Motunrayo Tosin-Oni

Dissertation Title: "Place, Racism, and Place-based Policies: Essays on Structural Racism and Community-Level Health Inequities"

This three-paper dissertation explores the relationship between structural racism and neighborhood-level health inequities. The first paper, Association between Historical Redlining and Severe Maternal Morbidity in New Jersey, examined the association between historical redlining and present-day severe maternal morbidity (SMM) rates in the state of New Jersey. Using hospital discharge data from New Jersey's State Inpatient Databases, redlining data from University of Richmond's Mapping Inequality Project, and neighborhood socioeconomic data from the American Community Survey, I estimated the effect of living in a redlined neighborhood (defined by ZCTAs) on risk of SMM. I found that compared to those who live in neighborhoods that received a historical grade of A or B, residents of C and D graded neighborhoods had 1.2 times and 1.4 times the odds of SMM, respectively. When controlling for neighborhood racial economic segregation, residents of D graded neighborhoods remained at greater (OR. = 1.1) odds of SMM than residents of A or B graded neighborhoods. In stratified analyses by race and ethnicity, residing in a D graded neighborhood was associated with higher odds of SMM for Black patients giving birth in New Jersey hospitals than for those living in A or B graded neighborhoods. This study supports evidence of a strong relationship between historical systemic racism, as assessed through redlining in NJ, and racial and neighborhood level inequalities in SMM.

Paper 2, Historical Redlining and Adverse Birth Outcomes in Massachusetts: 2016 to 2022, examines the relationship between historical redlining and present-day maternal and infant health inequities. Merging Massachusetts Pregnancy to Early Life Longitudinal Data System (PELL) with Mapping Inequality shapefiles and American Community Survey neighborhood demographics data, I assessed the associations between historical HOLC grade SMM, low birthweight, and preterm birth. I also conducted analyses stratified by race and ethnicity and by before and after the onset of the COVID-19 pandemic. I found that residents of MA neighborhoods historically graded C or D by HOLC were at increased odds of SMM (ORC =1.22, 95% CI: 1.13, 1.31; ORD= 1.28, 95% CI: 1.17, 1.40) compared to residents of AB-graded neighborhoods even after adjusting for individual characteristics and neighborhood deprivation. I found no statistically significant relationship between historical HOLC grade and preterm birth or low birthweight in MA. During the COVID-19 pandemic, living in C-graded neighborhoods was associated with 26% greater odds of SMM (ORC= 1.26, 95% CI: 1.13, 1.41) while living in D-graded neighborhoods was associated with 34% greater odds of SMM (ORD= 1.34, 95% CI: 1.18, 1.53). Compared with their racial counterparts residing in AB-graded neighborhoods, Black and API residents in D-graded neighborhoods had 41% and 42% greater odds of SMM, respectively, whereas White and Hispanic residents in D-graded neighborhood both had 23% greater odds of SMM. This study finds that despite MA's top-ranked healthcare system, the state needs to pay special attention to SMM rates and disparities. Neighborhood specific interventions and investments are necessary to target neighborhood specific risk factors.

The third paper is a qualitative, community-engaged study that aimed to understand how disadvantaged communities organize at the grassroots level to address their community's specific healthcare needs. Employing a Community Capitals Framework, I focused on a case study based in Boston, Massachusetts. I examined how the Hyde Park Health and Wellness Steering Committee, a grassroots community health coalition in Boston's Hyde Park neighborhood, build and leverage their community capitals in their mobilization for a community health center. I conducted 2 focus groups with 7 Steering Committee (SC) members and 14 semi-structured interviews with community members and political and healthcare stakeholders. The findings revealed that Hyde Park has a wealth of cultural, natural, and human capitals that create immense community pride that in turn makes mobilizing possible and successfully ongoing over 5 years. These capitals also help build community power and hold their elected officials accountable. Finally, I identified that despite what appears to be strong political and social capital present in the neighborhood and within the SC, there remain gaps in institutional linkage capital and financial capital necessary to accomplish the committee's largest goal. This paper also sheds light on the roles health equity minded policymakers and institutional stakeholders can play in supporting grassroots organizing.