Meeting the healthcare needs of the homeless continues to be a significant challenge in the United States. Homeless individuals suffer a disproportionately high burden of both communicable and non-communicable diseases and are at increased risk of dying prematurely. Additionally, this population faces barriers to receiving healthcare that are less prevalent for non-homeless persons. These include difficulties physically accessing care, underinsurance, and highly comorbid mental health and substance use disorders, all of which contribute to nonadherence and loss to follow-up. As such, homeless individuals report unmet needs across multiple types of healthcare services. Homeless people’s perceptions and attitudes towards healthcare also affect their propensity to utilize services. As with all patients, homeless individuals articulate a desire for compassionate, person-centered care involving meaningful engagement and trust. Yet, this is often not the case. Stigma and perceived discrimination from healthcare providers on the basis of poverty, race, mental illness or substance use have made the homeless feel unwelcome in many healthcare settings. Homeless people often describe being treated less compassionately by providers, feeling invisible, dehumanized, or reduced to objects. Perceived prejudice may contribute to poorer adherence and more frequent utilization of acute care or emergency services compared to routine ambulatory care. In this thesis, I explore homeless individuals’ attitudes of trust or mistrust towards the healthcare system using qualitative methods. I interviewed participants who identified as homeless at Philadelphia FIGHT and Broad Street Ministry, two healthcare and social service organizations that serve the homeless community in Philadelphia. I conducted interviews using a semi-structured interview guide. Below, I discuss my rationale for doing this study, my study methods, and results through five participant narratives elucidating key themes that arose during interviews. In the last chapter, I discuss why these results matter and how they can be used to inform future practice and policy aimed at reducing healthcare disparities for the homeless. / Urban Bioethics

A primary reason geospatial approaches are important in cancer research is that health and disease are shaped not only by factors such as age, race/ethnicity, genes, and clinical care but also by the environment where individuals work and act. While the use of geospatial approaches in cancer research is growing, several limitations remain. For example, for most population-based studies, cancer patients' neighborhood environments are based on only a single location derived from the residence at the time of diagnosis.This dissertation aimed to address this limitation by using a unique dataset of colon cancer patients diagnosed in New Jersey that include residential histories obtained through a data linkage with LexisNexis, a commercial data collection company. By incorporating residential histories, I moved beyond a cross-sectional approach to examine how residential histories and socio-spatial mobility can change a patient’s geographic context over time and influence survival. To demonstrate the application of these data in this dissertation, I completed three case studies. In the first case study, I compared whether including residential histories changed the risk of death estimates by neighborhood poverty compared to the traditional approach when including only the location at the time of diagnosis. Results suggested that the risk of death estimates from neighborhood poverty were generally similar in strength and direction regardless of residential histories inclusion. This finding was likely a result of minimal socio-spatial mobility of colon cancer patients (i.e., patients generally moving to census tracts with similar poverty levels). The second study aimed to compare the geographic risk of death estimates when using single location and residential histories in spatial models. Results overall showed that the geographic patterns of the risk of death estimates were generally similar between the models. However, not accounting for residential mobility resulted in underestimated geographic risk of death in several areas. This finding was related to the fact that approximately 35% of the colon cancer patients changed the residency, and 12% of the initial study population left New Jersey after the diagnosis. In the third case study, I examined whether landscape characteristics (e.g., built environment) were associated with the risk of death from colon cancer independent of individual-level factors, residential mobility, and neighborhood poverty. The results indicated that an increasing proportion of high-intensity developed-lands substantially increased the risk of death, while an increase in the aggregation and connectivity of vegetation-dominated low-intensity developed-lands reduced the risk of death. These findings suggested that places lacking greenspaces could have worse access to recreational sites that promote physical activity. Overall, this dissertation expands our knowledge about the geographic disparities in colon cancer in New Jersey. It also provides specific examples of integrating residential histories and remote sensing-based products into cancer disparities research. Including residential histories opens up new avenues of inquiry to better understand the complex relationships between people and places, and the effect of residential mobility on cancer outcomes. Combining multiple socio-demographic and environmental domains to estimate the neighborhood effects on cancer outcomes will increase our potential to understand the underlying pathways. / Geography

African American women are at a higher risk of experiencing maternal health complications than women of other races. Determining the factors that contribute to the severity of their maternal health complications can help bring awareness and exposure to the disparities among black women in maternal health. The purpose of this study was to explore the various elements that contribute to the high pregnancy mortality ratio and infant mortality ratio in black women and black infants. The secondary purpose was to determine the relationship between stereotypes about African American women as healthcare consumers and the disproportionate percentage of black women experiencing fatal maternal complications. A literature review examining the effects of physiological differences, external stressors, stigmas and stereotypes, and miscommunication with health care physicians was conducted from various online databases. Peer reviewed, research articles published in the English language from 1992-2020 that focused on factors during the prenatal and perinatal period that influenced the pregnancy-related mortality ratio were included for synthesis. Results from 14 studies that examined factors resulting in maternal health disparities in African American women were compared to determine accuracy and consistency with the data. The studies suggest that smaller pelvic structures, stigmas that label black women as over exaggerative, and distrust within African American communities with health care staff contribute to the different maternal outcomes in black women. Although the data remained consistent and proved there are similar factors that cause disparities in maternal care, many of the studies had small sample sizes indicating the need for further research on the subject.

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Research Objective: On behalf of the Appalachian Funders Network, with funding from the Robert Wood Johnson Foundation, East Tennessee State University and NORC at the University of Chicago documented the current burden of obesity, diabetes, and chronic disease mortality in central Appalachia. An analysis of county-level data was conducted in order to provide a comprehensive picture of the health condition of the region. Contributing factors, such as physical inactivity and food environment, were also investigated to determine how the built environment impacts obesity. Study Design: Several secondary data sources were utilized, including the County Health Rankings, CDC Diabetes Interactive Atlas, USDA Food Environment Atlas, and mortality data from the CDC National Center for Health Statistics, National Vital Statistics System. Variables analyzed included: adult obesity prevalence, adult diabetes prevalence, food insecurity, access to exercise opportunities, physical inactivity, and premature chronic disease mortality. The mortality analyses focused on four of the leading causes of death: heart disease, stroke, diabetes, and chronic lower respiratory disease, for persons age 25 to 64 from 2009 to 2013. When available, county-level estimates were used to create maps of the region, documenting the disparities compared to the rest of the nation. Population Studied: Health disparities were documented within the counties of central Appalachia, consisting of parts of Kentucky, North Carolina, Ohio, Tennessee, Virginia, and West Virginia. Principal Findings: More than two-thirds (68.6%) of the 234 counties in central Appalachia have an adult obesity prevalence above the national median of 30.9% (defined as BMI over 30). Over 85% of the counties in central Appalachia have a percentage of physically inactive adults higher than the national median of 26.4% (defined as not participating in physical activity or exercise in the past 30 days). When analyzing the combined chronic disease mortality for heart disease, stroke, diabetes and chronic lower respiratory disease, the combined national mortality rate is 93.0 deaths per 100,000 population. Nearly 90% of central Appalachian counties have a higher combined morality rate, and the state mortality rate for the Appalachian region of all six states is higher than the national rate. The disparity is more pronounced in rural communities, as the rural counties of central Appalachia have a higher mortality rate than urban counties within central Appalachia and rural counties across the United States. The combined mortality rate for these four diseases is 74% higher in rural central Appalachia than urban counties nationally. Conclusions: Compared to the rest of the country, people in central Appalachia are more likely to experience and prematurely die from obesity-related chronic disease, including diabetes and heart disease. Residents of rural central Appalachia face even more significant disparities as compared to urban residents within the region and nationally. Implications for Policy or Practice: Obesity and chronic disease in central Appalachia are significant public health concerns that must be addressed in order to improve the health of the region.

Background: The Tennessee veterans represents 8.3 percent of state’s adult population, these includes the service members from World War II to Iraq and Afghanistan conflicts. Some of the research done on veterans shows that approximately 14% to 16% of U.S. service members deployed suffer from mental health challenges like PTSD or depression and substance abuse. The issue of mental health and substance abuse worsen among veterans populations while transitioning to civil life. The mental health symptoms among 1,239 American veterans assessed online one month prior to the COVID-19 outbreak in the United States through next year shows slight increase in mental health symptoms over time. The proposed study examines the association between veteran status and depression, alcohol use, and smoking in Tennessee. Methods: We used cross-sectional data from the 2021 Behavioral Risk Factor Surveillance System a nationally representative U.S. telephone-based survey of adults aged 18 years and extracted data for Tennessee (n=4,788). Logistic regression analyses were conducted to test the association between coronary artery disease and depression. We controlled for past month income, race/ethnicity, educational status, gender, and age. Results: Overall, among U.S. military veterans 23.7% (n=145) were diagnosed with depression, 46.6% consumed alcohol in the last 30 days, while 15.2% (n=93) smoked cigarettes within the last 30 days. U.S military veterans status (OR=1.40, 95% CI, 1.12, 1.74) along with low income (OR=2.21, 95% CI, 1.91, 2.55) and female gender (OR=2.07, 95% CI, 1.78, 2.41) was significantly associated with depression. U.S military veteran status was not associated with alcohol use or smoking. Conclusion: The results implicate that the veterans in Tennessee are on higher risks of depression and alcohol consumption than non-veterans. Findings highlight the need of ongoing treatment and social support for the veterans population in Tennessee. Additional research is needed to understand the type of treatment and social support for this population. Keywords: Coronary Heart Disease, Mental Health Disorders, Health disparities in Tennessee

In the United States, individuals of Hispanic ethnicity receive disproportionately lower-quality healthcare. These healthcare disparities exacerbate unequal access to quality healthcare services, including disparities in cardiovascular disease (CVD) and human immunodeficiency virus (HIV) care. Research on the role of ethnicity on the CVD outcomes of people living with HIV (PLWH) has been limited. We hypothesize that immunological (CD4+ cell count) and virological (HIV viral load) control may play a role in the development of acute myocardial infarction (AMI) among PLWH, and that Hispanic ethnicity may worsen these outcomes. To verify our hypotheses, we conducted a retrospective cross-sectional study to investigate the strength and direction of association between CD4+ cell count (immunological cohort, n=513) and HIV viral load (virological cohort, n=261) on AMI among respondents of the All of Us Research Program. Hispanic and non-Hispanic respondents for both cohorts were comparable in terms of demographic characteristics, except for a significantly different distribution by race. While we identified increased proportion of non-Hispanic individuals with AMI in the immunologic (6.0% vs. 1.0%; P=0.04) and virologic (5.8% vs. 0%; P=0.007) cohorts, we were not able to identify CD4+ cell count or viral load as significant predictors significantly increasing the likelihood of AMI. Potential explanations discussed include self-selection bias resulting in incomplete laboratory data and an underpowered sample size. While the sample in this study did not support an increased likelihood of AMI by ethnicity, the results should be interpreted carefully in light of the limitations and the established pathophysiological and epidemiological associations posited, underscoring the importance of future research efforts that better represent ethnic minorities and the associations between HIV infection and CVD.

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