Indiana University-Purdue University Indianapolis (IUPUI) / Depression is the most commonly occurring mental illness the world over. It poses a significant health and economic burden across the individual and community. Not all occurrences of depression require the same level of treatment. However, identifying patients in need of advanced care has been challenging and presents a significant bottleneck in providing care. We developed a knowledge-driven depression taxonomy comprised of features representing clinical, behavioral, and social determinants of health (SDH) that inform the onset, progression, and outcome of depression. We leveraged the depression taxonomy to build decision models that predicted need for referrals across: (a) the overall patient population and (b) various high-risk populations. Decision models were built using longitudinal, clinical, and behavioral data extracted from a population of 84,317 patients seeking care at Eskenazi Health of Indianapolis, Indiana. Each decision model yielded significantly high predictive performance. However, models predicting need of treatment across high-risk populations (ROC’s of 86.31% to 94.42%) outperformed models representing the overall patient population (ROC of 78.87%). Next, we assessed the value of adding SDH into each model. For each patient population under study, we built additional decision models that incorporated a wide range of patient and aggregate-level SDH and compared their performance against the original models. Models that incorporated SDH yielded high predictive performance. However, use of SDH did not yield statistically significant performance improvements. Our efforts present significant potential to identify patients in need of advanced care using a limited number of clinical and behavioral features. However, we found no benefit to incorporating additional SDH into these models. Our methods can also be applied across other datasets in response to a wide variety of healthcare challenges.

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Where someone lives, how much education they have, their income, all are recognized as social determinants of health, and as being of greater importance in their overall health status and outcomes than are their doctors and medicines. But all of these are affected by times in which they have lived. These encompass the physical world, the social forms, institutions, economic activities, material goods, the customs, beliefs, morals, laws, norms, and arts of the world in which we move, and all change over time. The experiences of a body moving through time alter that body in direct and indirect ways, to create change that is persistent through time. A patient might reasonably say "to understand me you need to understand the times in which I have lived." Similarly the health of a population can only be fully understood if the history of that population is considered. A case study of an individual within a specific population is used to illustrate these points. / Urban Bioethics

This thesis discloses findings from a scoping review of Social and Structural Determinant of Health (SSDOH)-related academic and grey literature from neurosurgery and fields with neurosurgical overlap. The purpose of this thesis is to identify which social determinants have been assessed, for which surgical procedures they were evaluated, and what disparities were found. To identify studies to include or consider for this systematic review, the review team worked with a medical librarian to develop detailed search strategies for each database. Studies were screened by title and abstract independently by two reviewers. Disagreements between reviewers were resolved by a third reviewer, blinded to the decisions of the primary reviewers. The scoping review of the SSDOH in neurosurgical outcomes identified 99 studies from the year 1990 to 2020. Identified studies were targeted predominantly toward spine surgery patients, evenly distributed in analyses of gender, race and economic stability. The relatively low volume of neurosurgical papers focused on the SSDOH and emphasis on one subspecialty demonstrates the need for an expanded interest in the SSDOH in neurosurgery. / Urban Bioethics

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This dissertation research focused on breast cancer and social determinants that have been shown to influence the outcomes of this devastating disease. Although heart disease is the leading cause of death for women, more women feel that they will die from breast cancer. Breast cancer is the most common diagnosed cancer in women exacting an emotional and economic hardship for many women. There are no known causes of breast cancer, but there are certain genetic and social factors that pre-dispose women to this disease. Also, diagnosis at later stages of disease has been shown to have adverse outcomes for many. This research examined the effects that social determinants had on breast cancer stage of diagnosis. The social determinants researched to examine their influence on breast cancer outcomes were race, geographical location, health insurance, and income. Also, this research examined the influence of Public Health Law, 101-354, enacted to decrease health disparity from breast and cervical cancer for minorities and medically underserved women had on breast cancer diagnosis for women enrolled in the Mississippi Breast and Cervical Cancer Program. Complimentary to PHL 101-354, Public Health Law 106-354, the Breast and Cervical Cancer Treatment Act, was enacted giving states the option of providing health insurance through Medicaid for eligible women with a diagnosis of cancer of the breast or cervix, including precancerous conditions, for treatment services. The results of this study revealed that race and health insurance were the two major factors that negatively impacted stages of breast cancer diagnoses. Although hypothesized, geographical location and income did not significantly affect late stage breast cancer rates.

There is substantial evidence that suicidal behaviour is disproportionately observed among those with lower socioeconomic positions. Prior literature suggests that policy measures tackling severe socioeconomic deprivation may have impacts on decreasing the health gaps. Yet, little research has been conducted to examine the effects of social and welfare policies on suicidal behaviour and its inequality. This is in part because the understanding of the socioeconomic inequity in suicidal behaviour has been limited by the strong biological individualism, thereby overlooking the potential importance of social and welfare policies to tackle the population-level determinants of suicide. Using jurisdictional and temporal variations in social policies and patterns of suicide, this dissertation contributes to the literature by providing a summary of the current knowledge base of socioeconomic inequality in suicide and suicidal behaviour, identifying the knowledge gaps and future research questions, and adding novel evidence on the impacts of individual social policy and aggregate welfare generosity on suicide mortality and its inequality. In Chapter Two, consists of a scoping review of studies addressing socioeconomic inequalities in suicide and suicidal behaviour or the relationship between socioeconomic positions and different outcomes of suicidal behaviour in high-income countries with quality data. The literature is summarized to map the findings on the socioeconomic inequity in suicidal behaviour. The chapter concludes with an assessment of gaps in the current knowledge base and suggests a future research agenda. In Chapter Three, I examined whether relative welfare generosity in Canadian provinces is associated with overall suicide mortality and employment-based inequalities in suicide mortality by exploiting the provincial differences within Canada. In Chapter Four, I investigated the effects of two recent social pension reforms targeting older adults—Basic Old Age Pension (BOAP) and Basic Pension (BP)—implemented in South Korea on suicide mortality. Taken together, the findings of the dissertation contribute to the existing literature by mapping the relevant literature, identifying research gaps about socioeconomic inequalities in suicide, and suicidal behaviour, and examining the roles of social policy as a moderator of socioeconomic inequalities in suicide. / Dissertation / Doctor of Philosophy (PhD) / There is substantial evidence that suicide and suicidal behaviour are disproportionately observed among those with lower socioeconomic positions. Prior literature suggests that policy measures tackling severe socioeconomic deprivation may have impacts on reducing health gaps. However, little research is conducted to examine what effects can be brought by social and welfare policies on suicidal behaviour. This dissertation contains three studies on socioeconomic inequality in suicide and suicidal behaviour and examines the impacts of socioeconomic policies and welfare generosity that may tackle inequality. The overarching aim of the dissertation is to advance our understandings of socioeconomic inequality in suicide and suicidal behaviour by providing a systematic analysis of socioeconomic inequality in suicide and suicidal behaviour and roles of social policy and welfare generosity on suicide and suicide inequality. The dissertation contributes to the literature by mapping the relevant literature, identifying research gaps about socioeconomic inequalities in suicide, and suicidal behaviour and demonstrate novel findings about the roles of social policy.

Objectives: Understanding the impact of poverty on health can inform efforts to target social programs and regional economic development. This study examined the effects of poverty on health among the 95 counties of Tennessee. Methods: All of the counties of Tennessee were ranked by 5-year median household income, from the wealthiest to the poorest. The counties were divided into quintiles, from wealthiest to poorest, to reflect the general impact of wealth on health. Next, the five wealthiest counties and the five poorest counties were identified, allowing for examination of the extremes of poverty and wealth within Tennessee. Comparisons of quintiles and five wealthiest and poorest counties on key measures were performed using the independent t test. Results: People living in the wealthiest quintile lived on average 2.5 to 4 years longer and had lower rates of all health behaviors and health outcomes investigated compared with those in the poorest quintile. This disparity was even more pronounced when comparing the wealthiest five counties to the poorest five. The five poorest counties, for example, had twice the years of potential life lost and were overwhelmingly rural in character, with similar accompanying disparities such as median income, high unemployment, and a more aged population. Conclusions: This study highlights the fact that lower income is associated with significantly worse health outcomes in Tennessee and reinforces the importance of economic development, specifically, and addresses the social determinants, more generally, in helping to improve Tennessee's overall health statistics.

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BACKGROUND: Pancreatic ductal adenocarcinoma maintains a formidable mortality rate with rising incidence despite extensive research efforts. As of 2021 pancreatic cancer is the third leading cause of cancer-related deaths in the United States despite its incidence representing only 3% of all cancer diagnoses. Given the high mortality rate, research efforts push to improve prognosis by expanding knowledge and tools in the realms of diagnostics, genetics, development of screening modalities, and targeted treatments. Modifications in treatment algorithms have led to only modest improvements in outcome. Current research efforts focus on primary and secondary prevention aimed at modifications of known environmental and hereditary risk factors. Available studies highlight the relationship between relative geography and cancers; however, there is a paucity of research available on the Social Determinants of Health on access to pancreatic cancer care and outcomes. PROPOSED PROJECT: Data will be extracted from the Surveillance, Epidemiology, and End Results (SEER) database and combined with US Census data along with medical record information as relevant over a seven-year period from January 1, 2010, through December 31, 2017. Social Vulnerability Index scores will be derived from the available data as a surrogate for Social Determinant of Health and be assigned to each case of pancreatic cancer from 2010-2017. These scores will be grouped by zip code. Analysis will then be performed to identify the mean stage at time of diagnosis for each zip code. Further analysis will be performed to calculate survival curves for each zip code and cox proportional-hazards will be performed on results to determine statistical significance of SVI with respect to geography. CONCLUSIONS: The proposed study will investigate the impact of geography as a Social Determinant of Health (SDoH) within the United States on the stage at time of diagnosis for pancreatic ductal adenocarcinoma. As a secondary measure, overall survival following diagnosis of pancreatic ductal adenocarcinoma will be examined. SIGNIFICANCE: This study will identify the impact of social determinants of health on geography and correlate the impact on outcomes in pancreatic ductal adenocarcinoma in the United States of America. This study may also identify geographic regions in which the incidence of PDAC is higher than expected which would present a population to investigate for additional screening studies and development of risk prediction models.