<p>Education provides people with material, social, and cognitive resources which can bolster well-being, and a growing body of literature documents a positive association between adult children’s education and older parents’ health. Although researchers have begun to explore mechanisms which underlie and shape this association, few studies have considered the role of family context. Guided by the social foreground perspective, the central aims of this dissertation are to investigate: (1) whether adult children’s problems account for the relationship between adult children’s education and mothers’ depression and (2) whether the size of the association between adult children’s education and mothers’ depression varies between married and widowed mothers. To answer these questions, I utilize mediation and moderation techniques and data collected as part of the Within-Family Differences Study. Consistent with past work, I found that mothers with children who completed more education reported fewer depressive symptoms. In the first substantive chapter, mediation analyses suggested that this relationship was mediated by the proportion of adult children who have experienced physical and emotional problems in the last five years. Consistent with the life course perspective and cumulative inequality theory, these results highlight the ways in which (dis)advantages that impact health accumulate both across age and across generations. In the second substantive chapter, moderation analyses revealed that the association between adult children’s education and mothers’ psychological well-being was weaker among widowed mothers. I innovatively argue that these results are consistent with principles of socioemotional selectivity theory. Taken together, the results from these two chapters illuminate the importance of considering family context when studying the intergenerational implications of education for health. In addition, by augmenting our understanding of how and under what conditions adult children’s education matters for mothers’ psychological well-being, my results offer important insights for stakeholders invested in improving the psychological well-being of older adults.</p>

Obesity is caused by a variety of contributing factors including genetics, behavior, and environment, which contribute to weight gain in children and adults. The obesity epidemic is growing rapidly, predisposing both children and adults to preventable chronic diseases such as heart disease and type 2 diabetes. Obese children often become obese adults, further contributing to the obesity epidemic and its economic consequences including higher healthcare costs and lost productivity. The obesity epidemic also exposes significant health disparities; non-Hispanic Blacks and Hispanics represent a disproportionate number of obese adults and children in the United Community Health Workers (CHWs) are uniquely positioned to support current efforts in the prevention and treatment of childhood obesity. Studies have found CHWs to be effective at increasing healthy behaviors and reducing disparities in cancer screenings for adult minority groups. CHWs can be trained to provide a variety of health services, reducing the burden of healthcare professionals, and reducing cost of care. CHWs provide peer to peer, culturally sensitive health information in an individual’s preferred language. The proposed study is a three-year randomized controlled clinical trial with 262 participants divided equally into two groups, intervention, and control. Non-Hispanic Black and Hispanic children ages 1-5 years old will be recruited from their pediatrician’s offices in the Boston Metropolitan Statistical Area (MSA). Participants will be identified and enrolled by research assistants based on language of care and BMI (body mass index) as recorded in the electronic medical record (EMR). Both groups will receive standard of care treatment throughout the study. The intervention group will additionally receive monthly in-home CHW visits for the first one and a half years. CHWs will take quarterly BMIs and provide education materials on healthy eating and physical activity. The primary outcome is BMI and the secondary outcomes will include healthy behaviors such as average weekly servings of fresh fruits and vegetables. At the end of the study period, all guardians will be given a survey to assess their opinions on the standard of care treatment and CHW interventions. CHWs are an untapped resource in the fight against childhood obesity, reducing health disparities, and the obesity epidemic. However, more research is needed in this area and the proposed study is a step toward proving their efficacy and efficiency. In the United States, the implementation of CHWs over time could make a huge impact on public health by reducing preventable chronic diseases.

Single parents face many challenges when accessing healthcare for their children and themselves, and have health issues that may go unrecognized, particularly for single fathers. The number of single father households has increased dramatically over the past few decades. There were fewer than 300,000 single father households in 1960, but in 2011 that number increased to more than 2.6 million—a 8.6-fold increase from baseline. Despite this jump in numbers, the literature addressing health-related issues of single fathers is rather scant. In this blog, we disseminate the limited number of studies on the subject and make recommendations for nurses to address the health disparities for this unique segment of population.

Background: Coronary Heart Disease (CHD) & depression problems are increasing concerns globally as cardiovascular diseases (CVD) solely account for almost one-half of NCD deaths. Similarly, 280 million people i.e., 3.4% of the world population are suffering from depression. There is a direct association between CHD and depression as studies show that up to one in five people with CHD may experience depression. Coronary artery disease (CAD) is the most common type of CHD in the United States. There have been studies examining the association between these, but none in Tennessee. This study aims to investigate the association between CHD and depression. Methods: We used cross-sectional data from the 2021 Behavioral Risk Factor Surveillance System a nationally representative U.S. telephone-based survey of adults aged 18 years and extracted data for Tennessee (n=4,788). Logistic regression analyses were conducted to test the association between coronary artery disease and depression. We controlled for the past month's income, race/ethnicity, educational status, gender, and age. Results: Overall, 25.5% (n=1,209) reported having been diagnosed with depression, while 6.0% (n=289) reported coronary artery disease. Coronary artery disease predicted higher odds of depression (OR=1.86, 95% CI, 1.44, 2.41) along with low income (OR=2.14, 95% CI, 1.85, 2.48) and female gender (OR=1.94, 95% CI, 1.69, 2.23). Conclusion: High prevalence of depression is one of the major health challenges in Tennessee. Similarly, the prevalence of coronary artery disease was also prominent. We found a significant association with higher odds of depression among patients with coronary artery disease. Along with this, low income and female gender were also associated with depression. To address patients with depression, targeted efforts and disease management are needed among patients with CHD. More research focusing on the other associated variables is to be studied. Keywords: Coronary Heart Disease, Depression, Health disparities in Tennessee

In recent years, there has been increased focus on rural and Appalachian health because of disparate chronic health outcomes when compared to the rest of the US. Appalachia, a subsection of the US, has even worse health outcomes related to chronic diseases. Although Appalachia is its own unique region, there is significant overlap with rural areas in terms of shared cultural characteristics (e.g., strong sense of community, distrust in outsiders, lack of trust in traditional medicine, and strong Christian religious affiliations and faith in God), limited access to healthcare services, and disparate health outcomes. The research presented in this dissertation is significant because it provides insight into and compares healthcare utilization rates in women in Appalachia and surrounding areas. Study 1: In addition to racial discrimination, Black Appalachian women often face other obstacles involving other types of negative interpersonal experiences when seeking healthcare. Despite these known disparities, Black women are frequently underrepresented in Appalachian health research. This study investigated healthcare experiences for sixteen Black Appalachian women using semi-structured interviews to identify and subsequently address ways to eliminate barriers to care. Interview questions utilized the theory of intersectionality and the Social Ecological Model to create a framework to describe the complexity of healthcare utilization and barriers to care while providing context into each participant's background and lived experience. Interview questions explored four topics: 1) barriers to medical care; 2) social support; 3) ideal and actual healthcare experiences; and 4) desired changes to improve quality of care. We used an inductive analysis process to create a robust thematic coding schema, organizing responses into 60 total themes and 141 codes, and reported the most frequent. Our results explore the ways in which one's intersectional identity as a Black Appalachian woman affects interpersonal interactions and experiences when engaging with the healthcare system. Participants frequently reported barriers related to scheduling conflicts and delays, experiences with rushed appointments and inhospitable providers and support staff, and desires for accurate collection of medical information. Participant responses often emphasized difficulties with the organization of the medical system, revealing specific areas for future intervention to improve quality of care for Black Appalachian women. Study 2: Use of the emergency department (ED) for low acuity conditions (e.g., back pain, dental pain, sore throat) and primary care places an additional strain on ED staff and resources, while increasing waiting and treatment times for high acuity patients. Factors such as race, gender, and insurance type have a strong association with the likelihood of a patient using the ED for a low acuity concern. Women are more likely to utilize healthcare services, which also holds true in the context of the ED. Using a sample of adult women from Virginia, West Virginia, Tennessee, North Carolina, and Kentucky, I investigated which demographic factors, age, race, geographic location (metro, nonmetro, rural), employment, and insurance coverage, affect a patient's likelihood to visit the ED for a low acuity condition within a southwestern Virginia hospital system. Log-binomial regression was used to estimate unadjusted and adjusted prevalence ratios of acuity level by race, age, rurality level, employment, and insurance type with corresponding 95% CIs. Our sample included 28,222 female patients who visited the ED between January 1, 2021 and September 30, 2022. Low acuity visits accounted for 15.9% (n=4,485) of visits during the timeframe. In summary, our results suggest that older age and location in non-metro area are the most salient factors contributing to a higher likelihood of low acuity ED visits among women. Race, a primary variable of interest, did not have the relationship to acuity that was expected based on previous literature; Black women patients were less likely to have a low acuity visit than white women patients. During our study period, overall number of visits remained steady, while there was an increase in proportion of low acuity visits. Further research is needed into the underlying causes to more definitively explain this increase. / Doctor of Philosophy / In recent years, there has been increased focus on rural and Appalachian health because of disparate chronic health outcomes when compared to the rest of the US. Appalachia, a subsection of the US, has even worse health outcomes related to chronic diseases. Although Appalachia is its own unique region, there is significant overlap with rural areas in terms of shared cultural characteristics (e.g. strong sense of community, distrust in outsiders, lack of trust in traditional medicine, and strong Christian religious affiliations and faith in God), limited access to healthcare services, and disparate health outcomes. Black/African Americans are another population with higher rates of chronic disease and poorer health outcomes compared to their white and Latinx peers. The combination of poorer health outcomes and higher rates of chronic disease negatively impacts life expectancy and quality of life. One driving factor in these poor health outcomes across all of these groups is low rates of healthcare utilization, whether due to decreased access (as is the case for many rural populations), or other as of yet unidentified challenges. Although literature exists about rural health outcomes, Appalachian health outcomes, and health outcomes focusing on Black women, there is very limited literature that examines the intersectional impact of these characteristics on health. Health disparity research in this region does not currently stratify differences in outcomes by both race and gender, which prevents a detailed analysis of the full extent of the gap in health outcomes. This research presented in this dissertation is significant because it provides insight into and compares healthcare utilization rates in women in Appalachia and surrounding areas across the lifespan. Knowing the contextual factors influencing healthcare seeking behaviors and utilization is the first step to designing effective interventions that improve women's access to care. Interventions need to be intentionally designed to consider, and ultimately, shift medical care and community attitudes to decrease health disparities in Appalachia. To successfully decrease health disparities, it is necessary to consider all of a patient's identities or characteristics. The same contextual factors that affect their healthcare utilization can also impact their care experience.

No description available.

In response to the striking health and social inequalities existing across communities within a large Southern Ontario City the McMaster University School of Nursing has partnered with the local family health team, municipal government, and other community partners to evaluate a pilot program designed to enhance health and social outcomes within a specific priority neighbourhood. The innovative pilot program is a nursing-based system navigation role, grounded concurrently in the community and a local Primary Care Practice. The role is uniquely designed as the nurse provides navigation for individuals and families while functioning as a networker to facilitate improved service integration at a systems level. This study serves as a narrative person-centered evaluation of the program, emphasizing the impact on the lives of community members. This study employed the Three-Dimensional Narrative Inquiry Space method as described by Clandinin and Connelly (2000) to explore the experience of nine community residents utilizing navigation services through the Community Nurse Navigator/Networker (CNN). Programs tell a story; therefore, the collection and analysis of participants’ life stories, in conjunction with field notes, observations, and documents, created a common narrative of the experience of navigation in a community setting. A thematic analysis of participants’ life stories was conducted to present a common narrative of community members’ experience of navigation. The major finding of this study was the positive experience residents shared interacting with the CNN. Participants valued the development of a therapeutic relationship through social interactions, the significance of place on the impact of the CNN role, and the effect of the navigation role to address health disparities over time. Study findings have implications for continued development of the CNN role and other community-based nurse navigation roles in priority neighbourhoods to address health inequities. / Thesis / Master of Science in Nursing (MSN)

I conducted a four-month ethnographic fieldwork study to document the stories of thirteen post-kidney-transplant minority patients and three nephrologists at Boston Medical Center. My research explores how patients’ interactions with health professionals, medical regimens, dialysis treatments, and adaptation to living with transplanted kidneys constantly shape their identities and perceptual worlds. Patients’ narratives highlighted the emotional struggles they encountered along the path of End-Stage Renal Disease, which unfolded as distinct experiences influenced by their varied backgrounds. The majority of my patient-participants lived on the verge of poverty, and in some cases, their insurance status caused delays in their being registered on the transplant waiting list, making them endure a long wait. Some patients were afraid of wearing short sleeves because they thought the scars on their arms from dialysis treatment would lead others to think they were gangsters. Instantiations of various theories emerged from the saturated data and narrative analysis, from Bourdieu’s concept of habitus with regard to the process of how patients alter their consciousness through interactions with medicine to Foucault’s ideas of power relations and technologies of the self that address the issues of agency and power that influence the formation of patients’ identities. The intersection of these theoretical frameworks led me to develop the critical medical anthropological-oriented concept of biological citizenship. This paper examines 1) the ways in which “race” interacts with the theoretical concept of biological citizenship and 2) the ways in which socioeconomic status and race tailor a kidney transplant patient’s illness experience, and related discourse.

Mental and behavioral health difficulties are prevalent among children, and research suggests that the vast majority of these children do not receive needed services. Treatment disparities are even larger among rural youth given the scarcity of qualified specialty mental health providers, increased barriers to care, and greater mental health-related stigma compared to their urban counterparts. Many parents seek help and resources from their child’s primary care provider (PCP); however, the comprehensive management of psychosocial and behavioral concerns are often not feasible in traditional primary care settings. Integrating behavioral health services into pediatric primary care clinics has the potential to increase access to needed services, improve comprehensiveness and quality of care for patients, and reduce burdens on PCPs. Research on integrated behavioral health (IBH) models have indicated that it is a cost-effective service leading to improved treatment outcomes compared to usual primary care and that parents and physicians are generally satisfied and interested in this service delivery model. However, little is known about parents’ attitudes toward IBH and factors that may influence the acceptability of this type of care. Previous research has identified several factors associated with parent acceptability of mental health services for their child including symptom severity, attitudes toward child therapy, parenting stress, stigma, perceived barriers to care, and past experiences with services. However, it is unclear how these factors influence attitudes toward IBH, especially in rural areas. The current study examined parents’ attitudes toward co-located and integrated models of care, identified factors that affect acceptability of IBH, and explored differences between rural and urban parents’ attitudes. Results demonstrated that both rural and urban parents hold generally favorable attitudes toward IBH models and that parent attitudes toward general child therapy was strongly associated with IBH acceptability. Demographic variables (e.g., parent age, child age, minority status, socioeconomic status), need characteristics (e.g., parenting stress, child psychosocial symptoms), and other enabling factors (e.g., mental health-related stigma, prior service use, barriers to care) were not predictive of parent IBH acceptability. Urban parents rated co-located models of care as more acceptable and reported higher levels of parent psychosocial symptoms, stigma, and barriers to care compared to rural parents. These findings support efforts to continue integrating behavioral health services into pediatric primary care and highlight parent therapy attitudes as an important target for intervention to improve parent IBH acceptability. Findings also shed light on the need for more mixed-method research to understand the impact rural identity has on the acceptability and use of behavioral health services.

No description available.