Substantial evidence demonstrates that marriage is associated with better health outcomes and lower mortality risk. Some evidence suggests that there are gender and race/ethnicity differences between the marriage-health benefits association. However, previous studies on marriage and health have mainly focused on non-Hispanic White-Black differences. Limited information is available regarding the roles of Hispanics. The present study examined marital status, gender, and the differences between non-Hispanic Whites, non-Hispanic Blacks, and Hispanics, in health outcomes. A retrospective cohort analysis of 24,119 Hispanic, NH White, and NH Black adults admitted to a large hospital was conducted. A total of 16,661 patients identified as either married or single was included in the final analyses. Consistent with the broader literature, marriage was associated with beneficial hospital utilization outcomes. With respect to differences in these benefits, results suggest that married patients, Hispanic patients, and women, were less likely to experience in-hospital mortality. Similar effects were observed in aggregated length of stay with married Hispanic women hospitalized nearly 2 days less than their single counterparts (6.83 days and 8.66 days, respectively). These findings support existing literature that marriage is associated with health benefits, add to the emerging research of a Hispanic survival advantage, and broaden the understanding of marriage and health in terms of differences by racial/ethnicity.

The objective of this study was to examine if intra-racial income inequality contributes to higher infant mortality rates (IMRs) for African-Americans. The conceptual framework for this study is derived from Richard Wilkinson's psychosocial environment interpretation of the income inequality and health link. The hypotheses examined were that race/ethnicity-specific IMRs are influenced by intra-race/ethnicity income inequality, and that these effects of income inequality on health are mediated by level of social mistrust and/or risk profile of the mother. Using state-level data from several sources, the 2000 National Center for Health Statistics Linked Birth Infant Death database, 2000 U.S. Census, and 2000 General Social Survey, a number of regression equations were estimated. Results indicated that the level of intra-racial/ethnic income inequality is a significant predictor of non-Hispanic Black IMRs, but not the IMRs of non-Hispanic Whites or Hispanics. Additionally, among Blacks, the effect of their intra-racial income inequality on their IMRs was found to be mediated by the risk profile of the mother, namely, the increased likelihood of smoking and/or drinking and/or less prenatal care by Black women during pregnancy. Implications of the findings are discussed.

This thesis explores patterns of environmental inequality in Portland, Oregon; both the existence of spatial environmental inequalities and the structural and local forces which contribute to them. Research on environmental inequality, or inequitable exposure to toxins, has shown that minority and low-income populations experience the bulk of the exposure to environmental hazards. Although Portland is often cited as the archetype of a sustainable city, environmental inequality is a pervasive issue. This thesis examines the health inequalities that characterize underserved communities in Portland. Utilizing a mixed methods approach, the researcher uses 1) logistic regression to statistically assess the relationship between race, poverty, and Superfund site locations, and 2) in-depth interviews with members of Oregon's environmental justice movement to help understand the historical, social, political, and economic conditions of Portland and their subsequent influence on environmental inequalities. Quantitative data is pooled from 2000 census and 2011 Environmental Protection Agency (EPA) sources. The quantitative findings demonstrate that environmental inequality is present in Portland, with African Americans being particularly overrepresented in tracts with Superfund sites. The quantitative analyses ultimately suggest that minimally populated, highly impoverished tracts with approximately 11% African American residents are most likely to house a Superfund site. The qualitative findings show that a variety of structural and local forces play prominent roles in the formation of Portland's environmental inequalities. The qualitative analyses reveal this to be a multifaceted and complex process that is indicative of Portland's history of racial inequality, contemporary free market and business forces, and governmental interests which culminate in trends of inequitable development.

Cardiovascular disease (e.g., myocardial infarction, stroke, coronary artery disease) is the leading cause of death and disability worldwide. There is a growing body of literature that indicates sexual minority (e.g., gay, lesbian, bisexual, queer) adults are at a higher risk of cardiovascular disease than their heterosexual counterparts. The aim of this dissertation was to identify factors that contribute to the cardiovascular health (CVH) disparities that have been observed among sexual minority individuals. Guided by an adaptation of the minority stress model of CVH among sexual minority individuals, this dissertation includes three studies. In the first study (i.e., Chapter 2), we conducted a scoping review of the literature that investigated social determinants of cardiovascular health among sexual minority adults. Although findings were mixed, several social determinants of health were found to influence the CVH of sexual minority adults. For instance, sexual minority adults who lived in environments that were more supportive of sexual and gender minority people had lower odds of being overweight or obese. In the second study (i.e., Chapter 3), we used data from a racially and ethnically diverse sample of sexual minority women to examine the associations of family-related factors (i.e., sexual identity disclosure and family social support) with self-reported incident hypertension. Additionally, we examined whether these associations were moderated by race/ethnicity and sexual identity, or mediated by depressive symptoms. We found that higher levels of family social support were associated with lower levels of depressive symptoms among sexual minority women. However, family-related factors were not associated with self-reported incident hypertension. Further, race/ethnicity and sexual identity did not moderate the associations between family-related factors and reported incident hypertension. In the third study (i.e., Chapter 4), we used data from a nationally representative sample of adults to investigate sexual identity differences in ideal CVH (as defined by the American Heart Association’s Life Simple 7) and whether these associations were mediated by depressive symptoms. Compared to exclusively heterosexual women, mostly heterosexual and lesbian women were less likely to meet ideal criteria for tobacco use. In contrast, lesbian women were more likely to meet ideal criteria for glycosylated hemoglobin than exclusively heterosexual women. Among men, relative to exclusively heterosexual men, mostly heterosexual men were less likely to meet ideal criteria for tobacco use. Gay and bisexual men were less likely to meet ideal criteria for physical activity, whereas gay men were more likely to meet ideal criteria for body mass index compared to exclusively heterosexual men. Bisexual men were less likely to meet ideal criteria for blood pressure relative to exclusively heterosexual men. Depressive symptoms were found to partially mediate the association between sexual identity and physical activity only among mostly heterosexual women. Overall, these dissertation findings highlight CVH disparities among sexual minority adults. Clinicians should be educated about the CVH disparities that have been documented among sexual minority adults to provide personalized and culturally competent care. Results also indicate there is a need to develop behavioral interventions tailored specifically to the needs of sexual minority adults to improve their CVH outcomes and reduce CVH-related disparities.

Background: Sexual minority women (SMW; e.g., lesbian, bisexual women) are at substantially higher risk for hazardous drinking (HD) than their heterosexual, cisgender counterparts. There is considerable evidence that minority stressors at the individual (e.g., internalized stigma) and interpersonal (e.g., discrimination) levels are associated with HD among SMW, but minority stressors at the structural level (e.g., structural stigma) are understudied. Further, there is a wide gap in the literature on the relationships between multilevel minority stressors and HD. Additionally, there is evidence that these associations may differ by race/ethnicity and sexual identity, but relatively little is known about these differences, particularly in a multilevel context. Methods: This dissertation includes three studies that were guided by an adaptation of the minority stress model and the social ecological model. In the first study we conducted a systematic review of quantitative research studies that examined associations between structural stigma and alcohol-related outcomes among sexual and gender minority (SGM) adults in the United States. In the second study we used data from a diverse sample of SMW enrolled in the Chicago Health and Life Experiences of Women (CHLEW) study to determine whether structural stigma at Wave 4 (2017-2019) was prospectively associated with HD at Wave 5 (2019-2022), and whether this association was attenuated when accounting for individual- (i.e., internalized stigma, stigma consciousness) and interpersonal- (i.e., discrimination, sexual identity concealment) level minority stressors. In the third study we used data from Waves 4 and 5 of the CHLEW study to examine whether associations between multilevel minority stressors (i.e., internalized stigma, stigma consciousness, discrimination, sexual identity concealment, structural stigma) and HD varied by race/ethnicity and sexual identity. Results: The systematic review included 11 studies. There was moderate to strong support for a positive association between structural stigma and poor alcohol-related outcomes among SGM people, with differences by gender, sexual identity, race, and ethnicity. All studies used cross-sectional designs, and nearly half utilized non-probability samples. Transgender and nonbinary people, SGM people of color, and sexual identity subgroups beyond gay, lesbian, and heterosexual were underrepresented. Multilevel stigma and resiliency factors were understudied. In the second study, structural stigma was positively associated with HD alone, and when combined with interpersonal-level minority stressors. With the addition of individual-level minority stressors, the association between structural stigma and HD was attenuated, with partial attenuation (i.e., structural stigma was still significant) in the model combining all three levels, and full attenuation (i.e., structural stigma was no longer significant) in the model with only structural stigma and individual-level stressors. Discrimination was negatively associated with HD in the fully combined model and was not associated with HD in any other models. In the third study, we found that associations between structural stigma and HD did not vary by race/ethnicity or sexual identity. However, the associations between individual-level minority stressors (i.e., internalized stigma, stigma consciousness) and interpersonal-level minority stressors (i.e., sexual identity concealment) with HD varied somewhat by race/ethnicity and sexual identity. Conclusions: Findings from this dissertation highlight the importance of structural stigma in SMW’s HD and underscore the importance of both structural-level and multilevel minority stressors in designing interventions to effectively address HD drinking disparities and inequities among SMW. Future research is needed using intersectional approaches with probability samples, longitudinal designs, expanded measures of structural stigma, and samples that reflect the diversity of SGM people.

Background: Persistently elevated hospitalization rates in the home healthcare setting indicate the need to prioritize patients with undertreated conditions that can lead to negative outcomes. Urinary incontinence affects approximately 40% of older adults in home healthcare, yet often remains unaddressed. This leaves older adults with urinary incontinence at risk for potentially serious complications that can lead to emergency department visits, hospitalizations, and mortality. Multiple comorbidities, co-occurring symptoms, and disparities in care fuel the complexity of older adults in the home healthcare setting. The overall purpose of this dissertation was to leverage natural language processing to understand symptom clusters and factors associated with acute care utilization among older adults with urinary incontinence in home healthcare to improve comprehensive assessment, treatment, and outcomes. The aims of this dissertation were to: 1) identify relevant comorbidities among community-dwelling older adults with urinary incontinence; 2) develop and test a natural language processing algorithm to extract symptom information from home healthcare free-text clinical notes for older adults with urinary incontinence and analyze differences by race or ethnicity; 3) identify symptom clusters among older adults with urinary incontinence in home healthcare and examine differences by sociodemographic and clinical correlates; and 4) determine factors associated with the risk of emergency department visits or hospitalizations among older adults with urinary incontinence in home healthcare, including the impact of symptom clusters. Methods: This dissertation comprised four studies: 1) a scoping review of the literature to identify comorbidities to broadly characterize community-dwelling older adults with urinary incontinence, 2) a secondary analysis of cross-sectional electronic health record data using natural language processing to extract symptoms from free-text clinical notes and analyze differences by race or ethnicity using Chi-square tests and logistic regression models, 3) a secondary analysis of cross-sectional electronic health record data using hierarchical clustering to analyze the natural language processing-extracted symptom variables and examine differences in sociodemographic and clinical correlates using Chi-square tests, and 4) a retrospective secondary analysis of electronic health record data to identify factors, including symptom clusters, associated with emergency department visits or hospitalizations using Chi-square tests and backward stepwise logistic regression. Results: In the scoping review, we synthesized findings from 10 studies that identified comorbidities among community-dwelling older adults with urinary incontinence across neurologic, cardiovascular, respiratory, endocrine, genitourinary, musculoskeletal, and psychologic systems. In the natural language processing study, we identified eight symptoms of older adults with urinary incontinence (i.e., anxiety, constipation, dizziness, syncope, tachycardia, urinary frequency/urgency, urinary hesitancy/retention, and vision impairment/blurred vision) that were extracted from free-text clinical notes from approximately 29% of home healthcare episodes. Compared to White patients, home healthcare episodes for Asian/Pacific Islander, Hispanic, and Black patients were less likely to have any symptoms documented in clinical notes. In the clustering analysis, we identified five distinct symptom clusters: Cluster 1 (anxiety), Cluster 2 (broadly symptomatic), Cluster 3 (dizziness and anxiety), Cluster 4 (constipation, anxiety, and dizziness), and Cluster 5 (no symptoms) that correlate with sociodemographic and clinical characteristics. Finally, in the retrospective analysis, we found that Clusters 1-4 had higher odds of emergency department visits or hospitalizations, in addition to home healthcare episodes for Black and Hispanic patients, males, patients with an unhealed skin ulcer, and patients with a urinary tract infection 14 days prior to home healthcare admission. Conclusion: Older adults with urinary incontinence in home healthcare have complex physical and psychosocial needs, increasing the risk of negative outcomes. Improving comprehensive assessment and treatment for older adults with urinary incontinence is an urgent priority, given high hospitalization rates in home healthcare. Leveraging natural language processing, this dissertation identified key symptom clusters and factors associated with emergency department visits or hospitalizations, providing valuable insight for multidimensional interventions. Findings provide preliminary evidence to inform improvements in clinical practice, healthcare policies, and future research to enhance the care of older adults with urinary incontinence and reduce negative outcomes in the home healthcare setting.

The purpose of this study was twofold. First, the study evaluated Loma Linda University Medical Center's (LLUMC) Diabetes Treatment Center's (DTC) effectiveness in providing diabetes education and services to high risk minority populations. Second, the results of the study helped the DTC determine the need for expanding its present efforts in the form of community health prevention services to San Bernardino County residents.

The purpose of this study was to explore the religion – health link in a sample of adults and undergraduate students (N = 555) that identified as lesbian, gay, or bisexual (LGB), and to explore how perceptions of cultural humility of religious individuals and groups toward LGB individuals affect the relationship between religion and health. First, I found religious commitment among LGB individuals was positively correlated with satisfaction in life, but it was negatively correlated with physical health. Second, I found that cultural humility moderated the relationship between religious commitment and satisfaction in life for LGB individuals involved in a religious community. The lowest levels of satisfaction with life were found for individuals with low religious commitment and perceived the cultural humility of their religious community to be low. However, cultural humility did not moderate the relationship between religious commitment and mental and physical health outcomes. Third, I found cultural humility did not moderate the relationship between religious commitment and minority stress (i.e., internalized homophobia). Fourth, I found that cultural humility was a significant positive predictor of motivations to forgive a hurt caused by a religious individual. I conclude by discussing limitations, areas for future research, and implications for counseling.

Indiana University-Purdue University Indianapolis (IUPUI) / Research indicates that negative affective traits (e.g., depression) are predictors and consequences of excess adiposity. Given that racial minorities and positive affective traits have been underrepresented in past investigations, more prospective studies are needed which examine multiple affective traits in relation to obesity in these populations. The objective of the current study was to investigate the prospective, bidirectional associations between multiple affective traits and multiple adiposity indicators in African Americans using data from the African American Health (AAH) study. The AAH study is a prospective cohort study of African Americans aged 49-65 years at baseline (N = 998). The longest follow-up period in the current study was 9 years (N = 579). Self-reported and measured body mass index (BMI; kg/m2) and body fat percent (BF%) were used as adiposity indicators. Depressive symptoms were assessed with the 11-item Center for Epidemiologic Studies-Depression Scale (CES-D), and anxiety was assessed using the Generalized Anxiety Disorder-2 (GAD-2) scale. Positive affective traits were assessed with the Vitality subscale of the Short Form-36 and Positive Affect subscale from the CES-D. Latent variable path analysis, a structural equation modeling technique, was conducted. Although fit statistics indicated that the models fit the data (RMSEA < .06), examination of the structural paths revealed that the CES-D and GAD-2 were not predictors or consequences of self-reported BMI, measured BMI, or BF% (ps > .05). Likewise, Vitality and CES-D Positive Affect were not related to any adiposity indicator (ps > .05). The results of this prospective cohort study suggest that affective traits are not predictors or consequences of adiposity in middle-aged African Americans and that this group may require obesity prevention or intervention programs with little to no emphasis on affective traits. Possible explanations for the current results include ethnic differences in the mechanistic pathways between affective traits and adiposity.

Indiana University-Purdue University Indianapolis (IUPUI) / A significant body of literature has accumulated in the last decade that provides evidence of the growing health care disparities among racial and ethnic groups in the United States. The literature suggests that Black adults share a disproportionate burden in death, disability, and disease. In 2002, the Institute of Medicine report, Unequal Treatment, showed that racial-ethnic disparities in health cannot be entirely attributed to problems of health care access, clinical performance, or patients’ personal characteristics. Many studies have shown that institutional and individual level discrimination that Blacks face in the health care system impacts their health status. This study used secondary data analysis to examine how primary care experience impacts self-reported health status and health care utilization among Black adults. Data were from the Medical Expenditure Panel Survey (MEPS) implemented by the Agency for Healthcare Research and Quality (AHRQ). Specifically, MEPS Panel 10 (2005-2006) and Panel 11 (2006-2007) data were used in the analyses. The final sample comprised of N=15,295 respondents ages 18 and over. Logistic regression analyses were carried out using Stata Statistical Software, version 11. The study results reflect the disparities among Blacks and Whites on self-reported health and health care utilization. Blacks were 15% less likely to report good health status compared to Whites and had 0.11 less expected office-based doctor visits. Respondents who had better primary care experience had 0.05 times higher expected office-based doctor visits than respondents who did not have good primary care experience. Health care Social Workers should advocate for structural changes in health policy that will take into account the historical marginalization and contemporary inequities that continue to encompass the lives of many Black Americans.