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Moving Further Upstream to Promote Racial Equity: A Mixed Method Analysis of Private Nonprofit Hospital Community Benefit


This dissertation examines how private nonprofit hospital community benefit aligns with health, and the extent to which racial health inequities are addressed. While previous empirical work has examined hospital community benefit in relation to state laws, tax savings, and hospital ownership, less is understood about the relationship between private nonprofit hospital community benefit spending and community health-related needs. The first paper of this dissertation systematically reviews empirical studies to assess the relationship between private nonprofit hospital community benefit and health, and to determine how social health inequities are considered. The findings suggest that hospitals generally report higher amounts of community-directed spending in communities with lower levels of socioeconomic and community health need. The second paper is a cross-sectional study that examines the association between hospital characteristics, community-level indicators of social vulnerability, and private nonprofit hospital community benefit spending for vulnerable populations. Support is found for the hypothesis that hospital capacity, rather than indicators of community social vulnerability, affects the amount of community benefit that private nonprofit hospitals spend. The third paper uses a comparative case study to analyze how two private nonprofit hospital investments in housing and workforce development are rationalized and deployed. The findings indicate that community-based resources are essential to align hospital investments with community need, and to prevent the use of race-neutral decisions that emphasize socioeconomic need yet under- appreciate racialized barriers to health. Together, the three papers provide support for a racial equity approach to private nonprofit hospital community benefit that builds upon existing theoretical and empirical work, and helps to move research and practice further upstream to advance racial equity and improve population health.

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