Americans often face end-of-life with ineffective pain/symptom control. While hospice care prevents suffering for the terminally ill, only around 40% of individuals access services. Although few studies describe differences in terms of cancer vs. non- cancer diagnoses, hospice utilization/access disparities appear to exist. Analyzing 14 sociodemographic and clinical variables for 3,905 hospice discharge cases, this study highlights observed disproportions between cancer and non-cancer groups, identifying significant relationships amongst patient characteristics and hospice diagnosis. Factors found significantly related to diagnosis include components of the following: age, primary payment source, mortality status at discharge, hospice initiation location, length of stay, physical function, cognitive function, and presence of pain symptoms. Results confirm low overall hospice utilization rates, while validating diagnosis-specific differences driven by individual and population-based characteristics. In order to increase utilization/access rates and eliminate current disparities, patients presenting with certain terminal diseases may require greater provider flexibility in terms of hospice eligibility requirements.

Utilizing data from the Oklahoma Department of Health Pregnancy Risk Assessment Monitoring System (PRAMS) for the years 2004 through 2011, this study examines racial and ethnic differences in unhealthy maternal behaviors and the consequences of those actions on the health of both mother and child. The maternal behavior variables include smoking cigarettes, drinking alcohol, multivitamin use, and prenatal care utilization. The maternal health variables include gestational diabetes and hypertension. The labor and delivery outcome variables include placental issues, premature rupture of membranes (PROM), low birth weight, and child placement in an intensive care unit. This researcher hypothesized that minorities would engage in risky and unhealthy behaviors while pregnant more often than whites due to social disadvantages in the economic and educational realms. Furthermore, minorities would be more likely than whites to have unfavorable outcomes regarding labor, delivery, and health of the child due to lower socioeconomic status, poor maternal health, and underutilization of preventative care. The researcher finds that minority women seem to adhere to proper maternal health recommendations associated with personal choice, including smoking and drinking, though disparities are evident when compared to whites regarding behaviors associated with socioeconomic status, including prenatal care utilization and multivitamin use. African American women are more likely than whites to experience premature rupture of the membranes, have an underweight baby, and to place their baby in ICU, though less likely to experience placental issues. Native American women are less likely than whites to experience premature rupture of the membranes, have an underweight baby, and to place their baby in ICU, but more likely to experience placental issues. As expected, substantial changes have occurred in the maternal health and well-being of Oklahoma mothers over the course of the two PRAMS data collection phases.

In the United States, concern about breast cancer has generated policies and programs aimed at increasing screening mammography and treatment access for the uninsured and underinsured. Oriented toward the importance of early detection and the state's responsibility to ensure health care access to its citizens, these policies and programs reflect and reinforce a moral economy of disease management that shapes the ethical behavior of patients, providers, and advocates. In contrast, the moral economy of market-based health care generates norms and assumptions about individual responsibility for health and limits expectations of the state in providing access to health care. Using breast cancer care for structurally vulnerable women as a focal point, this dissertation examines the social effects of intersecting moral economies of breast cancer management and market-based health care. It describes the relationships between public policies, social and economic marginalization, and gaps in health care access. Based on 18 months of ethnographic field work in Southern Arizona, I report findings from interviews with physicians, nurses, advocates, clinic office staff, and community health workers; from recurring discussions with women undergoing treatment for breast cancer; and from participant-observation in cancer-focused events and activities. This dissertation explores how policies that extend low-cost or free health care to broad populations also reproduce social exclusion and complicate what it means to be uninsured in America. I describe how everyday practices of health care, including determinations of eligibility for public insurance, reflect and reinforce social inequities based on citizenship status, gender, and occupational status. I conclude that the organization of cancer care for structurally vulnerable women effectively directs the focus away from the state's responsibility to provide health care access and instead privatizes that responsibility so that it resides with structurally vulnerable clinics and non-licensed health care staff. Furthermore, a charity approach to managing cancer care for unauthorized U.S. residents diverts public responsibility for their social exclusion to private entities. Finally, the findings of this dissertation contribute to debates about health reform efforts, such as the Affordable Care Act, by outlining the relationship between moral worth and government entitlements.

Background. In Pima County, twenty-four percent of the population is obese, and this figure has steadily increased over the past ten years. A major cause is lack of regular exercise, which is a factor for other chronic health illnesses as well. An important intervention for improvement has been identified as regular, moderate-intensity physical activity. Proper surveillance is necessary to identify health disparities and barriers. The purpose of this scholarly practice inquiry (PI) was to use the American College of Sports Medicine American Fitness Index (ACSM-AFI) instrument to identify personal and community health disparities in Pima County, using the Global Strategy on Diet, Physical Activity and Health (DPAS) as a framework. Additionally, the purpose was to identify pertinent stakeholders who would benefit from these findings. Methods. This was a descriptive cross-sectional study that used publicly available surveillance data. The analysis of the ACSM-AFI instrument results for Pima County, Arizona yielded personal health indicators, community/environment indicators, county advantages, and challenges in comparison to national averages, and identification of pertinent stakeholders. The sample population for this study was comprised of the residents of Pima County, Arizona as determined by publically available surveillance data. Results. Pima County, compared to the national average, has a higher percent of moderately physically active residents, a lower percent of obese residents, more park-related expenditures, more swimming pools, more recreational centers, and more golf courses. Pima County has a lower percent of residents with health insurance, a higher death rate from diabetes and cardiovascular disease, lower parkland in city land area, a lower level of state requirements for Physical Education classes, fewer primary care providers, fewer dog parks, baseball diamonds, acres of parkland, and more violent crime. Conclusions. The major deficits, which should be the focus for community leaders, were health care coverage, cardiovascular and diabetes mortality, and environmental safety. These findings are relatable to obesity, metabolic syndrome, and socioeconomic barriers, which were identified in the initial literature review conducted for this PI. Examples of four major areas of pertinent stakeholders were the Pima County Health Department, the Pima County Business Community, the Arizona Daily Star, and The University of Arizona.

Asthma is a leading cause of hospitalizations among children in the United States. It accounts for millions of dollars in hospital charges at the national, state, and county levels. The prevention of these hospitalizations is an important public health issue given the financial costs of hospitalizations in an already overburdened healthcare system. This study addresses sociodemographic factors associated with hospitalizations for childhood asthma among children who reside in DeKalb County, Georgia. Results highlight the unequal burden of asthma in the southern portion of the county. Additional analysis suggests that changes to existing institution-level surveillance systems can be made to improve upon the quality of data available to researchers. This research calls for a state-wide asthma surveillance system that routinely collects information on the most common indicators of disease burden, thereby improving the ability of public health professionals to accurately determine and manage the needs of children with asthma.

Chronic disease is a major health burden in the United States, affecting about half of adults, and leading to poor health, disability, and death. However, the burden of chronic disease is not shared equally among Americans, with some groups (created by determinants such as race/ethnicity and socioeconomic resources) experiencing higher rates of morbidity and mortality. When measures of health and socioeconomic resources are examined together, a stepwise gradient pattern emerges. This social gradient has been established for individual measures, such as household income and social class, and several measures of morbidity and mortality. However, nationally, little research has been conducted using area-level measures, such as county economics, to examine its relationship with chronic disease. Three studies were completed using data from the Behavioral Risk Factor Surveillance System (BRFSS). County economic status was determined using unemployment, per capita market income, and poverty. The first study examined the relationship between county economic status and chronic disease and risk factors, both nationally and by metropolitan classification, using data from BRFSS 2013. Further, the social gradient was explored. The second study also used data from BRFSS 2013 to examine county economic status and prevalence of hypertension, arthritis, and poor health, after controlling for known risk factors. This study also examined results by US region. Finally, the third study assessed changes in disparities between persistently poor and persistently affluent counties for heart disease, hypertension, arthritis, and diabetes using data from BRFSS 2001-2010.

The current study employed quantitative and qualitative methods to examine predictors of adherence and diabetes health outcomes in Latino youth, and to gain understanding of mechanisms that underlie health behaviors and outcomes. Forty-nine Latino youth and their caregivers were recruited at a hospital-based outpatient diabetes clinic, 76% of the youth were either first or second-generation Latino youth (i.e., immigrant youth or youth whose parents are immigrants). A primary aim of this study was to quantitatively examine the impact of parent immigrant-related stress on child health behaviors and outcomes. This study complements these quantitative analyses by qualitatively exploring how (e.g., under what conditions) pathways to health are created. Specifically, qualitative analyses examined the unique experiences of Latino immigrant families in managing adherence to treatment and metabolic control, and gain insight into specific health promoters and barriers. Further, the author intended to qualitatively explain the effects of recently enacted immigration laws on Latino youths’ health behaviors and outcomes. Results revealed that higher levels of fear of deportation predict lower child-reported adherence, β = -41, p < .05. Higher levels of caregiver immigrant stress predict higher BMI rates in children, β = .30, p < .05. Immigrant related stressors, including fear of deportation, did not predict A1c or diabetes ketoacidosis (DKA) hospitalizations in the last year. Qualitative results highlight themes related to direct and indirect barriers to health behaviors and outcomes for youth, as well as ethnocultural promoters of coping and resilience.

In March 2012, President Obama issued a Presidential Memorandum creating an interagency Federal Working Group to explore the intersection of HIV/AIDS, violence against women and girls, and gender-related health disparities. Intimate partner violence (IPV) and HIV constitute major public health issues for women, particularly African American women who are disproportionately affected by HIV/AIDS. In 2012, the rate of HIV for African American women was four to 20 times higher than rates for females of other races. This study explores the complex relationship between IPV and STI/HIV risk in African American females. In an attempt to examine the intersection of IPV and STI/HIV risk this study used cross-sectional survey data to quantitatively examine the differences between women who had experienced IPV in the previous 12 months (cases) and women who had not experienced IPV in the previous 12 months (controls) in: 1) previous STI diagnosis, 2) accessing HIV testing and 3) mean scores of fear of condom negotiation due to physical violence. Chi-square analyses were completed to determine if the populations were statistically significant in terms of previous STI diagnosis and accessing HIV testing. An independent-samples t-test was conducted to compare the fear of condom negotiation scores for cases and controls. In addition, qualitative analysis was conducted to further elucidate the mechanisms from experiencing IPV to an increased risk of HIV infection. The quantitative analysis suggests a significant difference between fear of condom negotiation due to fear of physical violence. The qualitative analysis suggests that women who experience IPV are often forced to have sex with their partners, experience physical violence in response to condom negotiation and use drugs and/or alcohol to cope with the abuse. HIV prevention interventions need to address IPV as a possible risk factor. In addition, an enhancement of IPV screening in healthcare settings is needed. Future prospective studies are critical to address the issues of temporality and causality.

Chronic disease is a major health burden in the United States, affecting about half of adults, and leading to poor health, disability, and death. However, the burden of chronic disease is not shared equally among Americans, with some groups (created by determinants such as race/ethnicity and socioeconomic resources) experiencing higher rates of morbidity and mortality. When measures of health and socioeconomic resources are examined together, a stepwise gradient pattern emerges. This social gradient has been established for individual measures, such as household income and social class, and several measures of morbidity and mortality. However, nationally, little research has been conducted using area-level measures, such as county economics, to examine its relationship with chronic disease. Three studies were completed using data from the Behavioral Risk Factor Surveillance System (BRFSS). County economic status was determined using unemployment, per capita market income, and poverty. The first study examined the relationship between county economic status and chronic disease and risk factors, both nationally and by metropolitan classification, using data from BRFSS 2013. Further, the social gradient was explored. The second study also used data from BRFSS 2013 to examine county economic status and prevalence of hypertension, arthritis, and poor health, after controlling for known risk factors. This study also examined results by US region. Finally, the third study assessed changes in disparities between persistently poor and persistently affluent counties for heart disease, hypertension, arthritis, and diabetes using data from BRFSS 2001-2010.

Racial health disparities and social injustices in health care continue in the United States (US) despite decades of research, policies, and programs dedicated to their elimination (Feagin & Bennefield, 2014). Cultural competency education of health care providers has been one way purported to help sensitize professionals to these inequities, thus seeking to address racial bias, unequal treatment, and misunderstandings of minority populations (Office of Minority Health, 2001). Such education can begin when students enter academia to commence their health care education, and certainly occurs as a student moves on through their academic career, particularly as they enter their post-graduate level studies. Investigating the required cultural competency course of a Master of Public Health (MPH) program through the perspectives of faculty, current students, and alumni for its ability to develop culturally sensitive health care practitioners was the aim of this case study. Document analysis and direct observation of the one cultural competency course required for all concentrations in one MPH program was undertaken. This was a semester-long course and was offered face-to-face and online; both were observed. In-depth interviews of faculty, current students, and alumni of the same program were also conducted. Using the public health critical race (PHCR) praxis theoretical framework (Ford & Airhihenbuwa, 2010b), data was analyzed to determine how, and to what extent, faculty teach cultural competency, students internalize this instruction, and alumni put this education into practice. By using a critical theoretical framework designed for public health program development, this study found that such a framework has effective utility as a curriculum – this framework could be used to increase students understanding of racial issues that impact health and health care. Data also revealed a schematic believed, by faculty, students, and alumni, to be important for the development of cultural competence. The findings also point to the importance of creating space in the classroom for both minority and majority voices to feel free to express difficult issues without repercussions of stereo-typing and name-calling; and for faculty to be able to effectively deal with such discourse. Curriculum that addresses issues of health disparities and social justice, classroom praxis, and faculty role-modeling can be combined to create the institutional environment where culturally sensitive and socially just health care practitioners may emerge.