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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.

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.

<p dir="ltr">This dissertation includes two independent chapters which investigated the relations between upward social mobility (USM) and mental health in the United States. Chapter 1 was a systematized review which identified, cataloged, and synthesized the existing literature on the relations between USM and mental health in the United States. Four electronic databases were searched (i.e., PsycINFO, PubMed, Scopus, and Web of Science) and, through an exhaustive screening and data extraction process, a sample of 15 studies were reviewed. Chapter 1 used narrative synthesis (i.e., tabulation and thematic analysis) to describe and synthesize patterns across the existing literature. Notably, review findings revealed great variability in both research methodology used by studies as well as study findings. Moreover, review findings suggested that the variability observed among study findings was likely influenced by a lack of consistent operationalization of social mobility. Finally, recommendations for future research were provided.</p><p dir="ltr">Chapter 2 was an empirical study that examined moderators and mediators of the relations between USM and mental health. Based on the status-based identity framework (SBI; Destin et al., 2017), I hypothesized that USM would relate to poorer mental health, that belonging would mediate the relations between USM and mental health, and that internalized classism, interpersonal classism, and social class centrality would moderate the mediation. Data from a sample of 331 U.S. adults were collected via Prolific. While study results supported the first two hypotheses, only interpersonal classism was found to moderate the mediation. Specifically, the conditional indirect effect showed that those who experienced high and moderate levels of interpersonal classism had a negative relation between USM and belonging. Finally, study limitations and implications for research and clinical practice are discussed.</p>

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.

This study explored healthcare utilization among the Transgender and Gender Non-Binary (TGNB) population of Florida using Geographic Information Systems (GIS) to visualize and analyze the spatial distribution of unmet healthcare needs. The aim was to provide a clear comparison of unmet healthcare needs across various regions, highlight areas with the highest and lowest levels of unmet needs, and understand the demographic factors influencing these disparities. Utilizing survey data from the NIH-funded U=CARE study, which involved TGNB participants aged 18-26 from diverse racial/ethnic and socioeconomic backgrounds, the data were cleaned, geocoded, and analyzed within ArcGIS. Geocoded survey responses were linked to Florida Department of Transportation (FDOT) district boundaries. Choropleth maps were created to represent the percentage of respondents in each geographic unit reporting unmet healthcare needs, with color gradation indicating the intensity of these needs. Regional variations were found, with Northeast Florida and Northwest Florida showing the highest levels of unmet healthcare needs despite having the lowest participant counts, while Central Florida, which had the highest number of participants, also reported a substantial percentage of unmet healthcare needs. A demographic analysis indicated that younger participants, those with lower education levels, and individuals from diverse racial and ethnic backgrounds were more likely to report unmet healthcare needs. Districts with lower socioeconomic status (SES) showed higher levels of unmet needs, underscoring the critical role of socioeconomic factors in healthcare access. This study identifies specific regions and demographic groups with significant unmet healthcare needs, informing targeted healthcare interventions and policies. By integrating spatial and demographic analysis, it provides a comprehensive understanding of healthcare disparities among TGNB young adults in Florida, contributing valuable insights for improving health outcomes across diverse populations and addressing the specific healthcare challenges faced by this community.

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.