Black women have higher incidence rates of aggressive subtypes of endometrial cancer and worse survival rates compared with white women. The overall incidence rate has been increasing in black women and, accounting for their higher prevalence of hysterectomy, may be higher than in white women. Exposures related to obesity and metabolic disorders, reproductive factors, and use of exogenous hormones have been associated with endometrial cancer risk in prior studies. However, because these studies have primarily included white women, little is known about these associations in black women. We therefore examined associations of endometrial cancer with previously identified risk factors in 47,555 participants in the Black Women’s Health Study, a prospective cohort of U.S. black women. Study 1 focused on anthropometric and metabolic factors. After adjustment for age at menarche, parity, menopausal status, smoking, and use of oral contraceptives, estrogen-only female menopausal hormones (FMH), and estrogen plus progestin FMH, self-reported body mass index (BMI), BMI at age 18, greater weight gain since age 18, and diagnosis of diabetes were positively associated with endometrial cancer risk. Self-reported diagnosis of hypercholesterolemia and hypertension were not independently associated. In study 2, we examined associations with reproductive factors. Endometrial cancer incidence was higher among women with early age at menarche, a history of infertility, a greater number of lifetime menstrual cycles, and diagnosis of polycystic ovary syndrome. Parity and early age at first birth were associated with lower risk, while a greater number of births and breastfeeding were not associated with risk. Positive associations with late age at menarche among premenopausal women and longer duration of breastfeeding among obese women require confirmation in other studies. In study 3, we examined the associations of endometrial cancer with exogenous hormone use. The inverse association with oral contraceptive use was primarily among women who used oral contraceptives for ≥5 years. Incidence was higher among current users of estrogen-only and estrogen plus progestin FMH, and ever users of progestin only FMH. Lower risk was observed among former users of estrogen plus progestin FMH. / 2019-04-30

In recent years, there has been increased focus on rural and Appalachian health because of disparate chronic health outcomes when compared to the rest of the US. Appalachia, a subsection of the US, has even worse health outcomes related to chronic diseases. Although Appalachia is its own unique region, there is significant overlap with rural areas in terms of shared cultural characteristics (e.g., strong sense of community, distrust in outsiders, lack of trust in traditional medicine, and strong Christian religious affiliations and faith in God), limited access to healthcare services, and disparate health outcomes. The research presented in this dissertation is significant because it provides insight into and compares healthcare utilization rates in women in Appalachia and surrounding areas. Study 1: In addition to racial discrimination, Black Appalachian women often face other obstacles involving other types of negative interpersonal experiences when seeking healthcare. Despite these known disparities, Black women are frequently underrepresented in Appalachian health research. This study investigated healthcare experiences for sixteen Black Appalachian women using semi-structured interviews to identify and subsequently address ways to eliminate barriers to care. Interview questions utilized the theory of intersectionality and the Social Ecological Model to create a framework to describe the complexity of healthcare utilization and barriers to care while providing context into each participant's background and lived experience. Interview questions explored four topics: 1) barriers to medical care; 2) social support; 3) ideal and actual healthcare experiences; and 4) desired changes to improve quality of care. We used an inductive analysis process to create a robust thematic coding schema, organizing responses into 60 total themes and 141 codes, and reported the most frequent. Our results explore the ways in which one's intersectional identity as a Black Appalachian woman affects interpersonal interactions and experiences when engaging with the healthcare system. Participants frequently reported barriers related to scheduling conflicts and delays, experiences with rushed appointments and inhospitable providers and support staff, and desires for accurate collection of medical information. Participant responses often emphasized difficulties with the organization of the medical system, revealing specific areas for future intervention to improve quality of care for Black Appalachian women. Study 2: Use of the emergency department (ED) for low acuity conditions (e.g., back pain, dental pain, sore throat) and primary care places an additional strain on ED staff and resources, while increasing waiting and treatment times for high acuity patients. Factors such as race, gender, and insurance type have a strong association with the likelihood of a patient using the ED for a low acuity concern. Women are more likely to utilize healthcare services, which also holds true in the context of the ED. Using a sample of adult women from Virginia, West Virginia, Tennessee, North Carolina, and Kentucky, I investigated which demographic factors, age, race, geographic location (metro, nonmetro, rural), employment, and insurance coverage, affect a patient's likelihood to visit the ED for a low acuity condition within a southwestern Virginia hospital system. Log-binomial regression was used to estimate unadjusted and adjusted prevalence ratios of acuity level by race, age, rurality level, employment, and insurance type with corresponding 95% CIs. Our sample included 28,222 female patients who visited the ED between January 1, 2021 and September 30, 2022. Low acuity visits accounted for 15.9% (n=4,485) of visits during the timeframe. In summary, our results suggest that older age and location in non-metro area are the most salient factors contributing to a higher likelihood of low acuity ED visits among women. Race, a primary variable of interest, did not have the relationship to acuity that was expected based on previous literature; Black women patients were less likely to have a low acuity visit than white women patients. During our study period, overall number of visits remained steady, while there was an increase in proportion of low acuity visits. Further research is needed into the underlying causes to more definitively explain this increase. / Doctor of Philosophy / In recent years, there has been increased focus on rural and Appalachian health because of disparate chronic health outcomes when compared to the rest of the US. Appalachia, a subsection of the US, has even worse health outcomes related to chronic diseases. Although Appalachia is its own unique region, there is significant overlap with rural areas in terms of shared cultural characteristics (e.g. strong sense of community, distrust in outsiders, lack of trust in traditional medicine, and strong Christian religious affiliations and faith in God), limited access to healthcare services, and disparate health outcomes. Black/African Americans are another population with higher rates of chronic disease and poorer health outcomes compared to their white and Latinx peers. The combination of poorer health outcomes and higher rates of chronic disease negatively impacts life expectancy and quality of life. One driving factor in these poor health outcomes across all of these groups is low rates of healthcare utilization, whether due to decreased access (as is the case for many rural populations), or other as of yet unidentified challenges. Although literature exists about rural health outcomes, Appalachian health outcomes, and health outcomes focusing on Black women, there is very limited literature that examines the intersectional impact of these characteristics on health. Health disparity research in this region does not currently stratify differences in outcomes by both race and gender, which prevents a detailed analysis of the full extent of the gap in health outcomes. This research presented in this dissertation is significant because it provides insight into and compares healthcare utilization rates in women in Appalachia and surrounding areas across the lifespan. Knowing the contextual factors influencing healthcare seeking behaviors and utilization is the first step to designing effective interventions that improve women's access to care. Interventions need to be intentionally designed to consider, and ultimately, shift medical care and community attitudes to decrease health disparities in Appalachia. To successfully decrease health disparities, it is necessary to consider all of a patient's identities or characteristics. The same contextual factors that affect their healthcare utilization can also impact their care experience.

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In response to the striking health and social inequalities existing across communities within a large Southern Ontario City the McMaster University School of Nursing has partnered with the local family health team, municipal government, and other community partners to evaluate a pilot program designed to enhance health and social outcomes within a specific priority neighbourhood. The innovative pilot program is a nursing-based system navigation role, grounded concurrently in the community and a local Primary Care Practice. The role is uniquely designed as the nurse provides navigation for individuals and families while functioning as a networker to facilitate improved service integration at a systems level. This study serves as a narrative person-centered evaluation of the program, emphasizing the impact on the lives of community members. This study employed the Three-Dimensional Narrative Inquiry Space method as described by Clandinin and Connelly (2000) to explore the experience of nine community residents utilizing navigation services through the Community Nurse Navigator/Networker (CNN). Programs tell a story; therefore, the collection and analysis of participants’ life stories, in conjunction with field notes, observations, and documents, created a common narrative of the experience of navigation in a community setting. A thematic analysis of participants’ life stories was conducted to present a common narrative of community members’ experience of navigation. The major finding of this study was the positive experience residents shared interacting with the CNN. Participants valued the development of a therapeutic relationship through social interactions, the significance of place on the impact of the CNN role, and the effect of the navigation role to address health disparities over time. Study findings have implications for continued development of the CNN role and other community-based nurse navigation roles in priority neighbourhoods to address health inequities. / Thesis / Master of Science in Nursing (MSN)

I conducted a four-month ethnographic fieldwork study to document the stories of thirteen post-kidney-transplant minority patients and three nephrologists at Boston Medical Center. My research explores how patients’ interactions with health professionals, medical regimens, dialysis treatments, and adaptation to living with transplanted kidneys constantly shape their identities and perceptual worlds. Patients’ narratives highlighted the emotional struggles they encountered along the path of End-Stage Renal Disease, which unfolded as distinct experiences influenced by their varied backgrounds. The majority of my patient-participants lived on the verge of poverty, and in some cases, their insurance status caused delays in their being registered on the transplant waiting list, making them endure a long wait. Some patients were afraid of wearing short sleeves because they thought the scars on their arms from dialysis treatment would lead others to think they were gangsters. Instantiations of various theories emerged from the saturated data and narrative analysis, from Bourdieu’s concept of habitus with regard to the process of how patients alter their consciousness through interactions with medicine to Foucault’s ideas of power relations and technologies of the self that address the issues of agency and power that influence the formation of patients’ identities. The intersection of these theoretical frameworks led me to develop the critical medical anthropological-oriented concept of biological citizenship. This paper examines 1) the ways in which “race” interacts with the theoretical concept of biological citizenship and 2) the ways in which socioeconomic status and race tailor a kidney transplant patient’s illness experience, and related discourse.

Exclusionary discipline practices are often considered to be generally ineffective and inequitable, however, they are one of the more common disciplinary practices used in schools today. Although there are many positive alternatives to school exclusion, there are limited disciplinary practices specifically intended to target discipline with racial equity in mind. The GREET-STOP-PROMPT (GSP) intervention, developed by Cook and colleagues (2018), is one intervention found in the literature explicitly created to reduce racial discipline disparities. Although there is currently limited research evaluating the GSP intervention, the results indicate it to be a potentially promising method of equitably addressing student behavior. The purpose of the current study was to extend the literature to examine the effects of the GSP intervention on racial discipline disparities, as well as students’ academic engagement and disruptive behavior in the classroom. The current study evaluated the GSP intervention across three elementary classrooms in a rural school district located in the southeastern United States. Results indicated the GSP intervention did not have meaningful effects on student exclusion, racial disparities, academic engagement, and disruptive behavior, which ultimately failed to support the current researcher’s hypotheses. However, there was limited discipline data available to draw conclusions specifically related to the intervention’s effect on student exclusion and discipline disparities. Further exploration is necessary to evaluate the effectiveness of the GSP intervention in addressing student behavior in the classroom and reducing racial discipline disparities.

Since the mid-1980s, mortality rate improvements in urban areas have outpaced those in rural areas, leading to substantial urban-rural disparities in mortality. Research on urban-rural mortality disparities has focused exclusively on differences in mortality between urban and rural areas and has not examined differences in the amount of inequality in the length of life within these areas. Lifespan variation is an important dimension of health inequality that complements traditional metrics of mortality (i.e., mortality rates and life expectancy) by indicating the amount of inequality of lifespans within a population. This dissertation provides several contributions to our understanding of urban-rural differences in lifespan variation through three interrelated studies. First, I document trends in life expectancy and lifespan variation from 1990 to 2017 and show that nonmetropolitan populations have had smaller declines in lifespan variation than metropolitan populations. The urban-rural disparity in lifespan variation is mostly due to greater improvements in mortality in metropolitan areas but recent mortality increases among nonmetropolitan working-age adults have also contributed. Next, I investigate the extent of the rural mortality penalty among White and Black populations, an underexamined area in the rural mortality literature. Generally, I find that Black Americans living in rural places face an additional penalty; their lifespans are not only shorter but more variable. For Whites, improvements in large central metros are driving the urban-rural disparity. For Blacks, lower mortality rates in large suburbs are driving the disparity. This study underscores the importance of including Black Americans in studies of rural mortality. Finally, I show that most of the difference in lifespan variation between metro and nonmetro populations is due to preventable mortality among working-age adults (ages 25-64). Analyses of age and cause-specific mortality rates among working-age adults show that the largest disparities in preventable mortality are due to suicide and motor vehicle accidents in younger adults and heart disease and cancer in middle-aged adults. The results of these studies show that people living in rural places face an additional penalty; their lives are not only shorter, but the timing of death is more variable and uncertain.

Maternal mortality in Nigeria is unacceptably high, accounting for 14 percent of global maternal deaths, thereby making it a global public health issue. Given that maternal mortality is essentially a women problem, it is a matter of justice and discrimination. In addition, significant regional disparities in maternal mortality exist within Nigeria, particularly between the northern and southern parts of the country. The maternal mortality ratio in the North is six to ten times greater than that of the South. The country's maternal mortality crisis occurs along regional and socioeconomic lines-the poorer northern Nigeria has a disproportionately higher maternal mortality ratio than the wealthier southern Nigeria. This thesis explores the disparities in maternal health across different regions in Nigeria from an intersectional perspective, taking into account economic, religious, cultural, rural, and urban differences. The study adopts intersectionality theory to examine how these factors intersect to impact maternal health outcomes in Nigeria. Furthermore, the thesis employs a functional comparative law approach, using India and South Africa as comparators, to assess how the constitutional courts of these countries have applied intersectional perspective to right to health. It highlights the importance of adopting an intersectional approach to understanding maternal health disparities in Nigeria, as it considers the multiple and interconnected factors that contribute to poor maternal health outcomes. This is particularly crucial in the Nigerian context, where maternal mortality rates remain high and access to quality maternal health services is limited, particularly in rural and underdeveloped regions. The comparative analysis of India and South Africa sheds light on how these countries have approached constitutionalizing the right to health and intersectionality in their courts. In South Africa, the Constitutional Court has played a crucial role in advancing the right to health and applying an intersectional perspective in its judicial decisions, leading to improvements in maternal health outcomes. In India, the Supreme Court has also played an important role in interpreting the right to health to include other associated factors, but its impact on maternal health outcomes remains limited, particularly in rural areas. The thesis concludes by advocating for constitutionalizing maternal health in Nigeria, through incorporation of the right to health in the Nigerian Constitution to ensure that this right is enforceable through the court processes. The study recommends that an adoption intersectional perspective in the implementation of maternal health policies and programs, in order to address the multiple and interconnected factors that contribute to maternal health disparities in Nigeria. The findings of this thesis contribute to the existing literature on maternal health and the right to health, and have important implications for policymakers and health practitioners working to improve maternal health outcomes in Nigeria and other developing countries. By incorporating an intersectional and comparative approach, the thesis provides a comprehensive understanding of the challenges and opportunities for constitutionalizing maternal health in Nigeria and highlights the need for a more nuanced and integrated approach to maternal health policy and practice.

Mental and behavioral health difficulties are prevalent among children, and research suggests that the vast majority of these children do not receive needed services. Treatment disparities are even larger among rural youth given the scarcity of qualified specialty mental health providers, increased barriers to care, and greater mental health-related stigma compared to their urban counterparts. Many parents seek help and resources from their child’s primary care provider (PCP); however, the comprehensive management of psychosocial and behavioral concerns are often not feasible in traditional primary care settings. Integrating behavioral health services into pediatric primary care clinics has the potential to increase access to needed services, improve comprehensiveness and quality of care for patients, and reduce burdens on PCPs. Research on integrated behavioral health (IBH) models have indicated that it is a cost-effective service leading to improved treatment outcomes compared to usual primary care and that parents and physicians are generally satisfied and interested in this service delivery model. However, little is known about parents’ attitudes toward IBH and factors that may influence the acceptability of this type of care. Previous research has identified several factors associated with parent acceptability of mental health services for their child including symptom severity, attitudes toward child therapy, parenting stress, stigma, perceived barriers to care, and past experiences with services. However, it is unclear how these factors influence attitudes toward IBH, especially in rural areas. The current study examined parents’ attitudes toward co-located and integrated models of care, identified factors that affect acceptability of IBH, and explored differences between rural and urban parents’ attitudes. Results demonstrated that both rural and urban parents hold generally favorable attitudes toward IBH models and that parent attitudes toward general child therapy was strongly associated with IBH acceptability. Demographic variables (e.g., parent age, child age, minority status, socioeconomic status), need characteristics (e.g., parenting stress, child psychosocial symptoms), and other enabling factors (e.g., mental health-related stigma, prior service use, barriers to care) were not predictive of parent IBH acceptability. Urban parents rated co-located models of care as more acceptable and reported higher levels of parent psychosocial symptoms, stigma, and barriers to care compared to rural parents. These findings support efforts to continue integrating behavioral health services into pediatric primary care and highlight parent therapy attitudes as an important target for intervention to improve parent IBH acceptability. Findings also shed light on the need for more mixed-method research to understand the impact rural identity has on the acceptability and use of behavioral health services.

South Asians are a diverse population with unique genetic, cultural, and environmental factors that directly impact their overall health. Pre-disposed to several chronic illness such as cardiovascular disease, diabetes, obesity, and even some cancer, it is incredibly important to have adequate health data on this demographic to help diagnose and prevent these disease states. However, there is very limited data on South Asians and the reason behind this is multifold. First, barriers exist that specifically impact participation rates in ethnic minority groups such as South Asians. Next, a majority of clinical research studies utilize aggregated race and ethnicity categories, such as White, Black, Asian, American Indian, and Latino, which tend to cover up the individual health needs of its ethnic subgroups like South Asian. A literature review involving 20 published works and texts was carried out to determine the barriers that prevent clinical trial engagement in South Asians. The primary reasons for lack of involvement of South Asians in clinical trials were language difference, trial burden, lack of information, mistrust, gender roles, and of course the systemic insufficiency in actively recruiting specifically South Asian populations. In order to achieve health equity, it is essential to understand health disparities that exist within the system and work to find methods to alleviate them.