Browsing by Subject "Population health"

This thesis will examine hospital chaplaincy and its role within the changing paradigm of population health by addressing the question of what chaplaincy looks like beyond the walls of the hospital. The thesis will include several moves that account for the development of the profession and possible areas of growth in dialogue with public health and behavioral health. The first move is historical. This section will cover the development of chaplaincy at Atrium Health Wake Forest Baptist and its relationship to counseling, community engagement, and accrediting bodies. It will also discuss the formation of FaithHealth as both a divisional identity as part of Atrium Health Wake Forest Baptist and a distinct department of community engagement. The second move will be to present the role of chaplain manager within the division of FaithHealth of Atrium Health Wake Forest Baptist and its pioneering work of integrating chaplaincy, community engagement, and licensed counseling. The third move will describe the function of chaplain managers during the coronavirus pandemic and the structure that allowed the model to adapt to a changing landscape. The final move will evaluate the role of chaplain managers from the individuals that assume these roles and leaders within the medical system and provide a snapshot into future possibilities for this role and innovative ministry opportunities.The purpose of this work is threefold: 1) to provide a model for integrating spiritual care, behavioral health and population health into the role of chaplain manager; 2) to advocate for the profession’s continued expansion by adapting chaplaincy’s skillsets in community health; 3) to begin a conversation about modifying educational and professional bodies to best prepare graduates and professionals for the changing landscape of healthcare. Such a model could provide clearer vocational pathways for dual degree divinity school programs and forge new partnerships between public health and divinity schools. Furthermore, given the reinstated associational connection between pastoral counseling and clinical pastoral education, this model of integration could create new associational paths to certification. The connection between pastoral counseling and chaplaincy that thrived before managed care will be revisited as it shows different, yet complementary, fruits of deeply rooted spiritual care.

The social gradient of health is pervasive and unrelenting. Across nearly any layer of society – race, religion, economic standing, or others – the populations worst off in terms health are also the most socially disadvantaged. Over three studies, this dissertation examines some of the experiences that underlie the connection between social disadvantage and health, namely internalized perceptions of status, interpersonal interactions, and institutional actions. The first study examines the link between adolescents’ perceived social status and their mental health at a range of ages, identifying at what age mental health problems begin to track perceptions of status, as well as contextual factors that do (or do not) relate to perceptions of status. In the second study, data from a nationally representative survey in France are used to document rates of reporting discrimination within the healthcare setting by gender, immigrant status, race/ethnicity, and religion. Rates of foregoing medical care are also documented across the same groups, and the potential explanatory role of discrimination toward disparities in foregone care is then investigated. The third and final study looks at the role of institutional stigma, using state bans of Sharia law in the USA as an exemplary case of stigmatizing policies with minimal material consequences. National birth record data for the USA is used, and the variation in policy enactment over time and space is leveraged to examine birth outcomes for Muslim women who were pregnant at the time their state passed a ban. Findings reveal a decrease in the secondary sex ratio to targeted women, suggesting the stigmatizing policy acts as a population-level stressor with consequences for maternal health.

In this dissertation, I study medicalization, a wide spread phenomenon in this world but understudied in the current literature. The main theoretical focus of this dissertation is on expanding the medicalization theories. Questioning the breadth of conceptualization, the feasibility of measurement, and the depth of empirical implications in the extant medicalization theories, this dissertation proposes a new conceptual model of medicalization and further develops a quantitative measure of medicalization by disaggregating it into empirically valid dimensions that could be used to examine how degree of medicalization is related to social outcomes. Specifically, I conceptualize medicalization as an institutionalization process whereby the medical model becomes increasingly dominant in the explanation of health, illness, and other human problems and behavior. Medicalization is multidimensional and is represented by expansions in the three major components of the health care system: increasing medical investment, medical professionalization/specialization, and the relative size of the pharmaceutical industry.

Based on this new conceptual model and measurement, I probe three research questions: (1) how medicalization may impact population health in the context of recent epidemiologic transitions and how this impact may differ by the stages of epidemiologic transition and socioeconomic development; (2) what are the mechanisms that reproduce medicalization; and (3) how the lay public may respond to medicalization, the institution of medicine, and the medical profession.

This dissertation links several lines of theoretical and empirical research from medical sociology, demography, epidemiology, health economics and management, and medical science, and extensively employs OECD Health Data, World Development Indicators, the World Values Survey, the European Values Study data, the U.S. General Social Survey, and the U.S. National Health Interview Survey. It uses several advanced statistical methods, e.g., multiple imputations, latent variable analysis, mixed models, generalized estimating equations models, generalized method of moments models, difference-in-difference models, and hierarchical-age-period-cohort models.

Results for the first research question suggest that various dimensions of medicalization vary in importance on population health and these effects also differ by the stages of epidemiologic transition and socioeconomic development. I discuss the mechanisms linking various dimensions of medicalization to population health and then discuss these findings in the context of epidemiologic transition, fundamental causes of disease and death, and global health movement.

Results for the second research question suggest that medicalization at both the societal and individual levels negatively affect individual subjective health, which leads to increasing health care utilization. These social processes function together to promote and reproduce medicalization at societal level. I discuss several pathways linking medicalization to lower subjective health and other agents of medicalization.

Results for the third research question suggest that American's "confidence in the medical institution and profession" has continuously declined in the last three decades and groups with higher socioeconomic status report lower obedience to doctors' authority, but are more likely to trust doctors' ethics than their counterparts. I discuss the mechanisms for the changes in public confidence in the medical institution and profession, the status of medicine and the medical profession in the era of medicalization, the paradox of opposite trends in attitudes toward medicine and health utilization behavior, and group differences in obedience and trust.

Contemporary, empirically-based knowledge of transgender health is scant and lacks understanding of physical health, health problems or impairments, chronic health conditions, and the impact of individual factors known to affect health outcomes in other vulnerable populations such as socioeconomic position and sexual orientation (Bowleg, 2012; MacCarthy, Reisner, Nunn, Perez-Brumer, & Operario, 2015). Despite a growing body of health-related literature, additional research is needed to advance our understanding of health among transgender subgroups such as male-to-female (MTF, transgender women), female-to-male (FTM, transgender men), and gender nonconforming (GNC) adults. This knowledge will help prioritize health needs and identify pathways to improve the health and reduce the health inequities plaguing the transgender population in the U.S. (Feldman et al., 2016; Institute of Medicine, 2011).

The purpose of this dissertation research was to establish evidence regarding the health of transgender and GNC adults in the United States. Specifically, this dissertation 1) reviewed current literature on the experiences of transgender adults when they access and utilize healthcare, 2) identified and addressed methodological concerns related to conducting transgender health research using data from the 2015 Behavioral Risk Factor Surveillance System (BRFSS), and 3) explored the health status of three transgender subgroups (MTF, FTM, and GNC adults) and their cisgender male (CGM) and cisgender female (CGF) counterparts. Health status analyses included 1) bivariate logistic regression models and one-way analysis of variance methods to test for study group differences in individual factors and health status, and 2) multivariable logistic regression models to determine the differential effects of individual factors on health status in the five study groups. A posteriori pairwise contrasts of the study groups were conducted when a significant overall study group effect was detected.

The main findings from this dissertation include the following. First, transgender adults experience numerous obstacles accessing healthcare, discrimination from healthcare professionals and clinicians, and barriers to medically necessary care, such as cross-sex hormones, as well as primary and preventative healthcare. Second, the 2015 BRFSS data collection procedures introduced measurement error and sex misclassification that contributed towards problematic BRFSS sampling weights. Third, transgender adults have poorer health than their cisgender counterparts. However, when data are disaggregated into transgender subgroups, notable differences in the health of MTF, FTM, and GNC adults are revealed. Notably, GNC adults have poorer overall health than their transgender and cisgender counterparts.

Overall, the studies from this dissertation provide empirical evidence to inform health promotion and illness prevention in transgender and GNC adults. These findings make significant contributions to the transgender health knowledge base, and advance the field by identifying priority research topics, policy areas, and methodological considerations for public health surveillance and population surveys aimed at improving the health of transgender and gender nonconforming people. Findings also provide the foundation to improve healthcare delivery and educational programs for current and future health professionals. To further advance transgender health knowledge, a more comprehensive understanding of how gender identity and gender expression influence health status and healthcare utilization for transgender and GNC adults is needed.