This study analyses warehoused data collected by Georgia State University and Centers for Disease Control and Prevention (GSU/CDC) researchers after developing an HIV testing message for urban adults with low functional health literacy. It expands previous work by examining data collected when 202 primarily African-American homeless clients of an urban community based organization (CBO) reviewed both the low literacy brochure (Wallace et. al., 2006) and a standard HIV brochure (Georgia Department of Human Resources, 1997). Participants’ health literacy was assessed using 2 measures; the Rapid Estimate of Adult Literacy in Medicine or REALM (Davis, Crouch, Long & Green) and the Test of Functional Health Literacy Assessment or TOFHLA (Nurss, Parker & Baker, 2001). HIV risk was determined using an interview questionnaire developed by the research group (Belcher, Deming, Hunter & Wallace, 2005) which allowed participants to self-report recent alcohol and drug use, sexual behavior, sexually transmitted disease (STD) history and exposure to abuse and sexual coercion. Open-ended response questions regarding readability, understanding, main message, and importance for each brochure provided the qualitative data.This analysis confirms previous work showing accessibility, readability, cultural sensitivity and user-friendly formatting are important when attempting to engage at-risk adults with varying levels of functional health literacy in an HIV testing message. The visual aspects of the brochure can be essential in capturing the reader’s attention and should be relevant to the target audience (Wallace, Deming, Hunter, Belcher & Choi, 2006). Mono-colored graphics may be perceived as dated and irrelevant or worse yet, threatening to some readers. Whenever possible culturally appropriate color photos of people depicting relevant content should replace excess text and difficult medical terms should be eliminated. Wording on the cover and within the brochure should be used to focus the reader on a single main message.This data also shows that many participants considered the quantity of information just as important. For reasons not elucidated here, many respondents equated quantity of information with message quality. Based on these results it is important to further clarify how much information is enough to maintain legitimacy and the reader’s attention while simultaneously avoiding confusing mixed messages.

Help-seeking has been studied for over 20 years, but much is yet to be known about what variables influence parental help-seeking. In the present studies, participants were recruited from Texas, Mississippi, and Louisiana. Study 1, included 260 caregivers recruited from local school districts and a church. Using confirmatory factor analysis, results supported the hypothesized 3-factor structure of the Parental Attitudes Toward Psychological Services Inventory (PATPSI) and internal consistency ranged from moderate to high. Study 2 conducted subsequent analyses on the data from Study 1. Correlation analyses supported the relationships among parental attitudes, stigma, and help-seeking. Secondly, parents with previous use of child mental health services reported more positive attitudes and less stigma than parents with no previous use. Thirdly, no significant gender differences were found, but there was a trend toward parents reporting higher intentions for boys than girls. Additionally, African Americans reported less positive attitudes and more stigma than the other ethnic groups. Finally, moderation analyses suggested that attitudes are more likely to influence help-seeking for European Americans but not for African Americans, and stigma appeared to influence helpseeking for Hispanic Americans but not for European Americans; no moderation effects were found for child gender. Finally, analyses indicated that only stigma and attitudes were significant independent predictors of help-seeking. Study 3 was a sub-sample from Study 1 (N = 118) who completed additional measures. The purpose was to replicate findings from Study 2 and examine test-retest reliability of the PATPSI. Test-retest reliability for the PATPSI was low in this sample. Overall, results were consistent with Study 2. Results indicated that parents with previous service use reported higher externalizing symptoms (not internalizing) than those with no previous use. Inconsistent with Study 2, Asian Americans reported less positive attitudes, and African Americans reported less stigma than European Americans and Asian Americans. Additionally, stigma tolerance was found to have a stronger influence on European Americans likelihood of future service use than for African Americans. Furthermore, the interaction between problem type and gender was not a significant predictor of likelihood of future use. Finally, only previous service use and attitudes (not stigma) were independent predictors of likelihood of future use. Implications for future research and practice are discussed.

This dissertation study was designed to examine measurement equivalence of the Center for Epidemiological Studies Depression (CES-D) Scale across White, African American, and Mexican American elders. Specific aims were to identify race/ethnicity-, sociodemographic-, and acculturation and instrument language-related measurement bias in the CES-D. Three studies were conducted in this dissertation to accomplish these aims. Two existing national datasets were used: the New Haven Established Populations for Epidemiologic Studies of the Elderly (EPESE) for the White and African American samples and the Hispanic Established Populations for Epidemiologic Studies of the Elderly (H-EPESE) for the Mexican-American sample. Differential item functioning (DIF) analyses were conducted using both confirmatory factor analysis (CFA) and item response theory (IRT) methods. Study 1 focused on the role of race/ethnicity on the measurement bias in the CES-D. Results from Study 1 showed a lack of measurement equivalence of the CES-D among Mexican Americans in the comparison with both Whites and Blacks. Race/ethnicity-specific items were also identified in Study 1: two interpersonal relation items in Blacks and four positive affect items in Mexican Americans. Study 2 focused on identifying sociodemographic-related measurement bias in responses to the CES-D among diverse racial/ethnic groups. Results from Study 2 showed that gender and educational attainment affected item bias in the CES-D. The interaction between gender and educational level and race/ethnicity was also found in Study 2: Mexican American women and lower educated Blacks had a greater predisposition to endorse the 'crying' item. Focusing on Mexican American elders, Study 3 examined how level of acculturation and language influence responses to the CES-D. In Study 3, acculturation and instrument language-biased items were identified in Mexican American elders. Study 3 also suggested that acculturation-bias was entirely explained by whether the CES-D was administered in the English or the Spanish versions. Possible reasons for item bias on the CES-D are discussed in the context of sociocultural differences in each substudy. Findings from this dissertation provide a broader understanding of sociocultural group differences in depressive symptom measures among racially/ethnically diverse older adults and yield research and practice implications for the use of standard screening tools for depression.

Colorectal cancer (CRC) is the third most common cancer in the United States (U.S.) and is the second leading cause of cancer deaths. Although the incidence of CRC has been decreasing with CRC screenings, disparities of CRC and screening prevalence exist for racial and ethnic groups. The CRC incidence rates have dramatically increased in Korean Americans, however, there is little known about their CRC screening behaviors and the factors that may predict screening behaviors have not been fully investigated. The purposes of this study were to describe CRC screening behaviors and identify the predictors and barriers influencing CRC screening behaviors among Korean Americans. A sample of 254 Korean Americans participated in this study. Correlation, Multiple logistic regression, and Chi-square were used to analyze data. In this study, Korean American had lower rates of CRC screenings compared to the general U.S. population. Only 20% of the sample had ever had a fecal occult blood Test (FOBT), 49% had ever had a colonoscopy, and 19% responded they had ever had a sigmoidoscopy in their lifetime. Korean Americans had low rates of perception of cancer screening (annual physical exam and periodic cancer screening), moderate CRC knowledge, low cancer fatalism, limited CRC literacy, lack of health care access, and a low rate of receiving the physician's recommendation of CRC screenings. The greatest predictors influencing CRC screening were perception of cancer screening for a FOBT, and the physician's recommendation for a colonoscopy and a sigmoidoscopy. There were no significant differences by gender in CRC screening behaviors. However, significant differences were found between the two groups divided by length of U.S. residence. Compared to those who have lived in the U.S.>10 years, new immigrants had lower rates of all three CRC screening, lower perception of cancer screening, higher uninsured, less receiving physician's recommendation, and higher perceived barriers to CRC screening. The findings of this study suggest that improved efforts are needed to increase CRC screenings among Korean Americans. Further research is needed to increase a physician's recommendation for CRC screenings and awareness for the importance of annual checkups and periodic cancer screening among Korean Americans.

Introduction: Domestic research studies focused on the interrelationships between political ideology characteristics inherent in policy decisions and the contributions these political determinants exert over health indicators and outcomes are limited. Given the paucity of research that focuses on political and policy support of health at the county-level, this study sets out to utilize the University of Wisconsin Population Health Institute’s (UWPHI) annual County Health Rankings data and examine them within the context of county-based majority political partisanship and economic measures. Methods: This exploratory ecological study examined differences between independent variables: partisan voting behavior (trichotomized as conservative, moderate, and liberal) and median per capita household income in U.S. dollars (by quartile) on dependent variables related to mortality (years of productive life lost) and morbidity (number of poor mental and physical health days) at the county-level to compare differences in political and ideological underpinnings that may act as influencers on health outcomes. Multiple data sources were combined and matched to all 3,140 counties located in the U.S. Two-way between-subjects ANOVA statistical tests were conducted to determine if there is an effect of partisan voter index category on the three aforementioned dependent variables related to health outcomes, and median per capita income by quartile. Results: There was a statistically significant main interaction between median per capita household income by quartile and partisan voter index category on years of productive life lost, F(6,2789) = 19.3, p < .000, partial η2 = .040. While there were also statistically significant interactions between the independent and dependent variables of poor mental and physical health days, results of those analyses should be interpreted with caution. Pertaining to years of productive life lost, post hoc analyses of significant interactions revealed significant differences at the lower income quartile, but not in the expected direction. The conservative category had statistically significant lower years of productive life lost in comparison to the liberal category (M = -8.21, SE = 1.47, p = .000). Also, there were significant differences detected in the upper quartile suggesting that the liberal category has lower years of productive life lost in comparison to the conservative category (M = 7.06, SE = 1.06, p = .000). Conclusion: Results should be interpreted with caution and suggest more research and methodological refinements are needed, particularly related to categorizing county-level political dynamics.

The purpose of this capstone is to develop a program to address health literacy among African American adults. The social cognitive theory and the health belief model was used to create a model of an age appropriate, culturally sensitive program with a pre and post test to improve the health literacy in this population. The Community Health Literacy Improvement Program (CHIP) is a pilot program that will consist of a four week didactic intervention focused on combating prose, document, and quantitative health illiteracy. This program will be implemented through a community based nonprofit organization. Participants who complete the CHIP program will be able to identify risk factors for chronic diseases, assess their ability to avoid chronic diseases, and be able to locate community health resources. This proposed intervention will show that community based nonprofit organizations have an important role to play in building community buy in and establishing the agency necessary for community based, culturally sensitive programs such as CHIP to succeed.

<p>In 2010, approximately 84% of the American population lives in a metropolitan area. Different metropolitan areas are characterized by distinct labor markets and economies, housing markets and residential patterns, socioeconomic and demographic factors, and according to some, even distinct 'spirits.' The nature and influence of such structural factors lie at the heart of urban sociology, and have particularly profound effects on patterns of racial and ethnic stratification. This dissertation examines new urban structural changes arising within recent decades, and their implications for racial/ethnic stratification. Specifically, I study the transition to the 'new economy' and racial/ethnic wage inequality; increases in the level and inequality of housing prices and racial/ethnic stratification in homeownership; and increased income inequality, combined with population aging, and racial/ethnic disparities in disability and poor health. I measure metropolitan-level structural factors and racial/ethnic inequalities with data from 5% samples of the 1980, 1990, and 2000 Censuses; the 2010 American Community Survey (ACS); and the 1999-2001 and 2009-2011 Current Population Surveys (CPS). Cross-sectional multilevel regression models examine the spatial distributions of structural factors and racial/ethnic inequality, and the fixed-effects regression models identify the impact of changes in structural factors over time on observed trends in racial stratification. Additionally, I distinguish between effects on minority-white gaps in resource access, and minorities' levels of resource access. This dissertation also makes novel contributions to the field by empirically documenting complex patterns of inequalities among the country's four largest racial and ethnic groups. Perhaps most relevant to theories of racial stratification, this dissertation demonstrates seemingly race-neutral structural changes can have racially stratified effects. </p><p>Chapter 1 describes the foundational literature in urban sociology and racial/ethnic stratification, and provides an overview of the subsequent chapters. Chapter 2 measures the transition to the `new economy' with six structural factors of labor markets: skill-biased technological change, financialization, the rise of the creative class, employment casualization, immigration, and deunionization. Overall, the results indicate the observed Latino-white wage gap may be up to 40% larger in 2010 than in the theoretical absence of the new economy, and the black-white wage gap may be up to 31% larger. Chapter 3 focuses on the long-term trend toward higher and more unequally distributed home prices within local housing markets, epitomized by the housing crisis of the late 2000s. Increases in housing market inequality worsen the Asian-white homeownership gap, but narrow the black-white and Latino-white gaps. However, the level of homeownership is reduced for all groups. Chapter 4 empirically tests the frequently-debated Income Inequality Hypothesis, that macro-level income inequality undermines population health, and hypothesizes any negative effect on health is stronger in areas with greater population aging. The results provide no support for the Income Inequality Hypothesis or any of its proposed extensions, but the chapter's analytic approach may be fruitfully applied to future examinations of structural determinants of health. The theoretical and substantive conclusion of the dissertation is that metropolitan areas represent salient, and changing structural contexts that significantly shape patterns racial/ethnic stratification in America.</p> / Dissertation

Individuals diagnosed with schizophrenia commonly experience problems with accurately assessing their health status due to cognitive deficits including impaired working memory, amotivation, and communication difficulties. Little is known about whether these deficiencies influence health behavior decision-making among individuals with schizophrenia. Individuals with schizophrenia die an average of 25 years earlier than those without a mental illness. Approximately 60% of premature deaths in this population are from medical comorbidities; mortality rates due to cardiovascular and pulmonary diseases are two to three times higher than the general population. In order to reduce morbidity and mortality, it is important to find effective ways to assist these individuals in modification of risky behaviors (e.g., smoking, poor dietary habits, and sedentary lifestyles) and to incorporate daily health promoting behaviors (e.g., balanced diet and regular exercise). This qualitative descriptive study was conducted to describe the decision-making processes used by adults with schizophrenia when making health behavior decisions, identify what it means to be healthy from the perspectives of adults with schizophrenia, and identify the perceived barriers and facilitators that affect health behavior decisions. Ten adults diagnosed with schizophrenia were interviewed for this study. Fifty-percent of participants were female, ages 28 to 59 years, and received treatment in a community mental health centers. Data were analyzed using content analysis. Methods included the use of field notes, open and axial coding, and development of a visual model. Trustworthiness of the findings was established through the qualifications and experience of the investigator, peer scrutiny, and member checks. Three phases of health behavior decision making were identified: Recognizing Complex Components of Health, Personalizing Components of Health, and Tracking Health Status. The main category that described health behavior decision making was “Tracking Health Behaviors,” which resulted in the ability to maintain physical and mental health. Within each phase, specific actions associated with achieving and maintaining physical and mental health were identified and were displayed in a visual model. These findings provide a guide to clinicians in identifying health behavior decision making processes and may lead to the design of clinical interventions that improve the health status of adults with schizophrenia.

The purpose of this study was to determine the role of acculturation in the food consumption patterns of low income Hispanic women living in Texas and enrolled in the Women, Infants, and Children (WIC) Program by testing the following hypotheses: a) There are significant differences in consumption of fruit and vegetables by selected socio-demographic variables; and, b) less healthy food consumption patterns are associated with higher levels of acculturation in health-related research involving low-income Hispanic women living in Texas. A secondary-data analysis of the responses to the Texas Food & Nutrition (TEXFAN) questionnaire was performed. TEXFAN is a 122-item survey designed to measure WIC participants' consumption behaviors and to assess the impact of new food packages in Texas' WIC program. A total of 3,336 adult, non-pregnant women self-identified as having Hispanic ethnic background of all races were considered for this study. Analysis of Variance and Kruskal-Wallis tests showed significant differences in nutritional practices among Hispanic women for age, educational attainment, employment status, race, area of residence, and acculturation. Logistic Regression analysis confirmed the hypothesis that lower levels of acculturation are associated with healthier food consumption patterns. The majority of respondents (70.7%, N=2,358) did not consume the recommended five servings of fruits and vegetables a day; therefore, do not have healthy patterns of food consumption. Consequently, the majority of respondents (70.0%, N= 1,709) has a weight statuses above normal and at a higher proportion than women in the State of Texas and the nation. Acculturation continues to interest social and behavioral researchers but variations on conceptualization, definition, operationalization, and measurement negatively impact generalizability and applicability of results. Interventions not considering acculturation are not likely to be successful. Research has to include community, ecological, cultural and contextual factors (e.g., machismo, accessibility to sidewalks, availability of fresh healthy foods, etc.). Development of effective intervention programs should be aimed to increase consumption of healthy food and an adherence to the recommendations of the "Healthy Plate" and the "Dietary Guidelines for Americans 2010" among Hispanics. Also, interventions should generate necessary skills among Hispanics for empowering them to sustain proper nutritional behaviors and overcome barriers.

In 2013 Burma, the country of origin for many refugees of whom have resettled in the U.S. was in the top three countries for notification of suspected Latent Tuberculosis Infection (LTBI). Approximately 5%-10% of individuals diagnosed with LTBI are at risk of developing active tuberculosis (TB) disease; the highest risk occurs within two years following the diagnosis. Burmese refugees face a high potential of developing LTBI during resettlement in the U.S. and are at high risk for subsequent TB. Currently, we have limited knowledge of the Burmese Chin refugees' explanatory model (EM) of LTBI. Understanding the EM of these refugees is important because one's EM facilitates the recognition and response to illness, including early diagnosis and treatment. In the context of LTBI, this relates to the potential prevention of active TB disease. The purpose of this ethnographic study was to discover the Burmese Chin refugees' EM of LTBI and to describe the barriers experienced in receiving LTBI treatment. Kleinman's EM provided a conceptual framework to guide this study. A Burmese refugee gatekeeper assisted with community immersion and participant recruitment. Purposive and snowball sampling were used to recruit participants. Data were collected through participant observation and semi-structured interviews. Three data analysis strategies for ethnography that were used included domain, taxonomic, and componential analyses. Domain analysis began after open, inductive coding of the data. Data saturation was reached and the research questions were answered with eight participants. Data from 15 key informant interviews were abstracted into three domains: EM of LTBI, Fear and Stigmatization, and Barriers to Receiving LTBI Treatment. The over-arching theme, LTBI: My Shadowbox was derived from these three domains, 11 categories, and 25 subcategories through iterative and inductive data analysis. The analysis revealed the participants' language, behavior patterns, beliefs, values and health seeking experiences of LTBI in the U.S. The findings from this study will help to inform culturally tailored interventions to reduce LTBI and TB health disparities among Burmese Chin refugees and potentially other Burmese refugee subgroups in the U.S. Knowledge of the Burmese Chin refugees' EM of LTBI can inform health policy for reducing LTBI treatment barriers.