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This dissertation aims to examine racial and ethnic inequities in nursing home (NH) palliative care services and potentially avoidable hospitalizations at the end of life. Health disparities are pervasive in NHs, but disparities in NH end-of-life care (i.e. palliative care services, hospital transfers) have not been comprehensively examined. Chapter One provides an overview of this dissertation, which explores inequities in nursing home end-of-life care. Chapter Two is a systematic review that synthesized the current state of the science in racial and ethnic disparities in NH end-of-life care. Chapter Three was designed to describe palliative care services in U.S. NHs and associations with differences in the concentrations of Black and Hispanic residents, respectively, and the impact by region. Chapter Four is an analysis of racial and ethnic differences in NH potentially avoidable hospitalization incidence rates. Finally, Chapter Five is a synthesis of this body of work. It contains a summary of findings of this dissertation, a discussion of the results, practice and policy implications, and directions for future research.

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Bipolar disorder is a serious illness affecting approximately 2-4% of the population and is one of the world’s leading causes of disability. In individuals with bipolar disorder, medical comorbidity associated with cardiovascular, respiratory and endocrine disorders is related to increased rates of mortality. Recent updates to multi-system inflammatory related conceptualizations of bipolar disorder focus on the unique power that medical illness and biological processes may play as factors associated with course and outcome in bipolar disorder. The current study examined medical comorbidity and its associations with various demographic and psychological variables in individuals with bipolar disorder, schizophrenia, and major depressive disorder with psychotic features followed for 10 years from their first hospital admission. When compared to an age, gender and race-matched control sample from the population, those with bipolar disorder had significantly higher medical comorbidity across a range of medical diagnoses both at 6 months and 10 years after first hospital admission. Ten years following initial hospitalization, individuals in all three diagnostic groups reported increased rates of diabetes (OR: 2.0 – 3.7), stroke (OR: 4.6 – 7.0) and asthma (OR: 1.9 - 3.1), and individuals with bipolar disorder reported increased rates of cancer (OR = 2.1). A number of psychological and demographic symptoms were examined for their ability to predict the development of medical illness across the assessment interval. Overall rates of medical illness were elevated both early in illness course and 10 years after diagnosis, suggesting that broad sequelae of multi-system inflammation are present early and progress over time.

The Hispanic birthweight paradox, whereby Hispanic women exhibit a comparable or lower risk of bearing a low birthweight infant than their white counterparts despite relative socioeconomic disadvantage, has been observed across a number of research studies. However, the majority of evidence for the paradox has focused on Hispanics in aggregate form or on populations with primarily Mexican ancestry and has relied largely on outcome measures with important methodological shortcomings. Furthermore, studies have identified the variation of birthweight risk among Hispanics by nativity, maternal education and neighborhood composition, but the evidence has been scarce and inconsistent. The overall goal of this dissertation was to investigate the Hispanic health paradox with relation to measures of birthweight and infant size in births to women residing in New York City aged 20 years and older, using birth records for years 2003 through 2007 collected by the Office of Vital Statistics of the New York City Department of Health and Mental Hygiene (N=460,881). The main outcomes of interest in this study were mean birthweight, low birthweight (LBW, defined as < 2500 grams versus ≥ 2500 grams) and small for gestational age (SGA, calculated as the 10th percentile for birthweight at each week of gestational age and by sex). Multilevel logistic models with random effects were used to estimate odds ratios for the association between race/ethnicity and measures of birthweight and infant size, while controlling for individual-level and contextual factors and accounting for the correlation between observations within the same neighborhood. Analyses were conducted with Hispanics as an aggregate group as well as with race/ethnic-nativity subgroups. In addition, effect measure modification by maternal education and by neighborhood proportion of Hispanic population (NPHP) were examined. This research confirmed the Hispanic paradox in SGA analyses for Hispanics overall and for both U.S.-born and foreign-born Hispanics, but not in analyses with LBW or with mean birthweight. As compared to white women, black women exhibited 50% greater risk (OR:1.50;95%CI:1.45,1.55) and Hispanic women comparable risk (OR:1.03;95%CI:1.00,1.06) of having an SGA infant, in a fully adjusted model. With regard to LBW, the risk was more than double for black women (OR:2.25;95%CI:2.16,2.35) and close to 50% greater for Hispanic women (OR:1.46;95%CI:1.40,1.53) as compared to that of their white counterparts. In addition, the mean birthweight of infants born to Hispanic women was significantly lower compared to those born to white women. Furthermore, the relationship between race/ethnicity and all three measures of birthweight and infant size varied by maternal nativity status (p<0.0001), with infants of foreign-born women experiencing more favorable outcomes relative to their U.S.-born counterparts. The paradox with SGA was also apparent across most Hispanic race/ethnicity-nativity subgroups, The odds were greatest among black and Puerto Rican women overall (OR:1.52;95%CI:1.47,1.57 and OR:1.17;95%CI:1.13,1.22, respectively) and lowest among Mexican and South American women overall, (OR:0.91;95%CI:0.87,0.95 and OR:0.85;95%CI:0.80,0.89) as compared to white women in a fully adjusted model. The odds of SGA for infants born to Dominicans, Central Americans and Cubans in the fully adjusted model were similar to those born to whites. In addition, SGA varied by maternal nativity status (p<0.0001), with more favorable SGA odds observed among infants of most foreign-born women, as compared to whites. The exception was U.S.-born Puerto Ricans who consistently exhibited elevated risk of SGA relative to whites. The association of race/ethnicity-nativity with SGA varied by maternal educational attainment (p<0.0001), but the influence varied by subgroup. The observed advantage of foreign birth was stronger among less educated women of all Hispanic subgroups other than Puerto Ricans and Cubans. Similarly, the variation of SGA risk by neighborhood proportion of Hispanic population (NPHP) differed across subgroups (p<0.0001). NPHP did not appear to influence the association between race/ethnicity-nativity and SGA in a consistent pattern, but among black women and US-born Puerto Rican women greater NPHP was associated with a higher risk of SGA. Findings from this study underscore the importance of using SGA an accurate measure of infant size and of conducting analyses disaggregating race/ethnicity and nativity subgroups. Future research should focus on factors that contribute to the resilience of Hispanic subgroups in the face of adverse economic circumstances, such as the role of social support networks and acculturation. Greater understanding of the salubrious circumstances that lower the risk of adverse birth outcomes has major public health benefits, especially for a wide-ranging population of mothers, Hispanic and non-Hispanic, and their infants.

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published_or_final_version / Medical Sciences / Master / Master of Medical Sciences

Societies that foster high quality social environments and integration produce healthier populations. The mechanisms underlying the protective effect of social integration appear to be through various forms of social support. In the Canadian Aboriginal context, few authors have explored the relationship between health and social support. This gap in understanding is significant because Aboriginal frameworks of health point to the salience of larger social structures (i.e., family), yet patterns of population health point to distinctly social causes of morbidity and mortality (e.g., violence, alcoholism). An interesting paradox emerges: patterns of Aboriginal health suggest that social support is not working to promote health. This dissertation explores this paradox through a mixed-methods approach to describe the value of social support for Aboriginal health, and to critically examine the social-structural processes and mechanisms through which social support influences Aboriginal health at the community level. / Principal components analyses of the 2001 Aboriginal Peoples Survey (APS) identified social support as a consistent dimension of Metis and Inuit health, and multivariable logistic regression modelling of the 2001 APS identified social support to be a significant determinant of thriving health among Indigenous men and women (e.g., those reporting their health as excellent/very good versus good/fair/poor). The results also indicate a distinct social gradient in thriving health status and social support among Aboriginal Canadians. / Narrative analyses of 26 interviews with Aboriginal Community Health Representatives point to two key explanations for the health-support paradox: (i) social support is not a widely accessible resource; and (ii) the negative health effects of social support can outweigh the positive ones. The formation of health behaviours and cultural norms - which underpin social supports - are inextricably tied to the poor material circumstances that characterize Canada's Aboriginal communities. The thesis concludes with a critical examination of the processes through which environmental dispossession has influenced the determinants of Aboriginal health, broadly speaking. Effects are most acute within the material and social environments of Aboriginal communities. More research attention should focus on identifying the pathways through which the physical, material and social environments interact to influence the health of Aboriginal Canadians.

Thesis (MFamMed)--Stellenbosch University, 2015. / Background: Coronary heart disease is a global public health problem. Formerly considered rare in sub-Saharan Africa, evidence has shown that urbanization and the adoption of more affluent and sedentary lifestyle in subpopulations of this region, may result in increased prevalence. One such subpopulation is workers in the Nigerian petroleum industry and this study examines their risk factors for coronary heart disease. In addition the study compares the risk profile of onshore and offshore workers. Method: This is a descriptive cross sectional study undertaken to determine the level of risk factors for the development of cardiovascular disease in two groups of male workers of the petroleum industry in Nigeria; the onshore and the offshore workers. Four hundred workers were randomnly selected and invited to participate, with a desired sample size of 234. The data was collected by using an electronic questionnaire to explore life style factors like exercise, diet, and smoking that predispose to this disease. Anthropometric indices included body mass index, waist circumference and waist to hip ratio. Biochemical tests included lipid profile and fasting blood glucose. Systolic and diastolic blood pressure was also recorded. The prevalence of known hypertension and diabetes as well as the metabolic syndrome were determined. The questionnaire data was analysed and compared with the chi-square test using the software, Epi-info 2008 Windows Version 3.5.1 and the means of the continuous variables were determined and compared using analysis of variance (ANOVA). Results: 121 onshore and 110 offshore workers participated. Overall the cardiovascular risk profile of onshore versus offshore workers in the oil industry was worse. Onshore workers had increased waist circumference,; though there was no significant difference in the Waist-Hip Ratio, increased rates of metabolic syndrome, diabetes and hypertension and were less physically active. Dietary differences were less marked, but more beef and chicken were consumed by onshore while more fish was consumed by offshore workers. Conversely the offshore workers had a higher BMI and lower levels of protective HDL. Overall, in this population, the BMI and the umber of diabetics were higher and the HDL lower than the country figures. Conclusion The obesity profile of the two groups was comparable to that of the Western nations and could become worse. This also reflects the fact that within Nigeria there are sub-populations with cardio-metabolic profiles that depart significantly from the national average. This is most probably due to dietary factors and poor exercise habits and calls for intervention through health promotional activities / AFRIKAANSE OPSOMMING: Nie beskikbaar

Children in low-income and ethnic minority families are more likely to be in poor health, which may impact physical and economic well-being in adulthood. This study explored how maternal depression and parenting efficacy were associated with child health outcomes in a sample of low-income African American and Latino families. Results demonstrated that children in optimal health were more likely to have mothers with high parenting efficacy and fewer depressive symptoms. Differences between African American and Latino families illustrated the importance of considering both socioeconomic and racial and ethnic disparities in child health simultaneously. Parent characteristics may be opportune targets for addressing child health disparities, and future research should focus on understanding these associations and identifying parent behaviors associated with child health.