Public health informatics: A consensus on core competencies

Richards, Janise Elaine The University of Texas at Austin 2000 해외박사(DDOD)

This descriptive study identified competencies and the supporting skills and knowledge in public health informatics for public health informaticians and for general public health practitioners. Within the study's integrationist research design, which combines both qualitative and quantitative methods, the methods used were telephone interviews and a web-based Delphi survey. The interviews were substituted for round one of the traditional Delphi method. The interview data were analyzed using a constant comparison method and the final results were used to develop the Delphi survey items. A snowball sampling technique identified the study participants who met the selection criteria of expertise in public health informatics, public health education, public health practice or informatics education. Nine experts participated in the interview process and 23 in the Web-based Delphi. The interview results provided a new definition for public health informatics: Public health informatics is the innovative application of information science, computer science and information technology to improve management of information in public health practice and research, ultimately improving the health of the community. The interview results also indicated that public health informatics had four core domains: organizational and systems management, information systems, information technology, and public health sciences. Within these domains were 12 competencies and 60 supporting skills and knowledge items. After two rounds of the Web-based Delphi survey, the items reached consensus. Nine of the 12 competencies were determined to be critical and three were determined to be important for public health informaticians. For the general public health practitioner, two competencies were determined to be important, eight moderately important, and two insignificant. Of the supporting skills and knowledge, 55% were considered critical, 42% important, and 3% moderately important for public health informaticians. For general public health practitioners 20% were critical, 26% important, 36% moderately important and 18% insignificant or not important. This research can provide a foundation for developing public health informatics curricula in graduate programs and schools of public health and public health workforce training programs.

Clinic-based interventions to address childhood obesity: Part of the solution to a public health problem?

Ayash, Christine Raja Boston University 2011 해외박사(DDOD)

Context: Childhood obesity is a pressing threat to the future health and well-being of the US population. One-third of American children are either overweight or obese, with racial and ethnic minorities and low income children being disproportionately affected. Because obese children often become obese adults, early preventive efforts to impede the development and progression of childhood obesity may effectively curb the rising prevalence of adult obesity and its co-morbidities. Policies addressing the obesity epidemic have focused mostly on settings outside of health care, including numerous state initiatives and legislative actions targeting schools and the food industry. The health care system could also play a key role in responding to this epidemic, but thus far has been underutilized. Methods: This dissertation examines three key components of chronic disease care that may improve delivery of obesity-related care and enhance the contribution of the clinical setting to addressing this public health problem: (1) use of health information technology, (2) use of national pediatric obesity care guidelines, and (3) provider-parent communication tools. This research project employed both qualitative and quantitative methods, working at the Cambridge Health Alliance (CHA) and Harvard Vanguard Medical Associates (HVMA) provider groups to achieve three specific aims: (1) examine the effects of a computerized point-of-care alert and decision support system intervention on rates of diagnosis of obesity by CHA pediatricians; (2) identify barriers and facilitators for providers to adopt and adhere to national guidelines on assessment, prevention, and treatment of childhood obesity; (3) examine parents' perception of the quality of pediatricians' communication about their child's weight status and assess the level of parent and provider receptiveness to direct-to-mail communication tools. Findings: (1) A computerized point-of-care alert was effective in improving obesity diagnosis at CHA relative to HVMA, which did not adopt an alert. (2) CHA and HVMA pediatricians reported (a) reduced workflow efficiency due to electronic health record point-of-care alerts and decision support; (b) resistance to adopting and adhering to national guidelines because of the paucity of supporting evidence; (c) several barriers to effective care for obesity including patients' low socioeconomic status and residence in an "obesogenic" environment, and (d) the patient-centered medical home model to be a promising alternative delivery structure for effectively addressing the needs of overweight and obese patients. (3) Parents identified several gaps in communication with their child's provider including a lack of: (a) provider initiation; (b) directive messages regarding weight management; (c) continuous follow-up; and (d) provider awareness of community-based obesity-related services. Both pediatricians and parents favorably viewed the direct-to-parent letter tool designed to "activate" weight-related communication during a patient visit. Conclusions: The use of decision support tools in electronic medical records may improve the identification and diagnosis of obesity in pediatric primary care. Pediatricians in two large medical groups welcomed advanced models of chronic disease care, and parents welcomed stronger partnerships with providers to address several deficiencies in the care of obese children. These findings suggest potential benefits from redesigning primary care systems to address pediatric obesity. Further development, testing, and evaluation of electronic decision support and parent-provider communication tools will be necessary to determine the impact of these clinical interventions on population health.

The Frictions and Flows of Data-Intensive Transformations: A Comparative Study of Discourses, Practices, and Structures of Digital Health in the U.S. and India

Fiore-Silfvast, Brittany University of Washington 2014 해외박사(DDOD)

This dissertation examined the social and organizational implications of data-intensive transformations in healthcare through studying digital health and processes of informationalization in the U.S. and India. These transformations bring challenges of how to mobilize digital health data across different contexts of use and make data valuable for multiple stakeholders. To study these challenges I employed a combination of discourse analysis, ethnographic methods, and a comparative case study analysis to investigate digital health innovation across rural healthcare and urban consumer health and wellness settings in the U.S. and India. Through a communication lens this research examines sociotechnical interoperability for data across domains on three levels: discourses, communicative practices, and organizational structures and labor. Across the discourses and practices of different communities, I found communication gaps around health and wellness data. To explain these gaps I propose the concept of data valence to represent the different expectations and social values that mediate the social performance of data. Analysis through a data valence lens generated the following typology: actionability, connection, self-evidence, truthiness, discovery, accountability, and transparency. Mapping the multiple, and sometimes conflicting valences across contexts accounts for the multiple social and material lives of data and highlights tensions across stakeholder groups. I argue that this typology is portable to other fields of data-intensive work. In comparing cases of digital health pilot projects, the differences between reinforcing and redrawing professional boundary relations, and in the role of intermediary labor in translation of digital health data for clinical and administrative sensemaking, patient engagement, and algorithmic calibration, at one time support polyvalent data in the U.S. Telehealth case and hinder it in India mHealth. Further, in the aftermath of the terminated U.S. Telehealth project, aspects of the technology continued to materialize within organizational practices and structures, such that organizational changes became the technological residue of the pilot projects. This suggests digital health's emphasis on technological innovation overlooks essential organizational and communicative dimensions of informationalizing healthcare and needs to be expanded beyond measures of success and failure to account for how technological innovation extends into and co-evolves with a wider network of organizational practice.

Values and diet among colorectal cancer survivors and non-affected individuals in North Carolina

Hudson, Marlyn Allicock The University of North Carolina at Chapel Hill 2006 해외박사(DDOD)

Individual core values may be important to understanding and predicting behavioral decisions. This dissertation, presented in two manuscripts, examined the relationship between values and fruit and vegetable (FV) intake for colorectal cancer (CRC) survivors and non-affected persons. Hypotheses were tested using data from the North Carolina Strategies for Improving Diet, Exercise, and Screening (NC STRIDES) project, a population-based study of CRC risk prevention. Manuscript One describes the results of logistic regression analyses to evaluate whether values promote FV intake for 234 participants. Manuscript Two describes the results of case-comparison techniques to analyze counseling transcripts from 24 participants doing a values self-confrontation exercise. Findings include. Manuscript one. All participants selected family, health, and God's will as the most frequently endorsed values. Compared to CRC survivors, non-affected persons were more likely to choose the values responsibility and friendship. Race, sex, baseline FV intake, and intervention group were not statistically associated with endorsing a particular value. Being a survivor did not predict selection of health as a value or selection of value type (instrumental values vs. terminal values). Being a non-survivor did predict increased FV intake at follow-up. Neither selecting instrumental values nor health predicted increased FV consumption. Selecting instrumental values was not predictive for reporting higher importance or self-efficacy for FV intake. Manuscript two. The value health functioned to influence diet as: (1) a necessary component for other values, (2) a manifestation of God's will, and (3) a co-requisite value with responsibility for being in good health. Values functioned in both health promoting and limiting ways. For FV adherence, beliefs were more suggestive than categorizing participants based on values, sex, race, and CRC status. While logistic analyses provided no evidence supporting relationships between values and FV intake, case-comparison analyses underscore that values do influence diet. The values self-confrontation served to raise participants' awareness about their value hierarchies and helped establish how values influence diet choices. Future research should explore ascribed meanings to values in tandem with how values relate to the health behavior of interest. Understanding how and which values influence health behavior practices can impact intervention design for cancer preventive behaviors.

Housing Markets and Health Outcomes

Sportiche, Noemie Harvard University ProQuest Dissertations & Theses 2023 해외박사(DDOD)

This dissertation consists of three chapters on the relationship between housing markets and health outcomes.Chapter 1. Can Fair Share Policies Expand Neighborhood Choice? Evidence from Bypassing Exclusionary Zoning under Massachusetts Chapter 40BOpening up neighborhoods that offer greater opportunities for social mobility to low-and moderate-income households remains a challenge in the United States. Exclusionary zoning practices act as a barrier to current efforts by restricting the supply of affordable housing. In this paper, we examine whether fair share policies which seek to bypass these restrictive zoning practices offer a potential solution. Focusing on Massachusetts Chapter 40B, we find clear evidence that such policies expand the types of neighborhoods currently available to low- and moderate-income households. Leveraging novel data on 40B development addresses linked to a wide range of public and administrative records, we find that 40B housing is located in neighborhoods with greater economic mobility, better schools, greater social capital, less pollution, better health outcomes, and lower incarceration rates than both the typical Massachusetts resident and to the beneficiaries of the state's Low-Income Housing Tax Credit, Housing Choice Voucher, and Public Housing programs. Consistent with previous research on policies that have segregated affordable housing and opportunity, we also find that 40B neighborhoods are substantially whiter and wealthier than both types of comparison areas. Differences between 40B neighborhoods and those with other program beneficiaries - which are on the order of 1 to 2 standard deviations - are striking large. An examination of underlying policy mechanisms suggests that bypassing exclusionary zoning plays a central role in explaining these differences in neighborhood conditions.Chapter 2. Early-Life Impacts of Affordable Housing in High-Income Areas: Evidence from Massachusetts Chapter 40BDesegregation-focused housing policies aimed at reducing disparities in neighborhood conditions may also reduce disparities in health outcomes. This paper examines the effects of one such policy on the health of pregnant people and their newborn infants. Specifically, I study the impact of Massachusetts Chapter 40B, a major civil rights-era housing policy that increases the supply of affordable ownership and rental housing in higher-income areas to facilitate moves for lower-income households to those areas. Using a difference-in-differences approach that compares the health outcomes of birthing parents who move to 40B housing to those of demographically-matched birthing parents who move from similar origin neighborhoods, I find that moving to 40B housing produces meaningful improvements in birth outcomes and some gains in birthing parents' health only among 40B renters. I find no evidence of health effects among 40B owners. Among renters, improvements in birth outcomes are largest among Black beneficiaries, and are driven largely by people moving from neighborhoods with higher levels of poverty, more Black residents, and higher male incarceration rates. These results suggest that desegregation-focused housing policies like 40B could help improve racial and economic disparities in early-life health among certain populations.Chapter 3. Economic Crises and Mental Health: Effects of the Great Recession on Older AmericansWe examine the effect of the Great Recession of 2007-2009 on the mental health of older adults, using longitudinal Health and Retirement Study data linked to area-level data on house prices. We use a variety of measures to capture mental health and rely on the very large crosssectional variation in falling house prices to identify the impact of the Great Recession on those outcomes. We also account for people who moved in response to falling prices by fixing each person's location immediately prior to the house price collapse. Our central finding is that the Great Recession had heterogeneous effects on health. While mental health was not affected for the average older adult, mental health declined among homeowners with few financial assets, who were therefore more vulnerable to falling house prices. Importantly, health impacts in this group differed by race and ethnicity: depression and functional limitations worsened among Black and other non-white homeowners and medication use increased among white homeowners. There were no measurable impacts for Hispanic homeowners. These results highlight the importance of examining heterogeneity across multiple dimensions when examining the health impacts of economic conditions.

Local inequality and health: The neighborhood context of economic and health disparities

Bjornstrom, Eileen E. S The Ohio State University 2009 해외박사(DDOD)

The relationship between income inequality and health is the subject of intense debate in social epidemiology. The income inequality hypothesis asserts that ecological income inequality is detrimental for health due to reduced social or material resources. Relatedly, the relative position hypothesis suggests lower hierarchical position of individuals is associated with negative emotions and stress, with consequences for health and social cohesion. Debate centers on both the relevance of these theories as they apply to health and the appropriate mechanism(s) underlying the relationship. I draw from Wilkinson's (1992) paper that suggests that the distribution of income is more important in predicting health in wealthy nations due to relationships between relative deprivation, negative emotions, and decreased social cohesion and contrast its utility with Wilson's (1996) theory of the benefits of affluence that posits economic heterogeneity is beneficial, particularly in otherwise poor neighborhoods, because affluent residents model mainstream norms and uphold neighborhood institutions. Some scholars argue that inequality is not important in smaller units of analysis, such as neighborhoods. But these assertions are based primarily on studies outside the U.S. and have little theoretical basis. Moreover, tests of this theory in U.S. neighborhoods, where effects of inequality have typically been strongest, are rare. Further, though it is reasonable to expect that inequality is more problematic for those at the lower end of the hierarchy, and that neighborhood inequality may be differentially important across raceethnicity, the literature is largely absent on this topic. Finally, the relationship between relative position and health at the neighborhood level, and the way in which local context may be associated with it, is not fully understood. I use hierarchical multilevel Poisson and logistic regression models on data from the Los Angeles Family and Neighborhood Survey, the Los Angeles County Health Department, and the decennial census to address these gaps in the literature by systematically testing the strong and weak versions of the income inequality hypothesis at the neighborhood level on local age-specific and race-ethnic-specific mortality rates, and in multilevel models on individual morbidity. Then, I test the relative position hypothesis within neighborhoods on three morbidity outcomes; hypertension, obesity, and self-rated health. Due to commonalities across theory, collective efficacy, a local social resource based on cohesion, trust, and likelihood of intervention for the common good, is tested as a mediator of the relationship between economic structure and health. Results regularly suggest neighborhood context matters for both mortality and morbidity. Neighborhood economic well-being is especially relevant for mortality across race-ethnicity, while inequality was not important for all cause mortality among blacks or Latinos, but was detrimental for Whites in low income neighborhoods. The strong and weak versions of the income inequality hypothesis are disputed in multilevel models. Instead, results indicate economic heterogeneity is actually beneficial on average for hypertension, obesity, and self-rated health. Effects of inequality did not vary across individual income. Some race-ethnic differences were found wherein whites benefit more so than other groups from economic heterogeneity. Collective efficacy, as expected by Wilson, mediates a portion of the relationship between neighborhood affluence and health. In contrast with Wilkinson's expectations, though consistently associated with better health and lower mortality, collective efficacy did not mediate the effects of inequality, suggesting that social resources are not the mechanism though which inequality operates. Results suggest the relative position hypothesis applies to self-rated health, supporting Wilkinson at the individual level. Further, as expected by theory, the relationship was mediated by individual sense of control; a proxy for stress. Results do not suggest collective efficacy mediates any portion of the relationship between relative position and morbidity, and effects of relative position did not vary across the level of inequality in the neighborhood. I conclude that low relative position may be problematic for health, but neighborhood economic heterogeneity is not detrimental for individual health in local communities, and question the theoretical mechanism posited by Wilkinson. Instead, I suggest economically heterogeneous (or unequal) neighborhoods, perhaps especially in Los Angeles County, may contain characteristics that promote health. Implications for policy and future research are discussed.

Evaluation of the epidemiologic impact of a national primary health care policy on infant health outcomes in Brazil, from 1999 to 2002

Bezerra, Roberto Claudio Rodrigues The University of Arizona 2006 해외박사(DDOD)

Programa de Saude da Familia-PSF was initially proposed as a novel model of primary health care in Brazil in 1994 as it was implemented in several Brazilian municipalities. This national policy embraces different dimensions of primary care, but has a primary reliance on maternal and child health, especially on the survival of infants, given the unfavorable Brazilian child health scenario. This study has proposed that an improvement on infant health is expected to occur through three major mechanisms: overcoming of socio-cultural and geographical barriers of access to maternal and child health services; integrality of care; and community empowerment. An ecological longitudinal study design was utilized to assess the impact of the policy implementation on municipal indicators of infant health of 1201 municipalities, from 1999 to 2002. A group of municipalities that first implemented PSF in 1999 and were covered continuously from 1999 from 2002 were compared to a group of municipalities that didn't implement this policy within the same time period. This study has found that PSF has had an overall positive impact on infant health. Overall, it might be concluded that PSF implementation has brought an important short-term improvement on municipal indicators of infant health from 1999 to 2002, especially on the infant mortality rate. Such beneficial impact tended to be stronger in socially disadvantaged municipalities, commonly with unfavorable health care scenario. Thus, the expansion of primary health care capacity and overcoming of major gaps within the access to MCH services might explain such beneficial impact of PSF implementation in Brazilian municipalities.

Collaborative, competitive or co-opted? The role of health in Baltimore's zoning rewrite

Greiner, Amelia Louise The Johns Hopkins University 2011 해외박사(DDOD)

Zoning codes regulate how private land is used in part to "promote health and welfare." Often overlooked by public health researchers and curricula, these ordinances can influence neighborhood exposure to amenities and hazards. Zoning regulates topics such as housing density, location of liquor outlets, proximity of daily services to residences, parking requirements, landscaping---factors which directly and indirectly impact housing affordability, crime, food access, air- and water quality. Despite these links, public health researchers are often not involved in shaping zoning ordinances. For the first time in 40 years, Baltimore City is comprehensively rewriting its zoning code. Given this rare opportunity and Baltimore's health needs, several innovative groups are pressing the City to include health considerations in the rewrite. I present two years of data about the evolution and fate of health in the context of rewrite from observation of public, open and staff-level zoning rewrite meetings and interviews with key decision makers. As a participant observer, I evaluated the zoning code for health impacts and presented recommendations based on this analysis. By using a blend of Multiple Streams Framework and rhetorical analysis, I detail how the role of health in the rewrite is affected by various participants, other problems competing for attention in the rewrite, and the language used in reaction to health-relevant zoning topics. In the context of Baltimore City's zoning rewrite, many opportunities exist for promoting health. Overall, however, "health" is operationalized narrowly, and including a public health voice requires a significant expenditure of resources. Health considerations and research---particularly those addressing disparities---are often unfamiliar to key rewrite participants and do not drive zoning decision-making. All health considerations are weighed against political realities and impacts on development. Public health experts' participation in zoning code rewrites presents an opportunity to translate built environment research into land use practice. The challenges to doing so, however, are numerous. A clear need exists for building capacity among zoning decision makers to understand the connection between land use, human behavior, and health---and for public health participants to better understand the intricacies of urban planning and development.

Utilization of primary health care by poor children: The role of an Indonesian social safety net program

Suci, Eunike Sri Tyas Brown University 2004 해외박사(DDOD)

Though the child health indicators shows that child health in Indonesia has improved significantly since 1970s, indicators remain at levels well below those of neighboring countries. Indonesia is challenged by the problems of providing equal health services across provinces. The prolonged Indonesian economic crisis that began in 1997 worsened children's health. In 1998, the Indonesian government launched a broad social safety net program to prevent the poor from becoming poorer. In the health sector, the safety net took the form of the "JPSBK" initiative, through which the government provided free basic health services for poor families. As a component of the project, the Ministry of Health conducted a longitudinal study to measure the extent to which the JPSBK benefited poor families, especially mothers and children. I use data from this longitudinal study to examine: (i) effects of the JPSBK program on child health services utilization, (ii) determinants of reporting child sickness/symptom experience, and (iii) determinants of child health services utilization. I revised a model of health services utilization developed by Andersen and Newman (1973), which emphasized predisposing and enabling factors, and illness needs, to incorporate contextual determinants. My study employed a time series non-experimental "ex post facto" design and examined the changes in health services utilization between study rounds one and three in four provinces; the study sample size was 14,711. Two dichotomous dependent variables in the study were: reported child sickness/symptoms experience and child outpatient visits. The study found that over one year of the program, the number of poor children reported to have experienced sickness/symptoms decreased significantly. When they were sick, they were more likely to visit outpatient facilities and sought this care at health centers. One crucial determinant of outpatient visits was health card possession, the means by which poor children accessed free services. However, health cards were not always used during the visits for a various reasons: ignorance about, loss of the card, and refusal by a health facility to accept the card. The study recommended policy makers develop a more established program and provide health education in order to improve the health of poor children.

Work, marriage and community context effects on health among a cohort of Chinese women

Wang, Haijiang The Johns Hopkins University 2006 해외박사(DDOD)

Background. The economic system transformation in China has had a profound effect on individual health and well-being. Objective. To assess the effects of work involvement, marital status and transitions, and community context on women's health. Methods. Data are derived from the China Health and Nutrition Survey. 2530 women aged 20--59 in the 1991 survey and follow-up interview in 1993 and/or in 1997 are selected. Two-level logistic and poisson random intercept models are estimated to assess the effects of work involvement, marital status and transitions, and community context on women's health measured as self-rated health, reported illness in the last four weeks, hypertension and being overweight. Results. Wage work is beneficial for Chinese women's perceived health, compared to non-wage work categories such as field work, farm work and sideline activities (statistically significant logged odds are -0.37, -0.31 and -0.34, respectively, in the saturated model for overall women and -0.49, -0.39 and -0.67, respectively, in the saturated model for rural women). Both women never married and divorced, widowed or separated have a higher risk for hypertension (OR=1.70, 95% CI: 0.66-4.36 and OR=2.01, 95% CI: 1.01-3.99, respectively) relative to married women. Women with marital transitions are more likely to be at risk for hypertension (OR=2.03 for those exiting marriage, 95% CI: 1.12-3.70 and OR=2.54 for those entering marriage, 95% CI: 0.98-6.54) relative to women staying married. A similar effect pattern is found among women without hypertension in 1991 from a poisson model of incidence rate. Community variables are found to have independent effects on one or more specific subjective and objective health measures beyond a set of individual variables. There is no consistent pattern of community effects on either subjective or objective health measures. Conclusions. A detailed work typology more appropriately approximates the effects of work involvement on women's health in China, especially in rural China. Married women are less likely to be at risk for hypertension, while women experiencing marital transitions are more likely to suffer short-term adverse health effects. The community context where women live is also important to understand in explaining variation in health status.