Browsing by Author "George, Linda K"

Extensive evidence demonstrates how mental illness symptomatology can inhibit perceptions of and actual performance on important tasks. However, receiving treatment from the medical establishment for such symptomatology requires diagnosis, whereby the patient becomes labeled and subject to the stereotypes connected to that label. Mental illness labeling is associated with a variety of negative outcomes including inhibited access to unemployment, housing, health insurance, and marriage and parenthood opportunities and can disrupt interpersonal relationships. However, the repercussions of mental illness labeling for one area of life have remained largely overlooked; that area is task performance. Adults spend a substantial portion of their lives at work engaged in group-based or individual level tasks. This dissertation explores external perceptions of mental illness in task groups and the role of self-internalization of stereotypes about mental illness in individual task performance through two experimental studies.

Previous research has revealed that, on average, task partners with a mental illness are stigmatized and subject to diminished status when they are identified to participants as having been hospitalized for general psychological problems for an extended period of time. Study 1 of this dissertation explores the stigma- and status-based attributions triggered by engaging with a partner in a mutual task who is identified as having a specific mental illness label: none, Generalized Anxiety Disorder (GAD), Major Depressive Disorder (MDD), Attention-Deficit/Hyperactivity Disorder (ADHD), or schizophrenia.

Additionally, research has revealed that members of a group about which negative stereotypes exist may face a situational threat in a domain relevant task--stereotype threat. Race, gender, social class, age, and a variety of other sociodemographic attributes can trigger stereotype threat. However, little research has considered the potential for stereotype threat to emerge on the basis of mental illness labeling. Study 2 of this dissertation focusing on individual-level performance, exploring the potential for ADHD to trigger stereotype threat in test-taking situations.

Results from Study 1 suggest that the specific mental illness labels studied, presented devoid of symptomatology severity, do not trigger stigmatized attributions but may trigger some negative status attributions in the case of a task relevant diagnosis. (ADHD). Study 2 suggests that a task relevant diagnosis may also trigger stereotype threat in a test-taking situation, negatively impacting performance. Taken together, the results indicate that task relevance of one's mental illness label may be a driving factor in negative external and internal perceptions of mental illness.

There is widespread evidence that health disparities between whites and blacks in the U.S. cannot be fully explained by inter-group socioeconomic differences. Further, research shows that racism plays a significant role in explaining racial health disparities. However, there is less research that attends to what psychosocial and socioeconomic resources may be protective of black middle-class health over time. My research starts to fill this gap by examining whether racial identity and childhood socioeconomic status are protective of black health over time.

In Chapter 2, I use data from the American Changing Lives Study (ACL) and examine whether a strong racial identity is a protective mechanism in the relationship between racism and two health outcomes: self-rated health and depressive symptoms. My findings suggest that whether racial identity is protective depends on the health outcome and the frequency of racism respondents experience. My results also indicate that middle-class is not consistently a protective factor for black health.

In Chapter 3, I use data from the National Survey of American Life (NSAL) and the ACL to investigate whether childhood socioeconomic status is associated with adult health for blacks, and particularly black women. I argue that relative childhood socioeconomic advantage is more important for disadvantaged race and race/gender groups. Further, using an intersectional approach, I argue that it is most important for black women. My findings indicate that the association of childhood socioeconomic status and adult health is significant for blacks, but not whites. I also find that childhood socioeconomic status is especially important for black women.

This dissertation examines racial socialization in Afro-Brazilian families in order to understand how phenotypically diverse families negotiate racial hierarchies and ideologies of white supremacy. As an inductive, qualitative project, this research is based on over fourteen months of ethnographic fieldwork in Salvador, Bahia, Brazil in fifteen poor and working-class Bahian families and 116 semi-structured interviews with family members and informants. Findings suggest that one of the most prominent features of racial socialization is the pervasive devaluation of black/African influences, which is conveyed through implicit and explicit messages as well as concrete practices (including rituals) that promote the stigmatization of negatively valued racialized physical features. The study reveals a pattern of unequal distribution of affection based on racial appearance (phenotype), which is evident in parent-child, sibling, extended family, and romantic relationships. Findings suggest that negative appraisals of racial phenotype may significantly compromise affective bonds in families and have social psychological consequences impacting self-esteem and sense of belonging, while also eliciting suicidal ideations and anxieties. These outcomes are most pronounced for Afro-Brazilian females. Racial socialization also conveys the "strategically ambiguous" logic of color and racial classification, uncritically exposes family members to racist messages, jokes, and stereotypical images of Afro-Brazilians, and encourages cultural participation that superficially valorizes Afro-Brazilian culture and fosters nationalism, rather than racial identity. In contrast to traditional findings of racial socialization in the U.S., messages valorizing racial heritage are rare and efforts to prepare family members for bias rely on universal terms. Families do employ counter-discourses and creative strategies of resistance; and so, racial socialization is characterized by practices that reflect both resistance and accommodation to racial hierarchies. I conclude that racial socialization in families is influenced by and sustains racialization processes that maintain the broader system of white supremacy. Contrary to how racial socialization has been framed as having a purely protective role in families, this study illustrates how it may disadvantage blacks vis-à-vis whites and uniquely stigmatizes the most "black-looking" family members vis-à-vis those who more closely approximate an idealized (whiter) somatic norm. Future studies should triangulate data on racial socialization from other regions of the Americas.

In this dissertation, I study medicalization, a wide spread phenomenon in this world but understudied in the current literature. The main theoretical focus of this dissertation is on expanding the medicalization theories. Questioning the breadth of conceptualization, the feasibility of measurement, and the depth of empirical implications in the extant medicalization theories, this dissertation proposes a new conceptual model of medicalization and further develops a quantitative measure of medicalization by disaggregating it into empirically valid dimensions that could be used to examine how degree of medicalization is related to social outcomes. Specifically, I conceptualize medicalization as an institutionalization process whereby the medical model becomes increasingly dominant in the explanation of health, illness, and other human problems and behavior. Medicalization is multidimensional and is represented by expansions in the three major components of the health care system: increasing medical investment, medical professionalization/specialization, and the relative size of the pharmaceutical industry.

Based on this new conceptual model and measurement, I probe three research questions: (1) how medicalization may impact population health in the context of recent epidemiologic transitions and how this impact may differ by the stages of epidemiologic transition and socioeconomic development; (2) what are the mechanisms that reproduce medicalization; and (3) how the lay public may respond to medicalization, the institution of medicine, and the medical profession.

This dissertation links several lines of theoretical and empirical research from medical sociology, demography, epidemiology, health economics and management, and medical science, and extensively employs OECD Health Data, World Development Indicators, the World Values Survey, the European Values Study data, the U.S. General Social Survey, and the U.S. National Health Interview Survey. It uses several advanced statistical methods, e.g., multiple imputations, latent variable analysis, mixed models, generalized estimating equations models, generalized method of moments models, difference-in-difference models, and hierarchical-age-period-cohort models.

Results for the first research question suggest that various dimensions of medicalization vary in importance on population health and these effects also differ by the stages of epidemiologic transition and socioeconomic development. I discuss the mechanisms linking various dimensions of medicalization to population health and then discuss these findings in the context of epidemiologic transition, fundamental causes of disease and death, and global health movement.

Results for the second research question suggest that medicalization at both the societal and individual levels negatively affect individual subjective health, which leads to increasing health care utilization. These social processes function together to promote and reproduce medicalization at societal level. I discuss several pathways linking medicalization to lower subjective health and other agents of medicalization.

Results for the third research question suggest that American's "confidence in the medical institution and profession" has continuously declined in the last three decades and groups with higher socioeconomic status report lower obedience to doctors' authority, but are more likely to trust doctors' ethics than their counterparts. I discuss the mechanisms for the changes in public confidence in the medical institution and profession, the status of medicine and the medical profession in the era of medicalization, the paradox of opposite trends in attitudes toward medicine and health utilization behavior, and group differences in obedience and trust.

This dissertation explores the simultaneous trends towards increasing and decreasing medical intervention in childbirth. Using the medicalization literature as a theoretical framework, I use a mixed-methods approach to explore how both the medical community and laypeople think about and plan for childbirth.

First, the midwifery and obstetrics literatures from the past 35 years are reviewed to provide a medical and scientific context for the trends seen in childbirth over this time period. Second, descriptive and logistic regression analyses of the Center for Disease Control's Natality dataset, a census of U.S. birth certificate data, provide a picture childbirth trends and an understanding of the relationship between maternal characteristics and medicalized and natural births. Third, 35 qualitative interviews were conducted with pregnant women, focusing on their plans for their children's birth. The interviews also address the factors that influence women's plans and choices for childbirth, thus providing a better understanding of the social factors that affect birth plans.

The key finding of this research is that most women would prefer to be able to have the "best of both worlds" - the ability to experience childbirth as a natural process for as long as is safe and comfortable, combined with immediate access to the medical skills and technology that can assist them and their babies in an emergency.

The quantitative analyses demonstrate that alternatives to a mainstream model of childbirth are on the rise, even while these alternatives continue to represent only a small fraction of births. The increase in midwifery use while rates of hospital births remain relatively consistent suggests that many midwife-attended births are taking place in hospitals. These data support the finding that women like the idea of a natural birth, but also want to have ready access to trained doctors, surgeons, and the best medical care available in case something goes wrong.

There can be no doubt that childbirth, on the whole, had become a highly medicalized process. However, despite the fact that women want childbirth to be recognized as a natural process, there is no true movement for the demedicalization of childbirth. That is, women are not suggesting that medical intervention be removed entirely from childbirth. Instead, there need to be more options available to women, thus enabling them to give birth in a way that is comfortable and respectful of their preferences and goals, while simultaneously maintaining ready access to additional intervention, should it be necessary.

Implications for future research in childbirth and other fields of study are discussed.

Comparative social scientists have offered rich insights into how macro-level political factors affect stratification processes such as class, gender and racial inequality. Medical sociologists, on the other hand, have long emphasized the importance of stratification for health and health inequalities at the individual level. Yet, only recently has research in either field attended to the macro-level factors that impact health. This dissertation contributes to the growing scholarship in that area by investigating the influence of public healthcare social policies, organized labor and Left party power on infant mortality, life expectancy at birth and life expectancy at age 65. I do so using the framework of power resources, a theory which has been only sparsely applied to the study of health.

The analyses include country-level pooled time series models of 22 rich democracies between 1960 and 2010. Data is drawn from the Comparative Welfare States dataset (Brady et al 2014), which provides information on indicators of welfare state development, its causes, and its consequences between the periods 1960 to 2011. I use fixed effects regression models to examine the influence on health of two forms of healthcare spending, six forms of non-health social welfare transfers and the triad of union density, Left parties and socialized medicine. I also supplement with a variety of alternatives to test the sensitivity of results to estimation technique.

Chapter 1 discusses the foundational literature on the social determinants of health and political economy of health. Chapter 2 focuses on the role of public healthcare effort and socialized medicine as predictors of countries' infant mortality and life expectancy at birth and at age 60. I show that socialized medicine (as represented by the ratio to total health spending) improves all population health outcomes in addition to, and adjusted for, the effect of healthcare effort (as represented by the ratio to GDP). Moreover, socialized medicine is a better predictor of population health than healthcare effort and its effect sizes are comparable to those of GDP per capita. Chapter 3 examines the association of infant mortality and life expectancy with old age-survivor transfers, incapacity transfers, family transfers, active labor market transfers, unemployment transfers, housing transfers and education transfers. For infant mortality, overall and educational spending matters, whereas for life expectancy, incapacity does. Family transfers matter only for life expectancy at birth. For all outcomes, unemployment transfers are beneficial and housing and aging-survivor benefits are not significant. Chapter 4 investigates the association of organized labor with infant mortality and life expectancy and devotes additional attention to the potential role of Left parties and social policy in this relationship. Results suggest that in nations where a greater proportion of the labor force is unionized, more lives are lost below the age of one and individuals live shorter lives. These results are contrary to the hypotheses generated by the theory of power resources and allied research.

This dissertation contributes to literatures in medical sociology, sociology of inequality and political sociology. This dissertation highlights the pertinence of power resources theory to the subject of health and further encourages its application to this relatively new domain. Additionally, by highlighting the importance of institutions and politics for health, it extends research on macro-level sources of inequality to the outcome of health and complements the existing emphasis in medical sociology on the fundamental, distal causes of health.

This study uses social integration theory within a life course framework to examine the relationships among social engagement, physical limitations, cognitive limitations, and mortality. Data for this study come from the Americans' Changing Lives survey, a nationally representative panel study conducted in 1986, 1989, 1994, and 2002, with mortality information spanning from 1986 to 2005. First, structural equation modeling is used in cross-lagged panel models to examine gender differences in these relationships. Findings suggest that social engagement may have protective effects on health limitations for women but that physical and cognitive limitations can present barriers for social engagement among men. Second, growth mixture models were used to examine patterns of social engagement over time. This study then examined how these patterns of social engagement related to physical and cognitive limitations (using latent growth curve models) and mortality (using Cox proportional hazards models). Findings suggest the importance of maintaining high levels of social engagement and increasing social engagement over time for better physical and cognitive health and lower risk of mortality for older adults.

In this dissertation, I seek to begin building a new line of health inequality research that parallels the emerging structural racism literature by developing theory and measurement for the new concept of structural sexism and examining its relationship to health. Consistent with contemporary theories of gender as a multilevel social system, I conceptualize and measure structural sexism as systematic gender inequality in power and resources at the macro-level (U.S. state), meso-level (marital dyad), and micro-level (individual). Through a series of quantitative analyses, I examine how various measures of structural sexism affect the health of men, women, and infants in the U.S.

Chapter 2 focuses exclusively on the macro-level and drills down on a single indicator of structural sexism: political gender inequality. Using data compiled from several administrative sources across a twenty-two-year period, I find that women’s political representation in U.S. state legislatures is as strong —or stronger—a predictor of state infant mortality rates than even the state’s poverty level. This relationship holds both between states with varied levels of political gender inequality in a given year, and within the majority of states as women’s representation changes over time. To quantify the population-level costs, I estimate that women’s continued underrepresentation in legislative office was associated with nearly 3,500 excess infant deaths per year in the U.S. compared to what would be expected under conditions of gender parity.

Chapter 3 lays out a more comprehensive, multilevel framework for structural sexism and examines how it shapes the health of women and men at midlife. I measure macro-level structural sexism at the U.S. state-level using indicators of inequality in political, economic, cultural and reproductive domains. Using restricted geo-coded data from the NLSY79, individuals are located within states to capture their exposure to structural sexism. This chapter also incorporates individual- and spousal-level data from the NLSY79 in order to measure exposure to structural sexism at the meso- and micro-levels. Results show that among women exposure to more sexism at the macro- and meso-levels is associated with more chronic conditions, worse self-rated health, and worse physical functioning. Among men, macro-level structural sexism is also associated with worse health. However, at the meso-level greater structural sexism is associated with better health among men. At the micro-level, internalized sexism is not related to health among either women or men. These results highlight the importance of a multilevel approach.

As a whole, this work demonstrates that structural sexism takes a substantial toll on population health in the U.S. The findings also illustrate that effects of structural sexism on health depend both on an individual’s position within the gender system and the level at which sexism exposures are measured. Further research is needed to extend our understanding of how structural sexism shapes health across the life course.

More than 26,000 children under the age of 5 die every day on average, mostly in the developing world. Malnutrition accounts for up to half of those deaths, and diarrheal diseases account for another 17 per cent. The concentration of child malnutrition and diarrhea in developing countries should be of particular interest to sociologists because of the potential role of macro, structural and institutional forces in accounting for such cross-national disparities. This study focuses on country-level development, gender inequality, and democracy as three dimensions of structural violence that have important effects on child health in developing countries. In addition, the analysis also incorporates household and maternal characteristics that have already been shown to affect child health at the individual level. Using data from the Demographic and Health Surveys and several other archival sources, I conduct a multi-level analysis of young children nested in a sample of approximately 50 developing countries. Specifically, I estimate a series of hierarchical generalized linear logit models (HGLM) that predict the likelihood that a child is stunted, wasted, underweight, or has had a recent episode of diarrhea, based on a set of country- and individual-level explanatory variables.

The introduction in Chapter 1 describes the concept of "structural violence," the orienting theoretical framework for the dissertation. Chapter 2 combines several theoretical perspectives to examine the effects of household-level socioeconomic resources as well as country-level economic development, water, sanitation, health care, and education. Household wealth and maternal education are the most important predictors of child health at the individual level; whereas, GDP per capita, secondary school enrollment, and a "capability development" scale have the most robust effects at the country level. Chapter 3 focuses on women's decision-making and resource control by examining 5 aspects of gender inequality: education, employment, political participation, reproductive autonomy, and life expectancy. Taken together, the results demonstrate that child health is likely to be better in countries where women have more education, control over their reproduction, representation in national politics, as well as longer life expectancy. Finally, Chapter 4 explores the link between democracy and child health, paying particular attention to various ways of measuring democracy. Surprisingly, bivariate correlations between democracy and child health are weak, and multivariate models do not yield consistent or robust effects. Overall, this dissertation demonstrates how child health is embedded in social, political, and economic contexts of inequality larger than the individual that partially determine who faces increased health risk factors and who is protected from them.

This dissertation consists of three parts of empirical analyses investigating temporal patterns and consequences of (childhood) overweight and obesity, mainly in the United States and the People's Republic of China. Based on the China Health and Nutrition Survey, the first part conducts hierarchical age-period-cohort analyses of childhood overweight in China and finds a strong cohort effect driving the overweight epidemic. Results from the growth-curve models show that childhood overweight and underweight are related such that certain socio-economic groups with higher levels of childhood overweight also exhibit lower levels of childhood underweight. The second part situates the discussion on childhood obesity in a broader context. It compares temporal patterns of childhood overweight in China with these of adulthood overweight and finds that the salient cohort component is absent in rising adulthood overweight, which is dominated by strong period effects. A positive association between human development index and overweight/obesity prevalence across countries is also documented. Using multiple waves of survey data from the National Longitudinal Study of Adolescent Health, the third part analyzes the (latent) trajectory of childhood overweight/obesity in the United States. It finds that individuals with obesity growth trajectories are less likely to avoid mental depression, tend to have higher levels of neuroticism and lower levels of agreeableness/conscientiousness, and show less delinquent behaviors.

This dissertation examines congregations' sponsorship of social services for people living with mental disorders. Using data from a nationally representative sample of U.S. congregations, the 2000 US Census, and the 2006 General Social Survey, I address three research questions: What proportion of congregations sponsor services for people living with mental disorders?; How do congregational characteristics affect the likelihood that congregations sponsor these services?; How do neighborhood characteristics and community assessments affect the likelihood that congregations sponsor these services?; Does being a member of a congregation that sponsors these services affect their members' support for government spending on mental health care? The findings indicate that 8% of congregations sponsor services for people living with mental disorders and that religious ideology affects whether congregations sponsor these services. Congregations located in neighborhoods with disadvantaged populations are more likely to sponsor services if they conduct a needs assessment study of their communities while congregations in neighborhoods with advantaged populations are less likely to sponsor services for people living with mental disorders if they conduct a needs assessment study of their communities. Belonging to congregations that sponsor services for people living with mental disorders does not have a direct effect on their members' support for government funding of mental health care. It does, however, have indirect effects. People who belong to congregations that sponsor services for people living with mental disorders and who pray frequently are less likely to support increased government spending on mental health care.

An extensive body of research documents the strong influence of social relationships, social support, social integration and social networks on well-being. Nonetheless, conceptual clarity remains elusive and these terms are often used interchangeably, precluding confident conclusions and hindering cross-study comparisons. Guided by social network analysis, the social convoy model and the life course framework, I measure social network structure and composition through the use of typologies. I then examine the influences of social network structure and composition on an array of health indicators, including self-rated health, psychological distress and self-esteem.

This study uses data from the Americans' Changing Lives Survey, a nationally representative longitudinal panel survey of adults aged 25+ interviewed in 1986, 1989, 1994 and 2001/2002. I use hierarchical cluster analysis to create social network typologies from data on respondent reports of close confidants and develop two typologies, one for social network structure and the other for social network composition. In cross-sectional analyses, I use logistic regression and Poisson regression to examine the associations between these two social network typologies and poor/fair self-rated health, high self-esteem, and counts of depressive symptoms. I also perform two sets of longitudinal analyses to determine the predictive utility of network structure and composition for health. First, I use OLS regression to examine whether the social network typologies predict residual change scores for self-rated health, psychological distress, and self-esteem both 3 and 8 years after the baseline survey. Second, I use autoregressive cross-lagged models within a structural equation framework to disentangle the effects of social causation and social selection on the relationship between social network structure and the three indicators of health mentioned above.

The typologies representing social network structure and composition are strongly related to important social and demographic factors. In addition, there are strong and significant cross-sectional associations between these typologies and indicators of mental health, although their association with self-rated health is weak at best. The typologies are highly predictive of changes in mental health across waves, although again, they are not strongly related to changes in self-rated health. Lastly, this dissertation finds strong support for both social causation and selection processes at work in the relationships between social network structure and self-rated health and psychological distress. Support social selection, but not social causation, was found in regards to self-esteem.

This study examines whether trajectories of multiple social role occupancy, measured by level and dynamics of spouse, parent, and worker roles, are associated with mortality and concurrent trajectories of depressive symptoms and self-rated health. I frame hypotheses with role strain, role enhancement, role context, stress process, and life course theories to examine both within-person changes over age and between-person predictors of health status.

I use data from the Americans' Changing Lives Study, a nationally representative accelerated cohort panel study of U.S. adults interviewed in 1986, 1989, 1994, and 2001/2 with mortality tracking through 2006. I use latent class analysis to estimate disaggregated trajectories of role occupancy, role strain, role satisfaction, depressive symptoms, and self-rated health across the adult life course. I then use multinomial and logistic regression analyses to examine associations between role trajectories and health outcomes.

I find that (1) there is significant heterogeneity in trajectories of role occupancy and characteristics across the adult life course; (2) higher levels of social role occupancy are associated with better depressive symptom and mortality outcomes; (3) lower levels of role strain and higher levels of role satisfaction are associated with better depressive symptom outcomes, and (4); the association between role occupancy and health is robust to the inclusion of role characteristics. Thus, I find support for the role enhancement hypothesis in that higher levels of role occupancy are associated with better health outcomes irrespective of reward and strain associated with those roles.

Haitian immigrants and their Dominican-born descendants face sociopolitical exclusion in spite of their contribution to the Dominican economy. This project engages three key theoretical perspectives to explain inequality in the Dominican Republic. First, intersectionality theory informs analyses of gender- and nativity-based social factors that influence mental health. Mental health inequalities based on gender and nativity have been documented independently; however, few studies have examined how the intersection of these social locations influences mental health. Results show that contextual factors shape gender- and nativity-related stressors according to intersectional patterns, revealing the importance of intersectional analyses of mental health that include nativity as a site of structural oppression. Next, I use stress process theory to examine how documentation policy is a key driver of negative mental health outcomes among Haitian immigrants and their descendants. Results reveal two major findings. First, documentation policy can act as a primary stressor that yields additional stressors for affected populations. Second, documentation policy can produce the social locations which contribute to compound disadvantage as ethnic Haitians are excluded from multiple domains of social life at once: education, employment, political and social participation. Finally, I apply assimilation theory to examine how the racial context of reception affects immigrant incorporation. Data show that although anti-immigrant sentiment contributes to Haitians’ context of reception in the D.R., immigration officials use race and racialized characteristics to screen for Haitian ancestry. This points to the need to explore the racial context of reception when theorizing inequality among immigrants’ incorporation trajectories. Collective results from this project underscore the importance of including of nativity in intersectional analyses, examining the social consequences of documentation policies, and measuring immigrants’ social contexts comprehensively.

This dissertation explores how low-income and uninsured adults’ everyday experiences of inequality shape both the healthcare they have access to and the ways in which they navigate safety-net healthcare organizations in the years following the passage of the Affordable Care Act (ACA). Low-income and uninsured adults in the U.S. are the leading edge in the rising incidence of preventable chronic illness and are in need of high-quality preventive healthcare. However, social scientists have made little progress in understanding the role of healthcare safety-net organizations in the lives of low-income and uninsured adults as they traverse these settings amid everyday experiences of economic insecurity, pressing health needs, and interlocking systems of oppression in an era characterized by significant health and welfare policy changes, neoliberal privatization, and safety net resource fragmentation. The three studies in this dissertation advance this area of research by systematically analyzing multiple data sources centered on the perceptions and experiences of safety net healthcare workers and low-income and uninsured patients as they navigate a private primary care clinic in a mid-sized city in the southeastern U.S. which has become a New Immigrant Destination. In these studies, I explore the ways low-income and uninsured adults navigate a private nonprofit primary care safety net clinic and manage chronic health conditions amid everyday experiences of poverty and uncertainty. The first study explores how organizational features structuring patient eligibility and intake processes may exacerbate or lessen inequality among new patients as they enter primary care treatment in a private clinic in the healthcare safety net. The second study explores worker agency and offers a conceptual model to understand linkages between worker rule-breaking behaviors oriented to provide more equitable patient treatment or possibly harm patients, when and how organizational change occurs, patient background characteristics, and long-term patient health outcomes. The third study explores how individuals in one disadvantaged group, unauthorized Latina mothers, undertake strategies to combat cumulative health disadvantage as they access health-promoting safety net resources and traverse everyday social and economic hardships, uncertainty, and deportation threat.