican politics and the economy; changes toward which they have devised multiple responses, but upon which they have had limited control. In particular, I explore how members of these communities weighed options and maximized opportunities in their attempt to maintain, restore or enhance food security and local well-being during the coffee crisis of the 1990s. I show how, in the last decade, agricultural diversification for both home consumption and the market, and a partial retreat from commercial agriculture centered around coffee have become significant. Finally, I consider the nutritional effects of the coffee boom and bust years on the local populations paying particular attention to children, teenagers, and gender differences.

This dissertation brings together empirical analyses of the impact of social insurance programs on compensating wage differentials under different institutional frameworks. I study three periods: the late nineteenth century prior to the introduction of Unemployment Insurance, the Great Depression when Unemployment Insurance is introduced, and then the recent period, in which UI has been long established. Initially, late nineteenth century labor markets with no social programs for workers were investigated. Three different data sets were analyzed from two different states, Maine and Kansas, to examine the precautionary saving behavior of workers and the wage premium they received for the expected unemployment prevalent in their industry. Results showed that workers were receiving statistically and economically significant wage premiums in two of the three samples. Also, in two of the three samples, households were able to save against expected unemployment using family resources. In the second chapter, after reviewing the historical backgrounds of social insurance programs, namely Workers' Compensation, Compensation for Occupational Diseases, and Unemployment Insurance (UI), the empirical literature about the impacts of these programs on wages is reviewed. Later in the chapter, hours and earnings data for various manufacturing industries across forty-eight states for the years 1933-1939 are brought together with the state UI, Workers' Compensation, and Compensation for Occupational Diseases provisions to test the impact of these laws on wage rates. The economic history and origins of UI have not been elaborated before and no previous study has analyzed the simultaneous impacts of different social insurance programs. Results showed that higher accident rates, limited working hours and the higher regional cost of living had a positive impact on wages. Workers' Compensation continued to have a negative impact on wages. During its infancy, UI benefits did not have a statistically significant effect on wages. The last chapter analyzes the impact of UI and the unemployment rate for the labor market of the worker on wage rates using micro level modern data. Results from the analysis of the National Longitudinal Survey of Youth suggest that expected UI benefits have a negative and statistically significant impact on wages, holding worker and labor market characteristics constant. However, the unemployment rate of the labor market did not have a statistically significant impact on wages.

Starting in the early 1900s, Chileans began to address skyrocketing levels of infant mortality. Committed to establishing state welfare policies, health scientists led campaigns to improve infant health. They concentrated on reforming working class maternity. This began a historical connection among health science, public welfare and indigent mothers in Chile. Looking to expand their international role in medical philanthropy in the 1930s, the Rockefeller Foundation invested heavily in Chilean medicine. Following suggestions by leftist physicians, North American philanthropists expanded maternal and child health care. From the 1930s through the 1940s, Chilean and U.S. health professionals further collaborated to reform medical education, build schools of medicine, establish public clinics, open research centers and provide public health education. Cooperation between Chilean leftists and representatives of the Rockefeller Foundation finally succeeded in socializing medicine in 1952. The National Health Service constituted a significant part of Chile's growing welfare system. Supported by the Rockefeller Foundation and Chilean government, state medicine continued to focus on working class women and infants. Leaders from the Rockefeller Foundation's International Health Division attempted to limit their role in Chilean medicine as early as 1940. After helping Chileans to expand public health, Foundation leaders planned to withdraw from Chile. Prominent nationals, particularly leftist health scientists connected with socialized medicine, strongly protested this departure. Mutual interest between Chilean and North American health scientists in family planning persuaded the Rockefeller Foundation to remain. North Americans connected to the Rockefeller Foundation and wealthy Chileans feared social problems caused by burgeoning population. Leftists in the Chilean government worried that public funds could not match popular demand for state services. Population control advocates from the U.S., in turn, feared that growing populations in developing countries would consume world resources. Working with like-minded nationals, North American philanthropists, academics, diplomats and politicians instituted family planning in Chile. Population programs based on the mass distribution and study of previously untested intrauterine devices mushroomed. Pressure from the newly elected Communist president, Salvador Allende, as well as high-ranking U.S. politicians finally ended Chilean population control programs in the early 1970s.

This thesis paper researches the impact of illegal immigration on U.S. social services. The study focuses on information gathered from a group of illegal Mexican immigrants who have lived and worked in the U.S. The sample of illegal Mexican immigrants was attracted to the U.S. primarily for economic reasons. The U.S. economic system has directly and indirectly attracted Mexican workers into America for over a 100 years. The U.S. economy has directly attracted Mexican workers through recruitment practices employed by several U.S. business sectors. Indirectly, the powerful U.S. economy has historically attracted Mexicans north because the U.S.'s economy offers more economic opportunities than the Mexican economy. Illegal Mexican immigrants' presence in the U.S. economy has led to the increased use of U.S. social services and as a result of this extra use, a burden has been put on several social service institutions. To what extent this burden affects the U.S. economy is still not clear because illegal immigrants pay U.S. taxes that may compensate the system for this extra use.

<p> The Accountable Care Organization (ACO) has been introduced in the US as a health system reform initiative with potential to achieve the immediate and long-term goals of improving population health, improving quality and producing greater value for the healthcare dollars spent. Over the past half-century, a number of health system reforms have been designed and implemented with these goals as the intended outcomes. These efforts have produced, at best, incremental learning, variable improvements in performance outcomes, and modest cost-savings. Early evaluations of the health, quality and cost outcomes from ACO sites suggest that the long-term effectiveness of the ACO care model faces obstacles similar to those that have impeded the long-term success of past health system reform efforts. The fundamental question of how to transform the existing construct of care delivery towards one of open collaboration, team-based care and active management of health and patient populations remains elusive (Institute of Medicine, 2012).</p><p> It is under these conditions that three independent but thematically linked investigations were conducted. The first investigation, a comparative policy analysis of US-based health system reform efforts found that transforming the construct of care delivery&mdash;how care is organized and how care is delivered are fundamentally social and relational processes that impact the outcomes of reform. These processes have been underexplored alongside other change levers in the health services research and practice communities to the detriment of healthcare organizations confronted by the need to transform the construct of care delivery as the healthcare environment transitions towards accountable care. </p><p> The second and third investigations were focused at the level of the healthcare organization and its members. The instrumental case of a large integrated delivery system transforming its disease management program for diabetes towards an ACO model was used to further examine the social and relational dynamics of health system reform. The second investigation, a qualitative analysis of the social-psychological dimensions of the change process, found that ACO characterization, Uncertainty, conceptual perceptions of the notion of accountability, and Electronic Health Record implementation influenced how the network of providers made sense of transformation towards accountable care and their perception of system readiness to engage in change and be successful. </p><p> The third investigation, an applied example, demonstrated how relational coordination and social network analysis can be used as complementary tools to inform the design and implementation of interventions intended to transform the construct of care delivery in support of the goals of health system reform. Measurement of the quality of team performance found weak relational coordination ties across each network and among the roles treating and managing diabetes in a network. Social Network Analysis (SNA) of relational coordination found differential pathways for leveraging roles structures within a network in support of change efforts. </p><p> Collectively, these investigations suggest that if ACOs are to achieve the short- and long-term goals of health system reform, the social and relational dynamics of change are important to incorporate and consider alongside of other health system reform change levers.</p>