This dissertation examines the differential impact of voter suppression on life expectancy, gestational age, and birth weight by race-ethnicity. Voter suppression, though not typically studied by public health researchers, is a critical part of understanding how racial disparities in health are created, maintained, and even exacerbated. Voting is a civil right, and consequently, it is connected to many aspects of everyday life, especially the social determinants of health. Through its ability to concentrate power and resources, as suggested by Fundamental Cause Theory, voter suppression may impact health. Further, voter suppression and the logics that support it are grounded in the ideology of White Supremacy. While some may argue that the goal of voter suppression is to prevent voter fraud, the outcome is to disenfranchise certain groups of people, often defined by race. As such, in Aim 1, I first conduct a county-level analysis to investigate whether inequality in voting for Blacks compared to Whites is associated with four social determinants: segregation, income inequality, child poverty, and air pollution. Next, I test the relationships among voter suppression, county social determinants, and life expectancy, investigating whether social determinants mediate or moderate the impact of voting inequality on health. Data include Robert Wood Johnson Foundation County Health Rankings 2019 and Cooperative Congressional Election Survey (CCES) Data from 2008, 2012, and 2016 aggregated to the county-level are used (N=841 counties). I found that voting inequality is associated, at the county-level, with lower air pollution, higher segregation, and higher income inequality. Further, the strength of the association on social determinants varies with the level of voting inequality (none, low, high). Low voting inequality was a significant predictor of higher White life expectancy, but not significantly associated with Black life expectancy, in bivariate models and as covariates were added, but this relationship was attenuated once social determinants were added to the model. While mediation results were not significant, I did observe a significant interaction effect between segregation and voting inequality in bivariate analyses and one of marginal significance when all covariates were added in predicting Black life expectancy. This relationship is complex: when low and no voting inequality interact with segregation, lower life expectancy is predicted, but when high voting inequality interacts with segregation, we observe a protective effect through which higher levels of segregation are associated with higher life expectancy. In Aim 2, the items from the CCES were used to approximate county-level voter suppression. National Center for Health Statistics Birth Cohort (NCHS) Data was matched to the CCES using county identification codes. Using this multilevel data set, the impact of county-level voter suppression on two birth outcomes, gestational age and birthweight, were tested separately for three Presidential Elections (2008, 2012, and 2016). Voter suppression items included the proportion who had to wait 30 minutes or more to vote, proportion who were unable to vote in general and proportion unable to vote due to reasons such as long lines, loss of absentee ballot, etc. A second set of state-level analyses was conducted which tested the association of state voter identification requirements with birth outcomes. Results for voter suppression items were mixed, with some significant positive and negative associations, as well as many nonsignificant findings. However, when moderation by mother’s race was tested, a clear pattern emerged. While not all results were significant, the majority of significant interaction terms suggest that voter suppression has a disparate, negative impact upon birth outcomes for Black infants compared to White infants. Lastly, Aim 3 investigated the impact of the Shelby County v. Holder Supreme Court decision which invalidated Section 5 of the Voting Rights Act, thus removing voting protections in counties with a history of discrimination at the polls. These counties had been required to seek “preclearance” from the Department of Justice for any changes made to their electoral policies. To test the association between this policy decision and birth outcomes, using NCHS data from 2012-2013 and 2016-2017, a difference in differences approach was used to compare infant outcomes in preclearance counties and non-preclearance counties before and after the policy decision. While the policy decision was not significantly associated with birth outcomes once covariates were added in final models, moderation by mother’s race was tested. For gestational age, the difference in difference in differences estimate was significant and associated with higher gestational age for Black infants in counties previously covered by preclearance. Together, the results suggest that to understand the associations of voter suppression on birth outcomes, once must utilize a race conscious approach. To ignore the roles of race and racism in the pathways connecting voter suppression and health would yield an incomplete picture. Thus, voter suppression may be an important piece in understanding the persistence of racial disparities in birth outcomes and moving towards racial equity.

Nutritional content labels on fast food and restaurant menus and signage have gained popularity and momentum with the recognized need to motivate individuals to improve their eating habits outside the home. However, no known studies have assessed nutrition and menu labeling behavior among Latino consumers while taking into consideration factors such as gender and education. Higher levels of education may influence the utility of menu labeling as more educated individuals recognize the benefits of monitoring their eating; and in particular, the effects of education were expected to be strongest for Latino men. To address these issues, this thesis analyzed data collected from a convenience sample of Latino patrons (n=100) attending a community market in South Los Angeles that implemented menu labels. Pearson's chi-square tests and logistic regression was used to assess the relationship between gender, education, and the influence of menu labels on meal choice among Latino consumers who ranged in age from 18 to 67. Being a woman, married, and insured were significant correlates of utilization of nutrition and menu labels. Level of education and the interaction between gender and education, however, was not significantly associated with menu label utilization across the models analyzed. These results suggest that, in addition to providing nutritional content information, labeling interventions should implement strategies to educate consumers about healthy eating at the point-of-purchase and more directly motivate consumers to use the labeling information. Results also suggest that as Latino women are more sensitized to these intervention ideas, their behaviors need to be reinforced, whereas more efforts need to be taken to engage Latino men.

Culture-bound syndromes have proven to be significant indicators for social and psychiatric vulnerability for specific racial/ethnic minorities. However, the diagnostic criteria for these syndromes often fail to adequately address important historical and social circumstances that influence immigrant health. While culture plays a significant role in influencing the etiology and the symptom expression of certain disorders, the immigrant context is also an important indicator of mental health outcomes. In particular, factors such as English proficiency, generational status, and age at time of immigration can influence how they experience and express mental illness. The present study used logistic regression to assess the relationships among ethnicity and immigration-integration characteristics on the outcome of culture-bound syndromes from the National Latino and Asian American Study (NLAAS, n = 4528). Differences in racial/ethnic groups and immigration-integration factors were found. Compared to Filipinos and other Asians, Latinos had higher odds of reporting ataques de nervios. There were associations between ataques de nervios with age of immigration, generation, and English proficiency. Further, there was effect modification between English proficiency and ethnicity: Filipinos with limited English proficiency were associated with greater odds of reporting ataques de nervios as compared to Latinos and other Asians. Filipinos with excellent or good English proficiency were associated with decreased odds of reporting ataques de nervios as compared to Latinos and other Asians. The Latinos in our sample demonstrated an inverse relationship to Filipinos in their reports of ataques de nervios, while all other Asians reported similar levels of ataques de nervios at both levels of English proficiency. Culture-bound syndromes can serve as helpful indicators for identifying mental health needs in marginalized populations, but should be considered in the context of important historical, cultural, and social factors.

Accredited schools of public health are required to prepare graduate students to competently discuss how racism undermines health equity. A systematic assessment of academic public health norms is needed to clarify how graduate education structures the profession of public health to address racial health inequities. Three aims guided my investigation of common practices of knowledge transmission and production in schools of public health: (1) to determine what is taught to students regarding racial health equity; (2) to classify students’ use of race and theory; and (3) to categorize and contextualize students’ discussions of racism. In this sequential explanatory mixed methods study of existing documents, I examined accreditation self-study reports (N=34) and course syllabi (N=67) from schools of public health (Aim 1) and public health theses and dissertations published between 2018-2022 in the ProQuest Dissertations and Theses database (N=13,797 abstracts for Aim 2; N=25 full-text dissertations for Aim 3). I conducted computational text analysis to estimate keyword distributions, manual content analysis to trace racial health equity concepts, and critical race discourse analysis to interpret patterns.

Paper 1 revealed unequal exposure to race-related content. Fewer than half of the course syllabi listed learning objectives with racial health equity concepts. Two-thirds of schools of public health assigned journal articles with ‘race’ or ‘racism’. In Paper 2, 36% of abstracts from students’ dissertations and theses contained racial group and explicit theory terms; 62% omitted ‘race.’ The relative distribution of theories indicated students’ focus on proximal exposures rather than structural determinants. In Paper 3, eight percent of abstracts (N=403) contained social inequality theory and racial group terms. I identified three racism narratives within the full-text sample of dissertations: exposure to racism (N=9); potential exposure to racial inequity (N=3); and another exposure among people (N=13). Student-authors’ reflexivity and race conscious campus climates appear to promote public health research on racism. Dissertation findings can inform teaching, research, and practice approaches to racial health inequities. Exposing how everyday practices uphold white supremacist hegemony in schools of public health can accelerate the public health profession toward health equity.

Studies on the relationship of immigration on health often find that immigrants are healthier compared to their United States (U.S.)-born counterparts despite having lower socioeconomic attainment, a finding known as the “immigrant health paradox”. However, this health advantage declines over time. Two popular theories have been proposed as explanations for this advantage: migrant selectivity and acculturation. Migrant selectivity suggests that those who immigrate to the U.S. are not representative of their host country. Instead, immigrants may be positively selected upon social, socioeconomic, and health factors that allow for them to thrive upon arrival to the U.S. and give them the observed health advantage compared to U.S.-born residents. Acculturation theory suggests that immigrants’ health declines because of exposure and adoption of U.S. culture and values.Although these theories continue to remain popular, there remain two serious methodological issues to consider. First, in order to claim that migrant selectivity occurs, it would be necessary to compare immigrants to those who did not immigrate – non-migrants from the sending country. Thus, non-migrants serve as a more ideal counterfactual to evaluate the effects of migration on health. However, there remains a dearth of studies making this comparison because of the difficulty in simultaneously recruiting recent immigrants to the U.S. and their corresponding sending country counterparts. Second, there are also few longitudinal studies examining the effects of acculturation on health. Most studies are cross-sectional and rely on proxy measures of acculturation (e.g., English proficiency and years in the U.S.). Although these measures are useful, it is difficulty to disentangle whether changes in health are indeed related to acculturation or if they are due to secular effects. This dissertation uses the baseline, 1-year, and 2-year waves of the Health of Philippine Emigrants Study (HoPES, n = 1,637) to 1) examine if migrant selection for health, social and socioeconomic factors occurs prior to migration; 2) track how migrant health, social, and socioeconomic profiles change up to two years after migration; and 3) evaluate the extent that changes in social and socioeconomic factors explain changes in health for migrants post-migration. Overall, I found that migrants had lower levels of psychological distress and sleep disturbance compared to non-migrants both before migration, even after accounting for demographic, social, and socioeconomic factors. However, there was little evidence to suggest that migrants had lower allostatic load compared to non-migrants before departure. Furthermore, I found that psychological distress and sleep disturbance declined for both migrants and non-migrants through 2-year follow-up. However, migrants maintained a health advantage relative to non-migrants over time. Moreover, I found that migrants also had lower financial strain, fewer experiences of interpersonal discrimination, and higher social resources compared to non-migrants both before and after migration. Finally, I found that changes in financial strain, interpersonal discrimination, and social resources over time somewhat explained changes in psychological distress and sleep disturbance over time. Changes in these social factors over time did not differ between migrants and non-migrants. This dissertation builds upon the limited work examining immigrant health before migration as well as examining immigrant health longitudinally. This dissertation also provides a new theoretical examination of immigrant integration by examining how migrants change relative to their non-migrant counterparts. These results also reiterate the importance of migrant selection as a factor contributing to health, social, and socioeconomic advantages for migrants both before and after migration. Finally, although these social and economic factors partially contribute to changes in health over time, the finding that migrants do not differ from non-migrants over time emphasizes that changes in migrant health over time may be the result of secular effects, rather than acculturation.

Breast cancer is the most common cancer among women in the United States (US), including all major ethnic groups of Asian American, Native Hawaiian, and Pacific Islander (AANHPI) women. In contrast to recent trends of breast cancer incidence among other racial/ethnic groups in the US, the incidence of breast cancer among AANHPI women has been increasing rapidly over time. Incidence is also generally higher among women who are US-born relative to foreign-born and among those who have resided longer in the US, after controlling for age. These patterns suggest that factors related to living in the US context may increase breast cancer risk for these women. This dissertation draws upon the Stress-Exposure Disease Model and segmented assimilation theory to study the associations between psychosocial stress, social environments, and physical environments on odds of having breast cancer. Furthermore, breast cancer risk was assessed by examining health behaviors related to cancer (physical activity, alcohol use, fruit and vegetable consumption) and body mass index. Data was from the Asian Community Health Initiative (N=621), a case-control study of 139 breast cancer cases and 483 ethnicity- and age-matched controls, all self-identified AANHPI women living in the San Francisco Bay Area. Geographic Information Systems and multivariable linear regression were used to assess the roles of psychosocial stress, ethnic enclaves, and the built environment on breast cancer risk. Analyses controlled for well-known risk factors (e.g. age, family history of breast cancer, reproductive history, etc.). This research found that psychosocial stressors were not associated with having breast cancer. Greater general stress was associated with less physical activity. Low collective efficacy was associated with lower fruit consumption and low neighborhood safety was associated with lower vegetable consumption. Women living in high ethnic enclave, high socioeconomic status neighborhoods had the highest odds of having breast cancer. Additionally, living in high ethnic enclaves was associated with less strenuous physical activity and lower alcohol consumption. Features of the built environment were not associated with breast cancer risk. This research shows how social environments are associated with health for AANHPI women, contributing to our understanding of how health for this minority group is uniquely shaped by neighborhood contexts.

Childhood obesity is associated with adverse health outcomes across the lifecourse. Accordingly, there is growing interest in psychosocial correlates of child obesity, including the role of stress and a child’s social-emotional development on obesity risk. This dissertation examined the association between two parental stressors, relationship quality and parenting stress, on preschooler’s emotional regulation skills and their obesity risk. Inspired by the Risky Families Model, the overarching theoretical argument and research questions this dissertation addresses is whether higher levels of parental stressors lead to poor emotional regulation skills of the child, and if poor emotional regulation skills contribute to increased risk of child obesity. In addition, this dissertation assessed whether certain parenting resources, including the number of household routines and socioeconomic resources, served as protective factors.

I used data from the Early Childhood Longitudinal Study-Birth Cohort which provides a nationally representative sample of children born in the United States in 2001. To include a more comprehensive analysis of obesity risk, I examined 8 outcomes: frequency of family meals, soda consumption, fast food consumption, fruit consumption, vegetable consumption, sleep duration, odds of exceeding the 2 hour guideline for daily screentime and weight status (obese/not obese). I conducted multivariate Ordinary Least Squares regression , logistic regression, or negative binomial regression to show the relationship between 1) each parental stressor and a child’s emotional regulation skills, 2) a child’s emotional regulation skills and 8 obesity risk factors and 3) each parental stressor and the 8 obesity risk factors. For each analysis , I included measures of sociodemographic characteristics, socioeconomic resources, child-level characteristics and parent-level characteristics as covariates. Additionally, I tested whether protective factors moderated these associations including interaction terms.

Analyses were based on an analytic sample of 4,000 co-residential mother-father dyads at the preschool wave. In general, the results suggested that parental stressors were associated with a child’s emotional regulation skills and obesity risk. However, these associations often became non-significant once parent-level characteristics that influence family functioning, or the general social-emotional climate of the household, were added to the models. Thus, the findings indicated that parent-level characteristics including maternal depressive symptomology, conflict resolution styles and the number of household routines may influence a child’s behavior and obesity risk above and beyond the specific stressors this dissertation focused on. In addition, the overall findings also suggest that the relationships between parental stressors and child outcomes vary by parental gender as the associations are stronger among mothers than fathers. The results did not support the hypothesis that parenting resources moderated the association between the parental stressors and a child’s emotional regulation skills, but there was partial support for moderation when examining the association between a child’s emotional regulation skills and the obesity risk factors.

This dissertation contributes to the literature on psychosocial correlates of child obesity by highlighting the importance of examining familial characteristics that influence the general social-emotional climate of the household and the role of parents’ gender to better understand how the family environment and specific behaviors and practices influence early childhood health and development.

Objectives. We examined associations between self-reported unfair treatment and prescription medication use, illicit drug use, and alcohol dependence. Methods. We used data from the Filipino American Community Epidemiological Survey, a cross-sectional investigation involving 2217 Filipino Americans interviewed in 1998?1999. Multinomial logistic and negative binomial regression analyses were used in assessing associations between unfair treatment and the substance use categories. Results. Reports of unfair treatment were associated with prescription drug use, illicit drug use, and alcohol dependence after control for age, gender, location of residence, employment status, educational level, ethnic identity level, nativity, language spoken, marital status, and several health conditions. Conclusions. Unfair treatment may contribute to illness and subsequent use of prescription medications. Furthermore, some individuals may use illicit drugs and alcohol to cope with the stress associated with such treatment. Addressing the antecedents of unfair treatment may be a potential intervention route.

This study investigates how neighborhood deterioration is associated with stress and depressive symptoms and the mediating effects of perceived neighborhood social conditions. Data come from a community survey of 801 respondents geocoded and linked to a systematic on-site assessment of the physical characteristics of nearly all residential and commercial structures around respondents’ homes. Structural equation models controlling for demographic effects indicate that the association between neighborhood deterioration and well-being appear to be mediated through social contact, social capital, and perceptions of crime, but not through neighborhood satisfaction. Specifically, residential deterioration was mediated by social contact, then, social capital and fear of crime. Commercial deterioration, on the other hand, was mediated only through fear of crime. Additionally, data indicate that the functional definition of a ‘‘neighborhood’’ depends on the characteristics measured. These findings suggest that upstream interventions designed to improve neighborhood conditions as well as proximal interventions focused on social relationships, may promote well-being.