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).

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.

"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.

Community Mobilization Challenging Gender Power Imbalances: Women Sex Workers' Capacity to Engage in Health-Enhancing Practices in Southern India.

Research on women sex workers' condom use with non-paying intimate partners suggests social norms of gender power in these relationships constrain women's health-enhancing sexual practice. Theorizing gender relations and sexual practice as structural informs our analysis of elements of community mobilization interventions (CMI) that link to sex workers' capacity to engage consistently in health-enhancing practices, in this case, condom use. We use data from a survey of women (who exchanged sex for money in the preceding 12 months) conducted in the context of an HIV-prevention intervention in southern India. Results of multinomial logistic regression indicate: higher odds of health-enhancing sexual practice with intimate partners and paying clients among women sex workers expressing collective efficacy; lower odds of health-diminishing sexual practice with clients among women sex workers empowered through peer interactions; lower odds of health-diminishing sexual practice with clients and lower odds of health-enhancing sexual practice with partners among women sex worker living in households structured by normative gender power relations. We suggest future research on how CMI promoting health-enabling social environments with women in sex work contribute to their capacity to engage in health-enhancing practices.

RESUMEN: La investigación sobre el uso del condón por trabajadoras sexuales con parejas íntimas que no pagan sugiere que las normas de relaciones de género restringen la práctica sexual más segura en estas relaciones. Teorizar las relaciones de género y la práctica sexual como estructurales informa el análisis de aspectos de las intervenciones de movilización comunitaria (CMI) vinculados a la capacidad de las trabajadoras sexuales para adoptar el uso habitual de prácticas que mejoran la salud, en este caso, el uso del condón. Utilizamos datos de una encuesta de mujeres (que intercambiaron sexo por dinero en los 12 meses anteriores) realizada en el contexto de una intervención de prevención del VIH. La regresión logística multinomial indica: mayores probabilidades de prácticas sexuales que mejoran la salud con parejas íntimas y clientes que pagan entre mujeres que expresan eficacia colectiva; menores probabilidades de prácticas sexuales que disminuyen la salud con clientes entre mujeres empoderadas por las interacciones entre pares; menores probabilidades de prácticas sexuales que disminuyen la salud con los clientes así como menores probabilidades de prácticas sexuales que mejoran la salud con parejas íntimas entre mujeres en hogares estructurados por el poder normativo de género. Sugerimos investigaciones futuras sobre como las intervenciones de movilización comunitaria (CMI) que promueven prácticas sexuales que mejoran la salud entre las trabajadoras sexuales contribuyen a su capacidad para adoptar dichas prácticas.

Probing the Processes: Longitudinal Qualitative Research on Social Determinants of HIV.

Longitudinal qualitative research can provide rich understanding of the life circumstances of vulnerable groups who experience health inequities, of whether, how and why these circumstances change, and of how these circumstances and processes of change impact health. But, this rich understanding is not automatic and requires systematic and thoughtful approaches to data collection and analysis. The purpose of this paper is to describe two longitudinal qualitative studies embedded in mixed-methods studies of social determinants of HIV in the United States and the Dominican Republic. We compare these two studies to critically reflect on specific techniques that facilitate longitudinal and iterative data collection, management, and analysis, in particular the use of participant-specific matrices and analytic summaries across the distinct phases of the research. We conclude that combining cross-sectional and longitudinal analysis that engages with both themes and processes of change can contribute to improved contextualization and understanding of social determinants of HIV.

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.

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.

Quantifying the Restrictiveness of Local Housing Authority Policies Toward People With Criminal Justice Histories: United States, 2009-2018.

Objectives. To quantify variation in the restrictiveness of local public housing authority policies related to the admission and eviction of people with criminal justice histories.Methods. We conducted content analysis of housing authority policy documents for US cities with a population of 100 000 or more (n = 152). Factor analysis identified policy provisions to create a restrictiveness score (range = 0-8). We explored associations between restrictiveness scores and city-level measures of racial/ethnic diversity, racial/ethnic neighborhood segregation, ideology, and public housing scarcity.Results. Eight policy provisions, 6 relating to consideration of mitigating circumstances, explained 71.0% of the variance in housing authority policy provisions related to criminal justice histories. We observed small but significant positive associations between restrictiveness scores and racial/ethnic diversity (r = 0.22) and neighborhood segregation (r = 0.18). There was no correlation between restrictiveness scores of housing authorities within the same state (intraclass correlation = 0.0002).Conclusions. Housing authority policies vary substantially regarding the circumstances under which people with criminal justice histories can obtain and retain public housing. Exposure to constellations of policy provisions that might institutionalize health inequities and increase health risk among people with criminal justice histories can be quantified through a systematic process.

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.

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.

Dual Incarceration and Condom Use in Committed Relationships.

Incarceration fractures relationship ties and has been associated with unprotected sex. Relationships where both individuals have a history of incarceration (dual incarceration) may face even greater disruption and involve more unprotected sex than relationships where only one individual has been incarcerated. We sought to determine whether dual incarceration is associated with condom use, and whether this association varies by relationship type. Data come from 499 sexual partnerships reported by 210 individuals with a history of incarceration. We used generalized estimating equations to examine whether dual incarceration was associated with condom use after controlling for individual and relationship characteristics. Interaction terms between dual incarceration and relationship commitment were also examined. Among currently committed relationships, dual incarceration was associated with inconsistent condom use (AOR: 4.33; 95% CI 1.02, 18.45). Dual incarceration did not affect condom use in never committed relationships. Reducing incarcerations may positively impact committed relationships and subsequently decrease HIV-related risk.

Why female sex workers participate in HIV research: the illusion of voluntariness.

The purpose of this study was to examine factors influencing the motivation for and perceived voluntariness of participation in non-intervention HIV research among female sex workers (FSW) in India. FSW (n = 30) who participated in non-intervention HIV studies in the previous three years were recruited from a local community-based organization. Semi-structured qualitative interviews focused on women's personal and economic motivations for participation and their perceptions of the informed consent process. Interviews were audio-recorded, translated, transcribed, and reviewed for common themes. Content analysis indicated that while many women reported willing participation, reports of obligatory participation were also a common theme. Obligations included money-related pressures and coercion by other FSW, social pressures, not wanting to disappoint the researchers, and perceiving that they had a contractual agreement to complete participation as a result of signing the consent form. Findings suggest a need for additional efforts during and following informed consent to prevent obligatory participation in HIV research studies among FSW. Findings emphasize the importance of integrating ongoing participant feedback into research ethics practices to identify issues not well addressed via standard ethics protocols when conducting HIV research among vulnerable populations.

Comparing Black and White Drug Offenders: Implications for Racial Disparities in Criminal Justice and Reentry Policy and Programming.

Despite knowledge of racial bias for drug-related criminal justice involvement and its collateral consequences, we know less about differences between Black and White drug offenders. We compare 243 Blacks and White non-violent drug offenders in New Haven, CT for demographic characteristics, substance use, and re-entry services accessed. Blacks were significantly more likely to have sales and possession charges, significantly more likely to prefer marijuana, a less addictive drug, and significantly less likely to report having severe drug problems. For both races, drug treatment was the most common service accessed through supervision. These comparisons suggest different reasons for committing drug-related crimes and thus, different reentry programming needs. While drug treatment is critical for all who need it, for racial justice, we must also intervene to address other needs of offenders, such as poverty alleviation and employment opportunities.

Client-perpetrated and husband-perpetrated violence among female sex workers in Andhra Pradesh, India: HIV/STI risk across personal and work contexts.

OBJECTIVES: This study examines violence experienced in work and personal contexts and relation to HIV risk factors in these contexts among female sex workers (FSW) in Andhra Pradesh, India. METHODS: FSW at least 18 years of age (n=2335) were recruited through three rounds of respondent-driven sampling between 2006 and 2010 for a survey on HIV risk. Using crude and adjusted logistic regression models, any sexual/physical violence (last 6 months) perpetrated by clients and husbands were separately assessed in association with accepting more money for sex without a condom (last 30 days), consistent condom use with clients and husbands (last 30 days), and sexually transmitted infection (STI) symptoms (last 6 months). RESULTS: The mean age among participants was 32, 22% reported being currently married, and 22% and 21% reported physical/sexual violence by clients and husbands, respectively. In adjusted logistic regression models, FSW who experienced client violence were more likely to report accepting more money for unprotected sex trades (adjusted OR (AOR)=1.7; 95% CI 1.4 to 2.2), less likely to report consistent condom use with clients (AOR=0.6; 95% CI 0.5 to 0.7) and more likely to report STI symptoms (AOR=3.5; 95% CI 2.6 to 4.6). Women who reported husband violence were more likely to report accepting more money for unprotected sex trades (AOR=2.1; 95% CI 1.2 to 3.7), less likely to report consistent condom use with clients (AOR=0.5; 95% CI 0.3 to 0.8) and more likely to report STI symptoms (AOR=2.6; 95% CI 1.6 to 4.1). CONCLUSIONS: Among FSW, experiences of violence in work and personal contexts are associated with sexual HIV risk behaviours with clients as well as STI symptoms.

Change over Time in Police Interactions and HIV Risk Behavior Among Female Sex Workers in Andhra Pradesh, India.

Little is known about the effectiveness of intervening to change interactions between female sex workers (FSWs) and police in order to reduce HIV risk. Using data collected in the context of a HIV prevention intervention that included components to change policing practices (n = 1,680), we examine the association of FSWs' reports of negative police interactions and HIV risk behaviors and whether these associations varied over time. Results show negative police interactions declined significantly over time. FSWs who had more than one negative police interaction were more likely to experience STI symptoms (AOR 2.97 [95 % CI 2.27-3.89]), inconsistently use condoms with their clients (AOR 1.36 [95 % CI 1.03-1.79]), and accept more money for condomless sex (AOR 2.37 [95 % CI 1.76-3.21]). Over time, these associations were stable or increased. Even where interventions have reduced the number of police incidents experienced by FSWs, stakeholders in HIV prevention must remain vigilant in challenging these incidents.