Background: Gentrification, a macro-level factor in the San Francisco Bay Area, shapes the symbiotic relationship between context and composition in urban neighborhoods. Gentrification is a process in which formerly declining, under-resourced neighborhoods experience reinvestment an in-migration of increasingly affluent new residents. These processes can potentially diminish health protective mechanisms such as social networks, housing stability, and community resources. Conversely, it may enhance public services, sense of safety, and wealth.

Methods: The question framing this dissertation is: To what extent and under what circumstances does the macro-level process of gentrification exacerbate health inequities between existing low-income long-term residents and newer higher-income residents in gentrifying communities? To ground this study, Chapter 2 provides a mixed-methods systematic review of the literature analyzing the conceptual underpinnings of research on gentrification in relation to health and well-being, the mechanisms linking the exposure to health outcomes, and temporal and spatial considerations of both the exposure and etiology of the health outcome of interest. Chapter 3 uses all-cause mortality data from 2005 – 2013 in Alameda County to examine the association between preventable mortality, which is an indicator of health inequities, and gentrification in low-income and medium/high income census tracts, while accounting for lack of independence over time between both the exposure and outcome. In Chapter 4, to capture the potential heterogenous effects of gentrification and the importance of identifying mechanisms linking gentrification and preventable

mortality, we analyze qualitative data collected by in-depth interviews with long-term residents that have lived in two adjacent census tracts in the West Oakland neighborhood of Alameda County with distinct preventable mortality rates but similar stages of gentrification.

Discussion and Significance: Increasingly macrosocial approaches to public health are examining the health effects of resultant social structures and social systems that propel unequal power, relations, and resources. This dissertation uses the example of gentrification as case study to inform research trajectories, challenges, and points of innovation for future scholarship on macro-level factors. Research findings underscore the importance of examining macro-social factors as producers of spatially patterned health inequities in cities. An exclusive focus on individual and neighborhood level factors limits understanding on the forces producing health inequity. Grounding research with conceptual clarity, explicit use of theory, hypothesized mechanisms, and accounting for time and space can illuminate the role of gentrification and potential approaches to reduce inequities. Furthermore, discerning the complex synergistic roles of the life course of regions, neighborhoods and individuals and embracing rather than controlling for difference may help inform movements, policy and interventions toward reducing urban health inequities.

The lack of diversity in the physician workforce poses a complex problem for the US healthcare system. Despite numerous efforts over the last 45 years, the lack of representation in the physician workforce persists, with no significant signs of reversing course. There is therefore an urgent need to engage in research to aid in the development of innovative, systemic and sustainable methods of addressing barriers in the educational pipeline leading into medicine for URM students.

Much of the previous research in this area has focused largely on examining undergraduate program outcomes and impact on physician specialty/service area choice with very few examining the undergraduate premed experience in detail. These experiences can have deleterious effects which serve as barriers to academic achievement and outcomes, thereby preventing matriculation into medical school and the physician workforce. This research seeks to fill this gap in knowledge and employs qualitative methodology to accomplish three overarching goals:

1. Better understand the experiences of URM premed students as they navigate their undergraduate premed pathway. Focusing on the multi-level factors associated with academic achievement and enrollment in post-bac programs.

2. Explore the role and sustainability of post-baccalaureate premed programs in facilitating entry into medical school for URM graduates of the UC system.

3. Develop empirically based recommendations to ameliorate barriers and challenges reported by URM students in the UC system.

This dissertation resulted in three papers. The first paper illuminates the barriers and challenges faced by URM premed students and outlines their relation to student achievement and outcomes. The second paper sheds light on URM student perceptions and the specific reasons they apply to post-bac programs in addition to providing data that suggests that post-bacs are not a sustainable strategy to address diversity in the physician workforce. The third paper presents a list of empirically based recommendations aimed at addressing institutional-wide barriers to student achievement such as campus climate, academic/students services and course size and curriculum.

In spite of an expanding menu of contraceptive options, women in the United States (US) continue to experience high rates of unintended pregnancy, with 50% of all pregnancies being unintended. Unintended pregnancy has been associated with a number of adverse health outcomes for mothers and their children and results in significant financial cost to society. While the root causes of unintended pregnancy are likely complex and multi-factorial, the direct cause of an unintended pregnancy is sexual activity coupled with contraceptive misuse, failure or nonuse altogether. Although most women who do not wish to become pregnant have at some point used contraception, nonuse and inconsistent use of contraception in any given year is common. Thus, at its most proximal level, reducing unintended pregnancy requires increasing and improving contraceptive use among women and couples that want to avoid pregnancy.

This research focuses on contraceptive method choice as a critical decision because the method used by a woman has implications for how well she is able to prevent an unintended pregnancy. Further, dissatisfaction with the contraceptive methods women use is high, highlighting the importance of assisting women with choosing methods that meet their needs. Contraceptive method choice is a highly individualized decision made in the context of a woman’s life circumstances. This decision can be complex and involves a number of considerations that can affect a woman’s ability to successfully use the method. Given that the most commonly used and most effective methods require a prescription and/or an interaction with a health care provider in the US, factors related to the health care system influence the methods women choose. There is a need to develop patient-centered interventions that can assist women in choosing a contraceptive method that best meets their individual needs.

This dissertation presents the findings of three interrelated studies related to women’s contraceptive method choice. The first paper presents the findings of a critical literature review of the role of the US health care system in impacting women’s contraceptive method choice. In this study, I identified a comprehensive set of factors related to the health care system, such as the provision of specific services by providers, that are associated with contraceptive method choice. The second paper examined a component of the contraceptive choice decision-making process by assessing the importance women assign to several contraceptive attributes when choosing a method. This quantitative analysis tested hypotheses to determine if the importance women assigned to various contraceptive attributes aligned with the methods they chose. Finally, in the third paper, I explored patient perceptions of a contraceptive decision support tool that can be used in clinical settings to help women choose contraceptive methods. Specifically, this qualitative study used semi-structured interviews to describe patients’ perception of the value and utility of the tool in order to understand the mechanisms through which these tools have an impact on contraceptive method choice.

This dissertation presents findings from an evaluation of the national HIV counseling and testing program of St. Lucia. The research methods used include: semi-structured interviews, written document analysis, record reviews, and participant observations. Findings from the study will support decision making to assist in the improvement and expansion of CT service provision in the country.

The findings from this research provide evidence that there are many gaps in the national program. The major gaps include: 1) the lack of a full time coordinator to manage the CT program, 2) inadequate CT data collection, analysis, and use for decision making, 3) the absence of accurate denominator data (total tests conducted) from all sites providing CT services, 4) incomplete antenatal testing data, 5) absence of a training needs assessment or training plan, 6) shortages of personnel at all levels, 7) inadequate referral networks and linkages to support services for People Living With HIV/AIDS (PLWHA), 8) insufficient prioritization of the labs in all areas of planning, budgeting, personnel, renovations/refurbishments, training, and storage needs, 9) lack of adherence to national, regional, and international guidelines in rapid test use, 10) lack of evaluation of testing promotions and campaigns to determine reach, 11) inadequate space and infrastructure for CT service provision, and 12) insufficient inclusion of the private sector into all areas of the national program including dissemination of protocols, data collection forms, reporting structures, and training.

Detailed and specific recommends are made to address each of the identified gaps. In summary, these recommendations are that: 1) a full time coordinator is recruited for the national level for oversight and coordination, 2) new data collection instruments and processes for recording and reporting CT are developed, 3) all facilities conducting testing are required and supported to report to the national level, 4) systems are put in place to capture pregnant women and ensure that they are tested, receive their results, and that these are reported accordingly, 5) training needs and a training plan are developed and used to identify and train relevant staff, 6) additional personnel are hired to meet all needs including lab personnel, 7) referral networks are strengthened to ensure a continuum of care for patients in need, 8) labs are included during planning processes, 9) national guidelines are disseminated, 10) promotional efforts are evaluated, 11) infrastructure for CT service provision are improved, and 12) the private sector is included into all areas of the national program.

Compared to all other racial and ethnic groups in the United States, Mexican-American adolescents have by far the highest rates of early childbearing. Within the public health literature, these disproportionately high rates have generally been explored as a function of acculturation, which is described as a process involving the cultural, social, and psychological changes that take place post-migration. In order to elucidate acculturation's effect, specifically on the reproductive health and behavior of Mexican-Americans, this construct has received great attention from public health researchers examining disparities in early childbearing among the this population. Yet within sociology, where the Mexican-American immigrant population is also studied extensively, the focus is on the role of post-migration contextual factors (e.g., limited educational opportunities) and how these factors - as opposed to individual-level characteristics like acculturation - are related to the high rates of early childbearing.

Reflecting the sociological emphasis on the importance of structure, this dissertation considers the contexts into which the Mexican-American children of immigrants settle. While acculturation may play a role in creating risk, this process does not occur within a vacuum. These young women are exposed to specific contextual factors that may create a risk environment for early childbearing and related sexual risk behaviors. Thus, the goals of this dissertation are: to suggest that a consideration of context be further incorporated into public health investigations of the disproportionately high rates of early childbearing among Mexican-Americans; to illustrate how Mexican-American young women experience context as a risk for early childbearing, specifically at the neighborhood-level; and to determine how Mexican-American young women themselves conceptualize contextual risk as a driver of the disparate rates of early childbearing among their population.

In order to achieve these goals, I conducted three studies that focus on 2nd generation Mexican-American young women. This research includes: (1) a systematic literature review synthesizing the empirical evidence on the relationship between acculturation and early childbearing among this population; (2) a mixed methods study using focus groups and participatory photography to determine what neighborhood context is and how it is experienced by this population, with the aim of learning what neighborhood-level factors might influence risk for early childbearing; and (3) a small pilot study using focus groups to determine how this population conceptualizes their risk for early childbearing across neighborhoods in Alameda County, California. In the first study, I found that the research on acculturation and early childbearing among Mexican-Americans is inconclusive due to issues related to sampling, measurement, insufficient use of theory, and an absence of a consideration of context. Findings from the second study demonstrate that as part of their neighborhood context, Mexican-American young women experience racism and discrimination, gangs and violence, and limited opportunities for upward mobility, all of which are associated with the health of adolescents. Finally, in the third study, the young women identified individual, family, and community level factors - all supported by the literature on risks for early childbearing - that they believed to vary across neighborhoods, possibly influencing the disparate rates across the county.

The data collected from these studies highlights the importance of neighborhood characteristics as they influence risk of early childbearing among this population, demonstrating that contextual factors should be considered when investigating the high rates of early childbearing among Mexican-Americans. Moving forward, researchers investigating early childbearing among this population may benefit from an incorporation of neighborhood-level characteristics as potential risk factors for early childbearing among Mexican-American young women.

Racial residential segregation is known to affect the social, physical, and mental well-being of segregated minority groups in the United States. Racial residential segregation creates different exposures to a variety of resources that enhance health, including economic opportunity and access to health-promoting resources such as grocery stores and parks. Racial residential segregation also increases exposure to adverse conditions such as crime, alcohol, and toxic air pollutants. Few studies examining the relationship between segregation and health have focused on Asian Americans. However, data show that several Asian Americans groups experience considerable racial residential segregation, and are now the fastest growing population in the country. Furthermore, high-degrees of segregation have enabled political power in Black communities as a mechanism to counter the negative effects of isolation. Much less, however, is known about the effects of segregation on the political and social capital of Asian Americans and its benefits to health. Further research is needed to test the complex association between residential segregation, its mechanistic pathways, and overall health status of Asian Americans.

In this three-paper dissertation, I ask 1) What are the potential mechanisms by which racial segregation is associated with self-rated physical and mental health status among Asian Americans in the United States? 2) How does social capital and political empowerment, moderate the association of racial segregation and self-rated mental health status among Asian Americans? 3) How can building political empowerment be utilized by public health departments to address the effects of racial segregation and the health of Asian Americans? Paper #1 examines the empirical evidence of the association between residential segregation and Asian American health by critically reviewing the literature with a relational geography lens, and is one of the first papers to examine this literature. Paper #2 empirically tests the role of residential segregation on health status of AAs and the moderating roles of social capital and collective political participation. To do so, I employ multilevel modeling methods using the California Health Interview Survey (2011-12). Paper #3 studies the role of political empowerment in addressing segregation and health, and utilizes comparative multi-site case-study design, key informant interviews, participant observations, and document reviews that to review in California counties with high Asian-white residential segregation. Specifically, I document examples of collective political empowerment, and discuss the role of health practitioners--particularly those employed at local health departments--in building political empowerment as a health promotion and equity strategy.

Objectives

Methods

Results

Conclusions

Nationwide, there is a racial/ethnic disparity in incidence of HIV infection and AIDS mortality, with African Americans and Latinos having disproportionately higher rates of both HIV and AIDS than Whites and Asian/ Pacific Islanders. The racial disparity in late diagnosis of HIV/AIDS reflects that of timely –diagnosed HIV, suggesting that late diagnosis may be one important driver of the widening racial disparities seen in the AIDS epidemic. Late HIV diagnosis is defined as a diagnosis of AIDS simultaneously with or within one year of an initial HIV diagnosis.

This dissertation research was conducted in conjunction with a larger mixed –methods study to investigate late diagnosis of HIV among Latinos and African Americans in Oakland, and to collaboratively design, implement and evaluate two interventions to address the problem. To conduct a systematic and critical review of the literature on HIV/ AIDS diagnosis among Latinos and African Americans within the United States in order to identify the multi –level social determinants of racial/ ethnic inequities in late-stage HIV. The overarching goal of this dissertation research was to use a Community –Based Participatory Research (CBPR) approach to identify the individual, interpersonal, community, and societal factors, and their interactions, which facilitate or hinder timely HIV testing by at-risk populations among Latinos and African Americans living in Oakland, California. The dissertation had the following aims: 1) To conduct a systematic and critical review of the literature on HIV/ AIDS diagnosis among Latinos and African Americans within the United States in order to identify the multi-level social determinants of racial/ ethnic inequities in late-stage HIV. 2) To analyze qualitative data from the larger parent study in order to identify and examine multi-level factors that exacerbate or attenuate barriers to timely HIV testing and diagnosis among African Americans and Latinos in Oakland, California. 3) To use reflexive analysis and participant observation to examine the benefits and challenges of using a CBPR framework to guide academic/ community collaboration for research and action goals. In order to achieve these aims, I conducted the three studies included in this dissertation.

In the first study, I found that the majority of studies on racial disparities in HIV testing and diagnosis have been either cross-sectional or focused on one racial or ethnic group, often in one geographic location. In all studies that compared racial and ethnic groups (n=17), Latinos and African Americans were more likely to receive a late diagnosis than non-Hispanic Whites or Asian Americans. Furthermore, 95.8% (n= 23) of the reviewed studies focused on individual level risk factors or investigated structural barriers via measurements at the individual level. However, in my second study I found that significant factors identified by participants as relating to the late diagnosis of HIV lay beyond the traditional individual –level elements of attitude, norms, control beliefs, and power, and were located within the interpersonal, community, and/or societal levels of the ecological model.

In the third study, we found that use of a CBPR approach both benefited the study and presented challenges in four key areas: 1) inclusion/ exclusion; 2) bridging social capital and the role of bridge people; 3) education, status, race/ ethnicity, privilege and power imbalances; and 4) conflicting priorities. The findings from these three studies demonstrate the importance of including communities in investigations of late –stage HIV inequities. Community engagement added value to this study as all partners contributed to aligning every activity toward the dual goals of increased knowledge and improved practice. The study findings also demonstrated that disparities in HIV testing behaviors are shaped and maintained by ecological factors at multiple levels. Especially when investigating health disparities that cluster in marginalized and oppressed communities, community –academic collaboration and multi –level frameworks can enhance findings.