Context: Colorectal cancer (CRC) surgical treatment delay (TD) has been associated with mortality and morbidity; however, disparities by TD profiles are unknown. Objectives: This study aimed to identify CRC patient profiles of surgical TD while accounting for differences in sociodemographic, health insurance, and geographic characteristics. Design: We used latent class analysis (LCA) on 2005-2015 Tennessee Cancer Registry data of CRC patients and observed indicators that included sex/gender, age at diagnosis, marital status (single/married/divorced/widowed), race (White/Black/other), health insurance type, and geographic residence (non-Appalachian/Appalachian). Setting: The state of Tennessee in the United States that included both Appalachian and non-Appalachian counties. Participants: Adult (18 years or older) CRC patients (N = 35 412) who were diagnosed and surgically treated for in situ (n = 1286) and malignant CRC (n = 34 126). Main Outcome Measure: The distal outcome of TD was categorized as 30 days or less and more than 30 days from diagnosis to surgical treatment. Results: Our LCA identified a 4-class solution and a 3-class solution for in situ and malignant profiles, respectively. The highest in situ CRC patient risk profile was female, White, aged 75 to 84 years, widowed, and used public health insurance when compared with respective profiles. The highest malignant CRC patient risk profile was male, Black, both single/never married and divorced/separated, resided in non-Appalachian county, and used public health insurance when compared with respective profiles. The highest risk profiles of in situ and malignant patients had a TD likelihood of 19.3% and 29.4%, respectively. Conclusions: While our findings are not meant for diagnostic purposes, we found that Blacks had lower TD with in situ CRC. The opposite was found in the malignant profiles where Blacks had the highest TD. Although TD is not a definitive marker of survival, we observed that non-Appalachian underserved/underrepresented groups were overrepresented in the highest TD profiles. The observed disparities could be indicative of intervenable risk.

Minority groups experience disproportionately worse health outcomes. An identified solution is to increase the number of minorities providing healthcare in their own communities. Primary care complementary and alternative medicine (CAM) providers are a potential resource. Many investigators have demonstrated the efficacy of science-based pipeline programs for increasing the roles of students in allopathic health professions. Whether these programs influence matriculation of minorities into a CAM university is unknown. The main purpose of this study was to gain an understanding of a pre-college science academy at a CAM university and determine whether the experience increased interest in and motivation for CAM careers. It was also important to learn more about what factors may facilitate or impede minority student matriculation in a CAM university. In this phenomenological study, a mixed purposeful sampling strategy was used to select 9 students who had participated in a science academy at a CAM university. Individual in depth, semi-structured, interviews were conducted and analyzed using a process of inductive analysis. The results indicated that barriers to college matriculation included cost and the complexity of the process. The desire to elevate status steers some minorities who use CAM modalities as their indigenous health practice, towards high prestige allopathic careers. Participation in the science academy increased interest in and utility of CAM, but did not change preconceived career choices. These results contribute to the existing literature and can enrich social change initiatives by increasing the number of minorities providing healthcare in their own communities, and further understanding of the factors that influence underrepresented minority career choices.

African American women tend to experience higher health disparities in cancer-related illness than any other female population in the United States. The purpose of this qualitative case study was to identify and examine access-related barriers that play a significant role in the decision-making process of this population when seeking breast cancer health services. The central research question explored the effect that barriers to health care have on African American women in the Southeastern region of the United States. Secondary research questions explored the role the Patient Protection and Affordable Care Act of 2010 has on improving access to affordable, quality breast cancer screening services for the sample population. A critical theory lens of racism and ethnicity provided conceptual framework for this case study. Significant findings identified barriers to accessing breast cancer related health services as personal, community, social, systemic, and institutional. Personal barriers identified were related to access, autonomy, and benefits of the Affordable Care Act. Social barriers corresponded to cultural, financial burden, funding, health conditions, insurance, role within the family self-discovery, and spirituality. Community barriers included access, advocacy, and autonomy. Systemic and institutional barriers consisted of doctor listening, doctor's rapport, doctor treatment, lack of trust, and benefits of the Affordable Care Act. Implications for social change included bringing awareness of the need to establish a Breast Cancer Resource Center in the region to engage this population in preventive measures, improve health outcome and reduce health disparities.

In recent years, an array of political, environmental, and health activists have brought to light the previously overlooked structural inequalities that plague many urban cities and their underserved populations. With a growing population and an increased dichotomy between social classes in the United States, urbanization may be inevitable. However, how urban planners and public agencies choose to build and design these areas is malleable. Provision of safe and equitable living conditions by these individuals is an obligation of utmost importance, and as such, this thesis aims to both provide insight as to how the built environment, development patterns, and land use play a significant role in in morbidity and mortality in urban communities across the nation and world, as well as assist in bridging the divide between disciplines of urban health and urban planning as we look towards creating healthier, greener, more equitable cities. The built environment and health can and should be discussed in the same breath during urban planning and development, and thus, the preservation, presence, and development of urban green space should be prioritized during processes of urbanization, with active engagement and empowerment from the communities in which we seek to build. The existing inverse association between increased urbanization and community health necessitates an induction of change and a call for action from urban planners, city and state officials, health scientists, environmental conservationists, and communities as a whole. / Urban Bioethics

Meeting the healthcare needs of the homeless continues to be a significant challenge in the United States. Homeless individuals suffer a disproportionately high burden of both communicable and non-communicable diseases and are at increased risk of dying prematurely. Additionally, this population faces barriers to receiving healthcare that are less prevalent for non-homeless persons. These include difficulties physically accessing care, underinsurance, and highly comorbid mental health and substance use disorders, all of which contribute to nonadherence and loss to follow-up. As such, homeless individuals report unmet needs across multiple types of healthcare services. Homeless people’s perceptions and attitudes towards healthcare also affect their propensity to utilize services. As with all patients, homeless individuals articulate a desire for compassionate, person-centered care involving meaningful engagement and trust. Yet, this is often not the case. Stigma and perceived discrimination from healthcare providers on the basis of poverty, race, mental illness or substance use have made the homeless feel unwelcome in many healthcare settings. Homeless people often describe being treated less compassionately by providers, feeling invisible, dehumanized, or reduced to objects. Perceived prejudice may contribute to poorer adherence and more frequent utilization of acute care or emergency services compared to routine ambulatory care. In this thesis, I explore homeless individuals’ attitudes of trust or mistrust towards the healthcare system using qualitative methods. I interviewed participants who identified as homeless at Philadelphia FIGHT and Broad Street Ministry, two healthcare and social service organizations that serve the homeless community in Philadelphia. I conducted interviews using a semi-structured interview guide. Below, I discuss my rationale for doing this study, my study methods, and results through five participant narratives elucidating key themes that arose during interviews. In the last chapter, I discuss why these results matter and how they can be used to inform future practice and policy aimed at reducing healthcare disparities for the homeless. / Urban Bioethics

A primary reason geospatial approaches are important in cancer research is that health and disease are shaped not only by factors such as age, race/ethnicity, genes, and clinical care but also by the environment where individuals work and act. While the use of geospatial approaches in cancer research is growing, several limitations remain. For example, for most population-based studies, cancer patients' neighborhood environments are based on only a single location derived from the residence at the time of diagnosis.This dissertation aimed to address this limitation by using a unique dataset of colon cancer patients diagnosed in New Jersey that include residential histories obtained through a data linkage with LexisNexis, a commercial data collection company. By incorporating residential histories, I moved beyond a cross-sectional approach to examine how residential histories and socio-spatial mobility can change a patient’s geographic context over time and influence survival. To demonstrate the application of these data in this dissertation, I completed three case studies. In the first case study, I compared whether including residential histories changed the risk of death estimates by neighborhood poverty compared to the traditional approach when including only the location at the time of diagnosis. Results suggested that the risk of death estimates from neighborhood poverty were generally similar in strength and direction regardless of residential histories inclusion. This finding was likely a result of minimal socio-spatial mobility of colon cancer patients (i.e., patients generally moving to census tracts with similar poverty levels). The second study aimed to compare the geographic risk of death estimates when using single location and residential histories in spatial models. Results overall showed that the geographic patterns of the risk of death estimates were generally similar between the models. However, not accounting for residential mobility resulted in underestimated geographic risk of death in several areas. This finding was related to the fact that approximately 35% of the colon cancer patients changed the residency, and 12% of the initial study population left New Jersey after the diagnosis. In the third case study, I examined whether landscape characteristics (e.g., built environment) were associated with the risk of death from colon cancer independent of individual-level factors, residential mobility, and neighborhood poverty. The results indicated that an increasing proportion of high-intensity developed-lands substantially increased the risk of death, while an increase in the aggregation and connectivity of vegetation-dominated low-intensity developed-lands reduced the risk of death. These findings suggested that places lacking greenspaces could have worse access to recreational sites that promote physical activity. Overall, this dissertation expands our knowledge about the geographic disparities in colon cancer in New Jersey. It also provides specific examples of integrating residential histories and remote sensing-based products into cancer disparities research. Including residential histories opens up new avenues of inquiry to better understand the complex relationships between people and places, and the effect of residential mobility on cancer outcomes. Combining multiple socio-demographic and environmental domains to estimate the neighborhood effects on cancer outcomes will increase our potential to understand the underlying pathways. / Geography

African American women are at a higher risk of experiencing maternal health complications than women of other races. Determining the factors that contribute to the severity of their maternal health complications can help bring awareness and exposure to the disparities among black women in maternal health. The purpose of this study was to explore the various elements that contribute to the high pregnancy mortality ratio and infant mortality ratio in black women and black infants. The secondary purpose was to determine the relationship between stereotypes about African American women as healthcare consumers and the disproportionate percentage of black women experiencing fatal maternal complications. A literature review examining the effects of physiological differences, external stressors, stigmas and stereotypes, and miscommunication with health care physicians was conducted from various online databases. Peer reviewed, research articles published in the English language from 1992-2020 that focused on factors during the prenatal and perinatal period that influenced the pregnancy-related mortality ratio were included for synthesis. Results from 14 studies that examined factors resulting in maternal health disparities in African American women were compared to determine accuracy and consistency with the data. The studies suggest that smaller pelvic structures, stigmas that label black women as over exaggerative, and distrust within African American communities with health care staff contribute to the different maternal outcomes in black women. Although the data remained consistent and proved there are similar factors that cause disparities in maternal care, many of the studies had small sample sizes indicating the need for further research on the subject.

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Research Objective: On behalf of the Appalachian Funders Network, with funding from the Robert Wood Johnson Foundation, East Tennessee State University and NORC at the University of Chicago documented the current burden of obesity, diabetes, and chronic disease mortality in central Appalachia. An analysis of county-level data was conducted in order to provide a comprehensive picture of the health condition of the region. Contributing factors, such as physical inactivity and food environment, were also investigated to determine how the built environment impacts obesity. Study Design: Several secondary data sources were utilized, including the County Health Rankings, CDC Diabetes Interactive Atlas, USDA Food Environment Atlas, and mortality data from the CDC National Center for Health Statistics, National Vital Statistics System. Variables analyzed included: adult obesity prevalence, adult diabetes prevalence, food insecurity, access to exercise opportunities, physical inactivity, and premature chronic disease mortality. The mortality analyses focused on four of the leading causes of death: heart disease, stroke, diabetes, and chronic lower respiratory disease, for persons age 25 to 64 from 2009 to 2013. When available, county-level estimates were used to create maps of the region, documenting the disparities compared to the rest of the nation. Population Studied: Health disparities were documented within the counties of central Appalachia, consisting of parts of Kentucky, North Carolina, Ohio, Tennessee, Virginia, and West Virginia. Principal Findings: More than two-thirds (68.6%) of the 234 counties in central Appalachia have an adult obesity prevalence above the national median of 30.9% (defined as BMI over 30). Over 85% of the counties in central Appalachia have a percentage of physically inactive adults higher than the national median of 26.4% (defined as not participating in physical activity or exercise in the past 30 days). When analyzing the combined chronic disease mortality for heart disease, stroke, diabetes and chronic lower respiratory disease, the combined national mortality rate is 93.0 deaths per 100,000 population. Nearly 90% of central Appalachian counties have a higher combined morality rate, and the state mortality rate for the Appalachian region of all six states is higher than the national rate. The disparity is more pronounced in rural communities, as the rural counties of central Appalachia have a higher mortality rate than urban counties within central Appalachia and rural counties across the United States. The combined mortality rate for these four diseases is 74% higher in rural central Appalachia than urban counties nationally. Conclusions: Compared to the rest of the country, people in central Appalachia are more likely to experience and prematurely die from obesity-related chronic disease, including diabetes and heart disease. Residents of rural central Appalachia face even more significant disparities as compared to urban residents within the region and nationally. Implications for Policy or Practice: Obesity and chronic disease in central Appalachia are significant public health concerns that must be addressed in order to improve the health of the region.