La configuration ainsi que le fonctionnement de l’espace dakarois sont marqués par une permanente confrontation entre les « normes institutionnelles » et les modes populaires de production et de consommation de l’espace urbain.L’objectif général de ce travail est d’analyser la façon dont s’édifie et se développe l’espace urbain dakarois, et plus particulièrement les modes de production des espaces résidentiels et comment ils sont façonnés par des logiques contradictoires et des stratégies d’acteurs différenciées.La géo histoire de l’édification urbaine de Dakar qui nous a servi de trame, montre que la construction de la capitale sénégalaise est inscrite dans une lutte constante des acteurs pour l’appropriation des ressources spatio-territoriales marquées par le rejet et l’exclusion progressive des groupes sociaux économiquement fragiles dont les emprises résidentielles libérées de manière souvent violente ont été réaffectées à des acteurs sociaux à revenus plus élevés.Devant cette politique ségrégationniste, s’est développée une rigoureuse résistance des groupes sociaux populaires qui a fini par imposer ses formes et modalités de consommation spatiale devenues dominantes au point de produire une urbanité caractéristique d’une identité physionomique propre à la ville.L’Etat a développé une stratégie de reconquête politico – administrative, qui s’est notamment traduite sur le plan politique par l’approfondissement de la décentralisation avec la création des communes d’arrondissement couvrant l’ère des zones irrégulières, renforcées institutionnellement en commune de plein exercice avec l’acte III de la décentralisation.Le redéploiement de l’État se lit également à travers des dynamiques de reterritorialisation qu’il engendre avec les opérations de Restructuration Régularisation Foncière notamment. Il s’agit d’une entreprise de contrôle technico urbanistique avec un objectif d’intégration physique et socioéconomique des quartiers irréguliers à la « ville légale ».En effet, l’impératif de contrôle politico – administratif (décentralisation/déconcentration) et d’harmonisation technico urbanistique (restructuration/régularisation foncière) de la ville s’inscrivent dans un champ plus large qui vise l’élargissement du marché et sa consolidation.Ainsi en prétendant lutter contre les exclusions et les inégalités territoriales, les projets de RRF les reproduisent sous une forme renouvelée, en tant que champ de préparation de l’expansion du marché dans les territoires de l’informalité. / The configuration and functioning of Dakar area are marked by a permanent confrontation between the "institutional norms" and the popular modes of production and consumption of the urban space.The main objective of this work is to analyze the way in which the urban space of Dakar is being developed and built, and more especially the modes of production of residential spaces and how they are shaped by contradictory logics and differentiated actors strategies. The geo-history of urban construction in Dakar, which has served us as a framework, shows that the construction of the Senegalese capital is part of a constant struggle between actors for the appropriation of spatio-territorial resources. These latter are marked by the rejection and the progressive exclusion of social groups that have economically been fragile and whose residential ascendancies, which have often been violently liberated, have been reallocated to social actors with higher incomes.In front of this segregationist policy, a rigorous resistance of the popular social groups is developed and has finally imposed its forms and modalities of spatial consumption becoming dominant so as to produce an urbanity characteristic of a city-specific physiognomic identity.The state has developed, a politico - administrative recovery strategy has been expressed on political plan through the deepening of decentralization with the creation of borough communes covering the era of irregular zones, institutionalized in full - Act III of decentralization.The redeployment of the State is also reflected in the dynamics of making new-territories that it generates with the operations of Restructuring and land Regularization in particular. It is a technical-urbanistic control company which aims a physical and socio-economic integration of the irregular districts to the "legal city".Indeed, the imperative of politico-administrative control (decentralization / devolution) and the technical-urbanist harmonization (land restructuring / regularization) of the city are part of a wider field which aims at expanding the market and consolidating it.It thus appears that by claiming to fight against the territorial exclusions and inequalities, the RRF projects reproduce them in a renewed form, as a field of preparation for the expansion of the market in the informality territories.

This study investigated the association of race, age, and census tract area poverty level on breast cancer stage at diagnosis. The study was limited to women residing in Missouri, aged 18 years and older, diagnosed with breast cancer, and whose cases were reported to the Cancer Registry between 2003 and 2008. The risk, relative risk, and increased risk of late-stage at diagnosis by race, age, and census tract area poverty level were computed. We found that the odds of late-stage breast cancer among African-American women were higher when compared with their white counterpart (OR 1.433; 95% CI, 1.316, 1.560). In addition, the odds of advanced stage disease for women residing in high-poverty areas were greater than those living in low-poverty areas (OR 1.319; 95% CI 1.08; 1.201). To close the widening cancer disparities gap in Missouri, there is the need for effective and programmatic strategies to enable interventions to reach areas and populations most vulnerable to advanced stage breast cancer diagnosis.

The UpliftU® program is a long-term residential program for women and families who are homeless or at risk for homelessness. This program is one part of a larger, community-based non-profit organization serving low-income and homeless families in Hillsborough County, Florida for over 35 years. This program is not an emergency shelter program, but rather offers up to 18 months of participation in a self-sufficiency program to single women and families. The goal of the program is to prevent future homelessness for residents by helping them to reach their highest level of self-sufficiency. After volunteering at this organization for nine months, I completed an internship as the Health Specialist Case Manager for the UpliftU® program during the summer of 2008. The internship was conducted using ethnographic research methods to understand counseling team members' and resident mothers' perceptions of access to health care resources and their experiences in utilizing area health care services. This thesis compares the perspectives of the counseling team members with the resident mothers' perspectives, and examines barriers to and gaps in service provision, as reported by both groups. Findings from qualitative data analysis suggest that counseling team members conceptualize the barriers to health care as originating at the individual level with resident mothers' behaviors and actions, while resident mothers' expressed that they experience barriers to health care services at interpersonal and institutional levels. Resident mothers described how health professionals and staff treating them poorly leads to barriers to health care at an interpersonal level, and that at an institutional level the bureaucratic hassles associated with public insurance and public clinics also acted as barriers to care. Such differences in perception of causality of barriers to health care services between counseling team members and resident mothers have significant ramifications for resident mothers' health and ability to access health care services.

This dissertation seeks to extend quantitative research on environmental justice and address methodological limitations of previous studies by: (a) using new indicators of exposure to air pollution and contemporary risk modeling techniques; (b) assessing disparities in human health risks, instead of focusing only on potential exposure or proximity to pollution sources; and (c) using multivariate regression models that consider the effects of spatial dependence. The case study examines racial/ethnic and socioeconomic disparities in the geographic distribution of exposure to airborne toxic emissions from industrial point sources in the Houston-Galveston-Brazoria metropolitan statistical area. Industrial pollution sources for this study comprise facilities listed in the US EPA's Toxic Release Inventory (TRI). The Risk-Screening Environmental Indicator (RSEI) model is used to estimate potential human health risks from air pollutants based on data on toxicity and dispersion of chemical releases from TRI facilities. The analyses utilize four indicators of potential exposure to industrial pollution: (a) presence or absence of air emissions, (b) total quantities (pounds) of air emissions, (c) toxicity-weighted quantities of emissions and (d) modeled risk scores based on the cumulative health risk posed by air emissions. Traditional linear regression and spatial autoregressive techniques based on several neighborhood configurations are used to model the occurrence and magnitude of these four indicators, using relevant explanatory variables from the 2000 census, at the census tract and block groups levels of aggregation. Results indicate a disproportionate pattern of health risks from TRI facilities in the HGB-MSA, with the Hispanic population facing the highest exposure. The locations and magnitude of toxic pollution are significantly statistical effected by the presence of minority residents and population density. Additionally, key differences in the significance of explanatory variables between the spatial and conventional regression models demonstrate the importance of correcting for spatial dependence in environmental justice analysis. The analytical results for several variables are also sensitive to the choice of data resolution (tract or block group). Overall, this study indicates that more flexible spatial analytic techniques are required to improve the identification of environmental injustice and past studies utilizing conventional statistical methods should be revisited to explicitly account for spatial effects.

Multiple research studies have demonstrated racial, socioeconomic status (SES), and neighborhood disparities in first-line treatment of colorectal cancer patients, including those with metastatic colorectal cancer. However, disparities in adjunct monoclonal antibody treatment disparities have not been explored. The purpose of this study was to assess racial, SES, and neighborhood disparities in adjunct monoclonal antibody treatment of elderly metastatic colorectal cancer patients. The research was rooted in 3 theories: the fundamental cause theory, the diffusion of innovations theory, and theory of health disparities and medical technology. Data from the SEER-Medicare database and logistic regression were used to assess the relationship between the variables of interest and adjunct monoclonal antibody therapy. In this study, race (p = 0.070), SES (p = 0.881), and neighborhood characteristics (p = 0.309) did not significantly predict who would receive monoclonal antibody therapy. The results demonstrated a potential improvement in historically documented colorectal cancer treatment disparities. Specifically, historical treatment disparities may not be relevant to newer therapies prescribed to patients with severe disease. The difference could be related to improved access to care or a change in treatment paradigm due to the severity of metastatic colorectal cancer. Future studies aimed at understanding the causes of this social change (i.e., reduced treatment disparities) are warranted. Understanding the root cause of the reduced treatment disparities observed in this study could be used to reduce treatment disparities in other cancer populations.

Using the Health and Retirement Study Panel core files from 1996 to 2014, I analyze how Medicare Part D impacted access to prescription drug coverage by various demographic factors such as race, gender, and income. In Chapter 1, I find the highest take-up rates for those who were white, female, and with higher incomes. However, increases in coverage were high across the board, such that Medicare Part D also improved drug insurance coverage for those who were black, male, and with lower income. Thus, although Medicare Part D did increase prescription drug insurance coverage for seniors across the board, I also find potential for improvement in enrollment for difficult-to-reach groups. Next, Chapter 2 examines the impact of Medicare Part D on mortality. Although I do not find an impact on the life expectancy of respondents as a whole, I do find a significant positive effect for black respondents, indicating that Medicare Part D may have mattered more for disadvantaged groups. The largest impact is for black men, who have an additional 9 percentage point chance of living to age 73 for an additional 8 years of coverage (significant at the 5% level). When looking only at cardiovascular mortality, which is more likely to be influenced by drug coverage, I find improvements in life expectancy for the total population, with stronger effects for minorities and men. Overall, my findings suggest that Medicare Part D did move the needle on its goal: to improve the health of those who, without government intervention, had the most difficulty paying for prescription drugs. Chapter 3 looks at the impact of Medicare Part D prescription drug coverage on cost-related medication adherence, food insecurity, and finances among seniors. It would be reasonable to assume that Medicare Part D, which led to near-universal drug coverage among senior citizens, could allow seniors to shift money previously spent on drug expenditures to other areas. The strongest effect of Medicare Part D is on cost-related medication nonadherence, leading to a 21% decrease for an additional 8 years of Medicare Part D coverage. The impact is even stronger for the black male population (30%). I fail to reject the null hypothesis that Medicare Part D did not reduce food insecurity or household debt. Overall, Medicare Part D appears to have improved the financial stability of seniors.

Racial and ethnic minority populations suffer disproportionally from mental health disparities in the United States (Dillon et al., 2015; Holden et al., 2014). Research has indicated that a lack of culturally competent care contributes to these disparities (Holden & Xanthos, 2009). As multicultural competencies (American Psychological Association [APA], 2002; Council of National Psychological Associations for the Advancement of Ethnic Minority Interests, 2003) have been widely endorsed and implemented in professional organizations and training programs, research on their need and usefulness has increased over the last three decades (Worthington et al., 2007). However, the majority of research on multicultural competencies has relied on analogue studies, college students, and trainees as participants (Ridley & Shaw-Ridley, 2011; Worthington et al., 2007). The current study contributed to the multicultural competency literature by including perspectives from real clients with diverse backgrounds in community settings, along with assessing therapist multicultural competency (MCC). The study examined the relationship between therapist (n = 28) multicultural competency (MCC) and psychotherapy outcomes of clients (n = 2024) from diverse racial/ethnic backgrounds in a community mental health agency. Therapist MCC did not have a statistically significant positive relationship with treatment outcome. Therapist MCC also did not have a statistically significant positive relationship with reliable or clinically significant change in treatment outcome. Results do not indicate any mediating effect of therapist MCC between race and treatment outcomes. Gender predicted overall treatment outcomes, clinically significant change and reliable change in treatment. Findings suggest cultural variables may have played a role in treatment outcomes given the differences in treatment outcomes for female clients, despite the lack of association found between therapist MCC and treatment outcomes. Implications for clinical practice and research are discussed.

Objectives: Adherence to National Comprehensive Cancer Network (NCCN) guidelines for ovarian cancer treatment improves patient outcomes. The aim of this study was to assess disparities associated with ovarian cancer treatment in the state of Kentucky and central Appalachia. Methods: Data on patients diagnosed as having ovarian cancer from 2007 through 2011 were extracted from administrative claims-linked Kentucky Cancer Registry data. NCCN compliance was defined by stage, grade, surgical procedure, and chemotherapy. Selection criteria were reviewed carefully to ensure data quality and accuracy. Descriptive analysis, logistic regression, and Cox regression analyses were performed to examine factors associated with guidelines compliance and survival. Results: Most women were age 65 years or older (62.5%), had high grade (65.9%) and advanced stage (61.0%) ovarian cancer. Two-thirds of cases (65.9%) received NCCN-recommended treatment for ovarian cancer. The hazard ratio (HR) of death for women who did not receive NCCN-compliant care was 62% higher compared to the women who did receive NCCN compliant treatment (HR 1.62, 95% CI 1.11-2.35). Results from the logistic regression showed that NCCN-compliant treatment was more likely for: women age 65-74 years compared to age 20-49 (OR=3.32, 95% CI=1.32- 8.32), late stage compared to early stage cancers (OR 0.32, 95% CI 0.20-0.53), receipt of care at tertiary hospitals (OR=1.92, 95% CI=1.10-3.34), and privately insured compared to Medicaid (OR=0.31, 95% CI=0.13-0.77) or Medicare (OR=0.31, 95% CI=0.15-0.66). Conclusions: When the treatment of ovarian cancer did not follow NCCN-recommendations, patients had a significantly higher risk of death. Women were less likely to receive NCCN-compliant care if they were of younger age (20-49 years), had early stage disease, were not privately insured, or had care provided at a non-tertiary hospital.

The purpose of this study was to understand the role of Sport for Development (SFD) in addressing health disparities in low-SES communities. This was done using a multiple case study design, in which administrators, staff, and youth participants from five SFD programs were interviewed. A theoretical model, consisting of the theory of fundamental causes (Link & Phelan, 1995), the classification of SFD programs (Coalter, 2007), and the ecological model of health promotion (McLeroy, 1988), was developed to guide this study. Interviews were transcribed and then analyzed using a deductive coding process (Gilgun, 2005). The findings revealed that the SFD programs in this study were driven by goals such as providing access and opportunity to sport, helping youth develop life skills, and promoting health. The programs worked to achieve those goals by providing education, through their use of sport, and by providing resources and services. Finally, the programs in this study promote health at the intrapersonal, interpersonal, organization, environment, and policy levels. These findings hold various practical, scholarly, and policy implications and could shed light on how SFD programs may operate in order to reduce health disparities among low-SES populations.

Human papillomavirus (HPV) is the most common sexually transmitted virus, and is causally related to several cancers. HPV vaccination rates are far below HealthyPeople 2020 targets and vary across geographic, socioeconomic, and demographic populations. The purpose of this research was to test the relationships among socioeconomic and demographic variables, HPV vaccination, social vulnerability, and physician recommendation within select local areas in the United States. Fundamental cause theory and behavioral economics informed this quantitative secondary analysis of National Immunization Survey-Teen and Social Vulnerability Index data (n = 43,271). Statistical analyses included chi-square and binomial logistic regression. Teens whose mothers had less than a college degree were more likely to initiate the HPV vaccine series (p < .01), while teens living in Hidalgo County and Houston were less likely to initiate the series (p < .001). Younger teens (p < .001), males (p < .001) and teens whose mothers had some college (p < .01) were less likely to complete the series, while older teens (p < .001) and teens living in Philadelphia and Houston (p < .01) were more likely to complete the series. Fewer teens in Bexar County received a physician recommendation (p < .01); there was no difference between vaccine initiation and select local area. These findings highlight the need to consider local sociodemographic influences on underlying disparities in health and physician behavior. Informed interventions may produce positive social change by reducing variance in health care quality, tailoring public health efforts to local needs, and moving persons experiencing disparities in health outcomes toward a healthy future.