Predicting hotspots of unsheltered homelessness using geospatial administrative data and volunteered geographic information.

Unsheltered homelessness is an increasingly prevalent phenomenon in major cities that is associated with adverse health and mortality outcomes. This creates a need for spatial estimates of population denominators for resource allocation and epidemiological studies. Gaps in the timeliness, coverage, and spatial specificity of official Point-in-Time Counts of unsheltered homelessness suggest a role for geospatial data from alternative sources to provide interim, neighborhood-level estimates of counts and trends. We use citizen-generated data from homeless-related 311 requests, provider-based administrative data from homeless street outreach cases, and expert reports of unsheltered count to predict count and emerging hotspots of unsheltered homelessness in census tracts across the City of Los Angeles for 2019 and 2020. Our study shows that alternative data sources can contribute timely insights into the state of unsheltered homelessness throughout the year and inform the delivery of interventions to this vulnerable population.

Placement into Scattered-Site or Place-Based Permanent Supportive Housing in Los Angeles County, CA, During the COVID-19 Pandemic.

There are two dominant approaches to implementing permanent supportive housing (PSH), namely place-based (PB) and scattered-site (SS). Formal guidance does not distinguish between these two models and only specifies that PSH should be reserved for those who are most vulnerable with complex health needs. To consider both system- and self-selection factors that may affect housing assignment, this study applied the Gelberg-Anderson behavioral model for vulnerable populations to compare predisposing, enabling, and need factors among people experiencing homelessness (PE) by whether they were assigned to PB-PSH (n = 272) or SS-PSH (n = 185) in Los Angeles County during the COVID-19 pandemic. This exploratory, observational study also included those who were approved but did not receive PSH (n = 94). Results show that there are notable differences between (a) those who received PSH versus those who did not, and (b) those in PB-PSH versus SS-PSH. Specifically, PEH who received PSH were more likely to be white, US-born, have any physical health condition, and have lower health activation scores. PEH who received PB- versus SS-PSH were more likely to be older, Black, have any alcohol use disorder, and have higher health activation scores. These findings suggest that homeless service systems may consider PB-PSH more appropriate for PEH with higher needs but also raises important questions about how race may be a factor in the type of PSH that PEH receive and whether PSH is received at all.

East is east or is it? Racialization of Asian, Middle Eastern, and Pacific Islander persons.

The conventional use of racial categories in health research naturalizes "race" in problematic ways that ignore how racial categories function in service of a White-dominated racial hierarchy. In many respects, racial labels are based on geographic designations. For instance, "Asians" are from Asia. Yet, this is not always a tenable proposition. For example, Afghanistan resides in South Asia, and shares a border with China and Pakistan. Yet, people from Afghanistan are not considered Asian, but Middle Eastern, by the US Census. Furthermore, people on the west side of the Island of New Guinea are considered Asian, whereas those on the eastern side are considered Pacific Islander. In this article, we discuss the complexity of the racial labels related to people originating from Oceania and Asia, and, more specifically, those groups commonly referred to as Pacific Islander, Middle Eastern, and Asian. We begin with considerations of the aggregation fallacy. Just as the ecological fallacy refers to erroneous inferences about individuals from group data, the aggregation fallacy refers to erroneous inferences about subgroups (eg, Hmong) from group data (ie, all Asian Americans), and how these inferences can contribute to stereotypes such as the "model minority." We also examine how group averages can be influenced merely by the composition of the subgroups, and how these, in turn, can be influenced by social policies. We provide a historical overview of some of the issues facing Pacific Islander, Middle Eastern, and Asian communities, and conclude with directions for future research.

Investigating the Comparative Effectiveness of Place-Based and Scatter-Site Permanent Supportive Housing for People Experiencing Homelessness During the COVID-19 Pandemic: Protocols for a Mixed Methods, Prospective Longitudinal Study.

BACKGROUND: Permanent supportive housing (PSH) is an evidence-based practice to address homelessness that is implemented using 2 distinct approaches. The first approach is place-based PSH (PB-PSH), or single-site housing placement, in which an entire building with on-site services is designated for people experiencing homelessness. The second approach is scatter-site PSH (SS-PSH), which uses apartments rented from a private landlord while providing mobile case management services. OBJECTIVE: This paper describes the protocols for a mixed methods comparative effectiveness study of 2 distinct approaches to implementing PSH and the patient-centered quality of life, health care use, and health behaviors that reduce COVID-19 risk. METHODS: People experiencing homelessness who are placed in either PB-PSH or SS-PSH completed 6 monthly surveys after move-in using smartphones provided by the study team. A subsample of participants completed 3 qualitative interviews at baseline, 3 months, and 6 months that included photo elicitation interviewing. Two stakeholder advisory groups, including one featuring people with lived experience of homelessness, helped guide study decisions and interpretations of findings. RESULTS: Study recruitment was supposed to occur over 6 months starting in January 2021 but was extended due to delays in recruitment. These delays included COVID-19 delays (eg, recruitment sites shut down due to outbreaks and study team members testing positive) and delays that may have been indirectly related to the COVID-19 pandemic, including high staff turnover or recruitment sites having competing priorities. In end-July 2022, in total, 641 people experiencing homelessness had been referred from 26 partnering recruitment sites, and 563 people experiencing homelessness had enrolled in the study and completed a baseline demographic survey. Of the 563 participants in the study, 452 had recently moved into the housing when they enrolled, with 272 placed in PB-PSH and 180 placed in SS-PSH. Another 111 participants were approved but are still waiting for housing placement. To date, 49 participants have been lost to follow-up, and 12% of phones (70 of the initial 563 distributed) were reported lost by participants. CONCLUSIONS: Recruitment during the pandemic, while successful, was challenging given that in-person contact was not permitted at times either by program sites or the research institutions during COVID-19 surges and high community transmission, which particularly affected homelessness programs in Los Angeles County. To overcome recruitment challenges, flexible strategies were used, which included extending the recruitment period and the distribution of cell phones with paid data plans. Given current recruitment numbers and retention rates that are over 90%, the study will be able to address a gap in the literature by considering the comparative effectiveness of PB-PSH versus SS-PSH on patient-centered quality of life, health care use, and health behaviors that reduce COVID-19 risk, which can influence future public health approaches to homelessness and infectious diseases. TRIAL REGISTRATION: ClinicalTrials.gov NCT04769349; https://clinicaltrials.gov/ct2/show/NCT04769349. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/46782.

Does stereotype threat influence age-related differences on directed forgetting tasks?

Objectives: The Directed Forgetting paradigm has proven to be a powerful tool to explore motivated forgetting in the lab. Past work has shown that older adults are less able to intentionally suppress information from memory relative to younger adults, which is often attributed to deficits in inhibitory abilities. Instructions in traditional Directed Forgetting tasks contain terms that may elicit stereotype threat in older adults, which may negatively impact memory. Here, we tested whether the instructions in a Directed Forgetting task affected older adults' ability to appropriately control the contents of memory. Methods: In two experiments that differed in the number of words presented (30 vs. 48 items), younger and older adults were randomized into one of four crossed Conditions of a Directed Forgetting task. At encoding, participants were either instructed to remember/ forget items, or to think about/not think about items. At test, they were either asked whether the memory probe was old or new, or whether they had seen it before (yes/no). Each experiment contained data from 100 younger (18- 40 years) and 98 older (60+ years) adults, with ~25 participants per Condition. All participants were recruited from Prolific and tested online. Results: In neither Experiment 1 nor Experiment 2 did we find evidence of a stereotype threat effect, or age-related effects of directed forgetting. We did find that performance for to-be-forgotten items was worse in conditions with encoding instructions that contained words that might trigger stereotype threat relative to conditions that did not contain such words: when explicitly told to forget items, both older and younger adults forgot more items than did participants who were cued to not think about the words and put them out of mind. However, we found no such difference across the two different remember instructions: regardless of whether participants were told to remember or to think about items, recognition memory for to be retained items was high. The pattern of results across the two experiments was similar, except, not surprisingly, participants performed worse in Experiment 2 than Experiment 1. Interestingly, we found that higher accuracy for to be remembered items was associated with a more positive outlook of one's own memory relative to others. Discussion: These results suggest that directed forgetting may not always be impaired in older adults.

Revisiting revitalization: exploring how structural determinants moderate pathways between neighborhood change and health.

Vacant housing can produce many issues that affect residents' quality of life, especially in historically segregated communities of color. To address these challenges, local governments invest in strategic, place-based revitalization initiatives focused on the regeneration of vacant housing. Yet, the outcomes of these efforts remain contested. To maximize health benefits of revitalization investments, a more nuanced understanding of pathways between neighborhood changes and residents' responses, adaptations, and ability to thrive is necessary, though, remains largely absent in the literature. Using the Vacants to Value initiative in Baltimore, MD as a case study, we explore (1) how health manifests among certain groups in the context of vacant housing revitalization; (2) how vacant housing and its regeneration engender social and cultural environmental change i.e., gentrification; and (3) what structural determinants (cultural norms, policies, institutions, and practices) contribute to the distribution of material resources and benefits of revitalization. Results suggest that vacant housing revitalization requires more than just physical remedies to maximize health. Our findings demonstrate how vacant housing revitalization influences the physical environment, social environment, and structural determinants of material resources and community engagement that can ultimately impact residents' physical, mental, and social health. This study recommends that because housing disparities are rooted in structural inequalities, how policies, practices, and processes moderate pathways for residents to adapt and benefit from neighborhood changes is consequential for health and health equity. Establishing shared governance structures is a promising approach to foster equitable decision-making and outcomes. Going forward in urban regeneration, pathways to retain and strengthen the social environment while revitalizing the physical environment may be promising to achieve healthy communities.

A qualitative exploration of daily path and daily routine among people in Ukraine who inject drugs to understand associated harms.

BACKGROUND: Patterns of movement, heterogeneity of context, and individual space-time patterns affect health, and individuals' movement throughout the landscape is shaped by addiction, meeting basic needs, and maintaining relationships. Place and social context enable or constrain behavior and individuals use social networks and daily routines to accomplish individual goals and access resources. METHODS: This article explores drug use as part of daily routines and daily paths among people who inject drugs in Dnipro City, Ukraine. Between March and August 2018, we interviewed 30 people who inject drugs living in Dnipro City, Ukraine. Study participants completed a single interview that lasted between 1 and 2 hours. During the interview, participants described their daily routine and daily path using a printed map of Dnipro as a prompt. Participants were asked to draw important sites; give time estimates of arrival and departure; and annotate on the map the points, paths, and areas most prominent or important to them. Participants also described to what extent their daily routines were planned or spontaneous, how much their daily path varied over time, and how drug use shaped their daily routine. RESULTS: We identified 3 major types of daily routine: unpredictable, predictable, and somewhat predictable. Participants with unpredictable daily routines had unreliable sources of income, inconsistent drug suppliers and drug use site, and dynamic groups of people with whom they socialized and used drugs. Participants with predictable daily routines had reliable sources of income, a regular drug dealer or stash source, and a stable group of friends or acquaintances with whom they bought and/or used drugs. Participants with somewhat predictable daily routines had some stable aspects of their daily lives, such as a steady source of income or a small group of friends with whom they used drugs, but also experienced circumstances that undermined their ability to have a routinized daily life, such as changing drug use sites or inconsistent income sources. CONCLUSIONS: Greater attention needs to be paid to the daily routines of people who use drugs to develop and tailor interventions that address the place-based and social contexts that contribute to drug-use related risks.

Professionalism in Family Planning Care Workshop.

INTRODUCTION: When clinicians feel negative emotions toward patients, providinge patient-centered care can be difficult. This can occur in family planning scenarios, such as when a provider is uncomfortable with a patient choosing abortion. The Professionalism in Family Planning Care Workshop (PFPCW), framed around professionalism values, used guided reflection to foster self-awareness and empathy in order to teach future providers to provide patient-centered care. METHODS: In the PFPCW, learners discussed challenging patient interactions and family planning scenarios to develop self-awareness and identify strategies for maintaining therapeutic relationships with patients when they experience negative feelings toward them. We implemented the workshop across the United States and Canada and collected pre- and postsurvey data to evaluate program outcomes at Kirkpatrick evaluation levels of participant reaction and effects on learners' attitudes. RESULTS: A total of 403 participants participated in 27 workshops in which pre- and postworkshop surveys (70% and 46% response rates, respectively) were administered. Sixty-five percent of the participants were residents, and 36% had previously participated in a similar workshop. The majority (92%) rated the PFPCWs as worthwhile. Participants valued the discussion and self-reflection components. Afterward, 23% reported that their attitudes toward caring for people with unintended pregnancy changed to feeling more comfortable. Participants said they would employ self-reflection and empathy in future challenging interactions. DISCUSSION: In this pilot implementation study, our workshop provided learners with strategies for patient-centered care in challenging family planning patient interactions. We are currently modifying the workshop and evaluation program based on feedback.

Residents' Experiences of Negative Emotions toward Patients: Challenges to their Identities.

PhenomenonMedical learners are more likely than practicing physicians to experience negative emotions toward some patients whom they find challenging, and medical students experience such emotions related to their identity as learners. Little is known about experiences of residents, who are further along in their physician identity formation and have greater autonomy and competence. We explored and characterized how residents understand their experiences of the phenomenon of feeling negative emotions toward patients in relation to their identities as residents. Approach: In 2018, 305 final-year obstetrics and gynecology residents were invited to participate in interviews, which we conducted until reaching theoretical sufficiency. In semi-structured interviews conducted by phone, we probed interactions when residents felt negative emotions toward patients, including reasons for their feelings related to their professional identities, strategies, and curricular desires. The authors coded data and identified patterns using thematic analysis. Findings: Nineteen residents were interviewed by phone. Residents experienced negative emotions toward patients because of challenges to their identities as: physicians - wanting respect and specific unexpected patient behaviors; learners - desiring complete autonomy and experiencing challenges with attending physicians; teachers - wanting to be a role model and protect junior learners; and workers - trying to complete tasks. Among the strategies used to manage feelings toward patients, they struggled with "venting", or complaining about patients, which was not always helpful and residents recognized as perceived negatively by students. They desired curricular support for these interactions such as debriefs and other supported reflection, faculty modeling, and communication skills training. Insights: Like medical students and physicians in practice, residents experience negative emotions toward patients, often because of and made more difficult by their identities as physicians, learners, teachers, and workers. Educators should support residents' reflections about these interactions, model compassionate behavior when feeling challenged by patients, and address unhealthy coping strategies.

Beyond Proximity and Towards Equity: A Multidimensional View of Urban Greenspace Access.

Park access is primarily conceived of as a question of proximity. We sought to develop a multidimensional tool based on a broad theory of green space access to better understand objective and subjective factors that capture varying dimensions of urban green space access that may be associated with its use. Methods: We conducted a cross-sectional study in two communities bordering a large park in Baltimore City, Maryland. We randomly selected households for an in-person survey conducted between April to September 2019. Our primary outcome was self-reported number of park visits over the last 30 days. The main independent variables conceptualized park access based on Penchansky and Thomas' theory of access. Results: Based on 87 respondents, living within a 10-minute walk was not associated with park use. Park use was associated with the perception that there were park events that individuals could participate in (adjusted IRR 6.83 [95% CI 2.57, 18.2]) and feeling safe in the park during the day (adjusted IRR 6.26 [95% CI 2.18, 18.0]). Those who reported that living near the park was affordable reported fewer park visits (adjusted IRR 0.53 [95% CI 0.32, 0.86]). Conclusions: Physical proximity was not significantly associated with green space use, but perceptions of safety, programming, and neighborhood affordability were. Our findings highlight the importance of subjective factors as part of a broader theory of park access.

The mental health of Asian American adolescents and young adults amid the rise of anti-Asian racism.

Objectives: We describe the perceptions and experiences of anti-Asian racism and violence and depression severity prior to and during the COVID-19 pandemic among a sample of Asian American (AA) adolescents and young adults. Methods: We used data from the Young Asian American Health Survey (YAAHS), an online-recruited sample of AA adolescents (ages 13-17) and young adults (ages 18-29 years) conducted during May 2021 to March 2022. We presented descriptive statistics examining the univariate distribution and bivariate relationships of depression severity, sociodemographic characteristics, and experiences and perceptions of anti-Asian violence. Results: Our sample (n = 176) comprised AA adolescents and young adults from 17 Asian ethnicities. A quarter said that the frequency and/or severity of their personal experiences of anti-Asian harassment had increased since the pandemic started. 76% indicated feeling less safe now than before the pandemic. Two-thirds reported that their depressive symptoms have increased since the pandemic started. Participants who reported feeling less safe now than before the pandemic were more likely to report increased personal experiences with anti-Asian harassment and increased depression severity since the pandemic started than those who reported feeling as safe or safer before the pandemic (p < 0.01 for both). Discussion: Findings illustrate AA adolescent and young adults are experiencing multiple health and social crises stemming from increased anti-Asian racism during the COVID-19 pandemic. We urge policymakers to strengthen data systems that connect racial discrimination and mental health and to institute prevention measures and anti-racist mental health services that are age- and culturally-appropriate for AA adolescent and young adults.

Patterns of Sex Work Client Solicitation Settings and Associations with HIV/STI Risk Among a Cohort of Female Sex Workers in Baltimore, Maryland.

Female sex workers' (FSWs) risk for HIV/STIs is influenced by their work environments. While previous research has characterized vulnerability in a single workplace, many FSWs solicit clients from multiple settings. Using latent class analysis (LCA), we examined client solicitation patterns and associated HIV/STI-related behaviors (consistent condom use with clients, asking clients about HIV/STIs, and past 6-month HIV/STI testing) among 385 FSWs in Baltimore, Maryland. The LCA yielded a three-class solution: predominantly street (61.2%), mixed street/venue (23.7%), and multisource (street, venue, and online) (15.1%). Consistent condom use differed significantly (p < 0.01) by class, with the mixed street/venue having the lowest (40.6%) rate and the multisource having the highest (70.6%). Classes differed on HIV/STI testing (p < 0.01), with the predominantly street class having the lowest testing rate (56.2%) and multisource with the highest (85.7%). These findings underscore the importance of considering how solicitation patterns are linked to HIV/STI susceptibility of FSWs and adapting interventions accordingly.

Characterizations of motivation and identity in medical students' reflections about challenging patient interactions.

Purpose: Students' negative emotions in patient interactions can relate to their learning motivation and identity. Educators can support learning from these interactions by advocating for reflection. We explored how students, in reflection essays about emotionally difficult patient interactions that challenged their notions of professionalism, described aspects of motivation and identity. Materials and Methods: All third-year medical students on the ob-gyn clerkship complete written reflections about a "clinical situation that challenged or affirmed your professionalism." We conducted directed content analysis of essays (academic years 2014-2017) using relevant theories (self-determination, goal orientation and identity formation) based on previous work and organized the data into categories. Results: In 265 essays (of 396, 67%), students described patient interactions that challenged their notions of professionalism, of which 90% included descriptions of their emotions. When reflecting on these interactions, students described psychological needs acknowledged in self-determination theory, competence, autonomy in patient care and connection to the team. Students indicated challenges in identity when advocating for patients due to team hierarchy and evaluation concerns. Conclusions: Reflection essays about difficult patient interactions allow students to explore emotions, motivation and identity. They help educators understand whether the clinical learning environment is meeting students' needs to support learning in challenging interactions.

Sources of support for and resistance to abortion training in obstetrics and gynecology residency programs.

BACKGROUND: Only 64% of obstetrics and gynecology program directors report routine, scheduled training in abortion, despite the Accreditation Council for Graduate Medical Education's requirements for routine training. Most report that exposure to training is limited to specific clinical circumstances. OBJECTIVE: We sought to describe residency program directors' perspectives of support for and resistance to abortion training in residency training programs in the United States. MATERIALS AND METHODS: A national survey of directors explored the availability of abortion training as well as support for and resistance to abortion training within their departments and institutions. In addition, directors who indicated that training was not available at all, available only as an elective, or as routine but limited to specific clinical circumstances, were also asked which procedures were limited, in what ways, and by whom. Descriptive and bivariate analyses were performed. RESULTS: A total of 190 residency program directors (79%) responded from throughout the United States (30% in the Northeast, 30% in the South, 23% in the Midwest, and 16% in the West), and 14% described their program as religiously affiliated. Most directors (73%) reported at least some institutional or government restrictions to training, and reported an average of 3 types of restrictions. Hospital policy was the most commonly reported restriction, followed by state law. Programs with routine abortion training reported an average of 2 restrictions, compared with 4 restrictions in programs with optional training, and 5 restrictions in programs with no abortion training. CONCLUSION: Significant barriers to integrating abortion training into residents' schedules continue to exist decades after the Accreditation Council for Graduate Medical Education training mandate. We should use these data to develop better support and targeted strategies for increasing the number of trained abortion providers in the United States.