Research

Caste And Religion Based Discrimination In Healthcare Delivery: Evidence From India (Job Market Paper)

Despite overall improvements in population health in India, there remain significant differences in health outcomes along caste and religious lines. Due to the lack of rigorous evidence, it is unclear if these differences stem from a lack of access to healthcare or discrimination at point of care. I use a randomized controlled trial to measure the discrimination faced by patients at point of care by private health care providers in Bihar, India. I use standardized patients (SPs) seeking care for asthma that vary only in their religious and caste presentation to measure the causal effect of caste and religion on technical and interpersonal quality of care. SPs presenting as Muslims with religious indicators (such as eyeliner, a beard, and skullcap) received technical quality of care scores that were 0.29 standard deviations lower than upper case Hindu SPs and interpersonal quality of care scores that were 0.19 standard deviations lower than Hindu SPs. SPs presenting as Muslims without any religious indicators (only a Muslim name) or as Dalit (individuals of a lower-caste or without a caste) also received lower technical quality of care scores than upper-caste Hindu SPs but did not experience significantly worse interpersonal quality of care. Further, the lower care quality experienced by minority groups (Muslim or Dalit) was attenuated when the provider was also of a minority group but the difference in healthcare quality between the minority and Hindu SP types increased. These finds suggest that differences in health outcomes among underserved minorities such as Muslims and Dalits are driven, in part, by discrimination at the point of care – especially by providers of a different religious or caste identity. The results suggest that interventions such as implicit-bias trainings or assigning underserved communities with healthcare providers from the same communities could help improve outcomes for these groups. 

What Drives Poor Quality Of Care For Child Diarrhea? Experimental Evidence From Private Providers In India

Wagner, Z., Mohanan, M., Zutshi, R., Mukherji, A., Sood, N. Science, 2024 [link]

Nearly 500 thousand children die each year from diarrhea. Almost all these young lives could be saved with a low-cost and widely available treatment: oral rehydration salts (ORS). Even when children visit a health care provider (as most do) they are often not prescribed ORS and instead are prescribed antibiotics, which are usually inappropriate. The objective of this research is to rigorously document why private providers in India fail to prescribe ORS and instead prescribe antibiotics.  We used a cluster-randomized controlled trial including 2,210 providers across 253 towns in India to study the role of several leading explanations for under prescribing of ORS and over prescribing of antibiotics for child diarrhea: patient preferences, providers' financial incentives, and ORS stock-outs. To measure the effect of patient preferences, we randomly assigned providers to receive unannounced visits from standardized patients (SPs) expressing either a preference for ORS, a preference for antibiotics, or no preference. To measure the effect of financial incentives, a subset of no-preference SPs informed the provider that they would purchase medicines from a different location, eliminating the financial incentive to recommend more lucrative treatments. Finally, to estimate the effect of ORS stock-outs, we randomly assigned all providers in half of the 253 towns to receive a 6-week supply of ORS. Despite high levels of knowledge about appropriate diarrhea care, only 28% of providers prescribed ORS to SPs who did not express a preference. Expressing a preference for ORS increased ORS prescribing by 27 percentage points (96%) and reduced antibiotics prescribing by 10 percentage points (14%). Expressing a preference for antibiotics increased inappropriate antibiotics prescribing by 7.5 percentage points (10%), but did not affect ORS prescribing. Removing financial incentives increased ORS prescribing at pharmacies by 10 percentage points (58%), but had no effect on prescribing at clinics. Increasing supply of ORS increased ORS dispensing by about 3 percentage points among all clinics and by 8 percentage points at clinics that sell medicines. Combing our estimates with population surveys of caretakers and providers, we estimate that  40% of under-prescribing of ORS is explained by perceptions that patients do not prefer ORS, 15% is explained by stock-outs, 6% is explained financial incentives, and the remaining 39% is explained by other factors. These results imply that interventions to shift provider perceptions of patient preferences for ORS have the most potential, followed by subsidizing ORS supply at clinics that sell medicine, and addressing financial incentives at pharmacies. However, a substantial amount of under-prescribing of ORS is likely to remain even after addressing these barriers.

The Cost-Effectiveness Of Community Health Workers Delivering Free Diarrhea Treatment: Evidence From Uganda 

Wagner, Z., Zutshi, R., Asiimwe, J. B., & Levine, D. Health Policy and Planning, 2022 [link]

Community health workers (CHWs) are a vital part of the health infrastructure in Uganda and in many other low- and middle-income countries. While the need for CHWs is clear, it is less clear how they should dispense health products to maximize the health benefits to their community. In this study, we assess the cost-effectiveness of several competing CHW distribution strategies in the context of treatment for child diarrhoea. We used data from a four-armed cluster-randomized controlled trial to assess the cost-effectiveness of (1) free distribution of oral rehydration salts (ORS) via home deliveries prior to diarrhoea onset (free delivery arm), (2) free distribution via vouchers where households retrieved the treatment from a central location (voucher arm), (3) a door-to-door sales model (home sales arm) and (4) a control arm where CHWs carried out their activities as normal. We assessed the cost-effectiveness from the implementor’s perspective and a societal perspective in terms of cost per case treated with ORS and cost per disability-adjusted life year (DALY) averted. Free delivery was the most effective strategy and the cheapest from a societal perspective. Although implementor costs were highest in this arm, cost savings comes from households using fewer resources to seek treatment outside the home (transport, doctor fees and treatment costs). From the implementors’ perspective, free delivery costs $2.19 per additional case treated and $56 per DALY averted relative to the control. Free delivery was also extremely cost-effective relative to home sales and vouchers, but there was a large degree of uncertainty around the comparison with vouchers. Free distribution of ORS by CHWs prior to diarrhoea onset is extremely cost-effective compared to other CHW distribution models. Implementers of CHW programmes should consider free home delivery of ORS.

Microsimulation Projections Of Obesity Interventions On Cardiometabolic Health Disparities In The United States 

Richardson, A. S., Zutshi, R., Nguyen, P., Tysinger, B., & Sturm, R. Obesity, 2022 [link]

The aim of this study was to estimate long-term impacts of health education interventions on cardiometabolic health disparities. The model simulates how health education implemented in the United States throughout 2019 to 2049 would lead to changes in adult BMI and consequent hypertension and type 2 diabetes. Health outcome changes by sex, racial/ethnic (non-Hispanic White, non-Hispanic Black, and Hispanic), and weight status (normal: 18.5  BMI < 25; overweight: 25  BMI < 30; and obesity: 30  BMI) subpopulations were compared under a scenario with and one without health education. By 2049, the intervention would reduce average BMI of women with obesity to 27.7 kg/m2 (CI: 27.4-27.9), which would be 2.9 kg/m2 lower than the expected average BMI without an intervention. Education campaigns would reduce type 2 diabetes prevalence, but it would remain highest among women with obesity at 27.7% (CI: 26.2%-29.2%). The intervention would reduce hypertension prevalence among White women by 4.7 percentage points to 38.0% (CI: 36.4%-39.7%). For Black women in the intervention, the 2049 hypertension prevalence would be 52.6% (CI: 50.7%-54.5%). Results for men and women were similar. Long-term health education campaigns can reduce obesity-related disease. All population groups benefit, but they would not substantially narrow cardiometabolic health disparities.

Text Messaging Intervention For Young Smokers Experiencing Homelessness: Lessons Learned From a Randomized Controlled Trial 

S., Linnemayr, S., Zutshi, R., Shadel, W.G., Pedersen, E.R., DeYoreo, M., Tucker, J.  JMIR mHealth and uHealth, 2021 [link]

Smoking rates are significantly higher among young people experiencing homelessness than in the general population. Despite a willingness to quit, homeless youth have little success in doing so on their own, and existing cessation resources tailored to this population are lacking. Homeless youth generally enjoy the camaraderie and peer support that group-based programs offer, but continuous in-person support during a quit attempt can be prohibitively expensive. This study aimed to assess the feasibility and acceptability of an automated text messaging intervention (TMI) as an adjunct to group-based cessation counseling and provision of nicotine patches to help homeless youth quit smoking. This paper outlines the lessons learned from the implementation of the TMI intervention. Homeless youth smokers aged 18 to 25 years who were interested in quitting (n=77) were recruited from drop-in centers serving homeless youth in the Los Angeles area. In this pilot randomized controlled trial, all participants received a group-based cessation counseling session and nicotine patches, with 52% (40/77) randomly assigned to receive 6 weeks of text messages to provide additional support for their quit attempt. Participants received text messages on their own phone rather than receiving a study-issued phone for the TMI. We analyzed baseline and follow-up survey data as well as back-end data from the messaging platform to gauge the acceptability and feasibility of the TMI among the 40 participants who received it. Participants had widespread (smart)phone ownership—16.4% (36/219) were ineligible for study participation because they did not have a phone that could receive text messages. Participants experienced interruptions in their phone use (eg, 44% (16/36) changed phone numbers during the follow-up period) but reported being able to receive the majority of messages. These survey results were corroborated by back-end data (from the program used to administer the TMI) showing a message delivery rate of about 95%. Participant feedback points to the importance of carefully crafting text messages, which led to high (typically above 70%) approval of most text messaging components of the intervention. Qualitative feedback indicated that participants enjoyed the group counseling session that preceded the TMI and suggested including more such group elements into the intervention. The TMI was well accepted and feasible to support smoking cessation among homeless youth. Given high rates of smartphone ownership, the next generation of phone-based smoking cessation interventions for this population should consider using approaches beyond text messages and focus on finding ways to develop effective approaches to include group interaction using remote implementation. Given overall resource constraints and in particular the exigencies of the currently ongoing COVID-19 epidemic, phone-based interventions are a promising approach to support homeless youth, a population urgently in need of effective smoking cessation interventions.

Increased Risk For Sexual Violence Victimization On Drinking Days Involving Pregaming

Pedersen, E. R., Davis, J. P., Setodji, C., Dworkin, E. R., Leamon, I., Hummer, J. F., Zutshi, R., Clapp, J. D. Journal of Aggression, Maltreatment, and Trauma, 2022 [link]

Alcohol consumption has been associated with an increased risk of sexual violence victimization and perpetration. Pregaming, a popular activity among college students that involves heavy and quick drinking prior to going out for the night and often results in high blood alcohol levels (BALs), may convey an increased risk for sexual violence – potentially due to a greater likelihood of contact with intoxicated perpetrators and significantly impaired victim ability to consent or resist. Yet no published work has evaluated whether there is an increased risk for victimization on drinking days that involve pregaming. Using a sample of 390 college student drinkers who completed a past 30-day Timeline Followback, we examined heavy drinking behavior, estimated BALs, and experience of sexual violence victimization during 1,899 drinking days, of which 30% involved pregaming. After controlling for demographics, we found that participants drank approximately two more drinks and reached significantly higher BALs on drinking days where they pregamed as compared to drinking days where they did not pregame. Nearly 6% of drinking days that included pregaming involved sexual violence victimization, compared to about 2% of drinking days where pregaming did not occur. Participants were at 2.71 times the odds of experiencing sexual violence, primarily unwelcomed comments and nonconsensual sexual touching, during drinking days with pregaming. This study represents a first step towards a greater understanding of the sexual violence and pregaming link, but future research assessing perpetrator behavior and context-specific factors (e.g., amount consumed by victims and perpetrators, location of sexually violent events, and peers present) are needed.

Pilot Randomized Clinical Trial Of A Text Messaging-Based Intervention For Smoking Cessation Among Young People Experiencing Homelessness

Tucker, J.S., Linnemayr, S., Pedersen, E.R., Shadel, W.G., Zutshi, R., DeYoreo, M., Cabreros, I. Nicotine and Tobacco Research, 2021 [link]

Smoking rates are alarmingly high among young people experiencing homelessness (YEH), yet there are no evidence-based cessation programs for this population. This paper presents results from a pilot evaluation of a text messaging-based smoking cessation treatment, as an adjunct to brief group cessation counseling, to improve abstinence rates among 18–25-year-old smokers experiencing homelessness. The goal of this study was to estimate effect sizes for a larger trial and it was not powered to detect group differences. YEH smokers who had a working cell phone with them at recruitment were randomized to receive a group counseling session, nicotine patches, and written material on quitting (n = 37) or a similar program that also included a 6-week automated text messaging intervention (TMI) to provide ongoing support for quitting (n = 40). Smoking outcomes were evaluated through a 90-day follow-up. Seven-day point prevalence abstinence at 90-day follow-up was higher in the TMI condition than standard condition (17.50% vs. 8.11%, respectively; Cohen’s h = .37); however, the 90-day continuous abstinence rate was not statistically different from zero in either condition. Reductions in the number of days smoked in the past 30 days from baseline to follow-up were greater in the TMI condition than the standard condition (−14.24 vs. −8.62, respectively; Cohen’s d = .49).  Adding a 6-week TMI support to a brief group counseling and pharmacotherapy protocol holds promise for smoking reduction and abstinence among YEH smokers. Results indicate that further development and evaluation of the TMI in this population is warranted.

Text Message Intervention For Quitting Cigarette Smoking Among Young Adults Experiencing Homelessness: Study Protocol For A Pilot Randomized Controlled Trial

Tucker, J.S., Pedersen, E.R., Linnemayr, S., Shadel, W.G., DeYoreo, M., Zutshi, R. Addiction science & clinical practice, 2020 [link]

Cigarette smoking is much more prevalent among young people experiencing homelessness than in the general population of adolescents and young adults. Although many young homeless smokers are motivated to quit, there are no empirically-evaluated smoking cessation programs for this population. It is important that any such program address the factors known to be associated with quitting-related outcomes among homeless young people, to provide ongoing support in a way that accommodates the mobility of this population, and does not rely on scarce service provider resources for its delivery. The objective of this project is to develop and pilot test a text messaging-based intervention (TMI), as an adjunct to brief cessation counseling and provision of nicotine patches, to help homeless young people who want to quit smoking. This pilot study will utilize a cluster cross-over randomized controlled design with up to 80 current smokers who desire to quit and are recruited from three drop-in centers serving young people experiencing homelessness in the Los Angeles area. All participants will be provided with a minimum standard of care: a 30-min group-based smoking cessation counseling session and free nicotine replacement. Half of these smokers will then also receive the TMI, as an adjunct to this standard care, which will provide 6 weeks of ongoing support for quitting. This support includes continued and more intensive education regarding nicotine dependence, quitting smoking, and relapse; does not require additional agency resources; can be available “on demand” to users; and includes features to personalize the quitting experience. This study will investigate whether receiving the TMI adjunct to standard smoking cessation care results in greater reductions in cigarette smoking compared to standard care alone over a 3-month period. This study has the potential to address an important gap in the clinical research literature on cigarette smoking cessation and provide empirical support for using a TMI to provide ongoing assistance and support for quitting among young smokers experiencing homelessness.

Evidence Map Of Ductal Carcinoma In Situ Management Options

Bouskill, K., Hempel, S., Richardson, A., Ganz, P.A., Baxi, S., Zutshi, R., Larkin, J., Motala, A., Miles, J.N. and Crandall, C.J., Menopause, 2019 [link]

Ductal carcinoma in situ (DCIS) has the potential to progress to invasive carcinoma. The optimal management of DCIS and methods for individualizing treatment of DCIS are still being determined. This evidence map depicts the robustness and topical span of research on DCIS management choice on patient-centered and clinical outcomes. We searched PubMed, EMBASE, PsycINFO, PubMed Health, PROSPERO, and clinical practice guideline sites to identify systematic reviews of DCIS management options and consulted with topic experts. A bubble plot visualizes the literature volume and research content for patient-centered outcomes. An online decision tree facilitates discussions with patients and guides through the available evidence. In total, 40 systematic reviews met inclusion criteria. The research syntheses addressed DCIS management options, including the role of magnetic resonance imaging, axillary surgery/sentinel lymph node biopsy, and excisional biopsy. The map shows existing evidence for mutually exclusive treatment options including active surveillance, breast-conserving surgery, nipple-sparing mastectomy, and simple mastectomy. Research findings for intraoperative radiation, adjuvant radiation therapy, adjuvant hormone therapy, hypofractionation radiotherapy, accelerated partial breast irradiation, radiation therapy plus boost, and combined radiation and hormone therapy, as well as for breast reconstruction after mastectomy and surveillance mammography postsurgery are also displayed. The evidence map highlights a scarcity of robust evidence on patient-centered outcomes. The evidence map provides an overview of DCIS research showing the range of management options and remaining decisional dilemmas that follow a diagnosis of DCIS. It maps the evidence in accessible tools to guide practice and future research.