Background and PurposeGlobally and in the United States (US), colorectal cancer (CRC) is the second leading cause of cancer-related death, following lung cancer. In addition, there are established racial disparities in incidence and mortality for this disease, where ethnic minority groups have higher incidence and mortality rates. Blacks currently have the second-highest rates of CRC incidence and mortality, are diagnosed at more advanced stages, and have the lowest 5-year survival rates of all racial groups. Multiple influences impact this disparity including area- and individual-level factors. Area-level factors, encompassing social determinants of health (e.g. area-level poverty, housing characteristics, etc.), play a role in disease etiology and outcomes. In addition, timely CRC screening (CRCS) reduces CRC incidence and mortality; however, screening patterns, globally and in the US, are not optimal and differ by race, with ethnic minority groups having low CRCS adherence compared to non-Hispanic whites. Differences in CRCS behaviors and outcomes have been noted for Blacks, a term used to describe, for example, a heterogeneous racial group comprised of US-born Blacks and immigrants from Africa and the Caribbean. While CRCS barriers are well documented for the general population, CRCS barriers are less understood for Blacks and very little is known about CRCS habits and CRCS barriers within this heterogeneous racial group, with limited research including Caribbean immigrants and no known research including African-born immigrants. This dissertation uses a mixed-methods approach to describe CRC incidence, advanced stage at diagnosis, and mortality, CRCS behaviors, and CRCS barriers within the heterogeneous Black population in Philadelphia County, Pennsylvania. Aim 1. Assess colorectal cancer incidence, advanced stage at diagnosis, and colorectal cancer mortality, overall and among individuals who identify as Black/African American, and contextual disparities in Philadelphia County utilizing data from the Pennsylvania State Cancer Registry (2010–2016) and relevant US Census and American Community Survey data. Aim 2. Determine colorectal cancer screening adherence for Cancer Prevention Project of Philadelphia (CAP3) participants who self-identify as Black. Aim 3: Conduct gender-specific focus groups to elucidate the principal barriers to colorectal cancer screening adherence within an average-risk group of adults, ages 45–75, who self-identify as Black or African American, in an urban population. Methods Aim 1. Using an ecological design, descriptive, geographic spatial clustering and hierarchical logistic regression analyses were done to describe CRC incidence, advanced stage at diagnosis, and colorectal cancer-specific mortality in Philadelphia County at the individual- and area-level. CRC incidence, stage at diagnosis, and mortality data for histologically confirmed CRC cases were obtained from the Pennsylvania Cancer Registry from 2010 to 2016, with mortality data including deaths through 2020. Area-level data were retrieved from the US Census Bureau, American Community Survey, etc. Individual- and area-level descriptive characteristics were calculated for all CRC incident cases, cases diagnosed at advanced stage, and colorectal cancer-specific mortality, overall and for whites and Blacks. Geographic clusters with higher-than-expected relative risk for each outcome of interest at the census tract level (HRCT) were identified and individual- and area-level descriptive statistics were calculated for Blacks, overall and by HRCT status. Adjusted hierarchical logistic regression analyses using backward stepwise elimination with model quasi-information criterion was performed to identify potential predictors of HRCTs for CRC incidence and advanced stage at diagnosis. Aim 2. Cross-sectional data from age-eligible adults, 50–75 years (N=357) participating in the ongoing CAP3 study was used to measure CRCS prevalence and adherence and region of birth (e.g., Caribbean-, African-, US-born). Prevalence and adherence were based on contemporaneous US Preventive Services Task Force guidelines. Descriptive statistics and adjusted prevalence and adherence proportions were calculated by region of birth. Adjusted logistic regression models were performed to assess the association between region of birth and overall CRCS and modality-specific adherence. Aim 3. To assess CRCS barriers, we conducted six sex-specific focus groups (n=3 female, n=3 male) with individuals, ages 45-75, who self-identified as Black (i.e., US-, Caribbean, or African-born) and were. Focus groups were held in person and via Zoom, recorded and transcribed verbatim. Codes were developed using coding consensus, co-occurrence, and comparison and open, axial, and selective coding rooted in grounded theory. Dedoose was used to determine CRCS barrier themes as well as general and modality-specific barriers by sex and by region of birth. Results Aim 1. In Philadelphia County, there were 4,641 CRC incident cases, of which 2,086 (44.9%) were non-Hispanic Black (NHB), and 2,555 (53.1%) were white. Mean age at diagnosis for CRC incidence (65.0 vs. 68.9 years), advanced stage at diagnosis (63.2 vs. 67.4 years), and colorectal cancer-specific mortality (67.5 vs. 71.7 years) was lower for Blacks compared to whites (p-value<0.001). Blacks were also diagnosed at a more advanced stage (25.0% vs. 22.4%, p-value=0.038) or unknown stage (8.01% vs. 5.64%, p-value=0.001). For each outcome, when compared to whites, higher proportions of Blacks lived in areas with higher proportions of markers of low socio-economic status and lower proportions of CRCS adherence. Geographic clusters at a higher-than-expected risk of CRC incidence were found in Northeast Philadelphia, North Philadelphia, West Philadelphia, and Southwest Philadelphia. Geographic clusters at a higher-than-expected risk of CRC diagnosed at an advanced stage and colorectal cancer-specific mortality overlapped and were in the North, Kensington, and Southwest neighborhoods of Philadelphia. Area-level NHB, the primary independent variable of interest, reduced the odds of HRCT for CRC incidence (OR: 0.971, 95% CI: 0.960, 0.983) and was not significantly associated with HRCT for advanced stage at diagnosis. In addition, after adjustment, for every one-unit increase in the percent of area-level foreign-born Blacks, there was 1.17-increased odds of being a HRCT for CRC incidence (95% CI: 1.07, 1.28). Similarly, there was a significant positive association with area-level foreign-born Black and being in a HRCT for advanced stage at diagnosis (OR: 1.15, 95% CI: 1.05, 1.26). Other area-level variables that were associated with HRCT for CRC incidence were median rent, percent of mortgaged housing units, and per capita income, which reduced the odds of being a HRCT; Percent of mortgaged housing units also reduced the odds of being a HRCT for advanced stage at diagnosis. Further, CRCS adherence reduced the odds of being a HRCT for advanced stage at diagnosis by approximately 15% (OR: 0.849, 95% CI: 0.791, 0.911). Aim 2. Respondents were 69.5% female, 43.3% married/living with a partner, and 38.4% had <$25,000 annual income. Overall, 78.2% reported past CRCS; however, stool test had the lowest prevalence overall (34.6%). Caribbean (95.0%) and African immigrants (90.2%) had a higher prevalence of overall CRCS compared to US-born Blacks (59.2%) (p-value <0.001). African immigrants were five times more likely to adhere to overall CRCS than US-born Blacks (OR: 5.25, 95% CI: 1.34, 20.6). Immigrants had higher odds of being adherent to colonoscopy (Caribbean=OR: 6.84, 95% CI: 1.49, 31.5; African =OR: 7.15, 95% CI: 1.27, 40.3) compared to US-born Blacks. Aim 3. The majority of focus group participants were 60–64 years old and 72% were immigrants (41% African-born, 31% Caribbean-born). Most participants had had CRCS, but 45% were non-adherent to national CRCS guidelines. Overall, lack of knowledge/awareness, fear, and a sense of feeling healthy and subsequently not seeing the need for CRCS emerged as overarching themes to CRCS barriers. General barriers differed by gender: for women lack of physician recommendation or explanation of CRCS was important and for men not knowing anyone with a history of CRCS was commonly cited. .” Differences in modality-specific barriers by gender were also noted. Barriers also differed by region of birth. US-born Blacks described lack of community advocacy promoting CRC and CRCS awareness as a barrier. African-born Blacks expressed lack of routine CRCS and utilization of preventive medicine in their native country as barriers. US- and Caribbean-born Black males, communicated that discussing CRCS was taboo, which was tied to hegemonic masculinity leading to a lack of conversations about CRC and CRCS. The use of traditional home remedies emerged as a barrier given respondents felt these remedies would aid in preventing CRC thereby reducing the need for CRCS. Immigrant Blacks also described limited insurance coverage due to their citizenship status. Conclusions This dissertation provides the first known insight into various outcomes across the colorectal cancer continuum for the heterogeneous Black population including the growing immigrant Black subgroups in Philadelphia County. To reduce CRC incidence and mortality, interventions and resources to increase CRCS uptake need to target geographic locations with higher percentages of foreign-born Blacks, lower CRCS adherence, and areas with worse socio-economic markers. Also, while Black immigrants had higher CRCS adherence compared to US-born Blacks, CRCS is still sub-optimal in the Black population. Further, CRCS barriers exist and differ by gender, and importantly, there are nuanced barriers by region of birth. Thus, efforts to increase CRCS should address the common and unique barriers and promote stool-based testing, as stool test adherence was low and focus group participants were unfamiliar with this modality as it is not widely promoted or available in clinical practice. In short, these findings across the colorectal cancer continuum should be taken into account for resource allocation and when designing targeted or tailored interventions to promote CRCS uptake for the heterogeneous Black population, which would reduce CRC incidence, late-stage diagnosis, and mortality. / Epidemiology

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Bakgrund: "The Immigrant Health Paradox" indikerar att invandrade från ofta upplever en bättre psykisk hälsa i jämförelse med majoritetsbefolkningen, trots nackdelar som en lägre social status. Syfte: Studien syftade till att testa skillnader i internaliserade symptom och familjerelationer hos unga med svensk och utländsk bakgrund. Studien testade om en högre grad av emotionellt stöd, familjesammanhållning och akademiskt stöd kunde förklara skillnader i internaliserade symptom hos första och andra generationens invandrade från icke-väst och väst samt majoritetsbefolkningens unga. Även kön, föräldrarnas utbildningsbakgrund samt familjestruktur testades. Metod: Studien utgick från en kvantitativ ansats och statistiska analyser genomfördes med one-way anova samt multivariata regressionsanalyser. Data: Studien baserades på n=4344 svenska skolelever i årskurs 8, med en medelålder på 14,65 år. Data hämtades från första vågen (2010/2011) av "Children of Immigrants Longitudinal Survey in Four European Countries" (CILS4EU) som är baserad på 251 svenska skolor. Resultat: Resultaten visade vissa skillnader i internaliserade symptom och familjerelationer hos invandrade unga och majoritetsbefolkningens unga. Invandrade från icke-väst och andra generationen från väst rapporterade en lägre grad av internaliserade symptom i jämförelse med majoritetsbefolkningen, som delvis kunde förklaras av bättre emotionellt stöd samt familjesammanhållning och en intakt familjestruktur. En lägre grad av internaliserade symptom hos första generationen i jämförelse med andra generationen kunde inte urskiljas. Slutsats: Paradoxen kunde delvis bekräftas hos skolelever i Sverige genom en bättre psykisk hälsa hos invandrade unga från icke-väst och andra generationen från väst i jämförelse med majoritetsbefolkningen, som kunde förklaras av kvalitativt bättre familjerelationer hos invandrade unga.

Cultural competency is theorized as the sensitivity of practitioners from the dominant culture towards the diverse cultural backgrounds of their patients. Less attention is placed on how communication between providers and patients can enable patients to share their health care beliefs. An evidence review of the literature around the conceptualization of cultural competency in health care was performed, and interviews were conducted aiming to understand what immigrant patients perceive as culturally competent care and its effect on the relationship between them and their providers. Definitions of cultural competence varied, and no conclusive studies linking cultural competence to improved health outcomes were found. Findings from the participant interviews helped to address gaps in the literature by confirming a preference for a patient-centred approach to culturally competent care, in addition to identifying pre-existing expectations for the health care encounter and patient-dependent factors as additional elements influencing the physician-patient relationship.

In the recent political climate, the debate regarding undocumented immigrants and what, if anything, they are entitled to in the US has been incredibly contentious. In the bioethics portion of this thesis, I examine two of the major frameworks for distributive justice, cosmopolitanism and the political conception, address the criminal aspect of undocumented immigration, and suggest a switch from a focus on criminality to focusing on the forces that incentivize undocumented immigration to determine the type of claim undocumented immigrants have to health resources. In the biology portion, I examine three case studies: respiratory tract infection, HIV/AIDS, and tuberculosis to illustrate health disparities among undocumented populations. I conclude that based on their participation in shared social cooperation and the unspoken shadow contract of companies incentivizing undocumented immigrants to come to the US to provide cheap labor, undocumented immigrants do have a right to access healthcare in the US. However, we should account for risk factors such as other marginalized identities, country of origin, and rate and methods of disease transmission when determining exactly what that care should look like.

Cultural competency is theorized as the sensitivity of practitioners from the dominant culture towards the diverse cultural backgrounds of their patients. Less attention is placed on how communication between providers and patients can enable patients to share their health care beliefs. An evidence review of the literature around the conceptualization of cultural competency in health care was performed, and interviews were conducted aiming to understand what immigrant patients perceive as culturally competent care and its effect on the relationship between them and their providers. Definitions of cultural competence varied, and no conclusive studies linking cultural competence to improved health outcomes were found. Findings from the participant interviews helped to address gaps in the literature by confirming a preference for a patient-centred approach to culturally competent care, in addition to identifying pre-existing expectations for the health care encounter and patient-dependent factors as additional elements influencing the physician-patient relationship.

Over the past 15 years Monteverde, Costa Rica has undergone rapid economic, social, political, and environmental change due to a flourishing ecotourism economy. While the effects of ecotourism development in Monteverde are many, two important consequences have been: 1) the immigration of Nicaraguan nationals to the area seeking low-skilled wage labor; and 2) compromised water resources management due to pollution and rapid population growth. The objective of this research is to investigate and identify the inter-relationships between ecotourism development in Monteverde and its affect on infectious diseases outcomes within the context of immigration and water resources management. Specifically, this dissertation uses both anthropological and public health methods within a political ecology of health framework to compare prevalence rates of intestinal parasites between Nicaraguan immigrants and Costa Rican residents living in Monteverde. Results indicate that Nicaraguan immigrants suffer disproportionately from infections with intestinal parasites compared to Costa Rican residents. The results further indicate that community based water resources are not a significant source of infection. Instead, the prevalence of intestinal parasites is most likely the result of fecal-oral transmission at the household level and is related to indicators such as access to health care, underemployment, home ownership, and household sanitation infrastructure.

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.

This study aims to examine how the migration experience influences newcomer mothers’ young child feeding and care practices and their children’s overall health. The thesis comprises three separate manuscripts, each of which examines one of the three intermediate determinants of the nutritional status of young children (UNICEF 1990): access to healthcare, household food insecurity, and child feeding and care practices. The research was conducted in Toronto’s Jane-Finch neighbourhood, a suburban neighbourhood home to a high density of newcomers. Thirty-two participants (16 Sri Lankan Tamil and 16 Latin American) who had migrated to Canada within the past five years as refugee claimants or family sponsored immigrants participated in the study. Data collection consisted of semi-structured interviews with women from low-income households who had a child between the ages of 1 and 5 years. Spanish and Tamil speaking interviewers interviewed each participant two or three times. Data was analyzed using a mid-level approach in which broad analytical themes are determined prior to analysis and specific themes were then generated based on participants’ perspectives and are grounded in the data. The first manuscript examines newcomer mothers’ experiences accessing physicians for their children and identifies the major gaps between mothers’ expectations and their actual experiences that lead to barriers in communication and overall patient dissatisfaction. The second manuscript demonstrates that mothers’ past experiences with food insecurity affect two aspects of the construct of food insecurity: its managed aspect and its temporal nature. This finding has implications for the measurement of food insecurity in newcomer populations. The third manuscript reveals that newcomer mothers are exposed to several parallel and often conflicting systems of knowledge concerning health and nutrition for their children, and that their utilization of Canada’s Food Guide is impeded by its failure to acknowledge alternate parallel knowledge systems. These findings can be applied to the development of social and health policy aimed at improving cultural competency in healthcare and nutrition education and at ameliorating the income constraints leading to household food insecurity.

Cultural competency is theorized as the sensitivity of practitioners from the dominant culture towards the diverse cultural backgrounds of their patients. Less attention is placed on how communication between providers and patients can enable patients to share their health care beliefs. An evidence review of the literature around the conceptualization of cultural competency in health care was performed, and interviews were conducted aiming to understand what immigrant patients perceive as culturally competent care and its effect on the relationship between them and their providers. Definitions of cultural competence varied, and no conclusive studies linking cultural competence to improved health outcomes were found. Findings from the participant interviews helped to address gaps in the literature by confirming a preference for a patient-centred approach to culturally competent care, in addition to identifying pre-existing expectations for the health care encounter and patient-dependent factors as additional elements influencing the physician-patient relationship.