Existing literature provides support for a possible syndemic among adult film actresses. Multiple studies emphasize that a combination of economic, social, and cultural issues work together in tandem to synergistically amplify HIV/STI risk in this vulnerable population. It is critical to acknowledge how the detrimental effects of the high prevalence of substance abuse, psychological distress, intimate partner violence, and childhood sexual abuse work together in a system to heighten HIV/STI risk among adult-film actresses. Additionally, issues including the retrogressive dynamic and unequal power and hegemony in the industry function as facilitators which lower the overall health profile of adult-film actresses. It is therefore important to explore the additive relationship between multiple psychosocial health problems of HIV/STI risk among adult-film actresses. The goals of this study are to explore the tenets of the adult-film actress syndemic and use the ecosocial model to organize the associations between psychosocial health problems and HIV/STI risk. This thesis utilizes a two-phase, transformative explanatory sequential mixed methods design which combines multivariable logistic regression and ethnography to understand HIV/STI risk and how depression, childhood sexual abuse, intimate partner violence, and substance use are embodied in the daily lives of adult-film actresses. The quantitative component of this study utilized data collected from a survey of 134 adult- film actresses from the United States. Statistically significant relationships were seen between the independent variables (psychosocial problems) and the dependent variables (i.e., number of personal sex partners, perception of HIV risk, and participation in other sex work). Other relevant quantitative findings included the statistically significant relationships between the syndemic variable and multiple dependent variables. The second component of this study consisted of an ethnography that addressed the theoretical deficiencies in the quantitative phase. Eight adult-film actresses living in the United States were recruited through a testing agency located in Florida, a non-profit located in California, and social networking sites (You tube, Twitter, Facebook, and MySpace) and were then interviewed by phone. The ethnography provided substantive information on the processes which potentially undergird and fuel the syndemic among adult-film actresses including the link between traumatic childhood experiences, substance use and depression. Additional qualitative findings also included elucidating how components of occupational culture increase HIV/STI risk among adult-film actresses. Prominent qualitative themes included traumatic childhood experiences, tenuous romantic relationships and multiple rapes. The integration of both phases of this study provide information on how the interplay between micro, meso and macro level factors work together in a system to additively augment HIV/STI risk among adult-film actresses. Findings from this study have the potential to influence risk reduction policies that could improve the lives of adult-film actresses.

This dissertation study was designed to examine measurement equivalence of the Center for Epidemiological Studies Depression (CES-D) Scale across White, African American, and Mexican American elders. Specific aims were to identify race/ethnicity-, sociodemographic-, and acculturation and instrument language-related measurement bias in the CES-D. Three studies were conducted in this dissertation to accomplish these aims. Two existing national datasets were used: the New Haven Established Populations for Epidemiologic Studies of the Elderly (EPESE) for the White and African American samples and the Hispanic Established Populations for Epidemiologic Studies of the Elderly (H-EPESE) for the Mexican-American sample. Differential item functioning (DIF) analyses were conducted using both confirmatory factor analysis (CFA) and item response theory (IRT) methods. Study 1 focused on the role of race/ethnicity on the measurement bias in the CES-D. Results from Study 1 showed a lack of measurement equivalence of the CES-D among Mexican Americans in the comparison with both Whites and Blacks. Race/ethnicity-specific items were also identified in Study 1: two interpersonal relation items in Blacks and four positive affect items in Mexican Americans. Study 2 focused on identifying sociodemographic-related measurement bias in responses to the CES-D among diverse racial/ethnic groups. Results from Study 2 showed that gender and educational attainment affected item bias in the CES-D. The interaction between gender and educational level and race/ethnicity was also found in Study 2: Mexican American women and lower educated Blacks had a greater predisposition to endorse the 'crying' item. Focusing on Mexican American elders, Study 3 examined how level of acculturation and language influence responses to the CES-D. In Study 3, acculturation and instrument language-biased items were identified in Mexican American elders. Study 3 also suggested that acculturation-bias was entirely explained by whether the CES-D was administered in the English or the Spanish versions. Possible reasons for item bias on the CES-D are discussed in the context of sociocultural differences in each substudy. Findings from this dissertation provide a broader understanding of sociocultural group differences in depressive symptom measures among racially/ethnically diverse older adults and yield research and practice implications for the use of standard screening tools for depression.

Colorectal cancer (CRC) is the third most common cancer in the United States (U.S.) and is the second leading cause of cancer deaths. Although the incidence of CRC has been decreasing with CRC screenings, disparities of CRC and screening prevalence exist for racial and ethnic groups. The CRC incidence rates have dramatically increased in Korean Americans, however, there is little known about their CRC screening behaviors and the factors that may predict screening behaviors have not been fully investigated. The purposes of this study were to describe CRC screening behaviors and identify the predictors and barriers influencing CRC screening behaviors among Korean Americans. A sample of 254 Korean Americans participated in this study. Correlation, Multiple logistic regression, and Chi-square were used to analyze data. In this study, Korean American had lower rates of CRC screenings compared to the general U.S. population. Only 20% of the sample had ever had a fecal occult blood Test (FOBT), 49% had ever had a colonoscopy, and 19% responded they had ever had a sigmoidoscopy in their lifetime. Korean Americans had low rates of perception of cancer screening (annual physical exam and periodic cancer screening), moderate CRC knowledge, low cancer fatalism, limited CRC literacy, lack of health care access, and a low rate of receiving the physician's recommendation of CRC screenings. The greatest predictors influencing CRC screening were perception of cancer screening for a FOBT, and the physician's recommendation for a colonoscopy and a sigmoidoscopy. There were no significant differences by gender in CRC screening behaviors. However, significant differences were found between the two groups divided by length of U.S. residence. Compared to those who have lived in the U.S.>10 years, new immigrants had lower rates of all three CRC screening, lower perception of cancer screening, higher uninsured, less receiving physician's recommendation, and higher perceived barriers to CRC screening. The findings of this study suggest that improved efforts are needed to increase CRC screenings among Korean Americans. Further research is needed to increase a physician's recommendation for CRC screenings and awareness for the importance of annual checkups and periodic cancer screening among Korean Americans.

Introduction: Domestic research studies focused on the interrelationships between political ideology characteristics inherent in policy decisions and the contributions these political determinants exert over health indicators and outcomes are limited. Given the paucity of research that focuses on political and policy support of health at the county-level, this study sets out to utilize the University of Wisconsin Population Health Institute’s (UWPHI) annual County Health Rankings data and examine them within the context of county-based majority political partisanship and economic measures. Methods: This exploratory ecological study examined differences between independent variables: partisan voting behavior (trichotomized as conservative, moderate, and liberal) and median per capita household income in U.S. dollars (by quartile) on dependent variables related to mortality (years of productive life lost) and morbidity (number of poor mental and physical health days) at the county-level to compare differences in political and ideological underpinnings that may act as influencers on health outcomes. Multiple data sources were combined and matched to all 3,140 counties located in the U.S. Two-way between-subjects ANOVA statistical tests were conducted to determine if there is an effect of partisan voter index category on the three aforementioned dependent variables related to health outcomes, and median per capita income by quartile. Results: There was a statistically significant main interaction between median per capita household income by quartile and partisan voter index category on years of productive life lost, F(6,2789) = 19.3, p < .000, partial η2 = .040. While there were also statistically significant interactions between the independent and dependent variables of poor mental and physical health days, results of those analyses should be interpreted with caution. Pertaining to years of productive life lost, post hoc analyses of significant interactions revealed significant differences at the lower income quartile, but not in the expected direction. The conservative category had statistically significant lower years of productive life lost in comparison to the liberal category (M = -8.21, SE = 1.47, p = .000). Also, there were significant differences detected in the upper quartile suggesting that the liberal category has lower years of productive life lost in comparison to the conservative category (M = 7.06, SE = 1.06, p = .000). Conclusion: Results should be interpreted with caution and suggest more research and methodological refinements are needed, particularly related to categorizing county-level political dynamics.

Background: This study analyzes local wellness policies of 176 Georgia public school systems. The purpose of the study was to analyze potential relationships between demographic characteristics of Georgia school systems and compliance with the Child Nutrition and WIC Reauthorization Act of 2004, as well as the strength of wellness policy goals in the areas of nutrition, physical activity, and other school-based activities. Methods: Demographic data from the Georgia Department of Education were used as independent variables. Compliance ratings and the strength of wellness policy goals were derived from an evaluation tool developed by a research team at Georgia State University’s Institute of Public Health as part of a project contracted by the Georgia Department of Education. Analysis was conducted using Pearson’s correlation (two-tailed), crosstabulation, and linear regression. Results: Statistically significant positive associations were found between academic performance and strength of overall wellness policy goals (p < .05), as well as goals in the areas of nutrition education and other school-based activities (p < .01). Economic status of the student population was found to be positively associated with the strength of nutrition education goals (p < .05). No statistically significant associations were identified between demographic characteristics of school systems and physical activity goals. No associations were identified between involving community stakeholders in wellness policy development and having more comprehensive wellness policy goals. Conclusions: This study found statistically significant evidence of districts with stronger academic performance having more comprehensive overall wellness policy goals and stronger goals specifically in the areas of nutrition education and other school-based activities goals. Findings should assist the Georgia Department of Education in allocating its limited resources to help school systems improve wellness in public schools throughout Georgia. Recommendations are made to strengthen federal and state policy regarding school wellness, to conduct more research regarding the influence of community involvement on school wellness, and to provide guidance to local school systems having less resources and lower student academic performance in order to ensure health disparities are not further exacerbated.

The purpose of this capstone is to develop a program to address health literacy among African American adults. The social cognitive theory and the health belief model was used to create a model of an age appropriate, culturally sensitive program with a pre and post test to improve the health literacy in this population. The Community Health Literacy Improvement Program (CHIP) is a pilot program that will consist of a four week didactic intervention focused on combating prose, document, and quantitative health illiteracy. This program will be implemented through a community based nonprofit organization. Participants who complete the CHIP program will be able to identify risk factors for chronic diseases, assess their ability to avoid chronic diseases, and be able to locate community health resources. This proposed intervention will show that community based nonprofit organizations have an important role to play in building community buy in and establishing the agency necessary for community based, culturally sensitive programs such as CHIP to succeed.

<p>In 2010, approximately 84% of the American population lives in a metropolitan area. Different metropolitan areas are characterized by distinct labor markets and economies, housing markets and residential patterns, socioeconomic and demographic factors, and according to some, even distinct 'spirits.' The nature and influence of such structural factors lie at the heart of urban sociology, and have particularly profound effects on patterns of racial and ethnic stratification. This dissertation examines new urban structural changes arising within recent decades, and their implications for racial/ethnic stratification. Specifically, I study the transition to the 'new economy' and racial/ethnic wage inequality; increases in the level and inequality of housing prices and racial/ethnic stratification in homeownership; and increased income inequality, combined with population aging, and racial/ethnic disparities in disability and poor health. I measure metropolitan-level structural factors and racial/ethnic inequalities with data from 5% samples of the 1980, 1990, and 2000 Censuses; the 2010 American Community Survey (ACS); and the 1999-2001 and 2009-2011 Current Population Surveys (CPS). Cross-sectional multilevel regression models examine the spatial distributions of structural factors and racial/ethnic inequality, and the fixed-effects regression models identify the impact of changes in structural factors over time on observed trends in racial stratification. Additionally, I distinguish between effects on minority-white gaps in resource access, and minorities' levels of resource access. This dissertation also makes novel contributions to the field by empirically documenting complex patterns of inequalities among the country's four largest racial and ethnic groups. Perhaps most relevant to theories of racial stratification, this dissertation demonstrates seemingly race-neutral structural changes can have racially stratified effects. </p><p>Chapter 1 describes the foundational literature in urban sociology and racial/ethnic stratification, and provides an overview of the subsequent chapters. Chapter 2 measures the transition to the `new economy' with six structural factors of labor markets: skill-biased technological change, financialization, the rise of the creative class, employment casualization, immigration, and deunionization. Overall, the results indicate the observed Latino-white wage gap may be up to 40% larger in 2010 than in the theoretical absence of the new economy, and the black-white wage gap may be up to 31% larger. Chapter 3 focuses on the long-term trend toward higher and more unequally distributed home prices within local housing markets, epitomized by the housing crisis of the late 2000s. Increases in housing market inequality worsen the Asian-white homeownership gap, but narrow the black-white and Latino-white gaps. However, the level of homeownership is reduced for all groups. Chapter 4 empirically tests the frequently-debated Income Inequality Hypothesis, that macro-level income inequality undermines population health, and hypothesizes any negative effect on health is stronger in areas with greater population aging. The results provide no support for the Income Inequality Hypothesis or any of its proposed extensions, but the chapter's analytic approach may be fruitfully applied to future examinations of structural determinants of health. The theoretical and substantive conclusion of the dissertation is that metropolitan areas represent salient, and changing structural contexts that significantly shape patterns racial/ethnic stratification in America.</p> / Dissertation

Individuals diagnosed with schizophrenia commonly experience problems with accurately assessing their health status due to cognitive deficits including impaired working memory, amotivation, and communication difficulties. Little is known about whether these deficiencies influence health behavior decision-making among individuals with schizophrenia. Individuals with schizophrenia die an average of 25 years earlier than those without a mental illness. Approximately 60% of premature deaths in this population are from medical comorbidities; mortality rates due to cardiovascular and pulmonary diseases are two to three times higher than the general population. In order to reduce morbidity and mortality, it is important to find effective ways to assist these individuals in modification of risky behaviors (e.g., smoking, poor dietary habits, and sedentary lifestyles) and to incorporate daily health promoting behaviors (e.g., balanced diet and regular exercise). This qualitative descriptive study was conducted to describe the decision-making processes used by adults with schizophrenia when making health behavior decisions, identify what it means to be healthy from the perspectives of adults with schizophrenia, and identify the perceived barriers and facilitators that affect health behavior decisions. Ten adults diagnosed with schizophrenia were interviewed for this study. Fifty-percent of participants were female, ages 28 to 59 years, and received treatment in a community mental health centers. Data were analyzed using content analysis. Methods included the use of field notes, open and axial coding, and development of a visual model. Trustworthiness of the findings was established through the qualifications and experience of the investigator, peer scrutiny, and member checks. Three phases of health behavior decision making were identified: Recognizing Complex Components of Health, Personalizing Components of Health, and Tracking Health Status. The main category that described health behavior decision making was “Tracking Health Behaviors,” which resulted in the ability to maintain physical and mental health. Within each phase, specific actions associated with achieving and maintaining physical and mental health were identified and were displayed in a visual model. These findings provide a guide to clinicians in identifying health behavior decision making processes and may lead to the design of clinical interventions that improve the health status of adults with schizophrenia.

The purpose of this study was to determine the role of acculturation in the food consumption patterns of low income Hispanic women living in Texas and enrolled in the Women, Infants, and Children (WIC) Program by testing the following hypotheses: a) There are significant differences in consumption of fruit and vegetables by selected socio-demographic variables; and, b) less healthy food consumption patterns are associated with higher levels of acculturation in health-related research involving low-income Hispanic women living in Texas. A secondary-data analysis of the responses to the Texas Food & Nutrition (TEXFAN) questionnaire was performed. TEXFAN is a 122-item survey designed to measure WIC participants' consumption behaviors and to assess the impact of new food packages in Texas' WIC program. A total of 3,336 adult, non-pregnant women self-identified as having Hispanic ethnic background of all races were considered for this study. Analysis of Variance and Kruskal-Wallis tests showed significant differences in nutritional practices among Hispanic women for age, educational attainment, employment status, race, area of residence, and acculturation. Logistic Regression analysis confirmed the hypothesis that lower levels of acculturation are associated with healthier food consumption patterns. The majority of respondents (70.7%, N=2,358) did not consume the recommended five servings of fruits and vegetables a day; therefore, do not have healthy patterns of food consumption. Consequently, the majority of respondents (70.0%, N= 1,709) has a weight statuses above normal and at a higher proportion than women in the State of Texas and the nation. Acculturation continues to interest social and behavioral researchers but variations on conceptualization, definition, operationalization, and measurement negatively impact generalizability and applicability of results. Interventions not considering acculturation are not likely to be successful. Research has to include community, ecological, cultural and contextual factors (e.g., machismo, accessibility to sidewalks, availability of fresh healthy foods, etc.). Development of effective intervention programs should be aimed to increase consumption of healthy food and an adherence to the recommendations of the "Healthy Plate" and the "Dietary Guidelines for Americans 2010" among Hispanics. Also, interventions should generate necessary skills among Hispanics for empowering them to sustain proper nutritional behaviors and overcome barriers.

In 2013 Burma, the country of origin for many refugees of whom have resettled in the U.S. was in the top three countries for notification of suspected Latent Tuberculosis Infection (LTBI). Approximately 5%-10% of individuals diagnosed with LTBI are at risk of developing active tuberculosis (TB) disease; the highest risk occurs within two years following the diagnosis. Burmese refugees face a high potential of developing LTBI during resettlement in the U.S. and are at high risk for subsequent TB. Currently, we have limited knowledge of the Burmese Chin refugees' explanatory model (EM) of LTBI. Understanding the EM of these refugees is important because one's EM facilitates the recognition and response to illness, including early diagnosis and treatment. In the context of LTBI, this relates to the potential prevention of active TB disease. The purpose of this ethnographic study was to discover the Burmese Chin refugees' EM of LTBI and to describe the barriers experienced in receiving LTBI treatment. Kleinman's EM provided a conceptual framework to guide this study. A Burmese refugee gatekeeper assisted with community immersion and participant recruitment. Purposive and snowball sampling were used to recruit participants. Data were collected through participant observation and semi-structured interviews. Three data analysis strategies for ethnography that were used included domain, taxonomic, and componential analyses. Domain analysis began after open, inductive coding of the data. Data saturation was reached and the research questions were answered with eight participants. Data from 15 key informant interviews were abstracted into three domains: EM of LTBI, Fear and Stigmatization, and Barriers to Receiving LTBI Treatment. The over-arching theme, LTBI: My Shadowbox was derived from these three domains, 11 categories, and 25 subcategories through iterative and inductive data analysis. The analysis revealed the participants' language, behavior patterns, beliefs, values and health seeking experiences of LTBI in the U.S. The findings from this study will help to inform culturally tailored interventions to reduce LTBI and TB health disparities among Burmese Chin refugees and potentially other Burmese refugee subgroups in the U.S. Knowledge of the Burmese Chin refugees' EM of LTBI can inform health policy for reducing LTBI treatment barriers.