Background: Utilization of specialty care may not be a discrete, isolated behavior but rather, a behavior of sequential movements within the health care system. Although patients may often visit their primary care physician and receive a referral before utilizing specialty care, prior studies have underestimated the importance of accounting for these sequential movements.

Methods: The sample included 6,772 adults aged 18 years and older who participated in the 2001 Survey on Disparities in Quality of Care, sponsored by the Commonwealth Fund. A sequential logit model was used to account for movement in all stages of utilization: use of any health services (i.e., first stage), having a perceived need for specialty care (i.e., second stage), and utilization of specialty care (i.e., third stage). In the sequential logit model, all stages are nested within the previous stage.

Results: Gender, race/ethnicity, education and poor health had significant explanatory effects with regard to use of any health services and having a perceived need for specialty care, however racial/ethnic, gender, and educational disparities were not present in utilization of specialty care. After controlling for use of any health services and having a perceived need for specialty care, inability to pay for specialty care via income (AOR = 1.334, CI = 1.10 to 1.62) or health insurance (unstable insurance: AOR = 0.26, CI = 0.14 to 0.48; no insurance: AOR = 0.12, CI = 0.07 to 0.20) were significant barriers to utilization of specialty care.

Conclusions: Use of a sequential logit model to examine utilization of specialty care resulted in a detailed representation of utilization behaviors and patient characteristics that impact these behaviors at all stages within the health care system. After controlling for sequential movements within the health care system, the biggest barrier to utilizing specialty care is the inability to pay, while racial, gender, and educational disparities diminish to non-significance. Findings from this study represent how Americans use the health care system and more precisely reveals the disparities and inequalities in the U.S. health care system.

The rate of obesity has increased noticeably in China since the 1980s, brought about by the "After Mao" revolution. This dissertation examines the social determinants of obesity and weight gain among men and women, using 1991-2009 waves of the longitudinal China Health and Nutrition Survey. The first study emphasizes that rapid technological adoption at home may also have the potential to lead to obesity epidemics. I hypothesize that adopting household technology is a factor in weight gain, independent from daily calorie consumption and energy expenditure in exercise. The results show household technology ownership and weight gain are linked, while changes in overall energy intake and exercise may not function as mediators for this relationship. Future public health policy may evaluate interventions that are focused on increasing low-intensity activities impacted by household technologies. My second study discusses whether obesity wage penalties seen in Western societies, such as wage reductions for obese individuals, are observed in modern China. The results indicate that obese women are not subject to wage penalties, while current male obesity rates may be worsened by heightened economic outcomes and greater social acceptance by customers and colleagues. With increasing interpersonal interactions in the workplace in Chinese industries, and the lack of public awareness of the risks of obesity, Chinese public health strategies for preventing and controlling obesity should target male non-manual laborers, the most vulnerable population in the future. The third study analyzes the impact of parental and own socioeconomic status on adult body weight and extends the research by estimating the influence of intergenerational social mobility on current body mass index. In the context of increasing social inequality in China, the study shows parental SES, own SES, and social mobility to be negatively associated with body mass index among women; while respondent's SES is positively associated with body mass index among men. The study results support the theory that parental SES has a more significant impact on current body weight for men and women after controlling social mobility; indicating that social mobility may function as a mediator for the relationship between parental SES and current body mass index.

Purpose: This study examines the role of social support on adjustment to widowhood. Past research has indicated that the role of social support on adjustment to widowhood remains inconclusive, and needs further examination. This study examines the varying coping trajectories of middle-aged and retired bereaved spouses. Additionally, this study examines how bereavement stage may also influence one's adaptation to widowhood. Methods: This study used in-depth and semi-structured interviews as a means of understanding the role of social support on adjustment to widowhood. Participants were recruited through two hospice services available in a major metropolitan area in the United States. Convenient and purposive samplings are used in this study; this study will execute a grounded theory approach in order to determine the inconclusive role of social support on adjustment to widowhood. This study is contrasting between two stages- life course stages (middle aged versus retirement aged people) and bereavement stages (a year or less time following the death of a spouse versus three or more years following the death of a spouse). As a means of reducing bias and subjectivity, all data collected during the interview will be transcribed immediately. Results: Middle-aged bereaved spouses reported higher levels of motivation for adjusting positively and quickly towards widowhood due to their concern for protecting the well-being of their surviving young children compared to retired bereaved spouses. Differences between middle-aged widows and widowers have been found in this study; middle-aged widowers have a higher linkage to negative health behaviors. Retired bereaved spouses may fare better depending upon their housing location. Living in a retirement center may lower negative effects of bereavement on retired spouses' health. Conclusions: Types of social support received and expected varied between middle-aged widows and widowers. Gender norms may influence the type of social support widows and widowers receive. Middle-aged widowers are less likely to receive emotional support which may explain their higher linkage to negative health behaviors. Bereavement stage and housing location may be the key factors that influence widowhood trajectories of retired bereaved spouses. Living in a retirement center may lower the negative effects of bereavement on overall health.

Health-seeking behaviors are influenced by multiple factors including an assessment of the symptoms, what degree of personal commitment is involved in treatment, and what, if any, alternative methods of treatment are available. In the case of infertility, seeking treatment is likely to occur after the inability to get pregnant or carry a pregnancy to term persists for longer then a year or more. This is after prolonged exposure to the risk of pregnancy fails to provide a successful pregnancy, and the desire for children remains. Most research on health-seeking behaviors for infertility focus on the nulliparous woman who is at risk of primary infertility. This research furthers this examination by comparing the rates of health-seeking behaviors for women at risk of primary infertility to women at risk of secondary infertility. A woman at risk of primary infertility is identified as nulliparous in that she has never been pregnant, or has never had a pregnancy end in live birth. A woman at risk of secondary infertility is identified as parous and has already had one pregnancy end in live birth. Using three pathways that include social factors, biological mechanisms, and contextual effects, I hypothesize that the rates of health-seeking behaviors will vary by infertility risk and that women at risk of primary infertility will have higher rates of health-seeking behaviors for infertility. These hypotheses are based on the Behavioral Model of Health Services Utilization and the Health Belief Model that states health-seeking behaviors are influenced by the presence of enabling and predisposing factors, combined with internal and external cues. Findings from this dissertation suggest that the rates of health-seeking behaviors do indeed vary by infertility risk.

This research explores the socialization and culture of naturopathic students. Naturopathic physicians are a rapidly growing group of health care providers with a different ideology than conventional physicians. At present they work on the margins of the division of labor in health care. Only 15 U.S. states explicitly recognize, regulate, and license their practice, although the number is increasing. Therefore, the professional socialization of naturopathic students is framed within a context of a changing division of labor in health care. The recent growth of naturopathic physicians reflects the American public's increased interest and use of complementary and alternative medicine (CAM). However, these practitioners are not yet accepted as legitimate physicians by most conventional physicians. This research investigates how the professional socialization of students at a naturopathic medical school prepares them to assume their role as CAM providers in a division of labor that is dominated by conventional physicians. The research examines their choice to attend a naturopathic school, formal and informal socialization at the school, and the student culture. The main research site is a four-year, accredited naturopathic medical school where participant observation, intensive interviews, and a survey were used to collect data. Additional data are presented from observations at a national conference of the American Association of Naturopathic Physicians. Results indicate that the student culture and socialization process at the naturopathic medical school differ in some important ways from the previously documented socialization process at conventional medical schools. The average age of naturopathic students is much older than conventional medical students, and a much larger percentage are women. Unlike conventional medical students, who rely heavily on role models and previous knowledge of what it takes to become a medical doctor, naturopathic students select a career path based on values and beliefs that are more aligned with their own than conventional medicine. The formal and informal training and culture of naturopathic students prepares them to work alongside, rather than within, mainstream medicine. The documentation of how a group of CAM practitioners is created contributes to a better understanding of the ever-changing ideology and division of labor in health care.