Class of 2012 Abstract / Specific Aims: Health disparities are contributing to differences in access to healthcare and health outcomes among diverse groups in the United States. Causes of health disparities are multifactorial. One approach to minimize health inequalities is through educating future health care professionals. The purpose of this review is to identify and describe approaches for developing health disparities curriculum for health professions programs in the United States. Methods: A systematic review was conducted in April of 2012 to identify articles describing medical and nursing school curricula, educational courses, and activities focusing on health disparities in the United States. The search was conducted by utilizing Medline PubMed database. Articles describing a specific educational course/curriculum in health disparities in medical and nursing undergraduate or graduate programs were included in the review. The review did not take into account continuing education programs. All articles describing educational programs focus on healthcare disparities in the United States. Main Results: The search identified 153 articles focusing on specific health disparities curricula or education programs. Out of those articles 30 were included in the analysis. Results are pending. Conclusions: Anticipated results will aid in identifying successful and effective health disparities curricula for health professions programs in the United States.

Ever since the tax reform in 1994 in China, local governments have to rely more and more on land and real estate related fees as a major source of revenue. With the rapid development of the financial sector in China, local governments also rely more on bank loans with real estate assets as collaterals to finance capital expenditure projects and other government expenditure. Many theoretical studies have suggested that the reliance of local governments on land and real estate related revenue has fuelled housing prices and rendered the central government’s policy to contain housing price escalation ineffective. However, so far there has been little vigorous empirical analysis that supports this argument. This study use panel data from 31 provinces over the period 1999 to 2010 to analyses empirically the role of provincial governments’ behavior in determining housing price levels in China. Our empirical results suggest that the behavior of provincial governments has contributed significantly to regional housing price disparity after controlling for social and economic factors. In particular, we found that the level of fiscal autonomy (local government revenue as a percentage of GDP) has an overall positive impact on housing prices and that such impact is stronger for provinces that are geographically more distant from Beijing. We also found that although the central government’s policy on the RMB exchange rate reform in 2005 has an overall positive impact on real housing prices due to inflow of speculative hot money, such impact varied across different provinces and thus also contributed to regional housing price disparity. Our empirical results suggest that speculative hot money tended to flow into housing markets in provinces with a more developed tertiary sector. This is because regions with more developed tertiary sector usually have more mature real estate markets, lower information costs, better financial and legal services, which facilitates flow of fund into and out of the housing market. This study contributes to the body of knowledge on regional housing price disparity. Unlike previous studies that only focused mainly on the impact of economic, social and government planning policies, this study also aimed at studying the role of fiscal and monetary policies in China. The results have important policy and practical implications. First, while the financial incentives and responsibility given to provincial governments may increase economic efficiency, they may also lead to conflicting goals between central and local governments. In addition such financial incentives and responsibility may unexpectedly lead to housing price bubbles that are economically and socially undesirable. Second, the central government’s policy to reform the exchange rate formation mechanism of the RMB in 2005 has also contributed to housing price escalation which may not be desirable from both social and political perspectives. Even worse still, the impact was not uniform but stronger in provinces with a more developed tertiary sector, which are usually wealthier provinces. Increase in housing prices in these provinces may lead to faster regional economic growth and thus contributing to even more sever regional income disparity, which contradicts the central government’s goal of reducing income polarization. / published_or_final_version / Real Estate and Construction / Doctoral / Doctor of Philosophy

published_or_final_version / abstract / Urban Planning and Environmental Management / Doctoral / Doctor of Philosophy

Thesis (Ph. D.)--Washington State University, December 2006. / Includes bibliographical references (p. 212-225).

Class of 2012 Abstract / Specific Aims: Health disparities are contributing to differences in access to healthcare and health outcomes among diverse groups in the United States. Causes of health disparities are multifactorial. One approach to minimize health inequalities is through educating future health care professionals. The purpose of this review is to identify and describe approaches for developing health disparities curriculum for health professions programs in the United States. Methods: A systematic review was conducted in April of 2012 to identify articles describing medical and nursing school curricula, educational courses, and activities focusing on health disparities in the United States. The search was conducted by utilizing Medline PubMed database. Articles describing a specific educational course/curriculum in health disparities in medical and nursing undergraduate or graduate programs were included in the review. The review did not take into account continuing education programs. All articles describing educational programs focus on healthcare disparities in the United States. Main Results: The search identified 153 articles focusing on specific health disparities curricula or education programs. Out of those articles 30 were included in the analysis. Results are pending. Conclusions: Anticipated results will aid in identifying successful and effective health disparities curricula for health professions programs in the United States.

ABSTRACT When examining disparities in healthcare, notably those facing black men (Danaei et al. 2010; Thorpe Jr et al 2013), trust formation (Smith 2010; Levine 2013), internalization of stigma (Goffman 1963; Becker 2008), and identity construction (Hill Collins 2009, Crenshaw 2010) are three potentially important social processes worthy of consideration. Research has often sought to explore racialized differences in healthcare utilization and health outcomes by operationalizing trust (Adegbembo, Tomar, and Logan 2006; Carpenter et al. 2009), stigma (Wailoo 2006; Stuber, Meyer, and Link 2008), and identity (Mimiaga et al. 2009), but there is little research that speaks to the dynamic relationship between all three processes as they pertain to healthcare (Eaton et al. 2015). Furthermore, previous research on the three processes has not focused on new healthcare interventions and new medical technologies. This dissertation expands the conversation on trust, stigma, and identity by exploring how technological advances—namely, the use of virtual agents—can be employed to potentially increase engagement in healthcare for black men. This dissertation discusses the reciprocal nature of identity construction and internalization of stigma and the impact that both processes have on the health maintenance behaviors of black men, especially insofar as there exists an avenue for technology to mitigate current disparities. With stigma inherently being affixed to characteristics associated with identity, such as race or sexual orientation, and with stigmatized populations sometimes internalizing the negative labels society casts upon them (Becker 2008), understanding the manner in which these two social processes may serve to reinforce each other is key. Next, adopting a position consistent with Eaton et al. (2015), who argued that medical distrust mediates the effect of stigma on engagement in care, I highlight the process of trust and explore the roles of identity construction and internalization of stigma with respect to its formation. This dissertation explores the proactive use of distrust (Levine 2013), as well as what black men I spoke with are reporting that healthcare can do to (re)earn and maintain their trust. Finally, I detail the impact that (dis)trust has on healthcare utilization and the potential ability of embodied conversational agent (ECA) technology (virtual agents) to reduce the social and structural barriers that impact black men’s access to healthcare. In analyzing the relationship between trust and healthcare utilization, which is captured via patients’ healthcare experiences and their activation behaviors (Hibbard and Greene 2013), the impact of both processes on health outcomes are also examined. This dissertation utilizes a mixed methods research frame (Creswell and Creswell 2017), employing both qualitative and quantitative strategies. Focus groups (N=11; participants N=67), key informant interviews (N=12), and interviews (N=5) with participants who pilot test an online health promotion system (Gabe) are integral in providing this research with valuable insight into the ways in which trust, stigma, and identity impact the health behaviors of black men. Quantitative data from a pilot test (N=30) of the Gabe system, an ECA operated health promotion program designed for black men, are also analyzed. Data from risk assessments, demographic surveys, and participant use of the Gabe system serve to buttress the qualitative analysis. By employing an interdisciplinary approach, and exploring the dynamic relationships that exist across identity, stigma, and trust as they pertain to healthcare utilization, this dissertation presents a unique discussion surrounding the capacity of ECA technology to improve access to healthcare for marginalized populations. / Sociology

Health disparities in minorities and those of low socioeconomic status persist despite efforts to eliminate potential causes. Differences in the delivery of services can result in different healthcare outcomes and therefore, a health disparity. Some of this difference in care may attribute to discrimination resulting from clinical biases and stereotyping which may provide a possible source for the persistence of health disparities. Health disparities may occur because the delivery of services at some level is inadequate. Disparities resulting from the quality and quantity of care delivered by a practitioner result in differentiated delivery of healthcare, thus unequal health outcomes. The purpose of this study is to evaluate and identify potential disparities in routine screening practices of physician assistants.A randomized sample of practicing physician assistants in Kentucky were analyzed (N= 112) to determine if the race or socioeconomic status of a patient influenced their likelihood of offering different routine screening recommendations and screening test recommendations. Clinical vignettes were created with only the race and socioeconomic status of the patient modified, resulting in four separate vignettes. Through the use of a survey instrument, participants were randomly assigned to one of four written clinical vignettes. Statistical analysis using a MANOVA revealed that the race of a patient had a statistically significant multivariate effect on differences in screening recommendations and race and socioeconomic status had significant multivariate effects on screening test recommendations.Study results suggest that race and socioeconomic status continues to be a significant factor in the prevalence of healthcare disparities. More importantly, this study reveals that Physician Assistants may provide differentiated care based on a patient’s race. Limitations and future directions for this study may be used to examine PA educational curriculums for the inclusion of health disparities and possible continuing medical education opportunities for practicing PAs.

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

Background: Diabetes is one of the most common and pernicious chronic illnesses. Guidelines recommend visiting a physician for the secondary prevention of complications. Many risk factors and barriers exist, which hinder healthcare usage. Males are at higher risk for many health issues, including diabetes, yet research shows that women are more likely to receive preventive services. The purpose of this study is to examine whether putative risk factors and barriers to care are diabetes-specific and whether their impact varies by gender. Methods: The Behavioral Risk Factor Surveillance System was used to assess disparities between genders related to diabetes-specific care. In addition, logistic regression was used to determine whether barriers to healthcare, such as education, lack of health insurance, and out-of-pocket-costs, were also diabetes-specific; and did they significantly vary by gender. Results: Analyses demonstrated that males were less likely to visit the physician for their diabetes care. Results indicated that while there were main effects for the additional barriers, they did not vary by gender. Within-groups analyses showed that the odds of not receiving adequate care for those with a lack of insurance were greater for males. Conclusion: Results demonstrated that in many instances, both gender and the chosen barriers increased the odds that individuals would not receive the optimum level of care, although not varying by gender. The lack of an insurance plan was shown to reduce the likelihood that males would receive the appropriate care. These findings potentially aid in the development of more gender-specific interventions and policies.

INTRODUCTION: In the United States, Blacks and Hispanics compared to Whites are disproportionately infected with HIV. Testing for HIV is critical to reduce HIV transmission, lower risk behaviors, and improve access to treatment among persons living with HIV. However, racial & ethnic minorities are tested at later stages of HIV. Previous studies that examined racial discrimination and HIV testing reported inconsistent findings and additional knowledge is needed to understand whether differential treatment based on race is an important barrier to HIV testing. AIM: We examined whether HIV testing is influenced by how an individual reacts to race-based treatment, rather than experiences of discrimination alone, among Whites, Blacks, and Hispanics; and we determined if this relationship was modified race and ethnicity. METHODS: We performed a cross-sectional analysis of the 2012 Behavioral Risk Factor Surveillance System’s (n=12,579) self-reported HIV testing data and Reaction to Race (RR) module, which captures experiences of differential treatment based on race and an individual’s reaction to racialized treatment. Multivariable logistic regression was used to assess the association between RR-based treatment and HIV testing. Statistical interaction between RR-based treatment and race was assessed. RESULTS: Approximately 21% participants reported ever being tested for HIV, and 19% of the participants had one or more experiences of RR-based treatment. Prevalence of HIV testing was higher among Blacks (62%) and Hispanics (33%) compared to Whites (32%). In an adjusted model, the odds of HIV testing among those who reported one experience of Reactions to Race based treatment was 1.37 (95% CI: 1.08-1.75) times the odds among those with no experiences of RR-based treatment. We did not detect statistical interaction between RR-based treatment and HIV testing by race. DISCUSSION: Our findings suggest that experiences of racial discrimination may be counter intuitively associated with increased HIV testing overall and within each racial and ethnic group. Additional research is needed to clarify settings in which experiences of race-based treatment and the associated reactions to the treatment can positively or negatively influence HIV testing behaviors.