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4.  The Effect of Advance Directive Completion on Hospital Care Among Chronically Homeless Persons: a Prospective Cohort Study 
Advance care planning is relevant for homeless individuals because they experience high rates of morbidity and mortality. The impact of advance directive interventions on hospital care of homeless individuals has not been studied. The objective of this study was to determine if homeless individuals who complete an advance directive through a shelter-based intervention are more likely to have information from their advance directive documented and used during subsequent hospitalizations. The advance directive included preferences for life-sustaining treatments, resuscitation, and substitute decision maker(s). A total of 205 homeless men from a homeless shelter for men in Toronto, Canada, were enrolled in the study and offered an opportunity to complete an advance directive with the guidance of a trained counselor from April to June 2013. One hundred and three participants chose to complete an advance directive, and 102 participants chose to not complete an advance directive. Participants were provided copies of their advance directives. In addition, advance directives were electronically stored, and hospitals within a 1.0-mile radius of the shelter were provided access to the database. A prospective cohort study was performed using chart reviews to ascertain the documentation, availability, and use of advance directives, end-of-life care preferences, and medical treatments during hospitalizations over a 1-year follow-up period (April 2013 to June 2014) after the shelter-based advance directive intervention. Chart reviewers were blinded as to whether participants had completed an advance directive. The primary outcome was documentation or use of an advance directive during any hospitalization. The secondary outcome was documentation of end-of-life care preferences, without reference to an advance directive, during any hospitalization. After unblinding, charts were studied to determine whether advance directives were available, hospital care was consistent with patient preferences as documented in advance directives, and hospital resource utilization during admission. During the 1-year follow-up period, 38 participants who completed an advance directive and 37 participants who did not complete an advance directive had at least one hospitalization (36.9 vs. 36.2 %, p = 0.93). Participants who completed an advance directive were significantly more likely to have documentation or use of an advance directive in hospital, compared to participants who did not complete an advance directive (9.7 vs. 2.9 %, p = 0.047). Without reference to an advance directive, documentation of end-of-life care preferences occurred in 30.1 vs. 30.4 % of participants, respectively (p = 0.96), most often due to documentation of code status. There were no significant differences in resource utilization between admitted patients who completed and did not complete an advance directive. In conclusion, homeless men who complete an advance directive through a shelter-based intervention are more likely to have their detailed care preferences documented or used during subsequent hospitalizations.
Electronic supplementary material
The online version of this article (doi:10.1007/s11524-016-0105-2) contains supplementary material, which is available to authorized users.
doi:10.1007/s11524-016-0105-2
PMCID: PMC5359166  PMID: 28028678
Advance directives; Homeless; End-of-life care
5.  Longitudinal Associations between Change in Neighborhood Social Disorder and Change in Food Swamps in an Urban Setting 
Few studies have examined how neighborhood contextual features may influence the food outlet mix. We evaluated the relationship between changes in neighborhood crime and changes in the food environment, namely the relative density of unhealthy (or intermediate) food outlets out of total food outlets, or food swamp score, in Baltimore City from 2000 to 2012, using neighborhood fixed-effects linear regression models. Comparing neighborhoods to themselves over time, each unit increase in crime rate was associated with an increase in the food swamp score (b = 0.13; 95% CI, −0.00017 to 0.25). The association with food swamp score was in the same direction for violent crime and in the inverse direction for arrests related to juvenile crimes (proxy of reduced crime), but did not reach statistical significance when examined separately. Unfavorable conditions, such as crime, may deter a critical consumer base, diminishing the capacity of a community to attract businesses that are perceived to be neighborhood enhancing. Addressing these more distal drivers may be important for policies and programs to improve these food environments.
Electronic supplementary material
The online version of this article (doi:10.1007/s11524-016-0107-0) contains supplementary material, which is available to authorized users.
doi:10.1007/s11524-016-0107-0
PMCID: PMC5359167  PMID: 28074429
Food environment; Food swamp; Social disorder; Crime; Food outlets
6.  Developmental Patterns of Adolescent Marijuana and Alcohol Use and Their Joint Association with Sexual Risk Behavior and Outcomes in Young Adulthood 
Urban populations disproportionately experience poor sexual outcomes, including high rates of teenage pregnancy and sexually transmitted infections. However, the contribution of substance use across adolescence to poor sexual outcomes in young adulthood has not been investigated in depth, despite offering opportunities for more targeted prevention. This study aimed to estimate joint trajectories of adolescent alcohol and marijuana use to determine if they relate differently to four sexual outcomes: multiple sexual partners, sex without a condom, teenage pregnancy, and contraction of a sexually transmitted infection in young adulthood (by age 25). Data came from a longitudinal study of urban youth followed from age 6 to age 25, with annual assessments during adolescence and young adulthood (n = 608). The sample showed high levels of sexual risk, with young adults on average having sex without a condom once in the past month, 28.5% having multiple sexual partners in the past month, one quarter having contracted a sexually transmitted infection, and over 60% of the women being pregnant as a teenager and 36% of the men having gotten a partner pregnant. Applying longitudinal latent profile analysis to estimate joint trajectories of alcohol and marijuana use from grades 8–12, we identified four classes representing high dual use, moderate alcohol use, moderate alcohol use with increasing marijuana use, and non-use. Class membership differently predicted all four outcomes investigated with high dual users having the highest level of teenage pregnancy and the increasing marijuana trajectory having the highest risk of engaging with multiple sexual partners in the past month. Results suggest implications for both sexual risk and substance use prevention for urban youth.
doi:10.1007/s11524-016-0108-z
PMCID: PMC5359168  PMID: 28083726
African Americans; Blacks; Cannabis; HIV/AIDS; Latent profile analysis; Longitudinal patterns; Substance use effects
7.  How Feasible is Multiple Time Point Web-Based Data Collection with Individuals Experiencing Street Homelessness? 
Three barriers investigators often encounter when conducting longitudinal work with homeless or other marginalized populations are difficulty tracking participants, high rates of no-shows for follow-up interviews, and high rates of loss to follow-up. Recent research has shown that homeless populations have substantial access to information technologies, including mobile devices and computers. These technologies have the potential both to make longitudinal data collection with homeless populations easier and to minimize some of these methodological challenges. This pilot study’s purpose was to test whether individuals who were homeless and sleeping on the streets—the “street homeless”—would answer questions remotely through a web-based data collection system at regular “follow-up” intervals. We attempted to simulate longitudinal data collection in a condensed time period. Participants (N = 21) completed an in-person baseline interview. Each participant was given a remotely reloadable gift card. Subsequently, weekly for 8 weeks, participants were sent an email with a link to a SurveyMonkey questionnaire. Participants were given 48 h to complete each questionnaire. Data were collected about life on the streets, service use, community inclusion, substance use, and high-risk sexual behaviors. Ten dollars was remotely loaded onto each participant’s gift card when they completed the questionnaire within the completion window. A substantial number of participants (67% of the total sample and 86% of the adjusted sample) completed at least seven out of the eight follow-up questionnaires. Most questionnaires were completed at public libraries, but several were completed at other types of locations (social service agencies, places of employment, relative/friend/acquaintance’s domiciles, or via mobile phone). Although some of the questions were quite sensitive, very few participants skipped any questions. The only variables associated with questionnaire completion were frequency of computer use and education—both positive associations. This pilot study suggests that collecting longitudinal data online may be feasible with a subpopulation of persons experiencing homelessness. We suspect that participant follow-up rates using web-based data collection methods have the potential to exceed follow-up rates using traditional in-person interviews. If this population of persons experiencing street homelessness can be successful with this method of data collection, perhaps other disenfranchised, difficult-to-track, or difficult-to-reach populations could be followed using web-based data collection methods. Local governments are striving to decrease the “digital divide,” providing free or greatly discounted wi-fi connectivity as well as mobile computer lab access to low-income geographic areas. These actions, in combination with increased smart phone ownership, may permit vulnerable populations to connect and communicate with investigators.
doi:10.1007/s11524-016-0109-y
PMCID: PMC5359169  PMID: 28105585
Homeless; Longitudinal data collection; Information technology; Technology; Computers; Mobile phones; Tracking; No-show; Follow-up; Internet
8.  Comparing the Utilization and Cost of Health Services between Veterans Experiencing Brief and Ongoing Episodes of Housing Instability 
Housing instability is associated with costly patterns of health and behavioral health service use. However, little prior research has examined patterns of service use associated with higher costs among those experiencing ongoing housing instability. To address this gap, we compared inpatient and outpatient medical and behavioral health service utilization and costs between veterans experiencing brief and ongoing episodes of housing instability. We used data from a brief screening instrument for homelessness and housing instability that has been implemented throughout the US Department of Veterans Affairs (VA) health care system to identify a national sample of veterans experiencing housing instability. Veterans were classified as experiencing either brief or ongoing housing instability, based on two consecutive responses to the instrument, and we used a series of two-part regression models to conduct adjusted comparisons of costs between veterans experiencing brief and ongoing episodes of housing instability. Among 5794 veterans screening positive for housing instability, 4934 (85%) were experiencing brief and 860 (15%) ongoing instability. The average total annual incremental cost associated with ongoing versus brief episodes of housing instability was estimated at $7573, with the bulk of this difference found in inpatient services. Cost differences resulted more from a higher probability of service use among those experiencing ongoing episodes of housing instability than from higher costs among service users. Our findings suggest that VA programmatic efforts aimed at preventing extended episodes of housing instability could potentially result in substantial cost offsets for the VA health care system.
doi:10.1007/s11524-016-0110-5
PMCID: PMC5359170  PMID: 28116585
Housing; Homelessness; Veterans; Health service use
9.  Early Onset of Sexual Intercourse and Parental Incarceration among African American Youth Living in Urban Public Housing 
Mass incarceration, substance use, and adolescent early onset of sex (e.g., initiate sexual intercourse at 13 years of age or younger) are social problems with disparate impacts on low-income African American communities. Two out of every five inmates in state and federal prisons are African American and the vast majority of these inmates are from low-income communities. Furthermore, this population experiences more severe consequences of substance use and abuse compared to other populations. In sum, African American youth endure the lion share of problems that mass incarceration and substance use leave in their wake. It is likely that the early onset of sex reported by African American youth in national data is related to mass incarceration and substance use in their communities. Using a sample of 142 African American youth, this paper assesses whether parental incarceration or substance, or both, are related to the likelihood of early onset of sex. Analytic procedures included chi-square and sequential logistic regression. The sample reported a mean age of 19 and 36% reported early onset of sex. Being male, paternal incarcerated, and maternal alcohol problems were associated with an increased likelihood of early onset of sex. Results point to a need for supportive services for the children of incarcerated parents, particularly those living in urban public housing developments.
doi:10.1007/s11524-016-0111-4
PMCID: PMC5359171  PMID: 28116588
STI/HIV risk; Mass incarceration; Onset of sex; African American youth; Public housing; Substance use
10.  Relationship between Recreational Resources in the School Neighborhood and Changes in Fitness in New York City Public School Students 
Physical fitness in children has many beneficial effects, including the maintenance of a healthy weight. The built environment may influence youths’ physical fitness by encouraging physical activity. This paper assessed whether higher density of parks, playgrounds, and sports facilities around a school is related to improvements in fitness in middle school boys and girls. Fitness scores and other student covariates collected as part of NYC FITNESSGRAM between the 2006–2007 and 2010–2011 school years were linked with school neighborhood data on characteristics of the built environment for NYC public school students in grades 6–8. Data were analyzed in 2015. Medium, but not high, density of recreational resources in the area surrounding a school was associated with greater annual improvements in fitness for both boys and girls. This association appeared to be driven mainly by the presence of parks. Findings for sports facilities and playgrounds were inconsistent. Overall, few associations were observed between recreational resources near a school and changes in student fitness. Future studies of school influences on student fitness should consider the influence of school resources and the home neighborhood.
doi:10.1007/s11524-016-0114-1
PMCID: PMC5359172  PMID: 28116590
Fitness; Built environment; School health
11.  Occupational Safety in the Age of the Opioid Crisis: Needle Stick Injury among Baltimore Police 
At a time of resurgence in injection drug use and injection-attributable infections, needle stick injury (NSI) risk and its correlates among police remain understudied. In the context of occupational safety training, a convenience sample of 771 Baltimore city police officers responded to a self-administered survey. Domains included NSI experience, protective behaviors, and attitudes towards syringe exchange programs. Sixty officers (8%) reported lifetime NSI. Officers identifying as Latino or other race were almost three times more likely (aOR 2.58, 95% CI 1.12–5.96) to have experienced NSI compared to whites, after adjusting for potential confounders. Findings highlight disparate burdens of NSIs among officers of color, elevating risk of hepatitis, HIV, and trauma. Training, equipment, and other measures to improve occupational safety are critical to attracting and safeguarding police, especially minority officers.
doi:10.1007/s11524-016-0115-0
PMCID: PMC5359173  PMID: 28105586
Needle stick injury; Police; People who inject drugs
13.  Trends in Injection Risk Behaviors among People Who Inject Drugs and the Impact of Harm Reduction Programs in Ukraine, 2007–2013 
The study examined trends in injection risk behaviors among people who inject drugs (PWIDs) and assessed the impact of harm reduction programs in Ukraine during 2007–2013. We performed a secondary analysis of the data collected in serial cross-sectional bio-behavioral surveillance surveys administered with PWIDs in Ukraine in 2007, 2008, 2011, and 2013. Using data from 14 Ukrainian cities, we assessed short-term trends in injection risk behaviors with the Cochran-Armitage test for trend and multivariable logistic regression models, adjusted for age, sex, region, marital status, education level, occupation, age at injection drug use initiation, experience of overdose, and self-reported HIV status. The overall test for trend indicated a statistically significant decrease over time for sharing needle/syringe during the last injection (p < 0.0001), sharing needle/syringe at least once in the last 30 days (p < 0.0001), and using a common container for drug preparation (p < 0.0001). The prevalence of injecting drugs from pre-loaded syringes was high (61.0%) and did not change over the study period. After adjusting for all significant confounders and comparing to 2007, the prevalence of sharing needle/syringe during the last injection was unchanged in 2008 (OR = 1.06, 95% CI = 0.92, 1.21), and declined in 2011 (OR = 0.18, 95% CI = 0.15, 0.22) and 2013 (OR = 0.17, 95% CI = 0.14, 0.21). Sharing needles/syringes in the last 30 days significantly decreased when compared to that in 2007 (2008: OR = 0.81, 95% CI = 0.74, 0.89; 2011: OR = 0.43, 95% CI = 0.38, 0.47; and 2013: OR = 0.31, 95% CI = 0.27, 0.35). The prevalence of using common instruments for drug preparation also decreased compared to that in 2007 (2008: OR = 0.88, 95% CI = 0.85, 0.91; 2011: OR = 0.85, 95% CI = 0.85, 0.90; and 2013: OR = 0.74, 95% CI = 0.71, 0.76). The observed reduction in the prevalence of injection risk behavior over time is encouraging. Our findings suggest that prevention programs in Ukraine have positive impact and provide support for governmental expansion of these programs.
doi:10.1007/s11524-016-0119-9
PMCID: PMC5359175  PMID: 28097615
People who inject drugs; Injection risk behavior; HIV; Trend; Ukraine
14.  HIV-Related Sexual Risk among African American Men Preceding Incarceration: Associations with Support from Significant Others, Family, and Friends 
We evaluated the association between social support received from significant others, family, and friends and HIV-related sexual risk behaviors among African American men involved in the criminal justice system. Project DISRUPT is a cohort study among African American men released from prison in North Carolina (N = 189). During the baseline (in-prison) survey, we assessed the amount of support men perceived they had received from significant others, family, and friends. We measured associations between low support from each source (
doi:10.1007/s11524-016-0120-3
PMCID: PMC5359176  PMID: 28116586
Social support; Prison release; Sexual behavior; HIV; African American
Neighborhood physical disorder—the visual indications of neighborhood deterioration—may inhibit outdoor physical activity, particularly among older adults. However, few previous studies of the association between neighborhood disorder and physical activity have focused on this sensitive population group, and most have been cross-sectional. We examined the relationship between neighborhood physical disorder and physical activity, measured using the Physical Activity Scale for the Elderly (PASE), in a three-wave longitudinal study of 3497 New York City residents aged 65–75 at baseline weighted to be representative of the older adult population of New York City. We used longitudinal mixed linear regression controlling for a number of individual and neighborhood factors to estimate the association of disorder with PASE score at baseline and change in PASE score over 2 years. There were too few subjects to assess the effect of changes in disorder on activity levels. In multivariable mixed regression models accounting for individual and neighborhood factors; for missing data and for loss to follow-up, each standard deviation increase in neighborhood disorder was associated with an estimated 2.0 units (95% CI 0.3, 3.6) lower PASE score at baseline, or the equivalent of about 6 min of walking per day. However, physical disorder was not related to changes in PASE score over 2 years of follow-up. In this ethnically and socioeconomically diverse population of urban older adults, residents of more disordered neighborhoods were on average less active at baseline. Physical disorder was not associated with changes in overall physical activity over time.
Electronic supplementary material
The online version of this article (doi:10.1007/s11524-016-0125-y) contains supplementary material, which is available to authorized users.
doi:10.1007/s11524-016-0125-y
PMCID: PMC5359178  PMID: 28108872
Cities; Neighborhood physical disorder; Older adults; Physical activity; Urban health
Food insecurity is associated with negative chronic health outcomes, yet few studies have examined how providing medically appropriate food assistance to food-insecure individuals may improve health outcomes in resource-rich settings. We evaluated a community-based food support intervention in the San Francisco Bay Area for people living with HIV and/or type 2 diabetes mellitus (T2DM) to determine the feasibility, acceptability, and potential impact of the intervention on nutritional, mental health, disease management, healthcare utilization, and physical health outcomes. The 6-month intervention provided meals and snacks designed to comprise 100% of daily energy requirements and meet nutritional guidelines for a healthy diet. We assessed paired outcomes at baseline and 6 months using validated measures. Paired t tests and McNemar exact tests were used with continuous and dichotomous outcomes, respectively, to compare pre-post changes. Fifty-two participants (out of 72 initiators) had both baseline and follow-up assessments, including 23 with HIV, 24 with T2DM, and 7 with both HIV and T2DM. Median food pick-up adherence was 93%. Comparing baseline to follow-up, very low food security decreased from 59.6% to 11.5% (p < 0.0001). Frequency of consumption of fats (p = 0.003) decreased, while frequency increased for fruits and vegetables (p = 0.011). Among people with diabetes, frequency of sugar consumption decreased (p = 0.006). We also observed decreased depressive symptoms (p = 0.028) and binge drinking (p = 0.008). At follow-up, fewer participants sacrificed food for healthcare (p = 0.007) or prescriptions (p = 0.046), or sacrificed healthcare for food (p = 0.029). Among people with HIV, 95% adherence to antiretroviral therapy increased from 47 to 70% (p = 0.046). Among people with T2DM, diabetes distress (p < 0.001), and perceived diabetes self-management (p = 0.007) improved. Comprehensive, medically appropriate food support is feasible and may improve multiple health outcomes for food-insecure individuals living with chronic health conditions. Future studies should formally test the impact of medically appropriate food support interventions for food-insecure populations through rigorous, randomized controlled designs.
doi:10.1007/s11524-016-0129-7
PMCID: PMC5359179  PMID: 28097614
Food; Nutrition; HIV; Diabetes; Community-based; Food security; Food support; Food assistance; Intervention; Medically tailored
Between 20 and 40 % of female sex workers (FSWs) began sex work before age 18. Little is known concerning whether early initiation of sex work impacts later experiences in adulthood, including violence victimization. This paper examines the relationship between early initiation of sex work and violence victimization during adulthood. The sample included 816 FSWs in Mombasa, Kenya, recruited from HIV prevention drop-in centers who were 18 years or older and moderate-risk drinkers. Early initiation was defined as beginning sex work at 17 or younger. Logistic regression modeled recent violence as a function of early initiation, adjusting for drop-in center, age, education, HIV status, supporting others, and childhood abuse. Twenty percent of the sample reported early initiation of sex work. Although both early initiators and other FSWs reported commonly experiencing recent violence, early initiators were significantly more likely to experience recent physical and sexual violence and verbal abuse from paying partners. Early initiation was not associated with physical or sexual violence from non-paying partners. Many FSWs begin sex work before age 18. Effective interventions focused on preventing this are needed. In addition, interventions are needed to prevent violence against all FSWs, in particular, those who initiated sex work during childhood or adolescence.
doi:10.1007/s11524-016-0073-6
PMCID: PMC5126017  PMID: 27714491
Sex work; Violence; Adolescence; Africa
Middle- and low-income countries bear 80 % of the global chronic disease burden. Population-level, multi-sectoral approaches to promoting healthful lifestyles that take into local physical, socioeconomic, and sociocultural characteristics of both the environment and the population are needed. The “Nuestra Voz (Our Voice)” is one such approach that involves neighborhood residents acting as “citizen scientists” to systematically gather information on the barriers and facilitators of physical activity in their neighborhoods and then use their data to collectively advocate for local environmental- and policy-level changes to support active living. We pilot tested this approach in Cuernavaca, Mexico with adults and adolescents. This community-engaged and participatory approach is driven by residents, who utilize a GPS-enabled electronic tablet-based application with simple audio-based instructions to take photographs and record audio narratives of facets of their neighborhood that promote or hinder active living. After collecting these data, the citizen scientists come together in a community meeting and use their data to prioritize realistic, multi-level changes for promoting active living in their neighborhoods. A survey assessed participants’ acceptability of the approach. Participating citizen scientists included 32 adults and 9 adolescents. The citizen scientists rated the acceptability of five of the nine acceptability survey items with an average of 4.0 or higher out of 5.0, indicating they thought it was “fun,” were comfortable carrying the tablet, were likely to use it again, and would recommend it to friends and family. Items with average scores of less than 4 were all related to safety concerns. The most common barriers reported by citizen scientists using the tablet were poor sidewalk quality, presence of trash, negative characteristics of the streets, unpleasant aesthetics (e.g., graffiti), and presence of parks and recreational facilities. The Our Voice citizen scientist approach using the Discovery Tool has high potential for assisting communities in diverse settings to begin to identify both local barriers to active living as well as potentially useful strategies for promoting physical activity in culturally congruent ways that are appropriate and feasible in the local context.
doi:10.1007/s11524-016-0081-6
PMCID: PMC5126018  PMID: 27752825
Citizen science; Mexico; Active living; Neighborhoods
Community schools link students, families, and communities to educate children and strengthen neighborhoods. They have become a popular model for education in many US cities in part because they build on community assets and address multiple determinants of educational disadvantage. Since community schools seek to have an impact on populations, not just the children enrolled, they provide an opportunity to improve community health. Community schools influence the health and education of neighborhood residents though three pathways: building trust, establishing norms, and linking people to networks and services. Through such services as school-based health centers, nutrition education, family mental health counseling, violence prevention, and sexuality education, these schools build on the multiple reciprocal relationships between health and education. By developing closer ties between community schools and neighborhood health programs, public health professionals can help to mobilize a powerful new resource for reducing the health and educational inequalities that now characterize US cities. We suggest an agenda for research, practice, and policy that can build the evidence needed to guide such a strategy.
doi:10.1007/s11524-016-0082-5
PMCID: PMC5126019  PMID: 27726051
Community schools; Community health; Health inequities; Public education; Urban education
Preterm delivery (PTD), or birth before 37 completed weeks of gestation, is a serious public health issue, and racial disparities persist. In a recently published study, perceptions of the residential environment (or neighborhood context) were associated with PTD rates among urban African American women with low educational attainment (≤12 years); however, the mechanisms of these associations are unknown. Given this gap in the literature, we used data from the Life Influences on Fetal Environments Study of postpartum African American women from Metropolitan Detroit, Michigan (2009–2011; n = 399), to examine whether psychosocial factors (depressive symptomology, psychological distress, and perceived stress) mediate associations between perceptions of the neighborhood context and PTD. Validated scales were used to measure women’s perceptions of their neighborhood safety, walkability, healthy food availability (higher=better), and social disorder (higher=more disorder). The psychosocial indicators were measured with the Center for Epidemiologic Studies-Depression Scale, Kessler’s Psychological Distress Scale (K6), and Cohen’s Perceived Stress Scale. Statistical mediation was assessed using an unadjusted logistic regression-based path analysis for estimating direct and indirect effects. The associations between perceived walkability, food availability, and social disorder were not mediated by psychosocial factors. However, perceptions of neighborhood safety were inversely associated with depressive symptoms which were positively associated with PTD rates. Also, higher perceived neighborhood social disorder was associated with higher PTD rates, net of the indirect paths through psychosocial factors. Future research should identify other mechanisms of the perceived neighborhood context-PTD associations, which would inform PTD prevention efforts among high-risk groups.
doi:10.1007/s11524-016-0083-4
PMCID: PMC5126020  PMID: 27704384
Depressive symptomology; Neighborhood context; Psychosocial factors; Preterm delivery; African Americans; Urban health
Sexual and gender minorities have been shown to have greater rates of mental health, substance use disorders, and specific types of health problems compared to heterosexuals. Among the homeless population in several US urban areas, sexual and gender minorities are overrepresented but few studies have examined the mental and physical health status of homeless sexual and gender minorities, with studies on homeless gender minorities being particularly hard to find. Using survey data obtained from the city and county of San Francisco (2015 Homeless Survey), this study examined differences in causes of homelessness, physical and mental health problems, and domestic violence among homeless sexual and gender minorities and their heterosexual and cisgender (i.e., non-transgender) counterparts, respectively. Lesbians and bisexual women, and gay and bisexual men did not differ from their cisgender heterosexual counterparts. Cisgender men who identified as queer or “other” in response to sexual orientation questions had higher rates of psychiatric problems and posttraumatic stress disorder, while cisgender women who identified as queer or “other” had higher rates of psychiatric problems and drug and alcohol use. Transgender men who were homeless were found to be particularly at risk for physical health problems, mental health problems, and domestic violence or abuse. Transgender women were more likely to report posttraumatic stress disorder. This study suggests that transgender men and cisgender sexual minority men and women who identify as queer or “other” are groups among the homeless that may benefit from increased outreach and services.
doi:10.1007/s11524-016-0084-3
PMCID: PMC5126021  PMID: 27699581
Sexual minority; Gender minority; Homelessness; Mental health; Physical health; Substance use
Neighborhood socioeconomic status (SES), an overall marker of neighborhood conditions, may determine residents’ access to health care, independently of their own individual characteristics. It remains unclear, however, how the distinct settings where individuals seek care vary by neighborhood SES, particularly in US urban areas. With existing literature being relatively old, revealing how these associations might have changed in recent years is also timely in this US health care reform era. Using data on the Philadelphia region from 2002 to 2012, we performed multilevel analysis to examine the associations of neighborhood SES (measured as census tract median household income) with access to usual sources of primary care (physician offices, community health centers, and hospital outpatient clinics). We found no evidence that residence in a low-income (versus high-income) neighborhood was associated with poorer overall access. However, low-income neighborhood residence was associated with less reliance on physician offices [−4.40 percentage points; 95 % confidence intervals (CI) −5.80, −3.00] and greater reliance on the safety net provided by health centers [2.08; 95 % CI 1.42, 2.75] and outpatient clinics [1.61; 95 % CI 0.97, 2.26]. These patterns largely persisted over the 10 years investigated. These findings suggest that safety-net providers have continued to play an important role in ensuring access to primary care in urban, low-income communities, further underscoring the importance of supporting a strong safety net to ensure equitable access to care regardless of place of residence.
Electronic supplementary material
The online version of this article (doi:10.1007/s11524-016-0085-2) contains supplementary material, which is available to authorized users.
doi:10.1007/s11524-016-0085-2
PMCID: PMC5126022  PMID: 27718048
Primary health care; Neighborhood; Vulnerable populations; Safety net providers; Health care reform; Philadelphia; Multilevel analysis
There exists controversy as to the impact gentrification of cities has on the well-being of minorities. Some accuse gentrification of causing health disparities for disadvantaged minority populations residing in neighborhoods that are changing as a result of these socioeconomic shifts. Past scholarship has suggested that fears of displacement and social isolation associated with gentrification lead to poorer minority health. However, there is a lack of research that directly links gentrification to minority health outcomes. We address this gap with individual data from the 2008 Philadelphia Health Management Corporation’s Southeastern Pennsylvania Household Health Survey and census tract data from the 2000 Decennial Census and the 2006–2010 American Community Survey. We implement logistic multilevel models to determine whether and how a resident’s self-rated health is affected by gentrification of their neighborhoods. We find that while gentrification does have a marginal effect improving self-rated health for neighborhood residents overall, it leads to worse health outcomes for Blacks. Accounting for racial change, while gentrification leading to increases in White population has no measurable effect on minority health, “Black gentrification” leads to marginally worse health outcomes for Black respondents. These results demonstrate the limitations that improvements of neighborhood socioeconomic character have in offsetting minority health disparities.
doi:10.1007/s11524-016-0087-0
PMCID: PMC5126023  PMID: 27761683
Gentrification; Self-rated health; Multilevel modeling; Philadelphia

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