UC Berkeley

Abstract

The United States lags in its progress in preventing infant mortality and critical infant health outcomes compared to other high-income countries. Moreover, empirical research has demonstrated that racial and socioeconomic perinatal health inequities persist despite rising government expenditures on health care. Given the lack of success of clinical interventions in reducing infant health disparities, researchers have looked outside the healthcare setting to the places where families live, work, and play as sites for intervention. Public health researchers have contributed to health inequities research by examining where, how, and why various places such as neighborhoods, disadvantaged areas, and urban and rural areas impact infant health to improve or intervene on contributing health factors. Furthermore, by using a legal epidemiological approach to advance knowledge on how to disrupt upstream factors such as political structures, policies, and practices that codify infant health risks, policymakers, practitioners, and communities can start to diminish the reproduction of health inequities by altering, improving, and holding accountable our political system and actors.Infants in the eight-county San Joaquin Valley of California fare worse than most of the state’s population on maternal and infant health outcomes across key indicators. Particularly concerning are pockets of entrenched poverty, which include 450 disadvantaged unincorporated communities that have documented detrimental environmental and social conditions, such as contaminated water and air and lack of adequate housing. Many detrimental environmental exposures associated with poor infant health outcomes are present in these disadvantaged unincorporated communities. Communities outside of city boundaries are unincorporated communities, defined as settled populated areas whose community identity is commonly known but that lack incorporation status as a city. Moreover, in California, unincorporated communities lack municipal government representation and rely primarily on their county board of supervisors for local representation. Lack of representation can lead to political exclusion and diminished access to resources (i.e., power, money, influence, material resources, and services). Unfortunately, the limited attention to unincorporated communities in infant health research—and public health research, writ large—has created a blind spot to the potential structural vulnerability of communities outside city boundaries with no local governance. This project bridges the research gap on unincorporated communities by using multiple methods to examine incorporation status as a political determinant of infant health. The first study examined places (i.e., cities, towns, and settled communities) with or without incorporation status to understand if there is a relationship between incorporation status and adverse birth outcomes among singleton births in California’s San Joaquin Valley. We used population-level data from the California Department of Public Health Birth Statistical Master Files of births between January 1, 2006, and December 31, 2015, for the eight-county region to assess the relationship between residence in an unincorporated community and adverse infant health outcomes (small for gestational age, preterm birth, very preterm birth, and low birth weight). First, this project described a retrospective cohort of 531,668 births within the 8-county San Joaquin Valley summarizing the characteristics and risk factor distribution for infant health outcomes by incorporation status for a ten-year period (2006-2015). Second, using logistic regression analysis, we observed a relationship between living in an unincorporated community and elevated odds of preterm birth. When considering both a community’s incorporation status and economic disadvantage together, we similarly observed higher odds of a preterm birth in disadvantaged unincorporated communities compared to disadvantaged and advantaged incorporated communities. In the second study, qualitative methods were employed, leveraging a constructivist grounded theory approach with reflexive thematic analysis to understand how lack of incorporation status impacted the efforts of residents from a disadvantaged unincorporated community to address an infant health threat. Between 2007-2010, approximately 11 infants were identified as part of a birth defect cluster, three of whom died in Kettleman City, a small rural disadvantaged unincorporated community in the San Joaquin Valley of approximately 1,648 residents. Using semi-structured in-depth interviews, this study gained insights from 13 resident and 11 non-resident participants on how they understood the political arrangement for their disadvantaged unincorporated community to be an inadequate political structure for and generally unresponsive during a community health threat. Most participants perceived that the political structure for unincorporated communities is disenfranchising, constraining the capacity and will of county officials to act responsively to residents whose political power is diluted within the general county voting body. Participants attributed the marginalization by county officials who chose political inaction because of “who they are”- a “small rural Latino farmworker town.” Resident participants desired localized responsive political representation, as they felt disconnected from county officials who did not deploy their authority or government resources to help residents navigate the infant health threat in a timely manner. This dissertation suggests structural vulnerabilities for infant health in unincorporated communities in California’s San Joaquin Valley. It provides a foundation for future research on perinatal health and other health outcomes in unincorporated communities in California and beyond. Greater policy and research efforts are needed to understand and address the precarity of people in unincorporated communities that are structured as insignificant within the current political arrangement for those outside of a municipal boundary.