With growing cultural diversity in the United States (U.S.), health disparities continue to exist among many ethnic minority populations impacting the U.S. economy. Health disparities are health differences that are noted in a particular cultural group in respect to higher rates of diseases and deaths in comparison to others. These cultural groups have common attributes and can be based on race, ethnicity, disability, sexual orientation, income, residential location and many others. One such example is individuals of Puerto Rican heritage, the second largest Hispanic group living in the U.S. mainland. Puerto Ricans are identified to have multiple health disparities in comparison to other Hispanic and non-Hispanic population groups living in the U.S. Among other factors, common cultural health care beliefs and practices of individuals impact health outcomes. Healthcare professionals like nurses are expected to provide culturally competent care to vulnerable populations with known health disparities. Culturally competent care refers to delivering care congruent with patients' cultural beliefs and practices. Therefore, it is important to educate health professionals regarding caring for vulnerable populations. The purpose of this community-based participatory research (CBPR) study was to develop content for an educational tool, an online virtual interactive simulation (OVIS) case for developing cultural competency of nursing students in caring for the Puerto Rican population of New York City (NYC). The content development for OVIS was guided by the framework for Cultural Competency Simulation Experiences (CCSE), which was developed as a part of this dissertation. The CCSE framework guided the content development of OVIS using a CBPR approach. A community advisory board was developed which consisted of cultural, clinical and educational experts, residing in New York and Puerto Rico.

This dissertation examines China’s market reforms over the last few decades, and their implications for (re)shaping socioeconomic inequalities in health. Specifically, I study the effect of marketization and related structural changes at community level on individual health outcomes. The first part of this dissertation revisits the market transition theory of Nee (1989), using individual health status as the outcome variable to assess Nee’s theory. Using multiple waves of a longitudinal survey from 1991 to 2006, I compare temporal changes in the role of human capital, political capital, and state policy in determining health under marketization. In partial support of the market transition theory, the empirical results show that the significance of human capital for health increases with marketization, while the return to political capital and one’s household registration status diminishes with a growing market. Additionally, I distinguish between marketization effects on community level, and different aspects of community context in shaping the SES-health link. I find that the level of urbanization and available resources within each community exert influences on self-rated health and change the relative importance of individual socioeconomic conditions in shaping health. Overall, this study provides new longitudinal evidence from China to support the notion that health is influenced by dynamic processes moderated by the structural changes as well as the social stratification system. I discuss the findings in the context of China’s market reform, fundamental causes theory, and socio-ecological perspectives, highlighting that health is determined by a nexus of life experiences and social environment that impact individuals at different levels. / 10000-01-01

This dissertation study utilized the National Longitudinal Study of Adolescent to Adult Health to analyze empirical relationships between social determinants of health and adolescent pregnancy. Although rates of adolescent pregnancy are at an all-time low in the United States, disparities persist. Examining relationships between the social determinants of health and adolescent pregnancy provides support for funding and interventions that expand on the current focus of individual and interpersonal level factors. Based on the Healthy People 2020 Social Determinants of Health Framework, proxy measures for social determinants of health were identified within the Add Health study and analyzed in relationship with adolescent pregnancy. Results indicated that six of 17 measures of social determinants of health had an empirical relationship with adolescent pregnancy. These measures included the following: feeling close to others at school, receipt of high school diploma, enrollment in higher education, participation in volunteering or community service, litter or trash in the neighborhood environment, and living in a two parent home. The results of this study can inform future research, allocation of funds and interventions based on social determinants of health that show an association with adolescent pregnancy.

Access to healthcare is an important topic within medical anthropology, in part because access is denied or complicated through structural forces for many populations in the United States. Anthropological research explores the impact of lack of access to healthcare on the lives of at-risk populations, as well as the differing and unexpected ways that access is denied or limited (Adler and Newman 2002; Becker 2004; Becker 2007; Horton 2004; Horton, McCloskey, Todd, and Henricksen 2001; O'Daniel 2008). For low-income, rural and minority populations, research shows that access to healthcare is further complicated by a higher propensity to break appointments (Bean and Talaga 1992; Bean and Talaga 1995). The act of appointment breaking is an essential aspect of this discussion: it is through appointment breaking and other similar activities that it is possible to understand how people access care when it is “available” to them and what everyday barriers prevent them from having true and full access. In this project, I define appointment breaking as the act of missing a scheduled appointment without prior cancellation. Through this research, I explore how people understand their access to healthcare resources and what factors impact their use by focusing on appointment breaking at a Florida community health center. This research uses a critical medical anthropology approach and is grounded within the anthropological theories of access to healthcare, health disparities, structural violence, and the political economy of health; through this theoretical perspective, the issue of appointment breaking can be studied as a complex and integral aspect of access to healthcare, and rooted in the long history of medical anthropology studies on health disparities. Using qualitative research methods, specifically interviews and participant observation, as well as an analysis of the demographics of those patients that have missed appointments at this community health center, this study investigates the broader implications of a lack of access to care characterized by appointment breaking. This research connects the act of appointment breaking to cultural influences which shape access to healthcare. I found that barriers such as finances, mental health needs, personal issues, and lack of child care prevents patients from accessing healthcare, even through the safety net programs that are in place to serve at-risk populations, such as low income, rural, and minority populations. This research contributes to the existing literature on gaps in access to healthcare that is provided for at-risk populations and develops the anthropological research on the overlooked topic of appointment breaking. By exposing the issue of appointment breaking as a factor in the larger issues of access to care and health disparities, this research highlights the larger structural forces that impact access to care beyond access to insurance and the availability of affordable and accessible healthcare resources.

Diabetes mellitus affects 7.8% of the American population. National health statistic data and other research shows that racial/ethnic disparities exist in terms of prevalence and treatment outcomes. The present study investigated the role of patient health beliefs (i.e., locus of control, self-efficacy) and the doctor-patient relationship (e.g., satisfaction and collaboration with health care provider), as relative predictors of diabetic control (i.e., HbA1c levels) and overall satisfaction with diabetes care, in older adult participants with diabetes. Demographic, psychosocial, and diabetes-related data from the Health and Retirement Study (HRS) 2003 Diabetes Study were analyzed to compare treatment outcomes among non-Hispanic White, non-Hispanic Black, and Hispanic individuals with various types of diabetes. Non-Hispanic White individuals exhibited better diabetic control than their minority counterparts (F(2, 592) = 7.60, p < .001); however, no significant group differences were noted in terms of psychosocial factors. Diabetic control was best predicted by time since diagnosis (&#946; = -.21, p < .001), satisfaction with diabetes self-care (&#946; = .19, p < .001) and age (&#946; = .12, p < .01). In addition, satisfaction with provider care was best predicted by perceived collaboration with provider (&#946; = .44, p < .001), satisfaction with diabetes self-care (&#946; = .22, p < .001) and diabetes self-efficacy (&#946; = .08, p < .05). Recommendations for future research were discussed.

Obesity is an increasing problem in the United States with 17% of youth currently classified as obese and an even higher prevalence of obesity among disadvantaged populations. The food environment may be contributing to these high rates as there has been a well documented association among increased away from home food consumption and excess adiposity, as well as evidence to support that children\'s diets are composed of a large portion of restaurant foods. The main purpose of this study is to describe the quality of restaurant food offered to children in a rural health disparate region. Two trained research assistants conducted systematic audits of all food outlets offering a children\'s menu in the Dan River region using the Children\'s Menu Assessment (CMA) tool. A composite score for each outlet for was calculated from the 29 scored items on the CMA. The total sample consisted of 137 outlets with CMA scores ranging from -4 to 9 with a mean score of 1.6+2.7. Scores were lowest in the predominantly Black block groups (0.2+0.4) when compared to the predominately White block groups (1.4+1.6) and Mixed block groups (2.6+2.4) with significantly lower scores in the predominantly Black block group than the Mixed block groups (F=4.3; p<0.05). The results of this study reveal a lack of few healthy food options available for children in this region. These findings have the potential to contribute to public health efforts in developing public policy changes or environmental interventions for the children\'s food environment in the Dan River Region. / Master of Science

Background: The incidence and prevalence of chronic disease (CD) has increased in recent decades due to the advent of CD management and life-extending technologies. To address this burden on the population and healthcare system, evidence-based CD prevention programs have been developed to reduce the incidence and therefore the prevalence of these diseases. Despite the development and dissemination of effective interventions, African-Americans and Hispanics have disproportionately higher prevalence of CD and associated risk factors and disproportionately lower participation in CD prevention programs. Overweight/obesity and CDs may have intergenerational effects, with overweight adults being more likely to have overweight children who are in turn more likely to become overweight adults with CDs. These dissertative projects sought to disrupt this intergenerational cycle of CD by exploring how to engage people of minority background in CD prevention programs, to determine the acceptability and feasibility of a CD prevention program adapted to social media, the preferred method of health education for women of childbearing age, and to identify areas in Florida that would benefit from a CD prevention program such as this. Methods: Four focus groups of residents of disadvantaged and medically underserved areas and nine key informant interviews with local business owners were conducted using a standardized questionnaire to asses health beliefs, barriers to healthy behaviors, and preferred methods of health communication among the target population. These data were thematically analyzed in Atlas.ti version 8.0. Results of this analysis informed the adaptation of an existing CD prevention program, the national Diabetes Prevention Program (nDPP), to a social media platform, Facebook, to address the needs of the community. The first four weeks of the nDPP were adapted to Facebook using Powtoon and Canva software, were assessed for fidelity by a certified nDPP Lifestyle Coach, and underwent an iterative editing process in collaboration with a community partner, REACHUP, Inc., to ensure cultural appropriateness. Height, weight, and waist circumference were measured pre- and post-intervention via a standardized protocol. Perceived stress, social support, depressive symptoms, and health-related quality of life were also assessed pre- and post-intervention. The final dissertative project utilized the Centers for Disease Control and Prevention and Robert Wood Johnson Foundation’s 500 Cities Data in conjunction with USDHHS locations of existing federally qualified health centers (FQHCs) to identify urban census tracts in Florida with high prevalence of CD and associated risk factors and inadequate access to FQHCs. Results: Overall, residents and business owners in medically underserved areas of west central Florida identified distrust of medical professionals and pharmaceuticals as a barrier to receiving health care. Lack of transportation and safe recreational areas, were barriers to participating in health behaviors, though participants were concerned about how to prevent and manage diabetes, heart disease, and cancer. The preferred identified method of health communication for women of childbearing was social media, with Facebook being the most used social medium. The nDPP was chosen for adaptation to Facebook because it addressed most of the concerns of the target community. This Facebook-based adaptation of the nDPP, called HealthyLIFE, had no statistically significant results, though there were encouraging reductions in depressive symptom, perceived stress, and health-related quality of life. Tampa, St. Petersburg, Lakeland, and Jacksonville were the urban areas of Florida with the greatest prevalence of CD and associated risk factors, with areas with low insurance, low physical activity, poor physical health, high levels of poverty, high concentration of people of minority background, and high prevalence of stroke and diabetes were statistically significantly more likely to be within 0.5 miles of an FQHC. Discussion: The results of this dissertation demonstrate the need for qualitative research to inform interventions to disrupt the etiology of chronic disease at the population level, particularly for people of minority background and low socioeconomic status who may experience greater barriers to participating in healthy behaviors and accessing preventive healthcare services. Integrating this type of data into the design and implementation of chronic disease prevention programs and targeting these programs to geographic areas with high prevalence of CD and associated risk factors can increase uptake by populations with historically low participation in these programs. With FQHCs serving less than 25% of urban census tracts with high prevalence of chronic disease and associated risk factors, there is a need for cost-efficient, effective, scalable, and accessible chronic disease prevention programs like HealthyLIFE to improve population health and reduce health disparities between racial and socioeconomic groups.

LGBT+ patients, medical students, and healthcare providers have been shown to experience significant health disparities and poor health outcomes, to less frequently seek out healthcare, and to often face discrimination in healthcare settings. Researchers suggest the lack of high quality and in-depth training on LGBT+ health and communication skills may contribute to hostile clinic cultures and reinforce implicit and explicit biases towards LGBT+ patients. Despite the growing body of research and interest in curriculum reforms, there has not been an up to date, comprehensive review of LGBT+ health trainings and resources at U.S. medical schools since 2015. We conducted a systematic review of available information on the presence of LGBT+ trainings, support groups, and resources for medical students, residents, and faculty at all M.D.-granting institutions who are part of the Association of American Medical Colleges (AAMC). The systematic review was conducted between May and September 2020 through Google using pre-determined keyword search strategies. Collected information included type of programming, targeted audience, and length of training among others that was built into an easily accessible online database of LGBT+ health curriculums and resources. Similar to 2015, most U.S. medical schools (52%) do not have or do not provide easily accessible information about LGBT+ trainings for their students. Even fewer medical schools (39%) report that they require their students to take some form of LGBT+ health training, and almost no information is easily available on LGBT+ trainings for residents and medical school faculty. Our findings suggest that medical schools have made some progress in creating more inclusive curricula and training environments compared to 2015. However, there has not been a consensus in how medical students should be trained to be more aware of and to address biases, discrimination, and poor health outcomes affecting their LGBTQ+ patients and colleagues.

Breast cancer, according to research, is diagnosed in approximately one in every twenty-nine women in South Africa. Differences in gender, race and class produce disparities in health care, subjecting lower class women to lengthy waiting periods between diagnosis and treatment. Present research studies on breast cancer predominantly use quantitative methods. To understand women's lived experiences of the breast cancer trajectory this study explores experiences encountered during the waiting period, as well as the impacts of breast cancer and its treatment on feminine identity. For this a qualitative method was applied. Semistructured, in-depth interviews were conducted with five black and coloured breast cancer patients residing at two of CANSA's care homes. Participants varied in age and phases of treatment, were all married or widowed, had minor dependants, and had all travelled from distant and outlying areas. Based on a thematic analysis, six themes emerged from the data collected. These included: First experiences of cancer in the body; breast cancer and waiting periods from the patient's perspective; sources of support; meanings and perceptions of being a woman; conceptualising disease, and patients' needs. The analysis illustrates the importance of researching women's lived experiences and highlights that these need to be understood within a framework of socially constructed notions of gender, race and class in order to improve breast cancer treatment and psycho-social care.

Introduction: Transgender is an identity term used to describe people with diverse gender identities and expressions that differ from their sex assigned at birth. People who identify as transgender have worse health outcomes than the cisgender or non-transgender populations. Limited healthcare access and chronic stress from discrimination all contribute to worsening health outcomes for this population. However, research regarding this population is limited, particularly in the rural southern United States. The purpose of this study was to assess physicians’, nurse practitioners’, and physician assistants’ experience with, attitude towards, and knowledge of transgender healthcare in the Northeast Tennessee region. Methods: Medical providers, including NPs, PAs, DOs and MDs from Family Medicine, Emergency Medicine, Internal Medicine, Pediatrics, and Obstetrics and Gynecology in both academic and community settings were surveyed regarding their attitudes toward, knowledge of, and experiences with gender, sexual orientation, and sexuality as they relate to healthcare. All potential participants were informed that participation was voluntary. Limited demographics were gathered and surveys were collected in a confidential manner. Data were analyzed for statistical significance. Results: Initial analyses showed the majority of providers had not received training in transgender healthcare and perceived they had few to no trans-identified patients. Over half of all respondents felt competent in providing healthcare to trans people and the majority felt comfortable treating this population. Providers indicated it is important to know their patients’ sexual practices, gender identity and sexual orientation; however, the majority of providers do not ask patients their gender identity, sexuality, or desired pronouns. Respondents were unsure whether gender confirmation surgery is covered by insurance and widely accessible. In assessing clinical knowledge of providers, there were a wide variety of responses suggesting varying level of competence amongst providers. Responses were split regarding whether access to healthcare is the same for the transgender population as it is for the general population. Pediatric providers were asked about comfort in prescribing hormones, knowledge of mental health support in the area, referrals and discussing gender identity with patients. These responses fell along a normal distribution, indicating a variety of training, experiences, and opinion regarding trans healthcare for the adolescent population. Conclusions: Overall results from the preliminary data demonstrate a contradiction between ideology and practice. With most participants responding they felt comfortable and competent providing care to the transgender population, yet their responses indicated a lack of training and absence of inclusivity in their health care practices. This suggests that education is needed within the healthcare community on transgender healthcare.