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Now showing 1 - 10 of 38
  • Publication
    Polypharmacy: Patterns And Policy Propositions
    (2020-01-01) Do, Duy Hoang
    Sixty percent of U.S. adults report frequent use of prescription medications, a prevalence that is higher than ever before. Although medications are lifesaving when used properly, they can produce side effects ranging from minor problems like dizziness to severe events such as an increased risk of cancer. Polypharmacy – a phenomenon typically defined as concurrent use of multiple medications – may present unique risks for medication side effects, amplifying the effects of each of the medication in a set. Given the growing medication use across the country, this dissertation examined the causes of polypharmacy and the consequences of concurrent use of medications with side effects on population health and health care use. The first chapter provided background information on polypharmacy and medication side effects. The second chapter used the National Health and Nutrition Examination Survey (NHANES) to investigate whether and how the introduction of Medicare Part D, a large and sudden change to health care financing for Medicare beneficiaries, affected medication use for older adults. While Part D increased the use of lifesaving medications, it also increased polypharmacy. The third chapter used the NHANES to show that concurrent use of three or more medications with cognitive impairment side effects among U.S. older adults increased three-fold in the past two decades. Individuals who used three or more such medications experienced increased risks of cognitive deficits compared to non-users. The fourth chapter used the Medical Expenditure Panel Survey (MEPS) to document a growth of 36% in the concurrent use of at least three medications with mental health side effects among U.S. adults in the past two decades. Concurrent use of these medications was associated with an increase in psychiatric symptoms and the use/costs of mental health services. In the fifth chapter, I discussed how the processes of medicalization and pharmaceuticalization contributed to rising medication use and disparities in such use, which in turn had implications for population-level health disparities. Collectively, these findings shed light on patterns and disparities in population health associated with polypharmacy and speak directly to the role of broader social, economic, cultural, and institutional inequalities in generating and maintaining health disparities.
  • Publication
    Influences on Children's Human Capital in Rural Malawi
    (2013-01-01) Appiah-Yeboah, Shirley Afua
    The circumstances that characterize poor, rural communities in Malawi suggest that children's health-wealth gradient can vary from other settings. This dissertation begins with a description of the methods used to create a household wealth variable using assets data in the Malawi Longitudinal Study of Families and Health project. By using a fixed effects model to minimize omitted variable bias, I determine the influence of participating in a farm subsidy program on the levels of household wealth in 2004, 2006 and 2008. The results show that the program is positively associated with the wealth index score and this association is stronger when using lagged explanatory variables. This chapter demonstrates how asset data broadens the possibilities of wealth-poverty research that can be undertaken in poor settings. In the next chapter, I use the wealth index to identify a health-wealth gradient for children under 5 years, and I determine whether the gradient varies with age. I find that children in wealthier households have decreased risk of stunting but this is not significant until the oldest age groups (36-47 and 48-59 months). While there is no apparent health-wealth gradient across these ages, there is evidence of an emerging gradient as children get older. The final chapter explores the role of maternal social capital in children's schooling outcomes, using an index measure of women's membership in community groups and instrument variable analysis to address endogeneity concerns. I find that maternal social capital has a significant, positive association with primary school enrollment for younger children and primary school completion for older children. In contrast, maternal social capital has significant, negative association with school enrollment for older children. Maternal social capital is discussed within the context of government policies to improve enrollment and retention. Poor, rural children in Malawi face unique circumstances that have long-lasting implications. The findings across these chapters underscore the need for research that contextualizes and seeks to understand these specific challenges. If this can be achieved, Malawian children have a better chance in becoming healthier, productive adults.
  • Publication
    Three Essays on the Social, Economic, and Demographic Causes and Consequences of Low Fertility
    (2015-01-01) Anderson, Thomas Markley
    The demographic phenomenon of “low fertility” has received considerable attention over the last three decades within academic, political, and public spheres. While a large body of research has led to a deeper understanding of the underlying social and economic dimensions of low fertility, current theoretical and empirical approaches fail to explain puzzles pertaining to within and across population heterogeneity in fertility rates. This dissertation is comprised of three papers that investigate the social, economic, and demographic causes and consequences of low fertility. Chapter 1 sets forth a new theoretical approach to examining the interrelations between low fertility, socioeconomic development, and gender equity among developed countries. The main findings of this chapter are that 1) the pace and onset of socioeconomic development explain a significant proportion of the variation in fertility among developed countries, 2) low fertility may facilitate changes in gender norms through a “gender-equity dividend”, and 3) contrary to Second Demographic Transition theory, low fertility may be a transitory phase of the demographic transition. Whereas the Chapter 1 looks cross-nationally at gender and fertility dynamics, Chapter 2 takes a micro-level approach by exploring the relationship between fertility and gender norms in the United States. Using the National Longitudinal Survey of Youth (NLSY 79), I find that both men and women with progressive views on gender equity have lower fertility than their traditional counterparts, though these results were stronger, more consistent, and more significant across models for women. In Chapter 3 I argue that the rising costs of childrearing through “shadow education” have become a key fertility-reducing force across high, medium, and low-income countries. To investigate this hypothesis, I use data from the Programme for International Student Assessment (PISA) and find evidence of a “quality-quantity tradeoff” both within and across populations due to costly shadow education. Collectively, the findings of this dissertation signal that the causes and consequences of low fertility are multifaceted and evolving across time and space.
  • Publication
    What A Polygon Can't Tell You: Shifting From Area-Level To Point-Level Investigation Of Residential Segregation Patterns
    (2017-01-01) Fineman, Ross William
    The study of segregation is essential for understanding how place influences life outcomes. However, traditional segregation indices rely heavily on the use of areal units for calculation, which risks introducing both measurement and interpretation error. Researchers suggest that individual-level data avoids many of the problems facing traditional area-level indices. In this Dissertation, I use the recent release of the complete 1940 Census to investigate the potential problems with measuring segregation with areal units and develop a new method for measuring segregation at the individual level. In Chapter 1, I investigate the potential impact the modifiable areal unit problem (MAUP) may have on accurately measuring segregation when using areal unit indices. In Chapter 2, I develop a new measure of segregation, the Shortest Path Isolation (SPI) index, which captures the degree of racial isolation from the perspective of what an individual would experience. Using the SPI index developed in Chapter 2, Chapter 3 investigates how individual-level racial isolation in 1940 West Philadelphia is associated with access to neighborhood resources by race. Given that our understanding is only as good as our measurement, it is imperative that our measures accurately reflect our perceptions of segregation.
  • Publication
    Demographic Models Of Health And Mortality At Both Extremes Of The Lifespan
    (2017-01-01) Romero Prieto, Julio Enrique
    This dissertation consists of three essays. The first chapter proposes a model life table to investigate the human mortality at early ages. The model was estimated from the vital records, observing the experiences of 24 countries, which in some cases are at end of the nineteenth century and much of the twentieth century. Using few input values, the model predicts a mortality schedule for the first days, weeks, months, and years of life. Furthermore, the model is flexible to represent age patterns in conditions of either low or high mortality. Thus, the main application is as a method for indirect estimation, in contexts where vital records are incomplete, imperfect, or non-existent. In this direction, the second chapter takes advantage of the model to investigate the mortality patterns and the quality issues of the mortality estimates from self-reported data. To this end, a total of 252 Demographic and Health Surveys were analyzed in light of the predictions of the model, in order to identify particular characteristics of these populations. These comparisons lead to the conclusion that populations with high levels of mortality are more likely to show late patterns of under-five mortality. The model was also used to examine data quality issues regarding misreported ages at death. Particularly, this chapter proposes a simple solution to the problem of heaping at the age of 12 months and the underestimation of the infant mortality. The third chapter investigates the relationship between health status and survival expectations on a sample of mature adults aged 45+, who participated in the Malawi Longitudinal Study of Families and Health between 2006 and 2012. In particular, structural equation models were estimated assuming intertemporal relationships between physical health, mental health, and the formation of survival expectations. These models identify different pathways that have been discussed from theoretical and empirical approaches showing evidence of the concomitancy of physical and mental health issues, and the relevance of the expectations about life. This paper quantifies a significant impact of mental health on the prospective physical health and provides evidence on the differentiated adaptation pathways for men and women.
  • Publication
    Three Essays In Population Process
    (2017-01-01) Gansey, Romeo Jacky
    This dissertation addresses multiple topics of current population processes, including an impact evaluation of malaria control on child mortality in Tanzania, a study of living arrangements among the foreign-born in the United States, and an investigation of selectivity and the choice of migration destination among African emigrants. The dissertation follows a three-chapter format. The chapters are related to one another by their common focus on policy relevant topics for the health and wellbeing of populations. The first chapter investigates the specific contribution of malaria control to improvements in the health of children under five in mainland Tanzania by exploiting the timing of scale-up malaria interventions along with the variation in malaria endemicity across the country due to ecology. The analyses are based on birth history and socioeconomic information from the 2004-2005 and 2009-2010 waves of the Tanzanian Demographic and Health Survey and epidemiological information on malaria prevalence from the National Malaria Control Program. The results suggest that, on average, malaria control interventions have helped avert approximately 17.9 deaths for every 1,000 live births between 2004 and 2010. They also point to significant improvements in children's nutritional health attributable to malaria control. The second chapter examines living arrangements among the foreign-born in the United States by including all major sending regions of immigrants; by distinguishing between horizontal and vertical extension (coresidence within and across generations); and by accounting for the uneven geographic distribution of immigrants across the country. Drawing on data from the five percent sample of the 2001-2013 waves of the American Community Survey, the chapter shows not only large differentials in the prevalence of extension across immigrant groups, but also substantial variation in the type and predictors of extension, and the extent to which these differences with native whites are explained by socio-demographic composition and housing conditions. Overall, traditional theories of extension do a better job of explaining horizontal than vertical extension, and among relatively disadvantaged immigrant groups (i.e., Mexicans, Latin Americans (excluding Mexicans) and West Indians) than more positively selected groups (i.e., South East Asians, Canadians/Europeans, and Oceanians). African immigrants often fall in between these two extremes. The chapter also shows that accounting for immigrant concentration in more expensive housing markets explains an important share of the immigrant-native gap in extension, suggesting that previous analyses exaggerated the role of culture in explaining variation in living arrangements. The third chapter is concerned with emigrant selectivity and the factors that shape the choice of migration destinations. Using data from the 2009 Ghana survey of the Migration from Africa to Europe (MAFE) project and data from nationally representative surveys in the United Kingdom and the United States, this chapter investigates these issues among emigrants from Ghana. The results point to positive selection among current emigrants compared to both non-migrants and return migrants. They further show that return migrants tend to have more favorable socioeconomic characteristics than non-migrants. The results also indicate selectivity among emigrants by destination such that those who migrate to a destination further away are more positively selected. However, these results fail to show any effect of wage differentials at destination in explaining the choice of migration destination among emigrants to the United Kingdom and the United States. This chapter offers three contributions to the literature on migrant selectivity. First, it focuses on selectivity among return migrants versus current emigrants and compares emigrants across destinations. Second, it assesses whether socioeconomic characteristics used at either the individual or household level influence migrant selectivity. Finally, it tests empirically two theoretical pathways (neoclassical and network theories) relating migrant characteristics to the choice of migration destinations.
  • Publication
    Three Essays On Labor Market Incorporation And Remitting Behavior In Sub-Saharan Africa
    (2020-01-01) Souza, Emmanuel Francis
    This dissertation follows a three-chapter format, addressing migration-related issues in sub-Saharan Africa (SSA). The first and second chapters use Census data and logit models to examine labor market incorporation of African-born immigrants in South Africa, a country that has become a magnet for regional migration and a prime example of South-South migration. Chapter one examines a wide range of labor market outcomes for immigrant men relative to their internal migrant peers. It examines the extent to which prior models and arguments based on South-North migrants also apply to South-South flows. Results show considerable support for segmented assimilation perspectives. However, the existence of large informal sectors in the South African context is the central barrier to immigrants’ occupational and income attainment, a factor less relevant in the South-North context. In addition, better-resourced immigrant communities have better incorporation experiences than well-established communities. The second chapter investigates women’s labor market participation, considering women’s status, socio-cultural norms, and demographic trends in SSA. It explores the relative importance of human capital and family characteristics in explaining labor market disparities between immigrants and natives. Results underscore similar challenges to those experienced by immigrant men in South Africa. Comparatively, immigrants exhibit poor incorporation experiences than South African-born internal migrants. Family characteristics are the key factors explaining variations in immigrant women’s labor market decisions. In contrast, human capital factors are more salient for South African women, suggesting the importance of gender egalitarianism. Finally, the third chapter employs probit and Tobit models to examine household remittances in four SSA countries using World Bank data. It explores how family ties, migrant, and origin-household characteristics shape remitting behavior. Here, results are consistent with remitting patterns and motivations observed elsewhere. Altruism appears to be the primary motive behind remittances in SSA. However, the altruistic behavior is primarily driven by the obligation to remit rather than a selfless concern for the non-migrating household members as pure-altruism suggests. National origin variation in remitting behavior underscores the importance of access to international labor markets, gender dynamics, and origin countries’ level of development in shaping the pattern and use of remittances.
  • Publication
    Changes in HIV/AIDS Knowledge, Attitudes and Behaviors in Malawi
    (2014-01-01) Fedor, Theresa
    The three chapters of this dissertation collectively assess how HIV/AIDS knowledge, attitudes are behaviors are changing in Malawi. The first chapter assesses how married individuals use knowledge of HIV status to make behavioral changes to reduce HIV risk or make decisions about divorce. Instrumental variable models controlling for selection into HIV testing are estimated using data from the Malawi Longitudinal Study of Families and Health (MLSFH). Results indicate that knowledge of HIV status does not affect chances of divorce but does reduce the number of reported sexual partners among HIV-positive respondents, and increases reported condom use with spouses for both HIV-negative and HIV-positive respondents. The goals of the second and third chapters are to dig beneath behavior itself and look at how potential behavioral changes are motivated, as well as how basic HIV knowledge has changed. Chapter 2 examines ways that HIV prevention efforts may have changed beliefs and attitudes towards HIV risk and HIV prevention, in particular attitudes towards a woman's right to protect against HIV risk. Using MLSFH data, I compare participants and non-participants in a program providing extensive HIV counseling and testing. Results suggest that participants are more likely to believe that women have the right to take steps to protect themselves from HIV risk, are less likely to be extremely worried about HIV infection, and are more likely to think condom use is an acceptable means of protection against HIV. Chapter 3 explores how individuals update knowledge of HIV/AIDS transmission and prevention over time in Malawi. HIV knowledge uptake could potentially be different according to an individual's age, the time frame in which an individual was born, or could be changing predominately over time for all individuals (age, period or cohort). Using Demographic and Health Surveys Data for Malawi in cross-classified random effect age-period-cohort models, I find that period effects dominate over cohort or age effects, meaning that knowledge of effective HIV prevention tactics has increased most strongly over time, net of age and birth cohort effects.
  • Publication
    Health and Aging in Low-Resource Contexts: Three Essays on Healthy Life Expectancy in the Developing World
    (2015-01-01) Payne, Collin Frederick
    The population of the world is getting older. In 2010, worldwide, there were about 524 million people over the age of 65; by 2050, over 1.5 billion people will be in this age group. This shift in population will not affect only developed countries, however—much of this increase in the elderly population will occur in low- and middle-income countries. As populations age, low-income countries will need to invest in health care for older adults and in disease prevention programs to prevent or delay the onset of non-communicable diseases (such as heart disease, stroke, and cancer). Past research on population-level health in the developing world has been widely hindered by a lack of high-quality longitudinal data. My dissertation uses recently-collected longitudinal data to gain insight into overall trends in health in low- and middle-income contexts. My first chapter uses a multi-state life table approach to investigate the overall level of health and functional ability (the ability to carry out tasks of daily life) among the rural population in Malawi. I find that this population experiences a substantial burden of disability in later life, and that these high levels of disability greatly limit work efforts among older individuals. In my second chapter, I conduct a cross-national comparison of health and disability-free life expectancy using data from recent longitudinal surveys in Costa Rica, Mexico, Puerto Rico, and the US. I find that current disability-free life expectancy at age 65 is comparable across these populations, though future trends are uncertain. My third chapter investigates how Malawi’s 2008 rollout of Anti-Retroviral Therapy (ART) to rural clinics affected overall population health and mortality. I find that the introduction of ART led to substantial declines in mortality and an increase in adult life expectancy, and that population morbidity also decreased after the introduction of ART.
  • Publication
    Urbanization and Demographic Change in Sub-Saharan Africa: Three essays on fertility and child mortality differentials in a rapidly urbanizing context
    (2014-01-01) Corker, Jamaica
    Nearly all demographic research on sub-Saharan Africa (SSA) utilizes a strict urban/rural dichotomy, which implicitly assumes homogenous demographic outcomes within these categories. In this dissertation, I use data from the Demographic and Health Surveys (DHS) to demonstrate that using an urban continuum reveals substantial differences in the demographic outcomes among SSA's growing urban settlements. In the first chapter, I use event-history analysis to examine whether SSA's long-held urban child survival advantage is diminishing, accounting for differentials in city size and potential bias in survival rates due to migration. I find the overall under-5 survival advantage of urban over rural areas persists but that there is a widening of the advantage in the largest cities over smaller urban areas. In the second chapter, I model annual birth probabilities to examine whether there is a discernible "urban effect" of lower fertility among internal migrants in West Africa. Results suggest an association of urban residence and lower fertility, as women who moved either to or from urban areas have lower annual odds of a birth compared to both rural non-migrants and rural-to-rural migrants. I also find that women who relocate to the largest cities have lower fertility than do women who move to smaller urban areas, suggesting that the influence of urban residence on fertility is strongest where fertility rates are lowest. In the final chapter, I estimate total fertility rates and under-5 mortality probabilities for cities of different size in West Africa by linking DHS cluster data to census and geographic information systems (GIS) data for four distinct urban sub-categories. Results show a clear gradient in fertility and child mortality in urban areas according to size, with the largest cities most advantaged; this gradient is as steep between the largest and smallest urban areas as it is between the smallest urban and rural areas. I use the findings from this dissertation to argue for wider use of urban continuums in demographic research on SSA instead of the continued reliance on a strict urban/rural dichotomy that obscures important nuances in the interrelationship of urbanization and demographic change in this rapidly-urbanizing region.