Browsing by Subject "Health behaviors"

In this dissertation, I conduct three studies focusing on differences in social groups and their health outcomes or opinions related to medical practices. In Chapter 1, I outline each study and its findings.

Chapter 2 focuses on the Great Recession in the United States (2007–2009) and how this crisis is associated with health disparities. In this chapter, I use nine waves spanning 16 years (1998-2014) of the RAND version of the Health and Retirement Study (HRS) to examine disparities in cardiovascular disease, stroke, or related death (e.g., circulatory disease) among Americans ages 50 and older to determine whether these health disparities among different educational groups narrowed, widened, or remained constant during and after the Great Recession. In general, findings from discrete-time hazard analyses suggest that the disparities remained relatively constant with some (nonsignificant) evidence of some narrowing between the most educated and least educated groups.

Chapter 3 examines whether there is symmetry in the effects of certain health behaviors—smoking, drinking, weight management—on cardiovascular disease, stroke, or related death between socioeconomic groups. This chapter also uses nine waves (1998–2014) of the RAND HRS. Discrete-time hazard regression analyses indicate that while those with higher socioeconomic status maintain better health outcomes regardless of health behaviors, the effects of health behaviors are not equally distributed. Poor weight management and higher numbers of daily cigarettes are associated with a greater increased risk for those with more education than for those with less. The effects of heavy drinking, however, are less severe for the those with the most education compared to those with the least education.

Chapter 4 studies the role of social change by investigating trends in approval for euthanasia among cohorts in the United States and how those trends are influenced by cohort replacement and religious attitudes. This chapter uses 16 waves of the General Social Survey (1985–2014) and estimates differences in approval ratings between cohorts using logistic regression models. Results show that baby boomers are significantly more likely to approve of euthanasia than either their predecessors or successors, suggesting a cohort effect. Individuals belonging to more conservative religious groups and displaying higher levels of religiosity are less likely to approve. With the meaningful effect of cohorts on approval for euthanasia, findings suggest that as baby boomers age and as the population becomes less religious, approval for euthanasia might increase again.

BACKGROUND: Non-communicable diseases are currently the leading cause of death worldwide. Leading healthy lifestyles as a means of prevention is one of the most important aspects of preventing the occurrence of non-communicable diseases. Working from the premise that physicians globally serve as role models for patients and their health beliefs can influence how they interact and counsel patients, this international study ("MedLife") seeks to examine the self-report of health behaviors and clinical practice attitudes towards preventive counseling of medical students at institutions in China and the US, and identify any associations between these behaviors and students' clinical practice attitudes towards preventive counseling of future patients.

METHODS: From 2012-2013, a total of 860/1,216 (response rate = 71%) medical students from Duke University in the US and Peking University Health Science Center and Xi'an Jiaotong University in China completed culturally-adapted web versions of the 33-item "MedLife" questionnaire. Items from the survey were pulled from previously validated survey tools and included questions on diet, exercise, smoking, and alcohol consumption. Alcohol consumption was divided into heavy drinking and binge drinking. Prevalence estimates of health behaviors and attitudes towards preventive counseling in the domains of diet, exercise, smoking, and alcohol consumption were obtained in addition to measures of association between health behaviors and clinical practice attitudes towards counseling future patients on these issues. Finally, multivariate logistic regression analyses were performed to assess the associations between personal habits and clinical practice attitudes towards preventive counseling while adjusting for gender.

RESULTS: The median ages of students at Duke University in years 1, 2, 3, and 4 were 23 years, 24 years, 25 years, and 26 years, respectively. The median ages of students at both schools in China among second, fourth, and seventh year students were 19 years, 22 years, and 24 years, respectively. In addition, the percentage of total females at Duke University and in China who completed the survey was 51% and 54%, respectively. Prevalence estimates of a healthy lifestyle, defined as complying with widely recognized recommendations at Duke University in the domains of diet, exercise, smoking, non-binge drinking, and non-heavy drinking were 30%, 42%, 99%, 41%, and 97%, respectively. Prevalence estimates in China of a healthy lifestyle in diet, exercise, smoking, non-binge drinking, and non-heavy drinking were 17%, 33%, 97%, 94%, and 99%, respectively. Overall, approximately 30% of medical students at Duke and 25% of medical students in China had positive clinical practice attitudes towards preventive counseling in terms of diet, exercise, smoking, and alcohol consumption combined. No statistically significant associations between the self-report of health behaviors and clinical practice towards preventive counseling were found among Duke medical students. Second, fourth, and seventh year medical students in China together who complied with all lifestyle recommendations were two times more likely to have a positive clinical practice attitude towards preventive counseling on all healthy lifestyle domains (diet, exercise, smoking, and alcohol) combined (OR=2.03 95% CI=1.06-3.92; p=0.03). When adjusted for gender, this positive association among Chinese medical students was still statistically significant (OR=1.98 95% CI=1.02-3.83; p=0.04).

CONCLUSION: Medical students self-reported that they led unhealthy lifestyles in the domains of diet, exercise, and alcohol binge drinking at Duke and in the domains of diet and exercise in China. However, there was little evidence of an association between self-report of health behaviors and clinical practice towards preventive counseling for Duke medical students. But there was evidence among Chinese medical students to support an association between an overall self-reported healthy lifestyle and positive clinical practice attitudes towards preventive counseling on diet, exercise, smoking, and alcohol consumption combined, even after adjusting for gender. If clinicians are going to serve as role models and have their behaviors and lifestyle choices influence patients, medical schools need to ensure students lead healthy lifestyles in these areas and improve positive clinical practice attitudes towards preventive counseling on diet, exercise, smoking, and alcohol consumption to help curb the global cardiovascular disease epidemic. Student health and positive clinical practice attitudes towards preventive counseling should be a top priority for all medical schools, and it seems that policies aimed at improving student health in China are likely to be associated with positive clinical practice attitudes towards preventive counseling.

Indonesia consistently records higher levels of maternal mortality than other countries in Southeast Asia with its same level of socioeconomic development. I use a quasi-experimental, difference-in-differences approach to understand whether the role of information on the risk of death in childbirth can change women’s reproductive behaviors. In the first two chapters, I use the Maternal Mortality Module from the Demographic and Health Survey (DHS) in Indonesia to examine fertility and reproductive behavior responses to a sister’s death in childbirth. Fertility desires remain relatively unchanged but women take up behaviors in subsequent births that avert the risk of maternal death. In the last chapter, I combine population-representative data from the DHS with a village-level census (PODES) on service availability to understand how a village-level intervention to improve obstetric service use using a birth preparedness and complications readiness (BPCR) approach may improve obstetric service use. In this study, I find that the Desa Siaga intervention in Indonesia improved knowledge of the danger signs of complications among women but not among men relative to villages that did not get the program while controlling for endogenous program placement. More women got antenatal care due to the program but use of a skilled birth attendant and postpartum care did not change as a result of the intervention. Both genders report discussing a blood donor in preparation for delivery.