Indiana University-Purdue University Indianapolis (IUPUI) / Compared to people who are White and have high socioeconomic status (SES), those who are Black and have low SES are more likely to receive suboptimal pain care. One potential contributor to these disparities is biased provider decision-making—there is compelling evidence that providers are influenced by patient race and SES when making pain treatment decisions. According to the dual process model, people are more likely to be influenced by demographic stereotypes, including implicit beliefs, when they are under high cognitive load (i.e., mental workload). One stereotype belief relevant to pain care is that Black and low SES people are more pain tolerant. Aligned with the dual process model, providers who are under high cognitive load and have strong implicit beliefs that Black and low SES people are more pain tolerant may be particularly likely to recommend fewer pain treatments to them. To test this hypothesis, I recruited physician residents and fellows (n=120) to make pain treatment decisions for 12 computer-simulated patients with back pain that varied by race (Black/White) and SES (low/high). Half of the providers were randomized to the high cognitive load group in which they were interrupted during the decision task to make conversions involving hypertension medications for another patient. Remaining providers completed the task without being interrupted. Providers’ implicit beliefs about race and SES differences in pain tolerance were measured with two separate Implicit Association Tests (IATs). Multilevel modeling indicated that providers recommended stronger medications to low than high SES patients (OR=.68, p=.03). There was also a significant interaction between patient SES and cognitive load (OR=-.56, p=.05) and a trending interaction between patient race and cognitive load (OR=1.7, p=.07). Under low cognitive load, providers recommended more pain treatments to high SES (vs. low SES) and Black (vs. White) patients, but under high cognitive load, providers recommended more pain treatments to low SES (vs. high SES) patients and equivalent treatment to Black and White patients. There were no three-way interactions between patient demographics (race or SES), cognitive load, and providers’ implicit beliefs (race-pain or SES-pain IAT scores). However, there was a trending interaction between patient race and race-pain IAT scores (OR=2.56, p=.09). Providers with stronger implicit beliefs that White people are pain sensitive and Black people are pain tolerant recommended more pain treatments to White patients and fewer pain treatments to Black patients. Lastly, there was a trending effect that providers with stronger implicit beliefs that high SES people are pain sensitive and low SES people are pain tolerant recommended stronger medications in general (OR=13.03, p=.07). Results support that provider cognitive load is clinically relevant and impacts clinical decision-making for chronic pain for racially and socioeconomically diverse patients. Future studies are needed to further understand the impact of cognitive load on providers’ pain care decisions, which may inform evidence-based interventions to improve pain care and reduce disparities.

In the United States, low-income, ethnic/racial minorities and rural populations are at increased risk for poorer health outcomes compared to higher income, non-minorities, and urban populations. Two key determinants that influence rural health disparities are health literacy and social capital. Health literacy can be described as an individual-level factor and defined as, "the degree to which individuals have the capacity to obtain, process, and understand the basic health information and services needed to make appropriate health decisions." Social capital is a concept that accounts for the role of collective social functioning and has been defined as, "the features of social structures, such as levels of interpersonal trust and norms of reciprocity and mutual aid" which act as resources for individuals to facilitate collective action." The overarching goal of this research is to explore factors influencing health disparities, including health literacy, social capital in two rural regions of Virginia. The first study is embedded in Talking Health, a larger 2-arm RCT targeting adults in rural Southwest Virginia and examined participants' perceptions of and satisfaction with components of a behavioral intervention designed using health literacy concepts to decrease sugary beverage intake in rural, low-health literacy participants. The second study is also embedded in the Talking Health trial, yet focused on the maintenance of behavior 12-months after the intervention concluded. Guided by RE-AIM, this study examined the reach, effectiveness and implementation of a 12-month randomized extended care intervention aimed at enhancing long-term maintenance of behavior change and study retention when compared to a control condition. The last study is part of a larger telephone surveillance survey conducted in the Dan River Region located in south central Virginia. This study described current levels of social capital in the Dan River Region and examined the influence of social capital on FV consumption, physical activity, sugary beverage intake and BMI on a sample of rural and urban adults. / Ph. D.

Purpose: Hispanic or Latino older adults in the US are 1.5 times more likely to have Alzheimer’s and related dementias (ADRD) than white older adults. Nearly one third of all skilled home health (HH) patients and nearly one half of hospice patients have ADRD diagnoses. In ADRD’s long trajectory of decline, patient care transitions bring risks for poor outcomes. Minoritized patients are at high risk for live discharge from hospice, but little is known about those who transition from hospice to skilled HH, the fastest-growing long-term care setting in the US. Aims: to determine demographic and diagnostic variables among patients with ADRD who transition from hospice to skilled HH. Methods: We used Medicare claims data and descriptive statistics including Chi-Square to determine demographic differences in frequency of care transitions from hospice to skilled HH for (a) older adults with ADRD and (b) older adults with co-occurring ADRD and cardiovascular disease (CVD). Results: In N = 272,323 hospice episodes, we found that Hispanic or Latino older adults with co-occurring ADRD and CVD had significantly higher rates of care transitions from hospice to skilled HH (P=0.037) than other racial and ethnic groups with both diagnoses. Conclusions: This is the first study to our knowledge that provides evidence on disparities in care transitions from hospice to skilled HH for Hispanic or Latino older adults with ADRD and CVD. Multiple factors may impact this result. Implications include policy change and greater coordination across systems of care, with specific attention to health equity.

<p dir="ltr">Health equity remains a fundamental goal in public health, driven by the significant disparities in health outcomes experienced by marginalized populations. This study investigates the multifaceted factors contributing to health disparities and highlights the necessity of comprehensive approaches to mitigate these inequalities. </p><p dir="ltr">First, we examine the impact of legislative climates on health outcomes for transgender and cisgender populations. We implemented a marginal structural model with inverse probability weighting to understand the causal relationship between state-level policy environments and transgender health disparities. Our findings reveal that while cisgender individuals generally experience consistent healthcare utilization and better health outcomes, transgender people in less supportive states face significant barriers and worse health outcomes. </p><p dir="ltr">Second, we explore the role of gender-affirming medical care during adolescence in influencing adult psychological and general health outcomes. Using data from the 2015 US Transgender Survey, we compare the health outcomes of transgender and non-binary individuals who received gender affirming medical care (GAMC) during adolescence with those who did not. Our causal moderation analysis demonstrates that GAMC during adolescence is associated with reduced psychological distress in adulthood, with the effect significantly moderated by state-level policy stigma. </p><p dir="ltr">Lastly, we conduct a qualitative study on breast cancer disparities between Black and White patients, using semi-structured interviews and health services data to map patient journeys across the cancer control continuum. Our thematic analysis identifies significant barriers faced by Black women, including cultural discordance, communication challenges, and delays in diagnosis, underscoring the need for tailored interventions to enhance provider-patient communication and support.</p><p dir="ltr">This study emphasizes the importance of a holistic approach to achieving health equity, addressing individual, systemic, and legislative factors. By advocating for inclusive policies, improving provider-patient communication, and ensuring access to comprehensive care, we can work toward eliminating health disparities and promoting equitable health outcomes for all populations. The findings provide a foundation for future research and policy development aimed at achieving these critical goals.</p><p><br></p>

The Internet offers potential for reducing professional isolation of Appalachian health care providers by enhancing access to medical information and facilitating contact with colleagues. However, there is a gap in the knowledge of current computer and Internet access in Appalachia, and in the technology-related behaviors and attitudes of health care professionals there. This study examined Internet-related access and behaviors of Appalachian family physicians and advanced practice nurses. A survey was mailed to 429 graduates of East Tennessee State University's family medicine residency and advanced practice nursing programs currently in practice in southern and central Appalachia. Demographic information was collected from ETSU graduate records. The Dillman survey method included a pre-notice letter, two survey mailings, and post card and telephone follow-ups. Two hundred sixty-four providers (61.5%) returned surveys. Data were analyzed using SPSS. Respondents were similar to the total population in gender, provider discipline, age, and percentage in rural practice. Workplace computer access was common; 59.6% had sole access and 40.2% shared access. Internet access was: 82.7% broadband, 13.5% dial-up, and 2.4% no access. Although rural providers were more likely than urban to have slower dial-up access, they regularly used the Internet. Over 75% of providers accessed the Internet at home for work; 34% reported dial-up and 66% broadband home connection. Although 50% used the Internet for continuing education in 2004, most preferred in-person workshops or print-based modes of continuing education; 58.9% e-mailed daily and 80% accessed medical information via the Internet regularly. Other Internet uses included accessing online journals and patient information, receiving professional association updates, filing insurance, and writing prescriptions. The Internet is ubiquitous in Appalachia; health care providers access it for a variety of professional activities daily. Telemedicine was not a popular technological innovation. Of those 20.8% reporting telemedicine availability in the practice, few used it. When presented with a list of possible benefits of telemedicine, 41.1% selected "none of the above". Although many technological innovations are used regularly by Appalachian health care providers, barriers to the use of new technologies lie more in attitudes than in technology access.

Health-related disparities remain a persistent, serious problem across the nation's more than 60 million rural residents. Rural Populations and Health provides an overview of the critical issues surrounding rural health and offers a strong theoretical and evidence-based rationale for rectifying rural health disparities in the United States. This edited collection includes a comprehensive examination of myriad issues in rural health and rural health care services, as well as a road map for reducing disparities, building capacity and collaboration, and applying prevention research in rural areas. This textbook offers a review of rural health systems in Colorado, Kentucky, Alabama, and Iowa, and features contributions from key leaders in rural public health throughout the United States.

In 2010 Medicaid financed approximately 48% of all births in the United States and nearly 30% of all births in Virginia. Due to strict state-specific eligibility criteria, many low-income women qualify for Medicaid coverage exclusively as a result of pregnancy status. As the nation moves forward with the Patient Protection and Affordable Care Act (PPACA), state-elected Medicaid expansion has the potential to expand services to women of reproductive age that would precede pregnancy events and offer continuous access to care postpartum. Despite this potential influx of newly insured women, little is known about how this population may make decisions regarding reproductive healthcare services and if these selections influence process and outcome measures. This study examines two research aims that provide insight into these knowledge gaps. First, utility theory and discrete choice modeling is used to examine clinic and patient level factors associated with clinic type choice. Specifically, this study examines the role of high risk pregnancy status and travel distance to clinic as associated with clinic selection. Second, Donabedian’s Structure, Process, Outcome framework provides a conceptual lens to examine if clinic selection is associated with maternal and infant measures. The linear probability model and logistic regression models are employed to examine two process measures, including prenatal care inadequacy and postpartum visit nonattendance, and three outcome measures including maternal long acting reversible contraceptive method (LARC) use and infant birthweight and gestational age. Results examining clinic type selection reveal significant associations between independent and dependent variables. Women experiencing a high risk pregnancy are significantly more likely to select a hospital based clinic for care, compared to women experiencing a normal risk pregnancy. However, when specifically examining women experiencing their first pregnancy, this association is no longer significant. Additionally, as distance to clinic type increase, women are significantly less likely to select that clinic type for prenatal care. Clinic selection was found to be significantly associated with maternal measures, but not significantly associated with infant outcomes. Selecting a public health department or Federally Qualified Health Center for prenatal care services was associated with a significant decrease in inadequate prenatal care, postpartum visit nonattendance, and non-LARC use compared to a private physician office. Clinic type selection, however, was not found to be significantly associated with infant outcomes including preterm birth and low birthweight babies. Results from Research Aim 1 have a variety of implications for clinic and public policy and offer guidance for future research. Clinics that seek to provide care to pregnant Medicaid beneficiaries should examine local residential patterns of current and potential future pregnant Medicaid recipients and consider how these might affect decisions about future clinic locations. Results suggest that women are more likely to attend clinic types closer to their area of residence, and this close proximity may have additional implications beyond shorter travel time to clinic including the minimization of transportation and childcare issues. Results from Research Aim 2 analyses offer a variety of public policy implications and guidance for future research. This research provides evidence that public health facilities including public health departments and FQHCs have improved prenatal care adequacy and postpartum visit attendance compared to private physician offices, providing evidence that public funding should continue for these facility types. As the United States moves forward with PPACA, healthcare organization administration should turn to the public facilities in their communities to learn how to manage and improve the health of these patient populations and ultimately aim to improve access and quality care among the nation’s most vulnerable populations.

Among the health disparities affecting the U.S. Hispanic population today are those relating to risky behaviors such as substance abuse, intimate partner violence (IPV) and HIV/AIDS. However, few studies have examined how these conditions may impact this population. The purpose of this dissertation was to explore the experiences that Hispanic women in South Florida have with regard to substance abuse, IPV and risks for HIV/AIDS, to describe how these conditions may be related, and to develop a model that can be used to guide research and interventions targeting this population. This dissertation uses data collected in Project DYVA (Drogas y Violencia en las Americas- Drugs and Violence in the Americas), a pilot research study that utilized both qualitative (Phase I) and quantitative (Phase II) research methods to describe the experiences of Hispanic women in South Florida between the ages of 18 and 60 with regard to substance abuse, violence and risky sexual behaviors. Three studies were conducted as part of this dissertation. The first study utilizes data collected during the qualitative phase of Project DYVA. During this phase eight focus groups were conducted and analyzed using qualitative content analysis (N = 81). The second and third studies utilize data collected during the second phase of Project DYVA. In this phase cross-sectional questionnaires collecting information regarding demographics, acculturation, self-esteem, depression, substance abuse, IPV and risks for HIV, were administered to 82 Hispanic women. Univariate and multivariate statistics were used to explore the relationships between substance abuse, IPV and risk for HIV (study 2) and between resource availability, IPV and depression (study 3). The findings from this dissertation suggest that substance abuse, IPV and risk for HIV are closely related intersecting health issues. IPV, the condition that emerged as the most salient of the three, also appears to be closely associated with resource availability (i.e., self-esteem and income) and depression. Additional individual, cultural, relationship and socio-environmental factors that may play a significant role in shaping the experiences that Hispanic women have with regards to these intersecting conditions were also identified and organized into a model.

Environmental factors within communities play a significant role on the health and well-being of residents. These social and physical determinants have a substantial effect on health. This interaction can result in environmental injustices, inequality, and ultimately poor health for residents. The community of Galena Park, Texas, is a predominantly minority community of Hispanic and African-American residents with previously undocumented concerns related to air quality, the built environment, access to healthcare and the food environment. Through participatory engagement with Galena Park residents using Geographic Information Systems (GIS), this research examines the degree to which GIS is an effective tool in illustrating and visualizing environmental and social injustices. Findings from this research suggest that GIS only relays part of the story and is most powerful when the lived experiences of residents are integrated into the analytical process.

In response to the presence of health disparities among a diverse population of older adults, creating culturally competent health care services has emerged as a possible method to help reduce and eventually eliminate inequalities in health care. However, little information exists concerning the effectiveness of cultural competence, and even less is known about how culturally competent clients perceive their providers to be. This dissertation examined a number of indicators related to cultural competence, including the predictors of client-provider racial/ethnic concordance, client perceptions of the interpersonal sensitivity of their health care providers, and the overall satisfaction with care reported by older Non-Hispanic White, African American/Black, Hispanic/Latino, and Asian American adults. In order to accomplish these aims, three related studies were conducted, all drawing on data from the Commonwealth Fund 2001 Health Care Quality Survey. The first study focused on the factors that predicted racial/ethnic concordance between clients and their health care providers. The second study examined several factors that can affect the clients’ perception of their providers’ interpersonal sensitivity, including client-provider racial/ethnic concordance. The third and final analysis utilized the outcome variables from the two previous studies, in addition to the client-level variables, to determine which factors predicted satisfaction with care received. The results show that the factors that predicted client-provider racial/ethnic concordance and perceived interpersonal sensitivity varied across the four groups. In addition, perceived interpersonal sensitivity was a significant predictor of satisfaction with care for all four of the groups. The findings from this dissertation contribute to a broader understanding of racial/ethnic differences in client-provider racial/ethnic concordance, perceptions of interpersonal sensitivity, and overall satisfaction with care among older adults from racially and ethnically diverse backgrounds.