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As defined by the US Department of Health and Human Services, health disparities are "a particular type of health differences that are closely linked with social or economic disadvantages." These disadvantages include, but are not limited to, unequal access to quality health care and health information. Health disparities adversely affect groups of people based on racial or ethnic group, religion, socioeconomic status, gender, age, mental health, cognitive, sensory, or physical disability, sexual orientation, geographic location, or other characteristics historically linked to discrimination or exclusion. To address the root cause of health disparities there has been a call for more comprehensive frameworks for detecting, understanding, and designing interventions that will reduce or eliminate health disparities. One such framework is a Community-Based Participatory Research (CBPR) approach. CBPR is an orientation to research that focuses on relationships between academic and community partners, with principles of co-learning, mutual benefits, and long term commitment. CBPR also focuses on aspects of importance to the community with the aim of combining knowledge and action for social change to improve community health and eliminate health disparities. The overall goal of this dissertation is to build capacity and address health disparities among youth and adults in the Dan River Region. This region is federally designated as a medically under-served area/population and is located in the health disparate region of south central Virginia and north central North Carolina. This research draws on two CBPR projects, including an 8-week community garden program lead by the Dan River Partnership for a Healthy Community (DRPHC) and a 3-month childhood obesity treatment program, iChoose, led by the Partnering for Obesity Planning and Sustainability (POPS) Community Advisory Board (CAB). Since one of the primary aims for CBPR is to increase community capacity, this approach is the ideal process for engaging communities that suffer from health disparities. Thus, engaging community members as collaborators, our studies reported on the relevance and application of CBPR while simultaneously addressing health and capacity outcomes in the health disparate Dan River Region. / Ph. D.

Virginia Cooperative Extension's Family Nutrition Program (FNP), which includes EFNEP and SNAP-Ed, works to help limited-resource families across the state make informed food-choices. Virginia Cooperative Extension (VCE) lacks open-access physical activity resources representing individuals with varying weights, races, and ethnicities. In 2015, an integrated research-practice partnership was initiated for the development of an evidence-based physical activity resource for peer educators employed by FNP to use. The video suite, Move More, Virginia!, was created as open-access and includes demographically diverse individuals, representative of FNP clients. Study I determined client perceptions of physical activity and preferences for new resources. Study II identified FNP peer educators' perceptions of physical activity, their resource needs, and intent to use Move More, Virginia! resources. Both studies involved quantitative and qualitative data through surveys and focus groups. Formative data collected in Study I revealed the prominent themes related to clients (n=12) were physical activity facilitators (n= 100 meaning units (MU)) and physical activity barriers (n=77 MU). In Study II, peer educator responses(n=15) led to the emergence of four themes related to physical activity itself: barriers to incorporating physical activity within FNP (n=189 MU), physical activity facilitators (n=106), current delivery of physical activity (n=102 MU), and physical activity barriers (n= 16 MU). When prompted to share video specific feedback, the top theme was positive video feedback (n = 115 MU). Identified themes and subthemes provide deeper understanding of the organizational culture within FNP as thoughts, perceptions, and barriers to incorporating physical activity into FNP curriculum are highlighted. / Master of Science

Around 46.2 million Americans living in rural areas are disproportionately burdened by health disparities. Likewise, obesity and obesity-associated diseases (e.g., diabetes, cardiovascular disease) are much higher for rural residents when compared to their urban counterparts. There is a high need to understand and address the nutritional determinants of these health inequities among adults and adolescents. One area of concern in rural dietary habits pertains to added sugars and more specifically, sugar-sweetened beverages (SSB). Excessive added sugars and SSB intake have been strongly linked to many of the nutrition and chronic disease disparities impacting rural residents. Moreover, studies conducted in rural populations have found high consumptions of these in both adults and adolescents. There is an opportunity to better understand added sugars and SSB patterns in rural populations to inform the development of culturally relevant, multi-level interventions that address high consumption. Study #1 is a cross-sectional study that explores top food and beverage sources of added sugars in the diet of adults (n = 301) living in rural areas of Southwest Virginia. Study #2 uses a nationally representative sample of adolescents (n = 1,560) from the Family Life, Activity, Sun, Health and Eating (FLASHE) study sponsored by the National Cancer Institute, to explore factors across the levels of the socioecological model associated with adolescent SSB intake. Study #3 utilizes focus groups and a pilot trial to understand language preferences, acceptability and use of SMS aimed at caregivers to reduce SSB intake in both caregivers and adolescents living in rural areas of Southwest Virginia (n = 33). Collectively, these three studies offer recommendations and culturally relevant strategies for future large-scale trials aimed at reducing SSB intake among adolescents and caregivers in rural communities and ultimately reducing rural health disparities. / Doctor of Philosophy / Rural populations in the United States are at higher risk for being diagnosed with and dying from preventable and obesity-associated diseases like heart disease and cancer. Excessive added sugars and sugary drink (i.e. sodas, sweet tea/coffee, energy drinks, sweetened fruit drinks, sports drinks) intake have been strongly linked to many of the chronic diseases afflicting rural residents. Moreover, studies conducted in rural populations have found high consumptions of these, in both adults and adolescents. There is a great need to better understand added sugars and sugary drink patterns in rural populations so that we can develop programs to reduce consumption that are also culturally well received. Study #1 in this dissertation explores top food and beverage sources of added sugars in the diet of 301 adults living in rural areas of Southwest Virginia. Study #2 uses a nationally representative sample of 1,560 adolescents to explain why adolescent SSB intake might be higher. Study #3 aims to understand language preferences, acceptability and use of a text message program to reduce sugary drink intake in both caregivers and adolescents living in rural areas of Southwest Virginia. Collectively, these three studies offer recommendations and culturally relevant strategies for future large scale trials aimed at reducing sugary drink intake among adolescents and caregivers in rural communities and ultimately improving rural health.

Sociological theory and literature in the study of disparities in health and access to care in old age has, with few exceptions, not considered important political contexts for the aging AI/AN community. Political histories have unique implications for this population, and particularly those in old age. Native Peoples are affected by federal old age and health policies as well as AI/AN specific policies, which creates a unique intersection of inequality for this group. This project engages with three distinct areas of sociological scholarship in this area and works to highlight the strengths and gaps of existing frameworks to work towards more inclusive scholarship for Native Peoples in sociological scholarship. The first article uses a quantitative analysis using secondary data from the National Health Interview survey to explore how helpful sociological frameworks are in explaining health disparities in old age for the AI/AN population. The second article, using the same dataset, engages with Andersen's behavioral model of care utilization and its developments and couples it with important scholarship emerging about policy, AI/AN healthcare organization, and funding. The third article offers a qualitative analysis of reports and policy recommendations from Native organizations focused on increasing well-being for Native elders to further understand how healthcare, old age, and AI/AN specific polices work to create intersections of inequality for this group. This analysis further informs future directions for sociological theory and application to promote a more inclusive field in the sociology of aging and inequality. / Doctor of Philosophy / How policy impacts aging American Indian and Alaskan Native (AI/AN) has been largely overlooked in the field of sociology. Through three distinct studies, this dissertation project seeks to connect policy to disparities in health outcomes, issues in access to care, and the provisioning of health resources for this group. Native Peoples, through treaty agreements, have a right to healthcare, which has been poorly fulfilled by the US government. Because of this, Native Tribes and organizations have increasingly relied on other healthcare policies and social welfare programs to meet the needs of AI/AN elders. Policies like Medicare, Medicaid, and the Older Americans Act are all important policies in generating health resources for Native elders, but they also overlap in ways that can also create barriers to health equity. This project, in three articles, explores 1.) how policy-based resources affect health outcomes in old age across racial groups, 2.) how equitable healthcare access for the aging AI/AN population, and 3.) how organizations understand and navigate policy landscapes in order to promote health and well-being for Native elders. These three studies work together to inform theories of aging and health disparities in order to work towards scholarship that is more inclusive of Native Peoples.

The medical profession in recent decades has made culture and cross-cultural competence an issue for patient – physician relationships. Many in the profession attribute the necessity of cross-cultural competence to increased diversity, globalization, and health disparities; however, a historical analysis of medicine indicates that culture’s relevancy for health care and outcome is not new. The rise of clinics, which can be traced to 17th century France, the professionalization of physicians in 18th century U.S., and the civil rights movement of the 20th century illustrate that medicine, throughout its history, has grappled with culture and health. While medicine has a history of discussing cultural issues, the profession has not defined culture cogently. Medicine’s ambivalence in defining culture raises questions about how effectively medical educators prepare residents to be cross-culturally competent. Some medical educators have expressed that many didactic and experiential efforts result in stereotyping patients. Definitions of culture and their impact on stereotyping patients are the central problems of this study. Specifically, this study hypothesized that cultural beliefs impact ones willingness to accept stereotypes. Thus, this study sought to learn how faculty members and residents define culture. Faculty members also were compared to residents to glean the impact of cross-cultural education. This study used an explanatory mixed method design where quantitative and qualitative methods work complementarily to examine a complex construct like culture. A valid and reliable survey provided quantitative data to compare the two groups, while open-ended questions and interviews with faculty members provided context. The statistical results reveal that faculty members and residents share a philosophy of culture; however, when the two groups’ definitions are contextualized, they have many different beliefs. Differences also emerged with respect to predictability; cultural beliefs predict stereotyping among residents, but not faculty members. Faculty members attribute these differences to experiences, while residents believe that they do not learn about culture during their professional education.

The size of the Mexican-origin population in the United States means that its health patterns have important implications for the country’s overall population health. Understanding how this population is woven into the country’s complex social patterning of health is critical to understanding current social disparities in health. Drawing on a health disparities perspective and nationally representative datasets, this dissertation addresses key gaps in the social demographic literature on the health of the Mexican-origin population through three empirical chapters that examine how multiple measures of cardiovascular health are distributed across diverse social status and temporal configurations. I first examine how the obesity epidemic has unfolded across multiple temporal (age, period, and cohort) and social dimensions (gender, nativity, and race) for the Mexican-origin population. I find that period rather than cohort forces have shaped the rise in obesity among the Mexican-origin population. Furthermore, the pronounced group differences in obesity prevalence have remained stable across periods and cohorts, with the exception of a growing nativity gap among Mexican-origin women, among whom obesity has increased faster for U.S.-born individuals compared with foreign-born individuals. I next address the intersection of two additional temporal and social determinants of health: duration of residence in the United States and educational attainment. Building on research documenting a weak relationship between education and health for Mexican immigrants, I assess whether duration of U.S. residence strengthens this association. The patterns vary by outcome, but generally indicate that negative education gradients in health are more pronounced for long-term Mexican immigrants than for recent Mexican immigrants and that the education gradients of long-term Mexican immigrants resemble those of U.S.-born Whites. I then engage the literature linking acculturation to poor health among Mexican immigrants. Acculturation models of immigrant health have come under critique for ignoring the structural determinants of health. I engage in this debate by using segmented assimilation theory—which emphasizes the role of structural factors—to examine whether education conditions the association between acculturation and health. I find support for the idea that the detrimental influence of acculturation on cardiovascular health is concentrated among Mexican immigrant adults with low levels of education. / text

Breast and cervical cancer disparities among Hispanic and American Indian women are a significant public health problem. Breast cancer is the most common neoplasm among Hispanic women. Cervical cancer has a higher incidence and mortality among Hispanic women compared to non-Hispanic White women. Breast cancer detection often comes late for American Indian women and breast cancer survival for this population is relatively poor. Hispanic and American Indian women who reside in rural areas of Arizona are especially at-risk of non-participation in breast and cervical cancer screening programs. This dissertation utilized data from two sources: a health-education intervention trial designed to increase mammography screening among women living in a rural area along the U.S.-Mexico border of Arizona and survey data from multiple years of the Arizona Behavioral Risk Factor Survey (BRFS) focusing on breast and cervical cancer screening self-reported behaviors. The purpose of the dissertation research was to identify factors associated with cancer screening behaviors among Hispanic and American Indian women that reside in rural Arizona settings. Hispanic women who participated in the promotora-based educational intervention program were more likely to report receiving a mammogram at the followup compared to women who did not participate in the program. Results from both the baseline community survey and the BRFS showed that Hispanic women who received prior recommendations from a clinician to get both mammography and Pap smear were more likely to report they received a mammogram within the past year and a Pap smear within the past three years. Rural Hispanic and American Indian women reported lower rates of ever having had breast and cervical cancer screening compared to their urban counterparts. Breast and cervical cancer screening use in these populations can potentially be increased with at least two strategies. First, clinician recommendation of both mammograms and Pap smears and opportunistic screening during regular clinic visits may increase breast and cervical cancer screening coverage. Secondly, culturallyappropriate interventions that utilize promotoras or lay health advisors could increase screening rates. In conclusion, Hispanic and American Indian women that reside in rural areas of Arizona, whether throughout the State or along the U.S.-Mexico border, are two underserved populations in Arizona with low rates of breast and cervical cancer screening that need to be addressed in order to reduce the burden of cancer in these populations.