1,721,105 research outputs found
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Impact of Gentrification on Adult Mental Health
Get PDFGentrification is a dynamic process that changes the physical, economic, social, and cultural characteristics of historically underserved neighborhoods. This neighborhood transition process can improve the material and environmental circumstances of some residents and bring forth harmful consequences such as heightened financial stress and residential displacement for other community members. The subsequent impact of gentrification on population health is understudied, and little is known about how gentrification influences the mental wellness of residents.This dissertation advances the small but growing literature on the relationship between gentrification and adult mental health. Using multiple data sources, we identified Southern California neighborhoods that gentrified between 2010 and 2015 and investigated the impact of living in a gentrified neighborhood on mental health distress. Econometric techniques such as instrumental variables estimation and propensity score analyses were applied to reduce bias arising from residential selection and reverse causality.The first study compared three quantitative approaches for identifying gentrified neighborhoods and demonstrated that each approach generated a different set of results. Findings highlighted the importance of the strategy used for identifying gentrified neighborhoods, especially when assessing gentrification’s effects on health outcomes. The second study used five years of pooled data from the California Health Interview Survey to examine the causal relationship between gentrification and adult mental health. Relative to living in a low-income and not gentrified neighborhood, living in a gentrified neighborhood was associated with increased likelihood of serious psychological distress among longtime residents, renters, and people with low incomes. In the third study, we evaluated reasons for moving between residents who moved within gentrified and not gentrified neighborhoods and found evidence that people in gentrified neighborhoods were more likely to experience within-neighborhood displacement. Residents who experienced within-neighborhood displacement had greater likelihoods of having serious psychological distress.Taken together, findings suggest that gentrification imposes a mental health cost on longtime residents and the most financially vulnerable residents, which has important implications for population health. By elevating levels of mental health distress of population groups who are already disproportionately exposed to stressors, gentrification can exacerbate mental health inequities
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The Effects of Migration on Healthcare Decision-Making, Access, and Expenditures
Get PDFFilling gaps in our understanding of how the effects of migration extend through familiesand impact healthcare decisions, access, and expenditures, this dissertation examined how
migration is associated with health services in contexts that send a high number of migrants and a
major migrant destination. The first study (Chapter 2) evaluated the impact of male spousal
migration on the healthcare use and access for left-behind women and children using a quantitative
cross-country comparison of four countries in South and Southeast Asia. Results showed that male
spousal migration was positively associated with barriers to healthcare use across Bangladesh,
Indonesia, Nepal, and the Philippines through a reduction in both economic and social (gender related)
barriers to care - adding new evidence to the literature showing that migration can
contribute to the health and well-being of those left-behind. The second study (Chapter 3)
quantitatively measured receipt of international migrant remittances and healthcare expenditures
to show how this important source of income for families and for the economy of the Philippines
related to spending on healthcare. We found that remittance receiving households spent
significantly more on healthcare than non-remittance receiving households in both absolute and
proportional measures. Additionally, remittances did not provide financial protection against
catastrophic health expenditures (CHE) and a significantly higher proportion of remittance receiving
households experienced CHE compared to non-remittance households. The third study
(Chapter 4), based in the United States, examined the role of family structures and immigration
factors in health services decision-making. Through quantitative analyses of the interaction
between migration related characteristics and family structure, this study found that immigrants
had a higher probability of seeking healthcare when they needed it compared to their US born
counterparts who delayed or forewent needed care at higher rates, but that family structure affected
immigrant families differently and this was especially true for more newly arrived immigrants and
those on temporary visas or who were undocumented. The three papers of this dissertation expand
our understanding of the relationship between the migration and health systems and demonstrate
that relational frameworks can help capture some of the nuance of the complicated migration and
health relationship
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Social stratification and the healthcare safety net
Get PDFSocial inequalities can produce disparities in healthcare access and quality. This dissertation explores relationships between two social stratification processes- community residential segregation and social capital- on the supply of U.S. urban safety net providers. The first paper, "Community residential segregation and the local supply of Federally Qualified Health Centers," used data from the Area Resource File and the U.S. Census to examine growth in FQHCs in urban counties from 2000 to 2007. Residential segregation by poverty and race/ethnicity were measured using the dissimilarity index. Logistic and negative binomial regression models were used for dichotomous and count outcomes, respectively. Residential segregation measures were associated with both county FQHC supply at baseline and the addition of new FQHCs over time. Residential segregation may produce geographic segregation of health services, such that FQHCs may be required to fill the gaps arising from provider maldistribution. The second paper, "Residential segregation and the survival of U.S. urban public hospitals," used data from the American Hospital Association Annual Survey from 1987 to 2007. Cox proportional hazards models were used to estimate competing risks of hospital closure versus privatization. Poverty rates, intermediate poverty segregation, a low proportion of black residents, and low black residential segregation were associated with closure. Poverty associations suggest that areas with a high need for safety net services may be at risk to lose them, but segregated black communities may successfully advocate for maintenance of public hospitals. In contrast, Hispanic residential segregation was associated with privatization. Areas with segregated Hispanic communities may be less inclined to support public provision of services and have reduced opposition to privatization.The third paper analyzed the same sample of urban public hospitals in relation to measures of community social capital. Voting rates were associated with closure, whereas bridging social capital among elites was associated with privatization. The findings suggest that social capital among privileged groups bears more influence on public hospital outcomes than vertical connections between the disadvantaged and those in power.Taken together, the three papers suggest that social determinants may dictate both the need and societal response for the safety net
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Personalized Medicine and the Role of Patient Preferences, Risk Perception and Information Exchange
Get PDFThere are great expectations in the potential of personalized medicine to improve health outcomes by tailoring treatments to the needs of individual patients. Still, uncertainty remains on the values of these new technologies in the clinical setting. In particular, little is known about how physicians and patients use such information for decision-making, and about the influence of patient preferences, attitudes and information exchange in this process.This dissertation expands on existing frameworks modeling health behaviors and treatment decisions to conceptualize pathways intervening on treatment decisions. The model studied here is the decision of using chemotherapy in early-stage breast cancer treatment based on a genomic test. This test predicts the risk of tumor recurrence, and helps identify patients at low risk who may avoid potentially unnecessary chemotherapy. The three studies used data from a retrospective patient survey examining patient preferences, risk perception, and information exchange at the time of the treatment decision. Survey reports were linked to claims data and laboratory results for a diverse sample of privately insured women who had all received the genomic test. The methodology includes multivariate logistic regression models, a test for mediation using the Karlson-Holm-Breen method for nested logistic models, and a test for moderation using the inclusion of an interaction term. Limitations of the studies include a retrospective design, lack of information on the physician perspective, and omitted clinical factors that may confound the results. Results support that 1) risk perception mediates the effect of patient preferences on the treatment decision and is a suppressor of this effect, 2) information exchange moderates the effect of risk perception on the treatment decision, and 3) those relationships explain in part variations in treatment decisions observed in this sample. Specifically, we found variations in decision by race/ethnicity consistent with significant variations in risk perception and information exchange by race/ethnicity. The dissertation provides new knowledge on patient factors influencing the treatment decision. Importantly, those factors are mutable and suitable targets for interventions. Those factors may also be relevant to address disparities in breast cancer care, as they are strongly associated with race and ethnicity
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Understanding the Contributions and Relationships of Health Care Systems to Population Health, Value, and Equity
Get PDFOver the past decade, reforms to the U.S. health care system have sought to reduce spending on health care expenditures, while improving quality of care and population health. At the same time, increased attention to the social determinants of health has fostered a deeper discussion on the social responsibility of health care systems in furthering health equity at a population and community level. As the U.S. health care system attempts to meet the societal demands of delivering value and striving towards health equity, important questions arise—to what extent is health equity shaped by local government decisions on public budgets, hospital administrator decisions on community benefits spending, or individual decisions between clinicians and patients around low-value care? This dissertation provides a novel contribution on these questions with three studies that explicitly test hypotheses on these related issues.
The first study used claims data from Medicare, the nation’s largest health plan, and government finance data to examine the relationship between local government spending on social programs and the use of primary care, emergency department, and inpatient services among low-income older adults. We found that higher spending on welfare, public transit, housing, and other social services was associated with greater primary care use. We also found that higher spending on housing and public transit were associated with lower preventable hospitalizations, specifically from acute conditions. The second study used data from non-profit hospital tax returns and Medicare claims to examine the relationship between hospital community benefits spending and the use of primary care and emergency department (ED) services among older adults living in the same zip code as a non-profit hospital. This study did not find evidence that variation in community benefit spending over time was associated with differences in primary care or ED visits. The third study used claims data from a single health care system to examine variation in the provision of low-value services by race and ethnicity. We observed that Asian, Black, and Latino older adults were less likely to receive low-value care in general, but were more likely to receive a low-value prescription.Taken together, the findings from this dissertation clarify the relationships between health care organizations and their local communities. Moreover, this work highlights important systems and policy-level opportunities for improving equity, population health, and health care value
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Self-reported Legal Status in the California Health Interview Survey: An evaluation of data quality and application towards adolescent mental health
Get PDFLegal status is an important social determinant of health for immigrants and children of immigrant parents, which is typically not measured in public health surveys. The sensitivity of legal status and presumed response behavior to relevant questions are primary reasons why this topic goes unmeasured. Changes in immigration enforcement likely impact the sensitivity of the topic and may compromise data quality, however, this is also likely when legal status matters most for health outcomes. This dissertation evaluates the response behavior to questions of citizenship and immigration status in the California Health Interview Survey and applies these data to identify mental health risks for Latino adolescents with an unauthorized parent.The first study, When we ask, do they answer? Item-nonresponse to questions of citizenship and immigration status in the California Health Interview Survey, examined foreign born survey participants who did not answer questions of citizenship and immigration statusbetween 2001 and 2015. Nonresponse was low overall, however, increased over time and was largely attributable to respondents who were born in Mexico. The second study, When they answer, should we listen? Examining the quality of self-reported citizenship and immigration status, evaluated potential misreporting of legal status among Mexican-born participants between 2003 and 2015. This study utilized indirect estimation strategies which have been developed to produce profiles of the unauthorized population from surveys which do not ask legal status. Nearly a quarter of all Mexican-born participants reported that they were a non-citizen without agreen card, and these participants were demographically similar to external profiles of the unauthorized population. Predicted probabilities of unauthorized status produced by the indirect estimation procedure indicated that the threat of extensive misreporting was low and consistent over time. These results, paired with the findings of low nonresponse, indicate that participants were willing to answer questions of citizenship and immigration status and that these data are fit for use. The third paper, Severe Psychological Distress Among Latino Adolescents with an Unauthorized Parent examined adolescent mental health using data from 2007 to 2016 disaggregated by parental nativity and legal status. Multivariate logistic models indicated that Latino adolescents with an immigrant mother were less likely to report severe psychological distress and that children with an unauthorized father were more likely to report severe psychological distress. These findings reveal important heterogeneity among children in immigrant households and demonstrates the value of measuring legal status in a population survey. It is critical that data used to monitor public health trends more fully incorporate immigrants and their children by measuring domains which are relevant to their health and wellbeing. In addition to measuring what needs to be measured, researchers should continue to critically evaluate quality and put data which are fit to use to meaningful and timely use
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Identifying Opportunities to Improve the Health of At-Risk Youth through the Education and Juvenile Justice Systems
Get PDFThis dissertation applied a social determinants of health perspective to examine the relationships between health, academic, and juvenile justice-related structures, interventions, and outcomes among at-risk youths in the United States. The first study, Relationships between Student, Staff, and Administrative Measures of School Climate and Student Health and Academic Outcomes, examined student, staff, and administrative measures of school climate to understand the extent to which they were related to each other and student outcomes. Multilevel regression analyses showed student, staff, and administrative measures of school climate to be weakly correlated. Strong associations were found between student outcomes and student-reports of engagement and safety, while staff-reports and administrative measures of school climate showed limited associations with students’ outcomes.The second study, Understanding Racial and Ethnic Disparities in Arrest: The Role of Individual, Home, School, and Community Characteristics, identified characteristics of young adults who were more likely to become involved in justice-based punitive systems. Multilevel regression analyses showed significantly higher likelihood of having ever been arrested among Blacks, when compared to Whites, even after controlling for a range of delinquent behaviors. Notably, racial/ethnic disparities in arrest were no longer present after accounting for racial composition of the neighborhood. The third study, The Impact of Two Los Angeles County Teen Courts on Youth Recidivism: Comparing Two Informal Probation Programs, assessed a juvenile justice system diversion program being implemented in Los Angeles County. Logistic and survival models showed Teen Court participants to have lower rates of recidivism than comparison group participants, after controlling for potential confounders.This dissertation provides a research-grounded approach for how public health might apply its population health frame to support a more holistic vision for health and wellness within the education and juvenile justice systems. Moving forward, research and practice efforts to address the social determinants of health will require an expanded definition of what it means for youths to be “healthy,” greater willingness among researchers and practitioners to focus on multi-component/multi-system interventions, more meaningful communications and alignment between systems, and a more explicit focus on identifying factors that can facilitate successful policy and program implementation
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Understanding the Disparities in Cervical Cancer Screening for Economically Disadvantaged Women
Get PDFBackground: Cancer is the second leading cause of death in the United States, accounting for 22% of all deaths among women. Despite the importance of the Pap test in preventing and detecting cervical cancer, screening rates among poor women remain low. The pathways linking poverty with lower Pap test use remain unclear. The screening disparity for this low-cost test suggests that poor women may face other transaction costs, opportunity costs and barriers in accessing Pap tests that are not faced by women living above poverty. Data/Methods: The data set merged the 2005 California Health Interview Survey, 2000 Census, and safety net clinic data. I examine elements of the patient-provider interaction (racial/ethnic discrimination) and healthcare system (distance to the nearest safety net clinic) as possible mediators between individual-level poverty and Pap tests. I then examine the role of individual-level poverty in moderating the association between discrimination and Pap test use and safety net distance and Pap test use. I also examine whether the neighborhood-level poverty moderates the association between individual-level poverty and Pap tests, discrimination and Pap tests, and distance and Pap tests. The sample included women, 18-64, with a physician visit in the previous 5 years and no history of cervical cancer. Mediation was tested using Generalized Estimating Equations (GEE) and a weighted product-of-coefficients test. Moderation was tested using GEE and including interaction terms. Results: Poor women were significantly less likely to report a timely Pap test, had significantly higher odds of reporting discrimination, and were more likely to reside closer to a safety net clinic. Discrimination did not predict Pap tests and was not a mediator between individual-level poverty and Pap tests. Safety net distance predicted Pap tests and was a mediator between individual-level poverty and Pap tests. Neither individual-level poverty nor neighborhood-level poverty modified the proposed relationships with Pap test use. Conclusion: Racial/ethnic discrimination did not explain disparities in Pap tests. Proximity to a safety net clinic was shown to be protective against disparities and may play a role in addressing disparities in screening. Individual-level poverty and neighborhood-level poverty did not influence the role of proposed mediators in predicting Pap tests
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The impact of poverty and social protection on tuberculosis
Get PDFTuberculosis (TB) infects over 9 million people annually and is responsible for approximately 1.5 million deaths each year. Despite high treatment success rates, declines in incidence have averaged only 1.5% per year over the past decade. The newly adopted End TB Strategy sets a progressive agenda that moves beyond the medical sphere and includes a focus on upstream social determinants aimed at prevention. The strategy specifically calls for stronger poverty alleviation and social protection programs and policies. This dissertation sets out to support the need for social protection programs to combat TB, as well as attempting to answer the questions of who should be the recipients of such programs and in what form should they take.Paper one uses country-level data to show that spending on social protection is associated with decreased TB prevalence, incidence, and mortality. This work has a global purview and predicts a drop of 18 per 100,000 persons in TB prevalence rate from 1% increase in social protection spending. This is true even after adjusting for factors associated with TB rates such as level of economic development, the strength of the health system, and HIV burden.The second paper examines the relationship between household poverty and TB disease. Using household asset and characteristic data, this work creates household socioeconomic quintiles and attempts to show the relationship between this measure and individual active TB disease. The work utilized eight national TB prevalence surveys; large household surveys with a rigorous diagnostic TB algorithm. Although this approach found lower risk of TB disease for individuals in the poorest quintiles in four countries, a dose-response relationship was not observed. This paper also created an absolute wealth estimate, a US dollar-based measure of household wealth, which allowed for comparability across settings and also pooled country models. This measure of household socio-economic level did not have a clear association with individual TB risk. This work suggests novel ways of assessing the relationship between poverty and TB at the individual level that have the potential to be more efficient and to further the field of the social determinants of TB. The final paper of this dissertation focuses on a TB patient cost survey in Myanmar. This nationally representative survey includes 966 TB patients across the country and gathers information about their income and costs while seeking care. This survey is the first step in measuring the percentage of TB-affected households experiencing catastrophic costs due to the disease, defined as costs exceeding 20% of annual household income. This metric is one of the high level indicators in the End TB Strategy and will be measured by the World Health Organization and its partners in the majority of high burden countries in the coming years. The Myanmar survey found 65% of households experiencing catastrophic costs due to TB, with major cost drivers being patient’s time and additional food and/or nutritional supplements required because of the disease. Together these three papers support the need for social protection, alongside appropriate and timely medical care, in order to reach the ambitious targets set forth by the End TB Strategy
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Community-Based Participatory Research for Building Community-Based Organizational Capacity: A Programmatic Assessment
Get PDFCommunity-based participatory research (CBPR) is a paradigm for developing partnerships to address health disparities, however few studies have examined the role of CBPR principles in contributing to organizational capacity and leadership development, especially among community-based organizations (CBOs) in a partnership. A keener understanding of influencing factors for organizational capacity and development helps an organization to strengthen its capacity and sustain services. The Orange County Asian and Pacific Islander Community Alliance, a nonprofit organization based in Orange County, CA, has been engaged in CBPR partnerships for over 15 years. While they have engaged in the CBPR paradigm, they have not had the opportunity to evaluate its impacts on their partnerships and organization. The study examined PATH for Women, a breast and cervical cancer disparities collaborative framed in CBPR principles. This was a qualitative cross-sectional study focused on PATH for Women. The study explored CBPR principles, infrastructure, relationships and leadership and their associations to organizational capacity and leadership development. Key informant semi-structured interviews were conducted with PATH for Women partner organizations. The study revealed that the nine core CBPR principles were present and promoted in the partnership contributing to individual and organizational capacity building and leadership development. In particular the principles of building on strengths and resources, facilitating collaboration, and recognizing the community as a unit of identity were highlighted as important facilitators for organizational development. The study also revealed positive correlations between facilitating collaboration, integrating knowledge and action for social change, and the empowering process to address social inequalities with organizational visibility. In addition, the CBPR principles of an empowering process for social inequalities, integrating action for social change and facilitating collaboration were also positively correlated with leadership development. Increased skills, leadership development, increased and additional funding support, increased and leveraged relationships and networks, organizational recognition and visibility, and the ability to sustain programs and meet mission were described. The study identified that the PATH for Women partnership, framed in CBPR principles, provided growth and development for the participating organizations. Recommendations for consideration in implementing CBPR principles and promoting organizational capacity and development were also provided for consideration by community-based organizations
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