Background: While substantial progress has been made globally towards achieving United Nations Millennium Development Goal 4 (MDG 4) on child mortality, the decline is not sufficient to reach the targets set for 2015. The South Asian region, which includes India, was to achieve the MDG 4 target of 39 deaths per 1000 live births by 2015 but was estimated to have reached only 61 by 2011. A part of this under-achievement is due to the gender-differentials in child mortality in South-Asia. The inherent biological advantage of girls, reflected inlower mortality rates as compared to boys globally, is neutralized by their sociocultural disadvantage in India. The availability of technology for prenatal sex determination has promoted sex-linked abortions. Current government efforts include a law that regulates the use of ultrasound and other diagnostic techniquesfor prenatal testing of sex and a conditional cash transfer (CCT) scheme thatinvests a certain amount of funds at the birth of a girl child to attain maturity when the girl turns 18 years of age. This thesis describes the trends in genderspecific mortality during the period 1992-2011 and gender differentials in causes of death among children (paper I), compares gender differentials in child survivalby socio-economic status of the family (paper II), explores the contribution of non-specific effects of diphtheria-tetanus-pertussis (DTP) vaccination to the excess mortality among girls (paper III), and evaluates the impact of CCT schemes of the government and explores community attitudes and practices related to discrimination of girls (paper IV). Methods and Results: This study is set in Ballabgarh Health and DemographicSurveillance System (HDSS) of Haryana State in North India that covered a population of 88,861 across 28 villages in 2011. This study uses the electronic database that houses all individuals enumerated in the HDSS for the period 1992-2011 along with other demographic, socio-economic and health utilization variables. Sex ratio at birth (SRB) was adverse for girls throughout the study period, varying between 821 to 866 girls per 1000 boys. Overall, under-five mortality rates during the period 1992-2011 remained stagnant due to the increasing neonatal mortality rate and decreasing mortality in subsequent age groups. Mortality rates among girls were 1.6 to 2 times higher than boys during the post-neonatal period (1-11 months) as well as in the 1-4 year age group. Girls reported significantly higher mortality rates due to prematurity (relative risk of 1.52; 95% CI = 1.01-2.29); diarrhoea (2.29;1.59-3.29), and malnutrition (3.37; 2.05-5.53) during 2002-2007. The SRB and neonatal mortality rate were consistently adverse for girls in the advantaged groups. In the 1-36 month age group, girl children had higher mortality than boys in all SES groups. The age at vaccination for and coverage with ivabstractBacillus Calmette–Guérin, DTP, polio and measles vaccines did not differ by sex. There was significant excess mortality among girls as compared to boys in the period after immunization with DTP, for both primary (hazard ratio of 1.65; 95% CI 1.17-2.32) and DTPb (2.21; 1.24-3.93) vaccinations until the receipt of the next vaccine. No significant excess mortality among girls was noted after exposure to BCG (1.06; 0.67-1.67) or measles (1.34; 0.85-2.12) vaccine. A community survey showed poor awareness of specific government schemes for girl children. Four-fifths of the community wanted government to help families with girl children financially. In-depth interviews of government programme implementers revealed the themes of “conspiracy of silence” that was being maintained by general population, underplaying of the pervasiveness of the problem coupled with a passive implementation of the programme and “a clash between politicians trying to cash in on the public sentiment of need for subsidies for girl children and a bureaucratic approachof accountability which imposed lot of conditionalities and documentations to access these benefits”. While there has been some improvement in investment in girl children for immunization and education during the period 1992 to 2010, these were also seen among boys of the same houses and daughters in-laws who come from outside the state where such schemes are not in place. Conclusions: In the study area, girl children continue to be disadvantaged a tall periods in their childhood including in utero. In the short run, empowerment of individuals by education and increasing wealth without a concomitant change in culture of son-preference is harmful as it promotes the use of sex determination technology and female feticide to achieve desired family size and composition. There is a need to carefully review the use of health-enhancing technologies including vaccines so that they do not cause more harm to society. Current government efforts to address the gender imbalance are not working, as these are not rooted in a larger social context.

Background: Access to safe and nutritious food is a universal right, which is essential for well-being. Food security exists when “all people at all times have physical and economic access to sufficient, safe, and nutritious foods to meet their dietary needs and food preferences for an active and healthy life”. Despite a call by global leaders to ensure food security and eradicate food insecurity, food insecurity remains a serious public health concern in Canada. While public health nurses are ideally situated to advance this public health priority, they have been conspicuously absent from important research and decision-making tables where work to address these inequities take place. This is the impetus for this study. Purpose: To explore how public health nurses engage in work to address food insecurity. The study uncovers the dynamic interplay of structures, processes, and agency that enable and constrain public health nurses work. An understanding of the sociopolitical contexts of public health helps to strengthen public health nurses’ engagement in food insecurity thereby contributing to health equity in Canada. Methodology: A holistic qualitative case study approach informed by the tenets of critical realism was used to guide this study in Nova Scotia. Primary data sources were 19 individual interviews and a review of 33 documents. Data were transcribed verbatim. Data analysis was guided by Framework Analysis and matrix construction. The trustworthiness of data was ensured through Lincoln and Guba’s criteria for qualitative studies. Findings: Four major themes include: 1) Framing Food (In)Security, 2) The Role of Public Health Nurses; 3) Navigating the Terrain of Food Insecurity; and 4) Resources to Advance Food Insecurity Work in Public Health Nursing Practice. Discussion and Implications: The dynamic interplay among leaders with differing ideologies and organizational culture has an impact on health equity agendas and subsequently on public health nursing engagement in work to address food insecurity. Capitalizing on a “clash of cultures” is associated with effective community food security outcomes. We must continue to illuminate the tensions among public health nurses and other stakeholders as well as address issues of power relations both within and external to the public health system. Conclusion: Public health may benefit greatly from building capacity of public health nurses’ to engage in both upstream and downstream food insecurity work.

Thesis advisor: Karen S. Lyons / Background: Health equity is a complex phenomenon that embodies both the social determinants of health (structural and intermediary) and external factors, such as the health system. As a well-researched phenomenon, it is known that certain populations are more vulnerable than others to experiencing health inequities; specifically, those of low socioeconomic status, racial/ethnic minorities, older adults, and rural residents. However, gaps in knowledge exist in understanding why certain populations remain at higher risk of experiencing health inequities during a time of improved health insurance coverage and technological advances in health care. The purpose of this manuscript dissertation was to identify and address influential factors that serve as road blocks in achieving health equity, guided by the World Health Organization’s Conceptual Framework on the Social Determinants of Health. Methods: First, an integrative review was performed in order to determine current scope of practice restrictions and patient outcomes across the continuum of licensure for advanced practice registered nurses (APRNs), especially certified registered nurse anesthetists (CRNAs). Next, a secondary analysis of large national data set was done to identify the social determinants and risk factors for poor health effect among a national sample at high risk for poor health. And finally, a survey methodology study was completed to determine the roles that satisfaction with health care and physical function have on the perceived health status for rural, older adults in Massachusetts, and to explore the willingness of rural, older adults to use non-physicians for their health care needs. Results: The integrative review revealed the inconsistent use of APRNs at their full licensure. Nationally, APRNs had better geographic distribution in rural areas compared to physicians; yet many states continue to restrict APRN SOP. Second, across the U.S., older adults at the highest risk for poor health live in rural areas, are of lower socioeconomic status, and identify as racial/ethnic minorities. Third, both satisfaction with health care and the physical function of a small sample of older rural adults were significantly associated with physical health. And finally this body of work found that among a small sample of older rural adults, most were willing to use APRNs to meet their health care needs. Conclusions: With the ultimate goal of health equity it is necessary to empower those experiencing health inequities to be both aware of the problems as well as informed enough to push for change. Understanding why the experience of health differs among some individuals more than others helps to target change. The fusion of findings from this body of research has revealed a gap in health care that can be easily filled with simple policy change. APRNs at full SOP can generate means for high quality preventative, cost-saving care, and can better access the most vulnerable populations at a lower cost than physician counterparts. / Thesis (PhD) — Boston College, 2020. / Submitted to: Boston College. Connell School of Nursing. / Discipline: Nursing.

Ongoing research indicates that the burden of infection and mortality from the coronavirus disease 2019 (COVID-19) has been disproportionately borne by Latinx populations in the United States (U.S.). While Latinx people account for 18.4% of the U.S. population, they make up 23.1% of total COVID-19 cases and almost 38% of all COVID-19-related-deaths in the U.S. Latinx people face systemic socioeconomic and political challenges that adversely impact their risk of exposure to and recovery from COVID-19. This investigation will discuss the health disparities experienced by the U.S. Latinx population that have been exacerbated by the COVID-19 pandemic, with a particular focus on the social determinants of health (SDOH) and the unmet social needs for this population.

No description available.

This dissertation consists of three essays that study the role of information acquisition and processing in health decision-making. Each chapter underscores the ways in which new information shapes the choices of health providers and consumers. Understanding these responses sheds light on critical health policy problems, including the potential overuse of low-value health services, gaps between medical evidence and practice, and inequitable access to high-value health services. The first essay studies the role of a consumer’s family network in the formation of their risk perceptions. I assess whether people correctly interpret new risk information communicated through household health events and analyze how these responses impact household welfare. Individuals respond to new diagnoses in ways most consistent with individual reevaluations of health risk rather than other possible explanations. To assess welfare implications, I estimate a structural model of health choices in which individuals learn about risk after health events reveal information. I find that consumers over-respond to recent, salient health events by over-weighting their risks ex-post. This leads to individual and social welfare losses, and suggests that aiding consumers in interpreting health risk information should be an important aim of health literacy policies. The second essay explores how health providers respond to information about innovations in mental health treatments, paying particular attention to the heterogeneous adoption costs of different practices. I compare the impact of continuing education on takeup across innovations that incur learning costs (psychotherapy) and those that do not (psychopharmacology). I use a novel extension of an estimator proposed by Calvi et al. (2021) to estimate a dynamic treatment effect in the presence of classification error. Therapists respond more to education when learning costs are negligent, being about three percentage points more likely to write new prescriptions following a conference. The third essay assesses the tradeoff between adopting novel medical technologies and achieving health equity. I study the adoption of transcatheter valve replacement surgeries in Medicare patients; these surgeries disrupted the supply of medical interventions from cardiothoracic surgeons to interventional cardiologists. This transition led providers to adjust practice styles along two margins: medium-risk patients became more likely to receive surgery, and low-risk patients received fewer medical interventions overall. I incorporate these findings into a model of physician decision-making, showing that both the expansion of high-intensity intervention and the crowd-out of low-intensity treatment can be rationalized by the presence of technological spillovers. The model further highlights that crowd-out may be inequitably distributed across the patient population when treatment appropriateness is not directly observed. I validate these predictions in my setting, showing that technology adoption resulted in disproportionately high barriers to care for low-income patients.

Background: People who use illegal drugs are disproportionately affected by HIV and hepatitis C, stigmatization and social exclusion. Health inequities are worsened by drug policy of criminalization, which thwarts health promotion efforts and hinders access to services. To address these inequities, people who use drugs are increasingly included in decisions that affect them by sitting on policy, service delivery and research committees. This study addressed a gap in understanding how power inequities are transformed in committees where people who use drugs are at the table. Methods: In partnership with the Drug Users Advocacy League and the Society of Living Illicit Drugs Users, this participatory critical emancipatory inquiry explored power relations in four committees in Ontario and BC. Data were collected in 2013 through meeting observations, interviews, demographics surveys and document reviews. Data analysis was guided by theoretical frameworks grounded in critical theory and transformative learning theory. Results: Findings confirmed striking socioeconomic inequities between people who use drugs and others at the table. Inconsistent measures were taken by committees to alleviate barriers to inclusion. Despite openness to inclusion, committee members tended to underestimate people who use drugs. The presence of local organizations of people who use drugs ensured a more democratic selection of their representatives to sit on committees. Once at the table, creating a safe space entailed building trust, authentic relationships, relational and reflective dialogue, and skilled facilitation. Democratic practices of negotiated relationships and consensus-based decision-making enhanced meaningful inclusion. A structural environment in which drug policy criminalizes people who use illegal drugs hindered capacity to transform power inequities by feeding stigma, which worsens health and social inequities. Committees were committed to inclusion of people who use drugs though capacity to do so varied due to budgetary and human resources constraints. Study limitations, practice implications and future research directions are offered. / Graduate / 0700 / 0680 / lynnebel@uvic.ca

Doctor of Philosophy / Curriculum and Instruction Programs / Kay A. Taylor / This qualitative multiple participant case study examined Mexican American women‘s experiences at the intersection of race and gender in public high school. Mexican American women‘s experiences cannot be isolated and described independently in terms of either race or gender. The intersection of race and gender for Mexican American women has not been investigated fully. The few studies that include Mexican American females focus on dropouts and emphasize at risk factors such as gender, race, socioeconomic status, and language. Consequently, the gaps in the empirical literature are caused in part by the shortage of research on Mexican American women and the propensity toward examining Mexican American women from the deficit perspective. Critical Race Theory was the framework for the analysis and the interpretation in this study. The significant findings of this research support CRT, in that racism is prevalent and ordinary in the daily the lives of Mexican American females. The findings of the study included: First, racism is endemic and pervasive in public education. Second, colorblindness is the notion from which many educational entities operate. Third, the participants perceive social justice as the solution to ending all forms of racism and oppression. Finally, navigating the system is necessary to learn to be academically successful. The results contribute to the limited research on Mexican American women at the intersection of race and gender and the racism experienced in public high school to the overall CRT research in education, and in particular, to LatCrit research.

Several studies and local accounts have documented elevated levels of air pollution and toxics on or near US public schools. The low cost of brownfield lands and lands near major sources of air pollution have made siting schools on these areas enticing. Histories of using toxic chemicals in building materials explain their presence in school environments. The impacts to academic achievement associated with air pollution and exposure to lead as well as the health implications of regular, high exposure to air pollution and toxic chemicals necessitate policy changes. In this paper, the extent of these health and achievement impacts will be analyzed along with the current work being done by government and nongovernmental organizations to mitigate pollution in public schools. This study will also offer policy recommendations to address these issues and advance environmental equity in public schools.

This thesis is a subset of a larger “parent” project under the direction of my supervisor, Dr. Cecilia Benoit. The purpose of the larger project is to seize an unique research opportunity that has emerged with the development and implementation of the HerWay Home (HWH) program, a community-based initiative for pregnant and early parenting women who face substance use and other challenges in the Greater Victoria Area. My research has capitalized on the pre-implementation phase of the HWH program between 2010-2011. Thirteen in-person semi-structured interviews were conducted with women who would likely be clients for the HWH program, based on their pregnancy experiences, substance use concerns and other life challenges. The goal of this research has been to explore these women’s pregnancy and postpartum narratives and investigate what, in their view, should be crucial components of the HWH intervention in the short and longterm. My findings indicate that, consistent with the literature on pregnant and early parenting women facing substance use and other life challenges, a range of complex, intertwined disadvantages exist in their lives that translate into multiple barriers to accessing continuous health and social care during their pregnancy and after the birth of their child. An adapted model of the Health Lifestyle Theory is used to frame the analysis of the data collected from this research. The results from this research support the argument that the life choices of the participants are constrained by structural life chances and socially determined inequities that systematically disadvantage and disempower them. The findings also reveal an implicit sense of agency in the women’s narratives, as well as key specifics about what they view as the main gaps in care and their desired program services. The findings will be relayed to HWH organizers, and used to inform the development and implementation of the program’s services. / Graduate