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Purpose: Race has rarely been the focus of biomechanics investigations, despite affecting the incidence of musculoskeletal injury and disease. Existing racial differences in movement mechanics could drive disease development and help identify factors contributing to racial health disparities. This study aimed to 1) Identify racial differences in walking, running, and landing mechanics between African Americans and white Americans and 2) Determine whether racial differences can be explained by anthropometric, strength, and health status factors. Methods: Venous blood samples, anthropometric measures, lower extremity strength, and a health status assessment were collected for 92 participants (18-30y) in an IRB approved study. After measuring self-selected walking speed, 3D motion capture and force plate data were recorded during 7 trials in the following conditions: regular walking (1.35m/s), fast walking (1.6m/s), running (3.2m/s), and drop vertical jump (31cm box height). Fundamental gait measures and running and landing measures associated with overuse and impact injury risk were extracted using Visual3D and custom Matlab scripts. Multivariate and post-hoc univariate ANOVA models were fit to determine main and interaction effects of gender and race (JMP Pro 15, α=0.05) after which data was separated by gender. Stepwise linear regression models evaluated whether anthropometric, strength, and health status factors explained racial effects. Results: Several racial differences in walking, running, and landing mechanics were observed in both men and women, but differed between genders. Effect sizes of observed racial differences indicate the potential for both statistical and clinical significance. Although several racial differences during all tasks were explained by anthropometric, strength, and health status factors in women, none were explained by these factors in men. In women, explanatory factors were a combination of innate and modifiable. Conclusion: Future steps should include the development of racially diverse databases and the identification of potential factors to target in interventions aimed at reducing racial health disparities. / Doctor of Philosophy / Purpose: Race has rarely been the focus of biomechanics studies, but several injuries and diseases occur at different incidence rates between racial groups. This study aimed to 1) Identify racial differences in walking, running, and landing between African Americans and white Americans and 2) Determine whether racial differences are explained by body proportion, strength, and health status factors. Methods: Blood samples, body proportion measures, lower extremity strength, and a health status assessment were collected for 92 participants (18-30 years old). Motion analysis data was recorded and analyzed during the following tasks: regular walking, fast walking, running, and drop vertical jump. Biomechanical measures were compared between racial groups and genders. When racial differences were found, we evaluated whether the differences could be explained by body proportion, strength, and health status factors. Results: Several racial differences were found during walking, running, and landing tasks in both men and women, but were dependent on gender. Several observed racial differences in women could be explained by body proportion, strength, and health status factors, but no racial differences could be explained in men. In women, some of the factors that explained racial differences were structural and could not be altered while others were potentially modifiable by exercise or were the product of social environment. Conclusion: Based on these findings, biomechanical data should be collected from racially diverse populations. Some factors able to explain racial differences could be targeted to reduce racial health disparities.

Sociological theory and literature in the study of disparities in health and access to care in old age has, with few exceptions, not considered important political contexts for the aging AI/AN community. Political histories have unique implications for this population, and particularly those in old age. Native Peoples are affected by federal old age and health policies as well as AI/AN specific policies, which creates a unique intersection of inequality for this group. This project engages with three distinct areas of sociological scholarship in this area and works to highlight the strengths and gaps of existing frameworks to work towards more inclusive scholarship for Native Peoples in sociological scholarship. The first article uses a quantitative analysis using secondary data from the National Health Interview survey to explore how helpful sociological frameworks are in explaining health disparities in old age for the AI/AN population. The second article, using the same dataset, engages with Andersen's behavioral model of care utilization and its developments and couples it with important scholarship emerging about policy, AI/AN healthcare organization, and funding. The third article offers a qualitative analysis of reports and policy recommendations from Native organizations focused on increasing well-being for Native elders to further understand how healthcare, old age, and AI/AN specific polices work to create intersections of inequality for this group. This analysis further informs future directions for sociological theory and application to promote a more inclusive field in the sociology of aging and inequality. / Doctor of Philosophy / How policy impacts aging American Indian and Alaskan Native (AI/AN) has been largely overlooked in the field of sociology. Through three distinct studies, this dissertation project seeks to connect policy to disparities in health outcomes, issues in access to care, and the provisioning of health resources for this group. Native Peoples, through treaty agreements, have a right to healthcare, which has been poorly fulfilled by the US government. Because of this, Native Tribes and organizations have increasingly relied on other healthcare policies and social welfare programs to meet the needs of AI/AN elders. Policies like Medicare, Medicaid, and the Older Americans Act are all important policies in generating health resources for Native elders, but they also overlap in ways that can also create barriers to health equity. This project, in three articles, explores 1.) how policy-based resources affect health outcomes in old age across racial groups, 2.) how equitable healthcare access for the aging AI/AN population, and 3.) how organizations understand and navigate policy landscapes in order to promote health and well-being for Native elders. These three studies work together to inform theories of aging and health disparities in order to work towards scholarship that is more inclusive of Native Peoples.

Background: Primary open angle glaucoma (POAG) is the most common form of glaucoma in the United States and is the leading cause of irreversible blindness in African Americans. Although this is the case, there are no current primary care screening guidelines for this condition. The USPSTF cites that there is insufficient evidence to assess the balance of benefits and harms of screening for POAG in adults. This condition disproportionately affects African American and Hispanic patients. A systematic review performed earlier this year highlighted disparities in research participation among POAG clinical trials. No similar studies have been pursued outside of clinical trials. This is problematic because screening guidelines are heavily influenced by the literature related to the topic. Methods: A rapid scoping review of the literature will be performed with a particular focus on demographic data. Data was sourced from the included studies used in the systematic review performed in 2022 to inform the current USPSTF guidelines. Data collection will consist of the compilation of demographic data within each of the studies on a spreadsheet and will subsequently be analyzed according to subgroup corresponding to study type. Results: A total pooled sample of 16659 participants was obtained from the 16 included studies. After exclusion of an outlier study, total research participation across all studies was 27.9% and 5.5% for Black and Hispanic individuals, respectively. In clinical trials, 26.9% and 6.9% were Black and Hispanic individuals, respectively. Lastly, among nonclinical trials, 28.7% and 3.3% were Black and Hispanic individuals, respectively. Conclusions: Primary open angle glaucoma is a public health issue. The current recommendations for POAG screening are based on the currently available literature. However, it has been previously shown that disparities exist in research participation among Black and Latino individuals in clinical trials. The findings within this study corroborate those findings as well as highlight that disparities in research participation and representation persist among nonclinical trial research studies. This thesis underscores the ongoing need for equitable efforts in POAG research across all studies. With these efforts, recommendations for screening may be properly elucidated to inform more equitable care and identification of this disease. / Urban Bioethics

Background and PurposeGlobally and in the United States (US), colorectal cancer (CRC) is the second leading cause of cancer-related death, following lung cancer. In addition, there are established racial disparities in incidence and mortality for this disease, where ethnic minority groups have higher incidence and mortality rates. Blacks currently have the second-highest rates of CRC incidence and mortality, are diagnosed at more advanced stages, and have the lowest 5-year survival rates of all racial groups. Multiple influences impact this disparity including area- and individual-level factors. Area-level factors, encompassing social determinants of health (e.g. area-level poverty, housing characteristics, etc.), play a role in disease etiology and outcomes. In addition, timely CRC screening (CRCS) reduces CRC incidence and mortality; however, screening patterns, globally and in the US, are not optimal and differ by race, with ethnic minority groups having low CRCS adherence compared to non-Hispanic whites. Differences in CRCS behaviors and outcomes have been noted for Blacks, a term used to describe, for example, a heterogeneous racial group comprised of US-born Blacks and immigrants from Africa and the Caribbean. While CRCS barriers are well documented for the general population, CRCS barriers are less understood for Blacks and very little is known about CRCS habits and CRCS barriers within this heterogeneous racial group, with limited research including Caribbean immigrants and no known research including African-born immigrants. This dissertation uses a mixed-methods approach to describe CRC incidence, advanced stage at diagnosis, and mortality, CRCS behaviors, and CRCS barriers within the heterogeneous Black population in Philadelphia County, Pennsylvania. Aim 1. Assess colorectal cancer incidence, advanced stage at diagnosis, and colorectal cancer mortality, overall and among individuals who identify as Black/African American, and contextual disparities in Philadelphia County utilizing data from the Pennsylvania State Cancer Registry (2010–2016) and relevant US Census and American Community Survey data. Aim 2. Determine colorectal cancer screening adherence for Cancer Prevention Project of Philadelphia (CAP3) participants who self-identify as Black. Aim 3: Conduct gender-specific focus groups to elucidate the principal barriers to colorectal cancer screening adherence within an average-risk group of adults, ages 45–75, who self-identify as Black or African American, in an urban population. Methods Aim 1. Using an ecological design, descriptive, geographic spatial clustering and hierarchical logistic regression analyses were done to describe CRC incidence, advanced stage at diagnosis, and colorectal cancer-specific mortality in Philadelphia County at the individual- and area-level. CRC incidence, stage at diagnosis, and mortality data for histologically confirmed CRC cases were obtained from the Pennsylvania Cancer Registry from 2010 to 2016, with mortality data including deaths through 2020. Area-level data were retrieved from the US Census Bureau, American Community Survey, etc. Individual- and area-level descriptive characteristics were calculated for all CRC incident cases, cases diagnosed at advanced stage, and colorectal cancer-specific mortality, overall and for whites and Blacks. Geographic clusters with higher-than-expected relative risk for each outcome of interest at the census tract level (HRCT) were identified and individual- and area-level descriptive statistics were calculated for Blacks, overall and by HRCT status. Adjusted hierarchical logistic regression analyses using backward stepwise elimination with model quasi-information criterion was performed to identify potential predictors of HRCTs for CRC incidence and advanced stage at diagnosis. Aim 2. Cross-sectional data from age-eligible adults, 50–75 years (N=357) participating in the ongoing CAP3 study was used to measure CRCS prevalence and adherence and region of birth (e.g., Caribbean-, African-, US-born). Prevalence and adherence were based on contemporaneous US Preventive Services Task Force guidelines. Descriptive statistics and adjusted prevalence and adherence proportions were calculated by region of birth. Adjusted logistic regression models were performed to assess the association between region of birth and overall CRCS and modality-specific adherence. Aim 3. To assess CRCS barriers, we conducted six sex-specific focus groups (n=3 female, n=3 male) with individuals, ages 45-75, who self-identified as Black (i.e., US-, Caribbean, or African-born) and were. Focus groups were held in person and via Zoom, recorded and transcribed verbatim. Codes were developed using coding consensus, co-occurrence, and comparison and open, axial, and selective coding rooted in grounded theory. Dedoose was used to determine CRCS barrier themes as well as general and modality-specific barriers by sex and by region of birth. Results Aim 1. In Philadelphia County, there were 4,641 CRC incident cases, of which 2,086 (44.9%) were non-Hispanic Black (NHB), and 2,555 (53.1%) were white. Mean age at diagnosis for CRC incidence (65.0 vs. 68.9 years), advanced stage at diagnosis (63.2 vs. 67.4 years), and colorectal cancer-specific mortality (67.5 vs. 71.7 years) was lower for Blacks compared to whites (p-value<0.001). Blacks were also diagnosed at a more advanced stage (25.0% vs. 22.4%, p-value=0.038) or unknown stage (8.01% vs. 5.64%, p-value=0.001). For each outcome, when compared to whites, higher proportions of Blacks lived in areas with higher proportions of markers of low socio-economic status and lower proportions of CRCS adherence. Geographic clusters at a higher-than-expected risk of CRC incidence were found in Northeast Philadelphia, North Philadelphia, West Philadelphia, and Southwest Philadelphia. Geographic clusters at a higher-than-expected risk of CRC diagnosed at an advanced stage and colorectal cancer-specific mortality overlapped and were in the North, Kensington, and Southwest neighborhoods of Philadelphia. Area-level NHB, the primary independent variable of interest, reduced the odds of HRCT for CRC incidence (OR: 0.971, 95% CI: 0.960, 0.983) and was not significantly associated with HRCT for advanced stage at diagnosis. In addition, after adjustment, for every one-unit increase in the percent of area-level foreign-born Blacks, there was 1.17-increased odds of being a HRCT for CRC incidence (95% CI: 1.07, 1.28). Similarly, there was a significant positive association with area-level foreign-born Black and being in a HRCT for advanced stage at diagnosis (OR: 1.15, 95% CI: 1.05, 1.26). Other area-level variables that were associated with HRCT for CRC incidence were median rent, percent of mortgaged housing units, and per capita income, which reduced the odds of being a HRCT; Percent of mortgaged housing units also reduced the odds of being a HRCT for advanced stage at diagnosis. Further, CRCS adherence reduced the odds of being a HRCT for advanced stage at diagnosis by approximately 15% (OR: 0.849, 95% CI: 0.791, 0.911). Aim 2. Respondents were 69.5% female, 43.3% married/living with a partner, and 38.4% had <$25,000 annual income. Overall, 78.2% reported past CRCS; however, stool test had the lowest prevalence overall (34.6%). Caribbean (95.0%) and African immigrants (90.2%) had a higher prevalence of overall CRCS compared to US-born Blacks (59.2%) (p-value <0.001). African immigrants were five times more likely to adhere to overall CRCS than US-born Blacks (OR: 5.25, 95% CI: 1.34, 20.6). Immigrants had higher odds of being adherent to colonoscopy (Caribbean=OR: 6.84, 95% CI: 1.49, 31.5; African =OR: 7.15, 95% CI: 1.27, 40.3) compared to US-born Blacks. Aim 3. The majority of focus group participants were 60–64 years old and 72% were immigrants (41% African-born, 31% Caribbean-born). Most participants had had CRCS, but 45% were non-adherent to national CRCS guidelines. Overall, lack of knowledge/awareness, fear, and a sense of feeling healthy and subsequently not seeing the need for CRCS emerged as overarching themes to CRCS barriers. General barriers differed by gender: for women lack of physician recommendation or explanation of CRCS was important and for men not knowing anyone with a history of CRCS was commonly cited. .” Differences in modality-specific barriers by gender were also noted. Barriers also differed by region of birth. US-born Blacks described lack of community advocacy promoting CRC and CRCS awareness as a barrier. African-born Blacks expressed lack of routine CRCS and utilization of preventive medicine in their native country as barriers. US- and Caribbean-born Black males, communicated that discussing CRCS was taboo, which was tied to hegemonic masculinity leading to a lack of conversations about CRC and CRCS. The use of traditional home remedies emerged as a barrier given respondents felt these remedies would aid in preventing CRC thereby reducing the need for CRCS. Immigrant Blacks also described limited insurance coverage due to their citizenship status. Conclusions This dissertation provides the first known insight into various outcomes across the colorectal cancer continuum for the heterogeneous Black population including the growing immigrant Black subgroups in Philadelphia County. To reduce CRC incidence and mortality, interventions and resources to increase CRCS uptake need to target geographic locations with higher percentages of foreign-born Blacks, lower CRCS adherence, and areas with worse socio-economic markers. Also, while Black immigrants had higher CRCS adherence compared to US-born Blacks, CRCS is still sub-optimal in the Black population. Further, CRCS barriers exist and differ by gender, and importantly, there are nuanced barriers by region of birth. Thus, efforts to increase CRCS should address the common and unique barriers and promote stool-based testing, as stool test adherence was low and focus group participants were unfamiliar with this modality as it is not widely promoted or available in clinical practice. In short, these findings across the colorectal cancer continuum should be taken into account for resource allocation and when designing targeted or tailored interventions to promote CRCS uptake for the heterogeneous Black population, which would reduce CRC incidence, late-stage diagnosis, and mortality. / Epidemiology