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.

Impact of a Multi-Institutional Initiative to Engage Students and Early-Stage Scholars From Underrepresented Racial and Ethnic Minority Groups in HIV Research: The Centers for AIDS Research Diversity, Equity, and Inclusion Pathway Initiative.

BACKGROUND: The Centers for AIDS Research Diversity, Equity, and Inclusion Pathway Initiative (CDEIPI) aims to establish programs to develop pathways for successful careers in HIV science among scholars from underrepresented racial and ethnic populations. This article describes cross-site evaluation outcomes during the first 18 months (July 2021-December 2022) across 15 programs. METHODS: The aims of the evaluation were to characterize participants, describe feasibility, challenges, and successes of the programs and provide a basis for the generalizability of best practices to Diversity, Equity, and Inclusion (DEI) programs in the United States. Two primary data collection methods were used: a quarterly programmatic monitoring process and a centrally managed, individual-level, participant quantitative and qualitative survey. RESULTS: During the first year of evaluation data collection, 1085 racially and ethnically diverse scholars ranging from the high school to postdoctoral levels applied for CDEIPI programs throughout the United States. Of these, 257 (23.7%) were selected to participate based on program capacity and applicant qualifications. Participants were trained by 149 mentors, teachers, and staff. Of the N = 95 participants responding to the individual-level survey, 95.7% agreed or strongly agreed with statements of satisfaction with the program, 96.8% planned to pursue further education, and 73.7% attributed increased interest in a variety of HIV science topics to the program. Qualitative findings suggest strong associations between mentorship, exposure to scientific content, and positive outcomes. CONCLUSIONS: These data provide evidence to support the feasibility and impact of novel DEI programs in HIV research to engage and encourage racially and ethnically diverse scholars to pursue careers in HIV science.

Centers for AIDS Research (CFAR) Diversity, Equity, and Inclusion Pathway Initiative (CDEIPI): Developing Career Pathways for Early-Stage Scholars From Racial and Ethnic Groups Underrepresented in HIV Science and Medicine.

BACKGROUND: There is an urgent need to increase diversity among scientific investigators in the HIV research field to be more reflective of communities highly affected by the HIV epidemic. Thus, it is critical to promote the inclusion and advancement of early-stage scholars from racial and ethnic groups underrepresented in HIV science and medicine. METHODS: To widen the HIV research career pathway for early-stage scholars from underrepresented minority groups, the National Institutes of Health supported the development of the Centers for AIDS Research (CFAR) Diversity, Equity, and Inclusion Pathway Initiative (CDEIPI). This program was created through partnerships between CFARs and Historically Black Colleges and Universities and other Minority Serving Institutions throughout the United States. RESULTS: Seventeen CFARs and more than 20 Historically Black Colleges and Universities and Minority Serving Institutions have participated in this initiative to date. Programs were designed for the high school (8), undergraduate (13), post baccalaureate (2), graduate (12), and postdoctoral (4) levels. Various pedagogical approaches were used including didactic seminar series, intensive multiday workshops, summer residential programs, and mentored research internship opportunities. During the first 18 months of the initiative, 257 student scholars participated in CDEIPI programs including 150 high school, 73 undergraduate, 3 post baccalaureate, 27 graduate, and 4 postdoctoral students. CONCLUSION: Numerous student scholars from a wide range of educational levels, geographic backgrounds, and racial and ethnic minority groups have engaged in CDEIPI programs. Timely and comprehensive program evaluation data will be critical to support a long-term commitment to this unique training initiative.

Developing an Inclusive Generation of HIV Researchers Through Diversity and Community.

BACKGROUND: The DC Center for AIDS Research Diversity, Equity, and Inclusion Pathway Initiative (CDEIPI) is designed to increase the number of underrepresented minority (URM) students engaged in HIV research by providing an opportunity to participate in research and developing a sense of self-efficacy and community. SETTING: Currently in its second year, the program provides high school (HS) and undergraduate (UG) URM students (CFAR scholars) HIV mentored-research opportunities, and a range of professional development, outreach, and volunteer opportunities meant to build a sense of community and promote self-efficacy. A near-peer mentoring program, led by graduate students leads (GSL), was added in the second year to enhance community building. METHODS: We conducted a descriptive evaluation of the program using both individual surveys distributed to program participants and a series of focus groups conducted with current HS and UG scholars, and GSL. RESULTS: Based on initial evaluation results, this program was able to recruit a diverse group of scholars who have persisted in mentored HIV research, increased interests in pursuing careers in HIV research and care, developed research competencies, and increased confidence and self-efficacy. CONCLUSION: Our long-term goal is to build on this program by annually recruiting new cohorts, providing multiyear support to UG scholars, and developing additional evaluation tools to measure program impacts on the career trajectories of program participants, and identify program characteristics associated with those impacts.

"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.

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).

Eviction, post-traumatic stress, and emergency department use among low-income individuals in New Haven, CT.

We sought to examine whether and how landlord-related forced moves (inclusive of, but not limited to, legal eviction) were associated with emergency department (ED) use over time. We used survey data collected between 2017 and 2019 among 283 low-income participants in New Haven, CT to examine whether experiencing a legal eviction or other landlord-related forced move (T0) was associated with increased odds of ED use 6 months (T1) and 12 months (T2) later. We conducted bootstrapped mediation analyses to examine indirect effects of post-traumatic stress symptoms. One-fifth of participants (n = 61) reported a recent forced move at baseline (T0); half of these were legally evicted. Landlord-related forced moves were associated with ED use at T1 (AOR = 2.06, 95 % CI: 1.04-4.06) and T2 (AOR = 3.05, 95 % CI: 1.59-5.88). After adjustment for sociodemographic factors and other health-related confounders, legal eviction was not significantly associated with ED use at T1 (AOR = 1.61, 95 % CI: 0.68-3.81), but was significantly associated with ED use at T2 (AOR = 3.58, 95 % CI: 1.58-8.10). Post-traumatic stress symptoms accounted for 15.1% of forced moves' association with ED use (p <.05). Landlord-related forced moves are positively associated with subsequent ED use, and post-traumatic stress symptoms are one factor that may help explain this association. Structural interventions that promote housing stability are needed to advance health equity, and they may also help to reduce preventable ED use. Such interventions are imperative in the context of the COVID-19 pandemic, which has strained health system capacity and exacerbated housing instability for many low-income renters. Results underscore the relevance of trauma-informed care and integrated care management to clinical practice in emergency settings.

"I was reaching out for help and they did not help me": Mental healthcare in the carceral state.

BACKGROUND: Despite the limitations the carceral environment may impose on mental wellness, mental healthcare is increasingly becoming a carceral endeavor. Over the course of the last several decades, prisons and jails have become the de facto mental healthcare provider for thousands of incarcerated individuals. Furthermore, practices like mandated mental healthcare for supervised individuals further broaden the population experiencing mental healthcare within the criminal legal system at large. This study examines the perspectives of nine individuals who experienced mental healthcare within the carceral state, whether in prison or on parole or probation, with a special focus on how attributes of the carceral state create ideological and functional barriers to effective mental healthcare. METHODS: Data for the parent study of this analysis was collected via in-depth, one-on-one interviews of about one hour's length, conducted at six-month intervals over the course of 2 years. These interviews were analyzed using an iterative process of open-coding, thematic code development, and code application to participant interviews. RESULTS: The results showed a common perception of mental healthcare received within the carceral state as serving goals of the prison system, including control and punishment, rather than therapeutic goals of healing and empowerment. This often had negative implications for the quality of the treatment received, including patterns of diagnostic ambiguity, treatment that was ill-fitting to participants' needs, and treatment that was undermined by the new trauma created by the prison environment. The results also highlighted racial disparities prevalent within the carceral system. Despite the barriers created by the subjection of therapeutic practices to carceral goals, participants demonstrated resourcefulness and creativity in engaging with these treatment modalities to reap benefits where possible. CONCLUSIONS: Overall, these results highlight the inappropriateness of combining therapeutic and carceral spaces, the need for greater public attention to how carceral mechanisms disadvantage vulnerable populations, and the need for a cultural reconceptualization of mental illness such that it is met not with criminal punishment but appropriate care.

Association Between Rental Assistance Programs and Hemoglobin A1c Levels Among US Adults.

Importance: Programs that provide affordable and stable housing, such as federal rental assistance, may be associated with improved mean blood glucose levels and related diabetes outcomes. Objective: To assess whether 2 different types of federal rental assistance programs are associated with glycated hemoglobin A1c (HbA1c) levels among middle-aged and older US adults. Design, Setting, and Participants: This cohort study used data from the National Health and Nutrition Examination Survey (NHANES) linked with US Department of Housing and Urban Development records of rental assistance participation. Adults aged 45 years or older who were receiving 2 types of rental assistance (project-based housing or housing vouchers) at the time of the NHANES interview and those who would receive rental assistance within the subsequent 2 years (waitlist group) were included. Data were collected from January 1999 to December 2016 and analyzed in October 2021. Exposures: Rental assistance participation, including project-based housing (subsidized housing developments including public housing) and housing vouchers (tenant-based subsidies for private market housing). Main Outcomes and Measures: The primary outcome was continuous HbA1c level, a common measure of blood glucose reflecting diabetes control. Linear regression was used to estimate the association between the 2 rental assistance programs and HbA1c level. Logistic regression was used to assess the association between rental assistance programs and HbA1c cut points (prediabetes: 5.7% to ≤6.5%; diabetes: >6.5%; uncontrolled diabetes: ≥9% [to convert to proportion of total Hb, multiply by 0.01]). Analyses used weights created by the National Center for Health Statistics that adjust for linkage eligibility. Results: Among 1050 adults in the study (41.6% aged ≥65 years; 70.1% female), 795 were receiving rental assistance at time of the NHANES interview (450 lived in project-based housing, and 345 had housing vouchers), and 255 received rental assistance within 2 years after the interview. Participants in project-based housing had lower HbA1c levels compared with individuals in the waitlist group (ß, -0.290; 95% CI, -0.599 to 0.020), but the difference was not significant. No significant differences in HbA1c levels were found between those receiving housing vouchers and those in the waitlist group (ß, 0.051; 95% CI, -0.182 to 0.284). Receiving project-based housing was associated with a reduced likelihood of uncontrolled diabetes (-3.7 percentage points; 95% CI, -7.0 to -0.0 percentage points) compared with being in the waitlist group. Conclusions and Relevance: In this cohort study of a nationally representative sample of US adults, living in project-based, federally subsidized housing was associated with a reduced likelihood of uncontrolled diabetes. The findings suggest that affordable housing programs may be associated with improved diabetes outcomes.

The Effects of Rental Assistance on Housing Stability, Quality, Autonomy, and Affordability.

Federal rental assistance is an important source of affordable housing for low income households, given a growing and severe affordable housing crisis. However, few studies have examined the extent to which rental assistance may improve housing access. This paper examines associations between rental assistance receipt and four dimensions of housing: quality, stability, autonomy and affordability. We draw on data from a longitudinal cohort study of low-income adults in New Haven, Connecticut and use Generalized Estimating Equations to examine associations between rental assistance receipt and housing measures. We find that participants receiving rental assistance had lower odds of reporting housing instability, low quality housing, lack of autonomy related to housing, and some measures of housing unaffordability compared to those not receiving assistance. The large and highly significant effects remain after adjusting for demographic variables and factors that can impact access to rental assistance.

Eviction, intimate partner violence and HIV: Expanding concepts and assessing the pathways through which sexual partnership dynamics impact health.

Over 2 million renters in the United States are legally evicted annually, and even more renters experience other landlord-related forced moves each year. While past research has documented an association between legal eviction and HIV risk, no studies have examined the relationship between forced moves and sexual partnership dynamics longitudinally, or the pathways through which forced moves impact such risk. Addressing this gap is imperative, particularly given inequities that place Black renters and women at disproportionate risk of eviction. This study leverages data from a longitudinal cohort study of 282 adults in New Haven to examine whether landlord-related forced moves reported at baseline (including, but not limited to, legal eviction) is associated with HIV sexual risk reported six months later. We use bootstrapped path analyses to examine intimate partner violence (IPV) victimization and perpetration as potential mediators. One-fifth of participants (21.2%) had experienced a landlord-related forced move at baseline. At follow up, nearly two-thirds (63.8%) reported at least one HIV sexual risk factor, one in seven (14.2%) reported IPV victimization, and one in ten (10.3%) reported IPV perpetration. Individuals who reported landlord-related forced moves were more likely to report IPV victimization (standardized ß = 0.19, SE = 0.08, p = .02) and IPV perpetration (ß = 0.25, SE = 0.09, p = .003). Both IPV victimization and perpetration mediated the association between landlord-related forced moves and HIV sexual risk (indirect victimization effect, ß = 0.09, SE = 0.05, p = .06; indirect perpetration effect, ß = 0.16, SE = 0.07, p = .02), though IPV victimization was only marginally significant. In conclusion, IPV is itself a negative consequence of forced moves that also contributes to other negative health effects, like HIV risk. Therefore, providers should offer violence screening and referral for clients who have recently faced a forced move. Simultaneously, policy-level solutions to prevent eviction and increase housing affordability are urgently needed to address the rising burden - and inequitable distribution - of evictions among low-income renters.

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.

Association between local public housing authority policies related to criminal justice system involvement and sexually transmitted infection rates.

The policies of U.S. local public housing authorities influence which populations have access to stable housing, an important resource for health. We assessed whether the restrictiveness of local public housing authority policies related to people with criminal justice histories-a population at high risk for HIV/STIs-were associated with HIV/STI rates at the local-level. An ecological analysis was conducted using data from 107 local public housing authority jurisdictions. The independent variable was a score that quantified the presence/absence of eight policies related to the ability of people with criminal justice histories to obtain and retain public housing. The dependent variables were county-level rates of HIV, gonorrhea, syphilis, and chlamydia. Ordinary least squares regression with state fixed effects was used. We find that the restrictiveness of housing authority policies towards people with criminal justice histories were significantly associated with higher HIV and gonorrhea rates, but not syphilis or chlamydia. For example, local housing authorities with a policy score more restrictive than the median score had an additional 6.05 cases of HIV per 100,000 population (32.9% increase relative to the mean rate) and 84.61 cases of newly diagnosed gonorrhea (41.3% increase). Local public housing authority policies related to people with criminal justice histories could affect HIV/STI risk at the population-level. These policies should be considered in studies and interventions at the intersection of housing, health, and justice involved populations.

Does rental assistance improve mental health? Insights from a longitudinal cohort study.

Almost half of renters in the United States are rent-burdened, meaning that they pay more than 30% of their income toward housing costs. Rental assistance through programs administered by the U.S. Department of Housing and Urban Development, alleviates these financial strains for around 5 million households. However, due to budgetary constraints, fewer than one in four eligible households actually receive this assistance and waitlists average two years nationally. Using longitudinal data from a cohort of 400 low-income adults living in New Haven, CT, this paper investigates how access to rental assistance affects mental health through two analytical methods that address selection into rental assistance. First, we performed a cross-sectional analysis to identify how psychological distress differs among those receiving and those on a waitlist for rental assistance. Second, we used a within-person fixed-effects analysis to compare changes in individuals following entry into rental assistance. We find that those receiving rental assistance report significantly less psychological distress than those on waiting lists and that transitions into rental assistance are associated with statistically non-significant decreases in psychological distress. Our findings suggest that expanding rental assistance may be one potential step toward improving the mental health of low-income individuals in the United States.

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.

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.

"I don't know what home feels like anymore": Residential spaces and the absence of ontological security for people returning from incarceration.

Housing is central to health equity, and mass incarceration is an important but understudied aspect of housing vulnerability and health inequity. One way in which housing can be linked to health and health inequity is through ontological security. Ontological security, or a sense of feeling at home, is comprised of constancy, daily routines, privacy, and a basic security that enables the development of one's identity. It has been theorized as a mechanism by which people reap the health benefits of housing. Based on two waves of interviews in 2017-2018 with a sample of 27 people returning from incarceration in a northeast U.S. city, we describe participants' residential experiences during the first two years after release. Participants lived in residential group settings, with friends, partners and family, or were homeless. They experienced impermanence, punitive place rules, surveillance, and a lack of control. In contrast, participants spoke about their idea of home, imagined from the past or for the future, as a place of privacy, control, and wellbeing. This analysis expands the study of ontological security by detailing its absence among people returning from incarceration. The concept of ontological security holds promise in delineating the ways in which housing provides health benefits, and is particularly useful for understanding the needs and experiences of those returning from prison and seeking to restart their lives in the community. Relatedly, participant narratives point to the expansion of the carceral state beyond prison, including into residential space, with implications for the intersection of housing and health equity.