This dissertation explores historical processes and daily practices of indigenization within the context of British Columbia's model for delegating Aboriginal agencies for child and family services. This research draws from historical data, examining the ways in which contemporary indigenization within Aboriginal child welfare is shaped by Canada's colonial past- most notably, the historical relationship between the Indian Residential School System and Aboriginal child welfare in Canada. Grounded in indigenous methodologies, research practice, and critical theory, this dissertation queries indigenization within the Pacific Aboriginal Child Welfare Association (PACWA). This dissertation explores the complexity of the urban setting in which PACWA operates, providing case studies of daily practices of indigenization within the association, considering the roles of Aboriginal Elders and Knowledge Keepers throughout this process, and arguing for the need to reframe urban Aboriginal child welfare in Canada. This dissertation asserts that Indigenization at PACWA is making significant differences in the lives of children and families involved in Aboriginal child welfare and that Aboriginal families continue to have their children removed at alarming rates most often because they are living in the aftermath of colonization, amidst contemporary conditions that continue to marginalize Aboriginal peoples. Indigenization is a process that can and is being achieved within the context of child welfare in British Columbia today. It is a process connected to Aboriginal sovereignty, self-government, identity and mainstream-Aboriginal relations. It is also a process that is making significant impacts in the lives of those connected to Aboriginal child welfare (Aboriginal and otherwise), while simultaneously being challenged by the structural inequalities and political eddies that continue to marginalize urban Aboriginal peoples. This research demonstrates that successful indigenization practice, at the level of large organizations such as PACWA, requires that various levels of Canadian government view them as true partners in a project of decolonization and indigenization. This requires a recognition and honouring of history and diversity of Aboriginal peoples in Canada, validated by means of mutual respect and sharing power.

This dissertation examines the relationship between a clinical classification (autism) and the sociocultural and institutional contexts of its application. Historically in Morocco, as in many other global contexts, the autism label has not been widely used, and the professional disciplines typically charged with diagnosing and treating it (i.e., child psychiatry and special education) are relatively new there. Children have long been described and treated as majnun (“possessed”), mo’aq (“disabled”), hmaq (“crazy”), f shkel (“weird”) – but not typically as tawahhudi (“autistic”). Beginning in the 1980s, and then intensifying after 2000, Moroccan parent-activists have been working together with foreign and local experts to change that. Drawing on an Anglo-American neurocognitive behavioral model of autism diagnosis and treatment – in direct opposition to a French psychoanalytic one – they have been training a new cadre of experts, raising autism awareness, lobbying government agencies, and constructing an infrastructure to identify and educate children as autistic. This dissertation follows the category autism as it circulates with increasing speed and intensity across Morocco by way of nongovernmental parent associations operating special classrooms for disabled children and adolescents. It tracks the ways the category – as well as its attendant practices and concepts – reshapes local moral worlds and everyday domestic life. Drawing on philosopher Ian Hacking’s work on “making up people” and “the looping effect of human kinds” (2007), it seeks to understand how and to what extent activists and experts are making autism into a viable category, and thus a viable way to be a person in Morocco. In other words, what makes the category “stick” – or not? How does it gain traction in local worlds? How does it become alive and meaningful to Moroccan families? And in turn, how does the label autism itself – its meanings, definitions, uses, enactments – change and respond to complex processes initiated by its introduction to quotidian contexts of Moroccan social life? Through 26 months of fieldwork in family homes, a child psychiatry clinic in a public hospital, a parent-run classroom for disabled adolescents, 17 autism associations across the country, as well as several sites of vernacular healing, this dissertation provides an important ethnographic complement to Hacking’s work and extends his theoretical insights by focusing on the everyday practice of autism therapies. The first half of the dissertation examines the consequences of autism activism for the category itself. It shows how the histories of local institutions for the disabled, lexicons of disorder, and colonial encounters all shaped the prototypical image of the autistic child in Morocco. Further, it shows how novels institutional forms and mundane therapeutics practices lend the category a certain sense and vitality for parents. Drawing on life histories, it also demonstrates how the diagnosis “stick” (or become a durable identity) – or not – for a variety of economic, pragmatic, and sometimes idiosyncratic reasons. The second half of the dissertation examines the consequences of autism activism for the people involved. It shows how new styles of parenting circulate along with the category and it identifies a particular style of prosaic activism through which parents work to reframe understandings of autism by becoming experts on their own children and building “prosthetic environments” for them (Holmes 1990). Further, it situates autism activism in relation to highly publicized neoliberal development projects, showing how a complex triangulation between the Moroccan monarchy, state, and civil society creates novel expectations, aspirations, and exclusions. Through a close analysis of one family’s experience of attempting to implement autism behavioral therapies in their home, it also demonstrates the tensions internal to autism activism and examines struggles over the ethics of autism therapies. By detailing the dynamic ways in which the category autism interacts with and responds to the social, political, and institutional contexts of its application, this dissertation offers a novel perspective on international health activism and the globalization of psychiatric categories.

The ability of individuals living with human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) to effectively manage their health is dependent on the successful acquisition and use of health information. This may be particularly challenging in limited resource settings where numerous barriers may prevent people from finding, understanding, and applying the information that could lead to better health management. In this dissertation, I aimed to explore the health information behavior of HIV positive adults attending Clínica de Familia in La Romana, Dominican Republic. Offering free treatment and services to over 1,600 HIV positive adults makes this one of the largest HIV treatment centers in the Dominican Republic. Initially, an integrative review of the literature was conducted to summarize research that has explored the patient-identified information needs of HIV positive adults in Latin America and the Caribbean and to identify predominant health information needs of these individuals. Then, a retrospective chart review of 201 randomly selected medical records, two focus group discussions, and an adapted version of Wilson’s 1996 model of information behavior were used to develop a 64-item survey to assess health information behavior. The survey was administered during 107 individual interviews with HIV positive adults being seen at the Clinic. Participants were mostly female (60%), Dominican (75%), and lived in La Romana (59%). Approximately half of participants (49%) were married or in a serious relationship and about a third (33%) of participants had all or some of high school education or higher. Responses to information behavior survey items indicated that patients might not understand all of the health information they do receive, cultural variations may influence understanding of viral transmission, and that participants had low levels of health literacy. Data obtained through the surveys were further analyzed to identify patient characteristics associated with active health information seeking, higher information processing and more information use. Significantly associated patient characteristics were: having ever cared for someone who was very sick, age, gender, length of time at the clinic, and comorbidities. Providers at the Clinic as well as those working in underserved areas globally may use these results to advance their knowledge of the ways in which HIV positive adults interact with health information. This enhanced understanding can inform communication and health education programs that provide the information patients need to manage their health in a more usable way. Future research should examine what methods can be used to more effectively provide health information to patients living in constrained resource settings with limited educational backgrounds.

Investment in addressing structural stigma and discrimination against refugees in resource-poor urban areas is both needed, and possible. The large population of refugees residing in resource-poor urban areas is likely to grow, and tensions in a number of settings are now documented. Without interventions to adequately address such tensions, both the protection needs of refugee populations and the stability of hosting countries could be affected. Through qualitative analysis of an urban refugee dataset in Uganda, this dissertation identified community-level drivers of structural stigma and discrimination as safeguarding one’s body and property, defending status, and perpetuating exploitation. The designs of potentially successful programs to address these drivers were then identified though systematic review, and included one or more of the following: 1) the utilization of multiple intervention components; 2) direct information provision (e.g., lecture, role-play, other active engagement) or direct contact with stigmatized groups; 3) cooperative work between community members and stigmatized groups to better livelihoods; 4) popular opinion leaders who have authority to make change, and 5) traditional ceremonies valued by the communities for cleansing and healing. One such design involving an agricultural livelihood program in a resource-poor urban area of the Northeast United States was costed, utilizing a primarily bottom-up approach and a societal perspective in the collection of both financial and economic costs. The unit cost per participating family was significantly lower than government services that provide comparable nutritional support, but did not include components of working with the community to reduce stigma and discrimination. Thus, the studied program provided more services for a lower cost. In addition, it empowered stigmatized refugees to advocate for and support themselves, and engendered goodwill in the community by involving community members to work alongside refugee participants, improving upon a neglected piece of land, and providing fresh produce. Further research is needed to better measure the social and financial dividends of programs to address structural stigma and discrimination, particularly against urban refugees. Such research can only come in tandem with further investment, the imperative and potential of which are compellingly clear.

This dissertation uses three types of routinely collected data from HIV care and treatment facilities in sub-Saharan Africa to investigate the association between the availability of adherence support and active outreach services on patient non-retention, loss to follow-up, and measured death after ART initiation. Following a literature review summarizing the state of knowledge concerning the influence of programmatic services on patient retention in care and survival, these relationships are first examined in an aggregate analysis of over 232,000 patients at 349 HIV care and treatment facilities initiating ART between January 2004 and December 2008. Key findings are that several adherence support and outreach services are associated with reduced rates of non-retention, loss to follow-up, and death. Specifically, facilities offering three or more adherence support services, written educational materials promoting ART adherence, one-on-one or group adherence counseling sessions, reminder tools, and food rations to promote ART adherence were associated with reduced non-retention and loss to follow-up, while facilities offering on-site support groups for HIV+ patients, peer educators, provision of reminder tools, and food rations to promote ART adherence were associated with reduced death rates. In sub-analyses investigating six- and 12-month retention after ART initiation, facilities offering three or more separate adherence support services, routine review of medication pickup and/or dedicated ART pharmacists, and active patient outreach to trace patients missing visits had lower non-retention. Taken together, this analysis provides evidence that program-level services found efficacious in experimental settings are also effective in operational settings. Next, a sub-analysis is conducted among facilities also providing electronic patient-level data to investigate similarities and differences in the association between adherence support and outreach services and patient non-retention, loss to follow-up, and measured death using aggregate vs. patient-level estimates of these outcomes, and to assess whether adjustment for patient-level differences between facilities change these measures of association. In multivariate analyses, clinics offering active patient outreach had lower rates of non-retention in both the ART cohort analysis and the patient-level analysis, and clinics offering food rations to promote ART adherence were associated with a lower risk of ascertained death in both the facility-level and patient-level analyses, but this association was diminished after adjustment for patient-level covariates. In contrast, various adherence counseling or support services were associated with lower non-retention in the ART cohort analyses but not in the patient-level data analyses. When compared with the results in the first paper, fewer associations were observed, suggesting either that the countries with patient-level databases are not representative of the entire range of HIV care and treatment facilities assessed in the first paper, and/or the specific facilities with electronic databases are more similar to each other than they are to facilities without electronic databases. Finally, the dissertation concludes with an investigation into the relationship between loss to follow-up and measured death. For this analysis, estimates of the death probability among patients lost to follow-up are created under varying assumptions (either assuming that the death probability among those lost to follow-up is equivalent to the death probability within various strata of covariates, or assuming that the probability of death is greater among patients lost to follow-up). Key findings from this analysis are that ratio comparisons of death rates between facilities offering different services are robust to changes in the death probability if patients lost to follow-up are assumed to have a similar probability of death, conditioned on covariates, as those not lost to follow-up, but that associations between facility services and death rates are masked under the scenario where the facility service is associated with loss to follow-up and the death probability is assumed to be higher, conditioned on covariates, then the death probability among patients not lost to follow-up.

It is expected that by 2030, nearly 21% of the population will consist of older adults, aged 65 years and older. Those who reach 65 have an average life expectancy of an additional 19 years. Adequate nutrition is essential to health and quality of life, especially for older adults. Congregate and home-delivered meal programs are an ideal setting in which to provide nutrition education for older adults that can lead to increases in successful aging. This cross-sectional study involved development and distribution of a novel survey for nutrition educators working with congregate and home-delivered meal programs. The purpose of this study was to describe the type and frequency of nutrition education provided by nutrition educators at congregate and home-delivered meal sites, whether lessons are behaviorally focused and theory-based, and which educator factors influence theory-based, behaviorally focused nutrition education score. The researcher also sought to examine if education sessions were being evaluated for effectiveness, if malnutrition was playing a role in nutrition education, whether state policies impact nutrition education, and if differences in nutrition education exist between dietetic and non-dietetic health professionals. Dietetic professionals (n = 122) are conducting more theory-based, behaviorally focused nutrition education (TB-BF-NE) than non-dietetic professionals (n = 139) (p < 0.001). A regression analysis showed that the educator factors predicting TB-BF-NE were number of topics taught, group size, length of session, and conducting evaluation (R2 = .518, p < 0.001). State policies on dietetic oversight did not appear to have an impact. Educators reported malnutrition was a major issue for older adults but did not feel they had the tools to screen for or address malnutrition. The most common topics for nutrition education were food safety, healthy eating, and diabetes; the most common delivery method was handouts. Because this is the first study of its kind, further exploration is indicated. Nutrition educators working with congregate and home-delivered meal participants need to be better trained on providing theory-based and behaviorally focused nutrition education, conducting evaluations, and finding materials and evidence-based lessons for older adults. Better training can also help educators implement more interactive lessons that will maintain the attention of the older adults they serve.

Young people who have received special education services in the United States are vastly overrepresented in juvenile and adult criminal justice systems relative to their numbers in the general population. Although much existing research frequently assumes that deficits within young people are the cause of this problem, research also suggests that educational experiences can increase the likelihood that young people will get arrested. However, the exact mechanisms by which time at school seems to lead to prison for so many young people who have received special educational services is unclear. This study uses a Disability Studies (DS) framework to understand this problem. Disability Studies scholars view disability as a social construction; students do not have a disability that justifies differential treatment, they become disabled through school practices that privilege particular norms for doing and being at school. In addition, DS scholars and activists have taken up the mantra, “Nothing about us without us,” insisting that the perspectives of individuals with disabilities be included in any research about disability. This mixed methods study sought to understand both which school-level factors predict arrest for young people receiving special education services and how young people present and explain those and other school-level factors. I conducted regression analysis using administrative data from the New York City Department of Education and New York State Education Department to determine which school-level factors predict arrest, on average, for young people receiving special educational services in New York City’s public secondary schools for one school year. Then, I conducted semi-structured interviews with six young people who have received special education services and been arrested in NYC. This study suggests that school-level factors do significantly increase the likelihood that a school will have students receiving special education services who have been arrested. These school-level factors are alterable by policy and practice. This study further suggests that young people receiving special education services describe and evaluate their educations in relation to imagined “regular” schools rather than according to how their schools actually help or hinder them.

The baby boomer generation began turning sixty-five in 2011. Twenty percent of the U.S. population will be over age sixty-five by 2030. Such a rapidly aging population has posed significant challenges to transportation planning and operating agencies since this large number of aging boomers demand dependable transportation access so they can remain independent and age in place. It is crucial to understand, in a timely manner, aging Americans’ travel mode choices, their preferences and perspectives on transportation supports, and communication channels through which they prefer to receive information on existing and new transportation options. My dissertation presents three essays to explore these important and urgent issues. Essay One uses the 2009 National Household Travel Survey (NHTS) data to investigate whether the predominant travel preference—favoring private automobiles—hold for different groups of aging Americans. The analyses not only include the commonly used travel mode choice factors, such as socio-demographics, built environment, and transportation attributes; but also include behavioral aspects such as attitudes towards safety, congestion, public transit, and walking environment. Results show no evidence that Americans are giving up driving as they age. Therefore, planning as though baby boomers will give up driving private automobiles as they age is not likely to be successful. Results also imply that although it may not be effective for existing seniors, promoting positive attitudes on certain travel options that were otherwise not preferred by middle-aged boomers (e.g., public transit) could be a useful way to encourage this group of boomers to change their future travel mode choices. Essay Two discusses the design and implementation of my own survey on senior transportation options. A comprehensive survey questionnaire is constructed to target various user groups of senior transportation services, including seniors, caregivers and their elderly dependents, and younger individuals. All these respondents represent current or future customers of senior transportation services. The survey is then successfully implemented via the Amazon Mechanical Turk (MTurk) crowdsourcing platform. Survey data collected from the MTurk platform represents a fairly diversified population; it can capture respondents from different socio-demographic categories, and it shares a similar distribution pattern with the general population data (e.g., U.S. Census) and the large-scale nationwide transportation survey using random sampling method (e.g., NHTS). Essay Three analyzes my MTurk survey data and investigates the impact of behavioral factors derived from the Theory of Planned Behavior (TPB) on travel mode choices among different user groups of senior transportation services. Survey respondents’ preferences on types of senior transportation supports, as well as respondents’ preferable channels from which they want to receive information about senior transportation options, are also examined. Results show attitude factors (e.g., convenience, preference, and independence) in general are perceived as more important drivers for seniors’ mode choices than other aspects of TPB (e.g., social norm, feasibility, and cost). This indicates more attention should be drawn to attitude factors, rather than the traditional concerns such as feasibility and cost, when designing and implementing interventions on senior transportation services. Compared to the extant literature, this dissertation research reveals a more comprehensive set of the factors that affect aging Americans’ travel mode choices. In particular, it highlights the important role of behavioral factors in seniors’ travel model choices. This dissertation research also demonstrates that Amazon MTurk can serve as a valuable crowdsourcing platform for planning related surveys, experiments, and data collections, especially when addressing timely issues such as aging Americans’ travel needs. It generates useful insights for researchers and practitioners to develop effective policy and service interventions to improve senior’s transportation access, and to address transportation challenges along with the rapid population aging process.

No description available.

Researchers have documented that supporting student needs, particularly their social-emotional learning, is critical to their success in the classroom. However, little research has been done to explore how district and school leaders make decisions about allocating resources (funding, personnel, curricula, and infrastructure) to student support services, especially during times of fiscal constraint. This study explores the ways that some of the largest high-needs districts in the United States decide to provide the needed resources to maintain social-emotional learning and other student supports in schools as well as the effects of these policy decisions on resources and schools. It examines district leaders’ rationale and the bounds that shaped these decisions using bounded rationality theory. It focuses on a seven-year period from the 2006–07 school year to the 2013–14 school year, the time period before, during, and after the 2008 Recession. This study employs both quantitative and qualitative methods. Through a series of fixed-effects analyses, the study explores funding trends and the impact of student support services (SSS) funding on student support service staff as well as academic and non-academic outcomes. These analyses were conducted in two phases. First, the study explores the impact of SSS funding on the outcomes across the seven-year study period for the 120 largest districts in the United States as a reference and, then, conducts the same analyses exploring the impact within 48 large, high-needs, districts. Following these analyses, the researcher conducted a series of interviews with district leaders in 5 high-needs districts to learn how they were supporting the needs of their students and what considerations shaped the decisions to allocate resources to these support areas. Like the fixed-effects analyses, the interviews focus on the seven-year study period, though context beyond these years is included. The findings indicate that changes in student support services funding are related to changes in student support services staff and high school completion outcomes. The experiences of high-needs district leaders provide additional insight into the decision-making process around student support services funding and the observed variation. District leaders expressed various levels of challenges stemming from changes in federal, state, and local budget reductions as well as challenges in specific years like those that followed the 2008 Recession. These reductions coupled with other limitations and considerations led to different decisions across and within these districts. The constructs of bounded rationality aided in better understanding these limitations, district decisions, and the consequences for students and schools.