Three Essays in Health and Development.

The quality of healthcare is low in developing countries. In this dissertation, I examine two different proposals to improve healthcare quality: improve customer information regarding healthcare choices, or enroll individuals in health insurance. In Chapter 1, I present results from an audit study conducted in Uganda. I compare the price paid and the drug quality received between shoppers in the same village who either ask for a diagnosis (or declare the patient has malaria) or ask for a drug recommendation (or ask for a specific product. I find that shoppers who present information about either the diagnosis or recommended treatment pay approximately $0.18 (5 percent) less. Counter-intuitively, I find that customers who present information about either the diagnosis or the recommended treatment are 3.4 percentage points more likely to be sold a substandard drug. I develop a conceptual model to justify my findings and conclude that improved information will not improve quality in a market if information and detection of low quality are not sufficiently related. In Chapter 2, coauthored with Esther Atukunda, we present descriptive analyses from the same data collected in Uganda. We combine data from drug outlets, covert shoppers, and real customers to test hypotheses of how low quality drugs enter a market. We estimate that only 3.4 percent of purchased drugs are substandard: a much higher drug quality than found in previous studies. We develop three stylized facts: substandard medicines are typically diluted high-quality medicines; customers cannot tell which drugs are low quality; and vendors are complicit in the sale. We end with a discussion of policy interventions. In Chapter 3, coauthored with Rebecca Thornton, I present results from an experiment conducted in Nicaragua that randomly allocated health insurance subsidies to parents. We specifically examine differential effects among children who were part of an insured household, but ineligible for health insurance themselves due to an age restriction. Our results indicate that the health insurance significantly increases access to higher-quality providers and altered the entire family’s health demands. In particular, eligible and insured children substantially increase healthcare utilization, while ineligible children in insured households decrease healthcare visits.PhDPublic Policy and EconomicsUniversity of Michigan, Horace H. Rackham School of Graduate Studieshttp://deepblue.lib.umich.edu/bitstream/2027.42/113579/1/fitza_1.pd

Henry Whitestone : nineteenth-century Louisville architect.

Henry Whitestone (1819-1893) practiced architecture in the nineteenth century when the prevailing mode in architectural styles was a series of historical revivals. His work, with few exceptions, was entirely within the style of the Italian Renaissance Revival. The present study is an investigation of the historical styles he used and their probable sources, his place in the architectural milieu of the era and of Louisville, and a description of his life, his practice and his clients. In accomplishing these goals much new source material, heretofore unknown, has been used. Whitestone was extremely careful and exacting; he expected and received excellent craftsmanship. He was very conservative in his architectural practice, attempting few new styles. In fact, by the end of his career his work was already considered passe

Forecasting of Storm Surge Floods Using ADCIRC and Optimized DEMs

Increasing the accuracy of storm surge flood forecasts is essential for improving preparedness for hurricanes and other severe storms and, in particular, for optimizing evacuation scenarios. An interactive database, developed by WorldWinds, Inc., contains atlases of storm surge flood levels for the Louisiana/Mississippi gulf coast region. These atlases were developed to improve forecasting of flooding along the coastline and estuaries and in adjacent inland areas. Storm surge heights depend on a complex interaction of several factors, including: storm size, central minimum pressure, forward speed of motion, bottom topography near the point of landfall, astronomical tides, and most importantly, maximum wind speed. The information in the atlases was generated in over 100 computational simulations, partly by use of a parallel-processing version of the ADvanced CIRCulation (ADCIRC) model. ADCIRC is a nonlinear computational model of hydrodynamics, developed by the U.S. Army Corps of Engineers and the US Navy, as a family of two- and three-dimensional finite element based codes. It affords a capability for simulating tidal circulation and storm surge propagation over very large computational domains, while simultaneously providing high-resolution output in areas of complex shoreline and bathymetry. The ADCIRC finite-element grid for this project covered the Gulf of Mexico and contiguous basins, extending into the deep Atlantic Ocean with progressively higher resolution approaching the study area. The advantage of using ADCIRC over other storm surge models, such as SLOSH, is that input conditions can include all or part of wind stress, tides, wave stress, and river discharge, which serve to make the model output more accurate

T-bet controls severity of hypersensitivity pneumonitis

Hypersensitivity Pneumonitis (HP) is an interstitial lung disease that develops following repeated exposure to inhaled environmental antigens. The disease is characterized by alveolitis, granuloma formation and in some patients' fibrosis. IFNγ plays a critical role in HP; in the absence of IFNγ granuloma formation does not occur. However, recent studies using animal models of HP have suggested that HP is a Th17 disease calling into question the role of IFNγ. In this study, we report that initially IFNγ production is dependent on IL-18 and the transcription factor T-bet, however as the disease continues IFNγ production is IL-18-independent and partially T-bet dependent. Although IFNγ production is required for granuloma formation its role is distinct from that of T-bet. Mice that are deficient in T-bet and exposed to S. rectivirgula develop more severe disease characterized by an exacerbated Th17 cell response, decreased Th1 cell response, and increased collagen production in the lung. T-bet-mediated protection does not appear to be due to the development of a protective Th1 response; shifting the balance from a Th17 predominant response to a Th1 response by inhibition of IL-6 also results in lung pathology. The results from this study suggest that both Th1 and Th17 cells can be pathogenic in this model and that IFNγ and T-bet play divergent roles in the disease process

Metabolomics in the Analysis of Inflammatory Diseases

Most infections and traumatic injuries are cleared or repaired relatively rapidly and metabolic homoeostasis is soon restored. However, there is a broad range of inflammatory diseases which involve chronic activation of the immune system and, as a result, chronic persistent inflammation. We have been studying the metabolic consequences of chronic inflammatory diseases with the aim of identifying metabolic fingerprints which may provide clues about why the localised tissue disease persists

Risk factors for hearing loss in children: A systematic literature review and meta-analysis protocol

Background: Hearing loss in newborns and children is a public health concern, due to high prevalence and negative effects on their development. Early detection and intervention of childhood hearing loss may mitigate these negative effects. Population-based newborn hearing screening programs have been established worldwide to identify children at risk for congenital hearing loss and to follow children at risk for late onset or progressive hearing loss. This article presents the protocol for a systematic review that aims to review the risk factors associated with permanent hearing loss in children, including congenital, early, or late onset. Risk factors associated with progressive hearing loss will be investigated as a secondary aim. Methods: Scientific literature from the following databases will be investigated: MEDLINE, Ovid MEDLINE(R) Daily and Ovid MEDLINE(R), Embase, and CINAHL. The primary outcome is a permanent bilateral or unilateral hearing loss with congenital onset or onset during childhood (birth to 18 years). The secondary outcome is progressive hearing loss. Studies must report data on risk factors associated with permanent hearing loss; risk factors may be present at birth or later and result in immediate or delayed hearing loss. Randomized controlled trials, quasi-experimental studies, nonrandomized comparative and non-comparative studies, and case series will be included. The risk of bias will be assessed using the Qualitative Assessment Tool for Quantitative Studies (McMaster University). If aggregation of data is possible for a subsection of studies, we will pool data using meta-analysis techniques. If aggregation of data is not possible, a qualitative synthesis will be presented. We will assess the quality and strength of the overall body of evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE). The systematic review follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations. Discussion: The resulting information will inform the update of a provincial audiological surveillance protocol for the Ontario Infant Hearing Program and will be applicable to early hearing detection and intervention (EHDI) programs worldwide. Systematic review registration: We have registered the protocol in the International Prospective Register of Systematic Reviews (PROSPERO), registration number CRD42018104121

“It gives me confidence”: Caregiver Coaching From the Perspective of Families of Children Who Are Deaf or Hard of Hearing

Caregiver coaching is utilized in early intervention services with families of children who are deaf or hard of hearing to increase caregivers’ skills and confidence in supporting their child’s language development, but few studies have examined coaching from the perspective of the caregivers. The purpose of this study was to increase understanding of caregivers’ experiences of coaching in the context of listening and spoken language intervention services. Using semi-structured, qualitative interviews, this study examined 13 caregivers’ perspectives at three intervention sites in the US and Canada. Results indicate that caregivers perceive that practitioner characteristics, expectations, and the evolution of the coaching relationship over time contribute to a positive caregiver coaching relationship. This study contributes to the understanding of the caregiver coaching experience and has implications for new and experienced practitioners working to improve their practice by establishing and strengthening collaborative caregiver coaching relationships with the families they serve

“It’s About Walking Alongside a Family”: Practitioner Perspectives on Caregiver Coaching With Families of Children Who Are Deaf or Hard of Hearing

Practitioners utilize caregiver coaching in early intervention services, but coaching principles and practices are not well understood in the context of listening and spoken language (LSL) services with families of children who are deaf or hard of hearing. The purpose of this study was to examine practitioners’ experiences with coaching, including definitions, training, and practices they utilize in their work with families. Using semi-structured, qualitative interviews and video observation discussions, this study examined the perspectives of 14 practitioners providing LSL services to families at three intervention sites in the US and Canada. Results indicate that practitioners’ underlying beliefs about their coaching proficiency and caregivers’ capacity impact their coaching practices and how they engage with caregivers. Results highlight practices such as mentoring and accountability that supported practitioners’ coaching skills. This study contributes to the understanding of caregiver coaching in LSL practice and has implications for practitioners working to improve their coaching skills, which may improve LSL services and optimize child outcomes