Transportation barriers to care among frequent health care users during the COVID pandemic.

BACKGROUND: Transportation problems are known barriers to health care and can result in late arrivals and delayed or missed care. Groups already prone to greater social and economic disadvantage, including low-income individuals and people with chronic conditions, encounter more transportation barriers and experience greater negative health care consequences. Addressing transportation barriers is important not only for mitigating adverse health care outcomes among patients, but also for avoiding additional costs to the health care system. In this study, we investigate transportation barriers to accessing health care services during the COVID-19 pandemic among high-frequency health care users. METHODS: A web-based survey was administered to North Carolina residents aged 18 and older in the UNC Health system who were enrolled in Medicaid or Medicare and had at least six outpatient medical appointments in the past year. 323 complete responses were analyzed to investigate the prevalence of reporting transportation barriers that resulted in having arrived late to, delayed, or missed care, as well as relationships between demographic and other independent variables and transportation barriers. Qualitative analyses were performed on text response data to explain transportation barriers. RESULTS: Approximately 1 in 3 respondents experienced transportation barriers to health care between June 2020 and June 2021. Multivariate logistic regressions indicate individuals aged 18-64, people with disabilities, and people without a household vehicle were significantly more likely to encounter transportation barriers. Costs of traveling for medical appointments and a lack of driver or car availability emerged as major transportation barriers; however, respondents explained that barriers were often complex, involving circumstantial problems related to one's ability to access and pay for transportation as well as to personal health. CONCLUSIONS: To address transportation barriers, we recommend more coordination between transportation and health professionals and the implementation of programs that expand access to and improve patient awareness of health care mobility services. We also recommend transportation and health entities direct resources to address transportation barriers equitably, as barriers disproportionately burden younger adults under age 65 enrolled in public insurance programs.

Addressing transportation barriers to health care during the COVID-19 pandemic: Perspectives of care coordinators.

Prior to the COVID-19 pandemic, transportation barriers prevented millions of Americans from accessing needed medical care. Then the pandemic disrupted medical and transportation systems across the globe. This research explored ways the COVID-19 pandemic changed how people experienced transportation barriers to accessing health care. We conducted in-depth interviews with social workers, nurses, and other care coordinators in North Carolina to identify barriers to traveling for medical care during the pandemic and explore innovative solutions employed to address these barriers. Analyzing these interviews using a flexible coding approach, we found that the pandemic exacerbated existing transportation barriers and created new barriers. Yet, simultaneously, temporary policy responses expanded the utilization of telehealth. The interviews identified specific advantages of expanded telehealth, including increasing access to mental health services in rural areas, reducing COVID-19 exposure for high-risk patients, and offering continuity of care for COVID-19 patients with other health conditions. While telehealth cannot address all medical needs, such as emergency or cancer care, it may be well-suited for preliminary screenings and follow-up visits. The findings provide insights on how post-pandemic telehealth policy changes can benefit individuals facing transportation barriers to accessing health care and support more accommodating and convenient health care for patients and their families.

Place-Based Correlates of Exchange Sex Among People Who Inject Drugs in 19 U.S. Metropolitan Areas, 2012.

This study examined overall and gender-specific associations between place-based characteristics and opposite-sex exchange sex among people who inject drugs (PWID) in the U.S. PWID were recruited from 19 metropolitan statistical areas (MSAs) for the Centers for Disease Control and Prevention's 2012 National HIV Behavioral Surveillance. Administrative data were used to describe the economic, social, and political features of the ZIP codes, MSAs, counties, and states where PWID lived. Multilevel modeling estimated associations of place characteristics and exchange sex. We found that 52% of women and 23% of men reported past-year opposite-sex exchange sex (N = 7599). Female PWID living in states with stronger policies supporting working caregivers had lower odds of exchange sex (aOR = 0.80; 95% CI 0.69, 0.94). PWID living in ZIP codes with greater economic deprivation had higher odds of exchange sex (aOR = 1.10; 95% CI 1.03, 1.17). We found that a high percentage of male PWID exchanged sex with women; determinants and risks of this group merit exploration. If future research establishes that the relationships identified here are causal, interventions to reduce exchange sex among PWID should include policies supporting working caregivers and reducing poverty rates.

Centering Equity and Community in the Recovery of the COVID-19 Pandemic.

The COVID-19 pandemic has exposed socioeconomic, geographic, and medical vulnerabilities in our country. In North Carolina, inequalities resulting from centuries of structural racism exacerbate disparate impacts of infection and death. We propose three opportunities that leaders in our state can embrace to move toward equity as we weather, and emerge from, this pandemic.

Transportation Barriers to Health Care in the United States: Findings From the National Health Interview Survey, 1997-2017.

Objectives. To quantify the number of people in the US who delay medical care annually because of lack of available transportation and to examine the differential prevalence of this barrier for adults across sociodemographic characteristics and patient populations.Methods. We used data from the National Health Interview Survey (1997-2017) to examine this barrier over time and across groups. We used joinpoint regression analysis to identify significant changes in trends and multivariate analysis to examine correlates of this barrier for the year 2017.Results. In 2017, 5.8 million persons in the United States (1.8%) delayed medical care because they did not have transportation. The proportion reporting transportation barriers increased between 2003 and 2009 with no significant trends before or after this window within our study period. We found that Hispanic people, those living below the poverty threshold, Medicaid recipients, and people with a functional limitation had greater odds of reporting a transportation barrier after we controlled for other sociodemographic and health characteristics.Conclusions. Transportation barriers to health care have a disproportionate impact on individuals who are poor and who have chronic conditions. Our study documents a significant problem in access to health care during a time of rapidly changing transportation technology.

Mortgage Discrimination and Racial/Ethnic Concentration Are Associated with Same-Race/Ethnicity Partnering among People Who Inject Drugs in 19 US Cities.

Racial/ethnic homophily in sexual partnerships (partners share the same race/ethnicity) has been associated with racial/ethnic disparities in HIV. Structural racism may partly determine racial/ethnic homophily in sexual partnerships. This study estimated associations of racial/ethnic concentration and mortgage discrimination against Black and Latino residents with racial/ethnic homophily in sexual partnerships among 7847 people who inject drugs (PWID) recruited from 19 US cities to participate in CDC's National HIV Behavioral Surveillance. Racial/ethnic concentration was defined by two measures that respectively compared ZIP code-level concentrations of Black residents to White residents and Latino residents to White residents, using the Index of Concentration at the Extremes. Mortgage discrimination was defined by two measures that respectively compared county-level mortgage loan denial among Black applicants to White applicants and mortgage loan denial among Latino applicants to White applicants, with similar characteristics (e.g., income, loan amount). Multilevel logistic regression models were used to estimate associations. Interactions of race/ethnicity with measures of racial/ethnic concentration and mortgage discrimination were added to the final multivariable model and decomposed into race/ethnicity-specific estimates. In the final multivariable model, among Black PWID, living in ZIP codes with higher concentrations of Black vs. White residents and counties with higher mortgage discrimination against Black residents was associated with higher odds of homophily. Living in counties with higher mortgage discrimination against Latino residents was associated with lower odds of homophily among Black PWID. Among Latino PWID, living in ZIP codes with higher concentrations of Latino vs. White residents and counties with higher mortgage discrimination against Latino residents was associated with higher odds of homophily. Living in counties with higher mortgage discrimination against Black residents was associated with lower odds of homophily among Latino PWID. Among White PWID, living in ZIP codes with higher concentrations of Black or Latino residents vs. White residents was associated with lower odds of homophily, but living in counties with higher mortgage discrimination against Black residents was associated with higher odds of homophily. Racial/ethnic segregation may partly drive same race/ethnicity sexual partnering among PWID. Future empirical evidence linking these associations directly or indirectly (via place-level mediators) to HIV/STI transmission will determine how eliminating discriminatory housing policies impact HIV/STI transmission.

Innovative health care mobility services in the US.

BACKGROUND: Transportation barriers prevent millions of people from accessing health care each year. Health policy innovations such as shared savings payment models (commonly used in accountable care organizations) present financial incentives for providers to offer patient transportation to medical care. Meanwhile, ridesourcing companies like Uber and Lyft have entered the market to capture a significant share of spending on non-emergency health care transportation. Our research examines the current landscape of innovative health care mobility services in the US. METHODS: We conducted an environmental scan to identify case examples of utilization of ridesourcing technology to facilitate non-emergency health care transportation and developed a typology of innovative health care mobility services. The scan used a keyword-based search of news publications with inductive analysis. For each instance identified, we abstracted key information including: stakeholders, launch date, transportation provider, location/service area, payment/booking method, target population, level of service, and any documented outcomes. RESULTS: We discovered 53 cases of innovation and among them we identified three core types of innovation or collaboration. The first and most common type of innovation is when a health care provider leverages ridesourcing technology to book patient trips. This involves both established and nascent transportation companies tailoring the ridesourcing experience to the health care industry by adding HIPAA-compliance to the booking process. The second type of innovation involves an insurer or health plan formally partnering with a ridesourcing company to expand transportation offerings to beneficiaries or offer these services for the first time. The third type of innovation is when a paratransit provider partners with a ridesourcing company; these cases cite increased flexibility and reliability of ridesourcing services compared to traditional paratransit. CONCLUSIONS: Ridesourcing options are becoming a part of the mode choice set for patients through formal partnerships between ridesourcing companies, health care providers, insurers, and transit agencies. The on-demand nature of rides, booking flexibility, and integration of ride requests and payment options via electronic medical records appear to be the strongest drivers of this innovation.

Methodological challenges in conducting instrumentation research in non-communicative palliative care patients.

Well-designed, rigorously implemented instrumentation studies are essential to develop valid, reliable pain assessment tools in non-communicative (non-self-reporting) palliative care patients. When conducting a pain instrumentation study, a research team identified methodologic challenges surrounding informed consent, eligibility criteria, acute pain operational definitions, patient recruitment, missing data, and study-related training during a run-in phase at the beginning of the project and during the conduct of the study. The team dealt with these challenges through identifying root causes, implementing remedial measures, and collecting data to demonstrate improvement or resolution. Effective strategies included obtaining Institutional Review Board (IRB) approval for a waiver of informed consent, modifying eligibility criteria, ensuring that operational definitions and study procedures were consistent with clinical practice, decreasing time from screening to data collection to improve recruitment, increasing study nurse staffing by re-budgeting grant funds, focusing time and resources on high accruing clinical units, revising processes to minimize missing data, and developing detailed training for users of the instrument. With these multi-pronged solutions, the team exceeded the patient accrual target by 25% within the funding period and reduced missing data. While pain instrumentation studies in non-communicative patients have similar challenges to other palliative care studies, some of the solutions may be unique and several are applicable to other palliative care studies, particularly instrumentation research. The team's experience may also be useful for funders and IRBs.

Impact of School Location on Children's Air Pollution Exposure.

The role of school location in children's air pollution exposure and ability to actively commute is a growing policy issue. Well-documented health impacts associated with near-roadway exposures have led school districts to consider school sites in cleaner air quality environments requiring school bus transportation. We analyze children's traffic-related air pollution exposure across an average Detroit school day to assess whether the benefits of reduced air pollution exposure at cleaner school sites are eroded by the need to transport students by bus or private vehicle. We simulated two school attendance scenarios using modeled hourly pollutant concentrations over the school day to understand how air pollution exposure may vary by school location and commute mode. We found that busing children from a high-traffic neighborhood to a school 19 km away in a low-traffic environment resulted in average daily exposures 2 to 3 times higher than children walking to a local school. Health benefits of siting schools away from high-volume roadways may be diminished by pollution exposure during bus commutes. School districts cannot simply select sites with low levels of air pollution, but must carefully analyze tradeoffs between location, transportation, and pollution exposure.

Identifying Which Place Characteristics are Associated with the Odds of Recent HIV Testing in a Large Sample of People Who Inject Drugs in 19 US Metropolitan Areas.

This exploratory analysis investigates relationships of place characteristics to HIV testing among people who inject drugs (PWID). We used CDC's 2012 National HIV Behavioral Surveillance (NHBS) data among PWID from 19 US metropolitan statistical areas (MSAs); we restricted the analytic sample to PWID self-reporting being HIV negative (N = 7477). Administrative data were analyzed to describe the 1. Sociodemographic Composition; 2. Economic disadvantage; 3. Healthcare Service/Law enforcement; and 4. HIV burden of the ZIP codes, counties, and MSAs where PWID lived. Multilevel models tested associations of place characteristics with HIV testing. Fifty-eight percent of PWID reported past-year testing. MSA-level per capita correctional expenditures were positively associated with recent HIV testing among black PWID, but not white PWID. Higher MSA-level household income and imbalanced sex ratios (more women than men) in the MSA were associated with higher odds of testing. HIV screening for PWID is suboptimal (58%) and needs improvement. Identifying place characteristics associated with testing among PWID can strengthen service allocation and interventions in areas of need to increase access to HIV testing.

Place-based predictors of HIV viral suppression and durable suppression among heterosexuals in New York city.

Scant research has explored place-based correlates of achieving and maintaining HIV viral load suppression among heterosexuals living with HIV. We conducted multilevel analyses to examine associations between United Hospital Fund (UHF)-level characteristics and individual-level viral suppression and durable viral suppression among individuals with newly diagnosed HIV in New York City (NYC) who have heterosexual HIV transmission risk. Individual-level independent and dependent variables came from NYC's HIV surveillance registry for individuals diagnosed with HIV in 2009-2013 (N = 3,159; 57% virally suppressed; 36% durably virally suppressed). UHF-level covariates included measures of food distress, demographic composition, neighborhood disadvantage and affluence, healthcare access, alcohol outlet density, residential vacancy, and police stop and frisk rates. We found that living in neighborhoods where a larger percent of residents were food distressed was associated with not maintaining viral suppression. If future research should confirm this is a causal association, community-level interventions targeting food distress may improve the health of people living with HIV and reduce the risk of forward transmission.

Place-Based Predictors of HIV Viral Suppression and Durable Suppression Among Men Who Have Sex With Men in New York City.

We explore relationships between place characteristics and HIV viral suppression among HIV-positive men who have sex with men (MSM) in New York City (NYC). We conducted multilevel analyses to examine associations of United Hospital Fund (UHF)-level characteristics to individual-level suppression and durable suppression among MSM. Individual-level independent and dependent variables came from MSM in NYC's HIV surveillance registry who had been diagnosed in 2009-2013 (N = 7159). UHF-level covariates captured demographic composition, economic disadvantage, healthcare access, social disorder, and police stop and frisk rates. 56.89% of MSM achieved suppression; 35.49% achieved durable suppression. MSM in UHFs where 5-29% of residents were Black had a greater likelihood of suppression (reference: ≥30% Black; adjusted relative risk (ARR) = 1.07, p = 0.04). MSM in UHFs with <30 MSM-headed households/10,000 households had a lower likelihood of achieving durable suppression (reference: ≥60 MSM-headed households/10,000; ARR = 0.82; p = 0.05). Place characteristics may influence viral suppression. Longitudinal research should confirm these associations.

Evaluation of a rule-based method for epidemiological document classification towards the automation of systematic reviews.

INTRODUCTION: Most data extraction efforts in epidemiology are focused on obtaining targeted information from clinical trials. In contrast, limited research has been conducted on the identification of information from observational studies, a major source for human evidence in many fields, including environmental health. The recognition of key epidemiological information (e.g., exposures) through text mining techniques can assist in the automation of systematic reviews and other evidence summaries. METHOD: We designed and applied a knowledge-driven, rule-based approach to identify targeted information (study design, participant population, exposure, outcome, confounding factors, and the country where the study was conducted) from abstracts of epidemiological studies included in several systematic reviews of environmental health exposures. The rules were based on common syntactical patterns observed in text and are thus not specific to any systematic review. To validate the general applicability of our approach, we compared the data extracted using our approach versus hand curation for 35 epidemiological study abstracts manually selected for inclusion in two systematic reviews. RESULTS: The returned F-score, precision, and recall ranged from 70% to 98%, 81% to 100%, and 54% to 97%, respectively. The highest precision was observed for exposure, outcome and population (100%) while recall was best for exposure and study design with 97% and 89%, respectively. The lowest recall was observed for the population (54%), which also had the lowest F-score (70%). CONCLUSION: The generated performance of our text-mining approach demonstrated encouraging results for the identification of targeted information from observational epidemiological study abstracts related to environmental exposures. We have demonstrated that rules based on generic syntactic patterns in one corpus can be applied to other observational study design by simple interchanging the dictionaries aiming to identify certain characteristics (i.e., outcomes, exposures). At the document level, the recognised information can assist in the selection and categorization of studies included in a systematic review.

Contextual Predictors of Injection Drug Use Among Black Adolescents and Adults in US Metropolitan Areas, 1993-2007.

OBJECTIVES: We sought to determine whether contextual factors shape injection drug use among Black adolescents and adults. METHODS: For this longitudinal study of 95 US metropolitan statistical areas (MSAs), we drew annual MSA-specific estimates of the prevalence of injection drug use (IDU) among Black adolescents and adults in 1993 through 2007 from 3 surveillance databases. We used existing administrative data to measure MSA-level socioeconomic status; criminal justice activities; expenditures on social welfare, health, and policing; and histories of Black uprisings (1960-1969) and urban renewal funding (1949-1974). We regressed Black IDU prevalence on these predictors by using hierarchical linear models. RESULTS: Black IDU prevalence was lower in MSAs with declining Black high-school dropout rates, a history of Black uprisings, higher percentages of Black residents, and, in MSAs where 1992 White income was high, higher 1992 Black income. Incarceration rates were unrelated. CONCLUSIONS: Contextual factors shape patterns of drug use among Black individuals. Structural interventions, especially those that improve Black socioeconomic security and political strength, may help reduce IDU among Black adolescents and adults.

HIV Infection Among People Who Inject Drugs in the United States: Geographically Explained Variance Across Racial and Ethnic Groups.

OBJECTIVES: We explored how variance in HIV infection is distributed across multiple geographical scales among people who inject drugs (PWID) in the United States, overall and within racial/ethnic groups. METHODS: People who inject drugs (n = 9077) were recruited via respondent-driven sampling from 19 metropolitan statistical areas (MSAs) for the Centers for Disease Control and Prevention's 2009 National HIV Behavioral Surveillance system. We used multilevel modeling to determine the percentage of variance in HIV infection explained by zip codes, counties, and MSAs where PWID lived, overall and for specific racial/ethnic groups. RESULTS: Collectively, zip codes, counties, and MSAs explained 29% of variance in HIV infection. Within specific racial/ethnic groups, all 3 scales explained variance in HIV infection among non-Hispanic/Latino White PWID (4.3%, 0.2%, and 7.5%, respectively), MSAs explained variance among Hispanic/Latino PWID (10.1%), and counties explained variance among non-Hispanic/Latino Black PWID (6.9%). CONCLUSIONS: Exposure to potential determinants of HIV infection at zip codes, counties, and MSAs may vary for different racial/ethnic groups of PWID, and may reveal opportunities to identify and ameliorate intraracial inequities in exposure to determinants of HIV infection at these geographical scales.

A prospective analysis of the effect of neighbourhood and individual social capital on changes in self-rated health of people with chronic illness.

BACKGROUND: Social capital in the living environment, both on the individual and neighbourhood level, is positively associated with people's self-rated health; however, prospective and longitudinal studies are rare, making causal conclusions difficult. To shed more light on the direction of the relationship between social capital and self-rated health, we investigated main and interaction effects of individual and neighbourhood social capital at baseline on changes in self-rated health of people with a somatic chronic disease. METHODS: Individual social capital, self-rated health and other individual level variables were assessed among a nationwide sample of 1048 non-institutionalized people with a somatic chronic disease residing in 259 neighbourhoods in the Netherlands. The assessment of neighbourhood social capital was based on data from a nationwide survey among the general Dutch population. The association of social capital with changes in self-rated health was assessed by multilevel regression analysis. RESULTS: Both individual social capital and neighbourhood social capital at baseline were significantly associated with changes in self-rated health over the time period of 2005 to 2008 while controlling for several disease characteristics, other individual level and neighbourhood level characteristics. No significant interactions were found between social capital on the individual and on the neighbourhood level. CONCLUSIONS: Higher levels of individual and neighbourhood social capital independently and positively affect changes in self-rated health of people with chronic illness. Although most of the variation in health is explained at the individual level, one's social environment should be considered as a possible relevant influence on the health of the chronically ill.

Green space and changes in self-rated health among people with chronic illness.

This prospective study analyses change in self-rated health of chronically ill people in relation to green space in their living environment at baseline. Data on 1112 people in the Netherlands with one or more medically diagnosed chronic disease(s) were used. The percentage of green space was calculated for postal code area. Multilevel linear regression analysis was conducted. We found no relationship between green space and change in health; however, an unexpected relationship between social capital at baseline and health change was discovered.

Systematic Review of Active Travel to School Surveillance in the United States and Canada.

Active travel to school is one way youths can incorporate physical activity into their daily schedule. It is unclear the extent to which active travel to school is systematically monitored at local, state, or national levels. To determine the scope of active travel to school surveillance in the US and Canada and catalog the types of measures captured, we conducted a systematic review of peer-reviewed literature documenting active travel to school surveillance published from 2004 to February 2018. A study was included if it addressed children's school travel mode across two or more time periods in the US or Canada. Criteria were applied to determine whether a data source was considered an active travel to school surveillance system. We identified 15 unique data sources; 4 of these met our surveillance system criteria. One system is conducted in the US, is nationally representative, and occurs every 5-8 years. Three are conducted in Canada, are limited geographically to regions and provinces, and are administered with greater frequency (e.g., 2-year cycles). School travel mode was the primary measure assessed, most commonly through parent report. None of the systems collected data on school policies or program supports related to active travel to school. We concluded that incorporating questions related to active travel to school behaviors into existing surveillance systems, as well as maintaining them over time, would enable more consistent monitoring. Concurrently capturing behavioral information along with related environmental, policy, and program supports may inform efforts to promote active travel to school.

Spatial and Temporal Trends in Travel for COVID-19 Vaccinations.

Introduction: Understanding spatial and temporal trends in travel for COVID-19 vaccinations by key demographic characteristics (i.e., gender, race, age) is important for ensuring equitable access to and increasing distribution efficiency of vaccines and other health services. The aim of this study is to examine trends in travel distance for COVID-19 vaccinations over the course of the vaccination rollout in North Carolina. Methods: Data were collected using electronic medical records of individuals who had first- or single-dose COVID-19 vaccination appointments through UNC Health between December 15, 2020, and August 31, 2021 (N = 204,718). Travel distances to appointments were calculated using the Euclidean distance from individuals' home ZIP code centroids to clinic addresses. Descriptive statistics and multivariable regression models with individuals' home ZIP codes incorporated as fixed effects were used to examine differences in travel distances by gender, race, and age. Results: Males and White individuals traveled significantly farther for vaccination appointments throughout the vaccination rollout. On average, females traveled 14. 4 miles, 3.5% shorter distances than males; Black individuals traveled 13.6 miles, 10.0% shorter distances than White individuals; and people aged 65 and older traveled 14.5 miles, 2.6% longer distances than younger people living in the same ZIP code. Conclusions: Controlling for socioeconomic status and spatial proximity to vaccination clinics at the ZIP code level, males and White individuals traveled longer distances for vaccination appointments, demonstrating more ability to travel for vaccinations. Results indicate a need to consider differential ability to travel to vaccinations by key demographic characteristics in COVID-19 vaccination programs and future mass health service delivery efforts.

Socioeconomic and racial/ethnic spatial polarization and incarceration among people who inject drugs in 19 US metropolitan areas, 2015.

The purpose of this study is to test, for the first time, the association between spatial social polarization and incarceration among people who inject drugs (PWID) in 19 large U.S. metropolitan statistical areas (MSAs) in 2015. PWID were recruited from MSAs for the Centers for Disease Control and Prevention's 2015 National HIV Behavioral Surveillance. Administrative data were used to describe the ZIP-code areas, counties, and MSAs where PWID lived. We operationalized spatial polarization using the Index of Concentration at the Extremes (ICE), a measure that reflects polarization in race and household income at the ZIP-code level. We tested the association between spatial polarization and odds of past-year arrest and detainment using multilevel multivariable models. We found 37% of the sample reported being incarcerated in the past year. Report of past-year incarceration varied by race/ethnicity: 45% of non-Hispanic white PWID reported past-year incarceration, as did 25% of non-Hispanic Black PWID, and 43% of Hispanic/Latino PWID (N = 9047). Adjusted odds ratios suggest that Black PWID living in ZIP-code areas with a higher ICE score, meaning more white and affluent, had higher odds of past-year incarceration, compared to white PWID. In previous research, incarceration has been found to be associated with HIV acquisition and can deter PWID from engaging in harm reduction activities.