Patterns of Socioeconomic Marginalization among People Who Use Drugs: A Gender-Stratified Repeated Measures Latent Class Analysis.

Socioeconomic factors are important correlates of drug use behaviors and health-related outcomes in people who use drugs (PWUD) residing in urban areas. However, less is known about the complex overlapping nature of socioeconomic conditions and their association with a range of individual, drug use, and health-related factors in men and women who use drugs. Data were obtained from two community-recruited prospective cohorts of PWUD. Using a gender-stratified approach, we conducted repeated measures latent class analyses (RMLCA) to identify discrete latent socioeconomic subgroups. Multivariable generalized estimating equations were then used to identify correlates of class membership. Between June 2014 and December 2018, RMLCA of 9844 observations from 1654 participants revealed five distinct patterns of socioeconomic status for both men and women. These patterns were primarily distinguished by variations in income, material and housing security, income generation activity, exposure to violence, criminal justice involvement, and police contact. Across gender, progressive increases in exposure to multiple dimensions of socioeconomic disadvantage were found to be associated with frequent use of opioids and stimulants, accessing social services, and being hepatitis C virus antibody-positive. Similar but less congruent trends across gender were observed for age, binge drug use, engagement with opioid agonist therapy, and living with HIV. Gendered patterns of multiple and overlapping dimensions of socioeconomic adversity aligned with patterns of frequent drug use and health-related concerns, highlighting priority areas for gender-inclusive, multilevel responses to mitigate health disparities and meet the diverse socioeconomic needs of urban-dwelling men and women who use drugs.

Agricultural expansion and the ecological marginalization of forest-dependent people.

Agricultural expansion into subtropical and tropical forests causes major environmental damage, but its wider social impacts often remain hidden. Forest-dependent smallholders are particularly strongly impacted, as they crucially rely on forest resources, are typically poor, and often lack institutional support. Our goal was to assess forest-smallholder dynamics in relation to expanding commodity agriculture. Using high-resolution satellite images across the entire South American Gran Chaco, a global deforestation hotspot, we digitize individual forest-smallholder homesteads (n = 23,954) and track their dynamics between 1985 and 2015. Using a Bayesian model, we estimate 28,125 homesteads in 1985 and show that forest smallholders occupy much larger forest areas (>45% of all Chaco forests) than commonly appreciated and increasingly come into conflict with expanding commodity agriculture (18% of homesteads disappeared; n = 5,053). Importantly, we demonstrate an increasing ecological marginalization of forest smallholders, including a substantial forest resource base loss in all Chaco countries and an increasing confinement to drier regions (Argentina and Bolivia) and less accessible regions (Bolivia). Our transferable and scalable methodology puts forest smallholders on the map and can help to uncover the land-use conflicts at play in many deforestation frontiers across the globe. Such knowledge is essential to inform policies aimed at sustainable land use and supply chains.

Contact with Child Protective Services is pervasive but unequally distributed by race and ethnicity in large US counties.

This article provides county-level estimates of the cumulative prevalence of four levels of Child Protective Services (CPS) contact using administrative data from the 20 most populous counties in the United States. Rates of CPS investigation are extremely high in almost every county. Racial and ethnic inequality in case outcomes is large in some counties. The total median investigation rate was 41.3%; the risk for Black, Hispanic, and White children exceeded 20% in all counties. Risks of having a CPS investigation were highest for Black children (43.2 to 72.0%). Black children also experienced high rates of later-stage CPS contact, with rates often above 20% for confirmed maltreatment, 10% for foster care placement, and 2% for termination of parental rights (TPR). The only other children who experienced such extreme rates of later-stage CPS interventions were American Indian/Alaska Native children in Middlesex, MA; Hispanic children in Bexar, TX; and all children except Asian/Pacific Islander children in Maricopa, AZ. The latter has uniquely high rates of late-stage CPS interventions. In some jurisdictions, such as New York, NY, (0.2%) and Cook, IL (0.2%), very few children experienced TPR. These results show that early CPS interventions are ubiquitous in large counties but with marked variation in how CPS systems respond to these investigations.

The Eschucha (Listen) Podcast Project: Psychosocial Innovation for Marginalized Mexican Youth and Young Adults.

The COVID-19 pandemic was a challenging period for young people in Mexico, particularly those already contending with social and structural inequality. In March 2021, the Colectivo Frontera, a research collective based in Mexico City, Mexico, which works on advancing equity and psychosocial wellbeing among marginalized communities, carried out an 8-week, online project to provide psychosocial support and promote resilience for marginalized young people from different locations in Mexico. The project entailed weekly journaling with the Pandemic Journaling Project (PJP), as well as weekly phone sessions with a mental health specialist who provided emotional support (acompañamiento emocional) through practices of active listening. The project culminated in the Escucha (Listen) Podcast for which each youth participant created an episode about their experiences during the pandemic. Many also submitted a photo to accompany their recording; one produced a song. Participant episodes were compiled into a series of five chapters. Each chapter of the podcast centers on a common theme, including reflections on loved ones lost to COVID-19, social fragmentation, gender-based constraints on expressing emotions, and the experiences and perspectives of children. The project provides a compelling example of a low-cost approach to providing support for the mental health and wellbeing of marginalized young people. It also demonstrates the importance of creating projects that help young people make meaningful connections and that leverage their creativity to foster resilience, improve social cohesion, and elevate their perspectives and voices.

A theory of geo-social marginalization: A case study of the licensed cannabis industry in California.

The licensed cannabis industry represents one of the top five most economically valued agricultural commodities in California, yet farming largely remains on remote, environmentally sensitive, "marginal" lands. Using mixed methods, this paper examines the determinants of this marginalization, their embedded elaboration, and their relation to historical policy regimes. We used Generalized Additive Models (GAMs) to determine the most important predictors of licensed cannabis industry development since the inception of a statewide licensing program in 2018 and to compare the distribution of licensed cannabis to other forms of rural agriculture, including vineyards and pasture, to understand landscape factors and environmental sensitivity of land uses. We found that a county's median income and the extent of traditional (non-cannabis) agriculture, as measured by the proportion of on-farm (non-cannabis) employment, were both negatively associated with its amount of licensed cannabis agriculture. Ethnographic data suggests that cannabis is often excluded from traditional agricultural areas, through formal local-level bans, restrictive zoning, high "prime" farmland values, and cultural exclusions from other powerful resource users. The resulting relegation to "marginal" lands foments conflicts with amenity land users and environmentalists, even as it partly supports "legacy" cultivators whose farms were established under prior policy regimes. Results suggest that cannabis is more likely to be grown under conditions that introduce regulatory hurdles, including farming on steeper slopes, with natural streams onsite, and without access to large groundwater aquifers for irrigation. Our findings suggest that failure to allow licensed cannabis farming in traditional agriculture regions has led to a self-fulfilling prophecy wherein cannabis cultivation is largely relegated to environmentally sensitive areas where cultivation activity has an elevated tendency for environmental impacts.

Navigating healthcare systems: A qualitative study on socially marginalised patients' experiences of hospital transition and support by social nurses.

BACKGROUND: Socially marginalised patients face many challenges related to their health condition and often have several contacts with healthcare and social service workers. The Danish social nursing initiative, whose nurses have experience and knowledge about marginalisation, aims to support socially marginalised patients during hospital admission and through hospital transitions. However, there is limited knowledge about the hospital transitions of patients being supported by a social nurse. OBJECTIVES: The objectives of this study were to explore (1) the perspectives of socially marginalised patients on the transition from hospital to home and (2) how these patients experience the importance of social nursing on patient trajectories after hospital discharge. METHODS: A qualitative study with a phenomenological and hermeneutic approach was performed at a large hospital in southern Denmark. Adult patients who had contact with a social nurse during hospital admission were purposely sampled. Data were collected between January 2023 and March 2023. Initial patient interviews were conducted during hospital admission with a second interview 7-22 days after discharge. Systematic text condensation was used for the analysis, and Nvivo 12 supported data storage and coding. ETHICAL APPROVAL: The study is registered with the Danish Data Protection Agency (22/47509). Informed consent was given by the participants. RESULTS: Sixteen patients participated in the study. The participants experienced major challenges in their transitions from the hospital, which were generally related to their interactions with many different social and healthcare services. While the social nurses supported the patients and helped facilitate care during hospital admission and after discharge, the participants identified transitional care gaps related to multidisciplinary cooperation and standardised care options. CONCLUSIONS: This study identifies challenges related to the hospital transition of socially marginalised patients, which indicates a gap in healthcare services. Future research should focus on improving interprofessional collaboration with socially marginalised patients across healthcare services.

Youth sociopolitical development: A conceptual framework by racial and gender minoritized youth organizers.

Youth sociopolitical development (SPD) is a powerful protective and promotive factor for marginalized adolescents' social, emotional, physical, and academic well-being. Despite having unique insight and experiential knowledge about SPD processes, youth have been excluded from conceptual framework and model development. As part of a Youth Participatory Action Research project, 11 adolescents (ages 14-19) and one adult ask "How do adolescent community organizers with varying social and political experiences conceptualize youth SPD?" We used a multiple case study design, with a grounded theory analytic approach. The YPAR collective identified four interrelated, experiential domains of youth SPD: thinking, feeling, doing and relating. Within each domain, we identified and defined key constructs and practices. The YPAR collective's qualitative inquiry resulted in more nuance for existing frameworks of critical consciousness and critical action, and the collective pushes the SPD field to better integrate social and emotional aspects of SPD practice. They offer a conceptual framework that is rooted in their experiential, sensory, learned, and social knowledge, from a multiple-marginalized positionality. These insights enrich the fields of SPD research and practice.

"I was already there once": Cumulative attempt capital of marginalized women exiting substance use and street prostitution contributes to their recovery capital.

Despite a move to view substance use as a disease of the brain, relapse into drugs is still often viewed as a personal failure. Low recovery capital has been used to explain relapse among certain marginalized populations. Recovery capital is a recent framework that refers to the individual's sum of all internal and external assets that may assist in their recovery process. It includes four categories: physical, human, social, and cultural capital. However, this framework does not relate to the role of actual relapses in the recovery process, despite their common occurrence. To bridge this gap, in-depth interviews with 29 women formerly engaged in substance use and street prostitution in a large urban area were used to probe women about their relapse and recovery experiences. The current study demonstrates the value in repeat recovery setbacks, what I term "cumulative attempt capital": lessons learned from previous recovery attempts. I argue that previous attempts improve women's social and professional networks, help them learn from past mistakes, improve and maintain their health, and provide them with a sense of self-efficacy. This research expands our understanding of the positive role failed attempts play in one's recovery. Such reframing by service providers can alleviate a sense of shame and low self-worth for women in street prostitution and substance use and has implications for policy and program development.

The Power of Tailoring a Government-Funded Heart Health Program for Marginalized Women: Lessons from WISEWOMAN and Mujer Poderosa/Powerful Woman.

The Centers for Disease Control and Prevention's DP18-1816 Well-Integrated Screening and Evaluation for Women Across the Nation (WISEWOMAN) award to the Pennsylvania Department of Health combats the leading cause of death in Pennsylvania, cardiovascular disease. Pennsylvania's program (PA-WISE) includes an innovative approach to engage low-income women in cardiovascular disease prevention. PA-WISE collaborated with Latino Connection to pilot Mujer Poderosa/Powerful Woman (MP/PW), utilizing bilingual community health workers to engage, educate, and empower marginalized women to improve their health. Latino Connection discovered different approaches were needed by each community for engaging women and connecting with resources. MP/PW tailored outreach and intervention approaches to women's needs and expectations, responding to differences in education levels, acculturation, immigration status, and levels of trust. The experiences of MP/PW provide lessons on the importance of having and maintaining flexibility in responding to women's backgrounds and community characteristics and tailoring to meet the needs of marginalized women.

We Are Still Here: Omission and Perceived Discrimination Galvanized Civic Engagement Among Native Americans.

Leading up to the 2020 U.S. presidential election, Native American organizations and tribes launched get-out-the-vote campaigns that motivated Native peoples to vote in record numbers and helped flip battleground states. We conducted four studies (total N = 11,661 Native American adults) to examine the social and cultural factors explaining this historic Native civic engagement (e.g., campaigning). Results revealed that the more participants identified as being Native, the more they reported (a) engaging in civic activities, including get-out-the-vote behaviors during the 2020 election (Study 1); (b) civic engagement more broadly across a 5-year period (pilot study, Study 2); and (c) intentions to engage in civic activities in the future (Study 3). Moreover, participants who more strongly identified as Native were more likely to recognize the omission of their group from society and perceive greater group discrimination, which both independently and serially predicted greater civic engagement. These results suggest that leveraging the link between Native identification and group injustices can motivate action.

Our Souls Look Back and Wonder: Reflections on Belonging and Being Invisible in Medicine.

Addressing the unequal impact of health disparities on historically marginalized communities is a top public health priority. Diversifying the work force has been lauded as key to addressing this challenge. Contributing to diversity in the workforce is the recruitment and retention of health professionals previously excluded and underrepresented in medicine. A major obstacle to retention, however, is the unequal way in which health professionals experience the learning environment. Through this perspective of 4 generations of physicians and medical students, the authors seek to highlight the similarities that have persisted over 40 years in the experiences of being underrepresented in medicine. Through a series of conversations and reflective writing, the authors reveal themes that spanned generations. Two common themes among the authors are the feeling of not belonging and feeling invisible. This is experienced in various aspects of medical education and academic careers. The lack of representation, unequal expectations, and over taxation contributes to the feeling of not belonging, leading to emotional, physical, and academic fatigue. Feeling invisible, yet paradoxically being hyper-visible, is also common. Despite the challenges, the authors conclude with a sense of hope for the future, if not for them, for the generations to come.

Intersectionality and adolescent medicine: an overview.

PURPOSE OF REVIEW: This review defines intersectionality, discusses recent studies that use an intersectional framework in adolescent health research, and outlines ways where clinicians can use intersectionality to address health disparities in youth of color through clinical practice, research, and advocacy. RECENT FINDINGS: Research using an intersectional framework can identify populations at risk for certain disorders or behaviors. Recent studies in adolescent health research using an intersectional lens identified lesbian girls of color as an at-risk population for e-cigarette use, demonstrated lower skin color satisfaction among Black girls of all ages predicted greater binge-eating disorder symptoms, and showed that two-thirds of Latine (gender-neutral term that refers to people with Latin American roots) youth who recently immigrated to the United States experienced at least one traumatic event during their migration journey, putting them at risk for PTSD and other mental health disorders. SUMMARY: Intersectionality refers to how multiple social identities intersect to produce a specific experience that reflects overlapping systems of oppression. Diverse youth contain multiple identities that intersect to produce unique experiences and health inequities. Using an intersectional framework acknowledges that youth of color are not homogenous. Intersectionality becomes an important tool to care for marginalized youth and advance health equity.

Alcohol Use Severity among Hispanic Emerging Adults: Examining Intragroup Marginalization, Bicultural Self-Efficacy, and the Role of Gender within a Stress and Coping Framework.

Most research on cultural stressors and alcohol has focused on intercultural stressors. Continuing to exclude intracultural stressors (e.g., intragroup marginalization) from alcohol research will yield a biased understanding of the experiences of Hispanics living in a bicultural society. As we amass more studies on intracultural stressors, research will be needed to identify mutable sociocultural factors that may mitigate the association between intracultural stressors and alcohol. To address these limitations, we examined the association between intragroup marginalization and alcohol use severity and the extent to which gender and bicultural self-efficacy may moderate this association. A convenience sample of 200 Hispanic emerging adults ages 18-25 (men = 101, women = 99) from Arizona (n = 99) and Florida (n = 101) completed a cross-sectional survey. Data were analyzed using hierarchical multiple regression and moderation analyses. Higher intragroup marginalization was associated with higher alcohol use severity. Gender functioned as a moderator whereby intragroup marginalization was associated with higher alcohol use severity among men, but not women. Also, higher social groundedness functioned as a moderator that weakened the association between intragroup marginalization and alcohol use severity. Role repertoire did not function as a moderator. Our findings are significant because they enhance the reliability of the association between intragroup marginalization and alcohol use severity, and the moderating effect of gender in this respective association. This emerging line of research suggests that alcohol interventions targeting Hispanics may have a significant limitation by not accounting for intracultural stressors.

Workplace Harassment, Cyber Incivility, and Climate in Academic Medicine.

Importance: The culture of academic medicine may foster mistreatment that disproportionately affects individuals who have been marginalized within a given society (minoritized groups) and compromises workforce vitality. Existing research has been limited by a lack of comprehensive, validated measures, low response rates, and narrow samples as well as comparisons limited to the binary gender categories of male or female assigned at birth (cisgender). Objective: To evaluate academic medical culture, faculty mental health, and their relationship. Design, Setting, and Participants: A total of 830 faculty members in the US received National Institutes of Health career development awards from 2006-2009, remained in academia, and responded to a 2021 survey that had a response rate of 64%. Experiences were compared by gender, race and ethnicity (using the categories of Asian, underrepresented in medicine [defined as race and ethnicity other than Asian or non-Hispanic White], and White), and lesbian, gay, bisexual, transgender, queer (LGBTQ+) status. Multivariable models were used to explore associations between experiences of culture (climate, sexual harassment, and cyber incivility) with mental health. Exposures: Minoritized identity based on gender, race and ethnicity, and LGBTQ+ status. Main Outcomes and Measures: Three aspects of culture were measured as the primary outcomes: organizational climate, sexual harassment, and cyber incivility using previously developed instruments. The 5-item Mental Health Inventory (scored from 0 to 100 points with higher values indicating better mental health) was used to evaluate the secondary outcome of mental health. Results: Of the 830 faculty members, there were 422 men, 385 women, 2 in nonbinary gender category, and 21 who did not identify gender; there were 169 Asian respondents, 66 respondents underrepresented in medicine, 572 White respondents, and 23 respondents who did not report their race and ethnicity; and there were 774 respondents who identified as cisgender and heterosexual, 31 as having LGBTQ+ status, and 25 who did not identify status. Women rated general climate (5-point scale) more negatively than men (mean, 3.68 [95% CI, 3.59-3.77] vs 3.96 [95% CI, 3.88-4.04], respectively, P < .001). Diversity climate ratings differed significantly by gender (mean, 3.72 [95% CI, 3.64-3.80] for women vs 4.16 [95% CI, 4.09-4.23] for men, P < .001) and by race and ethnicity (mean, 4.0 [95% CI, 3.88-4.12] for Asian respondents, 3.71 [95% CI, 3.50-3.92] for respondents underrepresented in medicine, and 3.96 [95% CI, 3.90-4.02] for White respondents, P = .04). Women were more likely than men to report experiencing gender harassment (sexist remarks and crude behaviors) (71.9% [95% CI, 67.1%-76.4%] vs 44.9% [95% CI, 40.1%-49.8%], respectively, P < .001). Respondents with LGBTQ+ status were more likely to report experiencing sexual harassment than cisgender and heterosexual respondents when using social media professionally (13.3% [95% CI, 1.7%-40.5%] vs 2.5% [95% CI, 1.2%-4.6%], respectively, P = .01). Each of the 3 aspects of culture and gender were significantly associated with the secondary outcome of mental health in the multivariable analysis. Conclusions and Relevance: High rates of sexual harassment, cyber incivility, and negative organizational climate exist in academic medicine, disproportionately affecting minoritized groups and affecting mental health. Ongoing efforts to transform culture are necessary.

Practical and Ethical Considerations of Using Personal DNA Tests with Middle-School-Aged Learners.

Personalized genetic information is not widely utilized as a resource in learning environments, in part because of concerns about data privacy and the treatment of sensitive personal information. Here we describe the implementation of a curriculum centered on analyzing personalized genetic-ancestry test results during two-week science summer camps for middle-school-aged youth. Our research focused on how the examination of personalized DNA results affected learners' subsequent perceptions and performance, as measured by in-camp pre- and post-tests and surveys, analysis of voluntary student talk captured by audio and video recordings, and periodic one-on-one post-camp follow-ups. The curriculum was grounded in Next Generation Science Standards (NGSS) and focused around the central question of "Who am I?" Campers approached this question via guided lessons designed to shed light on their genetic uniqueness, the many attributes of their genotype and phenotype shared with others, their more distant genetic and evolutionary ancestries, and their roles as active agents in the healthy continuation of their lives. Data relevant to these questions came from edited subsets of ancestry-informative single-nucleotide polymorphisms (SNPs) and phenotype-related SNPs from the campers' genotype results, which their parents had received from a direct-to-consumer vendor. Our approaches to data privacy and the discovery, disclosure, and discussion of sensitive information on paternity, carrier status, and ancestry can be usefully applied and modified for many educational contexts. On the basis of our pilot implementations, we recommend additional and expanded research on how to incorporate personalized genetic ancestry information in a variety of learning contexts.