LUNG CANCER IN NEPAL: THE ROLE OF TRADITIONAL TOBACCO PRODUCTS AND COMBUSTION RELATED HOUSEHOLD AIR POLLUTION

The burden of chronic diseases such as cancer is increasing in low and middle income countries around the globe. Nepal, one of the world’s poorest countries, is no exception to this trend, with lung cancer as the leading causes of cancer deaths. Despite this, limited data is available on the environmental and behavioral risk factors that contribute to the lung cancer etiology in Nepal. The objectives of this dissertation are to: 1) investigate the ethnic differences in consumption of local tobacco products and their role in lung cancer risk in Nepal; 2) evaluate urinary metabolite of 1,3-butadiene as a biomarker of exposure to combustion related household air pollution (CRHAP); 3) investigate the association between CRHAP exposure and lung cancer risk using urinary metabolite of 1,3-butadiene as a biomarker of exposure; 4) investigate the association between CRHAP exposure and lung cancer risk using questionnaire based measure of exposure. Lung cancer cases (n=606) and frequency matched controls (N=606) were recruited from B.P. Koirala Memorial Cancer Hospital. We obtained biological samples and information on lifestyles including cooking habits and type of fuels used. We used liquid chromatograph tandem mass spectrometer (LC-MS/MS) to quantify urinary metabolites of 1,3-butadiene in urine samples. We employed a combination of logistic and linear regression models to detect any exposure-disease associations while controlling for known confounding variables. Overall, we found that ethnic groups in Nepal use different tobacco products that have different differing cancer potency -we observed the highest odds ratios for the traditional tobacco products. The biomarker analysis showed strong evidence that monohydroxybutyl mercapturic acid is associated with biomass fuel use among participants. However, we did not find significant association between urinary MHMBA and lung cancer risk. When we used questionnaire based measure of exposure to household air pollution, we observed significant, dose-response associations between CRHAP exposure and lung cancer risk, particularly among never-smokers. Our results show that important role of local tobacco products in lung cancer risk in Nepal. Furthermore, we demonstrate that CRHAP exposure is a risk factor for lung cancer risk, independent of tobacco smoking.

Predictors of Patient Activation Among Underserved Patients in a Nurse-managed Health Center: A Pilot Study

The concept of patient activation has gained traction as the term referring to patients who understand their role in the care process and have “the knowledge, skills and confidence” necessary to manage their illness over time (Hibbard & Mahoney, 2010). Improving health outcomes for vulnerable and underserved populations who bear a disproportionate burden of health disparities presents unique challenges for nurse practitioners who provide primary care in nurse-managed health centers. Evidence that activation improves patient self-management is prompting the search for theory-based self-management support interventions to activate patients for self-management, improve health outcomes, and sustain long-term gains. Yet, no previous studies investigated the relationship between Self-determination Theory (SDT; Deci & Ryan, 2000) and activation. The major purpose of this study, guided by the Triple Aim (Berwick, Nolan, & Whittington, 2008) and nested in the Chronic Care Model (Wagner et al., 2001), was to examine the degree to which two constructs– Autonomy Support and Autonomous Motivation– independently predicted Patient Activation, controlling for covariates. For this study, 130 nurse-managed health center patients completed an on-line 38-item survey onsite. The two independent measures were the 6-item Modified Health Care Climate Questionnaire (mHCCQ; Williams, McGregor, King, Nelson, & Glasgow, 2005; Cronbach’s alpha =0.89) and the 8-item adapted Treatment Self-Regulation Questionnaire (TSRQ; Williams, Freedman, & Deci, 1998; Cronbach’s alpha = 0.80). The Patient Activation Measure (PAM-13; Hibbard, Mahoney, Stock, & Tusler, 2005; Cronbach’s alpha = 0.89) was the dependent measure. Autonomy Support was the only significant predictor, explaining 19.1% of the variance in patient activation. Five of six autonomy support survey items regressed on activation were significant, illustrating autonomy supportive communication styles contributing to activation. These results suggest theory-based patient, provider, and system level interventions to enhance self-management in primary care and educational and professional development curricula. Future investigations should examine additional sources of autonomy support and different measurements of autonomous motivation to improve the predictive power of the model. Longitudinal analyses should be conducted to further understand the relationship between autonomy support and autonomous motivation with patient activation, based on the premise that patient activation will sustain behavior change.

RISKS TO FOOD AVAILABILITY AND ACCESS FROM CLIMATE POLICIES: AN INTEGRATED ASSESSMENT OF REGIONAL FOOD AVAILABILITY AND ACCESS WITH ALTERNATIVE CLIMATE MITIGATION STRATEGIES TO 2050

Although mitigating GHG emissions is necessary to reduce the overall negative climate change impacts on crop yields and agricultural production, certain mitigation measures may generate unintended consequences to food availability and access due to land use competition and economic burden of mitigation. Prior studies have examined the co-impacts on food availability and global producer prices caused by alternative climate policies. More recent studies have looked at the reduction in total caloric intake driven by both changing income and changing food prices under one specific climate policy. However, due to inelastic calorie demand, consumers’ well-being are likely further reduced by increased food expenditures. Built upon existing literature, my dissertation explores how alternative climate policy designs might adversely affect both caloric intake and staple food budget share to 2050, by using the Global Change Assessment Model (GCAM) and a post-estimated metric of food availability and access (FAA). My dissertation first develop a set of new metrics and methods to explore new perspectives of food availability and access under new conditions. The FAA metric consists of two components, the fraction of GDP per capita spent on five categories of staple food and total caloric intake relative to a reference level. By testing the metric against alternate expectations of the future, it shows consistent results with previous studies that economic growth dominates the improvement of FAA. As we increase our ambition to achieve stringent climate targets, two policy conditions tend to have large impacts on FAA driven by competing land use and increasing food prices. Strict conservation policies leave the competition between bioenergy and agriculture production on existing commercial land, while pricing terrestrial carbon encourages large-scale afforestation. To avoid unintended outcomes to food availability and access for the poor, pricing land emissions in frontier forests has the advantage of selecting more productive land for agricultural activities compared to the full conservation approach, but the land carbon price should not be linked to the price of energy system emissions. These results are highly relevant to effective policy-making to reduce land use change emissions, such as the Reduced Emissions from Deforestation and Forest Degradation (REDD).