This dissertation study was designed to examine measurement equivalence of the Center for Epidemiological Studies Depression (CES-D) Scale across White, African American, and Mexican American elders. Specific aims were to identify race/ethnicity-, sociodemographic-, and acculturation and instrument language-related measurement bias in the CES-D. Three studies were conducted in this dissertation to accomplish these aims. Two existing national datasets were used: the New Haven Established Populations for Epidemiologic Studies of the Elderly (EPESE) for the White and African American samples and the Hispanic Established Populations for Epidemiologic Studies of the Elderly (H-EPESE) for the Mexican-American sample. Differential item functioning (DIF) analyses were conducted using both confirmatory factor analysis (CFA) and item response theory (IRT) methods. Study 1 focused on the role of race/ethnicity on the measurement bias in the CES-D. Results from Study 1 showed a lack of measurement equivalence of the CES-D among Mexican Americans in the comparison with both Whites and Blacks. Race/ethnicity-specific items were also identified in Study 1: two interpersonal relation items in Blacks and four positive affect items in Mexican Americans. Study 2 focused on identifying sociodemographic-related measurement bias in responses to the CES-D among diverse racial/ethnic groups. Results from Study 2 showed that gender and educational attainment affected item bias in the CES-D. The interaction between gender and educational level and race/ethnicity was also found in Study 2: Mexican American women and lower educated Blacks had a greater predisposition to endorse the 'crying' item. Focusing on Mexican American elders, Study 3 examined how level of acculturation and language influence responses to the CES-D. In Study 3, acculturation and instrument language-biased items were identified in Mexican American elders. Study 3 also suggested that acculturation-bias was entirely explained by whether the CES-D was administered in the English or the Spanish versions. Possible reasons for item bias on the CES-D are discussed in the context of sociocultural differences in each substudy. Findings from this dissertation provide a broader understanding of sociocultural group differences in depressive symptom measures among racially/ethnically diverse older adults and yield research and practice implications for the use of standard screening tools for depression.

African Americans, Hispanics, and other minorities in the U.S. continue to face conditions of residential and educational segregation, lower socioeconomic status, and higher rates of mortality than whites. Better theory-based research that uses community and individual level factors to explain how health disparities are created and perpetuated is needed. The Community Context and Health Disparities Model, which extends the work of Schulz and Northridge (2004) with elements described by Williams and Collins (2001), is described. This framework identifies the pathways by which characteristics of the physical, built, social, economic, and healthcare environments impact health and are mediated by individual traits. Two measures of the healthcare environment, physician density and emergency room hospital accessibility, are created using Geographic Information Systems (GIS), compared to traditional measures of these concepts, and contrasted across racial and ethnic populations. The Community Context and Health Disparities Model is implemented to understand physical and mental health disparities among a sample of older adults in Miami-Dade County who were participants in the Survey of Older Floridians using hierarchical linear modeling (HLM). Exogenous measures of each community domain, including the healthcare measures created, are used as community-level predictors of self-rated health and number of depressive symptoms. The results show that community poverty rate predicts self-rated health, but is no longer significant after individual attributes are controlled. There is a significant interaction between Hispanic ethnicity and community poverty associated with self-rated health. Hispanics are negatively impacted by community poverty but other ethnic groups are not. Depressive symptoms are found to be primarily explained by individual characteristics. Future research, practice recommendations and policy implications of these findings are described.

The purpose of this study was to investigate the relationship between residential segregation (the physical separation of Blacks and Whites in residential contexts) and adverse perinatal outcomes (low birth weight, preterm delivery and small for gestational age births) in Florida, Georgia and Louisiana. The study determined the independent effect of the level of residential segregation on the likelihood of adverse perinatal outcomes after controlling for contextual and individual factors. The study also assessed whether the relationship between residential segregation and adverse perinatal outcomes were moderated by ethnicity and median income.The studied employed an observational, cross-sectional study design that utilized secondary data. Live birth certificates between 1999 and 2001 provided information on individual covariates and perinatal outcomes. Structural indicators of residential segregation and contextual covariates were obtained from the U.S. Census Bureau. Th e nested data structure for each birth outcome model was composed of individual, contextual, and structural data. Three-level, hierarchical generalized linear models were used to test research hypotheses.The study population consisted of non-Hispanic White and Black primaparous women between 15 and 49 years of age experiencing singleton live births delivered at less than or equal to 45 weeks gestation. The final sample consisted of 255,548 women nested within 4,360 census tracts and 63 Metropolitan or Micropolitan Statistical Areas. Residential segregation did not have a direct relationship with low birth weight, preterm delivery or small for gestational age, after controlling for other variables in multilevel models. Models testing the moderating effects of ethnicity indicated that increased Isolation decreased the risk of LBW among Black women. Several contextual --level variables and the majority of individual-level variables were significantly associated with perinatal outcome risk .Findings indicate that effects of residential segregation may be birth outcome and ethnic group specific. Relationships between individual factors, contextual factors and adverse perinatal outcomes signal the importance of proximal factors to perinatal outcomes. There is a need for specification of a broader constellation of biological, social and spatial factors and a thorough assessment of residential preferences and experiences in order to better understand the associations between neighborhoods and perinatal outcomes.

Access to health care is an important resource for sexually experienced adolescent females in the prevention of unintended pregnancy and sexually transmitted infections, including HIV. However, a paucity of research exists regarding the extent to which social disparities in access to health care exist among this vulnerable population of adolescents, including the potential contribution of the neighborhood context. Therefore, the primary aims of this dissertation were to examine (1) the extent to which racial and socioeconomic disparities in access to health care exist among sexually experienced adolescent females, (2) the extent to which access to health care among sexually experienced adolescent females varies across neighborhoods, and (3) the extent to which the neighborhood racial and socioeconomic context contribute to racial and socioeconomic disparities in access to health care among sexually experienced adolescent females. A multilevel design was employed for this dissertation utilizing secondary data from Wave I of the National Longitudinal Study of Adolescent Health (Add Health). Analyses included hierarchical generalized linear modeling to examine the receipt of a routine physical, the receipt of contraceptive services, and reported unmet health needs among the dissertation sample of 1,526 sexually experienced Non-Hispanic Black and Non-Hispanic White adolescent females between 15 years to 19 years of age who were dispersed across 546 neighborhoods. After adjusting for a variety of factors that may influence access to health care, the findings revealed no racial disparities and few socioeconomic disparities in access to health care among this sample of adolescents. No significant relationship was noted between the neighborhood racial and socioeconomic context and access to health care or social disparities in access to health care among this sample of adolescents. However, the findings revealed that access to health care among this sample of sexually experienced adolescent females varied across neighborhoods, above and beyond the individual composition of the neighborhood. Further studies are indicated to explore the underlying factors that contribute to socioeconomic disparities in access to health care among sexually experienced adolescent females, and the potential neighborhood characteristics that may contribute to differential access to health care across neighborhoods among this vulnerable population of adolescents.

LaRossa, Jaret, Gadgil, and Wynn (2000, 2001) conducted a content analysis of 495 comic strips published on Father’s Day and Mother’s Day in the United States from 1945 to 1999 in order to determine whether the culture of fatherhood and gender disparities in the media had changed over the past half-century. Drawing on their research, I conducted a similar kind of analysis of 246 comic strips published on Father’s Day and Mother’s Day in Japan from 1950 to 2004. By comparing and contrasting the results in the two studies, I show how comic portrayals of families have changed in Japan and in the United States, and demonstrate the value of analyzing comic strips in cross-national research.

The existence of unfair differences or disparities in access to and quality of health care is well known. However, the nature of disparities at different stages of the health seeking pathway and interventions to reduce them are less clear. Applying the tools of statistics and quasi experimental design-- interrupted time series, propensity score matching, hierarchical models---we can analyze how care is accessed in low, middle and high income countries and assess for disparities. The results are sometimes surprising and underscore the need to generate context specific evidence to ensure targeting of programs. My first paper evaluates the impact of a controversial policy, mandating of health insurance, on reducing disparities in health care access and affordability. Using longitudinal survey data from five states in USA (2002-2009), I show that living in MA, where health insurance is mandated, results in a higher probability of being insured and having a personal doctor and lower probability in forgoing care due to costs as compared to similar border states. The beneficial effect of the mandate is greatest in traditionally "disadvantaged" groups defined by race, income, education or employment status. My second paper examines gender disparities in access to medicines in sub Saharan Africa--Uganda, Kenya, Nigeria, Ghana, Gambia. Using medicines specific survey data, I construct a novel seven stage access to medicines pathway and assess gender disparities along it applying the Institute of Medicine framework. Contrary to prevailing belief, I find few gender differences in unadjusted outcomes which cease to be significant on controlling for health status and country characteristics. My third paper assesses disparities by educational attainment in process and outcomes of care. I use unique data extracted from an electronic medical record of diabetic patients in Mexico City. Using a matching algorithm, I control for only differences in health need and find few significant differences in processes and outcomes of care. The unmatched traditional regression based risk adjustments tend to overestimate the significance and magnitude of the association. The three papers demonstrate the need to use more sophisticated statistical tools to appropriately measure disparities and ensure the effectiveness of health programs.

Background: Disparities in care for seriously ill African American (AA) elders exist because of gaps in knowledge regarding culturally sensitive physiological, psychological, social, and spiritual needs and preferences. Conceptual Framework: The foundation of culturally sensitive patient-centered PC is formed from social, spiritual, psychological and physical experiences of serious illness. Purpose: Aim 1 was to describe categories and patterns of psych-social-spiritual healing from the perspective of AA elders with serious illness. Aim 2 was to examine the NIH Clinical Center's psych-social-spiritual healing measure as a valid, culturally appropriate measure for this population. Methods: A purposive sample of 28 AA elders with serious illnesses and from the Jackson MS area participated in this study. Aim One used the qualitative method of narrative analysis. Aim Two used cognitive interviewing methodology, including verbal probing and think aloud techniques. Findings: Aim One: Prior experiences, I changed, and Across past, present experiences and future expectations were the three main of the thematic analysis. The thematic categories in prior experiences were: been through it...made me strong, I thought about…others, and went down little hills...got me down. The thematic categories in I changed were: I grew stronger, changed priorities, do things I never would have done, and quit doing. The thematic categories in Across past, present experiences and future expectations were: God did and will take care of me, close-knit relationships, and life is better. The most prevalent theme of God did and will take care of me was divided into subthemes of: God did, God will and developing faith. Aim Two: Of the fifty-three items on the Psychological-Social-Spiritual Healing instrument, thirty-seven items were retained, eight items revised, and eight items deleted. Conclusions: Aim one: The narratives were stories of remarkable strength. This strength was grounded in the participants' "faith" in God that helped the aging seriously ill AA elder "overcome things." Aim Two: Linguistic validity was enhanced with expert input from the seriously ill AA elders. Pragmatic validity, using both the research team and participants' input, improved the content validity. These findings provide evidence towards a more valid and culturally sensitive tool.

Colorectal cancer (CRC) is the third most common cancer in the United States (U.S.) and is the second leading cause of cancer deaths. Although the incidence of CRC has been decreasing with CRC screenings, disparities of CRC and screening prevalence exist for racial and ethnic groups. The CRC incidence rates have dramatically increased in Korean Americans, however, there is little known about their CRC screening behaviors and the factors that may predict screening behaviors have not been fully investigated. The purposes of this study were to describe CRC screening behaviors and identify the predictors and barriers influencing CRC screening behaviors among Korean Americans. A sample of 254 Korean Americans participated in this study. Correlation, Multiple logistic regression, and Chi-square were used to analyze data. In this study, Korean American had lower rates of CRC screenings compared to the general U.S. population. Only 20% of the sample had ever had a fecal occult blood Test (FOBT), 49% had ever had a colonoscopy, and 19% responded they had ever had a sigmoidoscopy in their lifetime. Korean Americans had low rates of perception of cancer screening (annual physical exam and periodic cancer screening), moderate CRC knowledge, low cancer fatalism, limited CRC literacy, lack of health care access, and a low rate of receiving the physician's recommendation of CRC screenings. The greatest predictors influencing CRC screening were perception of cancer screening for a FOBT, and the physician's recommendation for a colonoscopy and a sigmoidoscopy. There were no significant differences by gender in CRC screening behaviors. However, significant differences were found between the two groups divided by length of U.S. residence. Compared to those who have lived in the U.S.>10 years, new immigrants had lower rates of all three CRC screening, lower perception of cancer screening, higher uninsured, less receiving physician's recommendation, and higher perceived barriers to CRC screening. The findings of this study suggest that improved efforts are needed to increase CRC screenings among Korean Americans. Further research is needed to increase a physician's recommendation for CRC screenings and awareness for the importance of annual checkups and periodic cancer screening among Korean Americans.

Introduction: Domestic research studies focused on the interrelationships between political ideology characteristics inherent in policy decisions and the contributions these political determinants exert over health indicators and outcomes are limited. Given the paucity of research that focuses on political and policy support of health at the county-level, this study sets out to utilize the University of Wisconsin Population Health Institute’s (UWPHI) annual County Health Rankings data and examine them within the context of county-based majority political partisanship and economic measures. Methods: This exploratory ecological study examined differences between independent variables: partisan voting behavior (trichotomized as conservative, moderate, and liberal) and median per capita household income in U.S. dollars (by quartile) on dependent variables related to mortality (years of productive life lost) and morbidity (number of poor mental and physical health days) at the county-level to compare differences in political and ideological underpinnings that may act as influencers on health outcomes. Multiple data sources were combined and matched to all 3,140 counties located in the U.S. Two-way between-subjects ANOVA statistical tests were conducted to determine if there is an effect of partisan voter index category on the three aforementioned dependent variables related to health outcomes, and median per capita income by quartile. Results: There was a statistically significant main interaction between median per capita household income by quartile and partisan voter index category on years of productive life lost, F(6,2789) = 19.3, p < .000, partial η2 = .040. While there were also statistically significant interactions between the independent and dependent variables of poor mental and physical health days, results of those analyses should be interpreted with caution. Pertaining to years of productive life lost, post hoc analyses of significant interactions revealed significant differences at the lower income quartile, but not in the expected direction. The conservative category had statistically significant lower years of productive life lost in comparison to the liberal category (M = -8.21, SE = 1.47, p = .000). Also, there were significant differences detected in the upper quartile suggesting that the liberal category has lower years of productive life lost in comparison to the conservative category (M = 7.06, SE = 1.06, p = .000). Conclusion: Results should be interpreted with caution and suggest more research and methodological refinements are needed, particularly related to categorizing county-level political dynamics.

Victims of teen dating violence (TDV) in the United States engage in risk behaviors that increase their vulnerability to ill health. Although teen dating violence affects millions of adolescents of diverse ethnic backgrounds, there is a higher prevalence of TDV among Blacks and Latinos. In order to develop effective interventions for diverse populations, it is critical to understand the risk behaviors associated with different victims of TDV. The purpose of this thesis is to determine whether there is a difference between the risk behaviors (alcohol abuse, illegal drug use and perilous sexual intercourse) engaged in by Black, Latino and White adolescent victims of TDV. The national 2005 Youth Risk Behavior Survey (YRBS) was the source of data. This thesis hypothesizes that there are different risk behaviors related to each ethnic group, and aims to provide information to support the development of culturally competent TDV interventions.