Background: Compared to the general United States (U.S.) population, Arizona counties along the U.S.-Mexico border have a higher prevalence of dental caries, which can be reduced with adequate fluoride exposure. Because of concern regarding local tap water quality, fluoride-free bottled water consumption is common in this region, raising concern that families are not receiving adequate fluoride to promote dental health. Objective: To evaluate the levels of fluoride in tap and bottled water as well as the use of fluoride supplements in an Arizona border community. Methods: Low-income Latino households (n = 90) who report use of bottled water as their primary source of water intake were recruited. Participants completed a questionnaire about their and their children's dental histories and use of fluoride supplements. Water samples (bottled and tap) were collected from a subset of households (n = 30) for analysis of fluoride. Results: Fluoride detection levels were significantly greater (p = 0.02, Fisher's exact test) in tap water (average = 0.49 mg/dL) than in bottled water, yet, the majority (22/30) were below the range for optimal dental health (0.7-1.2 mg/L). Concentration of fluoride in the majority (29/30) of bottled water samples was below the quantitative detection limit of 0.4 mg/L. Children were significantly less likely to have dental caries if they received fluoride varnishing treatments (p = 0.01, Fisher's exact test), lived in households that reported using fluoridated mouthwash (p < 0.001, Fisher's exact test), their parents received fluoride education (p = 0.01, Fisher's exact test), and their parents reported visiting a dentist yearly (p < 0.001, Fisher's exact test). Furthermore, none of the participants reported receiving recommendations from health-care providers about fluoride supplementation or variance in content by the type of water consumed. Conclusion: Although fluoride was significantly more likely to be detected in tap than bottled water, neither water source in this border community is likely to provide enough fluoride for optimal dental health. Low-income children in this region may benefit from regular access to fluoride varnishing treatments and/or use of fluoridated mouthwash, interventions that could be tested in future well-designed trials.

Social determinants of health (SDOH) are often used to discuss health inequities and systemic barriers experienced by minority populations. In the United States, the intersection of SDOH leaves these populations vulnerable to negative health outcomes. Missing from the SDOH discourse are the underlying historical causes for these disparities. Medical-Legal Partnerships (MLPs) have undertaken the role of educating the health and human services (HHS) workforce on interdisciplinary collaboration, cultural competence, and the skills to recognize experiences of negative SDOH. However, current research does not explore the foundational impact of historical trauma, more specifically Post Traumatic Slave Syndrome (PTSS), on experiences of negative SDOH. This ethnography primarily uses the personal accounts of black female HHS workforce members and participant observation from within a MLP to examine how historical trauma acts as a foundation for understanding the complex interactions of SDOH. The SDOH discourse does not challenge the medical and legal institutions that contribute to how minority populations experience negative SDOH. As currently structured, MLPs unintentionally reproduce a pedagogical narrative that erases the lived experiences of SDOH by only focusing on individual factors and not systems. Black female HHS workforce members agree that historical context is missing (e.g. PTSS) from the SDOH discourse and contemporary experiences of racism and discrimination. Historical context would change how HHS workforce members advocate for their patients as well as engage in system-challenging praxis within the medical and legal institutions. This suggests the need to examine how American institutions exclude particular histories and reinforces a white supremacist and patriarchal narrative.

While the concept of the community health worker (CHW) has existed since the mid-20th century, their function as a legitimate branch of the broader workforce in the United States has been tenuous. Their unique roles have the potential to reduce health disparities within marginalized communities, but stakeholder development of this position risks diminishing the crucial skills of these workers. Anthropological research on these workers has typically assessed them in the developing world, while public health research has focused primarily on their ability to impact specific health outcomes through quantitative studies. As a result of the limited and predominantly quantitative assessments of these workers, further research is needed to assess the lived realities of these workers at the grassroots level in the United States. The overarching aim of this project was to document the lived experience of CHWs in Indiana. Additionally, this project assessed their participation in advocacy and the impact of policy development on these workers. A collaborative approach was utilized in this project that embedded the researcher within a CHW organization while also amplifying the voice of the research partners. The project drew on the theoretical lenses of moral economy, deservingness, structural vulnerability, and the “regimes of care” and “politics of care.” The results demonstrate that CHWs face a variety of challenges within the professional workforce but have significant impacts within their communities. These workers emphasize empowerment through advocacy and building client self-sufficiency. Their participation in advocacy is split between impacts at the micro-, macro-, and professional-level. However, legislating the scope and responsibilities of this position by stakeholders unfamiliar with this model risks changing the foundation of the position itself. Steps to incorporate CHWs within the workforce must be collaborative and take into account their lived experience and input in order to allow them agency over the development of their position and to retain the most significant contributions. The contributions of this project are severalfold. First, this project advances theoretical debates within anthropology related to moral economy, regimes of care, politics of care while also addressing the legitimacy of CHWs as a complimentary member of the health care workforce. The findings also illustrate how the political economy of Indiana shapes the moral economy of care within which CHWs operate. Lastly, the project produced applied findings for CHWs, employers, and stakeholders to consider in further development of this position.

Expressed emotion (EE), the affective attitudes and behaviors of one toward another, can affect caregivers’ behaviors toward their child. Research examining associations between EE and child/family outcomes is mixed; these associations may be affected by other influences such as the presence of a chronic disease or parent mental health. In this study of families living in an urban area, we examined associations between EE and child outcomes (anxiety/depressive symptoms) and family functioning, with parent anxiety as a covariate. We evaluated child asthma status as a moderator as the presence of a chronic illness may strengthen the association between EE and child/family outcomes. Ninety-four children (mean±SD age=8.83±2.03 years, 48.9% female, 92.6% African American; 47 with asthma) and their parents (81.3% annual household income less than $25,000) completed an observational study including interviews and questionnaires. Measures included the Multidimensional Anxiety Scale for Children (MASC), Children’s Depressive Symptoms Inventory (CDI), Self-Report Family Inventory (SFI), Generalized Anxiety Disorder scale (GAD-7), and Five-Minute Speech Sample (FMSS) coded for EE. To examine study aims, regression analyses were conducted using PROCESS macro version 3.4. Asthma status (yes/no) was examined as a moderator. EE was associated with child anxiety symptoms, controlling for parent anxiety symptoms (F(1,70) =7.67, p=0.007). Criticism was also positively associated with asthma control (F(1,39)=4.33, p=.04, R2=.08). Asthma status did not moderate any of the associations. Results suggested that high levels of caregiver EE were associated with child anxiety symptoms, but asthma status did not moderate associations. It is possible that regardless of additional family demands related to asthma, EE is associated with child anxiety. Further examination into other systemic stressors (e.g., poverty, access to care) that may moderate these associations is warranted, as well as the impact that minimizing parent anxiety might have on overall EE.

Introduction: Long–standing disparities in colorectal cancer (CRC) outcomes and survival between Whites and Blacks have been observed. A person–centered approach using latent class analysis (LCA) is a novel methodology to assess and address CRC health disparities. LCA can overcome statistical challenges from subgroup analyses that would normally impede variable–centered analyses like regression. Aim was to identify risk profiles and differences in malignant CRC survivorship outcomes. Methods: We conducted an LCA on the Surveillance, Epidemiology, and End Results data from 1975 to 2016 for adults ≥18 (N = 525,245). Sociodemographics used were age, sex/gender, marital status, race, and ethnicity (Hispanic/Latinos) and stage at diagnosis. To select the best fitting model, we employed a comparative approach comparing sample-size adjusted BIC and entropy; which indicates a good separation of classes. Results: A four–class solution with an entropy of 0.72 was identified as: lowest survivorship, medium-low, medium-high, and highest survivorship. The lowest survivorship class (26% of sample) with a mean survival rate of 53 months had the highest conditional probabilities of being 76–85 years–old at diagnosis, female, widowed, and non-Hispanic White, with a high likelihood with localized staging. The highest survivorship class (53% of sample) with a mean survival rate of 92 months had the highest likelihood of being married, male with localized staging, and a high likelihood of being non-Hispanic White. Conclusion: The use of a person–centered measure with population-based cancer registries data can help better detect cancer risk subgroups that may otherwise be overlooked.

African American women have significantly higher mortality rates from heart disease and stroke than White women despite advances in treatment and the management of risk factors. Community health workers (CHWs) serve important roles in culturally relevant programs to prevent disease and promote health. This article describes the Pine Apple Heart and Stroke Project's activities to (1) revise the Women's Wellness Sourcebook Module III: Heart and Stroke to be consistent with national guidelines on heart disease and stroke and to meet the needs of African American women living in rural southern communities; (2) train CHWs using the revised curriculum; and (3) evaluate the training program. Revisions of the curriculum were based on recommendations by an expert advisory panel, the staff of a rural health clinic, and feedback from CHWs during training. Questionnaires after training revealed positive changes in CHWs' knowledge, attitudes, self-efficacy, and self-reported risk reduction behaviors related to heart disease, stroke, cancer, and patient-provider communication. This study provides a CHW training curriculum that may be useful to others in establishing heart disease and stroke programs in rural underserved communities.

Context: Colorectal cancer (CRC) surgical treatment delay (TD) has been associated with mortality and morbidity; however, disparities by TD profiles are unknown. Objectives: This study aimed to identify CRC patient profiles of surgical TD while accounting for differences in sociodemographic, health insurance, and geographic characteristics. Design: We used latent class analysis (LCA) on 2005-2015 Tennessee Cancer Registry data of CRC patients and observed indicators that included sex/gender, age at diagnosis, marital status (single/married/divorced/widowed), race (White/Black/other), health insurance type, and geographic residence (non-Appalachian/Appalachian). Setting: The state of Tennessee in the United States that included both Appalachian and non-Appalachian counties. Participants: Adult (18 years or older) CRC patients (N = 35 412) who were diagnosed and surgically treated for in situ (n = 1286) and malignant CRC (n = 34 126). Main Outcome Measure: The distal outcome of TD was categorized as 30 days or less and more than 30 days from diagnosis to surgical treatment. Results: Our LCA identified a 4-class solution and a 3-class solution for in situ and malignant profiles, respectively. The highest in situ CRC patient risk profile was female, White, aged 75 to 84 years, widowed, and used public health insurance when compared with respective profiles. The highest malignant CRC patient risk profile was male, Black, both single/never married and divorced/separated, resided in non-Appalachian county, and used public health insurance when compared with respective profiles. The highest risk profiles of in situ and malignant patients had a TD likelihood of 19.3% and 29.4%, respectively. Conclusions: While our findings are not meant for diagnostic purposes, we found that Blacks had lower TD with in situ CRC. The opposite was found in the malignant profiles where Blacks had the highest TD. Although TD is not a definitive marker of survival, we observed that non-Appalachian underserved/underrepresented groups were overrepresented in the highest TD profiles. The observed disparities could be indicative of intervenable risk.

Minority groups experience disproportionately worse health outcomes. An identified solution is to increase the number of minorities providing healthcare in their own communities. Primary care complementary and alternative medicine (CAM) providers are a potential resource. Many investigators have demonstrated the efficacy of science-based pipeline programs for increasing the roles of students in allopathic health professions. Whether these programs influence matriculation of minorities into a CAM university is unknown. The main purpose of this study was to gain an understanding of a pre-college science academy at a CAM university and determine whether the experience increased interest in and motivation for CAM careers. It was also important to learn more about what factors may facilitate or impede minority student matriculation in a CAM university. In this phenomenological study, a mixed purposeful sampling strategy was used to select 9 students who had participated in a science academy at a CAM university. Individual in depth, semi-structured, interviews were conducted and analyzed using a process of inductive analysis. The results indicated that barriers to college matriculation included cost and the complexity of the process. The desire to elevate status steers some minorities who use CAM modalities as their indigenous health practice, towards high prestige allopathic careers. Participation in the science academy increased interest in and utility of CAM, but did not change preconceived career choices. These results contribute to the existing literature and can enrich social change initiatives by increasing the number of minorities providing healthcare in their own communities, and further understanding of the factors that influence underrepresented minority career choices.

African American women tend to experience higher health disparities in cancer-related illness than any other female population in the United States. The purpose of this qualitative case study was to identify and examine access-related barriers that play a significant role in the decision-making process of this population when seeking breast cancer health services. The central research question explored the effect that barriers to health care have on African American women in the Southeastern region of the United States. Secondary research questions explored the role the Patient Protection and Affordable Care Act of 2010 has on improving access to affordable, quality breast cancer screening services for the sample population. A critical theory lens of racism and ethnicity provided conceptual framework for this case study. Significant findings identified barriers to accessing breast cancer related health services as personal, community, social, systemic, and institutional. Personal barriers identified were related to access, autonomy, and benefits of the Affordable Care Act. Social barriers corresponded to cultural, financial burden, funding, health conditions, insurance, role within the family self-discovery, and spirituality. Community barriers included access, advocacy, and autonomy. Systemic and institutional barriers consisted of doctor listening, doctor's rapport, doctor treatment, lack of trust, and benefits of the Affordable Care Act. Implications for social change included bringing awareness of the need to establish a Breast Cancer Resource Center in the region to engage this population in preventive measures, improve health outcome and reduce health disparities.

In recent years, an array of political, environmental, and health activists have brought to light the previously overlooked structural inequalities that plague many urban cities and their underserved populations. With a growing population and an increased dichotomy between social classes in the United States, urbanization may be inevitable. However, how urban planners and public agencies choose to build and design these areas is malleable. Provision of safe and equitable living conditions by these individuals is an obligation of utmost importance, and as such, this thesis aims to both provide insight as to how the built environment, development patterns, and land use play a significant role in in morbidity and mortality in urban communities across the nation and world, as well as assist in bridging the divide between disciplines of urban health and urban planning as we look towards creating healthier, greener, more equitable cities. The built environment and health can and should be discussed in the same breath during urban planning and development, and thus, the preservation, presence, and development of urban green space should be prioritized during processes of urbanization, with active engagement and empowerment from the communities in which we seek to build. The existing inverse association between increased urbanization and community health necessitates an induction of change and a call for action from urban planners, city and state officials, health scientists, environmental conservationists, and communities as a whole. / Urban Bioethics