Dissertations / Theses on the topic 'Healthy equity'

This dissertation examines whether spatial measures of health determinants and health outcomes are being used appropriately and effectively to improve the health of marginalized populations in the United States. I concentrate on three spatial measures that have received significant policy and regulatory attention in California and nationally: access to healthful foods, climate change, and housing quality. I find that measures of these health determinants have both significant limitations and unrealized potential for addressing health disparities and promoting health equity.

I define spatial triage as a process of using spatial data to screen or select place-based communities for targeted investments, policy action, and/or regulatory attention. Chapter 1 describes the historical context of spatial triage and how it relates to ongoing health equity research and policy. In Chapter 2, I evaluate spatial measures of community nutrition environments by comparing data from in-person store surveys against data from a commercial database. I find that stores in neighborhoods with higher population density or higher percentage of people of color have lower availability of healthful foods and that inaccuracies in commercial databases may produce biased measures of healthful food availability.

Chapter 3 focuses on spatial measures of climate change vulnerability. I find that currently used spatial measures of "disadvantaged communities" ignore many important factors, such as community assets, region-specific risks, and occupation-based hazards that contribute to place-based vulnerability. I draw from examples of successful actions by community-based environmental justice organizations and reframe "disadvantaged" communities as sites of solutions where innovative programs are being used to simultaneously address climate mitigation, adaptation, and equity goals.

In Chapter 4, I combine electronic health records, public housing locations, and census data to evaluate patterns of healthcare utilization and health outcomes for low-income children in San Francisco. I find that children who live in redeveloped public housing are less likely to have more than one acute care hospital visit within a year than children who live in older, traditional public housing. These results demonstrate how integrating patient-level data across hospitals and with data from other sectors can identify new types of place-based health disparities. Chapter 5 details recommendations for analytic, participatory, and cross-sector approaches to guide the development and implementation of more effective health equity research and policy.

Climate change is a significant public health danger, with a disproportionate impact on low-income and communities of color that threatens to increase health inequities. Many important social determinants of health are at stake in California climate change policy-making and planning, and the distribution of these will further impact health inequities. Not only are these communities the most vulnerable to future health impacts due to the cumulative impacts of unequal environmental exposures and social stressors, they are also least likely to be represented in climate change decision-making processes. Therefore, it is imperative that public health and social equity advocates participate in climate change policy-making that protects and enhances the health and well-being of vulnerable communities. Regions have emerged as important policy-making arenas for both climate change and public health in California, because many drivers of climate change are also social determinants of health (e.g. land use, housing, and transportation planning); these play out regionally and are under regional governmental authority. However, the public health sector is not engaged adequately with climate change planning given the magnitude of risks and opportunities inherent for health. Examination of where public health and equity partners have engaged in regional climate change planning and policy-making may offer lessons for how to change the drivers of health inequities and climate change through this work.

This dissertation examines why the public health sector in California is not more engaged with climate change work and regional scale planning given current threats to and opportunities for health, and whether and how public health and social equity stakeholders’ participation in climate change solutions and regional scale planning can improve health and inequities outcomes and decision-making processes. The overarching goal of this research was to inform efforts to increase public health work on climate change and regional-scale planning, strengthen partnerships between public health, social equity, and climate change stakeholders, and formulate strategies that address climate change and health equity.

The first chapter of this dissertation was conducted in conjunction with a study at the Center for Climate Change and Health at the Public Health Institute, where we conducted semi-structured in-depth interviews (n=113) with public health and climate change professionals and advocates. I performed structured coding and conducted inductive-deductive thematic analysis within and across respondent groups. I found that individual-level barriers to public health engagement with climate change include perceptions that climate change is not urgent, immediate, or solvable, and insufficient understanding of public health impacts, connections, and roles. Institutional barriers include a lack of public health capacity, authority, and leadership due to risk aversion and politicization of climate change; a narrow framework for public health practice; and professional compartmentalization. Opportunities include integrating climate change into current public health practice; providing support for climate solutions with health co-benefits; and communicating, engaging and mobilizing impacted communities and public health professionals.

In the second chapter, I conducted two case studies of Sustainable Communities Strategies planning to achieve greenhouse gas reduction targets through integrated regional land use and transportation planning under California Senate Bill 375 (San Francisco Bay Area and Southern California). I used in-depth interviews (n=50) with SCS planning participants, public document review, and participant observation. I analyzed interviews using thematic analysis in an iterative inductive-deductive process. In both regions, climate change planning was a major lever for increasing the language, consideration, funding, and measurement of health impacts into the SCS plans. Public health’s analytic skills and social determinants of health conceptual framework were valuable for both regional planning agencies and equity groups. Political context influenced the priority concerns, framing, and outcomes. Desire to improve public health was influential in both of these environments. In the Bay Area, a health equity frame promoted regional solutions that can improve health, equity, and climate change. In SCAG, a public health frame increased awareness, language, and future funding for active transportation. Public health was a less contested and commonly held value across diverse political jurisdictions that may be an entry point for future discussions of equity and climate change. In both regions, reform of regional governance processes was pursued to sustain institutionalization of health and equity concerns and improve regional democracy. I discuss implications and recommendations for engaging in multi-system integrated regional planning that can simultaneously improve climate change, health, and equity.

In the third chapter, I analyze the same data as a case for understanding regional-scale public health, social equity, and regional planning staff efforts to slow climate change and improve social determinants of health and social equity. In both regions multi-year SCS planning processes, public health and equity stakeholder engagement was instrumental in getting health goals, targets, and indicators into plans. In the Bay Area, advocacy efforts yielded health and equity language in policies and implementation funding guidelines and changes to the basic governance structure. In SCAG, advocacy efforts yielded significant future funding for active transportation and more metrics to monitor the health and equity impacts of planning. Participants in the SCS planning process described their motivations for engaging at the regional level, the barriers to effective regional planning, the achievements of their engagement, and recommendations for improving future efforts. In the interviews, three main themes emerged related to the opportunities and challenges of working at the regional scale: (1) Building regional identity as a foundation for advancing health and equity; (2) The importance of governance structures for health and equity, and the need for regional governance reform; (3) The prospects and barriers of building regional coalitions both within public health networks and with regional equity partners. I discuss implications and recommendations for public health’s engagement with regional planning agencies, creation of coalitions, and reforming of regional governance structures to sustain better consideration of climate change, health, and equity.

Early public health efforts in the United States addressed social conditions that contributed to poor health, with public health workers playing a role in large scale societal reforms, such as passing housing and sanitation laws, which led to diminishing deaths from infectious diseases. As chronic diseases became leading causes of death, public health research and practice became more focused on individual behaviors, widely thought to be the primary cause of chronic diseases. However, health inequities along the lines of place, race, class, and other forms or marginalization are still prevalent. A substantial body of research illustrates how social, political, economic, and environmental factors affect multiple health outcomes, including chronic diseases, and contribute to health inequities.

In public health practice, some local health departments (LHDs) and organizations that support their work have called for broader public health interventions that address social policies that contribute to health inequities in addition to providing direct services to individuals. With continued research and support, the approximately 2,800 LHDs nationwide can play a central role in reducing health inequities. However, engaging in this complex work necessitates new approaches, skills, frameworks, and organizational infrastructures for LHDs. The recent foreclosure crisis, which stands to increase racial and health inequities, provides a lens to examine whether and how LHDs can move from a rhetorical commitment to addressing social determinants of health (SDH) into actual public health interventions that reduce health inequities.

Through this dissertation, I examine LHDs’ role in the foreclosure crisis through three related papers. My aim is provide insight into how LHDs responded to the deep and fundamental shifts in access to stable and quality housing and wealth created by the foreclosure crisis that disproportionately impacted African-American, Latino, and some Asian/Pacific Islander communities. Through all three papers, I incorporate a focus on challenges and approaches to addressing the racialized causes and outcomes of the foreclosure crisis. My overall aim is to help advance local public health practice within LHDs to more effectively target the causes of health inequities, including gaining a better understanding of LHD approaches and needs related to addressing SDH through local policy.

In the first paper, A National Survey on Local Health Department Engagement in Addressing the Foreclosure Crisis, I describe the results of a national survey on LHD engagement in the foreclosure crisis, which includes LHD approaches to addressing foreclosure and barriers to engagement. Responses followed a diffusion of innovation pattern, with innovator, early adopter, early majority, late majority, and lagging LHDs. Respondents expressed a high level of interest in adopting innovative approaches to addressing SDH and described a need for models of how other LHDs are preventing or mitigating the impacts of foreclosure, especially through local policies.

In the second paper, Adopting an Innovative Public Health Practice to Address Foreclosure: A Case Study of Alameda County Public Health Department , and the third paper, Policy Entrepreneurs, Agenda-Setting, and Communication: An Exploration of How a Local Health Department Engaged in Addressing the Foreclosure Crisis, I describe findings from qualitative interviews with current and former ACPHD staff and partners. In the second paper, I identify factors that 1) differentiate ACPHD’s innovative approach from traditional LHD activities; and, 2) contributed to ACPHD being an innovator among LHDs.

Finally, in the third paper, I focus on ACPHD’s role as a policy entrepreneur in agenda-setting, including their communication approach. While the second paper focuses on how ACPHD developed into an innovative LHD in the area of local housing policy, the 3rd paper focuses on how in this role, ACPHD interacted in the local policymaking process. This case study also examines how the role of policy entrepreneur can be shared across two organizations (ACPHD and Causa Justa::Just Cause) and provides another way to conceive of entrepreneurism.