TITLE: Racial disparities associated with colon cancer screening in a nationally representative sample; A cross-sectional study AUTHOR INFO Yorandos Tafesse MD1 Manik Ahuja PhD, MA1 Author Affiliations: 1College of Public Health, East Tennessee State University, Johnson City, TN 37614, United States Colon cancer impacts nearly 2 million individuals in the U.S. each year. Early detection of colon cancer using colonoscopy can reduce the risk of mortality. The United States Preventive Services Task Force (USPSTF) recommends routine screening for colon cancer for all adults 50 to 75 years of age. Colon cancer screening behavior is different across a variety of predictor variables. Previous studies have identified older age, male gender, higher education, higher income, marriage, and the presence of chronic diseases to be associated with increased odds of colon cancer screening. However, less is known about the role of racial differences in screening. This study aims to determine if colon cancer screening rates are different between Whites and racial minorities in the United States controlling for potential confounders. This research can help bridge the existing gap on this topic and aid in identifying high-risk racial groups that could be targeted by future intervention strategies. We used cross-sectional data from the 2019 Behavioral Risk Factor Surveillance System, a nationally representative U.S. telephone-based survey of adults aged 18 years or older. We extracted data for adults age 50 or older (n=10,972). Logistic regression analyses were conducted to test the association between race and colon cancer screening. We also included chronic disease status, alcohol use, smoking, gender, and age in our model. Chronic disease status was coded as self-report 2 or more, 1 and 0 chronic diseases (referent), which included the summation of heart disease, hypertension, COPD, and diabetes. Overall, colon cancer screening is as follows among Whites (77.2%), Blacks (72.4%), Asian (60.1%), American Indian/Alaska Native (69.7%), and Hispanic (68.6%). Logistic regression results revealed that having 2 or more chronic diseases (OR=1.73; 95% CI 1.53,1.96), 1 chronic disease (OR=1.45; 95% CI 1.31,1.65), and female gender (OR=1.14; 95% CI 1.04,1.23) were associated with higher odds of screening. Race/ethnic minority status (OR=0.72; 95% CI 0.65, 0.81), low income (OR=0.64; 95% CI 0.57,0.70), and less than high school education (OR=0.71; 95% CI 0.59,0.84) were associated with lower odds of screening. Our research showed that racial minorities have lower odds of colon cancer screening after adjusting for gender, age, chronic diseases, income, and education status. Preventive practices should focus on increasing awareness on and availability of colon cancer screening means to racial minorities in the United States. Further research on the association between race and other screening modalities will help maximize the impacts of targeted interventions.

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BACKGROUND: Despite decades of research aimed at prevention, preterm birth remains an enormous leading cause of infant mortality in the United States and worldwide. Of concern, racial disparities in preterm birth remain an intractable public health issue. In an effort to reduce preterm birth, organizations such as the American Congress of Obstetricians and Gynecologists (ACOG) released policy statements in 2009 aimed at reducing early elective deliveries. Subsequently, the incidence of preterm birth in the United States has decreased, but whether this decrease is due to a reduction in iatrogenic or "medically-indicated" preterm birth is unknown. Further, the effect of the reduction in early elective deliveries on racial disparities is unknown. Our hypotheses were that 1) after 2009, preterm births would be less likely to be medically-indicated than due to spontaneous causes and 2) black-white differences in preterm births would be unchanged. OBJECTIVES: 1) Determine the proportion of preterm deliveries at Beth Israel Deaconess Medical Center (BIDMC) from 2004-2013 that were medically-indicated versus spontaneous. 2) Due to persistent disparities, determine if shifts in type of preterm delivery varied by race/ethnicity. METHODS: We reviewed the first 87 deliveries in 2013 and randomly selected 15% of the records for each year from 2004-2013. Additionally, we reviewed 69 charts to oversample black women's deliveries. We manually abstracted data from BIDMC's online medical record and designated each delivery as either medically-indicated (preeclampsia, poor fetal growth, hypertension, or other fetal/maternal condition) or spontaneous (preterm labor, preterm premature rupture of membranes or cervical incompetence). Two reviewers independently reviewed 18 records for concordance of medically-indicated versus spontaneous preterm birth typing. If the first reviewer could not phenotype the delivery, then a neonatologist and obstetrician were consulted. We reviewed 971 out of the 5,566 preterm deliveries and included 930 that were confirmed preterm and had a clear medically-indicated or spontaneous phenotype. We dichotomized the time period into early (2004-2009) and late (2010-2013). Statistical methods included comparisons of early versus late using Chi-Square tests, logistic regression models to adjust for potential confounding variables, and stratified analyses (singletons and black versus white). RESULTS: There were 46,981 deliveries at our institution during the study period, 5,566 of which were preterm. Among the 930 preterm deliveries sampled from the 10-year period, 45.6% were medically-indicated with a non-significant, subtle difference between the early (48.3%) and late (41.9%) (P=0.05) time periods. The odds ratios of medically-indicated versus spontaneous preterm birth in late versus early were 0.77 (P=0.05) and 0.73 (P=0.03) for all participants, unadjusted and adjusted, respectively. While not statistically significant, a higher proportion of preterm deliveries among black women were medically-indicated in the early (50.4%) versus late (40.6%) periods (P=0.19). There was a similar trend among white women between the early (50.0%) and late (46.9%) periods (P=0.48). The odds ratios of medically-indicated versus spontaneous preterm birth from late versus early were 0.67 (P=0.19) and 0.63 (P=0.14) for black participants, unadjusted and adjusted, respectively. For white participants, the odds ratios were 0.88 (P=0.48) for unadjusted and 0.80 for adjusted (P=0.20). Overall at BIDMC, the preterm delivery rate was significantly higher in the early period (12.3%) compared to the later period (11.2%) (P=0.0003). While we observed a reduction of preterm birth among all women, black women experienced a 20.8% decrease (from 16.2% in the early period to 12.8% in the late) in preterm birth, while white women experienced just a 4.9% decrease (from 12.4% to 11.7%), resulting in a narrowing of the racial disparity of preterm birth in our institution. CONCLUSION: At a Massachusetts birth hospital we found a reduction in the incidence of preterm deliveries over a 10-year period that coincided with policy efforts to reduce early elective deliveries. There was a reduction in the proportion of preterm births that were medically-indicated from 48.3% to 41.9%. The reduction in medically-indicated preterm birth was most evident among black women at BIDMC with concurrent decrease in the overall preterm birth rate among black women resulting in a near elimination of the racial disparity in preterm birth at BIDMC. Future work includes statistical analysis to account for the oversampling of deliveries in 2013 as well as oversampling of black women's deliveries using inverse probability weighting. We also plan to analyze which underlying conditions (preeclampsia, intrauterine growth restriction, fetal distress, etc.) were responsible for the reduction of the medically-indicated deliveries.

BACKGROUND: Previous studies have shown that there are racial disparities in type 2 diabetes (T2DM) remission following bariatric surgery, with African-Americans (AA) in particular experiencing a subsequent relapse. In recent years, some have attributed these findings to racial differences in fasting insulin levels, with AA having higher levels, as increasing evidence for an alternate model of T2DM pathophysiology gains support. In this model, basal hyperinsulinemia is considered a primary event in T2DM disease development, rather than a compensatory response to increased insulin resistance. This study aimed to compare glycemic outcomes after bariatric surgery in different races, namely African-Americans (AA), Hispanic-Americans (HA), and Caucasian-Americans (CA), and to determine whether there were any associated changes in insulin levels and insulin resistance that may lend support to this revised model of T2DM pathophysiology. METHODS: A retrospective medical record review of 1,326 patients (389 AA, 179 HA, and 758 CA) who underwent bariatric surgery at Boston Medical Center (BMC) from 2004 to 2015 was conducted. Baseline characteristics and maximum percent weight loss were compared using one-way ANOVA and Chi-square tests of independence. Changes in mean glycated hemoglobin (HbA1c), insulin levels, insulin resistance (HOMA-IR), and blood glucose levels were analyzed using linear mixed models, overall and by racial group. The same procedures were conducted in both the overall patient population and a T2DM subpopulation. RESULTS: Over an 11-year postoperative observation period, all racial groups underwent a significant decrease in HbA1c (P<0.001) within the first two years following surgery. While HbA1c levels remained stable in CA and HA, they began to rise at 2 years in AA only (P=0.043). Additionally, analyses of covariates, including age at surgery (P=0.005), initial BMI (P<0.001), and maximum weight loss (P=0.049), revealed that all three were significant factors affecting mean HbA1c levels. However, when included in the mixed model, the race x time interaction effect on mean HbA1c remained significant. There was also a significant overall decrease in both insulin and HOMA-IR. When stratified by race, analysis of the T2DM population showed that insulin levels began to increase again by the 2nd year after surgery in AA, while in CA and HA they continued to decrease and subsequently stabilize. Analysis of the total patient population showed that HOMA-IR levels in AA, as well as in CA and HA, continued to decrease at this 2-year time point. Decreases in blood glucose levels after surgery were significant overall (P<0.001), but not significant when stratified by race. CONCLUSIONS: After the initial “metabolic reset” that occurs within the first 2 years after bariatric surgery, during which HbA1c levels normalize in the vast majority of patients, it was observed only in the AA population that there was a steady increase in HbA1c to levels near those recorded at baseline. This coincided with an observation of increasing insulin levels despite decreasing insulin resistance seen in AA only. Our results suggest that current discussions regarding a revised model of T2DM pathophysiology, in which hyperinsulinemia precedes insulin resistance, may help explain the racial disparities in glycemic control observed in both post-surgical and non-surgical contexts of T2DM outcome. However, future prospective studies are needed to further the preliminary results of this study.

With the various studies that point to racial disparities at different levels of the United States' criminal justice system, it is necessary to uncover all places within the system where racial disparities might exist. Understanding that Black inmates are disproportionately represented within the prison system led to the hypothesis that Black inmates receive harsher punishments than White inmates when they violate a rule while in prison. A cross-sectional study, "Survey of Inmates in State and Federal Correctional Facilities, 2004," which was available through ICPSR, was used in order to test the hypothesis. The data were collected from October 2003 through May 2004. For the current study, only inmates who had committed armed robbery, aggravated assault, or murder were in the sample. After the modification of the variables comprised of race, rule violations, and punishment type, the sample size was 652. First, an OLS regression was used in three models, which showed that major rule violations had a significant effect on the type of punishment an inmate received, but race did not. Second, age groups were employed to run an OLS regression within each of the four age groups. This revealed that major rule violations had a significant effect on the type of punishment an inmate received in four of the age groups, but race was not significant in any of the models. Implications and possible explanations regarding these findings are discussed.

As restorative justice gained popularity in schools as a potential strategy for helping to reverse the deleterious effects of zero-tolerance policies, numerous misunderstandings and misapplications have emerged. This study focused on the experiences of school-based restorative justice practitioners and sought to foreground their voices and perspectives to highlight what is necessary for restorative justice work in schools to be effective. Critical narratives were used to elucidate participants’ perspectives and to allow their voices to serve as the focal point for the study. Findings were as follows: (a) the depth and ongoing nature of preparation practitioners undertake to sustain restorative justice work must be emphasized; (b) rather than a program or set of steps, restorative justice must be experienced as a set of principles or a philosophy grounded in genuine care and concern for individual people; (c) a cultural, political, and social shift is required for restorative justice to be implemented with integrity; and (d) restorative justice is a project of humanization and re-establishing democratic ideals. As such, educators in the field are encouraged to embrace the depth and complexity of the philosophical underpinnings of restorative justice and to acknowledge the personal, internal work that must be undertaken to serve a transformative function in school communities.

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

Using the Health and Retirement Study Panel core files from 1996 to 2014, I analyze how Medicare Part D impacted access to prescription drug coverage by various demographic factors such as race, gender, and income. In Chapter 1, I find the highest take-up rates for those who were white, female, and with higher incomes. However, increases in coverage were high across the board, such that Medicare Part D also improved drug insurance coverage for those who were black, male, and with lower income. Thus, although Medicare Part D did increase prescription drug insurance coverage for seniors across the board, I also find potential for improvement in enrollment for difficult-to-reach groups. Next, Chapter 2 examines the impact of Medicare Part D on mortality. Although I do not find an impact on the life expectancy of respondents as a whole, I do find a significant positive effect for black respondents, indicating that Medicare Part D may have mattered more for disadvantaged groups. The largest impact is for black men, who have an additional 9 percentage point chance of living to age 73 for an additional 8 years of coverage (significant at the 5% level). When looking only at cardiovascular mortality, which is more likely to be influenced by drug coverage, I find improvements in life expectancy for the total population, with stronger effects for minorities and men. Overall, my findings suggest that Medicare Part D did move the needle on its goal: to improve the health of those who, without government intervention, had the most difficulty paying for prescription drugs. Chapter 3 looks at the impact of Medicare Part D prescription drug coverage on cost-related medication adherence, food insecurity, and finances among seniors. It would be reasonable to assume that Medicare Part D, which led to near-universal drug coverage among senior citizens, could allow seniors to shift money previously spent on drug expenditures to other areas. The strongest effect of Medicare Part D is on cost-related medication nonadherence, leading to a 21% decrease for an additional 8 years of Medicare Part D coverage. The impact is even stronger for the black male population (30%). I fail to reject the null hypothesis that Medicare Part D did not reduce food insecurity or household debt. Overall, Medicare Part D appears to have improved the financial stability of seniors.

Racial and ethnic minority populations suffer disproportionally from mental health disparities in the United States (Dillon et al., 2015; Holden et al., 2014). Research has indicated that a lack of culturally competent care contributes to these disparities (Holden & Xanthos, 2009). As multicultural competencies (American Psychological Association [APA], 2002; Council of National Psychological Associations for the Advancement of Ethnic Minority Interests, 2003) have been widely endorsed and implemented in professional organizations and training programs, research on their need and usefulness has increased over the last three decades (Worthington et al., 2007). However, the majority of research on multicultural competencies has relied on analogue studies, college students, and trainees as participants (Ridley & Shaw-Ridley, 2011; Worthington et al., 2007). The current study contributed to the multicultural competency literature by including perspectives from real clients with diverse backgrounds in community settings, along with assessing therapist multicultural competency (MCC). The study examined the relationship between therapist (n = 28) multicultural competency (MCC) and psychotherapy outcomes of clients (n = 2024) from diverse racial/ethnic backgrounds in a community mental health agency. Therapist MCC did not have a statistically significant positive relationship with treatment outcome. Therapist MCC also did not have a statistically significant positive relationship with reliable or clinically significant change in treatment outcome. Results do not indicate any mediating effect of therapist MCC between race and treatment outcomes. Gender predicted overall treatment outcomes, clinically significant change and reliable change in treatment. Findings suggest cultural variables may have played a role in treatment outcomes given the differences in treatment outcomes for female clients, despite the lack of association found between therapist MCC and treatment outcomes. Implications for clinical practice and research are discussed.

Schools should be safe and supportive spaces for all students, yet Black students tend to face biased treatment in the education system, which often results in harsh disciplinary measures. This research examined the role of animalistic dehumanization (i.e., perceiving others as animal-like and uncultured and denying uniquely human characteristics), in predicting choice of harsher disciplinary measures for Black students as opposed to White students. It was hypothesized that individuals who dehumanize Black students to a greater degree would be more likely to believe that Black students need to be disciplined through harsher measures. Additionally, it was hypothesized that the link between dehumanization and choice of disciplinary measure would be mediated by empathy, attribution of mind, and/or perceived threat. Both Study 1 (in which dehumanization was assessed) and 2 (in which dehumanization was experimentally manipulated) failed to provide evidence supporting the role of dehumanization in differential choices of school disciplinary measures for Black vs. White students. However, both studies provided evidence suggesting that dehumanization of and negative attitudes toward Black Americans are still prevalent and related in American society, and that animal learning perceptions and paradigms influence participant perceptions of threat from students and disciplinary decisions. These findings indicate a need for continued investigation of racial stereotypes about students when assessing racial disparities in school discipline.