Thesis (M.S.)--University of North Carolina at Wilmington, 2005. / Includes bibliographical references (leaves: [25]-33)

Source: Dissertation Abstracts International, Volume: 70-07, Section: B, page: 4061. Advisers: Sally W. Vernon; Xianglin L. Du. Includes bibliographical references.

Thesis (Dr. P.H.)--University of Texas Health Science Center at Houston, School of Public Health, 2008. / Source: Dissertation Abstracts International, Volume: 69-02, Section: B, page: 0969. Adviser: Charles E. Begley. Includes bibliographical references.

This study was motivated by the commitment of the researcher to contribute towards the agenda for the development of women, in particular women affected and infected with HIV/Aids, through a better understanding and improved knowledge of the national and international legal and policy framework aimed at empowering women in South Africa. This study builds on countless efforts which have been implemented internationally to transform the world and create a peaceful and liveable world for women who have been historically oppressed, unrecognised and, in the case of women affected and infected with HIV, stigmatised. An increasing trend towards recognising the need to advance women and acknowledge their status in the community on the part of the international community was observed and then explored in the literature review which was conducted for the purposes of the study. The development of women is dependent on an enabling environment which is free from all forms of discrimination. Poverty, gender-based violence, cultural perceptions, as well as traditional and religious practices, all contribute to the challenges facing women. In addition, HIV/Aids is a continuous threat and impacts greatly on the lives of both women and their families. The aim of the study was to explore the contribution that the Commission of Gender Equality (CGE) makes towards a better quality of life for women and also to contribute to the development of a strategy to optimise the integration of HIV/Aids issues into the mandate of the CGE. The requisite data was collected through an extensive literature study of the research field, a document analysis and personal interviews with Commissioners of the CGE. The data were complemented and supported by the inputs of focus groups in which community members provided inputs about their experiences of the role played by the CGE at a community level. ii Data revealed limitations in the effective functioning and the measurable impact of the CGE. These were subsequently addressed in the design of a suggested strategic plan. The limitations included aspects relating to CGE organisational structure; the knowledge and skills of personnel, the lack of role clarification; the lack of a coordinated strategy; as well as a deficient working plan which, in its current format, shows a lack of continuity as a result of high staff turnover, a weak continuity strategy when commissioners’ term of office ends, limitations in terms of financial resources, and the absence of monitoring and control systems. / Health Studies / D. Litt. et Phil. (Health Studies)

This dissertation explored mistrust through focus group discussions (study 1), responses to standardized laboratory vignettes (study 2), and survey questionnaires (study 3). In the first study, I found that African American community members (N=60) experienced perceived discrimination, medical mistrust, and poor communication in numerous and interrelated ways. For example, medical mistrust occurred when clinicians did not convey respect to patients, leaving patients to wonder whether their clinician's treatment was discriminatory or not. Based on these findings, I wanted to see whether these experiences of perceived discrimination and mistrust were related to other dimensions of Black experience, such as racial identity. I conducted a secondary analysis of data from a laboratory study (Somnath Saha, PI) in which 104 primary care patients viewed video-recorded, standardized vignettes depicting a cardiologist recommending heart bypass surgery to a patient diagnosed with angina and 3-vessel coronary artery disease. In this study, those who viewed a video of European American cardiologist-actors had lower physician mistrust and lower hypothetical likelihood of having bypass surgery compared to those who viewed the video of African American cardiologist-actors. However, racial centrality did not moderate the relationship between ethnicity of the cardiologist-actor and patients' decision making. The third study explored other dimensions of racial identity (e.g., unfavorable public regard for African Americans) and mistrust (e.g., medical mistrust), while also exploring their association with perceived healthcare discrimination among African American community members (N=210). In this study, perceived discrimination was positively associated with racial centrality, but not associated with unfavorable public regard. Perceived discrimination was also positively associated with medical mistrust and physician mistrust. Although racial centrality and unfavorable public regard were not significant moderators between perceived discrimination and the two dimensions of mistrust, they were positively associated with medical mistrust. Together, these studies provide a better understanding of African Americans' healthcare attitudes and experiences, particularly mistrust toward medical institutions and clinicians. For example, the association between racial centrality and perceived discrimination may suggest that past experience of discrimination in healthcare may influence a person to seek others who experience similar stressors, giving way to identifying more with her or his racial group. Racial centrality may influence a person's trust towards healthcare, prior to entering the doctor's office. However, once the person enters the doctor's office, racial centrality may play a less significant role the patient's trust towards her or his provider. These findings generated new questions to explore for future studies. For example, future studies should explore the relationship between racial centrality and African Americans' healthcare behavioral responses. In addition, the current studies only focused only on attitudes and perspectives; future studies should investigate how the construct medical mistrust may influence health-related outcomes such as adherence in race-discordant patient-provider relationships.

<p>This study aimed to contribute to the current debate around equity in health care resource allocation by measuring the current allocation of resources, relative to need in the Northern Cape. It also discussed the level of inequities in health financing/expenditure and staffing at the primary health care level between different districts of the Northern Cape.</p>

Health disparities among rural African Americans include disproportionately higher morbidity and mortality rates associated with cardiovascular disease. Interventions designed to decrease cardiovascular risk can potentially improve health outcomes among rural, underserved communities. The purpose of this study was to test the effect of a cardiovascular health promotion intervention among rural African Americans. An experimental study randomized by church clusters was done in two rural counties in northern Florida. A total of 229 participants, 114 in the intervention group and 115 in the control group, were recruited from twelve rural African American churches. The pretest-posttest design included instruments chosen to measure cardiovascular health habits and knowledge as well as changes in produce consumption, dietary fat intake, and exercise using the major components of the Integrated Model of Behavioral Prediction: intentions, norms, attitudes, and self-efficacy. Linear mixed model was the statistical test used to detect the program effects. Participants who received the intervention had significant increases in scores for the cardiovascular health habits (p < .01) and health knowledge (p < .01) variables compared with the control group. There were also significant group differences regarding intentions to increase produce consumption (p < .01) and reduce dietary fat intake (p < .01). The cardiovascular health program was associated with other statistically significant results including produce consumption attitudes (p = .01) and norms (p < .01), dietary fat attitudes (p = .04) and norms (p < .01), and exercise attitudes (p < .01). There were also significant results found for perceived behavioral control/self-efficacy regarding increasing produce consumption (p < .01), reducing dietary fat intake (p = .03), and increasing exercise (p = .01). Compared to the control group, the cardiovascular health promotion intervention was effective in fostering positive health effects for most of the variables measured. The findings supported the theoretical framework used for guiding the study, the Integrative Model of Behavioral Prediction Nurse-led health promotion interventions within church settings can be effective means for reducing overall cardiovascular risk and health disparities among rural African American populations. / Includes bibliography. / Dissertation (Ph.D.)--Florida Atlantic University, 2015. / FAU Electronic Theses and Dissertations Collection

This thesis presents a challenge to policy initiatives that presume that patient-centered care will reduce racial disparities in health. Data from the Medical Expenditure Panel Survey were used to test patient assessment of provider behavior defined as patient-centered care according to the National Health Disparities Report of the Agency for Healthcare Research and Quality of the Department of Health and Human Services. Results indicated patient-centered care improves self-rated health status, but blacks still report worse health status than whites experiencing comparable patient-centered care. Further, black-white differences in patient-centered care had no affect on health status. Rival theories of black-white differences in health, including social class and health literacy, provided better explanations of disparities than assessment of provider behaviors. These findings suggest that policies designed to financially incentivize patient-centered care practices by providers should be considered with caution. While patient-centered care is better quality care, financial incentives could have a negative effect on minority health if providers are deterred from practices that serve disproportionate numbers of poor and less literate patients and their families. Measurement of the concept of patient-centered care in future health disparities research was also discussed.

<p>This study aimed to contribute to the current debate around equity in health care resource allocation by measuring the current allocation of resources, relative to need in the Northern Cape. It also discussed the level of inequities in health financing/expenditure and staffing at the primary health care level between different districts of the Northern Cape.</p>

Chapter 1 presents the backgrounds and research questions of the dissertation project. Although everyone hopes to die with dignity, a “good death” is often privileged. Inequality in end-of-life care in the United States is striking; older minorities are 3 times more likely to receive intrusive care and experience hospital readmission and less likely to use hospice care and die at home. With the hope to address disparities in end-of-life outcomes, as part of the Affordable Care Act, Medicare expanded its benefit and started to reimburse end-of-life care planning services from 2016. This dissertation examines the roles of health insurance policy and its advocated intervention in ensuring person-centered dying experiences in the United States and the public readiness for establishing a similar end-of-life care policy in China. The second chapter examines whether physician–patient advance care planning (ACP) discussions, the “intervention” embedded in the policy, is effective at prompting end-of-life care planning behaviors and improving end-of-life experiences. I also studied the heterogenous effects by race and ethnicity. I used exit data about 7,282 deceased Medicare-eligible respondents from the Health and Retirement Study (HRS) from 2012 to 2020, a nationally representative biennial survey of U.S. older adults. I conducted latent class analysis to identify different end-of-life experiences and used multinomial logistic regression models to study the relationship between having ACP discussions with doctors and different end-of-life experiences in full and stratified samples by race and ethnicity. Then I used path analyses to test whether completing legal documentation initiated by ACP services explains the effectiveness of the intervention. The results show three types of end-of-life experiences among White, Black, and Hispanic older adults; significant effects of end-of-life care discussions with doctors on uncomfortable dying experiences and extensive use of invasive treatments in the older White population; and the partial mediating role of completion of legal health care documents on the relationship between ACP discussions and end-of-life outcomes. This study identified the limited effectiveness of physician–patient ACP discussions among minority older adults and emphasizes the importance of quality, content (e.g., to cover legal documentation during the conversation), and cultural appropriateness of ACP consultations led by doctors. The third chapter examines the heterogenous intent-to-treat effect of the Medicare policy on older adults’ motivation to plan for care by exploiting policy intervention as a natural experiment. Taking advantage of the longitudinal nature of the HRS, I used core data with 47,982 observations nested in 15,647 individuals across 9 years (2012–2020). I used two quasi-experimental models—interrupted time series analysis and difference-in-difference—to study the care-planning outcomes before and after the policy implementation between older adults eligible or not eligible for Medicare. I studied the heterogenous effects in stratified samples by race and ethnicity, immigration background, and socioeconomic status proxied by education and wealth. I used coarsened exact matching to address the potential bias of the comparison group not being the ideal counterfactual control unit. I found that in the total population, the Medicare policy was associated with a significant increase in the proportion of older adults who completed a living will and designated a durable power of attorney for health care, but not having an ACP conversation. Furthermore, although there were immediate positive policy effects, the increases in ACP outcomes driven by the ACA Medicare benefit expansion were not sustained. Finally, I found no evidence that the ACA Medicare benefit expansion was effective in improving the rates of ACP among Black, Hispanic, Asian, Native American, or non-U.S.-born older adults. I also identified heterogeneous policy effects by socioeconomic status. I discuss promising recommendations for health care policy and practice to improve the participation rate of end-of-life care planning. Chapter 4 explores the feasibility of encouraging physicians to discuss end-of-life care wishes with older patients in China. Knowledge of a medical diagnosis is critical for end-of-life decision making. However, a patient’s right to know their diagnosis is neither guaranteed nor protected by law in China. Doctors typically inform family members of the patient’s illness diagnosis and prognosis and let them decide whether to disclose this information to the patient. This study examined middle-aged and older Chinese adults’ preferences for disclosing their and significant others’ diagnoses and whether sociodemographic, economic, and cultural factors were associated with these preferences. The research team surveyed 571 adults aged 50 or older in Shanghai from 2021 to 2022. The outcome measures are preferences for diagnosis disclosures, including whether and to whom diagnoses should be disclosed. I characterized preference types using latent class analysis and estimated multinomial logistic regression to identify the covariates associated with each preference type. Three latent classes were identified. The transparent group (34%) believed patients, whether self or a significant other, should be informed of their diagnoses. The contradictory group (50%) held conflicting attitudes; they preferred to know their diagnosis but preferred that significant others not be informed of their diagnoses. The avoidant group (16%) preferred not to know their diagnosis or to disclose significant others’ diagnoses to them. Familism attitudes were positively associated with holding contradictory views. Experiences with hospitalization and medical decision-making for family members were associated with holding transparent views. I discuss the importance of illness disclosure for honoring patients’ autonomous decision-making.