Integrating Social Determinants of Health With Treatment and Prevention: A New Tool to Assess Local Area Deprivation.

We assessed the appropriate geographic scale to apply an area deprivation index (ADI), which reflects a geographic area's level of socioeconomic deprivation and is associated with health outcomes, to identify and screen patients for social determinants of health. We estimated the relative strength of the association between the ADI at various geographic levels and a range of hospitalization rates by using age-adjusted odds ratios in an 8-county region of New York State. The 10-km local ADI estimates had the strongest associations with all hospitalization rates (higher odds ratios) followed by estimates at 20 km, 30 km, and the regional scale. A locally sensitive ADI is an ideal measure to identify and screen for the health care and social services needs and to advance the integration of social determinants of health with clinical treatment and disease prevention.

Multicellular bacteria deploy the type VI secretion system to preemptively strike neighboring cells.

The Type VI Secretion System (T6SS) functions in bacteria as a contractile nanomachine that punctures and delivers lethal effectors to a target cell. Virtually nothing is known about the lifestyle or physiology that dictates when bacteria normally produce their T6SS, which prevents a clear understanding of how bacteria benefit from its action in their natural habitat. Proteus mirabilis undergoes a characteristic developmental process to coordinate a multicellular swarming behavior and will discriminate itself from another Proteus isolate during swarming, resulting in a visible boundary termed a Dienes line. Using transposon mutagenesis, we discovered that this recognition phenomenon requires the lethal action of the T6SS. All mutants identified in the genetic screen had insertions within a single 33.5-kb region that encodes a T6SS and cognate Hcp-VrgG-linked effectors. The identified T6SS and primary effector operons were characterized by killing assays, by construction of additional mutants, by complementation, and by examining the activity of the type VI secretion system in real-time using live-cell microscopy on opposing swarms. We show that lethal T6SS-dependent activity occurs when a dominant strain infiltrates deeply beyond the boundary of the two swarms. Using this multicellular model, we found that social recognition in bacteria, underlying killing, and immunity to killing all require cell-cell contact, can be assigned to specific genes, and are dependent on the T6SS. The ability to survive a lethal T6SS attack equates to "recognition". In contrast to the current model of T6SS being an offensive or defensive weapon our findings support a preemptive mechanism by which an entire population indiscriminately uses the T6SS for contact-dependent delivery of effectors during its cooperative mode of growth.

Neighborhood walkability and active travel (walking and cycling) in New York City.

Urban planners have suggested that built environment characteristics can support active travel (walking and cycling) and reduce sedentary behavior. This study assessed whether engagement in active travel is associated with neighborhood walkability measured for zip codes in New York City. Data were analyzed on engagement in active travel and the frequency of walking or biking ten blocks or more in the past month, from 8,064 respondents to the New York City 2003 Community Health Survey (CHS). A neighborhood walkability scale that measures: residential, intersection, and subway stop density; land use mix; and the ratio of retail building floor area to retail land area was calculated for each zip code. Data were analyzed using zero-inflated negative binomial regression incorporating survey sample weights and adjusting for respondents' sociodemographic characteristics. Overall, 44 % of respondents reported no episodes of active travel and among those who reported any episode, the mean number was 43.2 episodes per month. Comparing the 75th to the 25th percentile of zip code walkability, the odds ratio for reporting zero episodes of active travel was 0.71 (95 % CI 0.61, 0.83) and the exponentiated beta coefficient for the count of episodes of active travel was 1.13 (95 % CI 1.06, 1.21). Associations between lower walkability and reporting zero episodes of active travel were significantly stronger for non-Hispanic Whites as compared to non-Hispanic Blacks and to Hispanics and for those living in higher income zip codes. The results suggest that neighborhood walkability is associated with higher engagement in active travel.

Socio-economic status, neighbourhood food environments and consumption of fruits and vegetables in New York City.

OBJECTIVE: Recommendations for fruit and vegetable consumption are largely unmet. Lower socio-economic status (SES), neighbourhood poverty and poor access to retail outlets selling healthy foods are thought to predict lower consumption. The objective of the present study was to assess the interrelationships between these risk factors as predictors of fruit and vegetable consumption. DESIGN: Cross-sectional multilevel analyses of data on fruit and vegetable consumption, socio-demographic characteristics, neighbourhood poverty and access to healthy retail food outlets. SETTING: Survey data from the 2002 and 2004 New York City Community Health Survey, linked by residential zip code to neighbourhood data. SUBJECTS: Adult survey respondents (n 15 634). RESULTS: Overall 9?9% of respondents reported eating $5 servings of fruits or vegetables in the day prior to the survey. The odds of eating $5 servings increased with higher income among women and with higher educational attainment among men and women. Compared with women having less than a high-school education, the OR was 1?12 (95% CI 0?82, 1?55) for high-school graduates, 1?95 (95% CI 1?43, 2?66) for those with some college education and 2?13 (95% CI 1?56, 2?91) for college graduates. The association between education and fruit and vegetable consumption was significantly stronger for women living in lower- v. higher-poverty zip codes (P for interaction,0?05). The density of healthy food outlets did not predict consumption of fruits or vegetables. CONCLUSIONS: Higher SES is associated with higher consumption of produce, an association that, in women, is stronger for those residing in lower-poverty neighbourhoods.

Costs of care for people living with combined HIV/AIDS, chronic mental illness, and substance abuse disorders.

To determine healthcare access and costs for triply diagnosed adults, we examined baseline data from the HIV/AIDS Treatment Adherence, Health Outcomes and Cost Study, a multi-site cohort study of HIV+ adults with co-occurring mental and substance abuse disorders conducted between 2000 and 2004. Baseline interviews were conducted with 1138 triply diagnosed adults in eight predominantly urban sites nationwide. A modified version of Structured Interview for DSM-IV Axis I Disorders (SCID) was used to assign Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) diagnoses for the preceding year. Utilization of a broad range of inpatient and outpatient services and medications over the preceding three months was patient-reported in face-to-face interviews. We then applied nationally representative unit costs to impute average monthly expenditures. We measured (poor) access to care during the three-month period by whether the patient had: (a) no outpatient medical visits; (b) at least one emergency room visit without an associated hospitalization; and (c) at least one hospitalization. At baseline, mean expenditures were $3880 per patient per month. This is nearly twice as high as expenditures for HIV/AIDS patients in general. Inpatient care (36%), medications (33%), and outpatient services (31%) each accounted for roughly one-third of expenditures. Expenditures varied by a factor of 2:1 among subgroups of patients, with those on Medicare or Medicaid, not in stable residences, or with poor physical health or high viral loads exhibiting the highest costs. Access to care was worse for women and those with low incomes, unstable residences, same-sex exposure, poor physical or mental health, and high viral loads. We conclude that HIV triply diagnosed adults account for roughly one-fifth of medical spending on HIV patients and that there are large variations in utilization/costs across patient subgroups. Realized access is good for many triply diagnosed patients, but remains suboptimal overall. Deficiencies in HIV care are unevenly distributed, tending to concentrate on already disadvantaged populations.

Bringing health and social policy together: the case of the earned income tax credit.

The principal objective of our research is to examine whether the earned income tax credit (EITC), a broad-based income support program that has been shown to increase employment and income among poor working families, also improves their health and access to care. A finding that the EITC has a positive impact on the health of the American public may help guide deliberations about its future at the federal, state, and local levels. The authors contend that a better understanding of the relationship between major socioeconomic policies such as the EITC and the public's health will inform the fields of health and social policy in the pursuit of improving population health.

The complexities of measuring access to parks and physical activity sites in New York City: a quantitative and qualitative approach.

BACKGROUND: Proximity to parks and physical activity sites has been linked to an increase in active behaviors, and positive impacts on health outcomes such as lower rates of cardiovascular disease, diabetes, and obesity. Since populations with a low socio-economic status as well as racial and ethnic minorities tend to experience worse health outcomes in the USA, access to parks and physical activity sites may be an environmental justice issue. Geographic Information systems were used to conduct quantitative and qualitative analyses of park accessibility in New York City, which included kernel density estimation, ordinary least squares (global) regression, geographically weighted (local) regression, and longitudinal case studies, consisting of field work and archival research. Accessibility was measured by both density of park acreage and density of physical activity sites. Independent variables included percent non-Hispanic black, percent Hispanic, percent below poverty, percent of adults without high school diploma, percent with limited English-speaking ability, and population density. RESULTS: The ordinary least squares linear regression found weak relationships in both the park acreage density and the physical activity site density models (R(a)(2) = .11 and .23, respectively; AIC = 7162 and 3529, respectively). Geographically weighted regression, however, suggested spatial non-stationary in both models, indicating disparities in accessibility that vary over space with respect to magnitude and directionality of the relationships (AIC = 2014 and -1241, respectively). The qualitative analysis supported the findings of the local regression, confirming that although there is a geographically inequitable distribution of park space and physical activity sites, it is not globally predicted by race, ethnicity, or socio-economic status. CONCLUSION: The combination of quantitative and qualitative analyses demonstrated the complexity of the issues around racial and ethnic disparities in park access. They revealed trends that may not have been otherwise detectable, such as the spatially inconsistent relationship between physical activity site density and socio-demographics. In order to establish a more stable global model, a number of additional factors, variables, and methods might be used to quantify park accessibility, such as network analysis of proximity, perception of accessibility and usability, and additional park quality characteristics. Accurate measurement of park accessibility can therefore be important in showing the links between opportunities for active behavior and beneficial health outcomes.

Cost-effectiveness analysis of integrated care for people with HIV, chronic mental illness and substance abuse disorders.

BACKGROUND: Triply diagnosed patients, who live with HIV and diagnosed mental health and substance abuse disorders, account for at least 13% of all HIV patients. This vulnerable population has substantial gaps in their care, attributable in part to the need for treatment for three illnesses from three types of providers. AIMS OF THE STUDY: The HIV/AIDS Treatment Adherence, Health Outcomes and Cost study (HIV Cost Study) sought to evaluate the cost-effectiveness of integrated HIV primary care, mental health, and substance abuse services among triply diagnosed patients. The analysis was conducted from a health sector budget perspective. METHODS: Patients from four sites were randomly assigned to intervention group (n=232) or control group (n=199) that received care-as-usual. Health service costs were measured at baseline and three, six, nine and 12 months and included hospital stays, emergency room visits, outpatient visits, residential treatment, formal long-term care, case management, and both prescribed and over-the-counter medications. Costs for each service were the product of self-reported data on utilization and unit costs based on national data (2002 dollars). Quality of life was measured at baseline and six and 12 months using the SF-6D, as well as the SF-36 physical composite score (PCS) and mental composite score (MCS). RESULTS: During the 12 months of the trial, total average monthly cost of health services for the intervention group decreased from USD 3235 to USD 3052 and for the control group decreased from USD 3556 to USD 3271, but the decreases were not significant. For both groups, the percentage attributable to hospital care decreased significantly. There were no significant differences in annual cost of health services, SF-6D, PCS or MCS between the intervention and control group. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: The results of this randomized controlled trial did not demonstrate that the integrated interventions significantly affected the health service costs or quality of life of triply diagnosed patients. Professionals could pursue coordination or integration of care guided by the evidence that it does not increase the cost of care. The results do not however, provide an imperative to introduce multi-disciplinary care teams, adherence counseling, or personalized nursing services as implemented in this study. IMPLICATIONS FOR HEALTH POLICIES: There is not enough evidence to either limit continued exploration of integration of care for triply diagnosed patients or adopt policies to encourage it, such as financial reimbursement, grants regulation or licensing. IMPLICATIONS FOR FURTHER RESEARCH: Future trials with interventions with lower baseline levels of integration, longer duration and larger sample sizes may show improvement or slow the decline in quality of life. Future researchers should collect comprehensive cost data, because significant decreases in the cost of hospital care did not necessarily lead to significant decreases in the total cost of health services.

Triply-diagnosed patients in the HIV/AIDS Treatment Adherence, Health Outcomes and Cost Study: patterns of home care use.

Although AIDS is a chronic illness, little is known about the patterns and correlates of long-term care use among triply diagnosed HIV patients. We examined nursing and home care use among 1,045 participants in the HIV/AIDS Treatment Adherence, Health Outcomes and Cost Study, a multi-site study of HIV-positive patients with at least one mental health and one substance disorder. Patient interviews and medical record review data were used to examine the average monthly cost of nursing home, formal home and informal home care. Multinomial logit and two-part regression models were used to identify correlates of the use of formal and informal home care and the number of informal home care hours used. During the three months prior to baseline, 2, 7 and 23% of participants used nursing home, formal home and informal home care, respectively. Patients who were better-educated, had higher incomes, had Medicaid insurance (with or without Medicare coverage) and whose transmission mode was homosexual sex had higher regression-adjusted probabilities of receiving any formal home care; Latinos and physically healthier patients had lower probabilities. Women and patients who abused drugs or alcohol (but not both) were more likely to receive informal care only. Overall, patients who were female, better-educated, physically or mentally sicker or single-substance abusers were more likely to receive any home care (either formal or informal), while those contracting HIV through heterosexual sex were less likely. Women received 28 more monthly hours of informal care than men and married patients received 31 more hours than unmarried patients. We conclude that at least one mutable policy factor (Medicaid insurance) is strongly associated with formal home care use among triply diagnosed patients. Further research is needed to explore possible implications for access among this vulnerable subpopulation.

Improving population health by reducing poverty: New York's Earned Income Tax Credit.

Despite the established relationship between adverse health outcomes and low socioeconomic status, researchers rarely test the link between health improvements and poverty-alleviating economic policies. New research, however, links individual-level health improvements to the Earned Income Tax Credit (EITC), a broad-based income support policy. We build on these findings by examining whether the EITC has ecological, neighborhood-level health effects. We use a difference-in-difference analysis to measure child health outcomes in 90 low- and middle- income neighborhoods before and after the expansion of New York State and New York City's EITC policy between 1997-2010. Our study takes advantage of the relatively exogenous source of income variation supplied by the EITC-legislative changes to EITC policy parameters. This feature minimizes the endogeneity problem in studying the relationship between income and health. Our estimates link a 15-percentage-point increase in EITC benefit rates to a 0.45 percentage-point reduction in the low birthweight rate. We do not observe any measurable link between EITC benefits and prenatal health or asthma-related pediatric hospitalization. The magnitude of the EITC's impact on low birthweight rates suggests ecological effects, and an additional channel through which anti-poverty measures can serve as public health interventions.

Income and employment of people living with combined HIV/AIDS, chronic mental illness, and substance abuse disorders.

BACKGROUND: This paper examines the labor market outcomes of HIV triply-diagnosed adults having a combination of HIV, mental illness and substance abuse problems. AIMS OF THE STUDY: We sought to determine the sources of money income for HIV triply diagnosed adults (public or private), receipt of transfer income (e.g., welfare) and financial support from others. We further sought to ascertain their employment status and analyze the characteristics associated with full- and part-time employment. METHODS: We use self-reported money income during the past 30 days and self-reported employment status. We calculate earnings losses due to illness by subtracting self-reported earnings from average earnings for all U.S. workers based on 5-year age and gender categories. We provide descriptive statistics to show how income and employment vary by patient characteristics and logistic regression analysis to examine correlates of income and employment. RESULTS: Average income is below the poverty level for single individuals, with more than two-thirds coming from public income sources. The likelihood of receiving disability/retirement income was lower among those with the worst mental health (RR=0.80; 95% CI=0.64, 0.97). Blacks were more likely than others to rely on public assistance (RR=1.24; 95% CI=1.02, 1.55) and married individuals were less likely (RR=0.60; 95% CI=0.41, 0.79). While most private income comes from employment, less than 15 percent of this population is employed full- or part-time. On a monthly basis, the average individual in our sample lost $2,726 in income when compared to the earnings of individuals of the same age and sex in the general population. The relative probability of current full-time/part-time employment was lower among females (RR=0.56; 95% CI=0.34, 0.83); such employment also was lower among those in the worst physical health (RR=0.39; 95% CI=0.26, 0.65) and those in moderate physical health (RR=0.55; 95% CI=0.34, 0.81) relative to those in the best physical health. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: This population represents an important opportunity for better health and labor market outcomes through prevention and improved treatment adherence. IMPLICATIONS FOR HEALTH POLICIES: Despite its relatively small size (at least 100,000), this population merits closer attention due to a combination of their high medical and companion social costs (e.g., income transfers) and the large potential for improving their ability to earn income. IMPLICATIONS FOR FURTHER RESEARCH: Future research should determine the marginal contribution of mental health conditions or substance abuse on income or labor market outcomes relative to individuals having only HIV/AIDS. This would allow policymakers to better understand how much of income and employment can be attributed to HIV/AIDS, mental health or substance abuse. Future work also should examine the impact of integrated treatment services on income and employment for this population.

Breast-feeding promotion interventions: good public health and economic sense.

The health benefits of breast-feeding are well documented, as are the positive effects of breast-feeding promotion interventions. There is a clear dose-response relationship between breast-feeding and infant health in the first year of life, and beyond. Further, nearly all breast-feeding promotion interventions improve--at least minimally--breast-feeding initiation and duration rates. However, the extent to which the costs of such interventions might be offset by the potential health care cost savings during the infant's first year of life has not been examined. From a health policy perspective, such an economic analysis is indicated.

Psychiatric and social barriers to HIV medication adherence in a triply diagnosed methadone population.

Although antiretrovirals can prolong life, medication adherence also poses a constant challenge for HIV-infected individuals because the success of antiretroviral regimens demands nearly perfect adherence to medications. This paper describes the psychiatric and social barriers to adherence in a convenience sample of HIV-positive clients in methadone treatment in the Bronx, New York. The study sample was part of a national study of HIV treatment adherence and health care utilization among triply diagnosed populations, the HIV/AIDS Treatment Adherence Health Outcomes and Cost Study. The triply diagnosed study sample is defined here as HIV-infected individuals who screened into the study with at least one psychiatric diagnosis in addition to opioid dependence on agonist therapy (methadone treatment) and at least one substance use diagnosis. Interviewers utilized modified versions of the Structured Clinical Interview for DSM-IV Disorders (SCID-I), the Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II), and the Addiction Severity Index (ASI-Lite), among a battery of Cost Study instruments. Results showed that within this sample, borderline personality disorder was significantly associated with nonadherence to HIV medications. A related finding showed a significant relationship between serious social/family problems and nonadherence. These findings build on previous research on the impact of psychiatric illness on HIV medication adherence and suggest that psychiatric assessment and treatment options be linked to adherence interventions.

Overweight and obesity: can we reconcile evidence about supermarkets and fast food retailers for public health policy?

The aim of this study is to determine whether access to fast food outlets and supermarkets is associated with overweight and obesity in New York City neighborhoods. We use a Bayesian ecologic approach for spatial prediction. Consistent with prior research, we find no association between fast food density and overweight or obesity. Consistent with prior research, we find that supermarket access has a salutary impact on overweight and obesity. Given the lack of empirical evidence linking fast food retailers with adverse health outcomes, policymakers should be encouraged to adopt policies that incentivize the establishment of supermarkets and the modification of existing food store markets and retailers to offer healthier choices. Reaching within neighborhoods and modifying the physical environment and public health prevention and intervention efforts based on the characteristics of those neighborhoods may play a key role in creating healthier communities.

Neighbourhood food environments and body mass index among New York City adults.

BACKGROUND: Studies evaluating the impact of the neighbourhood food environment on obesity have summarised the density or proximity of individual food outlets. Though informative, there is a need to consider the role of the entire food environment; however, few measures of whole system attributes have been developed. New variables measuring the food environment were derived and used to study the association with body mass index (BMI). METHODS: Individual data on BMI and sociodemographic characteristics were collected from 48 482 respondents of the 2002-2006 community health survey in New York City and linked to residential zip code-level characteristics. The food environment of each zip code was described in terms of the diversity of outlets (number of types of outlets present in a zip code), the density of outlets (outlets/km(2)) and the proportion of outlets classified as BMI-unhealthy (eg, fast food, bodegas). RESULTS: Results of the cross-sectional, multilevel analyses revealed an inverse association between BMI and food outlet density (-0.32 BMI units across the IQR, 95% CI -0.45 to -0.20), a positive association between BMI and the proportion of BMI-unhealthy food outlets (0.26 BMI units per IQR, 95% CI 0.09 to 0.43) and no association with outlet diversity. The association between BMI and the proportion of BMI-unhealthy food outlets was stronger in lower (

Social security and mortality: the role of income support policies and population health in the United States.

Social Security is the most important and effective income support program ever introduced in the United States, alleviating the burden of poverty for millions of elderly Americans. We explored the possible role of Social Security in reducing mortality among the elderly. In support of this hypothesis, we found that declines in mortality among the elderly exceeded those among younger age groups following the initial implementation of Social Security in 1940, and also in the periods following marked improvements in Social Security benefits via legislation and indexing of benefits that occurred between the mid-1960s and the early 1970s. A better understanding of the link between Social Security and health status among the elderly would add a significant and missing dimension to the public discourse over the future of Social Security, and the potential role of income support programs in reducing health-related socioeconomic disparities and improving population health.

Insurance coverage among people living with combined HIV/AIDS, chronic mental illness, and substance abuse disorders.

HIV triply-diagnosed adults (those with chronic mental illness and substance abuse disorders) must rely heavily on public insurance to cover high annual medical costs (approximately $50,000). This study examines the nature and determinants of insurance coverage (including managed care) for this population, along with annual transitions in coverage. Relative to people living with HIV/AIDS in general, fewer triply-diagnosed adults rely on private coverage (3% vs. 30%), but their rate of being uninsured is only slightly lower (16% vs. 20%). More than one third of such adults below poverty are uninsured-a matter of significant policy concern since the annual income of this group is less than 10% of the amount needed to cover their expected medical expenses. Those with the lowest mental health status were disproportionately represented in managed care. While coverage appears relatively stable over time, those with low incomes and moderate mental health status may face barriers in securing Medicaid.

Not Just a Walk in the Park: Methodological Improvements for Determining Environmental Justice Implications of Park Access in New York City for the Promotion of Physical Activity.

The purpose of this study is to test the hypothesis that access to parks in New York City is not equitable across racial and ethnic categories. It builds on previous research that has linked access to parks and open space with increased physical activity, which in turn may reduce the risk for adverse health outcomes related to obesity. Systematic patterns of uneven access to parks might help to explain disparities in these health outcomes across sociodemographic populations that are not fully explained by individual-level risk factors and health behaviors, and therefore access to parks becomes an environmental justice issue. This study is designed to shed light on the "unpatterned inequities" of park distributions identified in previous studies of New York City park access. It uses a combination of network analysis and a cadastral-based expert dasymetric system (CEDS) to estimate the racial/ethnic composition of populations within a reasonable walking distance of 400m from parks. The distance to the closest park, number of parks within walking distance, amount of accessible park space, and number of physical activity sites are then evaluated across racial/ethnic categories, and are compared to the citywide populations using odds ratios. The odds ratios revealed patterns that at first glance appear to contradict the notion of distributional inequities. However, discussion of the results points to the need for reassessing what is meant by "access" to more thoroughly consider the aspects of parks that are most likely to contribute to physical activity and positive health outcomes.