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Historical redlining, a discriminatory practice of the 1930s, present-day social vulnerability (SVI), and sports and recreational injury (SRI) hospitalizations are interconnected topics that highlight the intersection of race, class, and health in the United States but the relationships have not been studied to date. Thus, the overall aim of this dissertation is to examine the effects of historical redlining and present-day social vulnerability on SRI hospitalizations in the United States. The first study systematically reviewed studies that examined the relationships between neighborhood characteristics and SRI using multilevel modeling approach. Studies reviewed show that certain neighborhood factors, such as living in urban communities, were associated with increased risk of SRI. The second study examined the association between historical redlining and present-day neighborhood SVI in the United States. Results show that formerly redlined areas have higher SVI presently. The third study examined the association between historical redlining and present-day SRI hospitalization in the United States. Results show that redlining was not associated with increased odds of SRI hospitalizations, but was associated with longer length of hospital stay (LOS) among Black and Hispanic patients, and higher total hospital charges among Hispanic patients. The fourth study examined the association between individual and neighborhood social vulnerability and sports and recreation-related traumatic brain injury (SR-TBI) hospitalizations among pediatric patients in the United States. Results show that Native American children had higher odds of hospitalization for SR-TBI, longer LOS, but lower odds of discharge to post-acute care compared to White children. Older age was associated with higher odds of hospitalization and longer LOS while male sex was associated with shorter LOS for SR-TBI in children. Compared to children with private insurance, children with public insurance had longer LOS while uninsured children had shorter LOS. Also, hospitalization in neighborhood with higher overall SVI was associated with longer LOS. This study advances our knowledge on the impact of structural racism on present-day SRI outcomes and will inform policy makers to prioritize health equity by addressing the underlying social determinants of health and the root causes of disparities in SRI outcomes. / Doctor of Philosophy / Every year, around 9 million people get hurt while playing sports or participating in recreational activities in the United States. Out of these, more than a third go to the emergency department for treatment, and several thousands need to stay in the hospital because their injuries are more serious. Even though only a small number of sports and recreational injuries (SRI) require hospitalization compared to those treated in the emergency department or outpatient clinics, these injuries tend to be more severe. They can cause significant harm to a person's physical, mental, and emotional well-being, and they also put a lot of pressure on the healthcare system and society as a whole. This dissertation assessed how historical discrimination against certain neighborhoods, called redlining, and present-day social vulnerability affect sports and recreational injury hospitalizations in the United States. This research found that the neighborhood where people live or are hospitalized matter for how often they are hospitalized for SRI, their length of stay in hospital, the amount of money they pay while in hospital, and how often they receive follow-up care after leaving hospital. While historical redlining was not directly linked to higher odds of hospitalization, it was associated with longer hospital stays for Black and Hispanic patients and higher costs for Hispanic patients. This research also found that children from socially vulnerable backgrounds were more likely to be hospitalized for sports-related traumatic brain injuries (SR-TBI) and stay in hospital longer, but were less like to receive follow-up care after leaving hospital. For instance, children from Native American backgrounds were three times more likely to be hospitalized for SR-TBI and stayed in the hospital 27% longer, but were 99.9% less likely to receive follow-up care after leaving hospital compared to White children. Also, children with public health insurance tended to have longer stays in hospital for SR-TBI compared to those with private health insurance. This research highlights how structural discrimination can impact health outcomes, and suggests that policymakers should address the root causes of health disparities in order to promote health equity.

Purpose: The relationship between racial disparities and the health-related quality of life (HRQoL) of lung cancer patients is not well understood. The purpose of this study was to quantify the overall HRQoL of lung cancer patients and compare differences in HRQoL among racial groups in the United States. Methods: We analyzed data from the Behavioral Risk Factors Surveillance System (BRFSS), a population-based national cross-sectional study conducted by the Centers for Disease Control and Prevention. The BRFSS is conducted annually in all 50 states and collects information on demographics, health behaviors, health-related experiences, health conditions, use of medications, and use of preventive services. Three HRQoL scores (unhealthy days per month, frequent mental distress, fair/poor health) were generated using the four Healthy Days Measures questions that have been validated as HRQoL measures by previous research. Results: We found that the HRQoL measures of the Non-Hispanic Black group were not statistically different from those of the Non-Hispanic White group for any of the three measures examined. However, the Hispanic group (OR = 3.14, 95%CI=1.40 – 7.02) and Other races (OR = 1.85, 95%CI=1.04-3.27) had significantly higher odds of frequent mental distress when compared to the Non-Hispanic White group. Conclusions: Quality of life among lung cancer patients is a heavily under-researched area of the cancer survivorship experience. Rarer, is data examining specifically how racial disparities affect the quality of life of lung cancer survivors. More research is needed to examine this important topic to create a foundation for more beneficial lung cancer interventions in the future.

Tennessee is a state in the United States South region, which is disproportionately burdened with higher levels of chronic disease and mental health disorders. Despite its unique cultural heritage and close-knit communities, the region faces a range of challenges related to access to mental health services, stigma, social and economic factors that can negatively impact mental health outcomes. Racial disparities in mental health among Black people are a significant challenge in the region that requires urgent attention. There is a need for increased funding for mental health initiatives in rural and underserved areas of Tennessee. The proposed study examines the association between physical health and depression among Blacks in Tennessee. We used cross-sectional data from the 2021 Behavioral Risk Factor Surveillance System a nationally representative U.S. telephone-based survey of adults aged 18 years and extracted data for participants who self-identified as race/ethnicity Black, and who reside in Tennessee (n=476). Logistic regression analyses were conducted to test the association number of past month physically unhealthy days and depression (outcome). We controlled for income, race/ethnicity, educational status, gender, health insurance status, and age. Results indicate that 19.9% (n=195) reported having been diagnosed with depression, while 25.0% (n=119) reported 1-14 physically unhealthy days in the past month, and 15.3% (n=73) reported 15-30 unhealthy days. Our logistic regression analysis revealed that 15-30 physically unhealthy days (OR=4.47, 95% CI, 2.37, 8.40), 1-14 physically unhealthy days (OR=3.59, 95% CI, 2.07, 6.24), and female gender (OR=2.00, 95% CI, 1.14, 3.49). The findings reveal a strong association between physically unhealthy days and depression among Black people in Tennessee. Greater efforts to address both poor physical health and mental health among Blacks are essential. Efforts to improve access to mental health services, reduce mental health stigma, and address social and economic factors that can negatively impact mental health outcomes are essential to addressing this challenge, particularly among Blacks in Tennessee.

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Improving cancer care through clinical research is a major public health issue. However, in Georgia, the exact number of cancer clinical trials is unknown, indicating the need for baseline data regarding cancer clinical trial locations and cancer burden. This study provides the first statewide analysis of cancer clinical trial locations using Geographic Information Systems (GIS). This study examines cancer clinical trial locations by county, according to incidence rates, racial patterns and mortality rates of the four major cancer types: breast, colorectal, lung, and prostate. Findings from this study suggest that metro-Atlanta counties have higher densities of cancer clinical trials. This study also found that there were little or no cancer clinical trials available in counties with the highest rates of overall incidence, African American incidence and overall mortality. This research demonstrates the need to increase availability of cancer clinical trials in counties with the highest cancer burden.

Preeclampsia (PE), characterized by hypertension and proteinuria after 20 weeks of gestation, affects 5-8% of pregnancies worldwide. Although preeclampsia is a significant cause of maternal and perinatal mortality and morbidity, its etiology remains to be elucidated. Racial differences have been observed for preeclampsia, with U.S. Blacks having higher rates and more severe disease, compared to U.S. Whites and Hispanics. One potential source of racial differences in preeclampsia is genetic variation between populations. Genetic susceptibility to preeclampsia is well established, but the specific contributions of maternal vs. fetal genes, and how these vary among racial groups is poorly understood. This dissertation addressed racial differences in the genetics of preeclampsia in Chileans, U.S. Blacks, and U.S. Whites through candidate gene studies and variance components modeling. First, we determined whether three genes, which are relevant to the pathophysiology of preeclampsia, Catechol-O-methyltransferase (COMT), Methylenetetrahydrofolate reductase (MTHFR), and Endoplasmic reticulum aminopeptidase 2 (ERAP2), were associated with the risk for preeclampsia in Chilean and U.S. Black mothers and fetuses. We found that the maternal COMT and an interaction between the fetal COMT and MTHFR were associated with the risk for preeclampsia in Chileans. We also found that the fetal ERAP2 was associated with the risk for preeclampsia in U.S. Blacks. We next used structural equation modeling of a unique Children of Twins (COT), supplemented with full and half-siblings, study design to investigate the fetal genetic, maternal genetic, shared environmental, and unique environmental contributions to preeclampsia in U.S. Whites and Blacks. Through this modeling we uncovered a unique source of racial differences in preeclampsia. We found that U.S. Whites and Blacks showed a similar prevalence of preeclampsia in first births, but across the next three births, the prevalence in Whites declined to a greater degree than in Blacks. In conclusion we have identified specific maternal and fetal genes that contribute to the risk for preeclampsia. Furthermore, we have identified sources of racial differences in preeclampsia, which include differences in associations between COMT, MTHFR, and ERAP2 and the risk for preeclampsia among populations and differences in the prevalence of preeclampsia across subsequent births between U.S. Whites and U.S. Blacks.