Oregon, especially the Portland metro area, has become an important relocation destination for migrants, including many from Africa (Curry, and Al 2010). According to data from the Immigrants and Refugees Community (2011) in Portland, there are more than 15,000 African migrants, and they are the fourth largest immigrant community in the area, which includes representations from over 28 African countries. This study is about migrant’ worldviews and healthcare preferences in Oregon. My study centers on African migrant’s health experiences within a broader context of how sending countries worldviews and health care system informs attitudes and healthcare preferences in Oregon. Focus groups, life histories and survey data were collected over a period of 18 months from participants of 12 countries living in Eugene and Portland, Oregon. The findings indicate that migrants worldviews results from prior socialization processes that shapes Africans and guides their interactions and healthcare preferences in the US healthcare system.

<p> <b>Background:</b> While the data indicate that Oklahoma&rsquo;s nursing home care is lower in quality than the national average, there is a gap in the literature as to what staff perceive as barriers to quality care in Oklahoma. Staff perceptions impact organizational outcomes. Examining staff-perceived barriers presents the opportunity to approach improvement from the perspective of those responsible for implementing interventions. </p><p> <b>Hypothesis:</b> Nursing home staff in Oklahoma perceive the following as common barriers to delivering high quality care: (i) culture and structure of the organization; (ii) lack of authority and autonomy related to tasks and care delivery; (iii) high job demands related to disease burden; and (iv) limitations of the physical environment. The central question addressed is what do staff perceive as barriers to providing high quality care in Oklahoma nursing homes? </p><p> <b>Methods:</b> A written survey and interview guide were used to collect information from 28 nursing home staff from seven nursing homes in Oklahoma. The survey was crafted to test the perceptions of barriers in alignment with the conceptual model. Quantitative methods were used to determine the sample and analyze written survey responses. Qualitative methods were used to code themes from the interviews to elements of the conceptual model to determine if responses aligned with the hypothesis. </p><p> <b>Results:</b> Frequently cited barriers to delivering quality care include: social relationships inclusive of meals, care planning, activities, and dedicated staff time with residents; environmental factors inclusive of room size, privacy, layout, and access to outdoors; job demands inclusive of workload, time pressures, cognitive load, and demands from residents and families; performance evaluation, rewards, and incentives inclusive of recognition, appreciation, wage, bonus pay, performance feedback; and, supervisory and management style inclusive of consistency, equity, perceived fairness, and stress. </p><p> <b>Conclusion:</b> Real and perceived barriers to high quality care exist. Perceptions vary by staff role, and perceptions can be aligned with organizational structure and strategies through communication, transparency, and a justice-based approach. Along with changes to regulation and rules, improvement efforts must occur at the facility level with support from leadership and engagement of staff.</p>

Deficiencies in the quality of pre-hospital care constitute a serious public health problem that has largely been neglected by the scientific community. Trauma and complications of acute disease produce medical emergencies outside of the hospital setting. Treating patients with these conditions involves an inherent trade-off between providing treatment on-site and reducing time to hospital care. My dissertation compares two models of providing pre-hospital care, and highlights a data-driven approach to identifying potentially fraudulent ambulance claims. Chapters 1 and 2 compare effects of Advanced Life Support (ALS) and Basic Life Support (BLS) on outcomes after out-of-hospital medical emergencies. Most Medicare patients seeking emergency medical transport are treated by ambulance providers trained in ALS. Evidence supporting the superiority of ALS over BLS is limited. I analyzed claims from a 20% sample of Medicare beneficiaries from non-rural counties between 2006-2011 with cardiac arrest, major trauma, stroke, acute myocardial infarction (AMI), or respiratory failure. To address unmeasured confounding, I exploited variation in geographic penetration in ALS rates across counties, using instrumental variables analysis. In particular, I predicted the probability of ALS use for each patient as a function of ALS rates in each county for patients with other diagnoses, using a multilevel, multivariate model. Survival to 90 days for trauma, stroke, cardiac arrest, and AMI patients was higher with BLS than ALS; respiratory failure patients did not exhibit differences in survival. I conducted a secondary analysis based on propensity score-based balancing weights, and this produced generally similar results. I concluded ALS is associated with substantially higher mortality for several acute medical emergencies compared to BLS, and may harm patients through delayed hospital care and iatrogenic injury. In Chapter 3, I link patient demographic information and ambulance, outpatient, and inpatient claims to look for the inconsistency of having a claim for an ambulance transport with seemingly no real patient - a 'ghost'. I find 1.9% of emergency transports have this inconsistency. I estimate the distribution of ghost ride rates by suppliers and separately, by counties, using an expectation-maximization algorithm. I find the ghost rides are not evenly distributed across counties or suppliers. Although it is not possible to conclusively distinguish billing anomalies due to fraud from data entry errors and similar explanations, this type of analysis may provide useful starting points for further investigation of Medicare fraud. / Health Policy

This dissertation evaluates lifestyle strategies for the management of cardiovascular risk factors and prevention of cardiovascular disease (CVD). In Chapter 1, I systematically review and summarize the evidence of the effect of yoga, a popular mind-body practice, on cardiovascular disease and metabolic syndrome risk factors. I perform a narrative systematic review and a random-effects meta-analysis of randomized controlled trials (RCTs) of posture-based yoga practice. I find that yoga showed significant improvement in a variety of risk factors for CVD and metabolic syndrome, including body mass index, systolic blood pressure, and total cholesterol when compared to no or minimal intervention control groups. When compared to active exercise controls, yoga produced similar risk factor level reduction. Promising evidence supports yoga’s role in improving cardio-metabolic health. Findings are limited, however, by small trial sample sizes, heterogeneity, and moderate RCT quality. In Chapter 2, I evaluate the comparative effectiveness of four different lifestyle strategies for reducing 10-year CVD risk. I used published literature on risk factor reductions associated with group therapy for smoking cessation, Mediterranean diet, aerobic exercise (walking), and yoga together with the Pooled Cohort risk algorithms to calculate a personalized optimal strategy for risk reduction based on different risk profiles. I find that for smokers, successful smoking cessation is an optimal strategy for reducing risk whereas for non-smokers or for smokers who do not quit successfully, stress reduction through yoga produces the greatest risk reductions. In Chapter 3, I examine the cost-effectiveness of aerobic exercise and yoga compared to current medical practice for primary prevention of CVD in US adults. I use a subset of RCTs from Chapter 1, along with published literature on utilities, costs, and other parameters as inputs into a validated disease microsimulation model. I calculate the costs per quality-adjusted life year ($/QALY) of aerobic exercise and yoga with an exercise on prescription approach from the societal and healthcare perspective as well as if the activities were reimbursed. Results suggest that both interventions are not cost-effective using a threshold of $100,000/QALY due to high patient time costs in the societal perspective; when the activities are reimbursed and gains in quality of life are taken into account, then the activities can be cost-effective. Future research can explore patient preference and adherence and utility gains from physical activity. / Health Policy

This dissertation examines the relationship between life course social mobility and socio-economic disparities in health using data from the Health and Retirement Study. Chapter 1 explores how eligibility for the Korean War GI Bill, which provided socio-economic benefits to veterans, impacted the mental health of veterans compared to non-veterans. Using coarsened exact matching (CEM) to rigorously control for selection into the military, Korean War era veterans were matched to non-veterans. Regression models were used to predict number of depressive symptoms (NDS) and an indicator for depression. Pooled results were null, however veterans from low socio-economic backgrounds benefited from military service while veterans from high socio-economic backgrounds did not, resulting in a reduction in socio-economic disparities in NDS and depression prevalence. Chapter 2 examines if the benefits from Korean War era military service had a spillover effect to wives of veterans. Using CEM, veteran wives were matched to wives of non-veterans. Pooled results were null, however, among women from high socio-economic backgrounds, veteran wives had fewer NDS than non-veteran wives; there was no effect of husband’s military service among wives from low socio-economic backgrounds. Chapter 3 examines the relationship between life course social mobility and markers for stress (C-reactive protein), blood sugar (hemoglobin A1c), cholesterol (high density lipoprotein), and kidney function (Cystatin C). Results from linear regression models indicate that all outcomes followed a social gradient whereby individuals who experienced high SES at both time points had the best biomarker levels, while individuals who experienced low SES at both time points had the worst biomarker levels. Individuals who experienced upward mobility over the life course had statistically equivalent biomarker levels as individuals who experienced high SES at both time points, while individuals who experienced downward mobility had statistically equivalent biomarker levels as individuals who experienced low SES at both time points. These results suggest that the deleterious effects of a low SES childhood may be ameliorated or eliminated by upward social mobility in adulthood for these outcomes.

Introduction: Smoking is the leading cause of preventable death in the United States, and obesity is the second cause. Both are risk factors for various types of cancer. Specifically, smoking is linked to lung, esophageal, bladder, kidney, and stomach cancers; and obesity is linked to postmenopausal breast, colorectal, endometrial, pancreatic, and gallbladder cancers. Multiple factors affect health behavior, and this dissertation investigated the role of media and health communication as modifiable influences related to smoking and obesity. Methods: Paper 1 examined the association between average hours of television viewing per day and smoking status among all Hispanic adults (n=675) and within the subgroups of Puerto Rican (n=182) and Dominican (n=396) adults using multivariable logistic regression models. Paper 2 explored how health information sources inform decision-making related to childhood obesity among Hispanic mothers during their children’s first 1000 days of life (conception-age 24 months) using seven focus groups. Paper 3 documented the development and uptake of a media competition (with 595 student participants) implemented in the context of a multi-sector community intervention targeting childhood obesity prevention through process evaluation. Paper 3 also examined community, organizational and provider characteristics that explain variation in implementation effectiveness and described diffusion of the media competition across community sectors using 54 key informant interviews. Results: In Paper 1, Hispanic adults who watched 5+ hours (5-15 hours) of TV per day were more likely to be a smoker than those who watched ≤2 hours, with the same association among Puerto Ricans. In Paper 2, trusted health information sources for Hispanic mothers included health care providers, female and male family members, BabyCenter.com and other Internet sources, selected social media, and television. In Paper 3, salient themes that emerged as implementation facilitators were having a cascade of champions and adaptability through providing opportunity to participate in the media competition outside traditional class time. Discussion: Papers 1 and 2 support the importance of understanding the nuances and differences in Hispanic adults in order to design appropriate media and health communication interventions. Paper 3 provides insight about how to replicate media competitions for children in other communities. / Social and Behavioral Sciences

Malaria and HIV are the two diseases that cause the most disability and loss of life in sub-Saharan Africa. Treatments play a critical role in ameliorating the impact of these diseases on patients and their communities. This dissertation focuses on three elements of treatment: The impact of HIV treatment on childhood education, integration of HIV care and sexual and reproductive healthcare, and adherence to treatment. In chapter one, we assessed the impact of adult HIV treatment on the educational attainment of children in the same household through a regression discontinuity analysis. Adult HIV treatment results in large gains in the educational attainment of children in the same household (intention-to-treat [ITT]: 0.30 years, p=0.017; complier average causal effect [CACE]: 1.17, p=0.036). This increase in educational attainment is important for increasing individual and community well-being and human capital. In chapter two, we estimated the association between moving through the HIV treatment cascade and contraceptive use through a bivariate probit analysis. We find large increases in condom use among HIV-positive women as they move through the treatment cascade, with increases of 22.8 percentage points (p<0.001) among women on ART for 4-7 years relative to women who are unaware of their HIV-positive status. This finding is a positive indication of the integration of HIV care and reproductive healthcare. In chapter three, we conducted a randomized trial to assess the impact of text message reminders on adherence to antimalarial treatment and in chapter four we estimated whether patient factors predict antimalarial treatment adherence and modify the impact of text reminders using logistic regression models. We found that a short, simple text message reminder increases adherence to antimalarial treatment (OR: 1.45, p=0.030) and that no patient factors we assessed statistically significantly predicted antimalarial treatment adherence. While adherence to treatment remains difficult to predict, short, simple text message reminders could increase antimalarial treatment adherence. / Global Health and Population

Health systems aim to improve population health. Despite global efforts, millions of children still die every year from vaccine preventable diseases and undernutrition attributed deaths. Moreover, about 293,000 maternal deaths occurred in 2013. The sources of these deaths include various inequalities such as vaccine coverage, nutritional status, and health services utilization. In order to make progress toward mortality reduction, we need to address the sources that are most likely to affect the poorest. One strategy is conditional cash transfers (CCTs), which provides cash payments in exchange for compliance with health-related conditionality. This dissertation explores evidence from two large randomized experiments in Indonesia, PKH (a large-scale household CCT) and Generasi (a large-scale incentivized community block grant). Chapter two investigates whether PKH improves vaccination coverage among poor children. After two years of implementation, the results show that PKH leads to significant increase in vaccination coverage for all vaccine types among children younger than 12 months old. The evidence also suggests that PKH is equity enhancing by reducing the differences in vaccination coverage between children living in more and less supply-ready areas and children of more and less educated mothers. Chapter three investigates the impact of PKH and Generasi on child food intake. The results show that both programs increase child food intake particularly for protein-rich items. They increase milk and fish intake up to 19% and 14% compared to the control group means, respectively. Improving child nutrition outcomes, PKH reduces wasting and severe wasting up to 41% and Generasi reduces the prevalence of severely underweight children up to 47%, compared to the control areas. Chapter four explores how PKH and Generasi help improve determinants of maternal mortality among poor women. Evidence shows different results between the two programs with Generasi produces more positive impact in many aspects of determinants. Both programs, however, are unlikely to have a large effect on maternal mortality due to factors that might significantly reduce the program’s effectiveness. For instance, while the programs improved utilization, they did so at community-based facilities, which are not appropriate for delivery services in the case of obstetric emergency. / Global Health and Population

Maternal and child mortality, particularly during the neonatal period, are among the most challenging global health issues of this era. This burden disproportionately affects the poorest populations, across and within countries. And although many of these deaths would be avertable, improvements in most countries have been slow. This dissertation explores three main research questions: (1) what is the effect of maternal health on infant outcomes?; (2) what survival gains could be attained through improved interventions, across the continuum of care?; and (3) how do health system characteristics affect the potential impact and cost-effectiveness of such interventions? The first paper uses decision modeling to evaluate how increased use of family planning and of improved intrapartum care could reduce maternal deaths in Nepal—as well as the cost-effectiveness of doing so, and of accompanying interventions to achieve these targets. The second paper estimates the potential impact of administering interventions from the Safe Childbirth Checklist at health facilities in India, and how “real world” implementation might see different results due to health system characteristics. Lastly, the third paper examines child survival outcomes following a maternal death in Ethiopia, using a long-term household-level longitudinal dataset. Together, these papers aim to provide new insights on approaches to reducing the high level of mortality among women and children. / Global Health and Population

Contexts are important social determinants of individual health trajectories and population level patterns of health disparities. This dissertation examines three types of contexts—social networks, physical environments, and social positions—using innovative quantitative approaches. Chapter 1 examines the intersectional social positions created by interlocking social identities—race/ethnicity, sex, income, education, and age—and their relationship to health disparities in the obesity epidemic. We outline an innovative analytic approach to evaluating intersectionality using multilevel models. After adjustment for the contributions of the main effects, a large intersectional effect remains. While clear social patterning emerges, interactions are not necessarily  patterned  according  to  ‘multiple  jeopardy’   and  ‘multiplicative  benefit’  as  might  have  been  expected. These findings reveal the complex social patterning of the obesity epidemic, and challenge us to consider possible refinements to intersectionality theory. Chapter 2 evaluates whether U.S. adolescent social networks are segregated by family income level. Network segregation or integration may affect adolescent health trajectories through a variety of pathways, yet the extent to which networks are socioeconomically segregated is poorly understood. We approach the evaluation of income segregation through a novel lens by explicitly considering three scales of analysis within social networks: the network community level, the dyadic level, and a level in between. We find evidence of income segregation at all three levels, though this segregation is neither extreme nor universal. Family income appears to be a socially salient factor in the structure of adolescent social networks. In Chapter 3, three contexts of relevance to the adolescent obesity epidemic—schools, neighborhoods, and social networks—are examined simultaneously. Using a novel combination of social network community detection and cross-classified multilevel modeling, we compare the contributions of each of these contexts to the total variation in adolescent body mass index. After adjusting for relevant covariates, we find that the school-level and neighborhood-level contributions to the variance are modest compared with the network community-level. These results are robust to multiple sensitivity tests. This study highlights the salience of adolescent social networks and indicates that they may be a promising context to address in the design of health promotion programs.