This online COVID-19 pandemic era investigation with Black hypertensive adults (N=612) who were 93.6% U.S. born, 54.7% male, 44.3% female with a mean age of 37 years sought to identify predictors of self-ratings for being medication non-adherent and for racism and discrimination impacting engagement with medical providers. Findings showed over 70% were medication non-adherent on Morisky Medication Adherence Scale, and 49.3% self-classified as medication non-adherent. Regarding behaviors of following provider instructions for taking medication, maintaining appointments, and uninterrupted receipt of medication, these deteriorated during the pandemic, but improved by currently—as resilience; yet, maintaining appointments and uninterrupted receipt of medication were better currently than pre-pandemic. While social support was low and unchanged from before the pandemic to currently, social support with medications deteriorated during the pandemic, but improved currently. Participants rated providers as follows: having closest to moderate cultural competence; moderate level of discrimination; moderately high for discriminating against their personal demographics, identity, or appearance (e.g. 85.3% for being Black, 80.6% for skin color, 66% for hair); 64.5% exposed them to racism/ discrimination so it impacted engagement with providers for willingness to regularly attend appointments; and, low-moderate frequency of microaggressions related to being Black. Not surprisingly, moderate medical mistrust was found. Two backward stepwise logistic regression models highlighted recurrent predictors for medication adherence as being 1-less provider discrimination for demographics/ identity/ appearance, and 2-less frequent provider microaggressions for being Black; and, one highlighted higher provider cultural competence. In a third model, greater provider discrimination was a predictor of self-classifying for racism/discrimination impacting engagement with providers. Findings highlight less provider discrimination and less frequent microaggressions by providers as key experiences—such that lower levels of exposure to provider racism, discrimination and microaggressions emerge as powerful determinants of medication adherence. The study has important implications for the urgency of addressing providers’ racism, discrimination and racial microaggressions as factors playing a role in medication non-adherence and patients’ unwillingness to return for medical appointments. Training in cultural competence is vitally needed with specific attention in training to actually observing, addressing and changing providers’ behavior of enacting racism, discrimination, and microaggressions with Black hypertensive patients.

This dissertation aims to examine racial and ethnic inequities in nursing home (NH) palliative care services and potentially avoidable hospitalizations at the end of life. Health disparities are pervasive in NHs, but disparities in NH end-of-life care (i.e. palliative care services, hospital transfers) have not been comprehensively examined. Chapter One provides an overview of this dissertation, which explores inequities in nursing home end-of-life care. Chapter Two is a systematic review that synthesized the current state of the science in racial and ethnic disparities in NH end-of-life care. Chapter Three was designed to describe palliative care services in U.S. NHs and associations with differences in the concentrations of Black and Hispanic residents, respectively, and the impact by region. Chapter Four is an analysis of racial and ethnic differences in NH potentially avoidable hospitalization incidence rates. Finally, Chapter Five is a synthesis of this body of work. It contains a summary of findings of this dissertation, a discussion of the results, practice and policy implications, and directions for future research.

This dissertation investigates the effectiveness of and disparities in timely goals of care (TGOC) discussions in nursing homes (NHs), as well as hospitalizations due to infections. Chapter One provided an overview of the dissertation, including its aims and conceptual frameworks. Chapter Two is a systematic review of the current evidence concerning the timing of goals of care discussions in NHs and their impact on end-of-life outcomes. Chapter Three examines the differences in TGOC discussions in NHs for Black. Chapter Four analyzes the association between TGOC discussions and hospitalizations due to infections. Finally, Chapter Five synthesizes all findings. Key findings demonstrate that while effective TGOC discussions are associated with reduced hospitalizations due to infections in NH residents, significant racial and ethnic disparities exist, particularly among NHs with higher proportions of Black residents and those located in socioeconomically disadvantaged areas. These findings highlight the need for improved TGOC practices and targeted interventions to address systemic barriers and ensure equitable end-of-life care.

The problem that this study addressed was the high rate of maternal mortality for Black women in the United States, which has been rising, including before the COVID-19 pandemic. The goal was to identify significant predictors of medical mistrust. The study recruited a convenience sample via an online social media campaign. The resultant sample was 100% Black and female (N=192) with a mean age of 33.23 (SD= 4.980, min=24, max=61), while 94.8% were born in the United States (n=182). Using background stepwise regression, the following were found to be significant predictors of a higher level of medical mistrust: older age (B = .033, p = .001); higher levels of education (B = 0.205, p = .000); lower annual household income (B = -.055, p = .026); higher level of perceived racism, discrimination, and inequity in treatment from medical staff (B = 0.137, p = .046); lower levels of cultural sensitivity/ competence/ humility ratings for medical staff (B = -.155, p = .002); higher past year mental distress (i.e., Depression, Anxiety, Insomnia and Trauma) (B = .369, p = .000); and lower levels of social support post-partum (B = -0.162, p = .004)—with 46.5% of the variance predicted by the model (R2 = 0.698, Adjusted R2 = 0.465). The study findings highlight a crisis of Black maternal mortality in the United States, as well as a crisis in healthcare service delivery to Black women, as uncovered via this study. The data betrays a dimension of the crisis in healthcare service delivery to Black women who report experiencing discrimination for being Black at 75.5%, for their appearance (skin tone, hair, etc.) at 62.0%, and for being overweight or obese at 28.6%. Implications of the findings are discussed, while recommendations for future research are offered. In terms of those implications, perhaps most importantly, this data effectively identifies the year after a high-risk birth hospitalization as an essential time for ensuring Black women enter counseling with licensed and certified mental health professionals.