As defined by the US Department of Health and Human Services, health disparities are "a particular type of health differences that are closely linked with social or economic disadvantages." These disadvantages include, but are not limited to, unequal access to quality health care and health information. Health disparities adversely affect groups of people based on racial or ethnic group, religion, socioeconomic status, gender, age, mental health, cognitive, sensory, or physical disability, sexual orientation, geographic location, or other characteristics historically linked to discrimination or exclusion. To address the root cause of health disparities there has been a call for more comprehensive frameworks for detecting, understanding, and designing interventions that will reduce or eliminate health disparities. One such framework is a Community-Based Participatory Research (CBPR) approach. CBPR is an orientation to research that focuses on relationships between academic and community partners, with principles of co-learning, mutual benefits, and long term commitment. CBPR also focuses on aspects of importance to the community with the aim of combining knowledge and action for social change to improve community health and eliminate health disparities. The overall goal of this dissertation is to build capacity and address health disparities among youth and adults in the Dan River Region. This region is federally designated as a medically under-served area/population and is located in the health disparate region of south central Virginia and north central North Carolina. This research draws on two CBPR projects, including an 8-week community garden program lead by the Dan River Partnership for a Healthy Community (DRPHC) and a 3-month childhood obesity treatment program, iChoose, led by the Partnering for Obesity Planning and Sustainability (POPS) Community Advisory Board (CAB). Since one of the primary aims for CBPR is to increase community capacity, this approach is the ideal process for engaging communities that suffer from health disparities. Thus, engaging community members as collaborators, our studies reported on the relevance and application of CBPR while simultaneously addressing health and capacity outcomes in the health disparate Dan River Region. / Ph. D.

Virginia Cooperative Extension's Family Nutrition Program (FNP), which includes EFNEP and SNAP-Ed, works to help limited-resource families across the state make informed food-choices. Virginia Cooperative Extension (VCE) lacks open-access physical activity resources representing individuals with varying weights, races, and ethnicities. In 2015, an integrated research-practice partnership was initiated for the development of an evidence-based physical activity resource for peer educators employed by FNP to use. The video suite, Move More, Virginia!, was created as open-access and includes demographically diverse individuals, representative of FNP clients. Study I determined client perceptions of physical activity and preferences for new resources. Study II identified FNP peer educators' perceptions of physical activity, their resource needs, and intent to use Move More, Virginia! resources. Both studies involved quantitative and qualitative data through surveys and focus groups. Formative data collected in Study I revealed the prominent themes related to clients (n=12) were physical activity facilitators (n= 100 meaning units (MU)) and physical activity barriers (n=77 MU). In Study II, peer educator responses(n=15) led to the emergence of four themes related to physical activity itself: barriers to incorporating physical activity within FNP (n=189 MU), physical activity facilitators (n=106), current delivery of physical activity (n=102 MU), and physical activity barriers (n= 16 MU). When prompted to share video specific feedback, the top theme was positive video feedback (n = 115 MU). Identified themes and subthemes provide deeper understanding of the organizational culture within FNP as thoughts, perceptions, and barriers to incorporating physical activity into FNP curriculum are highlighted. / Master of Science

Around 46.2 million Americans living in rural areas are disproportionately burdened by health disparities. Likewise, obesity and obesity-associated diseases (e.g., diabetes, cardiovascular disease) are much higher for rural residents when compared to their urban counterparts. There is a high need to understand and address the nutritional determinants of these health inequities among adults and adolescents. One area of concern in rural dietary habits pertains to added sugars and more specifically, sugar-sweetened beverages (SSB). Excessive added sugars and SSB intake have been strongly linked to many of the nutrition and chronic disease disparities impacting rural residents. Moreover, studies conducted in rural populations have found high consumptions of these in both adults and adolescents. There is an opportunity to better understand added sugars and SSB patterns in rural populations to inform the development of culturally relevant, multi-level interventions that address high consumption. Study #1 is a cross-sectional study that explores top food and beverage sources of added sugars in the diet of adults (n = 301) living in rural areas of Southwest Virginia. Study #2 uses a nationally representative sample of adolescents (n = 1,560) from the Family Life, Activity, Sun, Health and Eating (FLASHE) study sponsored by the National Cancer Institute, to explore factors across the levels of the socioecological model associated with adolescent SSB intake. Study #3 utilizes focus groups and a pilot trial to understand language preferences, acceptability and use of SMS aimed at caregivers to reduce SSB intake in both caregivers and adolescents living in rural areas of Southwest Virginia (n = 33). Collectively, these three studies offer recommendations and culturally relevant strategies for future large-scale trials aimed at reducing SSB intake among adolescents and caregivers in rural communities and ultimately reducing rural health disparities. / Doctor of Philosophy / Rural populations in the United States are at higher risk for being diagnosed with and dying from preventable and obesity-associated diseases like heart disease and cancer. Excessive added sugars and sugary drink (i.e. sodas, sweet tea/coffee, energy drinks, sweetened fruit drinks, sports drinks) intake have been strongly linked to many of the chronic diseases afflicting rural residents. Moreover, studies conducted in rural populations have found high consumptions of these, in both adults and adolescents. There is a great need to better understand added sugars and sugary drink patterns in rural populations so that we can develop programs to reduce consumption that are also culturally well received. Study #1 in this dissertation explores top food and beverage sources of added sugars in the diet of 301 adults living in rural areas of Southwest Virginia. Study #2 uses a nationally representative sample of 1,560 adolescents to explain why adolescent SSB intake might be higher. Study #3 aims to understand language preferences, acceptability and use of a text message program to reduce sugary drink intake in both caregivers and adolescents living in rural areas of Southwest Virginia. Collectively, these three studies offer recommendations and culturally relevant strategies for future large scale trials aimed at reducing sugary drink intake among adolescents and caregivers in rural communities and ultimately improving rural health.

The medical profession in recent decades has made culture and cross-cultural competence an issue for patient – physician relationships. Many in the profession attribute the necessity of cross-cultural competence to increased diversity, globalization, and health disparities; however, a historical analysis of medicine indicates that culture’s relevancy for health care and outcome is not new. The rise of clinics, which can be traced to 17th century France, the professionalization of physicians in 18th century U.S., and the civil rights movement of the 20th century illustrate that medicine, throughout its history, has grappled with culture and health. While medicine has a history of discussing cultural issues, the profession has not defined culture cogently. Medicine’s ambivalence in defining culture raises questions about how effectively medical educators prepare residents to be cross-culturally competent. Some medical educators have expressed that many didactic and experiential efforts result in stereotyping patients. Definitions of culture and their impact on stereotyping patients are the central problems of this study. Specifically, this study hypothesized that cultural beliefs impact ones willingness to accept stereotypes. Thus, this study sought to learn how faculty members and residents define culture. Faculty members also were compared to residents to glean the impact of cross-cultural education. This study used an explanatory mixed method design where quantitative and qualitative methods work complementarily to examine a complex construct like culture. A valid and reliable survey provided quantitative data to compare the two groups, while open-ended questions and interviews with faculty members provided context. The statistical results reveal that faculty members and residents share a philosophy of culture; however, when the two groups’ definitions are contextualized, they have many different beliefs. Differences also emerged with respect to predictability; cultural beliefs predict stereotyping among residents, but not faculty members. Faculty members attribute these differences to experiences, while residents believe that they do not learn about culture during their professional education.

Objectives We first sought to assess if bicyclist typology was associated with health. Second, we investigated whether bicyclist typology was related to health through physical activity and commute bicycling. Finally, we sought to develop profiles of disposition toward commute bicycling following proposed changes to a specific destination and the significance of pertinent covariates. Methods Data from the 2014 Georgia State University-Bicycling Survey were used. We first estimated the adjusted odds of worse health-related quality of life by bicyclist typology. A mediation model was then used to estimate the relative total and direct effects of bicyclist typology on health-related quality of life and relative indirect effects through physical activity and commute bicycling. A finite mixture modeling approach was used to identify latent classes of disposition toward whether proposed changes to a specific destination would increase likelihood of commute bicycling. The manual 3-Step protocol was used to assess the effect of covariates on the probability of latent class membership. Results Respondents who had never bicycled, were not motivated to commute bicycle, and who required greater bicycle facilities to feel comfortable commute bicycling had higher odds of worse health-related quality of life. Physical activity and, to a lesser extent, commute bicycling status mediated the effect of bicyclist typology on health-related quality of life. The seven-class solution was decided on as the “best” model for disposition toward whether proposed destination improvements would increase the likelihood of commute bicycling. Several covariates were identified that impact the probability of latent class assignment. Conclusions Initial evidence of a health disparity by bicyclist typology was revealed. Physical activity appears to serve as the primary means through which bicyclist typology has an effect on health. Urban environments that make physical activity, including commute bicycling, more comfortable for a larger proportion of the population may be a potential important health intervention. Understanding the patterns of disposition toward whether proposed destination improvements would increase the likelihood of commute bicycling may assist in targeting and prioritizing commute bicycling-related interventions toward subpopulations of interest.

Background: The sexually transmitted infections (STIs), chlamydia and gonorrhea, disproportionately affect racial and ethnic minorities. Community attributes like poverty and prevalence of STIs, along with residential segregation and its impact on composition of sexual networks contribute to these disparate rates. The Southeast had the highest rates of chlamydial and gonorrheal infection among the four regions of the United States. Because relationships between race and place can confound national statistics, it is important to examine whether racial disparities within the region are associated with higher rates of infection. Purpose: The study aims to evaluate local geospatial clustering of gonorrhea and chlamydia rates in the Southeast, and their persistence during 2000-2005 and any associations with residential segregation, income inequality, unemployment and uninsured rates, and race. Methods: Using the Local Indicators of Spatial Association tests of spatial clustering, cluster maps were created for each STI outcome and year. Independent sample t-tests were then used to examine the difference in means of each community level variable across counties composing the high-rate clusters and all other counties in the region. Results: Over 60% of counties composing high-rate clusters persisted as high rate clusters over time, and were significantly associated with higher levels of community disadvantage than all other counties (p < 0.01). Overall gonorrhea rates decreased from 2000 to 2005 and chlamydia rates increased, while their associations with community disadvantage remained persistently strong over time. Conclusions: Counties with higher rates of chlamydia and gonorrhea persist over time and experience persistently higher levels of residential segregation and income inequality, as well as higher unemployment and uninsured rates, and higher proportions of blacks in the population. The social environment and segregated sexual networks may play important roles in the persistently high rates of chlamydia and gonorrhea observed for certain regions within the Southeast. Continued surveillance of reportable STIs and their probable predictors is needed in order to better understand the persistent disparities in STI rates across counties in the Southeast.

The purpose of the present study was to examine how low-income, racial and ethnic minority, urban families experience and manage their child’s asthma. The rationale for this study stems from existing literature on asthma disparities and documented predictors of increased asthma morbidity and mortality. In particular, this study considered how specific types of stress may disproportionately impact low-income, racial and ethnic minority, urban families that have a child with asthma. This study aimed to determine associations between urban stressors (stressful life events, perceived discrimination, subjective socioeconomic status) and child asthma outcomes (emergency department visits, school days missed, asthma control), and considered depressive symptoms and asthma self-efficacy as mediators in these associations. Analyses were conducted in a sample of 97 urban caregivers and their children in Richmond, Virginia. Findings revealed that neighborhood stress was significantly associated with asthma control. Stressful life events were significantly associated with school days missed. Perceived discrimination and subjective SES were not significantly related to any child asthma outcomes. Bootstrapping procedures demonstrated that child depressive symptoms mediated the relation between neighborhood stress and asthma control. Child asthma self-efficacy did not significantly mediate associations between neighborhood stress and any child outcomes. Caregiver depressive symptoms and caregiver asthma self-efficacy did not significantly mediate any associations between caregiver-reported urban stressors and child asthma outcomes. Results from the present study suggest that urban stressors, especially neighborhood stress and stressful life events, are important to consider in the context of child asthma management and subsequent health outcomes. Exposure to urban stressors may further contribute to pediatric asthma disparities because they are disproportionately experienced by low-income, racial and ethnic minority, urban families. Each urban stressor that was related to a child outcome was associated with a particular asthma outcome. Specifically, child-reported neighborhood stress was related to asthma control. Caregiver-reported stressful life events were associated with school days missed. These findings suggest that exposure to specific types of stress may impact asthma management differently. Future research should, therefore, explore the impact and contribution of specific stressors in greater depth. Further, child depressive symptoms significantly mediated the relation between neighborhood stress and asthma control, although caregiver depressive symptoms did not significantly mediate any associations between urban stressors and child asthma outcomes. Additionally, both child and caregiver depressive symptoms were significantly associated with multiple urban stressors and child asthma outcomes. Depressive symptoms may, therefore, be important to target in future research as possible explanatory variables or variables that contribute to stress appraisals and child asthma outcomes.

Master of Science / Department of Journalism and Mass Communications / Nancy Muturi / Health disparities are prevalent among ethnic minorities, including immigrants in the United States. These disparities come in the form of low health insurance, low social economic status, ethnic discrimination, language and cultural barriers. As ethnic minorities, international students also suffer from numerous health problems that are associated with their lower social, economic and immigration status when they come to the United States. Health communication is an effective tool for increasing health literacy and for reducing health disparities. Applying the uses and gratification theory and the staged model of trust, the study was conducted among 120 American students and 135 international students to examine the extent to which access to health information, the type of information accessed, how they use it, and how they determine what trustworthy information is differed between the two groups. Key findings indicate that nutrition is the most common health topic accessed online by college students regardless of place of origin. Though both groups access online health information with the same motivation of information, they use online health information in different situations. Source credibility is the most important factor for college students in determining trustworthy health websites, and government websites and other health organization websites were found to be more trustworthy. The study also provides both theoretical and practical implications, which include consideration of ethnic backgrounds in disseminating health information through online channels and understanding the needs and motivation for people’s access to health information and how they use it to be able to meet those needs. In designing health communication campaigns that target college students, the study proposes that the differences between native-born and international students need to be taken into consideration.

Thesis advisor: Stephanie Berzin / A growing body of evidence shows that sexual minority youth disproportionately suffer from poor mental health and substance abuse outcomes in comparison to their heterosexual peers. Parental support has been found to be a strong protective factor for these youth. There is a lack of research, however, that examines the role of non-parental adult support, such as natural mentors (e.g., teachers, grandparents, and coaches). Guided by minority stress and resiliency theories, the current study aims to deepen our understanding of whether natural mentors act as a resilience resource for sexual minority youth. The current study uses the National Longitudinal Study of Adolescent to Adult Health (Add Health) restricted-use dataset. This is a large, nationally representative sample of both heterosexual (n=12,667) and sexual minority youth (n=1,413), ages 18 to 26. Variable-centered (i.e., multiple regression analysis with moderation) and person-centered (latent class analysis) statistical techniques were utilized to explore the effect of the presence and characteristics of natural mentoring relationships on a range of mental health and substance abuse outcomes. Results show that natural mentors have a similar relationship with health outcomes, regardless of sexual orientation. Perceived closeness is a critical characteristic of the mentoring relationship, exhibiting significant associations with depression, suicide ideation, self-esteem, life satisfaction, and binge drinking. Furthermore, those who have lifelong, close relationships with non-parental adult family members receive the most benefit. It is noteworthy that sexual minority youth are significantly less likely to have a permanent family mentor. Rather, they are more likely to have mentors from high school with whom they lack closeness as they transition into adulthood. Several suggestions for individual and school-based interventions to assist sexual minority youth in developing and maintaining long-term relationships with non-parental adult family members are discussed. The current study emphasizes the importance of supporting and advocating for greater policy change that will directly address minority stressors that sexual minority youth face. Findings from the current study make a significant contribution to the social work field by extending our knowledge regarding resiliency among sexual minority youth and offering concrete avenues for intervention. / Thesis (PhD) — Boston College, 2015. / Submitted to: Boston College. Graduate School of Social Work. / Discipline: Social Work.

The aim of this study was to explore the Health Service Utilization (HSU) of homeless people in Dublin. In particular, it sought to identify a critical realist explanatory model for why the HSU of homeless people differs from that of the general population. Critical realist (CR) ethnography was used as the research methodology and was supplemented with forty-seven semi-structured interviews and two focus groups. The HSU of homeless participants in Dublin is described. When compared to the domiciled population, homeless people were found to have a tendency to present late on in their illness, to have higher utilization of primary care services and lower utilization of secondary care services and to avoid psychiatric services. The factors that influenced participants HSU tendency are identified as external or internal influences on HSU. External factors are described as physical, administrative or attitudinal barriers or deterrents; or external promoters of health service usage. Internalised inhibitors and promoters are illustrated as either cognitions or emotions that are developed in reaction to external circumstances and which either negatively or positively impact on health service usage. Interactions between health professionals and participants that resulted in exclusion (by the health professional or self-exclusion) are described as Conversations of Exclusion. A critical realist model was outlined that offers an explanation for why homeless people’s HSU differs from that of the general population in Dublin. This model included a description of the generative mechanisms identified as producing the HSU tendencies in the study population. The implications of this new model are discussed in the light of the literature and previous models that seek to explain the HSU of homeless people.