Different Responses to Social Capital Among Black People and White People: What Racial Differential Item Functioning Reveals for Racial Health Equity.

Social capital has been conceptualized as features of social organization, such as networks, and norms that facilitate coordination and cooperation for mutual benefit. Because of long-standing anti-Black structural oppression in the United States, social capital may be associated with health differently for Black people than for other racial/ethnic groups. Our aim was to examine the psychometric properties of social capital indicators, comparing responses from Black and White people to identify whether there is differential item functioning (DIF) in social capital according to race. DIF examines how items are related to a latent construct and whether this relationship differs across groups such as different racial groups. We used data from respondents to the Southeastern Pennsylvania Household Health Survey in 2004, who lived in Philadelphia (n = 2,048), a city with a large Black population. We used item response theory analysis to test for racial DIF. We found DIF across the items, indicating measurement error, which could be related to the way these items were developed (i.e., based on cultural assumptions tested in mainstream White America). Hence, our findings underscore the need to interrogate the assumptions that underly existing social capital items through an equity-based lens, and to take corrective action when developing new items to ensure that they are racially and culturally congruent.

A systematic review of how social connectedness influences associations between racism and discrimination on health outcomes.

Racial discrimination is a well-known risk factor of racial disparities in health. Although progress has been made in identifying multiple levels through which racism and racial discrimination influences health, less is known about social factors that may buffer racism's associations with health. We conducted a systematic review of the literature with a specific focus on social connectedness, racism, and health, retrieving studies conducted in the United States and published between January 1, 2012, and July 30, 2022, in peer-reviewed journals. Of the 787 articles screened, 32 were selected for full-text synthesis. Most studies (72%) were at the individual level, cross-sectional, and among community/neighborhood, school, or university samples. Studies had good methodological rigor and low risk of bias. Measures of racism and racial discrimination varied. Discrimination scales included unfair treatment because of race, schedule of racist events, experiences of lifetime discrimination, and everyday discrimination. Measures of social connectedness (or disconnectedness) varied. Social-connectedness constructs included social isolation, loneliness, and social support. Mental health was the most frequently examined outcome (75%). Effect modification was used in 56% of studies and mediation in 34% of studies. In 81% of studies, at least 1 aspect of social connectedness significantly buffered or mediated the associations between racism and health. Negative health associations were often weaker among people with higher social connectedness. Social connectedness is an important buffering mechanism to mitigate the associations between racial discrimination and health. In future studies, harmonizing metrics of social connectedness and racial discrimination can strengthen causal claims to inform interventions.

Associations of online religious participation during COVID-19 lockdown with subsequent health and well-being among UK adults.

BACKGROUND: In-person religious service attendance has been linked to favorable health and well-being outcomes. However, little research has examined whether online religious participation improves these outcomes, especially when in-person attendance is suspended. METHODS: Using longitudinal data of 8951 UK adults, this study prospectively examined the association between frequency of online religious participation during the stringent lockdown in the UK (23 March -13 May 2020) and 21 indicators of psychological well-being, social well-being, pro-social/altruistic behaviors, psychological distress, and health behaviors. All analyses adjusted for baseline socio-demographic characteristics, pre-pandemic in-person religious service attendance, and prior values of the outcome variables whenever data were available. Bonferroni correction was used to correct for multiple testing. RESULTS: Individuals with online religious participation of ≥1/week (v. those with no participation at all) during the lockdown had a lower prevalence of thoughts of self-harm in week 20 (odds ratio 0.24; 95% CI 0.09-0.62). Online religious participation of <1/week (v. no participation) was associated with higher life satisfaction (standardized ß = 0.25; 0.11-0.39) and happiness (standardized ß = 0.25; 0.08-0.42). However, there was little evidence for the associations between online religious participation and all other outcomes (e.g. depressive symptoms and anxiety). CONCLUSIONS: There was evidence that online religious participation during the lockdown was associated with some subsequent health and well-being outcomes. Future studies should examine mechanisms underlying the inconsistent results for online v. in-person religious service attendance and also use data from non-pandemic situations.

Activity Space Assessments to Investigate Neighborhood Exposure to Racism-Related Stress and Related Substance Use Among Young Black Men: Connecticut, 2019.

Objectives. To use activity space assessments to investigate neighborhood exposures that may heighten young Black men's vulnerability to substance use and misuse. Methods. We surveyed young Black men in New Haven, Connecticut in 2019 on the locations (activity spaces) they traveled to in a typical week and their experiences of racism and any alcohol and cannabis use at each location. Results. A total of 112 young Black men (mean age = 23.57 years; SD = 3.20) identified 583 activity spaces. There was significant overlap between racism-related events and substance use (alcohol and cannabis use) at specific locations. Areas with a higher prevalence of violent crime also had a greater frequency of racism-related events and substance use. Conclusions. An activity space approach is a promising method for integrating objective and subjective experiences within neighborhood contexts to better understand the frequency and co-occurrence of racism-related stress and substance use among young Black men. (Am J Public Health. 2023;113(S2):S136-S139. https://doi.org/10.2105/AJPH.2023.307254).

Church Closings Were Associated with Higher COVID-19 Infection Rates: Implications for Community Health Equity.

This study investigates the changes in physical church closings years 2013 to 2019 in New York City (NYC), Philadelphia, and Baltimore and the association with COVID-19 infection rates. We applied Bayesian spatial binomial models to analyze confirmed cases of COVID-19 as of February 28, 2022, in each city at the zip code-level. A one unit increase in the number of churches closed corresponded to a 5% higher COVID-19 infection rate, in NYC (rate ratio = 1.05, 95% credible interval = 1.02-1.08%), where the association was significant. Church closings appears to be an important indicator of neighborhood social vulnerability. Church closings should be routinely monitored as a structural determinant of community health and to advance health equity.

Social Capital, Black Social Mobility, and Health Disparities.

This review aims to delineate the role of structural racism in the formation and accumulation of social capital and to describe how social capital is leveraged and used differently between Black and White people as a response to the conditions created by structural racism. We draw on critical race theory in public health praxis and restorative justice concepts to reimagine a race-conscious social capital agenda. We document how American capitalism has injured Black people and Black communities' unique construction of forms of social capital to combat systemic oppression. The article proposes an agenda that includes communal restoration that recognizes forms of social capital appreciated and deployed by Black people in the United States that can advance health equity and eliminate health disparities. Developing a race-conscious social capital framing that is inclusive of and guided by Black community members and academics is critical to the implementation of solutions that achieve racial and health equity and socioeconomic mobility.

Development of a Psychometric Tool to Measure Community Solidarity Among Sexual Minorities: Evidence From a Pay-it-Forward Randomized Controlled Trial.

BACKGROUND: Community solidarity is increasingly important in public health. However, few studies have examined solidarity in relation to health outcomes. The purpose of this study was to develop a psychometric tool to measure solidarity among Chinese men who have sex with men (MSM) and assess whether community solidarity relates to differences in sexually transmitted infection testing. METHODS: We used data from the pay-it-forward randomized controlled trial of 301 men from Beijing and Guangzhou, China. Men who have sex with men were randomized into pay-it-forward (participants receive free gonorrhea/chlamydia testing as gifts and choose to donate toward subsequent MSM's tests), pay-what you-want, and standard payment arms. After testing decision, participants completed a cross-sectional questionnaire to assess community solidarity. Factor analysis was conducted to identify dimensions of solidarity. The solidarity factors were compared across study arms and assessed against gonorrhea/chlamydia test uptake in multivariable logistic regression. RESULTS: Two hundred eighty-eight participants responded to the survey. We identified 3 latent community solidarity factors: engagement, social network support, and sense of belonging. Several items related to belonging were significantly greater among participants in the pay-it-forward scenario compared with those assigned to other scenarios. Higher sense of belonging was associated with higher odds of gonorrhea and chlamydia test uptake. CONCLUSIONS: Community solidarity among MSM in China can be characterized by 3 factors: engagement, social network support, and sense of belonging. Sense of belonging was higher in the pay-it-forward intervention arm and may be associated with the uptake of gonorrhea/chlamydia test. Future studies are warranted to confirm the psychometric structure of community solidarity and further investigate behavioral mechanisms of pay it forward.

Associations of prenatal exposure to mixtures of organochlorine pesticides and smoking and drinking behaviors in adolescence.

It is important to identify the factors that influence the prevalence of disinhibitory behaviors, as tobacco and alcohol use in adolescence is a strong predictor of continued use and substance abuse into adulthood. Organochlorine pesticides (OCPs) are persistent organic pollutants that pose a potential risk to the developing fetus and offspring long-term health. We examined associations between prenatal exposure OCPs and their metabolites (i.e., p,p'-DDT, p,p'-DDE, o,p'-DDT, oxychlordane, and hexachlorobenzene (HCB)), both as a mixture and single compounds, and alcohol consumption and smoking at adolescence in a sample (n = 554) from the Child Health and Development Studies prospective birth cohort. Bayesian Kernel Machine Regression demonstrated a trend of higher risk of alcohol use and smoking with higher quartile mixture levels. Single-component analysis showed increased odds of smoking and drinking with increases in lipid-adjusted p,p'-DDE serum levels (aOR = 2.06, 95% CI 0.99-4.31, p = 0.05, per natural log unit increase). We found significant effect modification in these associations by sex with higher p,p'-DDT serum levels (aOR = 0.26, 95% CI 0.09-0.076, p = 0.01, per natural log unit increase) was associated with lower odds of smoking and drinking in female adolescents, while higher p,p'-DDE serum levels (aOR = 2.98, 95% CI 1.04-8.51, p = 0.04, per natural log unit increase) was associated with higher odds of the outcomes. Results of the mutually adjusted model were not significant for male adolescents. Further research to understand reasons for these sex-differences are warranted.

Development of a community-based COVID-19 intervention in rural Ghana: a document analysis.

BACKGROUND: The COVID-19 pandemic has caused the loss of millions of lives and economic breakdowns in many countries across the globe. Despite the limited availability of vaccines and the challenges of poor health infrastructure, few interventions have been developed and implemented for those who live in rural areas, particularly in sub-Saharan Africa. In response, Cocoa360, a global health nonprofit in rural Ghana designed an intervention called Cocoa360's COVID-19 Preparedness and Outbreak Prevention Plan (CoCoPOPP). This paper aimed to examine the extent to which CoCoPOPP's design aligned with the Promoting Action on Research Implementation in Health Services (PARIHS) framework. METHODS: We reviewed documents influencing CoCoPOPP's design between March and June 2021. A total of 11 documents were identified for analysis. Using the Promoting Action on Research Implementation in Health Services (PARIHS) framework as a guide, thematic analysis was done to analyze the extracted data. RESULTS: Overall, CoCoPOPP's design aligned with the evidence, context, and facilitation domains of the PARIHS framework. It positioned CoCoPOPP as an intervention that considered the unique context of a rural Ghanaian setting. It was guided by robust and high-quality published and non-published evidence and engaged external and internal stakeholders during its implementation. CoCoPOPP's context-dependent nature positions it for potential replication in sub-Saharan Africa's rural communities with similar farming contexts. Specific areas that were less well and/or not addressed were the unintended negative consequences of community engagement, the absence of primary data in the guiding evidence, and the lack of a facilitation continuum coupled with the role of power during the facilitation process. CONCLUSION: CoCoPOPP, Cocoa360's response to the COVID-19 pandemic in rural Ghana, is an evidence-driven, context-dependent public health intervention that has been designed to reduce COVID-19 infections and prevent potential deaths. This study underscores the importance of considering the unique community and cultural contexts, employing evidence, and engaging local and external actors as facilitators when designing interventions to respond to global health pandemics.

Understanding social capital among young black gay and bisexual men living with HIV: a qualitative exploration.

Social capital, defined as the sum of an individual's resource-containing, reciprocal and trustworthy social network connections, has been associated with improved engagement in care among people living with HIV globally. We conducted a qualitative interview study of social capital among 28 young Black gay, bisexual and other men who have sex with men ages 18-29 living with HIV in Atlanta, Georgia. We asked participants about bonding capital (relationships between individuals with similar demographic characteristics), bridging capital (relationships with individuals of different backgrounds), collective efficacy (involvement with community organisations) and satisfaction with their social networks. We found that participants described bonding capital from friends and family in depth, while more gaps were noted in bridging capital and collective efficacy. Bonding capital derived from families was especially critical to participants' satisfaction with their social capital. Findings suggest that interventions targeting young Black gay, bisexual and other men who have sex with men should build upon strong bonds with family and friends, and/or fill gaps in bridging capital and collective efficacy by connecting young men to mentors and organisations.

Racial disparity in ART adherence is closed in states with high social trust: Results from the Medical Monitoring Project (MMP), 2015.

Racial/ethnic disparities persist in antiretroviral therapy (ART) adherence and viral suppression. We examined associations between state-level social trust and individual-level ART adherence and viral suppression and assessed whether these relationships varied by race/ethnicity. The Medical Monitoring Project (MMP) annually reports nationally representative estimates of the behavioral and clinical characteristics of HIV-positive adults in primary care. A total of 3298 adults diagnosed with HIV between 2015 and 2016 from 16 US states were included. We used weighted logistic regression to model the association between state-level social trust, race/ethnicity (Non-Hispanic Black, White, and Hispanic/Latino), and cross-product interactions with ART adherence (a binary measure derived from three self-reported questions), and viral suppression (a binary measure corresponding to plasma HIV RNA < 200 copies/ml). Social trust was the percentage of people in each state who agreed that most people in their neighborhood could be trusted. A high level of social trust was associated with a higher likelihood of ART adherence (PR [prevalence ratio] = 1.17; 95% confidence interval [CI]: 1.05-1.30). In covariate-adjusted analyses, the association between state-level social trust and individual-level ART adherence significantly varied by race/ethnicity (Wald χ2 F = 9.8 [df = 4], p = 0.044). Social trust was positively associated with ART, but the effect was smaller for Blacks than for Whites (PR = 0.66; 95% CI: 0.57-0.82) in states with the lowest social trust. Black-White differences were closed and no longer significant above mean social trust (PP [predicted probability] = 0.50 vs. 0.53, at two standard deviations). Racial/ethnic disparities in ART adherence were closed among individuals living in states with high social trust. Understanding the mechanisms that promote social trust among neighbors may have downstream impacts on reducing disparities in ART adherence among people with HIV (PWH).

Mortality, Health, and Substance Abuse by Religious Attendance Among HIV Infected Patients from the Veterans Aging Cohort Study.

Religion and spirituality have been associated with higher survival and improved biological markers among people living with HIV/AIDS (PLWH). Prior results have largely been among small cohort studies. We examined the association using a larger sample and longitudinal data from the Veterans Aging Cohort Study (VACS) years 2002-2012 (n = 3,685). Attending services at least monthly was associated with higher social support (80% vs 75%, p = 0.002), less unhealthy alcohol use (35% vs 39%, p = 0.006), less marijuana use in the past year (23% vs 32%, p < 0.001), less overall drug use within the past year (27% vs 31%, p = 0.01), and lower depression (20% vs 24%, p = 0.004). Attending services monthly was associated with a reduced mortality risk adjusting for age, race, gender, education, MSM, HCV, VL, CD4, and adherence to ARV (adjusted HazardRatio [aHR] = 0.89, 0.80-0.99). However, after controlling for smoking status, this association of mortality and religious attendance became non-significant (aHR = 0.93, 0.84-1.04).

RESUMEN: La religión y la espiritualidad se han asociado con una mayor supervivencia y mejores marcadores biológicos entre las personas que viven con VIH / SIDA (PLWH). Los resultados anteriores han sido en gran parte entre estudios de cohortes pequeñas. Examinamos la asociación utilizando una muestra más grande y datos longitudinales del Estudio de cohorte de envejecimiento de veteranos (VACS) años 2002­2012 (n = 3,685). Asistir a los servicios al menos mensualmente se asoció con un mayor apoyo social (80% frente a 75%, p = 0.002), menos consumo de alcohol no saludable (35% frente a 39%, p = 0.006), menos consumo de marihuana en el último año (23% vs 32%, p < 0.001), menos consumo total de drogas en el último año (27% vs 31%, p = 0.01) y depresión más baja (20% vs 24%, p = 0.004). La asistencia mensual a los servicios se asoció con una reducción del riesgo de mortalidad ajustada por edad, raza, sexo, educación, HSH, VHC, VL, CD4 y adherencia al ARV (HazardRatio ajustado [aHR] = 0.89, 0.80­0.99). Sin embargo, después de controlar el tabaquismo, esta asociación de mortalidad y asistencia religiosa se volvió no significativa (aHR = 0.93, 0.84­1.04).

Neighborhood Social Cohesion and Inequalities in COVID-19 Diagnosis Rates by Area-Level Black/African American Racial Composition.

Geographic inequalities in COVID-19 diagnosis are now well documented. However, we do not sufficiently know whether inequalities are related to social characteristics of communities, such as collective engagement. We tested whether neighborhood social cohesion is associated with inequalities in COVID-19 diagnosis rate and the extent the association varies across neighborhood racial composition. We calculated COVID-19 diagnosis rates in Philadelphia, PA, per 10,000 general population across 46 ZIP codes, as of April 2020. Social cohesion measures were from the Southeastern Pennsylvania Household Health Survey, 2018. We estimated Poisson regressions to quantify associations between social cohesion and COVID-19 diagnosis rate, testing a multiplicative interaction with Black racial composition in the neighborhood, which we operationalize via a binary indicator of ZIP codes above vs. below the city-wide average (41%) Black population. Two social cohesion indicators were significantly associated with COVID-19 diagnosis. Associations varied across Black neighborhood racial composition (p <0.05 for the interaction test). In ZIP codes with ≥41% of Black people, higher collective engagement was associated with an 18% higher COVID-19 diagnosis rate (IRR=1.18, 95%CI=1.11, 1.26). In contrast, areas with <41% of Black people, higher engagement was associated with a 26% lower diagnosis rate (IRR=0.74, 95%CI=0.67, 0.82). Neighborhood social cohesion is associated with both higher and lower COVID-19 diagnosis rates, and the extent of associations varies across Black neighborhood racial composition. We recommend some strategies for reducing inequalities based on the segmentation model within the social cohesion and public health intervention framework.

Religion, Spirituality, and Health: New Considerations for Epidemiology.

Religion and spirituality are important social determinants that drive public health practice. The field of epidemiology has played a vital role in answering long-standing questions about whether religion is causally associated with health and mortality. As epidemiologists spark new conversations (e.g., see Kawachi (Am J Epidemiol. (https://doi.org/10.1093/aje/kwz204)) and Chen and VanderWeele (Am J Epidemiol. 2018;187(11):2355-2364)) about methods (e.g., outcomes-wide analysis) used to establish causal inference between religion and health, epidemiologists need to engage with other aspects of the issue, such as emerging trends and historical predictors. Epidemiologists will need to address 2 key aspects. The first is changing patterns in religious and spiritual identification. Specifically, how do traditional mechanisms (e.g., social support) hold up as explanations for religion-health associations now that more people identify as spiritual but not religious and more people are not attending religious services in physical buildings? The second is incorporation of place into causal inference designs. Specifically, how do we establish causal inference for associations between area-level constructs of the religious environment (e.g., denomination-specific church membership/adherence rates) and individual- and population-level health outcomes?

Social Capital and Risk of Concurrent Sexual Partners Among African Americans in Jackson, Mississippi.

Concurrent sexual partnerships (i.e., relationships that overlap in time) contribute to higher HIV acquisition risk. Social capital, defined as resources and connections available to individuals is hypothesized to reduce sexual HIV risk behavior, including sexual concurrency. Additionally, we do not know whether any association between social capital and sexual concurrency is moderated by gender. Multivariable logistic regression tested the association between social capital and sexual concurrency and effect modification by gender. Among 1445 African Americans presenting for care at an urban STI clinic in Jackson, Mississippi, mean social capital was 2.85 (range 1-5), mean age was 25 (SD = 6), and 62% were women. Sexual concurrency in the current year was lower for women compared to men (45% vs. 55%, χ2(df = 1) = 11.07, p = .001). Higher social capital was associated with lower adjusted odds of sexual concurrency for women compared to men (adjusted Odds Ratio [aOR] = 0.62 (95% CI 0.39-0.97), p = 0.034), controlling for sociodemographic and psychosocial covariates. Interventions that add social capital components may be important for lowering sexual risk among African Americans in Mississippi.

Reducing the African American HIV Disease Burden in the Deep South: Addressing the Role of Faith and Spirituality.

Nearly half of HIV infections in the United States are concentrated among African Americans, and over half of new HIV infections occur in the South. African Americans have poorer outcomes in the entire continua of HIV and PrEP care. Complex social, structural, and behavioral factors contribute to our nation's alarming racial disparities in HIV infection, particularly in the Deep South. Despite the importance of faith, spirituality and religious practice in the lives of many African Americans, there has been little scientific investment exploring how African Americans' religious participation, faith and spirituality may impact our nation's HIV epidemic. This article summarizes the state of the science on this critical issue. We also identify opportunities for new scholarship on how faith, spirituality and religious participation may impact HIV care continuum outcomes in the South and call for greater federal research investment on these issues.

The Role of Religious Service Attendance, Psychosocial and Behavioral Determinants of Antiretroviral Therapy (ART) Adherence: Results from HPTN 063 Cohort Study.

Early and sustained antiretroviral therapy (ART) adherence can suppress the HIV virus in individuals and reduce onward transmission of HIV in the population. Religiosity has been associated with better HIV clinical outcomes. Data are from a longitudinal, observational study of 749 HIV-infected individuals from Brazil, Zambia, and Thailand (HPTN 063). Ordered logistic regression assessed whether religious service attendance was associated with ART adherence (self-reported and plasma HIV-RNA) and moderated the association between alcohol problems and ART adherence. In each country, > 80% of participants reported high self-reported ART adherence (good/very good/excellent). Religious service attendance exceeded 85% but was statistically unrelated to adherence. In combined-country models, (p = 0.03) as alcohol problems increased, the probability of high self-reported ART adherence, as well as viral-load, became weaker at higher compared to low service attendance frequency. Future studies should evaluate spirituality variables and replicate the moderation analyses between religious attendance and alcohol problems.

The Longitudinal Effects of Non-injection Substance Use on Sustained HIV Viral Load Undetectability Among MSM and Heterosexual Men in Brazil and Thailand: The Role of ART Adherence and Depressive Symptoms (HPTN 063).

The effect of non-injection substance use on HIV viral load (VL) is understudied in international settings. Data are from HPTN063, a longitudinal observational study of HIV-infected individuals in Brazil, Thailand, and Zambia, with focus on men with VL data (Brazil = 146; Thailand = 159). Generalized linear mixed models (GLMM) assessed whether non-injection substance use (stimulants, cannabis, alcohol, polysubstance) was associated with VL undetectability. ART adherence and depressive symptoms were examined as mediators of the association. In Thailand, substance use was not significantly associated with VL undetectability or ART adherence, but alcohol misuse among MSM was associated with increased odds of depression (AOR = 2.75; 95% CI 1.20, 6.32, p = 0.02). In Brazil, alcohol misuse by MSM was associated with decreased odds of undetectable VL (AOR = 0.34; 95% CI 0.13, 0.92, p = 0.03). Polysubstance use by heterosexual men in Brazil was associated with decreased odds of ART adherence (AOR = 0.25; 95% CI 0.08, 0.78, p = 0.02). VL suppression appears attainable among non-injection substance users. Substance use interventions among HIV-positive men should address depression, adherence, and VL undetectability.

Alcohol Outlet Density and Area-Level Heavy Drinking Are Independent Risk Factors for Higher Alcohol-Related Complaints.

Alcohol outlet density has well-documented associations with social and health indicators such as crime and injury. However, significantly less is known about the relationships among alcohol-related complaints. Bayesian hierarchical Poisson regression with spatial autocorrelation was used to model the association between on- and off-premises alcohol outlet density and area-level prevalence of current drinkers and heavy drinking, and graffiti density-an indicator of physical disorder-in association with calls from civilians reporting illegal use, alcohol sales, and other alcohol-related activities (hereafter alcohol-related complaints). Complaints were separated into two groups based on whether they occurred at (a) clubs/bars/restaurants or (b) elsewhere. Alcohol-related complaints and graffiti were collected from NYC Open Data. Alcohol density data are from ESRI Business Analyst and information on the prevalence of drinking from the New York City Community Health Survey. The unit of analysis consisted of ZIP codes in New York City (n = 167), and the design was a cross-sectional analysis of aggregated data between 2009 and 2015. In multivariable models, a one-unit increase in off-premises alcohol outlet density was associated with a 47% higher risk of alcohol-related complaints at clubs, bars, and restaurants [rate ratio (RR = 1.46, 95% CI = 1.21, 1.77)]. Area-level prevalence of heavy drinking was associated with a 59% higher risk of alcohol-related complaints at the club, bars, and restaurants (RR = 1.59, 95% CI = 1.34, 1.86) and a 40% higher risk of complaints elsewhere (RR = 1.40, 95% CI = 1.20, 1.63). In New York City, area-level heavy drinking prevalence is a strong independent mechanism that links alcohol outlet density to alcohol-related complaints. Area-level heavy drinking should be investigated as a predictor of other public health problems such as drug overdose mortality.

"It still affects our economic situation": long-term economic burden of breast cancer and lymphedema.

PURPOSE: Financial toxicity after breast cancer may be exacerbated by adverse treatment effects, like breast cancer-related lymphedema. As the first study of long-term out-of-pocket costs for breast cancer survivors in the USA with lymphedema, this mixed methods study compares out-of-pocket costs for breast cancer survivors with and without lymphedema. METHODS: In 2015, 129 breast cancer survivors from Pennsylvania and New Jersey completed surveys on demographics, economically burdensome events since cancer diagnosis, cancer treatment factors, insurance, and comorbidities; and prospective monthly out-of-pocket cost diaries over 12 months. Forty participants completed in-person semi-structured interviews. GLM regression predicted annual dollar amount estimates. RESULTS: 46.5% of participants had lymphedema. Mean age was 63 years (SD = 8). Average time since cancer diagnosis was 12 years (SD = 5). Over 98% had insurance. Annual adjusted health-related out-of-pocket costs excluding productivity losses totaled $2306 compared to $1090 (p = 0.006) for those without lymphedema, or including productivity losses, $3325 compared to $2792 (p = 0.55). Interviews suggested that the cascading nature of economic burden on long-term savings and work opportunities, and insufficiency of insurance to cover lymphedema-related needs drove cost differences. Higher costs delayed retirement, reduced employment, and increased inability to access lymphedema care. CONCLUSIONS: Long-term cancer survivors with lymphedema may face up to 112% higher out-of-pocket costs than those without lymphedema, which influences lymphedema management, and has lasting impact on savings and productivity. Findings reinforce the need for actions at policy, provider, and individual patient levels, to reduce lymphedema costs. Future work should explore patient-driven recommendations to reduce economic burden after cancer.