Date on Master's Thesis/Doctoral Dissertation

12-2025

Document Type

Doctoral Dissertation

Degree Name

Ph. D.

Department

Health Promotion and Behavioral Sciences

Degree Program

Public Health Sciences with a specialization in Health Promotion, PhD

Committee Chair

Kerr, Jelani

Committee Co-Chair (if applicable)

DuPre, Natalie

Committee Member

Jones, Gaberiel

Committee Member

Wendel, Monica

Author's Keywords

Residential segregation; index of concentration at the extremes (ICE); breast cancer disparities; structural racism; neighborhood contexts; social determinants of health

Abstract

Female breast cancer (BC) remains the most commonly diagnosed non-skin cancer and the second leading cause of cancer death among U.S. women. Despite advances in detection and treatment, substantial inequities in BC outcomes persist, driven in part by structural forces such as residential segregation. This dissertation examined the relationship between residential segregation, BC outcomes, and key contextual factors in Louisville, Kentucky. Using data from the Kentucky Cancer Registry, American Community Survey, CDC’s Population-Level Analyses and Community Estimates, and the National Neighborhood Data Archive, the study tested two hypotheses: (1) higher Black/low-income segregation is associated with elevated risks of adverse BC outcomes—advanced-stage diagnosis, delayed treatment, and BC mortality; and (2) contextual factors moderate these associations. Logistic regression and Cox proportional hazards models were used to estimate effects across outcomes. This three-paper dissertation is organized into seven chapters covering background, literature, theoretical framing using the Revised Social Determinants of Health model, methods, analytic findings, and an integrative general discussion. Both racial and racialized-economic segregation were significantly associated with higher risks of all examined outcomes. Neighborhood healthcare access moderated the segregation–mortality relationship, with higher-access areas exhibiting unexpectedly higher mortality among residents of highly segregated neighborhoods. This study is the first to apply the Revised Social Determinants of Health framework to link residential segregation with BC outcomes. Findings emphasize the need for policies that address racial and economic marginalization as interconnected systems shaping cancer inequities and highlight the importance of identifying and removing barriers to healthcare use that extend beyond geographic availability.

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