Structural Racism, the Social Determination of Health, and Health Inequities: The Intersecting Impacts of Housing and Mass Incarceration.

Public health researchers have directed increasing attention to structural racism and its implications for health equity. The conceptualization of racism as historically rooted in systems, structures, and institutions of US society has important implications for addressing social determinants of health (SDOH). It requires theorizing SDOH as embedded in and expressions of racially oppressive historical structures that are manifested in and maintained by policies, programs, and practices in multiple domains that dynamically intersect to reinforce and reproduce in new ways: race inequities in health. We develop this argument using housing, a SDOH recognized as reflecting longstanding racist practices and policies that, among other things, have restricted the affordable housing options of Black people to segregated neighborhoods with limited resources. We argue that understanding and addressing the health inequities resulting from structural racism associated with housing requires simultaneously understanding and addressing how housing intersects with mass incarceration, another SDOH and manifestation of structural racism. We suggest that unless these intersections are intentionally analyzed and confronted, efforts to address the impacts of housing on racial health disparities may produce new forms of health inequities. (Am J Public Health. 2023;113(S1):S58-S64. https://doi.org/10.2105/AJPH.2022.307116).

Rental assistance improves food security and nutrition: An analysis of National Survey Data.

The U.S. is experiencing a severe housing affordability crisis, resulting in households having to make difficult trade-offs between paying for a place to live and basic health necessities such as food. Rental assistance may mitigate these strains, improving food security and nutrition. However, only one in five eligible individuals receive assistance, with an average wait time of two years. Existing waitlists create a comparable control group, allowing us to examine the causal impact of improved housing access on health and well-being. This national quasi-experimental study utilizes linked NHANES-HUD data (1999-2016) to investigate the impacts of rental assistance on food security and nutrition using cross-sectional regression. Tenants with project-based assistance were less likely to experience food insecurity (B = -0.18, p = 0.02) and rent-assisted individuals consumed 0.23 more cups of daily fruits and vegetables compared the pseudo-waitlist group. These findings suggest that the current unmet need for rental assistance and resulting long waitlists have adverse health implications, including decreased food security and fruit and vegetable consumption.

The Affordable Rental Housing Crisis and Population Health Equity: a Multidimensional and Multilevel Framework.

The US is facing a severe affordable rental housing crisis that contributes to multiple forms of housing insecurity including homelessness, crowded and poor quality housing conditions, unstable housing arrangements, and cost burdens. A considerable body of evidence finds that housing insecurity is an important determinant of health. However, the existing literature may fall short of conceptualizing and measuring the full impact of housing insecurity on population health and on racial health equity. In this paper, we seek to expand the conceptualization of housing as a determinant of population health equity by considering housing insecurity as a manifestation of structural racism that intersects with other manifestations and impacts of structural racism to affect, not only the health of housing insecure individuals, but also the health of the networks and communities in which these individuals live. First, we situate the current housing crisis within larger systems of structural racism. We extend prior work documenting the confluence of ways that racist policies and practices have created unequal burdens of housing insecurity to also discuss the ways that the meanings and impacts of housing insecurity may be shaped by racism. Next, we consider how the health impacts of this unequal burden of housing insecurity can extend beyond individual households to affect networks and communities. Ultimately, we provide a multilevel framework that can inform research, policy, and practice to address housing and health equity.

"'Oh gosh, why go?' cause they are going to look at me and not hire": intersectional experiences of black women navigating employment during pregnancy and parenting.

BACKGROUND: Workplace legal protections are important for perinatal health outcomes. Black birthing people are disproportionally affected by pregnancy discrimination and bias in the employment context and lack of family-friendly workplace policies, which may hinder their participation in the labor force and lead to gender and racial inequities in income and health. We aimed to explore Black pregnant women's experiences of pregnancy discrimination and bias when looking for work, working while pregnant, and returning to work postpartum. Additionally, we explored Black pregnant women's perspectives on how these experiences may influence their health. METHODS: Using an intersectional framework, where oppression is based on intersecting social identities such as race, gender, pregnancy, and socioeconomic status, we conducted an analysis of qualitative data collected for a study exploring the lived experience of pregnancy among Black pregnant women in New Haven, Connecticut, United States. Twenty-four women participated in semi-structured interviews (January 2017-August 2018). Interview transcripts were analyzed using grounded theory techniques. RESULTS: Participants expressed their desire to provide a financially secure future for their family. However, many described how pregnancy discrimination and bias made it difficult to find or keep a job during pregnancy. The following three themes were identified: 1) "You're a liability"; difficulty seeking employment during pregnancy; 2) "This is not working"; experiences on the job and navigating leave and accommodations while pregnant and parenting; and 3) "It's really depressing. I wanna work"; the stressors of experiencing pregnancy discrimination and bias. CONCLUSION: Black pregnant women in this study anticipated and experienced pregnancy discrimination and bias, which influenced financial burden and stress. We used an intersectional framework in this study which allowed us to more fully examine how racism and economic marginalization contribute to the lived experience of Black birthing people. Promoting health equity and gender parity means addressing pregnancy discrimination and bias and the lack of family-friendly workplace policies and the harm they cause to individuals, families, and communities, particularly those of color, throughout the United States.

"The Squeaky Wheel Gets the Grease": Rental Assistance Applicants' Quests for a Rationed and Scarce Resource.

In 2016, only one in five eligible U.S. households received rental assistance and waiting lists averaged two years nationally. The gap between available rental assistance and need requires systems to allocate this scarce resource. The way potential rental assistance recipients experience and navigate these systems is likely to shape who ultimately receives assistance. We draw on repeated qualitative interviews (N=238) with low-income New Haven residents (N=54) to examine how participants understand and navigate rental assistance applications and waiting lists. Participants encountered multiple challenges in their search for rental assistance. They described an opaque and complex application and waiting process requiring significant knowledge to navigate. They also described considerable labor associated with monitoring waiting lists, a challenge made more difficult for some by their lack of a stable address. Additionally, participants described significant labor and knowledge required to strategically navigate prioritization systems that often required them to advocate for their deservingness of scarce housing resources. Our findings suggest that the allocation of rental assistance through complex processes that depend on applicant knowledge, labor, and advocacy may create barriers to housing, particularly for more vulnerable and marginalized housing seekers.

"Police shootings, now that seems to be the main issue" - Black pregnant women's anticipation of police brutality towards their children.

BACKGROUND: A disproportionate number of people who are killed by police each year are Black. While much attention rightly remains on victims of police brutality, there is a sparse literature on police brutality and perinatal health outcomes. We aimed to explore how Black pregnant women perceive police brutality affects them during pregnancy and might affect their children. METHODS: This qualitative study involved semi-structured interviews among 24 Black pregnant women in New Haven, Connecticut (January 2017 to August 2018). Interview questions explored neighborhood factors, safety, stressors during pregnancy, and anticipated stressors while parenting. Grounded theory informed the analysis. RESULTS: Participants, regardless of socioeconomic status, shared experiences with police and beliefs about anticipated police brutality, as summarized in the following themes: (1) experiences that lead to police distrust - "If this is the way that mommy's treated [by police]"; (2) anticipating police brutality - "I'm always expecting that phone call"; (3) stress and fear during pregnancy - "It's a boy, [I feel] absolutely petrified"; and (4) 'the talk' about avoiding police brutality - "How do you get prepared?" Even participants who reported positive experiences with police anticipated brutality towards their children. CONCLUSIONS: Interactions between Black people and police on a personal, familial, community, and societal level influenced how Black pregnant women understand the potential for police brutality towards their children. Anticipated police brutality is a source of stress during pregnancy, which may adversely influence maternal and infant health outcomes. Police brutality must be addressed in all communities to prevent harming the health of birthing people and their children.

Social Determination of HIV: Women's Relationship Work in the Context of Mass Incarceration and Housing Vulnerability.

We contrast a typical "social determinants of health" framing with a more dynamic and complex "social determination of health" framing to analyze HIV-related sexual risk among women in low-income, segregated neighborhoods in New Haven, CT. Using an abductive approach, we analyze repeated, longitudinal qualitative interviews conducted over a 2-year period with a sample of 14 HIV-negative women who engaged in sex with men during the study period. Three case studies are presented to demonstrate how behaviors and sexual practices typically described as HIV "risks" can be understood as part of the work of establishing and maintaining monogamous committed relationships, which we call "relationship work," shaped in a context characterized by housing vulnerabilities and the many manifestations of mass incarceration and the surveillance state. We conclude by suggesting that for these women, their relationship work is the work of HIV prevention and life in low-income segregated neighborhoods is their HIV-related risk.

Housing Instability and HIV Risk: Expanding our Understanding of the Impact of Eviction and Other Landlord-Related Forced Moves.

The study purpose is to comprehensively measure landlord-related forced moves (inclusive of, but not restricted to, legal eviction), and to examine whether landlord-related forced moves is associated with HIV risk. Baseline survey data was collected between 2017 and 2018 among 360 low-income participants in New Haven, Connecticut. We used multivariable logistic regression analyses to examine associations between landlord-related forced moves and HIV sexual risk outcomes. Seventy seven out of three hundred and sixty participants reported a landlord-related forced move in the past 2 years, of whom 19% reported formal eviction, 56% reported informal eviction and 25% reported both. Landlord-related forced moves were associated with higher odds of unprotected sex (AOR 1.98), concurrent sex (AOR 1.94), selling sex for money or drugs (AOR 3.28), exchange of sex for a place to live (AOR 3.29), and an HIV sexual risk composite (ARR 1.46) (p < .05 for all). We found robust associations between landlord-related forced moves and HIV sexual risk. Findings suggest that the social and economic consequences of landlord-related forced moves may impact sexual vulnerability.

Eviction, Health Inequity, and the Spread of COVID-19: Housing Policy as a Primary Pandemic Mitigation Strategy.

The COVID-19 pandemic precipitated catastrophic job loss, unprecedented unemployment rates, and severe economic hardship in renter households. As a result, housing precarity and the risk of eviction increased and worsened during the pandemic, especially among people of color and low-income populations. This paper considers the implications of this eviction crisis for health and health inequity, and the need for eviction prevention policies during the pandemic. Eviction and housing displacement are particularly threatening to individual and public health during a pandemic. Eviction is likely to increase COVID-19 infection rates because it results in overcrowded living environments, doubling up, transiency, limited access to healthcare, and a decreased ability to comply with pandemic mitigation strategies (e.g., social distancing, self-quarantine, and hygiene practices). Indeed, recent studies suggest that eviction may increase the spread of COVID-19 and that the absence or lifting of eviction moratoria may be associated with an increased rate of COVID-19 infection and death. Eviction is also a driver of health inequity as historic trends, and recent data demonstrate that people of color are more likely to face eviction and associated comorbidities. Black people have had less confidence in their ability to pay rent and are dying at 2.1 times the rate of non-Hispanic Whites. Indigenous Americans and Hispanic/Latinx people face an infection rate almost 3 times the rate of non-Hispanic whites. Disproportionate rates of both COVID-19 and eviction in communities of color compound negative health effects make eviction prevention a critical intervention to address racial health inequity. In light of the undisputed connection between eviction and health outcomes, eviction prevention, through moratoria and other supportive measures, is a key component of pandemic control strategies to mitigate COVID-19 spread and death.

Understanding Entrustment Decision-Making by Surgical Program Directors.

BACKGROUND: The process of entrustment-placing trust in a trainee to independently execute a task-has been proposed as a complementary metric to assess competence. However, entrustment decision-making by trainee supervisors is not well understood in surgical training. We aim to explore processes underlying entrustment decision-making (EDM) by general surgery program directors. MATERIALS AND METHODS: Purposive sampling was used to recruit 20 program directors from Accreditation Council for Graduate Medical Education-accredited general surgery training programs to participate in a one-hour semistructured interview. We analyzed interviews using an iterative and inductive approach to identify novel themes associated with the process of trainee entrustment. RESULTS: Qualitative analysis identified that program directors rely on a network of faculty to make entrustment decisions regarding trainees. Perceived trainee competence to perform independent clinical tasks varies significantly in and out of the operating room (OR), with a strong emphasis on entrustment for technical competencies to the exclusion of cognitive competencies. In the OR, entrustment is informed by an attending's reflexive trust and physical presence, trainee labels, and presumed discernment. Outside of the OR, trainee labels, presumed discernment, and transference of competence were identified as critical themes. CONCLUSIONS: Modifiable components of entrustment are equally dependent on trainee and faculty behavior. Entrustment is more heavily informed by trainee performance in the OR, despite program directors uniformly stating that judgment outside of the OR is the most critical component of resident training. The inclusion of EDM to evaluate trainee progression should be considered as an important adjunct to established Accreditation Council for Graduate Medical Education milestones.

Intimate Partner Violence Influences Women's Engagement in the Early Stages of the HIV Pre-exposure Prophylaxis (PrEP) Care Continuum: Using Doubly Robust Estimation.

Intimate partner violence (IPV) is associated with pre-exposure prophylaxis (PrEP) acceptability among US women, but whether IPV influences other steps along the PrEP care continuum remains unclear. This study estimated the causal effects of IPV on the early stages of the PrEP care continuum using doubly robust (DR) estimation (statistical method allowing causal inference in non-randomized studies). Data were collected (2017-2018) from a cohort study of 124 US women without and 94 women with IPV experiences in the past 6 months (N = 218). Of the 218 women, 12.4% were worried about getting HIV, 22.9% knew of PrEP, 32.1% intended to use PrEP, and 40.4% preferred an "invisible" PrEP modality. IPV predicts HIV-related worry (DR estimate = 0.139, SE = 0.049, p = 0.004). IPV causes women to be more concerned about contracting HIV. Women experiencing IPV are worried about HIV, but this population may need trauma-informed approaches to help facilitate their PrEP interest and intentions.

Clinical management of Type II Diabetes among the unstably housed: a qualitative study of primary care physicians.

BACKGROUND: Housing is a growing challenge for US adults in an increasingly unaffordable housing market. These housing challenges can create barriers to effective management and control of Type II Diabetes. However, little is known about how housing challenges are perceived and navigated by clinicians who care for patients with Type II Diabetes. OBJECTIVE: To examine how primary care clinicians perceive and navigate their patients' housing challenges in the context of Type II Diabetes management. METHODS: We conducted semi-structured interviews with 18 primary care clinicians practising in four clinical settings in New Haven, Connecticut. Two investigators systematically coded the interviews. Analysis of coded data was used to determine themes. RESULTS: Participants considered housing as significant to their patients' health and a potential barrier to optimal diabetes management. Participants sought to improve their patients' housing through advocacy, referrals and interdisciplinary collaborations. They also adjusted clinical decisions to adapt to patients' housing challenges. In making clinical adjustments, participants struggled to find a balance between what they perceived to be feasible for unstably housed patients and maintaining a standard of care. Some participants navigated this balanced by employing creative strategies and individualized care. CONCLUSION: In highlighting the challenges that clinicians face in maintaining a standard of care for unstably housed diabetes patients, our findings speak to the need for more guidance, resources and support to address housing in a clinical setting.

Making Sense of Trainee Performance: Entrustment Decision-Making in Internal Medicine Program Directors.

Background: Competency-based assessment is an important but challenging aspect of residency education but determines trainees' progression towards the ultimate goal of graduation. Entrustment decision making has been proposed as a supplementary metric to assess trainee competence. This study explores the process by which Program Directors (PDs) make entrustment decisions in Internal Medicine (IM) training programs. Study Design: Purposive sampling was used to recruit PDs from ACGME-accredited IM training programs to participate in a semi-structured interview. We analyzed interviews using an iterative, grounded theory-based approach to allow identification of themes that define the process of trainee entrustment. Results: Sixteen PDs were interviewed. Qualitative analysis showed that PDs use a dynamic process to understand trainee entrustability and progression towards competence, including construction of assessment networks, comparing performance to expected trajectory of trainee competence development, and bidirectional filtering and weighing of assessment data. Conclusions: PDs serve as a central processor by which assessment data on trainees is filtered, weighted, and compared an expected trajectory, all to gain understanding of trainee performance. Assessment networks are crucial to understanding trainee competence. While expected trajectory is an important tool to determine how trainees are progressing, its continued use may inject bias into the assessment process and slow transition to true competency-based assessment.

Reducing the Justice Gap and Improving Health through Medical-Legal Partnerships.

A recent study by the Legal Services Corporation reported that 71% of low-income U.S. households experienced at least one civil legal problem in 2017 and that 86% of these needs went unresolved. In this article, we examine the potential for medical-legal partnerships (MLPs) to address this "justice gap." We draw on qualitative interviews, conducted with 20 parents and guardians in one pediatric MLP, to identify barriers to legal access and examine how the MLP model may uniquely address these barriers. Our data suggest that MLPs can (1) identify legal needs and create awareness of legal rights among individuals who would not have sought legal services; (2) create an access point for legal services; (3) improve access to legal advice and brief intervention; (4) support ongoing relationships between patients and lawyers that allow for the timely identification of subsequent legal needs; (5) foster trust and confidence in the legal system; and (6) address affordability concerns. These findings suggest that by improving access to justice, MLPs can address critical social and legal determinants of health and, ultimately, advance health equity.

Eviction From Renter-occupied Households and Rates of Sexually Transmitted Infections: A County-level Ecological Analysis.

BACKGROUND: Housing instability is linked to numerous health outcomes, but the specific impact of eviction from renter-occupied households, an event that has immediate implications for residential stability for low-income individuals, on sexually transmitted infections (STI) rates has not been adequately studied. METHODS: We examined county-level associations between eviction rates in 2014 and rates of chlamydia and gonorrhea in the following year using publicly available data sources (Eviction Lab National Database and AtlasPlus, respectively). Descriptive statistics compared medians and nonparametric distributions with Krusal-Wallis tests. Linear regression was used to compare tertile categories of eviction rates and STI rates while controlling for potential confounders. RESULTS: Median rates of chlamydia in counties with low, medium, and high rates of eviction were 229, 270, and 358 cases per 100,000 population, respectively (P < 0.001). The corresponding median rates of gonorrhea were 25, 37, and 75 cases per 100,000 population (P < 0.001). These associations remained statistically significant after controlling for all covariates in adjusted models. The beta coefficients and 95% confidence intervals (95% CI) for chlamydia and gonorrhea comparing high to low county-level eviction rates were 63.8 (95% CI, 45.1-82.5) and 20.4 (95% CI, 13.5-27.4), respectively. Similar associations were observed across levels of poverty and in both metropolitan and nonmetropolitan counties. CONCLUSIONS: County-level eviction rates are associated with chlamydia and gonorrhea rates in a significant and robust way independent of other known predictors of STI. These results suggest that evictions result in residential instability in a way that may increase STI risk.

Drug Treatment Accessed through the Criminal Justice System: Participants' Perspectives and Uses.

The criminal justice system has become a major pathway to drug treatment across the USA. Millions of criminal justice dollars are spent on an array of treatment programs for justice-involved populations, from pre-sentence diversionary programs to outpatient services for those on community supervision. This study uses 235 qualitative, longitudinal interviews with 45 people convicted of drug offenses to describe participants' perspectives on criminal justice-related drug treatment (programs within correctional facilities; court, probation, or parole-ordered mandates and referrals; and self-referrals made with the goal of reducing criminal justice involvement), beyond discourses about help with addiction. Interviews took place in New Haven, CT, between 2011 and 2014 every 6 months, for a maximum of five interviews with each participant. Many participants who were referred to drug treatment did not consider these programs appropriate for their needs, as many did not perceive themselves to have a drug problem, or did not consider substance use to be their primary problem. Frustrations regarding the ill-fitting nature of mandated programs were coupled with theories about non-health-related policy goals of criminal justice-mandated drug treatment, such as prison overflow management and increased profit for the state. Nonetheless, participants used drug treatment to advance their own goals of coping with life's challenges, reducing their criminal justice system involvement, proving worthiness through rehabilitation, and accessing other resources. These participants' perspectives offer a wide lens through which to view the system of criminal justice-related drug treatment, a view that can guide us in critically evaluating provision of drug treatment and developing more effective systems of appropriate rehabilitative services for people who are justice involved.

The Effects of Length of Residence and Exposure to Violence on Perceptions of Neighborhood Safety in an Urban Sample.

Perceptions of neighborhood safety shape the well-being of individuals and communities, affecting neighborhood walkability, associated physical activity behaviors, and health conditions. However, less is known about the factors that determine perceptions of safety. One factor that may affect perceptions of neighborhood safety is the length of time someone has lived in their neighborhood. We use a representative, adult sample of urban low-income residents from the 2015 New Haven Health Survey (n = 1189) to investigate the associations between length of residence (new residents of < 1 year in neighborhood versus longer-term residents of 1 or more years in neighborhood) and perceptions of neighborhood safety (whether feeling unsafe to walk at night). We then examine the potential moderating effect of exposure to neighborhood violence on these associations. We find that the association between length of residence and perceived safety differs by exposure to neighborhood violence. Among those unexposed to neighborhood violence, longer-term neighborhood residents were more likely to feel unsafe compared to new residents (OR = 2.03, 95% CI 1.19, 3.45). Additionally, the effect of exposure to violence on feelings of safety was larger for new residents (OR = 9.10, 95% CI 2.72, 30.44) compared to longer-term residents (OR = 1.88, 95% CI 1.28, 2.77). Our findings suggest that length of residence may have implications for feelings of safety, and that experiences of violence may uniquely contribute to feelings of unsafety among new residents. These findings hold implications for interventions and policy efforts aimed at neighborhood safety improvements through community development, housing, or city urban planning initiatives, particularly for new neighborhood residents or those who experience neighborhood violence.

Navigating Limited and Uncertain Access to Subsidized Housing After Prison.

An emerging literature has documented the challenges that formerly incarcerated individuals face in securing stable housing. Given the increasingly unaffordable rental market, rental subsidies represent an important and understudied source of stable housing for this population. The existing literature has described substantial discretion and a varied policy landscape that determine former prisoners' access to housing subsidies, or subsidized housing spaces that are leased to members of their social and family networks. Less is known about how former prisoners themselves interpret and navigate this limited and uncertain access to subsidized housing. Drawing on data from repeated qualitative interviews with 44 former prisoners, we describe the creative and often labor-intensive strategies that participants employed to navigate discretion and better position themselves for subsidized housing that was in high demand, but also largely out of reach. Our findings also illustrate the potential costs associated with these strategies for both participants and members of their social and family networks.

'The big ole gay express': sexual minority stigma, mobility and health in the small city.

Recent research has examined how gay and bisexual men experience and navigate the variations in sexual minority stigma that exist across geographic contexts, with implications for their health. We extend this literature on stigma, mobility, and health by considering the unique and understudied setting of the small city. Drawing on semi-structured interviews (n = 29) conducted in two small US cities (New Haven and Hartford), we find that these small cities serve as both destinations and points of departure for gay and bisexual men in the context of stigma. New Haven and Hartford attracted gay and bisexual men from surrounding suburbs where sexual minority stigma was more prevalent and where there were fewer spaces and opportunities for gay life. Conversely, participants noted that these small cities did not contain the same identity affirming communities as urban gay enclaves, thus motivating movement from small cities to larger ones. Our data suggest these forms of mobility may mitigate stigma, but may also produce sexual health risks, thus drawing attention to small cities as uniquely important sites for HIV prevention. Furthermore, our analysis contributes to an understanding of how place, stigma and mobility can intersect to generate spatially distinct experiences of stigmatised identities and related health consequences.

A qualitative analysis of multi-level barriers to HIV testing among women in Lebanon.

While the number of HIV cases in the Middle East and North Africa region is low compared to other regions, recent studies show that incidence is increasing especially among high-risk populations; in particular, little is known about women and HIV in the region. Through semi-structured interviews with sexual healthcare providers and staff at non-governmental organisations, we sought to understand barriers to HIV testing among women in Lebanon. Using snowball sampling, key informants were recruited from greater Beirut (12 physicians, 9 non-governmental organisation staff). Data were analysed using a grounded theory framework. Findings identified barriers to HIV testing among women at each level of an adapted social-ecological model (i.e. social-cultural barriers, policy barriers, interpersonal healthcare provider barriers and intrapersonal barriers). Primary findings include the culture of sex as taboo; lack of sexual health education among women; fear of disclosing HIV testing and diagnosis; financial barriers linked to stigmatising insurance policies; and provider attitudes towards women. Findings can be used to inform HIV-related sexual health interventions at multiple levels for women in Lebanon and the greater region.