Background: Hispanics account for more than half of the total United States (US) population growth between 2000 and 2010. To gain a comprehensive understanding of a predominantly Hispanic urban community in Northern Manhattan, the aims of this cross-sectional observational study were: (1) to characterize the actual and perceived neighborhood food environment in Northern Manhattan, (2) to understand the relationship between the actual and perceived neighborhood food environment, sociodemographic characteristics and the likelihood of consuming five or more servings of fruits and vegetables per day, and (3) to describe the contribution of participants’ sociodemographic characteristics and health behavior to their health outcomes. Methods: This cross-sectional observational study was undertaken as part of the larger Washington Heights/Inwood Informatics Infrastructure for Comparative Effectiveness Research (WICER) project. English or Spanish-speaking Hispanic participants (n=4,019) 18 years and older living in Northern Manhattan’s five ZIP codes were recruited and interviewed by English-Spanish bilingual community health workers. Food outlets selling fruits and vegetables were identified using the North American Industry Classification System (NAICS) definitions obtained from the ReferenceUSA’s national business database. The neighborhood food environment was characterized by integrating the geocoded addresses of WICER study participants with external geographic-level data on food outlets present in the participants’ respective 0.25-mile and 0.5-mile residential radii. Data were analyzed using bivariate and multivariate binary logistic regressions. Results: The food outlet types that sell fruit and vegetable in Northern Manhattan include small and medium/large size Supermarket/Grocery store, Meat Market, and Fruit and Vegetable Market. The majority of these food outlets (91.5%) are single location stores that have a smaller store space. The presence of Fruit and Vegetable Markets (2+ Stores in 0.25-mile: OR=1.59, p = 0.003; 1 Store in 0.5-mile: OR=2.28, p = 0.008; 2+ Stores in 0.5-mile: OR=3.10, p = 0.00) significantly increase the odds of participant’s perception that a large selection of fresh fruits and vegetables is available in their neighborhood. The presence of Fruit and Vegetable Markets (2+ Stores in 0.25-mile: OR=1.51, p = 0.003; 1 Store in 0.5-mile: OR=2.25, p = 0.004; 2+ Stores in 0.5-mile: OR=3.31, p = 0.00) as well as the presence of medium/large size Supermarket/Grocery in 0.25-mile (OR=1.05, p = 0.013) significantly increase the odds of participant’s perception that the fresh fruits and vegetables in their neighborhood are of high quality whereas the presence of Meat Market in the participant’s 0.25-mile (OR=0.74, p = 0.002) significantly lower the odds. The presence of Fruit and Vegetable Markets (1 Store in 0.25-mile: OR=1.23, p = 0.047; 2+ Stores in 0.25-mile: OR=1.37, p = 0.020; 2+ Stores in 0.5-mile: OR=1.94, p = 0.018) as well as the presence of medium/large size Supermarket/Grocery (0.25-mile: OR=1.05, p = 0.020; 0.5-mile: OR=1.05, p = 0.018) significantly increase the odds of participant’s perception that a large selection of low-fat products is available in their neighborhood whereas the presence of Meat Market in the participant’s 0.25-mile (OR=0.83, p = 0.042) significantly lowers the odds. Variables that significantly increase the participants’ odds of consuming five or more servings of fruits and vegetables per day include having more than a high school education (0.25-mile and 0.5-mile models: OR=1.62, p = 0.004) and being foreign-born (0.25-mile model: Foreign-born in Dominican Republic: OR=1.77, p = 0.032; Foreign-born outside of the United States or the Dominican Republic: OR=2.44, p = 0.007; 0.5-mile model: Foreign-born in the Dominican Republic: OR=1.73, p = 0.040; Foreign-born outside of the United States or the Dominican Republic: OR=2.48, p = 0.006). In contrast, the participants’ perception that a large selection of fresh fruits and vegetables is available in their neighborhood (0.25-mile model: OR=0.63, p = 0.011; 0.5-mile model: OR=0.64, p = 0.016) and the presence of Fruit and Vegetable Market in their 0.5-mile radius (1 Store: OR=0.32, p = 0.006; 2+ Stores: OR=0.38, p = 0.009) significantly lower the odds. Variables that significantly increase the odds of body mass index (BMI) in the overweight range were age (OR=1.02, p = 0.00), being foreign-born outside of the United States or the Dominican Republic (OR=1.76, p = 0.006), self-reported diabetes (OR=1.37, p = 0.026), and perceived weight as overweight (OR=4.46, p = 0.00) whereas being female (OR=0.67, p = 0.00) significantly lowers the odds. Variables that significantly increase the odds of BMI in the obese range were age (OR=1.02, p = 0.00), self-reported diabetes (OR=1.78, p = 0.00), and perceived weight as overweight (OR=19.39, p = 0.00) whereas having more than a high school education (OR=0.72, p = 0.021) significantly lowers the odds. Variables that significantly increase the odds of hypertension were age (OR = 1.04, p = 0.00) and self-reported diabetes (OR = 1.57, p = 0.00) whereas being female (OR = 0.72, p = 0.00) significantly lowers the odds. Education (>High School) significantly increases the odds (OR=1.43, p = 0.00) of self-report of good health. In contrast, variables that significantly lower the odds were age (OR=0.98, p = 0.00), being female (OR=0.60, p = 0.00), higher fruit and vegetable consumption (OR=0.66, p = 0.007), self-reported diabetes (OR=0.51, p = 0.00), and obesity (OR=0.64, p = 0.00). Variables that significantly increase the odds of self-report of good health include having more than a high school education (OR = 1.43, p = 0.00) whereas age (OR = 0.98, p = 0.00), female gender (OR = 0.60, p = 0.00), higher fruit and vegetable consumption (OR = 0.66, p = 0.007), self-reported diabetes (OR = 0.51, p = 0.00), and obesity (OR = 0.64, p = 0.00) significantly lower the odds. Conclusion: This study contributed to our understanding of the relationships among neighborhood food environment, health behaviors, and health outcomes in a predominantly Hispanic underserved urban community in New York City. While most findings were similar to those reported in the literature, our findings related to the relationship between participants’ perceived neighborhood food environment and actual healthy food access and fruit and vegetable consumption were in contrast to other studies in that increased perceived availability and actual availability lowered the odds of consuming five or more servings of fruits and vegetables per day. This surprising finding merits additional qualitative and quantitative research to examine the complex relationships among perceived access, availability, and consumption of healthy foods as well as improved measures of fruit and vegetable consumption.

The purpose of this three-paper dissertation is to examine the influence of different social processes on insomnia symptoms among Latinx adults. Qualitative and quantitative methods were used in an effort to adequately capture the complex ways in which these processes impact insomnia symptoms in this population. Given that insomnia is more prevalent among women than men and that previous studies suggest different gender patterns in the influence of social processes on mental health exist, each paper includes an exploratory aim that investigates potential gender differences in the associations it examines. Paper 1 uses thematic content analysis to explore how Latinx adults with chronic insomnia describe the social processes through which social ties impact their lived experience of insomnia. Paper 2 tests the independent and synergistic effects of family and friend social support and social strain on insomnia symptoms. Lastly, Paper 3 builds upon previous studies demonstrating a positive association between acculturation stress and insomnia symptoms among Latinx adults by examining two emotion-focused coping strategies (i.e., brooding and alcohol use) as potential mechanisms driving this association. Taken together, the findings from these three papers suggest there may be a need for mental health providers to evaluate and address social processes when diagnosing and treating insomnia among Latinx adults.

This dissertation aims to examine racial and ethnic inequities in nursing home (NH) palliative care services and potentially avoidable hospitalizations at the end of life. Health disparities are pervasive in NHs, but disparities in NH end-of-life care (i.e. palliative care services, hospital transfers) have not been comprehensively examined. Chapter One provides an overview of this dissertation, which explores inequities in nursing home end-of-life care. Chapter Two is a systematic review that synthesized the current state of the science in racial and ethnic disparities in NH end-of-life care. Chapter Three was designed to describe palliative care services in U.S. NHs and associations with differences in the concentrations of Black and Hispanic residents, respectively, and the impact by region. Chapter Four is an analysis of racial and ethnic differences in NH potentially avoidable hospitalization incidence rates. Finally, Chapter Five is a synthesis of this body of work. It contains a summary of findings of this dissertation, a discussion of the results, practice and policy implications, and directions for future research.

Diabetes has alarming prevalence rates not only in the U.S., but also worldwide. Ethnicity plays a large role with Hispanic-Americans having one of the highest prevalence rates. Diabetes is a complicated disease that requires significant lifestyle modifications. The health belief model (HBM) has been investigated as a theory to explain behavior change. However, little research has been done to determine its utility to Mexican-Americans. In the current study, participants were Mexican-American adults (N = 66) with type II diabetes who were recruited from family medicine clinics. Self-report questionnaires included the General Acculturation Index (GAI) and the Multidimensional Diabetes Questionnaire (MDQ). Participants had the option to complete them in either Spanish or English. Laboratory values were collected from medical charts. A MANCOVA indicated that two variables were significant, perceived severity (PS) and misguided support behaviors (MSB), p < .05. With respect to the HBM, PS was identified as a component of an individual's perception, acculturation was a modifying factor, and MSB was a component of the likelihood to change factors. These three affected glycemic control. Odds ratios determined that individuals with better glycemic control had less perceived severity and less misguided supportive behavior. Individuals with the least acculturation were more likely to have best glycemic control. Significant results were found for each of the three main columns of the model suggesting that the HBM has utility for the Hispanic-American population with type II diabetes. Results suggest that health care personnel should be aware of the ramifications of patients' perceived severity of their illness as well as the amount the "nagging" type support they receive from friends and family on glycemic control. This awareness can lead to the development of interventions aimed at improving glycemic control and the quality of life in Mexican-Americans with diabetes. Specifically, programs focused on incorporating the family may lead to improved psychosocial and educational outcomes since familial relationships are crucial in this population.

Racial microaggressions are a type of perceived discrimination entailing a brief pejorative message by a perpetrator, whether verbal or nonverbal, intentional or unintentional, about a target person that operates below the level of conscious awareness. Research supports a relationship between perceived discrimination and worse mental and physical health outcomes, with the literature centered mainly on non-Hispanic blacks. Less research exists on how perceived discrimination, specifically racial microaggressions, affects the mental and physical health of Hispanic/Latinos. This study examined how exposure to racial microaggressions, using an experimental design whereby a confederate delivers two types of racial microaggressions, influences affect and cardiovascular reactivity (CVR) among Hispanic/Latinos and non-Hispanic whites. Results revealed that the experience of racial microaggressions did not evoke larger and longer lasting emotional and physiological arousal among Hispanic/Latinos and non-Hispanic Whites. Future directions are discussed.

Sociopolitical and economic factors shape the lived experience of immigrants and subsequent US-born generations. Often marked by immigrant-related federal and subfederal (i.e., state, county, and city) government policies, but also inclusive of public sentiment toward immigrants, an anti-immigrant climate limits Latino immigrants’ and US-born Latinos’ access to pro-health resources and services, keeps them in a lower socioeconomic position, increases their exposure to interpersonal and structural discrimination, and directly and indirectly exposes them to acute and chronic stressors that can take a toll on their cardiovascular health. The objective of this dissertation is to examine the association between anti-immigrant climate, first defined using policies and then defined using anti-Latino immigrant sentiment, and a panel of traditional and non-traditional cardiovascular disease risk factors among immigrant and US-born Latino adults living in the United States. This dissertation is organized into five sections: 1) an introduction, 2) a systematic review and critical analysis of the literature on US federal and subfederal policies and physical and mental health outcomes among Latino adults, 3) an empirical study of subfederal immigrant-related policies enacted in 2007 and their association with a panel of cardiovascular disease risk factors among Latino adult participants in the National Health Interview Survey, 4) an empirical study of anti-Latino immigrant sentiment during the 2016 Presidential campaign and election and a panel of incident cardiovascular disease risk factors in a cohort of Latino participants of the Hispanic Community Health Survey/Study of Latinos, and 5) a discussion of findings and implications for future research. The systematic review did not identify any studies of immigrant-related policies and traditional cardiovascular disease health condition risk factors of obesity, hypertension, high cholesterol, or diabetes. Exclusionary policies were associated with poor mental health and poor self-rated health and no relationship between policies and adverse birth outcomes was observed. In the empirical study of subfederal immigrant-related policies, I did not observe a statistically significant association between exposure to exclusionary policy climates in 2007 and a greater increase in the prevalence of cardiovascular disease risk factors relative to exposure to neutral/inclusive policy climates. Although no statistically significant difference-in-differences were observed, Latinos living in exclusionary states had a statistically significant increase in the prevalence of high alcohol consumption one year after exposure, while the prevalence remained unchanged among Latinos living in neutral/inclusive states. This increase was reflective of increases among foreign-born Latinos, not US-born Latinos. In the empirical study of anti-Latino immigrant sentiment during the 2016 Presidential campaign and election, findings from models of high depressive symptoms suggested that among Latinos of Mexican and Central American background, the exposed were more likely to have incident high depressive symptoms than the unexposed. Findings also suggested an association between exposure status and incident current alcohol use, particularly among the foreign-born. An inverse association between exposure and risk of hypertension was observed, with further differences by duration of US residence. Patterns for alcohol consumption across both empirical studies suggest that future studies should continue to explore the effect of anti-immigrant climate on acute changes in alcohol consumption among Latinos in the US. Additionally, findings from the systematic review and the second empirical study also support the continued study of the relationship between anti-immigrant climate and mental health outcomes. As the sociopolitical climate of the US becomes increasingly harsh toward Latino immigrants and their families, studies should examine other health outcomes in order to understand which dimensions of health are affected by exposure to an anti-immigrant climate among one of the largest ethnic populations in the US.

Substantial evidence demonstrates that marriage is associated with better health outcomes and lower mortality risk. Some evidence suggests that there are gender and race/ethnicity differences between the marriage-health benefits association. However, previous studies on marriage and health have mainly focused on non-Hispanic White-Black differences. Limited information is available regarding the roles of Hispanics. The present study examined marital status, gender, and the differences between non-Hispanic Whites, non-Hispanic Blacks, and Hispanics, in health outcomes. A retrospective cohort analysis of 24,119 Hispanic, NH White, and NH Black adults admitted to a large hospital was conducted. A total of 16,661 patients identified as either married or single was included in the final analyses. Consistent with the broader literature, marriage was associated with beneficial hospital utilization outcomes. With respect to differences in these benefits, results suggest that married patients, Hispanic patients, and women, were less likely to experience in-hospital mortality. Similar effects were observed in aggregated length of stay with married Hispanic women hospitalized nearly 2 days less than their single counterparts (6.83 days and 8.66 days, respectively). These findings support existing literature that marriage is associated with health benefits, add to the emerging research of a Hispanic survival advantage, and broaden the understanding of marriage and health in terms of differences by racial/ethnicity.

The Hispanic birthweight paradox, whereby Hispanic women exhibit a comparable or lower risk of bearing a low birthweight infant than their white counterparts despite relative socioeconomic disadvantage, has been observed across a number of research studies. However, the majority of evidence for the paradox has focused on Hispanics in aggregate form or on populations with primarily Mexican ancestry and has relied largely on outcome measures with important methodological shortcomings. Furthermore, studies have identified the variation of birthweight risk among Hispanics by nativity, maternal education and neighborhood composition, but the evidence has been scarce and inconsistent. The overall goal of this dissertation was to investigate the Hispanic health paradox with relation to measures of birthweight and infant size in births to women residing in New York City aged 20 years and older, using birth records for years 2003 through 2007 collected by the Office of Vital Statistics of the New York City Department of Health and Mental Hygiene (N=460,881). The main outcomes of interest in this study were mean birthweight, low birthweight (LBW, defined as < 2500 grams versus ≥ 2500 grams) and small for gestational age (SGA, calculated as the 10th percentile for birthweight at each week of gestational age and by sex). Multilevel logistic models with random effects were used to estimate odds ratios for the association between race/ethnicity and measures of birthweight and infant size, while controlling for individual-level and contextual factors and accounting for the correlation between observations within the same neighborhood. Analyses were conducted with Hispanics as an aggregate group as well as with race/ethnic-nativity subgroups. In addition, effect measure modification by maternal education and by neighborhood proportion of Hispanic population (NPHP) were examined. This research confirmed the Hispanic paradox in SGA analyses for Hispanics overall and for both U.S.-born and foreign-born Hispanics, but not in analyses with LBW or with mean birthweight. As compared to white women, black women exhibited 50% greater risk (OR:1.50;95%CI:1.45,1.55) and Hispanic women comparable risk (OR:1.03;95%CI:1.00,1.06) of having an SGA infant, in a fully adjusted model. With regard to LBW, the risk was more than double for black women (OR:2.25;95%CI:2.16,2.35) and close to 50% greater for Hispanic women (OR:1.46;95%CI:1.40,1.53) as compared to that of their white counterparts. In addition, the mean birthweight of infants born to Hispanic women was significantly lower compared to those born to white women. Furthermore, the relationship between race/ethnicity and all three measures of birthweight and infant size varied by maternal nativity status (p<0.0001), with infants of foreign-born women experiencing more favorable outcomes relative to their U.S.-born counterparts. The paradox with SGA was also apparent across most Hispanic race/ethnicity-nativity subgroups, The odds were greatest among black and Puerto Rican women overall (OR:1.52;95%CI:1.47,1.57 and OR:1.17;95%CI:1.13,1.22, respectively) and lowest among Mexican and South American women overall, (OR:0.91;95%CI:0.87,0.95 and OR:0.85;95%CI:0.80,0.89) as compared to white women in a fully adjusted model. The odds of SGA for infants born to Dominicans, Central Americans and Cubans in the fully adjusted model were similar to those born to whites. In addition, SGA varied by maternal nativity status (p<0.0001), with more favorable SGA odds observed among infants of most foreign-born women, as compared to whites. The exception was U.S.-born Puerto Ricans who consistently exhibited elevated risk of SGA relative to whites. The association of race/ethnicity-nativity with SGA varied by maternal educational attainment (p<0.0001), but the influence varied by subgroup. The observed advantage of foreign birth was stronger among less educated women of all Hispanic subgroups other than Puerto Ricans and Cubans. Similarly, the variation of SGA risk by neighborhood proportion of Hispanic population (NPHP) differed across subgroups (p<0.0001). NPHP did not appear to influence the association between race/ethnicity-nativity and SGA in a consistent pattern, but among black women and US-born Puerto Rican women greater NPHP was associated with a higher risk of SGA. Findings from this study underscore the importance of using SGA an accurate measure of infant size and of conducting analyses disaggregating race/ethnicity and nativity subgroups. Future research should focus on factors that contribute to the resilience of Hispanic subgroups in the face of adverse economic circumstances, such as the role of social support networks and acculturation. Greater understanding of the salubrious circumstances that lower the risk of adverse birth outcomes has major public health benefits, especially for a wide-ranging population of mothers, Hispanic and non-Hispanic, and their infants.

Persons with serious mental illness (SMI) are in worse physical health compared to persons in the general population and are more likely to develop medical conditions, such as obesity and diabetes, which place them at risk for cardiovascular disease (CVD). There is some evidence that Hispanics with serious mental illness are at greater risk for developing CVD risk factors compared to non-Hispanic Whites with SMI mainly due to health disparities. This study asks the questions: 1) What self-management behaviors do Hispanics with SMI and at risk of CVD engage in or attempt to engage in?, 2) How do measures of self-efficacy and patient activation correspond to self-management behaviors and barriers?, and 3) How do patients’ and stakeholders’ reports of barriers converge or diverge? Self-efficacy theory and social ecology theory were used as theoretical frameworks. Twenty four consumers were recruited from an outpatient mental health clinic. Seventeen stakeholders were recruited through various sites. A convergent mixed methods approach was used. Quantitative measures of self-efficacy and patient activation were compared to qualitative data on self-management behaviors and barriers to healthy living. Additionally, two sets of qualitative data on consumers’ and stakeholders’ perceptions of barriers to healthy living were compared to determine if they converged. Self-management behaviors identified included: healthy eating, seeking medical care, engaging in physical activity, involving others, self-motivation, use of faith, and engaging in structured and unstructured activities. Consumers with high levels of self-efficacy and patient activation tended to engage in more self-management behaviors regularly and perceived fewer barriers. Consumers with the lowest levels of self- efficacy and patient activation engaged in fewer self-management behaviors regularly and encountered more barriers. Consumer and stakeholder perceptions of barriers to healthy living experienced by consumers did converge, with the exception of the following additional barriers which were only identified by stakeholders: lack of health education, lack of formal education, consumer beliefs and fears, and body image. Using an ecological approach, barriers were identified at different environmental levels, often interacting. Overall, self-efficacy and patient activation may have an important influence on self-management behaviors among Hispanics with SMI and at risk for CVD. There is the possibility that barriers may moderate this relationship. Additionally, an ecological approach to understanding barriers to healthy living can be used to locate barriers and develop interventions which address them.

This study addressed cultural factors that prevent Hispanic diabetics from getting diagnosed early, controlling their glycemic levels, and obtaining appropriate transportation, health insurance, and better education on nutrition.