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.

Mixed Methods for Research on Support Networks of People Experiencing Chronic Illness and Social Marginalization.

Substantial research has focused on how social networks help individuals navigate the illness experience. Sociologists have begun to theorize beyond the binary of strong and weak social network ties (e.g., compartmental, elastic, and disposable ties), citing the social, economic, and health conditions that shape their formation. However, limited research has employed mixed social network methods, which we argue is especially critical for examining the "non-traditional" social support networks of marginalized individuals. We employ quantitative social network methods (i.e., the egocentric network approach) in addition to in-depth interviews and observations, with a novel tool for capturing network data about social groups, to surface these kinds of supportive relationships. Using the case of "nameless ties"-non-kin, non-provider ties who were unidentifiable by given name or were grouped by context or activity rather than individually distinguished-we show how mixed social network methods can illuminate supporters who are commonly overlooked when only using traditional social network analysis. We conclude with a proposal for mixed methods and group alter approaches to successfully observe liminal support ties that is ideal for research about individuals experiencing chronic disability, poverty, housing insecurity, and other forms of social marginalization.

Pesticide Take-Home Pathways, Storage, and Application Methods Among Hmong Farmers in Central Valley, California.

OBJECTIVE: Pesticide exposure via take-home pathways is a major health concern among farmers. However, little is known about the effects of pesticide take-home pathways on small-scale Hmong farmers in the Central Valley. This study explored factors that contribute to pesticide exposure via the take-home pathway among small-scale Hmong farmers in the Central Valley. METHODS: Detailed ethnographic observations of small-scale farms and corresponding homes were coupled with in-depth qualitative interviews with Hmong farmers to assess the extent of the pesticide take-home pathway. RESULTS: The study found daily challenges and numerous ways that pesticide particles may be introduced into farmers' homes. Given the paucity of research about Hmong farmers' pesticide take-home pathways, the study's findings advance the scholarship on pesticide exposures in the Hmong farmer community. CONCLUSION: This study advocates for more culturally and linguistically appropriate pesticide exposure training and educational programs tailored to Hmong farmers in the United States.

Childhood Residential Mobility and Mental and Physical Health in Later Life: Findings From the Reasons for Geographic and Racial Differences in Stroke (REGARDS) Study.

The study objective was to investigate the effects of childhood residential mobility on older adult physical and mental health. In REasons for Geographic and Racial Differences in Stroke (REGARDS) Study, we used linear regression models to investigate if number of moves during childhood predicted mental and physical health (SF-12 MCS, PCS), adjusting for demographic covariates, childhood socioeconomic status (SES), childhood social support, and adverse childhood experiences (ACEs). We investigated interaction by age, race, childhood SES, and ACEs. People who moved more during childhood had poorer MCS scores, ß = -0.10, SE = 0.05, p = 0.03, and poorer PCS scores, ß = -0.25, SE = 0.06, p < 0.0001. Effects of moves on PCS were worse for Black people compared to White people (p = 0.06), those with low childhood SES compared to high childhood SES (p = 0.02), and high ACEs compared to low ACEs (p = 0.01). As family instability accompanying residential mobility, family poverty, and adversity disproportionately affect health, Black people may be especially disadvantaged.

Reproducibility and implementation of a rapid, community-based COVID-19 "test and respond" model in low-income, majority-Latino communities in Northern California.

OBJECTIVE: To evaluate implementation of a community-engaged approach to scale up COVID-19 mass testing in low-income, majority-Latino communities. METHODS: In January 2021, we formed a community-academic "Latino COVID-19 Collaborative" with residents, leaders, and community-based organizations (CBOs) from majority-Latinx, low-income communities in three California counties (Marin/Merced/San Francisco). The collaborative met monthly to discuss barriers/facilitators for COVID-19 testing, and plan mass testing events informed by San Francisco's Unidos en Salud "test and respond" model, offering community-based COVID-19 testing and post-test support in two US-census tracts: Canal (Marin) and Planada (Merced). We evaluated implementation using the RE-AIM framework. To further assess testing barriers, we surveyed a random sample of residents who did not attend the events. RESULTS: Fifty-five residents and CBO staff participated in the Latino collaborative. Leading facilitators identified to increase testing were extended hours of community-based testing and financial support during isolation. In March-April 2021, 1,217 people attended mass-testing events over 13 days: COVID-19 positivity was 3% and 1% in Canal and Planada, respectively. The RE-AIM evaluation found: census tract testing coverage of 4.2% and 6.3%, respectively; 90% of event attendees were Latino, 89% had household income <$50,000/year, and 44% first-time testers (reach), effectiveness in diagnosing symptomatic cases early (median isolation time: 7 days) and asymptomatic COVID-19 (41% at diagnosis), high adoption by CBOs in both counties, implementation of rapid testing (median: 17.5 minutes) and disclosure, and post-event maintenance of community-based testing. Among 265 non-attendees surveyed, 114 (43%) reported they were aware of the event: reasons for non-attendance among the 114 were insufficient time (32%), inability to leave work (24%), and perceptions that testing was unnecessary post-vaccination (24%) or when asymptomatic (25%). CONCLUSION: Community-engaged mass "test and respond" events offer a reproducible approach to rapidly increase COVID-19 testing access in low-income, Latinx communities.

A Qualitative Investigation of the Experiences of Tobacco Use among U.S. Adults with Food Insecurity.

BACKGROUND: Low-income U.S. adults experiencing food insecurity have a disproportionately high prevalence of cigarette smoking, and quantitative studies suggest that food insecurity is a barrier to quitting. To guide effective tobacco control strategies, this study aimed to understand the experiences, perceptions, and context of tobacco use and cessation among low-income populations experiencing food insecurity. METHODS: We conducted in-depth, semi-structured interviews with 23 adults who were currently smoking cigarettes and were experiencing food insecurity, mostly living in rural settings. Participants were recruited through food-pantry-based needs assessment surveys and study flyers in community-based organizations. The interview guide explored participants' histories of smoking, the role and function of tobacco in their lives, their interest in and barriers to quitting, as well as lived experiences of food insecurity. We used reflexive thematic analysis to analyze transcribed interviews. RESULTS: Within a broader context of structural challenges related to poverty and financial strain that shaped current smoking behavior and experiences with food insecurity, we identified the following five themes: smoking to ignore hunger or eat less; staying addicted to smoking in the midst of instability; smoking being prioritized in the midst of financial strain; life stressors and the difficulty of quitting smoking and staying quit; and childhood adversity at the intersection of food insecurity and tobacco use. CONCLUSION: The context of tobacco use among adults with food insecurity was highly complex. To effectively address tobacco-related disparities among those who are socially and economically disadvantaged, tobacco control efforts should consider relevant lived experiences and structural constraints intersecting smoking and food insecurity. Findings are applied to a conceptualization of clustering of conditions contributing to nicotine dependence, food insecurity, and stress.

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

'You run out of hope': an exploration of low-income parents' experiences with food insecurity using Photovoice.

OBJECTIVE: Using an adaption of the Photovoice method, this study explored how food insecurity affected parents' ability to provide food for their family, their strategies for managing household food insecurity and the impact of food insecurity on their well-being. DESIGN: Parents submitted photos around their families' experiences with food insecurity. Afterwards, they completed in-depth, semi-structured interviews about their photos. The interviews were transcribed and analysed for thematic content using the constant comparative method. SETTING: San Francisco Bay Area, California, USA. PARTICIPANTS: Seventeen parents (fourteen mothers and three fathers) were recruited from a broader qualitative study on understanding the experiences of food insecurity in low-income families. RESULTS: Four themes were identified from the parents' photos and interviews. First, parents described multiple aspects of their food environment that promoted unhealthy eating behaviours. Second, parents shared strategies they employed to acquire food with limited resources. Third, parents expressed feelings of shame, guilt and distress resulting from their experience of food insecurity. And finally, parents described treating their children to special foods to cultivate a sense of normalcy. CONCLUSIONS: Parents highlighted the external contributors and internal struggles of their experiences of food insecurity. Additional research to understand the experiences of the food-insecure families may help to improve nutrition interventions targeting this structurally vulnerable population.

"Housing Is Health Care": Treating Homelessness in Safety-net Hospitals.

As medicine integrates social and structural determinants into health care, some health workers redefine housing as medical treatment. This article discusses how health workers in two U.S. urban safety-net hospitals worked with patients without stable housing. We observed ethnographically how health workers helped patients seek housing in a sharply stratified housing economy. Analyzing in-depth interviews and observations, we show how health workers: (1) understood housing as health care and navigated limits of individual care in a structurally produced housing crisis; and (2) developed and enacted practices of biomedical and sociopolitical stabilization, including eligibilizing and data-tracking work. We discuss how health workers bridged individually focused techniques of clinical care with structural critiques of stratified housing economies despite contradictions in this approach. Finally, we analyze the implications of providers' extension of medical stabilization into social, economic, and political realms, even as they remained caught in the structural dynamics they sought to address.

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.

Housing Stability and Hepatitis C Infection for Young Adults Who Inject Drugs: Examining the Relationship of Consistent and Intermittent Housing Status on HCV Infection Risk.

Housing status affects drug using behaviors, but less is known about the relationship between housing patterns and hepatitis C virus (HCV) infection. HCV-negative young people who inject drugs (PWID) were enrolled into a prospective cohort (2003-2019) with quarterly study visits. We used Cox regression to estimate the independent association of recent housing status (housed vs. unhoused, housing stability, and housing trajectory) on HCV incidence. Among 712 participants, 245 incident HCV infections occurred over 963.8 person-years (py) (cumulative incidence 24.4/100 py). An inverse relationship between time housed and HCV incidence was observed (always unhoused 45.0/100 py, 95% confidence interval (CI) 37.1, 54.5; variably housed 18.0/100 py, 95% CI 15.0, 21.3; and always housed 7.0/100 py, 95% CI 3.0, 17.3). In Cox regression models controlling for confounders, those unhoused versus housed at baseline had a 1.9-fold increased infection risk (95% CI 1.4, 2.6). Those always unhoused versus always housed had a 1.5 times greater risk of HCV (95% CI 1.0, 2.3), and those spending a portion of time in stable housing a lower risk (adjusted relative hazard 0.05, 95% CI 0.3, 0.9) with a similar trend for those being housed for less time. Young adult PWID experiencing both recent and chronic states of being unhoused are at elevated risk for HCV infection. Importantly for this group of PWID, our findings indicate that some frequency of residential housing significantly reduces HCV infection risk.

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.

Linking food insecurity and smoking cessation: In response to "Food insecurity transitions and smoking behavior among older adults who smoke".

This Letter to the Editor raises questions regarding a recently published article, "Food insecurity transitions and smoking behavior among older adults who smoke."

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.