This research study began with an interest in understanding how social workers address poverty and/or low income in hospital settings. It discusses the ways in which hospital social workers address poverty in front line practice, while connecting how the experience of poverty and/or low income can further complicate one’s health and access to healthcare. This paper also discusses the ways that macro political ideologies, structural barriers and societal stigma impact how social workers address poverty in frontline hospital practice. Poverty is a social determinant of health, which is why understanding how hospital social workers address poverty in front line practice is important. Given the influence of neoliberalism and its impact on the growing gap between the rich and poor, it is suggested that poverty and low/income will continue throughout Canadian society. This paper also discusses, how accessing healthcare and navigating the system may become difficult for those experiencing poverty. This study is based on a thematic analysis of the findings from six semi-structured interviews with individuals practicing as social workers in two large teaching hospitals in southern Ontario. The data is interpreted and discussed using a critical framework, specifically, anti-oppressive practice and Marx theory. The subsequent findings indicate that in practice front-line social workers address poverty in practical ways. Major themes that emerged from this research include: addressing stigma, navigating “the system”, systemic and structural barriers, no family, no friends, and connecting with resources. / Thesis / Master of Social Work (MSW)

In recent years, there has been increased focus on rural and Appalachian health because of disparate chronic health outcomes when compared to the rest of the US. Appalachia, a subsection of the US, has even worse health outcomes related to chronic diseases. Although Appalachia is its own unique region, there is significant overlap with rural areas in terms of shared cultural characteristics (e.g., strong sense of community, distrust in outsiders, lack of trust in traditional medicine, and strong Christian religious affiliations and faith in God), limited access to healthcare services, and disparate health outcomes. The research presented in this dissertation is significant because it provides insight into and compares healthcare utilization rates in women in Appalachia and surrounding areas. Study 1: In addition to racial discrimination, Black Appalachian women often face other obstacles involving other types of negative interpersonal experiences when seeking healthcare. Despite these known disparities, Black women are frequently underrepresented in Appalachian health research. This study investigated healthcare experiences for sixteen Black Appalachian women using semi-structured interviews to identify and subsequently address ways to eliminate barriers to care. Interview questions utilized the theory of intersectionality and the Social Ecological Model to create a framework to describe the complexity of healthcare utilization and barriers to care while providing context into each participant's background and lived experience. Interview questions explored four topics: 1) barriers to medical care; 2) social support; 3) ideal and actual healthcare experiences; and 4) desired changes to improve quality of care. We used an inductive analysis process to create a robust thematic coding schema, organizing responses into 60 total themes and 141 codes, and reported the most frequent. Our results explore the ways in which one's intersectional identity as a Black Appalachian woman affects interpersonal interactions and experiences when engaging with the healthcare system. Participants frequently reported barriers related to scheduling conflicts and delays, experiences with rushed appointments and inhospitable providers and support staff, and desires for accurate collection of medical information. Participant responses often emphasized difficulties with the organization of the medical system, revealing specific areas for future intervention to improve quality of care for Black Appalachian women. Study 2: Use of the emergency department (ED) for low acuity conditions (e.g., back pain, dental pain, sore throat) and primary care places an additional strain on ED staff and resources, while increasing waiting and treatment times for high acuity patients. Factors such as race, gender, and insurance type have a strong association with the likelihood of a patient using the ED for a low acuity concern. Women are more likely to utilize healthcare services, which also holds true in the context of the ED. Using a sample of adult women from Virginia, West Virginia, Tennessee, North Carolina, and Kentucky, I investigated which demographic factors, age, race, geographic location (metro, nonmetro, rural), employment, and insurance coverage, affect a patient's likelihood to visit the ED for a low acuity condition within a southwestern Virginia hospital system. Log-binomial regression was used to estimate unadjusted and adjusted prevalence ratios of acuity level by race, age, rurality level, employment, and insurance type with corresponding 95% CIs. Our sample included 28,222 female patients who visited the ED between January 1, 2021 and September 30, 2022. Low acuity visits accounted for 15.9% (n=4,485) of visits during the timeframe. In summary, our results suggest that older age and location in non-metro area are the most salient factors contributing to a higher likelihood of low acuity ED visits among women. Race, a primary variable of interest, did not have the relationship to acuity that was expected based on previous literature; Black women patients were less likely to have a low acuity visit than white women patients. During our study period, overall number of visits remained steady, while there was an increase in proportion of low acuity visits. Further research is needed into the underlying causes to more definitively explain this increase. / Doctor of Philosophy / In recent years, there has been increased focus on rural and Appalachian health because of disparate chronic health outcomes when compared to the rest of the US. Appalachia, a subsection of the US, has even worse health outcomes related to chronic diseases. Although Appalachia is its own unique region, there is significant overlap with rural areas in terms of shared cultural characteristics (e.g. strong sense of community, distrust in outsiders, lack of trust in traditional medicine, and strong Christian religious affiliations and faith in God), limited access to healthcare services, and disparate health outcomes. Black/African Americans are another population with higher rates of chronic disease and poorer health outcomes compared to their white and Latinx peers. The combination of poorer health outcomes and higher rates of chronic disease negatively impacts life expectancy and quality of life. One driving factor in these poor health outcomes across all of these groups is low rates of healthcare utilization, whether due to decreased access (as is the case for many rural populations), or other as of yet unidentified challenges. Although literature exists about rural health outcomes, Appalachian health outcomes, and health outcomes focusing on Black women, there is very limited literature that examines the intersectional impact of these characteristics on health. Health disparity research in this region does not currently stratify differences in outcomes by both race and gender, which prevents a detailed analysis of the full extent of the gap in health outcomes. This research presented in this dissertation is significant because it provides insight into and compares healthcare utilization rates in women in Appalachia and surrounding areas across the lifespan. Knowing the contextual factors influencing healthcare seeking behaviors and utilization is the first step to designing effective interventions that improve women's access to care. Interventions need to be intentionally designed to consider, and ultimately, shift medical care and community attitudes to decrease health disparities in Appalachia. To successfully decrease health disparities, it is necessary to consider all of a patient's identities or characteristics. The same contextual factors that affect their healthcare utilization can also impact their care experience.

Oral health is an important aspect of overall health, but many vulnerable populations such as migrant farmworkers are without access to oral healthcare. Although some non-government organizations such as faith-based organizations have attempted to fill gaps left by government and private sectors, a lack of a dental safety net creates limited access to oral health services for migrant farmworkers. Access to care is further constrained by structural factors including low wages, migration route, and high costs of care. Building off a critical medical anthropology approach in understanding oral healthcare access, I argue that limited oral health access for migrant workers in the Tampa Bay area is the result of economic constraints and not cultural beliefs or educational shortcomings. This research therefore demonstrates the social determinants of oral health, and how social disparities can become embodied in marginalized groups such as migrant farmworkers.

abstract: This research is an anthology of a series of papers intended to describe the health state, healthcare experiences, healthcare preventive practice, healthcare barriers, and cardiovascular disease (CVD) risk factors of Asian Americans (AA) residing in Arizona (AZ). Asian Americans are known to be vulnerable populations and there is paucity of data on interventions to reduce CVD risk factors. An extensive literature review showed no available disaggregated health data of AA in AZ. The Neuman Systems Model guided this study. Chapter 1 elucidates the importance of conducting the research. It provides an overview of the literature, theory, and methodology of the study. Chapters 2 and 3 describe the results of a cross-sectional descriptive secondary analysis using the 2013, 2015, and 2017 Behavior Risk Factor Surveillance System (BRFSS) datasets. The outcomes demonstrate the disaggregated epidemiological phenomenon of AA. There were variations in their social determinants of health, healthcare barriers, healthcare preventive practice, CVD risk factors, and healthcare experiences based on perceived racism. It highlighted modifiable and non-modifiable predictors of hypertension (HTN) and diabetes. Chapter 4 is an integrative review of interventions implemented to reduce CVD risks tailored for Filipino Americans. Chapter 5 summarizes the research findings. The results may provide the community of practicing nurses, researchers, and clinicians the evidence to plan, prioritize, and implement comprehensive, theoretically guided, and culturally tailored community-led primary and secondary prevention programs to improve their health outcomes. The data may serve as a tool for stakeholders and policy makers to advocate for public health policies that will elevate population health of AA or communities of color in AZ to be in line with non-Hispanic White counterparts. / Dissertation/Thesis / Doctoral Dissertation Nursing 2020

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