The first chapter of this dissertation examines the effect of insurance mandates on infant immunization rates. Immunizations are one of the greatest public health achievements of the 20th century. While US infant immunization rates have been increasing in the last 20 years, the cost of fully immunizing a child with all recommended vaccines has almost tripled. This is partly due to new additions in the list of recommended vaccines, but also due to the use of new, safer, but more expensive technologies in vaccine production and distribution. In recent years, many states have mandated that recommended childhood vaccines be covered by private health insurance companies. Currently, there are 33 states with such a mandate. In this paper, I examine whether the introduction of mandates on private insurers affected immunization rates. Using state and time variation, I find that mandates increased the immunization rate for three vaccines — the diphtheria-tetanus-pertussis, polio and measles vaccines — by about 1.8 percentage points. I also find evidence that the mandates shifted some vaccinations from public to private sources. The second chapter of this dissertation studies the issue of whether concerns about autism affected vaccine takeup. In the wake of strong claims that there existed a link between autism and the measles-mumps-rubella MMR) vaccine, which was refuted by later research, I examine whether fewer parents immunized their children. This task becomes difficult as the timing of the controversy in the US coincided with expansions in medical access for children and other programs that affect childhood immunizations, as well as another controversy regarding mercury containing preservatives in childhood vaccines. Using a time trends analysis and a few differencing strategies that compare the take up of MMR to other vaccines, I find that the MMR-autism controversy led to a decline of about 2 percentage points in the take up of MMR and a negative spillover on other vaccines. I find some evidence that more educated mothers responded more to the controversy, which is consistent with more educated individuals absorbing health information more quickly. However, this disparity persisted even after new research and information about the lack of such link became widespread in the media. The third chapter of this dissertation analyzes the effectiveness of a peer counseling breastfeeding support program for low income women in Michigan who participate in the Women, Infants and Children WIC) program. Because there was excess demand for services provided by the program, many women who requested to participate were not subsequently contacted by the peer counselors. We compare the breastfeeding outcomes between the two groups and identify the effectiveness of the program based on the differences between the women who requested to participate and were enrolled relative to those who requested participation, but were not contacted due to lack of capacity. Our analysis uses survey data from the program as well as administrative data from Vital Records, Medicaid, and WIC from the state of Michigan. After providing evidence that our key assumption in identifying the effect if program is consistent with the data, we estimate that the program caused the breastfeeding initiation to increase by about 27 percentage points and the mean duration of breastfeeding to increase by more than 3 weeks. The support program we evaluated was very effective at increasing breastfeeding among low income women who participate in WIC, a population that nationally breastfeeds at rates well below the national average and below what is recommended by public health professionals.
Posts Tagged ‘HealthSciences’:
Essays in health economics
This dissertation consists of three essays on empirical issues in health economics. The first essay considers the selection-efficiency trade-off in competitive health insurance markets, where insurers face incentives to exploit unpriced heterogeneity by selecting low-risk individuals “cream-skimming”). The German Social Health Insurance does not adjust payments to sickness funds for geographic differences in costs, thereby generating incentives for funds to select against relatively more expensive areas, such as West Germany. In an audit study I present funds with fictive applicants from different locations and infer recruitment efforts by measuring callback for letters, emails and phone calls. The findings suggest that sickness funds are less responsive to requests from West German applicants, a result consistent with cream-skimming in this market. The second essay evaluates the impacts of two school nutrition policies, Californias state-wide beverage policy and Los Angeles Unified School Districts food-and-beverage standards of 2004, on adolescent dietary behavior and obesity. Two large datasets on physical measures and food intake facilitate the construction of reliable control groups, including a “synthetic” control unit consisting of unaffected districts that are reweighted to closely resemble Los Angeles in the pre-intervention period. Both policies are found ineffective at reducing the prevalence of overweight or obesity. However, the district policy decreased consumption of its key targets, soda and fried foods. The third essay examines the reliability of self-reported data in empirical analysis. Self-reported data is prone to systematic measurement error that may be constant or change in response to external events. The essay illustrates these issues with data on self-reported and measured overweight/obesity status, and BMI, height and weight z-scores of public school students in California from 2004 to 2006. In the cross-section, the prevalence of overweight/obesity is significantly lower in self-reported data relative to measured data. A district nutrition policy changed the reporting bias differentially in the treatment and control districts, so that program evaluations could find spurious positive or mill impacts of the intervention.
An examination of college freshmen’s food choices
The prevalence of obesity and overweight has heightened over the last 40 years. Over two thirds of the US adult population is overweight or obese. Further, 18% of adolescents, ages 12 to 19, are obese, which is an increase of over 13% since the late 1970s. Food environment and peer influence have been emerging areas of study and are thought to be catalysts to unhealthy eating choices. College students present a unique opportunity to look at the impact of a changing food environment, including changes in peer groups. This study is concerned with how students peers impact their food consumption and ultimately weight. College freshmen were recruited during their first month on campus at Kansas State University. The students participated in a year-long, three-part study to track their eating habits, weight and height. The students parents were also asked to participate by filling out a survey on eating habits. The students also asked one friend they ate with at least once a week to fill out a food record with them. The collected information was transformed into daily average calories for each of six food groups and for macronutrients. A peer ratio was created from the parents and friends calorie intakes to determine the similarity in consumption by each food group or macronutrient. A system of equations was specified and estimated for both food groups and macronutrients. For the food group model, beverages were the only food group with a statistically significant peer ratio term. The coefficient on the ratio was positive, indicating that students would consume more calories from beverages, as their college friends consumed more calories from beverages relative to the students parents at home. In the macronutrient model, protein had a statistically significant and positive peer ratio. An examination of the impacts of predicted calories consumed from food groups, along with other individual characteristics, on students BMI in the spring term, indicated that increasing snack consumption led to an increase in BMI while increasing bread consumption caused a decrease. Eating more meals at the university dining center also increased BMI. An analysis for the predicted macronutrient values revealed a similar relationship with eating more meals at the dining center, but the predicted macronutrients did not have statistically significant impacts on BMI.
Essays in labor and health economics: Economic effect of obesity on wages and its impact over time
This dissertation presents estimates of the effect of weight on wages in the U.S. Several questions are of interest. Do heavier people earn lower wages? Are the effects of weight on wages evenly distributed over the whole range of wages or are the effects concentrated in the lower, middle or upper part of the wage distribution? Do the effects of weight on wages change over time? This dissertation uses two large data sets, the National Longitudinal Surveys of Youth, NLSY79 and NLSY97, and several regression strategies in an attempt to provide answers to these questions. Differences across gender and race are explored. The key finding is that weight lowers wages for white females. Negative correlations between weight and wages observed for other gender-ethnic groups appear to be due to unobserved heterogeneity. The results also suggested that the weight penalty, if it exists, increases with wages for almost all sub-groups except Black males. Finally, the negative effect of weight appears to have decreased when we compare the weight penalty between two cohorts, NLSY79 cohort and NLSY97 cohort, aged between 19 and 29. More research is needed so that we can gain insights about the causes of these penalties. It also provides incentives for policy makers to come up with policies that will help people attain and maintain a healthy weigh.
Experiences of postpartum psychosis from the perspectives of women with the diagnosis and psychiatric nurses
Postpartum psychosis occurs in approximately two out of every 1000 women after childbirth. Although rare, it is a very serious illness with a potential for suicide and infanticide. The suffering associated with this illness and the effects on the entire family system are severe. Nurses need a comprehensive understanding of this disorder, how women present and experience the illness and the nursing care required to keep women and their newborns safe. They also need to promote early detection to facilitate prompt treatment. To date, there is little research examining the womens experiences and the nursing care provided to this population. Two descriptive qualitative studies were completed. One study analyzed internet narratives of ten women with the diagnosis of postpartum psychosis and the other study analyzed ten interviews with psychiatric nurses working on inpatient psychiatric units in Sweden. These two studies and subsequent secondary analyses addressed four research questions. How do women diagnosed with postpartum psychosis describe their experience? What are psychiatric nurses descriptions of women with postpartum psychosis and what are their responses to these women when caring for them on an inpatient psychiatric unit? What nursing care strategies are used by nurses in caring for women with postpartum psychosis? How do psychiatric nurses describe the use of presence when caring for women with PPP? The women described overwhelming fear, a detachment and inability to care for their babies, delusions and hallucinations, shame and guilt, sleep deprivation, a sense of being controlled, disorganized, confused and paranoia during hospitalization. A number also felt abandoned and discontented with the nursing staff and the nursing care they received. The nurses described a kaleidoscope of symptoms and a range of positive and negative emotional responses they had towards the women. Nursing strategies included satisfying basic needs, keeping the women and babies safe and secure, connecting the women with reality, creating a partnership, teaching the women and their family members, giving hope and facilitating recovery. The nurses described their use of physical presence in great detail and the learning that took place in the context of caring for this population. Future research studies need to examine the on-going interaction of patients and nurses on inpatient psychiatric units. Nurses and nursing students need education about disease manifestations, womens experiences, nursing care strategies and ways to address nurses own emotional reactions.
Employee voice and upward communication: A phenomenological collective case study of leadership behaviors in performance excellence award winning health organizations
This study was exploratory in nature, utilizing a phenomenological collective case study approach. The phenomenon under study was the lived experiences of individuals surrounding employee voice and upward communication. The purpose was to understand CEO behaviors and actions that promote employee voice and upward communication in performance excellence award-winning healthcare organizations. The results suggested the award-winning CEOs facilitated employee voice and upward communication by being approachable, largely achieved through their regular presence throughout their organization. By being consistently visible and available to employees, these CEOs fostered relationships, built trust, and promoted open, upward communication. Leaders in the current case studies created a cultural focus on continuous improvement largely built around transparency of information, and particularly looking for the bad news from their employees. Voice invitation and positive voice response from leaders’ reinforced critical upward feedback as not only welcome, but expected. Findings from the study provided insight into leadership behaviors promoting employee voice and upward communication, which may be valuable to both scholars and practitioners. In-depth descriptions of CEO actions and behaviors address a gap in the current literature and add to the understanding of the phenomenon of employee voice and critical upward feedback.
Examining the behavioral interactions between urban residents and their food environment: A case study of greater Lansing, Michigan
Access to nutritious food is essential to human survival and the consumption of fresh produce is an important part of a healthy diet. Previous research has found that residents of urban neighborhoods who lack access to fresh produce have greater difficulty maintaining a healthy diet. This thesis considers the interaction between residents of Greater Lansing, Michigan and their food environment. An in-person survey of 185 Greater Lansing residents was conducted during the summer of 2010 at twelve retail stores that sold fresh produce items. Participants were asked questions about their access to transportation, shopping habits, diet, and primary location of residence. Statistical analyses were conducted to examine the relationships between the collected data and calculated models of spatial accessibility. Findings suggest that (1) the perception of Greater Lansing residents is that food shopping is not done in close proximity to the primary residence； (2) there is not a straightforward association between calculated access to and the consumption of fresh produce； (3) supermarkets are the dominant food source for residents； and (4) individuals who receive nutritional assistance are significantly more likely to shop at neighborhood stores and consume a less healthy diet. Understanding how Greater Lansing residents interact with their food environment is essential in finding solutions to the growing obesity and overweight epidemic.
The relationship between workplace and employee household preparedness: Application of an ecological and stage-based model of behavior change
In the last decade, governments, businesses, and households the United States have been encouraged to prepare for domestic hazards as part of the U.S. all-hazards preparedness goal. Of these groups, businesses and households have received the greatest outreach, but are still largely underprepared. To help these groups enhance their readiness, response, and recovery, investigators must understand what factors affect their preparedness behavior. This study theorized that preparedness behavior was a function of person and environment factors from the workplace and the employee household that jointly interacted to shape preparedness knowledge at work and action at home. In the literature, there are few, if any, social ecological studies or conceptual models that account for these person-environment factors or for nested environments when studying workplace and household preparedness. To address this absence, this study developed and tested a new social ecological, stage-based, and nested Model of Workplace-Household Preparedness, and two new all-hazards preparedness tools to better align the research with national readiness goals. To assess these models and scales, a cross-sectional, analytic survey design was applied and then supplemented by qualitative key informant interviews. Data were collected in 2009 from convenience samples of private, large, critical infrastructure companies in California and their employees. The final study sample included 16 companies, 18 emergency managers, and 2,571 full-time employees. Results showed that employee workplace and household preparedness was shaped through unique combinations of person and environment factors at different stages of behavior change i.e., hazard appraisal, decision-making, action). The nested interface of the workplace and household environments also directly shaped preparedness behavior, as did positive messages received from ones social network, particularly through work. The all-hazards preparedness scales also proved to be psychometrically-valid measures, and the research provided new benchmarks on the preparedness status of Californias private sector and its workforce at the start of the 21st century. This research adds to the literature empirical support for the role of multiple, nested environments in shaping individual preparedness behavior, and the utility of social ecological and stage-based models in explaining individual behavior change. These findings can be applied to help strengthen workplace and household preparedness.
Cognitive health: A study of the attitudes, behaviors and activities of the 2010 AARP National Spelling Bee participants
The degree to which life-long cognitive activity is responsible for healthy aging of the human brain is one of the controversial issues in medical science. Some studies suggest that a cognitively-active lifestyle may mitigate or delay the onset of chronic age-related diseases such as dementia. Previous research has illuminated factors that influence cognitive health, yet little is known about populations that engage in cognitive activity and what influences them to engage in cognitive activity. This descriptive study explored the attitudes, habits and motivations regarding cognitive health of an older, highly educated, life-long learning-oriented population, the AARP National Senior Spelling Bee participants and their family and friends. Bee registrants completed a brain fitness survey and participated in focus groups. From this small study, it appears that participation in a senior spelling bee is tied to a cognitively active life with a high degree of education. Spelling Bee Participants display lifestyle preferences, such as reading, learning and socializing, that are in line with cognitive health. Participants report a high level of enjoyment, validation and camaraderie when participating and preparing for the Bee. In essence, they do what they like to do and that just happens to be good for their cognitive health. More research is necessary to understand whether these habits will benefit Bee Participants as they age. Future assessment of this group could be useful in answering the ultimate question: Does a cognitively active lifestyle promote healthy aging of the brain?
Frictionless Expectations: When Bioethics Travels to Serbia
Over the last seven years, the European Union (EU) has promoted the institutionalization of bioethics in Serbia as part of EU citizenship. This paper looks at what it is about bioethics that makes it possible to take its universal application for granted and why are actors such as the Consul of Europe invested in transporting bioethics from their origins in the United States and Western Europe to Serbia. I start by examining discourse around institutionalized bioethics that makes transplanting of its ideas and practices appear unproblematic. Drawing on the concept of audit cultures and looking at bioethics as an audit mechanism, I show how promoting bioethics becomes an ethical end in itself. Finally, I consider how Westerners have historically construed Serbia as backwards, savage, and violent. I suggest that promoting bioethics as a condition of EU citizenship might be a means of making ethical subjects or of civilizing Serbia.