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Problem: There is a lack of knowledge about women who are screened for breast cancer, have an abnormal finding on mammogram, and then do not return in a timely manner for diagnostics and treatment. Lack of follow- up likely constitutes delayed treatment and poorer outcomes. Delays may result in later entry into the health system with advanced disease, more extensive and expensive care, burdening resources. Late stage breast cancer likely results in poorer health outcomes or early death.Purpose and Aims: The purpose of this research is to describe contextual characteristics at the health delivery level as well as individual characteristics of women with abnormal mammography, and their association with use of follow- up health services. Particularly, this research examines the differences between women who are early and late responders after an abnormal mammogram.Population: The participants were a convenience sample of 380 women who participated in mobile breast cancer screening. A subset of women with inconclusive or abnormal mammogram findings was the focus of analysis.Methods: This research utilized a descriptive design with quantitative data collection through participant survey at mobile mammogram screening events in multiple urban and rural Arizona sites. Participants requiring further health care were followed by chart review. Analysis of correlations with the outcome variable: time to first follow- up appointment for recommended health care in women with abnormal mammograms was conducted.Findings: Data indicated the time to the first follow- up appointment ranged from 1- 110 days with follow- up for 77.4% of participants within 60 days, 6.5% within 60-90 days, and 16.1% without follow- up after 90 days. Significant relationships between contextual and individual characteristics and follow- up were found. Categories included organizational health system characteristics of geographic location, clinical breast exam and shared case management; individual characteristics of beliefs including value of health care; finance including out of pocket costs and perceptions of financial assistance; perceived needs including breast symptoms; and satisfaction with the last health visit and mammograms in general.Implications: Recognition of barriers to follow- up after breast cancer screening is important for development of interventions to improve outcomes and has implications for screening and treatment management programs, community health centers and private practice. Health disparity related to screening without adequate options for access to health care is ethically untenable. Nurses are well positioned to reduce barriers to health care.

The purpose of this research was to develop, validate, and test an instrument to evaluate motivations to eat in low-income women during the early postpartum period. The instrument was also used in a sample of young college women to further validate the measure and explore determinants of eating in this population. In study 1, the Eating Stimulus Index was validated in 179 low-income women in early postpartum. Validity and reliability were determined via principal components analysis, internal consistency reliability, and test-retest reliability using a subgroup of 31 low-income new mothers. The factor analysis produced an eight factor structure with reliability coefficients ranging from 0.54-0.89. Convenience eating (r=-0.25, P<0.01), emotional eating (r=-0.17, P<0.05), and dietary restraint (r=-0.21, P<0.01) were significantly related to weight status. In study 2, the relationship between eating motivations and diet quality, determined via the Dietary Guidelines Adherence Index, was established in 115 low-income women in early postpartum. High diet quality was related to fruit and vegetable availability (r=0.25, P<0.01), convenience eating resistance (r=-0.36, P<0.001), and vegetable taste preference (r=0.23, P<0.05). Motivations to eat differed between overweight and obese women with the primary motivation being convenience eating and taste, respectively. In study 3, determinants of weight loss were examined in 58 low-income women in early postpartum participating in an 8-week weight loss intervention. Participants were evaluated at pre- and post-study for all measures. Factors related to weight loss included increases in dietary restraint, weight management skills, and weight loss self-efficacy and decreases in fruit juice servings, total energy, and discretionary energy intakes. After hierarchical regression analysis, improvement in weight loss self-efficacy was the most significant determinant (β=0.263, P<0.05) followed by decreases in discretionary energy intake (β=-0.241, P<0.05). In study 4, determinants of diet quality were assessed in a sample of 88 young college women using the Eating Stimulus Index. Low diet quality was associated with poor fruit and vegetable availability, convenience eating resistance, vegetable taste preference, and weight management self-efficacy, while high diet quality was related to increased frequency of meals prepared at home and decreased frequency of meals consumed at fast food restaurants. / text

Low-income women, including women who receive welfare, are some of the most misunderstood citizens in the U.S. Low-income women often live in extreme situations that are complicated by poverty and multiple issues related to human capital, social support, mental health, and substance use. These factors make low-income women unique in that they contribute not only to the women’s current situations, but to their potential for future self-sufficiency. The majority of previous studies have described these factors as barriers to self-sufficiency. This study explored these factors differently by examining the extent to which human capital is associated with mental health problems and substance use problems and whether those associations are moderated by social support among low-income women. By exploring human capital among low-income women, this study closes a gap in the literature. Previous literature has examined human capital as an outcome of life choices and circumstances. This study is unique in that human capital is conceptualized as a combination of strengths that are employed in unique ways and that help determine whether life outcomes among low-income women will be related. This study examined secondary data collected from 11,495 low-income women who participated in the University of Kentucky’s Targeted Assessment Program (TAP) between July 2005 and July 2011 and is informed by theoretical literature on human capital, social support, and relationships, as well as empirical literature on study factors related to problems experienced by low-income women (i.e., mental health problems, substance use problems, and social support). Study hypotheses were developed to examine the relationships between human capital and mental health and substance use among low-income women and whether social support moderates those relationships. Results indicate that while some human capital factors are indicative of fewer mental health and substance use problems, perceived social support was a significant indicator of each of the mental health and substance use factors. Perceived social support was not found to moderate relationships between predictor and outcome variables.

The present study tested a model addressing whether interpersonal Openness and interpersonal and intrapersonal Coping Resources mediated the relationship between interpersonal Victimization and the Psychological Symptoms women experience as a result of these traumas. Victimization indicators (physical violence, sexual assault, psychological abuse, and revictimization), Coping indicators (optimism, self-esteem, private self-consciousness, social network and therapy), Openness indicators (self-silencing, communal orientation, trust, self-monitoring, and network orientation), and Psychological Symptoms indicators (global distress, dissociation, and suicidal ideation) were examined separately for African American (n = 245), Euro-American (n = 185), and Mexican American (n = 202) women. Structural Equation Modeling revealed that for African American and Euro-American women, Openness partially mediated the victimization-distress relationship. The model for Mexican Americans was the most complex with Openness and intrapersonal Coping fully mediating the psychological effects of victimization. Approximately 50% of the variance in psychological symptoms resulting from victimization was predicted by this model for African American and Euro-American women; over 80% of the variance was predicted for Mexican Americans. Thus, the importance of Openness to relationships in alleviating the psychological sequelae following interpersonal victimization was underscored by the results. Similarities and differences between these models are discussed. Implications of the results for future research and intervention are addressed.

A model for health care utilization was applied to a sample of low income women. Demographic Predisposing, Psychosocial Predisposing, Illness Level, and Enabling indicators were examined separately for African American (n = 266), Anglo American (n = 200), and Mexican American (n = 210) women. Structural Equation Modeling revealed that for African American and Anglo American women, Illness Level, the only significant path to Utilization, had a mediating effect on Psychosocial Predisposing indicators. The model for Mexican Americans was the most complex with Enabling indicators affecting Illness Level and Utilization. Psychosocial Predisposing indicators were mediated by Illness Level and Enabling indicators which both directly affected Utilization. Implications of the results for future research are addressed.

Thesis advisor: Gilda Morelli / Although trying to survive on a low income is challenging for all individuals, the experience of losing government supports can propel households into a crisis situation which may cause them to act or react in distinctive ways. This study used a survey of 78 low-income women followed by in-depth interviews with 18 of these women to explore how two groups of women--those close to losing government supports (i.e., within three months) and those further from losing government supports (i.e., experienced at least one year ago)--plan for and cope with financially vulnerable periods in their lives and how they fare as a result. There are two parts to this research. First, information on government support use, social support, proactive coping, and overall well-being were gathered using survey techniques. Linear regression and mediation analyses were conducted to further explore the association between these constructs. Proactive coping was found to be a significant predictor of well-being (R2=.305, &#946;=.552, p<.01), but social support did not mediate this relation. Findings from the survey also demonstrated the women in the near loss group scored higher on proactive coping and well-being measures, and the far from loss group scored higher on measures of social support. Second, a sub-sample of the survey participants were chosen for an in-depth interview based on when they lost (or were anticipating to lose) government supports. This sub-sample was invited to discuss their resource loss experience, how they planned for and coped with this loss, and what role other factors such as social support, consideration of future consequences, choice deferral, and perceived transaction costs played in this process and what it meant for their well-being. The conversations with the women revealed that the group near a loss situation deferred decisions less frequently and had shorter planning horizons focusing more on the immediate (and less on the future) consequences of their decisions. While the far from loss group discussed, with less urgency, their plans as being distant and spoke of their more extensive social support networks. Both groups discussed similar sentiments of shame, degradation, and inconvenience associated with their experiences at the welfare office, and although the cost of this transaction outweighed the benefit for the women in the far from loss group, the near loss participants chose to endure it to receive the assistance. This research demonstrated that individuals who face government support loss because of an increase in income and who proactively plan make better strides towards becoming economically self-sufficient and investing in the health and well-being of their families now and in the future. This, in turn, may continue to encourage and promote the ability to act in proactive ways and may lead to greater overall well-being. / Thesis (PhD) — Boston College, 2009. / Submitted to: Boston College. Graduate School of Arts and Sciences. / Discipline: Psychology.

The purpose of this research was to discern associations of nutrition knowledge, attitudes, and diet with postpartum weight retention 1 year following childbirth. Subjects for this research were low-income, Hispanic, non-Hispanic black, and non-Hispanic white women recruited in a hospital 0 -- 1 day postpartum. In study 1, a nutrition attitudes scale was developed and validated in 134 low-income women at 1.5 months post-delivery. The final scale was administered to a second group of 206 women at 1.5, 6 and 12 months postpartum. Attitudes at each time were compared to demographics and weight status. Obese women at 1 year had higher barriers to healthful eating subscale averages than normal and overweight subjects at 1.5 and 6 months, and overweight participants at 12 months. Obese individuals also had greater emotional eating subscale scores than both normal and overweight subjects at 12 months. In study 2, a test of general nutrition knowledge was developed and validated in a sample of 151 women at 1 day post-delivery. The validated instrument was then administered to a test sample of 140 women at 0 and 12 months postpartum. Body weights were measured at 1.5, 6, and 12 months and height 1.5 months. Women with < 5% weight retention at 1 year had greater knowledge at 0 (53% vs.49%, p<0.05) and 12 months (55% vs. 51%, p <0.05) than those with >̲5%. Women who lactated >̲ 6 months had more knowledge than those who lactated < 6 months. In study 3, 182 women visited the research site at 1.5, 3, 6, and 12 months postpartum where dietary data were collected via one 24-hour recall and 2 days of diet records. Weight status was measured during each clinic visit; height was measured at 1.5 months. At 1 year postpartum, obese women had a greater percentage of energy from carbohydrates than their normal weight counterparts (52.5 % vs. 49.6%, p<0.05). Less than half of the population met the recommendations for folate, calcium, magnesium, and vitamins B6, D, E and C at all time points, regardless of ethnicity, BMI and lactation status. / text

The purpose of this research was to develop and va lidate a Risk Scale for Postpartum Weight Retention in low-income tri-ethnic women. In Study I, the scale was created in 187 subjects given six questionnaires and monitored for weight from 0 - 6 months postpartum. There were a total of 263 items derived from the questionnaires and 39 were related to weight change at 6 months postpartum (r = -0.20 to 0.61, p < 0.005). Expert review and exploratory multivariate analyses were used to reduce the questionnaire to six items that included weights, fat habits, weight control practices and self-esteem. Weight change was calculated as weight in kilograms retained from prepregnancy to 6 months postpartum. An initial method of evaluation, multiple regression, accounted for 45.8% of the variance in weight change (p < 0.001). A simpler method for clinicians, a ROC curve, discriminated between women who retained < 10 kg prepregnancy weight vs >̲ 10 kg. Area under the curve was 0.87; sensitivity was 76% and specificity, 80%. In Study II, validity was determined in a sample of 75 women who visited health clinics at 1.5 and 6 months postpartum. The risk scale and a demographic questionnaire were administered at 1.5 months postpartum; weight and waist circumference were measured at 1.5 and 6 months after delivering a child. When cross-validated in this sample, multiple regression explained 35.7% of the variance in weight. The ROC curve classified 81% of subjects into correct weight categories, with sensitivity of 65% and specificity, 89%, (p < 0.001). To enhance the predictive ability and reliability of the risk scale, weight at 1.5 months was replaced by waist circumference at 1.5 months postpartum. In the revised scale, multiple regression explained 41.5% of the variance in weight retention (p < 0.001). The updated ROC curve had an area under the curve of 0.83; with a sensitivity and specificity of 65 and 92%, respectively (p < 0.01). These results indicate that the risk scale is a valid measure of postpartum weight retention, using either complex multiple regression or simpler ROC methods. Additionally, waist circumference greatly increases its predictive power in Study II. / text