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

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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.

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.

Background: Within the Ontario context, a recent shift towards integrated care has led to primary care reforms that have aimed to achieve the quadruple aim benchmarks. Particular focus has been placed on population health management, a key pillar of the quadruple aim metrics, which recognizes and aims to address the broader social, structural and institutional determinants that impact upon population health outcomes. As a result, this study aims to identify and describe the key characteristics of integrated primary care and social care models, programs, and initiatives in Ontario that aim to address the social determinants of health. It also aims to identify barriers and facilitators in the implementation of these integrated care initiatives to support future implementation efforts. Methods: A qualitative descriptive study design was utilized and was conducted in two phases: 1) document analysis; and 2) 13 in-depth semi-structured interviews with policymakers, managers/ administrators, clinicians and service providers involved in leading integrated primary and social care initiatives in Ontario. Results: Developing and implementing these initiatives had primarily required the introduction of new governance and delivery arrangements. This included the adoption of shared governance structures where equal decision-making authority was often established between health and social partners, and the introduction of a system navigator role who was commonly co-located within primary care. There were minimal insights in relation to the development of new financial arrangements aside from a few joint funding agreements, as almost all initiatives did not share financial resources and few modified staff or provider remuneration. Initiatives experienced barriers including a lack of permanent or long-term funding and technological infrastructure to support patient tracking, follow-up, and information sharing between health and social partners. However, the system navigator position was found to be an essential role in bridging communication gaps between sectors and delivering integrated care for clients. In addition, factors such as pre-existing informal and formal partnerships between primary care and social care organizations, communication and trust between health and social partners, and organizational leadership support for integration were viewed as enablers. Discussion and Conclusions: The lessons learned from participants’ experiences in planning and implementing integrated primary care and social care models are timely and can inform future implementation and scale up as the province continues to move towards integrated care arrangements in efforts to achieve the quadruple aim benchmarks. Specific recommendations for policy and future research are proposed. / Thesis / Master of Public Health (MPH) / Health systems in Canada are positioned to treat symptoms of health issues instead of addressing the root causes of illness and disease, such as lack of housing, access to healthy and nutritious food, and stable employment opportunities. Recently, health system reforms in Ontario have shifted to population health-based approaches to care which recognize and aim to address these non-medical determinants of health outcomes. Primary care, which is often an individual's first point of contact with the health system, may be uniquely positioned to fulfill this mandate due to the capabilities of primary care providers to develop and sustain relationships with patients along the life course. Primary care practitioners may be more aware of patients' underlying social needs that result in adverse health outcomes. This study aimed to identify models of care in Ontario that coordinate care for patients between health and social services such as housing and employment support. It was conducted in two phases. Phase one included a targeted document search which used government policy documents, stakeholder websites, and journal databases to identify these integrated models of care in Ontario. In phase two, 13 stakeholders identified from existing models were interviewed to explore their experiences with models that integrate primary care and social care services and the barriers and facilitators to implementing such models. The study found that most initiatives had made modifications to governance and delivery arrangements to support implementation, including the adoption of shared governance approaches and a system navigator position responsible for coordinating care for clients. The initiatives primarily experienced barriers with funding insecurity, communication and information sharing between health and social partners, and technology. However, communication and trust between health and social partners and organizational leadership support were factors that supported the implementation of initiatives. The findings from this research may support future implementation and scale-up of these coordinated models of care in Ontario.

Background: The childbearing years place socioeconomically disadvantaged African American women at increased risk for poor diet quality, excess weight gain, and cardiometabolic complications. Little is known about the attitudes, beliefs, values, and contextual constraints that shape these high risk mothers’ dietary and physical activity behaviors. Objective: The purpose of this study was to examine health perceptions of diet quality and physical activity among low-income African American women in the early postpartum period, and how these perceptions manifest as barriers or facilitators to health. Additionally, we examined how they may differ by known predictors of health, such as education, age, parity, and BMI. Methods: We conducted semi-structured, individual interviews with 20 women who were between 3-6 months postpartum. Mothers were approached and recruited in the waiting room of a university-affiliated, outpatient prenatal care clinic in Philadelphia, PA. Enrollment in the study was restricted to women who self-identified as African American, were at least 18 years old, and met the federal income guidelines to qualify for assistance (Medicaid, WIC). Individual interviews were audio recorded and transcribed verbatim, with transcripts verified by research staff. Thematic coding and content analysis were performed by 3 researchers using NVivo 10 software to assist with data management. Results: Barriers and facilitators of healthy eating and physical activity after childbirth fell into 4 major themes of mothers’ lives: 1) new structural reality in the postpartum period; 2) physiologic changes after delivery; 3) correct/incorrect perceptions of healthy eating and activity; and 4) social determinants influencing behaviors. Mothers described the transition from pregnancy to the early postpartum period as having a significant negative impact on their eating and activity behaviors due to heightened fatigue, time constraints, and the monotony of daily life with a newborn. We found more than double the number of perceived barriers to engaging in healthy eating than facilitators with regard to fluctuations in food supply, cost of food, and the built environment. Mothers with obesity and less education were more likely to have misperceptions; these misperceptions additionally served as strong barriers to making healthy lifestyle choices. Changes in mothers’ physical symptoms and health status (e.g., developing diabetes, hypertension), on the other hand, facilitated healthy behaviors. Conclusion: This research deepens our understanding of the primary drivers of health behaviors among low-income African American women in the postpartum period. We identified barriers which limit and facilitators which support these mothers’ ability to engage in healthy behaviors, though there were far fewer facilitators of healthy eating and physical activity. Interventions designed to overcome these barriers and capitalize on these facilitators have the potential to improve health outcomes for this population. / Urban Bioethics

The current fragmented delivery of health care has contributed to unplanned hospital readmissions as a leading problem in the United States. Reducing readmissions to urban teaching hospitals is difficult. Many patients living in urban communities face social, economic, language, and transportation barriers to maintaining their health. Both the patient and the medical center experience the burden of readmission and are challenged with addressing SDoH and social injustices at several levels. Medicare views hospital readmissions as a marker representing lower quality of health care delivery to penalize hospitals providing care to the poor. This thesis addresses multiple social and economic factors associated with hospital readmissions, explores the interrelated components of readmissions at the personal and hospital system level, and delves into the interactions of bioethical principles associated with urban living. Hospital readmissions remain a serious issue nationwide and in order to reduce the rates of re-hospitalization the social and economic inequalities contributing to hospital readmissions are significant and must be addressed. / Urban Bioethics

Housing is a key social determinant of health. Further to this, my research will show that it is through housing that all other health determinants are fully actualized. For refugee claimant (RC) families, housing is the most immediate and pressing need upon their arrival in Canada. The objective of this exploratory qualitative study is to examine the housing experiences of refugee claimant (RC) families in the Greater Toronto and Hamilton Area (GTHA) and its impact on the health, well-being, settlement and integration of this population from the perspectives of services providers. Given the increasing inflows of asylum seekers in Canada over the past few years, there is an urgent need to examine their housing experiences and subsequent impacts on health and well-being. Using purposive sampling, seven service providers from five different refugee centres and family shelters in the GTHA were recruited. Individual, semi-structured interviews were conducted, recorded, transcribed, and then analyzed thematically. Findings demonstrate that accessing both emergency and permanent housing upon arrival is particularly difficult for RCs, given that the demand for housing continues to surpass availability in the emergency shelter system and private housing market in the GTHA. In their search for permanent housing, many RCs rely on the private housing market, where discrimination and affordability are common barriers. With an uneven and difficult trajectory towards housing access, many RCs face health issues associated with stress, poverty, and homelessness, which disrupt their settlement and integration in Canada. This research concludes by offering recommendations for policy and program level changes to improve refugee housing access in the GTHA. These recommendations include increasing service provision capacity in shelters, expanding transitional housing options for RCs, increasing investments in subsidized housing, limiting government involvement in REITS and increasing incentives to build more subsidized housing. / Thesis / Master of Social Work (MSW)