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Background: The current global refugee crisis requires attention from the public health community to improve the health and wellbeing of forcibly displaced groups. Eighty-six percent of refugees are hosted in developing countries, while 58% migrate to urban centers in search of opportunities. Although there are benefits to urban migration, refugees residing in Nairobi, Kenya are vulnerable to police extortion, arrests, deportations, and social exclusion as a result of anti-refugee policies. Despite threats to psychosocial wellbeing, many refugees successfully cope with acute and cumulative stressors to exhibit positive mental health outcomes in the context of adversity. This dissertation explores the ways urban Congolese refugees in Nairobi negotiate and navigate personal, social, and environmental resources to mitigate stress and promote psychosocial wellbeing. Research Aims: The dissertation included the following three aims: (1) document stressors experienced by urban Congolese refugees in Nairobi; (2) describe the range of coping supports available to Congolese refugees; identify how individuals, families, and groups navigate and negotiate these resources; and (3) explore relationships that exist among stressors, supportive resources, and reported mental health status of urban Congolese refugees. Methods: Mixed-methods exploratory research took place over a 12-month period in Nairobi. Preliminary research was conducted between May and August 2012, and dissertation fieldwork occurred between January and August 2014. Qualitative research included ethnographic participant observation, semi-structured in-depth interviews, and small group discussions with Congolese refugees (n=70). Additional interviews were conducted in Kenya with academics (n=3), intergovernmental employees (n=4), representatives from government agencies (n=2), and refugee service providers (n=18). Quantitative research was comprised of two surveys administered to Congolese refugees (N=244) in 150 households. The Self-Reporting Questionnaire (SRQ-20) assessed mental health functioning, and a survey developed in-field inventoried perceived stressors and supports. Results: The results by aim were: (1) stressors fell within three primary domains: inadequate material resources, political and personal insecurity, and emotional distress; (2) Congolese refugees utilized three salient coping strategies, comprised of reliance on religious communities and faith in God, participation in borrowing networks, and managing memories; and (3) isolation was associated with poor mental health functioning, while perceived support from religious communities enhanced mental health outcomes. Recommendations: Organizations should bolster community-based programs and strengthen partnerships with religious communities to improve the psychosocial wellbeing of urban Congolese refugees. Conclusions: Shifting the paradigm with refugee populations from a deficits-centric to resilience-focused framework recognizes the inherent strengths of individuals, families and communities with refugee status, and has the potential to mold future research and praxis that aims to enhance the wellbeing of displaced populations.

Objectives: Specific work processes and management structures that contribute to high rates of occupational illness and injury in agricultural industries are not well described in academic literature. This qualitative study of work organization in the U.S. fresh tomato industry investigates how work processes and management structures impact tomato workers’ occupational health. Methods: After conducting literature review and key informant interviews, semi-structured interviews and focus groups were conducted with 36 individuals with experience working in the U.S. fresh tomato industry. Interviews and focus groups were audio-recorded, transcribed, coded, and analyzed using a modified grounded theory approach. Results: These data indicate that participants endured income insecurity and hazardous supervisory practices, including wage theft, retaliation, intimidation, and humiliation, that put them at risk of preventable illness and injury. Support from workers’ organizations and health-conscious supervisory practices helped mitigate some of these occupational hazards. Conclusion: Participants’ adverse work experiences may be considered sequelae of workers’ lack of job control and positions of socioeconomic structural vulnerability. Other aspects of tomato work organization, including health-conscious supervisory practices and the involvement of workers’ organizations, indicate that modifying work organization to better safeguard health is possible. Such modifications present compelling opportunities for employers, employees, organizations, community and government leaders, and health care professionals to help create healthier occupational environments for tomato workers.

The aim of this thesis is to argue what it means to embody clinical competence for treating im/migrant patients. Im/migrants are a distinct yet heterogeneous patient population. They come to the U.S. for a variety of reasons, with a great diversity of backgrounds, upbringings, experiences, and ways of life. Considering the structural violence and push and pull factors directly connected to reasons for im/migration and experiences of distress upon settlement in the U.S., the central framework of this thesis is im/migration as a structural determinant of health. The operations of social structures, through policy, law enforcement, and discriminatory belief systems, make im/migrants structurally vulnerable. When healthcare providers treat im/migrant patients from a structurally informed approach to care, the context of these patients’ needs become more apparent and likelihood of positive health outcomes increases. Central to this structural approach, as I explain, is understanding how to best communicate with, gain the trust of, and provide effective social interventions for im/migrant patients relative to the operations of violent social structures. Im/migrant status truly is a determinant of health in its own right, and accordingly, care for im/migrant patients is also a specialized clinical realm with specific skills and competencies. As I argue, healthcare providers can only attain—embody—the competence for treating im/migrants through an awareness of how social structures affect these patients’ lives and modifies the delivery of care.

This essay seeks to understand the possible reasons behind the high rates of non-white ethnic minorities, such as the Somali-Swedish community among hospitalized Covid-19 patients in Sweden. It interrogates the possibility of a White middle-class bias in the Swedish government and the National Pandemic Group’s management of the covid-19 crisis. I analyze data from daily press conferences held by the National Pandemic Group and public statements from government and national pandemic group representatives regarding updates in the management of the covid-19 crisis. In analyzing these statements, focus has been on assessing the risk analysis and citizen recommendations presented to the public by the national pandemic group. Results show that the specific vulnerabilities of ethnic minorities and the socio-economic inequalities between majority White Swedes and ethnic minorities has not been taken under much consideration by the Swedish government or the national pandemic group, which can be interpreted as resulting from a white middle class bias. The conclusions of this essay show that this may have contributed to the high rates of Swedish-Somalis and other ethnic groups such as the Iraqi-Swedes and Turkish-Swedes among hospitalized Covid-19 patients. This might have been prevented, had the Swedish government acknowledged and acted upon the socio-economic inequalities between different social groups.

Skilled home health (HH) is the largest long-term care setting and the fastest-growing site of healthcare in the United States (U.S.). Home Health Value-Based Purchasing (HHVBP) is a structure of Medicare that penalizes U.S. HH agencies for high hospitalization rates. Prior studies have shown inconsistent evidence about associations of race with hospitalization rates in HH. Evidence supports that Black or African Americans are less likely to participate in advance care planning (ACP), or to complete written advance directives, which could affect their potential for hospitalization when nearing end of life. In this quasi-experimental study, we used Medicare administrative datasets, the Weighted Acute Care Services Use Rates (WACSUR) score, and the Advance Care Planning Protocol (ACPP) score to determine whether the proportion of Black HH patients in the U.S. was correlated with acute care use rates and the robustness of agency protocols on ACP. We used primary and secondary data from the U.S. from 2016-2020. We included Medicare-certified HH agencies. Spearman’s correlation coefficient was used. We found a statistical trend showing that the greater proportion of Black patients enrolled in a HH agency, the greater tendency to have a high hospitalization rate. Our findings suggest that HHVBP may encourage patient selection and exacerbate health disparities. Our findings support recommendations for alternative measures of quality in HH to include measures of goal-concordant care coordination when patients are denied admission to HH.

This thesis is about food practices and change among Mexican migrants living in West Queens, New York City. Public health research suggests that Mexican migration to the US has a negative impact on food practices, with diets being less nutritious over a migrant’s stay in the United States and obesity being more common among longer-term than more recently-arrived individuals. Through ethnography, I explore how migration shapes food practices and examine the nuanced process of nutritional change that is often obscured in large-scale epidemiological studies. Food practices are important not just because they shape vulnerabilities to chronic diseases but also because they serve as prisms by which to examine migrants’ lives, pressures and aspirations. The three aims of this ethnography are to explore the food practices that Mexicans engage in after migration; to examine the social, temporal and political-economic contexts shaping food practices and change; and to describe how migrants themselves makes sense of nutritional change. I explore these themes using the approach of structural vulnerability, which views health practices and outcomes as influenced by social structures, relationships and inequalities. In so doing, I provide a critique of the public health literature’s use of the concept of acculturation to explain food practices, which largely obscures the role played by structural contexts and constraints. Through participant observation, conversations and interviews with Mexican migrants in West Queens, NYC, I have identified three contexts shaping food practices and change after migration: household dynamics and labour division; time constraints and work schedules; and the ‘food environment’, referring to the availability of food items and weight loss products. Gender dynamics, documentation status and class modified the way in which these contexts were perceived and negotiated by informants, which had further consequences on food practices. In these settings, informants were often encouraged to consume high-energy foods and large portions, to replace meals with snacks, to eat prepared or convenience foods, and to experiment with weight loss products. To rationalize nutritional change and body size disparities, informants employed multiple discourses. Some discourses emphasized the role of structural contexts and constraints related to time, money and documentation status, while others emphasized the role played by cultural beliefs, habits and acculturation. An ethnographic approach informed by structural vulnerability serves to articulate how the everyday lives and social contexts in which Mexican migrants are embedded, shape experiences of nutritional change. This thesis exposes a disconnect between the way in which the public health literature conceptualizes nutritional change and how it is lived ‘on the ground’.

La problématique du financement du développement dans les pays en développement se trouve au coeur de cette thèse. Cette dernière s'articule autour de quatre chapitres sur les questions liées au financement du développement. Le chapitre 1 explore les effets des épisodes budgétaires dans les principaux pays donateurs principaux de l'OCDE (Organisation pour la Coopération et le Développement Economique) sur leur offre d'aide au développement aux pays en développement. On observe que les épisodes budgétaires affectent significativement l'offre d'aide, avec une différence comportementale en termes d'offre d'aide du groupe de pays de l'Union européenne versus le groupe de pays de l'OCDE n'appartenant pas à L'Union européenne. Le chapitre 2 s'intéresse aux conséquences des transferts des migrants et de l'imprévisibilité de l'aide au développement sur la probabilité de consolidation budgétaire dans les pays en développement. Les résultats montrent que les transferts des migrants affectent positivement et significativement cette probabilité alors que l'effet est statistiquement nul pour l'imprévisibilité de l'aide. Ces résultats suggèrent en l'occurrence qu'une meilleure gestion des recettes issues de ces transferts durant les périodes de boom économique pourrait aider à éviter de telles situations et offrir une marge de manoeuvre plus importante à ces gouvernements pour la mise en oeuvre de politiques contra-cycliques pendant les périodes de basse conjoncture. Le chapitre 3 analyse l'existence ou non d'effet de la vulnérabilité structurelle des pays en développement sur leur dette publique totale. Les résultats suggèrent qu'un tel effet existe : en l'occurrence, on montre l'existence d'une relation en forme de 'U' entre la vulnérabilité structurelle de ces pays et leur dette publique totale. En focalisant dans le chapitre 4 sur les pays de la zone Franc CFA, nous examinons si leur vulnérabilité structurelle conduit les gouvernements à un endettement excessif. Les résultats suggèrent que plus ces pays sont vulnérables, plus ils sont enclins à un endettement excessif et qu'au-delà d'un seuil de vulnérabilité, leur probabilité d'endettement excessif diminue. Ces résultats obtenus aussi bien pour l'ensemble des pays en développement que pour les pays de la zone Franc CFA suggère que les Institutions Internationales telles que la Banque Mondiale et le Fonds Monétaire International (FMI) devront prendre en compte cette vulnérabilité dans l'évaluation des politiques de développement ainsi que leurs recommandations – en particulier sur les questions liées à l'endettement – pour ces pays. / The issue of financing development in developing countries is at the heart of this thesis. The latter revolves around four chapters on financing development related matters. The chapter 1 explores how fiscal episodes in the main traditional OECD (Organization for Economic Cooperation and Development) donors affect their supply of development aid towards developing countries. Evidence is shown that fiscal episodes affect significantly aid supply, with a behavioural difference between European Union and Non-European countries in terms of aid supply. The chapter 2 deals with the consequences of development aid unpredictability and migrants' remittances on fiscal consolidation in developing countries. We find evidence that while migrants' remittances exert a positive and significant effect on the likelihood of fiscal consolidation in developing countries, development aid unpredictability does not. These results particularly suggest that a better management of the revenues derived from these private transfers during their booms could help avoid such situations and allow greater room of maneuver for governments’ recipients to implement countercyclical measures during bad times. The chapter 3 investigates whether the structural vulnerability of developing countries matters for their public indebtedness and evidence is obtained that it does. More specifically, we observe the existence of U-curve relationship between this structural vulnerability and the total public debt of these countries. Focusing on the specific case of CFA Franc Zone countries in chapter 4, we examine the relationship between the structural vulnerability and the probability of entering into excessive public debt. We also obtain evidence of a nonlinear effect of the structural vulnerability indicator with respect to the probability of entering into excessive debt: a rise in the structural vulnerability of these countries increases their probability to engage into excessive debt; however this probability declines after a certain threshold of their structural vulnerability. These results (both for developing countries and particularly for CFA Franc Zone countries) suggest that international development institutions such as the World Bank and International Monetary Fund (IMF) should take into account such vulnerability in their assessment of the adequate development policies and recommendations - especially those related to debt issues -, to these countries.