Cigarette smoking is the leading cause of preventable morbidity and mortality in the United States. While smoking rates have steadily declined among the general population, smoking is becoming increasingly concentrated among socioeconomically disadvantaged groups due to higher initiation and lower cessation rates. This dissertation examines determinants and mechanisms of smoking cessation in the context of the Kick it for Good study (KIG), a community smoking intervention for Boston public housing residents. In the first study, we explored mediators and moderators of the KIG intervention effect on smoking cessation. We did not find any significant mediators for 3-mo cessation outcomes, although there was modest evidence for mediation by self-efficacy to quit at 12-months. We found living with other smokers and perceived stress were moderators of the KIG intervention effect on smoking cessation. In the second study, we examined predictors of attitudes and knowledge of nicotine replacement therapy (aNRT). We found discussing smoking cessation with a healthcare provider and use of nicotine replacement therapy (NRT) were associated with more positive attitudes and greater knowledge of NRT. The KIG intervention did not impact aNRT outcomes throughout the study period. In the third study, we examined the effect of depression on smoking cessation and whether this effect was moderated by social support. We found smokers with depression classified by the 10-item Center for Epidemiologic Studies Depression Scale (CES-D-10) were more likely to report smoking abstinence than those without depression. Social support did not moderate the effect of depression on cessation. We also conducted a sensitivity analysis to determine if the cutoff of 10 for the CES-D was valid in this population of low-income and racially/ethnically diverse smokers. We did not find evidence of depression misclassification by the CES-D-10, although there remains the need to validate the scale in socioeconomically disadvantaged populations. These findings provide valuable information on how smokers living in Boston public housing were able to achieve smoking abstinence in the context of a cessation intervention. The insights gained from these results may be applied to future intervention studies to help address the disparity in smoking rates among socioeconomically disadvantaged smokers.

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Health disparities are a recognized public health concern and the need to address these disparities remains worthy of bringing new methods that assist in closing the gap. This research examined the effectiveness of data science to highlight health disparities, and to convey the value of data science applications in related health care applications. The goal of this research was accomplished by undertaking a multi-phased and multi-method approach, best represented in three individual essays. In essay one, a systematic literature review assessed the state in current academic literature of data science applications used to explore health disparities and to determine its applicability. The systematic review was guided by the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines. Essay two assessed the capacity of data science software to address the effectiveness of these data science technologies in examining health disparities data. This was conducted using KDnuggets data pertaining to analytics, data science, and machine-learning software. The research in this essay demonstrated the potential utility of leading software to perform the kinds of data science operations that can achieve improved care in healthcare networks by addressing health disparities. Essay three provided an appropriate case study to showcase the value data science brings to the healthcare space. This study used a geographic information system to create and analyze choropleth maps to determine the distribution of prostate cancer in Texas. SPSS software was used to assess the social determinants of health that may explain prostate cancer mortality.

In recent decades, neurologists have been directing more of their research efforts to exploring the sources of health disparities in medical and surgical treatment of epilepsy. Many studies reveal that racial and ethnic minority patients continue to receive suboptimal care, which has some dire repercussions on their physical and mental health, as well as their social well-being because epilepsy is a chronic disease that tends to affect multiple aspects of the patient’s life. Although the earliest landmark studies emphasized the importance of mixed methodology research, the studies that followed tended to rely heavily on quantitative methods to unravel patterns of disparities with sparse use of qualitative methods to give voice to the patients concerned. In this work, I present a mixed methodology framework that is particularly suitable to investigating health disparities in epilepsy care, which affirms the complementary nature of quantitative and qualitative methods. I explore some of the challenges that clinicians face to utilizing qualitative methods, and introduce some of the validity criteria and techniques of qualitative research that make it a valuable methodology to understand disparities. I highlight some of the ethical concerns with recent studies in health disparities in epilepsy care which adopt only quantitative or qualitative methodology, and contribute very little to eliminating disparities compared to the potential contribution of mixed methodology research. This will be supported by various examples from research led by clinicians, public health professionals, and social scientists. / Urban Bioethics

Established in 1965 as a part of President Johnson’s War on Poverty effort, the federal community health center (CHC) program is a primary source of federally-subsidized quality health care services for medically-vulnerable populations in the United States. Despite its current role as a medical safety-net for the nation’s health care system, the CHC program did not begin as a public health program, but rather as a social justice program. Since its formalization, the CHC program has enjoyed relatively consistent Congressional support as a cost-effective means of providing primary healthcare to indigent populations; however, the narrative of the program has shifted overtime from a focus of empowerment and lifting communities out of poverty, to the fortification of the national health care system as a cost-effective provider of quality healthcare care for all. In this manuscript, I argue that this transition from community empowerment and the mitigation of fundamental causes of disease to a more risk-based emphasis on the issue of access, has diminished the urgency around the engagement of the structural effects of poverty on health in favor of a “one size fits all” approach to the provision of basic health care. In an effort to objectively quantify the effects of geographic access on health as a means for evaluating the success of the contemporary program, this research project explores the extent to which proximal access to a CHC is significantly associated with various self-reported indicators of positive health outcomes. My primary research method is multivariable regression utilizing secondary data from the 2012 Southeastern Pennsylvania Household Health Survey, the 2008-2012 5-year American Community Survey Estimate, and the Health Resources and Services Administration Data Warehouse. Using statistical modeling, I test the effect of CHC access on three distinct measures of individual health: (1) self-reported health status, (2) the likelihood of having pain lasting 6 months or more, and (3) the likelihood of having a usual source of health care. Within each model, I also test a series of interaction terms through nested sub-models to uncover any conditional effects of access for selected social groups. This statistical design offers the opportunity to explore whether the main association between access to a CHC and health varies based on the social characteristics and/or social environment of the individual. The findings of my analysis suggest that the effect of CHC access varies for different social groups, with less disadvantaged groups, such as poor non-Hispanic whites with high social capital, and poor individuals living in areas of low disadvantage, receiving the greatest benefit from proximal CHC access. However, individuals at the extremes of social disadvantage benefit least from CHC access alone. I argue that while the provision of CHC access is a noble and necessary tactic for fighting the persistence of health disparities in our medically-vulnerable communities, focusing on access alone is insufficient to solve the problem. The pendulum must switch back to community empowerment and the eradication of structural threats to health to initiate real change for medically-vulnerable populations. / Sociology

Research on health in old age finds gender and racial differences in physical and mental health and points to several social factors that can influence health in later life, including marriage. However, it remains unclear whether the health impacts of marriage differ between men and women or across racial groups in later life. Using the Health and Retirement Study, this project aims to explore the impact of both marital status and marital history on health outcomes, and how gender and race impact these effects. To capture a comprehensive view of health, this study incorporates a wide range of measures, addressing both physical and mental health. Using the gender relations framework, Chapter 2 examines the impact of marital status and history on gender differences in physical health outcomes, including self-rated health, functional limitations, and chronic conditions, of older Americans; Chapter 3 explores the influence of marital status and history on gender differences in mental health outcomes, including life satisfaction, positive affect, depression, and alcohol consumption, of older Americans. Along with the intersectionality framework, Chapter 4 investigates the effect of gender and race intersections on the relationship between marital status, marital history, and self-rated health of older Americans. The results highlight the critical need to consider both gender and race when evaluating the impact of marriage on health outcomes in later life. / Doctor of Philosophy / As the population ages, understanding how different factors affect health in later life becomes increasingly important. While past research has examined health differences across genders and marital status, this study takes a broader approach by exploring the combined impact of gender, marital status, marital history, and race on health outcomes in older adults. Using data from a large national survey, this study finds that marital status and marital history significantly influence both physical and mental health, and that these effects differ by gender. Moreover, gender and race together shape how marital experiences affect health. This research highlights the need to consider both gender and race when studying the effects of marriage on health in later life. These insights are essential for informing policies aimed at promoting healthier aging for all the people.

Type 2 Diabetes Mellitus (T2DM) was once a disease process found only in the adult population. However, incidence rates of T2DM in children and adolescents are increasing at alarming rates and becoming a grave public health concern. As many as 5,089 individuals under the age of 20 are newly diagnosed with T2DM each year. The military community is not immune to these national trends and T2DM among military dependents is growing at similar rates to that of the civilian population. The primary aim of this DNP project was to investigate if barriers exist with regard to pediatric military dependents, ages 10-17 years, receiving appropriate diagnosis, and treatment of T2DM. Previously published literature has identified health disparities exist within the Military Health System (MHS), despite beneficiaries having equal access to care. This project also sought to assess providers' use of Evidence Based Practice (EBP) and Clinical Practice Guidelines (CPGs) in the treatment of pediatric patients' ages 10-17 with T2DM, as it has been indicated that use of evidence based guidelines for management of T2DM vary among military treatment facilities. Results of the DNP Project reflected information found in previous evidence based literature. Fifty percent of providers felt there is "probably" a health disparity among Type 2 Diabetic youth who seek care at a Military Treatment Facility (MTF). Diverse responses were received regarding applicable health disparity indicators among MHS beneficiaries, indicating these disparities may be multifactorial. Routine incorporation of EBP and CPGs into clinical practice also appeared to vary among participants. It is evident that further research may positively contribute to current understanding of health disparities among MHS beneficiaries.

In national surveys of adolescents, Latina females have been found to have higher rates of suicidal ideation and attempts when compared to Latino males and to non-Latino White and Black males and females (Centers for Disease Control [CDC], 2014). The reasons for these gender and racial disparities in suicidal behavior have not been definitively established. Prior research indicates that suicidal behavior among adolescents is influenced by both individual-level psychological symptoms and by psychosocial risk factors (Bridge, Goldstein, & Brent, 2006; King & Merchant, 2008; Prinstein, Boergers, Spirito, Little, & Grapentine, 2000). Among Latina adolescents in particular, the interplay between cultural processes and family relationships has been identified as a key influence on suicidal behavior (Zayas, 2011). The purpose of this study was to build upon Zayas’s (2011) model of suicidality among adolescent Latinas by evaluating the relative effects of individual, family, and peer factors on suicidal ideation, plans, and attempts. A latent variable structural equation model (SEM) was developed and tested using a sample that included 946 Latinas aged 13 to 18 who were interviewed for a national psychiatric epidemiological survey, the National Comorbidity Survey – Adolescent Supplement (NCS-A; Kessler, 2013). The SEM model measured the direct and indirect effects of the latent variables of generation status, peer support, negative peer influence, family relationships, and depression on suicidality. Results of the study indicated that higher levels of depression, poorer family relationships, and higher levels of negative peer influence resulted in higher levels of suicidality. The influence of family relationships and negative peer influence on suicidality were partially mediated by depression; however, negative peer influence also had a substantial direct effect on suicidality. Results of this study support a clinical focus on multisystemic interventions for Latina adolescents that address functioning at individual, family, and peer levels, as well as further investigation into the pathways by which negative peer influence impacts suicidality in this population. / text

Thesis advisor: Janet E. Helms / Black women have been more likely to suffer from negative health conditions in comparison to Black men and White women. The biopsychosocial model might suggest that gendered racism and related stress may contribute to poor health, but the model has not been adapted to address the specific psychological factors that uniquely affect Black women’s health. Therefore, the purpose of this study was to investigate the relationship between gendered racism and eating and exercise practices of Black women in addition to examining racial and gender identity as potential mediators of the effects of gendered racism on health behaviors of Black women. Adult Black women (N= 153) were invited to complete measures that assessed gendered-racism experiences and stressors, racial identity (BRIAS), womanist identity (WIAS), and health behaviors. Multivariate multiple regression analyses revealed that more experiences of gendered racism were related to lower levels of emotional eating, but higher levels of uncontrolled eating and physical activity. WIAS Immersion/Emersion (idealization of women), WIAS Encounter (confusion regarding gender beliefs) and BRIAS Immersion (idealization of Black people) were significant mediators of these relationships. A post hoc canonical correlation analysis indicated that experiencing higher levels of gendered racism was related to greater use of less sophisticated racial and gender identity schemas, which were related to lower levels of emotional eating and higher levels of uncontrolled eating and physical activity. These results suggested that BRIAS and WIAS concepts should be integrated rather than treating them as separate sets of variables when investigating gendered racism. Collectively, the results of the main and post hoc analyses indicated that race and gender constructs were related to health practices, but not in explicable ways. Limitations of existing measures for studying this population are discussed and results are used to speculate about the implications of biological, psychological, and socio-cultural factors on the health engagement practices of Black women. / Thesis (PhD) — Boston College, 2015. / Submitted to: Boston College. Lynch School of Education. / Discipline: Counseling, Developmental and Educational Psychology.

Thesis advisor: Thomas O'Hare / Depression in adolescence is associated with a number of negative consequences, including low school achievement, substance abuse, increased risk of later major depression, and suicide. Adolescent children of immigrants are arguably at greater risk of depression than their native counterparts, due to greater likelihood of migration-related stress, a minority racial/ethnic background, lower socioeconomic status, and lower proficiency in the host society language. Informed by theories of assimilation and social network theory, this study examines the contribution of assimilation, sociodemographic factors, and social supports to depressive symptoms in immigrant and native United States adolescents. Nationally representative data on United States adolescents from Waves I and II of the National Longitudinal Study of Adolescent Health (N = 4,263) are analyzed. Results demonstrate immigrant adolescents report significantly higher levels of depressive symptoms and more risk factors for depression than their native peers. However, hierarchical regression analysis shows generational status ceases to be a significant correlate of depressive symptoms when age, sex, race/ethnicity, socioeconomic status, and home language are controlled. Mediation analysis shows unique relationships between control variables, social supports, and depressive symptoms. Findings are in accordance with social network theory, but challenge assimilation theories premised on the assumption that immigrants face unique migration related challenges that are overcome through generations. Findings support adolescent children of immigrants and native children share common non-migratory related risk factors of depressive symptoms, and adolescent children of immigrants are at greater likelihood of experiencing these risk factors. Practice and policy implications are discussed. / Thesis (PhD) — Boston College, 2013. / Submitted to: Boston College. Graduate School of Social Work. / Discipline: Social Work.