The Human papillomavirus (HPV) vaccine was introduced to Malawi to reduce the high rate of cervical cancer mortality among Malawian women. This thesis analyzed 2015-16 Malawi Demographic and Health Survey data collected from currently married or partnered women ages 15-49 to identify characteristics associated with adoption of two recently-introduced childhood vaccines (rotavirus and pneumococcal), which served as a proxy for the HPV vaccine. Multivariate logistic regression was conducted to identify early adopters who had vaccinated their youngest child against rotavirus and pneumococcal infection. The results of my analyses show that women’s empowerment, assessed through participation in family decisions and attitudes towards violence, women’s exposure to media, and women’s employment status were positively associated with adoption of both the rotavirus and pneumococcal vaccines. Identifying which Malawian women are less likely to vaccinate their children could inform specialized interventions designed to reach these sub-populations. Identifying determinants of vaccine adoption is an important step towards improving HPV vaccine uptake and ultimately reducing cervical cancer mortality in Malawi.

Homelessness is a pervasive and urgent social problem. Using a life course and socioecological framework, this dissertation examines how shelter status and homeless trajectories shape health outcomes. I present three studies.1) To understand the impact of shelter status on health outcomes, I conducted a systematic review of 42 studies on unsheltered homelessness and health. Unsheltered populations experience higher rates of chronic disease, serious mental illness, and substance abuse compared to sheltered populations. Unsheltered homelessness is strongly associated with chronic homelessness that exacerbates serious mental illness and substance use, which is often co-occurring. Despite having large unmet health needs, unsheltered populations have lower health care utilization and often lack health insurance. 2) To understand the impact of duration and frequency of homelessness on health, I conducted secondary data analysis using the Los Angeles Homeless Services Authority (LAHSA) youth survey data from 2018 and 2019 for unsheltered young adults (aged 18-24). Rates of unsheltered homelessness for racial and sexual minority young adults were high relative to Los Angeles County’s population. Young adults experiencing long-term homelessness had twice the odds of having a physical health condition, mental health condition, and substance use disorder and of having any health condition. Youth with multiple marginal identities may be especially vulnerable to poor health outcomes. Primary reasons for homelessness among young adults were financial insecurity, household conflict, and not having social support. 3) To explore antecedents and consequences of housing insecurity and homeless among young adults, I conducted 13 qualitative interviews with University of California, Los Angeles (UCLA) students. Structural and individual factors influence housing insecurity, which leads to poor health and academic outcomes. Social stigma and shame are barriers to help seeking for students. More research and high-quality data are needed to examine the relationship between homelessness and health and to identify causal mechanisms. Public health practitioners can advance unsheltered health by improving access to shelter and housing and expedite exits out of homelessness by connecting young adults to health and social services. Resolving structural constraints at the community and institutional level may be most effective at reducing young adult homelessness in Los Angeles County.

Whether living in the United States (US) or the US Commonwealth of Puerto Rico (PR), a colonial territory since 1898, Puerto Ricans experience inequities across an array of health conditions. Several studies have examined common public health explanatory variables, typically within the context of individual-level lifestyle choices, to understand the disparate health outcomes observed among Puerto Ricans living throughout the greater US, which includes individuals living in the 50 states and PR. However, few have assessed the impact of the Puerto Rican political context on health. This is a significant gap in the public health literature, as the health, well-being, and lived experiences of Puerto Ricans are fundamentally shaped by the colonial relationship that exists between the US and PR, regardless of geographic location. When studying Puerto Rican health, the permanence of this colonial context coupled with the persistence of health inequities, calls for special attention to the political determinants of health. These determinants, relating to political structures such as voting, government, and policies, influence the conditions under which communities live, work, and recreate. Therefore, this dissertation investigates how the political determinants of health affect the health outcomes of Puerto Ricans living in the greater US, including individuals living in the States and Puerto Rico. This is accomplished through three unique investigations, employing distinct methodologies, described across three separate empirical papers. The first two studies examine how these political structures manifest into political perceptions that have the potential to influence health outcomes among the Puerto Rican diaspora living in the States. The third study assesses how the political relationship between the US and PR produces conditions that result in the exclusion of PR from US-based public health systems. Within these three investigations, and throughout this dissertation, a political determinants of health approach is applied to the study of Puerto Rican health inequities to intentionally acknowledge and address the permanence of colonialism in PR and its impact on health. As a result, this dissertation contributes to a body of scholarship that serves to shift our collective gaze away from traditional approaches to public health research and towards addressing the political structures that produce health inequities among Puerto Ricans living in the greater US.