Thesis (Ph. D.)--University of Oregon, 1988. / Vita. Includes bibliographical references (leaves 131-137).

Source: Dissertation Abstracts International, Volume: 70-07, Section: B, page: 4118. Adviser: Charles L. Begley. Includes bibliographical references.

Thesis (Ph. D.)--Ohio State University, 2001. / Vita. Includes bibliographical references (leaves 298-309).

Thesis (Ph. D.)--Columbia University, 2006. / Includes bibliographical references (leaves 420-447).

Racial health disparities and social injustices in health care continue in the United States (US) despite decades of research, policies, and programs dedicated to their elimination (Feagin & Bennefield, 2014). Cultural competency education of health care providers has been one way purported to help sensitize professionals to these inequities, thus seeking to address racial bias, unequal treatment, and misunderstandings of minority populations (Office of Minority Health, 2001). Such education can begin when students enter academia to commence their health care education, and certainly occurs as a student moves on through their academic career, particularly as they enter their post-graduate level studies. Investigating the required cultural competency course of a Master of Public Health (MPH) program through the perspectives of faculty, current students, and alumni for its ability to develop culturally sensitive health care practitioners was the aim of this case study. Document analysis and direct observation of the one cultural competency course required for all concentrations in one MPH program was undertaken. This was a semester-long course and was offered face-to-face and online; both were observed. In-depth interviews of faculty, current students, and alumni of the same program were also conducted. Using the public health critical race (PHCR) praxis theoretical framework (Ford & Airhihenbuwa, 2010b), data was analyzed to determine how, and to what extent, faculty teach cultural competency, students internalize this instruction, and alumni put this education into practice. By using a critical theoretical framework designed for public health program development, this study found that such a framework has effective utility as a curriculum – this framework could be used to increase students understanding of racial issues that impact health and health care. Data also revealed a schematic believed, by faculty, students, and alumni, to be important for the development of cultural competence. The findings also point to the importance of creating space in the classroom for both minority and majority voices to feel free to express difficult issues without repercussions of stereo-typing and name-calling; and for faculty to be able to effectively deal with such discourse. Curriculum that addresses issues of health disparities and social justice, classroom praxis, and faculty role-modeling can be combined to create the institutional environment where culturally sensitive and socially just health care practitioners may emerge.

With growing cultural diversity in the United States (U.S.), health disparities continue to exist among many ethnic minority populations impacting the U.S. economy. Health disparities are health differences that are noted in a particular cultural group in respect to higher rates of diseases and deaths in comparison to others. These cultural groups have common attributes and can be based on race, ethnicity, disability, sexual orientation, income, residential location and many others. One such example is individuals of Puerto Rican heritage, the second largest Hispanic group living in the U.S. mainland. Puerto Ricans are identified to have multiple health disparities in comparison to other Hispanic and non-Hispanic population groups living in the U.S. Among other factors, common cultural health care beliefs and practices of individuals impact health outcomes. Healthcare professionals like nurses are expected to provide culturally competent care to vulnerable populations with known health disparities. Culturally competent care refers to delivering care congruent with patients' cultural beliefs and practices. Therefore, it is important to educate health professionals regarding caring for vulnerable populations. The purpose of this community-based participatory research (CBPR) study was to develop content for an educational tool, an online virtual interactive simulation (OVIS) case for developing cultural competency of nursing students in caring for the Puerto Rican population of New York City (NYC). The content development for OVIS was guided by the framework for Cultural Competency Simulation Experiences (CCSE), which was developed as a part of this dissertation. The CCSE framework guided the content development of OVIS using a CBPR approach. A community advisory board was developed which consisted of cultural, clinical and educational experts, residing in New York and Puerto Rico.

BACKGROUND: Despite decades of research aimed at prevention, preterm birth remains an enormous leading cause of infant mortality in the United States and worldwide. Of concern, racial disparities in preterm birth remain an intractable public health issue. In an effort to reduce preterm birth, organizations such as the American Congress of Obstetricians and Gynecologists (ACOG) released policy statements in 2009 aimed at reducing early elective deliveries. Subsequently, the incidence of preterm birth in the United States has decreased, but whether this decrease is due to a reduction in iatrogenic or "medically-indicated" preterm birth is unknown. Further, the effect of the reduction in early elective deliveries on racial disparities is unknown. Our hypotheses were that 1) after 2009, preterm births would be less likely to be medically-indicated than due to spontaneous causes and 2) black-white differences in preterm births would be unchanged. OBJECTIVES: 1) Determine the proportion of preterm deliveries at Beth Israel Deaconess Medical Center (BIDMC) from 2004-2013 that were medically-indicated versus spontaneous. 2) Due to persistent disparities, determine if shifts in type of preterm delivery varied by race/ethnicity. METHODS: We reviewed the first 87 deliveries in 2013 and randomly selected 15% of the records for each year from 2004-2013. Additionally, we reviewed 69 charts to oversample black women's deliveries. We manually abstracted data from BIDMC's online medical record and designated each delivery as either medically-indicated (preeclampsia, poor fetal growth, hypertension, or other fetal/maternal condition) or spontaneous (preterm labor, preterm premature rupture of membranes or cervical incompetence). Two reviewers independently reviewed 18 records for concordance of medically-indicated versus spontaneous preterm birth typing. If the first reviewer could not phenotype the delivery, then a neonatologist and obstetrician were consulted. We reviewed 971 out of the 5,566 preterm deliveries and included 930 that were confirmed preterm and had a clear medically-indicated or spontaneous phenotype. We dichotomized the time period into early (2004-2009) and late (2010-2013). Statistical methods included comparisons of early versus late using Chi-Square tests, logistic regression models to adjust for potential confounding variables, and stratified analyses (singletons and black versus white). RESULTS: There were 46,981 deliveries at our institution during the study period, 5,566 of which were preterm. Among the 930 preterm deliveries sampled from the 10-year period, 45.6% were medically-indicated with a non-significant, subtle difference between the early (48.3%) and late (41.9%) (P=0.05) time periods. The odds ratios of medically-indicated versus spontaneous preterm birth in late versus early were 0.77 (P=0.05) and 0.73 (P=0.03) for all participants, unadjusted and adjusted, respectively. While not statistically significant, a higher proportion of preterm deliveries among black women were medically-indicated in the early (50.4%) versus late (40.6%) periods (P=0.19). There was a similar trend among white women between the early (50.0%) and late (46.9%) periods (P=0.48). The odds ratios of medically-indicated versus spontaneous preterm birth from late versus early were 0.67 (P=0.19) and 0.63 (P=0.14) for black participants, unadjusted and adjusted, respectively. For white participants, the odds ratios were 0.88 (P=0.48) for unadjusted and 0.80 for adjusted (P=0.20). Overall at BIDMC, the preterm delivery rate was significantly higher in the early period (12.3%) compared to the later period (11.2%) (P=0.0003). While we observed a reduction of preterm birth among all women, black women experienced a 20.8% decrease (from 16.2% in the early period to 12.8% in the late) in preterm birth, while white women experienced just a 4.9% decrease (from 12.4% to 11.7%), resulting in a narrowing of the racial disparity of preterm birth in our institution. CONCLUSION: At a Massachusetts birth hospital we found a reduction in the incidence of preterm deliveries over a 10-year period that coincided with policy efforts to reduce early elective deliveries. There was a reduction in the proportion of preterm births that were medically-indicated from 48.3% to 41.9%. The reduction in medically-indicated preterm birth was most evident among black women at BIDMC with concurrent decrease in the overall preterm birth rate among black women resulting in a near elimination of the racial disparity in preterm birth at BIDMC. Future work includes statistical analysis to account for the oversampling of deliveries in 2013 as well as oversampling of black women's deliveries using inverse probability weighting. We also plan to analyze which underlying conditions (preeclampsia, intrauterine growth restriction, fetal distress, etc.) were responsible for the reduction of the medically-indicated deliveries.

BACKGROUND: Previous studies have shown that there are racial disparities in type 2 diabetes (T2DM) remission following bariatric surgery, with African-Americans (AA) in particular experiencing a subsequent relapse. In recent years, some have attributed these findings to racial differences in fasting insulin levels, with AA having higher levels, as increasing evidence for an alternate model of T2DM pathophysiology gains support. In this model, basal hyperinsulinemia is considered a primary event in T2DM disease development, rather than a compensatory response to increased insulin resistance. This study aimed to compare glycemic outcomes after bariatric surgery in different races, namely African-Americans (AA), Hispanic-Americans (HA), and Caucasian-Americans (CA), and to determine whether there were any associated changes in insulin levels and insulin resistance that may lend support to this revised model of T2DM pathophysiology. METHODS: A retrospective medical record review of 1,326 patients (389 AA, 179 HA, and 758 CA) who underwent bariatric surgery at Boston Medical Center (BMC) from 2004 to 2015 was conducted. Baseline characteristics and maximum percent weight loss were compared using one-way ANOVA and Chi-square tests of independence. Changes in mean glycated hemoglobin (HbA1c), insulin levels, insulin resistance (HOMA-IR), and blood glucose levels were analyzed using linear mixed models, overall and by racial group. The same procedures were conducted in both the overall patient population and a T2DM subpopulation. RESULTS: Over an 11-year postoperative observation period, all racial groups underwent a significant decrease in HbA1c (P<0.001) within the first two years following surgery. While HbA1c levels remained stable in CA and HA, they began to rise at 2 years in AA only (P=0.043). Additionally, analyses of covariates, including age at surgery (P=0.005), initial BMI (P<0.001), and maximum weight loss (P=0.049), revealed that all three were significant factors affecting mean HbA1c levels. However, when included in the mixed model, the race x time interaction effect on mean HbA1c remained significant. There was also a significant overall decrease in both insulin and HOMA-IR. When stratified by race, analysis of the T2DM population showed that insulin levels began to increase again by the 2nd year after surgery in AA, while in CA and HA they continued to decrease and subsequently stabilize. Analysis of the total patient population showed that HOMA-IR levels in AA, as well as in CA and HA, continued to decrease at this 2-year time point. Decreases in blood glucose levels after surgery were significant overall (P<0.001), but not significant when stratified by race. CONCLUSIONS: After the initial “metabolic reset” that occurs within the first 2 years after bariatric surgery, during which HbA1c levels normalize in the vast majority of patients, it was observed only in the AA population that there was a steady increase in HbA1c to levels near those recorded at baseline. This coincided with an observation of increasing insulin levels despite decreasing insulin resistance seen in AA only. Our results suggest that current discussions regarding a revised model of T2DM pathophysiology, in which hyperinsulinemia precedes insulin resistance, may help explain the racial disparities in glycemic control observed in both post-surgical and non-surgical contexts of T2DM outcome. However, future prospective studies are needed to further the preliminary results of this study.

This dissertation examines China’s market reforms over the last few decades, and their implications for (re)shaping socioeconomic inequalities in health. Specifically, I study the effect of marketization and related structural changes at community level on individual health outcomes. The first part of this dissertation revisits the market transition theory of Nee (1989), using individual health status as the outcome variable to assess Nee’s theory. Using multiple waves of a longitudinal survey from 1991 to 2006, I compare temporal changes in the role of human capital, political capital, and state policy in determining health under marketization. In partial support of the market transition theory, the empirical results show that the significance of human capital for health increases with marketization, while the return to political capital and one’s household registration status diminishes with a growing market. Additionally, I distinguish between marketization effects on community level, and different aspects of community context in shaping the SES-health link. I find that the level of urbanization and available resources within each community exert influences on self-rated health and change the relative importance of individual socioeconomic conditions in shaping health. Overall, this study provides new longitudinal evidence from China to support the notion that health is influenced by dynamic processes moderated by the structural changes as well as the social stratification system. I discuss the findings in the context of China’s market reform, fundamental causes theory, and socio-ecological perspectives, highlighting that health is determined by a nexus of life experiences and social environment that impact individuals at different levels. / 10000-01-01

This dissertation study utilized the National Longitudinal Study of Adolescent to Adult Health to analyze empirical relationships between social determinants of health and adolescent pregnancy. Although rates of adolescent pregnancy are at an all-time low in the United States, disparities persist. Examining relationships between the social determinants of health and adolescent pregnancy provides support for funding and interventions that expand on the current focus of individual and interpersonal level factors. Based on the Healthy People 2020 Social Determinants of Health Framework, proxy measures for social determinants of health were identified within the Add Health study and analyzed in relationship with adolescent pregnancy. Results indicated that six of 17 measures of social determinants of health had an empirical relationship with adolescent pregnancy. These measures included the following: feeling close to others at school, receipt of high school diploma, enrollment in higher education, participation in volunteering or community service, litter or trash in the neighborhood environment, and living in a two parent home. The results of this study can inform future research, allocation of funds and interventions based on social determinants of health that show an association with adolescent pregnancy.