Faculty Bibliography

This paper examines the political embeddedness of public-sector primary care in urban India. The low quality of urban healthcare in many low- and middle-income countries is well documented. But there is relatively little analysis showing how the politics of urban healthcare delivery contribute to quality shortfalls. This study integrates urban and political theory and draws on ethnographic fieldwork in municipal government-run primary care clinics in Pune, India. I conceptualize Pune's municipal doctors as street-level bureaucrats: frontline state agents charged with delivering public services, who regularly confront conflicts between their mandate and its realization in practice. I observe how the municipal doctors experience and respond to these conflicts; delineate the historical design of the municipal institutions in which they operate; and interview doctors, nurses, nonclinical staff, administrators, and elected officials, who collectively shape primary care delivery in municipal clinics. My findings show how the doctors' work is characterized by routine departures from public service ideals. The departures stem from local electoral politics (politicians' patronage and clientelistic relations with municipal employees and patients) and weak administrative capacity (misuse and incompetent planning of public resources). The doctors are compelled to follow extra-policy directives, meaning instructions that have little to do with healthcare goals and that emphasize the political utility rather than medical purpose of their work. In response, the doctors circumscribe their clinical practice. They aim, as one doctor put it, only to "ensure the ordinary," or to sustain a deficient status quo. In these conditions, improving quality of care requires not just behavioral interventions targeted at doctors. It requires normative, social, and organizational shifts in public service planning and delivery so that doctors are positioned - materially and affectively - to meet urban healthcare challenges in low-resource contexts.

Hypertension affects a third of U.S. adults and is especially high among Asian American groups. The Racial and Ethnic Approaches to Community Health for Asian AmeRicans (REACH FAR) project delivers culturally adapted, evidence-based hypertension-related programs to Bangladeshi, Filipino, Korean, and Asian Indian communities in New York and New Jersey through 26 sites: ethnic grocery stores, restaurants, and Muslim, Christian, and Sikh faith-based organizations. Knowledge of the implementation mechanisms of culturally adapted programs is limited and is critical to inform the design and execution of such programs by and in community sites. We applied four categories of the Consolidated Framework for Implementation Research-intervention and individuals' characteristics, inner and outer setting-to analyze factors influencing implementation outcomes, that is, site leaders' perceptions about adopting, adapting, and sustaining REACH FAR. We conducted semistructured interviews with 15 leaders, coded them for implementation outcomes, and recoded them to identify contextual factors. Our findings show that REACH FAR resonated in sites where leaders perceived unhealthy diet and lifestyles in their communities (intervention characteristics), sites had historically engaged in health programs as a public-service mission (inner setting), and leaders identified with this mission (individuals' characteristics). Site leaders strived to adapt programs to respond to community preferences (outer setting) without compromising core objectives (inner setting). Leaders noted that program sustainability could be impeded by staff and volunteer turnover (inner setting) but enhanced by reinforcing programs through community networks (outer setting). The findings suggest that to facilitate implementation of culturally adapted health behavior programs through community sites, interventions should reinforce sites' organizational commitments and social ties.

BACKGROUND:Evidence shows community health workers (CHWs) can effectively deliver proven behavior-change strategies to prevent type 2 diabetes mellitus (diabetes) and enhance preventive care efforts in primary care for minority and low-income populations. However, operational details to integrate CHWs into primary care practice remain less well known. OBJECTIVE:To examine clinicians' perceptions about working with CHWs for diabetes prevention in safety-net primary care. SETTING/METHODS:Clinicians are primary care physicians and nurses at two New York City safety-net hospitals participating in CHORD (Community Health Outreach to Reduce Diabetes). CHORD is a cluster-randomized trial testing a CHW intervention to prevent diabetes. DESIGN/METHODS:Guided by the Consolidated Framework for Implementation Research, we studied how features of the CHW model and organizational context of the primary care practices influenced clinicians' perspectives about the acceptability, appropriateness, and feasibility of a diabetes-prevention CHW program. Data were collected pre-intervention using semi-structured interviews (n = 18) and a 20-item survey (n = 54). APPROACH/METHODS:Both survey and interview questions covered clinicians' perspectives on diabetes prevention, attitudes and beliefs about CHWs' role, expectations in working with CHWs, and use of clinic- and community-based diabetes- prevention resources. Survey responses were descriptively analyzed. Interviews were coded using a mix of deductive and inductive approaches for thematic analysis. KEY RESULTS/RESULTS:Eighty-seven percent of survey respondents agreed CHWs could help in preventing diabetes; 83% reported interest in working with CHWs. Ninety-one percent were aware of clinic-based prevention resources; only 11% were aware of community resources. Clinicians supported CHWs' cultural competency and neighborhood reach, but expressed concerns about the adequacy of CHWs' training; public and professional emphasis on diabetes treatment over prevention; and added workload and communication with CHWs. CONCLUSIONS:Clinicians found CHWs appropriate for diabetes prevention in safety-net settings. However, disseminating high-quality evidence about CHWs' effectiveness and operations is needed to overcome concerns about integrating CHWs in primary care.

BACKGROUND:South Asians experience a disproportionate burden of high blood pressure (BP) in the United States, arguably the most preventable risk factor for cardiovascular disease. OBJECTIVE:We report 12-month results of an electronic health record (EHR)-based intervention, as a component of a larger project, "Implementing Million Hearts for Provider and Community Transformation." The EHR intervention included launching hypertension patient registries and implementing culturally tailored alerts and order sets to improve hypertension control among patients treated in 14 New York City practices located in predominantly South Asian immigrant neighborhoods. DESIGN/METHODS:Using a modified stepped-wedge quasi-experimental study design, practice-level EHR data were extracted, and individual-level data were obtained on a subset of patients insured by a Medicaid insurer via their data warehouse. The primary aggregate outcome was change in proportion of hypertensive patients with controlled BP; individual-level outcomes included average systolic BP (SBP) and diastolic BP (DBP) at last clinic visit. Qualitative interviews were conducted to assess intervention feasibility. MEASURES/METHODS:Hypertension was defined as having at least 1 hypertension ICD-9/10 code. Well-controlled hypertension was defined as SBP<140 and DBP<90 mm Hg. RESULTS:Postintervention, we observed a significant improvement in hypertension control at the practice level, adjusting for age and sex patient composition (adjusted relative risk, 1.09; 95% confidence interval, 1.04-1.14). Among the subset of Medicaid patients, we observed a significant reduction in average SBP and DBP adjusting for time, age, and sex, by 1.71 and 1.13 mm Hg, respectively (P<0.05). Providers reported feeling supported and satisfied with EHR components. CONCLUSIONS:EHR initiatives in practices serving immigrants and minorities may enhance practice capabilities to improve hypertension control.

This special issue of Global Public Health presents a collection of articles that analyse power and its mechanisms in health systems and health policy processes. Researchers have long noted that the influence of power is implicated throughout the global health field, yet theories and methods for examining power-its sources, workings, and effects-are rarely applied in health policy and systems research. By engaging with the social sciences and humanities, contributors to this collection aim to analytically sharpen and thematically broaden the study of power and politics in global health. Contributors analyse the exercise of power by actors typically considered powerful on the global stage as well as actors across the health system who may be powerful in national or local contexts. Additionally, the papers draw attention to actors, interest groups, and practices not usually viewed as politically salient in health policy and systems research in low- and middle-income countries. The papers not only analyse power but also identify ways to counteract it, such as by using human rights-based frameworks to investigate and challenge power asymmetries. Collectively, they show how researchers working on global health issues can theorise power and deepen political analysis of health policy and systems.

Studies of power in health care settings in low- and middle-income countries largely describe providers' exercise of discretionary power in frontline roles, leaving under-specified the macro-institutions and mechanisms of power that drive health care outcomes. In this study I conceptualise providers' actions not in terms of discretionary power but as obligatory responses to 'authority' over them. Authority denotes an actor's rightfully held social power over others, who accept to follow that actor's directives. Explaining authority's workings entails studying how it operates from its subjects' perspectives. I analyse in particular the authority of popular opinion-which derives from citizens' claims to state services-over primary care doctors in municipal health facilities in Pune, India. Through year-long ethnographic fieldwork, I examine doctors' experience of popular opinion, social relations between doctors and communities, and the institutional history of state-provided urban primary care. Findings show that doctors routinely confront popular disregard for their services. But under conditions of long-standing neglect of municipal services, tenuous state-society relations, and an avid, widely preferred private sector, doctors appear unable and wary to deliver more than minimum clinical care. Their circumscribed response reflects mechanisms by which the power of popular opinion, under policy neglect, impels them to maintain a deficient status quo.