Increasing evidence suggests that the environment is related to many public health challenges. Unequal distributions of services and resources needed for healthy lifestyles may contribute to increasing levels of health disparity. However, empirical studies are not sufficient to understand the relationship between health disparity and the built environment. This dissertation examines how health disparity are associated with the built environment and if the environmental conditions that support physical activity and healthy diet are associated with lower health disparity. This research uses a multidisciplinary approach, drawing from urban planning, regional economics and public health. The data came from the Behavioral Risk Factor Surveillance System, and the GIS derived environmental data and the 608-respondent survey data from a larger study conducted in urbanized King County, Washington. Health disparity was measured with the Gini-coefficient, and health status and obesity were used as indicators of health. Hot spot analysis was used to identify the spatial aggregations of high health disparity, and multiple regression models identified the environmental correlates of health disparity. The overall trend showed that disparity has increased in most states in the US over the past decade and the southern states showed the highest disparity levels. Strong spatial autocorrelations were found for disparities, indicating that disparity levels are not equally distributed across different geographic areas. From the multivariate analyses estimating disparity levels, spatial regression models significantly improved the overall model fit compared to the ordinary least-square models. Areas with more supportive built environments for physical activity had lower health disparities, including proximity to downtown (+) and access to parks (+), day care centers (+), offices (+), schools (+), theaters (+), big box shopping centers (-), and libraries (-). Overall results showed that the built environment, compared to the personal factors, was more strongly correlated with health disparities. This study brings attention to the problem of health disparity in the US, and provides evidence supporting the existence of spatial disparity in the environmental support for a healthy lifestyle. Further research is needed to better understand environmental and socioeconomic conditions associated with health disparity among more diverse population groups and in different environmental settings.

Using data gathered over the course of two months through participant observation and semi-structured interviews with health providers (n=19) and community members (n=20), this research analyzes patient access to health care resources and describes community members' and health care providers' perceptions of pressing health concerns in their area. The results of this research show the types of health care resources in the county, the similarities and differences between health providers' and community members' perceptions, and how the unique characteristics of this community influence health care access and health disparity.

A qualitative approach was used to explore the influence of mass media campaigns on Black women’s perceptions of breast cancer. The primary purpose of this study was to address the high breast cancer mortality rate among young Black women, thus informing strategies to increase awareness of risk and encourage prevention activities. Black women have higher incidence rates before age 45 and are more likely to die from breast cancer at every age. Although the breast cancer mortality variance has been linked to socioeconomic status, studies have shown that differences in cancer knowledge and beliefs persist even when educational and socioeconomic measures are statistically controlled. Because little is known about how various ethnic group members form ideas about breast cancer in the U.S., semi-structured interviews were conducted with 27 Black women between the ages of 30 and 40 to determine their knowledge and beliefs about breast cancer, as well as their personal perceptions of susceptibility to being diagnosed with breast cancer, in order to illuminate the interplay of culture and health belief systems on participants’ understanding of breast cancer messaging. To explore the potentially complex dynamics involved in how young Black women come to construct meanings about breast cancer, a theoretical framework that coupled Cultural Models Theory with the Risk Perception Attitude framework was used to address how health campaigns influence the behaviors and breast cancer detection experiences of Black women. Findings from the study revealed that young Black women’s perceptions of breast cancer are primarily driven by personal experiences, as opposed to mass media influences. The Black women in this study had a lack of knowledge of risk and prevention factors and did not perceive themselves to be affected by breast cancer due to their young age. In spite of cultural taboos against discussing health issues with family and friends, the women in this study tended to take responsibility for their health and were proactive in seeking and acting on health information.

INTRODUCTION: To address a lack of population-level studies that examine the association between ambulatory care utilization and cardiovascular outcomes among Asian Americans, this study examined 1) ambulatory care utilization among different racial/ethnic groups and 2) the association between ambulatory care utilization and cardiovascular outcomes. METHOD: This was a retrospective analysis of 2009–2012 Medicare fee-for-service data. Primary outcomes were 1) hospitalization for angina, an ambulatory care sensitive condition, and 2) inpatient AMI mortality. Intermediate outcomes of interest were ambulatory care utilization. First, a descriptive analysis of patients’ predisposing and enabling factors was performed, and then bivariate association between these predisposing and enabling factors and ambulatory care utilization was examined. Lastly, using multivariate logistic regression models I estimated the association between ambulatory care utilization and cardiovascular outcomes, adjusting for socio-demographic and geographical characteristics. RESULTS: There were 999,999 people in the analytic sample, drawn from 21.6 million Medicare fee-for-service enrollees. In 2009, there were significant differences in racial/ethnic ambulatory care utilization. Significantly lower percentage of Asians had frequent ambulatory care visits (>30 visits) and outpatient cardiology clinic visits (>30 visits) (both p-values<0.01), after adjusting for predisposing and enabling factors. Asians had the highest observed inpatient mortality (15.9%) and low ambulatory utilization was associated with increased odds (OR=1.85 [1.11–3.08]) of inpatient AMI mortality. CONCLUSION: Among Medicare fee-for-service enrollees, Asians had fewer ambulatory clinic visits. Low ambulatory care utilization was associated with increased odds of AMI mortality. Further research is needed to understand the causal relationship between ambulatory care utilization and cardiovascular outcomes. / 2018-11-08T00:00:00Z

Stroke is associated with significant health disparity and predominantly affects the elderly. Stroke outcome is significantly improved if an individual is able to get "clot-bursting" medication. A significant predictor of an on-time arrival to the emergency room for treatment in the event of a stroke is the ability to accurately recognize stroke signs and symptoms. The purpose of this study was to determine the factors (demographic, socioeconomic, and educational) that predict the knowledge of stroke signs/symptoms and intent to call 911 in the event of a stroke. The study was grounded in the social ecological theoretical model and analyzed archived data from 11,537 African Americans to answer the research questions. Multivariable analysis and chi-square analysis for trend were done to determine the predictors of knowledge of stroke signs and symptoms, intent to call 911, and their respective trends. Results show that respondents who were 18-39 years of age were less likely to have a low to no knowledge (OR = 0.46, CI = 0.27 - 0.80), while those who had a high school (OR = 1.95, CI = 1.28 - 2.96) or less than high school (OR = 2.83, CI = 2.03 - 3.96) level of education were more likely to have low to no knowledge of stroke signs and symptoms. Further, while males were less likely (OR = 0.65, CI = 0.64 - 0.66), respondents age 40-64 years (OR = 1.87, CI = 1.14 - 3.09), and those with moderate to adequate knowledge of stroke (OR = 1.39, CI = 1.18 - 1.65), were more likely to say they intend to call 911 in the event of a stroke. This study may lead to policies to improve stroke knowledge among the elderly. Targeted stroke education based on age, education, and socioeconomic status should be a component of such policy. Additionally, this study may lead to the provision of sidewalks and health education programs to improve risk factor control and could thus impact stroke incidence.

The goal of this investigation is to explore the relationship of health provider communication techniques and their impact on patient understanding, satisfaction, and self-efficacy. This investigation looked at the two specific communication techniques of concern elicitation and mutual agenda setting which occur during the beginning of a medical visit. Encounters were recorded with patient knowledge and transcribed to be analyzed. Following a coding manual created from both previous research and original input, the transcripts were organized and read through to process data. Focusing on the two communication techniques—concern elicitation and mutual agenda setting—I looked at the beginning of the encounter to note any usage of the techniques. Using a series of independent samples t-tests, I found that patient understanding was significantly correlated with concern elicitation. At the same time, the length of visits that used concern elicitation and mutual agenda setting was not significantly greater than the length of visits in which these techniques were not used. This implies using these communication techniques clinical practice does not risk losing precious time. This investigation can also give support to more in depth research on various other communication techniques and their potential benefits in bridging the disparity in health literacy.

This systematic review examined literature spanning the last 10 years from Canada, the U.K., the U.S.A., Australia, and New Zealand. Findings highlight the significant gap in comparative literature examining (structural) racism as a determinant of South Asian healthcare access, utilization, and outcomes, and identifies areas of future research to address South Asian health equity concerns. / Background: Race, or specifically racism, has been well-established as a critical determinant of health, though current healthcare practices and policies in Western countries do not adequately address these issues. South Asians are the largest minority group in Canada, and they face disproportionate rates of chronic illnesses, mental health conditions, and barriers to care globally. However, their experiences in healthcare settings and the impact of race and racism on their health equity remain unexplored. This systematic review examined whether race affects healthcare access, utilization, and outcomes of South Asians compared to White-majority populations in Western countries. Methods: Embase, PsycInfo, Ageline, and CINAHL, were searched following PRISMA guidelines, as well as Google Scholar. Articles from 2013-2022 were included if they discussed racism, discrimination, or disparities/inequalities in South Asian physical and mental health, healthcare access, and utilization, outcomes compared to White populations in Canada, the U.K., the U.S.A., Australia, and New Zealand. The Mixed Methods Appraisal Tool (MMAT) was used to assess methodological quality. Data was synthesized narratively. Results: The review included 89 studies from Canada (n=19), the U.K. (n=51), the U.S.A. (n=17), and Australia (n=2), with most studies (n=76) utilizing cross-sectional or cohort designs and examining physical health outcomes (n=50). Study samples predominantly included Indians, Pakistanis, and Bangladeshis over other subgroups. Notably, there was no overall increase in comparative studies over the last decade; however, the U.K. observed an 85% increase compared to an 82% and 64% decrease in Canada and the U.S.A., respectively. The review also identified limited research on experiences within healthcare settings and mental health outcomes, sexual/reproductive health, and all health outcomes for children/youth. Few studies directly discussed the impacts of structural or organizational racism or discrimination on outcomes, though some commented on individual racism as well. Instead, studies relied on the social determinants of health as proxies for structural racism, such as education and income. Conclusion: This review highlights the significant lack of comparative research on the impact of structural, organizational, and individual racism on the healthcare access, utilization, and outcomes of South Asians compared to White-majority populations in Western countries. The review emphasizes the need for more primary, comparative research that quantifies and contextualizes South Asian experiences in obtaining healthcare services. Future research must employ rigorous and representative sampling methods, diverse study designs, and quantitative and qualitative measures that capture implicit, covert, and overt racism in healthcare among South Asians. Additionally, studies should measure factors such as religion, housing, language, and racialized institutional policies, in addition to the typically examined social determinants of health. Finally, this review highlights the need to collect and report disaggregated race and ethnicity health data with input from community leaders, and stratify these data by South Asian subgroups to avoid homogenization of distinct cultures and differential experiences in healthcare systems. Overall, acknowledging racism in healthcare and institutional policies is essential to effectively dismantle these issues and ensure health equity for South Asians. / Thesis / Master of Public Health (MPH)

Parkinson’s Disease (PD) is a neurodegenerative disorder affecting multiple domains in patients. Previous studies have illustrated the impact of healthcare disparities in patients with PD, illustrating worsened health outcomes between Black and White patient groups in all steps of the healthcare system such as diagnosis. Furthermore, the current literature has also illustrated the impact of low literacy levels on health-related outcomes in PD patients. While its role specifically in PD patients needs further understanding, language barriers have also affected patients and their interactions with the healthcare system, and its role in PD patients should be considered. In this research study, we aim to address the gaps in the existing literature through a mixed-methods design, using both qualitative and quantitative methods to address patients of Black/African-American, Hispanic/Latinx ethnicities or patients who speak Haitian Creole and Spanish regarding their experiences with diagnosis and treatment of PD.. We also aim to assess providers and their attitudes towards barriers they feel their patients from these populations may face, and to ultimately use the data of this study to develop educational videos for PD patients of these backgrounds. Ultimately, the findings of this research study may be influential not only for PD patients from these backgrounds by potentially improving their healthcare experience, but also other researchers continuing to investigate these disparities in PD and medicine overall.

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