Lessons from Two Latino Communities Working with Academic Partners to Increase Access to COVID-19 Testing.

OBJECTIVE: We sought to examine the experiences of community partners in a community-academic partnership to promote COVID-19 testing in two majority Latino communities. METHODS: We conducted semistructured, in-depth interviews in English and Spanish with community-based organization leaders and community health workers/promotoras (n = 10) from June to July 2021. Interviews focused on identifying partner roles in planning and testing implementation and evaluating communication among partners. Interviews were transcribed and analyzed in ATLAS.ti version 8.4.5. Analyses involved deductive and inductive approaches to identify key themes. RESULTS: Participants described both strengths and challenges to the collaborative approach within each of three core themes: building relationships in the time of COVID-19; uplifting existing community leadership; and commitment of the academic partners and community-based organizations to conduct partnership activities in Spanish. CONCLUSION: Community-academic partnerships that invest in strong relationships, community leadership, and a commitment to the community's preferred language offer a promising approach to addressing COVID-19 testing barriers. Findings provide direction for future research on how community members and academic partners can come together to inform strategies to continue addressing the COVID-19 pandemic.

Health care utilization among women of reproductive age living in public housing: Associations across six public housing sites in San Francisco.

Housing is a key social determinant of health and health care utilization. Although stigmatized due to poor quality, public housing may provide stability and affordability needed for individuals to engage in health care utilization behaviors. For low-income women of reproductive age (15-44 y), this has implications for long-term reproductive health trajectories. In a sample of 5,075 women, we used electronic health records (EHR) data from 2006 to 2011 to assess outpatient and emergency department (ED) visits across six public housing sites in San Francisco, CA. Non-publicly housed counterparts were selected from census tracts surrounding public housing sites. Multivariable regression models adjusted for age and insurance status estimated incidence rate ratios (IRR) for outpatient visits (count) and odds ratios (OR) for ED visit (any/none). We obtained race/ethnicity-specific associations overall and by public housing site. Analyses were completed in December 2020. Public housing was consistently associated with health care utilization among the combined Asian, Alaskan Native/Native American, Native Hawaiian/Pacific Islander, and Other (AANHPI/Other) group. Public housing residents had fewer outpatient visits (IRR: 0.86; 95% Confidence Interval [CI]: 0.81, 0.93) and higher odds of an ED visit (OR: 1.81; 95% CI: 1.32, 2.48). Black women had higher odds of an ED visits (OR: 1.32; 95% CI: 1.07, 1.63), but this was driven by one public housing site (site-specific OR: 2.34; 95% CI: 1.12, 4.88). Variations by race/ethnicity and public housing site are integral to understanding patterns of health care utilization among women of reproductive age to potentially improve women's long-term health trajectories.

Lifecourse Educational Trajectories and Hypertension in Midlife: An Application of Sequence Analysis.

BACKGROUND: Higher educational attainment predicts lower hypertension. Yet, associations between nontraditional educational trajectories (eg, interrupted degree programs) and hypertension are less well understood, particularly among structurally marginalized groups who are more likely to experience these non-traditional trajectories. METHODS: In National Longitudinal Survey of Youth 1979 cohort data (N = 6 317), we used sequence and cluster analyses to identify groups of similar educational sequences-characterized by timing and type of terminal credential-that participants followed from age 14-48 years. Using logistic regression, we estimated associations between the resulting 10 educational sequences and hypertension at age 50. We evaluated effect modification by individual-level indicators of structural marginalization (race, gender, race and gender, and childhood socioeconomic status [cSES]). RESULTS: Compared to terminal high school (HS) diploma completed at traditional age, terminal GED (OR: 1.32; 95%CI: 1.04, 1.66) or Associate degree after

Risk factors for hyperthermia mortality among emergency department patients.

PURPOSE: This study examines risk factors for heat-related mortality due to hyperthermia in emergency department patients, a vulnerable population. METHODS: This matched case-control study used statewide, longitudinally linked emergency department (ED) data and death records from California. Cases comprised California residents (≥18 years) who presented to a state-licensed ED and died of hyperthermia during the study period (2009-2012). For each case, up to five ED patients were randomly selected as live controls and matched on sex and age. Patients' demographic characteristics and history of ED utilization for alcohol use, drug use, psychiatric disorders, heart-related conditions, chronic respiratory disease, neurodegenerative disorders, and cerebrovascular disease were assessed in relationship to hyperthermia mortality. RESULTS: Using multivariate conditional logistic regression models, hyperthermia mortality cases had higher odds of prior ED utilization for alcohol use (OR = 11.16, 95% CI = 3.87, 32.17) compared to controls. Cases were also more likely than controls to have Medicare insurance (OR = 5.80, 95% CI = 1.70, 15.15) or self-pay (OR = 5.39, 95% CI = 1.73, 16.79), at their most recent ED visit. CONCLUSIONS: ED patients presenting with alcohol problems may face increased risk of hyperthermia mortality. To help reduce heat-related mortality, EDs should consider interventions that target patients vulnerable to heat exposure.

Understanding the benefits of different types and timing of education for mental health: A sequence analysis approach.

OBJECTIVES: Individuals increasingly experience delays or interruptions in schooling; we evaluate the association between these non-traditional education trajectories and mental health. METHODS: Using year-by-year education data for 7,501 National Longitudinal Survey of Youth 1979 participants, ages 14-48 (262,535 person-years of education data), we applied sequence analysis and a clustering algorithm to identify educational trajectory groups, incorporating both type and timing to credential. Linear regression models, adjusted for early-life confounders, evaluated relationships between educational trajectories and mental health component scores (MCS) from the 12-item short form instrument at age 50. We evaluated effect modification by race, gender, and race by gender. RESULTS: We identified 24 distinct educational trajectories based on highest credential and educational timing. Compared to high school (HS) diplomas, < HS (beta=-3.41, 95%CI:-4.74,-2.07) and general educational development credentials (GEDs) predicted poorer MCS (beta=-2.07,95%CI:-3.16,-0.98). The following educational trajectories predicted better MCS: some college immediately after High School (beta=1.52, 95%CI:0.68,2.37), Associate degrees after long interruptions (beta=1.73, 95%CI:0.27,3.19), and graduate school soon after Bachelor's completion (beta=1.13, 95%CI:0.21,2.06). Compared to White men, Black women especially benefited from educational credentials higher than HS in predicting MCS. CONCLUSIONS: Both type and timing of educational credential predicted mental health. Black women's mental higher especially benefited from higher educational credentials.

Perceptions of SNAP and Stocking Standards: A Qualitative Study of California Small Food Store Owners and Managers.

The Supplemental Nutrition Assistance Program (SNAP) is critical to alleviating food insecurity, but low diet quality among program participants is a concern. Nutrition-related interventions have focused on SNAP-authorized food retailers, but the perspectives of small food store owners and managers have not been represented in national policy discussions. This study aimed to explore the opinions of store owners/managers of SNAP-authorized small food stores about their overall perceptions of the program and the stricter stocking standards previously proposed in 2016. We conducted in-depth, semi-structured interviews with 33 small food store owners and managers in San Francisco and Oakland, California in 2016. Interviews were analyzed for thematic content using the general inductive approach. Four themes emerged from owners/managers' discussion of their overall perceptions of SNAP: the beneficial impact of SNAP on their business, how SNAP enables them to connect with the broader community, the importance of SNAP in preventing hunger, and the nutrition-related struggles that SNAP participants face. Store owners/managers had a generally favorable response towards the proposed stricter stocking standards. Additional themes discussed pertained to the concern about whether stocking changes would lead SNAP participants to purchase more healthful food and some logistical challenges related to sourcing and storing perishable foods.

Association of Adult Depression With Educational Attainment, Aspirations, and Expectations.

INTRODUCTION: Social factors across one's lifespan may contribute to the relationship between low educational attainment and depression, but this relationship has been understudied. Previous studies assessing the association between educational attainment and depression did not fully account for prior common determinants across the life course and possible interactions by sex or race/ethnicity. It is also unclear whether the link between educational attainment and depression is independent of the role of aspired educational attainment or expected educational attainment. METHODS: We used generalized linear log link models to examine the association between educational attainment at age 25 and depression at age 40 in the National Longitudinal Survey of Youth 1979 cohort, adjusting for confounders and mediators from childhood, adolescence, and adulthood. RESULTS: Members of each educational attainment group were less likely to be depressed at age 40 than those with less education. After adjusting for educational aspirations and educational expectations, the risk ratios became closer to the null. Neither sex nor race/ethnicity interacted with educational attainment. Additionally, low educational expectations in adolescence, but not low educational aspirations, was associated with a higher risk of depression at age 40. CONCLUSION: Our study provides a nuanced understanding of the role of education, educational expectations, and educational aspirations as part of education's effect on risk of depression after controlling for a thorough set of confounders and mediators. Our findings may help advance the study of social determinants of depression.

Does the Type and Timing of Educational Attainment Influence Physical Health? A Novel Application of Sequence Analysis.

Nontraditional education trajectories are common, but their influence on physical health is understudied. We constructed year-by-year education trajectories for 7,501 National Longitudinal Survey of Youth 1979 participants aged 14 to 48 years (262,535 person-years of education data from 1979 to 2014). We characterized trajectory similarity using sequence analysis and used hierarchical clustering to group similar educational trajectories. Using linear regression, we predicted physical health summary scores of the participants at age 50 years from the 12-item Short-Form Survey, adjusting for available confounders, and evaluated effect modification by sex, race/ethnicity, and childhood socioeconomic status. We identified 24 unique educational sequence clusters on the basis of highest level of schooling and attendance timing. General education development credentials predicted poorer health than did high school diplomas (ß = -3.07, 95% confidence interval: -4.07, -2.07), and bachelor's degrees attained at earlier ages predicted better health than the same degree attained at later ages (ß = 1.66, 95% confidence interval: 0.05, 3.28). Structurally marginalized groups benefited more from some educational trajectories than did advantaged groups (e.g., Black vs. White Americans with some college; those of low vs. high childhood socioeconomic status who received an associate's or bachelor's degree). Both type and timing of educational credentials may influence physical health. Literature to date has likely underestimated the impact of educational trajectories on health.

Racial Discrimination in the Life Course of Older Adults Experiencing Homelessness: Results from the HOPE HOME Study.

Over 2.5 million people experience homelessness yearly in the United States. Black persons are overrepresented by three-fold among those experiencing homelessness but little research has examined the relationship between race and homelessness. We aimed to understand the relationship between race and the experience of homelessness for older adults. We used grounded theory methodology to analyze in-depth qualitative interviews (n = 65) of persons experiencing homelessness. We recruited participants who were enrolled in two sub-studies of the Health Outcomes of People Experiencing Homelessness in Older Middle AgE (HOPE HOME) Study in Oakland California. We identified two major themes within interviews with Black participants (n=52) related to race: (1) participants experienced overt racial discrimination in early life and (2) structural racism precipitated and perpetuated adult homelessness. Further, we identified sub-themes of structural racism that contributed to participants becoming or staying homeless: criminal justice discrimination, employment discrimination, exposure to violence, premature death, and limited family wealth. We developed a theoretical model of how these elements of structural racism may increase susceptibility to homelessness. These relationships between racial discrimination and homelessness may serve as targets for policies aimed at preventing homelessness.

Gentrification and Displacement in the San Francisco Bay Area: A Comparison of Measurement Approaches.

Gentrification may play an important role in influencing health outcomes, but few studies have examined these associations. One major barrier to producing empirical evidence to establish this link is that there is little consensus on how to measure gentrification. To address this barrier, we compared three gentrification classification methodologies in relation to their ability to identify neighborhood gentrification in nine San Francisco Bay Area counties: the Freeman method, the Landis method, and the Urban Displacement Project (UDP) Regional Early Warning System. In the 1580 census tracts, 43% of the population had a bachelor's degree or higher. The average median household income was $79,671 in 2013. A comparison of gentrification methodologies revealed that the Landis and Freeman methodologies characterized the vast majority of census tracts as stable, and only 5.2% and 6.1% of tracts as gentrifying. UDP characterized 46.7% of tracts at risk, undergoing, or experiencing advanced stages of gentrification and displacement. There was substantial variation in the geographic location of tracts identified as gentrifying across methods. Given the variation in characterizations of gentrification across measures, studies evaluating associations between gentrification and health should consider using multiple measures of gentrification to examine the robustness of the study findings across measures.

Stratified citizenship, stratified health: Examining latinx legal status in the U.S. healthcare safety net.

Our paper explores how legal status stratification shapes the health and health care of low-income patients with chronic illnesses in the U.S. healthcare safety net. Drawing on data from over two years of ethnographic fieldwork at urban safety-net clinics, we examine efforts by Complex Care Management (CCM) teams to stabilize patients with uncontrolled chronic illnesses through primary care-integrated support. We show that stratified citizenship and geographic variability correspond to different possibilities for health care. We suggest an approach to immigration as a structural determinant of health that accounts for the complex, stratified, and changing nature of citizenship status. We also highlight how geographical differences and interactions among local, state, and federal policies support the notion that citizenship is stratified across multiple tiers with distinctive possibilities and constraints for health. While county-based health plans at each of the study sites include residents with varying legal status, lack of formal legal status remains a substantial obstacle to care. Many immigrants are unable to take full advantage of primary and specialty care, resulting in unnecessary morbidity and mortality. In some cases, patients have returned to their country of origin to die. While CCM teams provide an impressive level of support to assist immigrant patients in navigating healthcare and immigration bureaucracies, legal and geographic stratification limit their ability to address broader aspects of these patients' social context.

Changes in Food Insecurity and Smoking Status over Time: Analysis of the 2003 and 2015 Panel Study of Income Dynamics.

PURPOSE: To examine whether food insecurity longitudinally affects smoking status. DESIGN: Population-based prospective study. SETTING: Data from the 2003 and 2015 Panel Study of Income Dynamics (PSID). PARTICIPANTS: Four thousand five hundred sixty-three adults who were smokers and nonsmokers, participating in the 2003 (current study baseline) and 2015 (current study follow-up) waves of PSID. MEASURES: Based on self-reported smoking status at baseline and follow-up, respondents were categorized as continued smoking, stopped smoking, started smoking, and continued nonsmoking. Similarly, respondents were categorized as stayed food secure, stayed food insecure, became food insecure, and became food secure based on responses to the Food Security Survey at baseline and follow-up. ANALYSIS: Two logistic regression analyses to examine (1) among smokers at baseline the odds of stopping versus continuing smoking by follow-up and (2) among nonsmokers at baseline the odds of starting versus continuing nonsmoking by follow-up. In both models, change in food insecurity status was the primary independent variable, controlling for demographics including poverty. RESULTS: Among smokers at baseline, becoming food insecure (vs staying food secure) was independently associated with lower likelihood of stopping smoking by follow-up (odds ratio [OR] = 0.66). Among nonsmokers at baseline, becoming food insecure (vs staying food secure) was independently associated with higher likelihood of starting smoking by follow-up (OR = 3.77). CONCLUSIONS: Food insecurity is a risk factor for smoking, which has significant implications for developing interventions to reduce smoking prevalence, especially among low-income groups.

Do the health benefits of education vary by sociodemographic subgroup? Differential returns to education and implications for health inequities.

PURPOSE: Evidence suggests education is an important life course determinant of health, but few studies examine differential returns to education by sociodemographic subgroup. METHODS: Using National Longitudinal Survey of Youth 1979 (n = 6158) cohort data, we evaluate education attained by age 25 years and physical health (PCS) and mental health component summary scores (MCS) at age 50 years. Race / ethnicity, sex, geography, immigration status, and childhood socioeconomic status (cSES) were evaluated as effect modifiers in birth year adjusted linear regression models. RESULTS: The association between education and PCS was large among high cSES respondents (ß = 0.81 per year of education, 95% CI: 0.67, 0.94), and larger among low cSES respondents (interaction ß = 0.39, 95% CI: 0.06, 0.72). The association between education and MCS was imprecisely estimated among White men (ß = 0.44; 95% CI: -0.03, 0.90), while, Black women benefited more from each year of education (interaction ß = 0.91; 95% CI: 0.19, 1.64). Similarly, compared to socially advantaged groups, low cSES Blacks, and low and high cSES women benefited more from each year of education, while immigrants benefited less from each year of education. CONCLUSIONS: If causal, increases in educational attainment may reduce some social inequities in health.

Long-term Mortality in Pediatric Firearm Assault Survivors: A Multicenter, Retrospective, Comparative Cohort Study.

OBJECTIVES: The objective was to determine whether children surviving to hospital discharge after firearm assault (FA) and nonfirearm assault (NFA) are at increased risk of mortality relative to survivors of unintentional trauma (UT). Secondarily, the objective was to elucidate the factors associated with long-term mortality after pediatric trauma. METHODS: This was a multicenter, retrospective cohort study of pediatric patients aged 0 to 16 years who presented to the three trauma centers in San Francisco and Alameda counties, California, between January 2000 and December 2009 after 1) FA, 2) NFA, and 3) UT. The Social Security Death Master File and the California Department of Public Health Vital Statistics (2000-2014) were queried through December 31, 2014, to identify those who died after surviving their initial hospitalization and to delineate cause of death. Multivariate Cox proportional hazards regression was performed to determine associations between exposure to assault and long-term mortality. RESULTS: We analyzed 413 FA, 405 NFA, and 7,062 UT patients who survived their index hospital visit. A total of 75 deaths occurred, including 3.9, 3.2, and 0.7% of each cohort, respectively. Two-thirds of all long-term deaths were due to homicide. After multivariate adjustment, adolescent age, male sex, black race/ethnicity, and public insurance were independent risk factors for long-term mortality. FA (adjusted hazard ratio [AHR] = 1.8, 95% confidence interval [CI] = 0.82-4.0) and NFA (AHR = 1.9, 95% CI = 0.93-3.9) did not convey a statistically significant difference in risk of long-term mortality compared to UT. Being assaulted by any means (with or without a firearm), however, was an independent risk factor for long-term mortality in the full study population (AHR = 1.9, 95% CI = 1.01-3.4) and among adolescents (AHR = 1.9, 95% CI = 1.01-3.6). CONCLUSION: Children and adolescents who survive assault, including by firearm, have increased long-term mortality compared to those who survive unintentional, nonviolent trauma.

Gentrification and binge drinking in California neighborhoods: It matters how long you've lived there.

BACKGROUND: Neighborhood context plays a role in binge drinking, a behavior with major health and economic costs. Gentrification, the influx of capital and residents of higher socioeconomic status into historically-disinvested neighborhoods, is a growing trend with the potential to place urban communities under social and financial pressure. Hypothesizing that these pressures and other community changes resulting from gentrification could be tied to excessive alcohol consumption, we examined the relationship between gentrification and binge drinking in California neighborhoods. METHODS: California census tracts were categorized as non-gentrifiable, stable (gentrifiable), or gentrifying from 2006 to 2015. Outcomes and covariates were obtained from the California Health Interview Survey using combined 2013-2015 data (n = 60,196). Survey-weighted logistic regression tested for associations between gentrification and any binge drinking in the prior 12 months. Additional models tested interactions between gentrification and other variables of interest, including housing tenure, federal poverty level, race/ethnicity, sex, and duration of neighborhood residence. RESULTS: A third of respondents reported past-year binge drinking. Controlling for demographic covariates, gentrification was not associated with binge drinking in the population overall (AOR = 1.13, 95% CI = 0.95-1.34), but was associated with binge drinking among those living in the neighborhood <5 years (AOR = 1.49, 95% CI 1.15-1.93). No association was seen among those living in their neighborhood ≥5 years. CONCLUSIONS: For those newer to their neighborhood, gentrification is associated with binge drinking. Further understanding the relationship between gentrification and high-risk alcohol use is important for policy and public health interventions mitigating the impact of this process.

Complex care and contradictions of choice in the safety net.

This article explores the complicated and often-contradictory notions of choice at play in complex care management (CCM) programmes in the US healthcare safety net. Drawing from longitudinal data collected over two years of ethnographic fieldwork at urban safety-net clinics, our study examines the CCM goal of transforming frequent emergency department (ED) utilisers into 'active' patients who will reduce their service utilisation and thereby contribute to a more rational, cost-effective healthcare system. By considering our data alongside philosopher Annemarie Mol's (2008) conceptualisation of the competing logics of choice and care, we argue that these premises often undermine CCM teams' efforts to support patients and provide the care they need - not only to prevent medical crises, but to overcome socio-economic barriers as well. We assert that while safety-net CCM programmes are held accountable for the degree to which their patients successfully transform into self-managing, cost-effective actors, much of the care CCM staff provide in fact involves attempts to intervene on structural obstacles that impinge on patient choice. CCM programmes thus struggle between an economic imperative to get patients to make better health choices and a moral imperative to provide care in the face of systemic societal neglect. (A virtual abstract of this paper can be viewed at: https://www.youtube.com/channel/UC_979cmCmR9rLrKuD7z0ycA).

Defining trauma in complex care management: Safety-net providers' perspectives on structural vulnerability and time.

In this paper, we delineate how staff of two complex care management (CCM) programs in urban safety net hospitals in the United States understand trauma. We seek to (1) describe how staff in CCM programs talk about trauma in their patients' lives; (2) discuss how trauma concepts allow staff to understand patients' symptoms, health-related behaviors, and responses to care as results of structural conditions; and (3) delineate the mismatch between long-term needs of patients with histories of trauma and the short-term interventions that CCM programs provide. Observation and interview data gathered between February 2015 and August 2016 indicate that CCM providers define trauma expansively to include individual experiences of violence such as childhood abuse and neglect or recent assault, traumatization in the course of accessing health care and structural violence. Though CCM staff implement elements of trauma-informed care, the short-term design of CCM programs puts pressure on the staff to titrate their efforts, moving patients towards graduation or discharge. Trauma concepts enable clinicians to name structural violence in clinically legitimate language. As such, trauma-informed care and structural competency approaches can complement each other.

Assessing Patient Activation among High-Need, High-Cost Patients in Urban Safety Net Care Settings.

We sought to examine the literature using the Patient Activation Measure (PAM) or the Patient Enablement Instrument (PEI) with high-need, high-cost (HNHC) patients receiving care in urban safety net settings. Urban safety net care management programs serve low-income, racially/ethnically diverse patients living with multiple chronic conditions. Although many care management programs track patient progress with the PAM or the PEI, it is not clear whether the PAM or the PEI is an effective and appropriate tool for HNHC patients receiving care in urban safety net settings in the United States. We searched PubMed, EMBASE, Web of Science, and PsycINFO for articles published between 2004 and 2015 that used the PAM and between 1998 and 2015 that used the PEI. The search was limited to English-language articles conducted in the United States and published in peer-reviewed journals. To assess the utility of the PAM and the PEI in urban safety net care settings, we defined a HNHC patient sample as racially/ethnically diverse, low socioeconomic status (SES), and multimorbid. One hundred fourteen articles used the PAM. All articles using the PEI were conducted outside the U.S. and therefore were excluded. Nine PAM studies (8%) included participants similar to those receiving care in urban safety net settings, three of which were longitudinal. Two of the three longitudinal studies reported positive changes following interventions. Our results indicate that research on patient activation is not commonly conducted on racially and ethnically diverse, low SES, and multimorbid patients; therefore, there are few opportunities to assess the appropriateness of the PAM in such populations. Investigators expressed concerns with the potential unreliability and inappropriate nature of the PAM on multimorbid, older, and low-literacy patients. Thus, the PAM may not be able to accurately assess patient progress among HNHC patients receiving care in urban safety net settings. Assessing progress in the urban safety net care setting requires measures that account for the social and structural challenges and competing demands of HNHC patients.