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Trauma and trauma-related symptoms often remain hidden in the lives of low-income midlife and older women. In primary care encounters, midlife and older women are infrequently asked about trauma histories, and symptoms of trauma are commonly misinterpreted. As stress and trauma raise risk morbidity and mortality, under-recognition of trauma is a health equity issue. This secondary qualitative analysis explores stress and trauma as factors that affect primary/preventive care engagement in low-income midlife and older women. Semi-structured interviews were completed with 22 low-income midlife and older women from December 2020-January 2021. A deductive-inductive content analysis approach was guided by the Behavioral Model for Vulnerable Populations. Three categories were identified: (1) stress and competing demands; (2) history and impact of trauma; (3) integrated trauma-related behavioral health focus. Co-designing and culturally adapting stress and trauma screening and interventions may optimize stress and trauma-focused primary care while promoting health equity with socially marginalized women.

Disparities in children's school readiness (SR) in the U.S. are well-documented and have detrimental long-term consequences. Clinic-based early education interventions are limited. This report summarizes collaborative efforts of pediatricians and community stakeholders to develop and implement clinic-based interventions to promote early learning and SR among low-income children.

La Clínica del Pueblo (LCDP), a federally qualified health center that serves the low-income, Latino/a/x community in D.C., used the Partnership Assessment Tool for Health (PATH) to assess two cross-sector partnerships: a medical-legal partnership with a legal services agency and a five-year partnership with FRESHFARM focused on alleviating food insecurity.

County-based health care financial assistance programs offer improved access to health care for indigent populations by reducing or eliminating costs to receive care. We examined health care financial assistance programs serving the 10 most populous U.S. counties. We found that the percent enrollment in a county's program is strongly correlated with the percent uninsured (r=.86) and the percent undocumented (r=.83), and moderately correlated with the percent indigent (r=.43) in a county, suggesting the importance of health care financial assistance programs for these groups. Furthermore, the typical county-based health care financial assistance program covers the same income range (0-138% federal poverty level) and offers similar benefits (including coverage of emergency care and inpatient care) as Medicaid. Counseling services are frequently available to assist applicants. These characteristics allow them to serve as an alternative source of health care funding to those who are ineligible for Medicaid coverage.

Adequate, safe, and affordable housing is an important determinant of health, yet studies on subsidized housing and health are limited in number and scope. This exploratory survey assessed the health conditions, needs, accessibility of services, and health issues perceived as most important by federally-subsidized affordable housing participants in Virginia. Results for residents of public housing complexes, tenants with housing vouchers, and a nationally representative sample are compared. Findings highlight issues related to cost of care, transportation, medication adherence, depression, and asthma. While housing subsidies are intended to reduce economic burden by enabling residents to use financial resources for other purposes (e.g., preventive health care, access to food), findings suggest that participants continue to experience cost-related barriers and poor health.

Safety-net health systems serve primarily low-income, racially/ethnically diverse patients who bear a disproportionate burden of disease and high social needs. Many safety-net institutions are publicly funded and are under-resourced to deliver high-quality and timely care. Further, little clinical and translational research includes safety-net populations due to lack of funding, structure to support research, and low prioritization. However, we argue that US health care as a whole will lose key insights across all levels of translational medicine-T1-T4 research, if safety-net health systems do not participate in research. Solutions such as targeted funds for safety-net research, consortium arrangements for research infrastructure, and increasing ways for clinician-researchers to have their primary home in safety-net settings are suggested to fill this gap. Achieving health equity in the U.S. is contingent upon safety-net inclusion in research to advance knowledge and develop, test, and evaluate innovations applicable across all patient populations.

OBJECTIVE To evaluate effects of the medical home on health status and health care use among children living in poverty compared with children not living in poverty. METHODS Data from the 2016-2017 National Survey of Children's Health were used to examine the associations of having a medical home with health outcomes of interest, among children living in poverty and among children not living in poverty. RESULTS Among 69,039 children ages 0-17 years, children living in poverty had lower medical home access (31%) compared with those not living in poverty (50%). Medical home access was favorably associated with health outcomes, but the strength of these association did not vary according to poverty status. CONCLUSIONS Notwithstanding the efficacy of the medical home at promoting child health, children living in poverty did not have greater health benefits associated with medical home access compared with children not living in poverty.

Introduction In Nigeria, high inflation rates, increasing consumer price index, insurgency, and displacement of households have negatively affected household income expenditures on food resulting in food insecurity. This study aimed at determining the food security status and factors affecting this among households in Enugu state, Nigeria. Methods A descriptive cross-sectional study of 800 households in Enugu state, Nigeria. Results As many as 61.1% of households in Enugu State were found to be food-insecure. The factors influencing food security status were wealth index, belonging to a cooperative society, lack of money to buy food items, and the number of accessible marketplaces. Various coping strategies included skipping meals (77%), reducing quantity of meals (92.6%), purchasing less preferred meals (72.3%) and borrowing food and money (31.3%). Conclusion The prevalence of food-insecure households was high, mostly due to poverty, not belonging to a cooperative society, and few accessible marketplaces. There is a need for economic and political stability that is supportive of households.

Background Children living in poverty frequently experience health-related social needs. The pediatric primary care setting is a common touchpoint, allowing for risk identification and resource connection. Methods This is an evaluation of the effect of a community resource liaison's (CRL) first year embedded in a pediatric primary care center, 8/1/2015-7/31/2016. Primary outcomes include needs identified and connections made. Secondary outcomes include preventive service completion and acute utilization. Results During the study, the CRL interacted with 236 primary care patients, addressing 395 identified needs. The most common needs concerned housing and utilities, public benefits, and food/resource insecurity. The CRL patients were significantly more likely than non-CRL patients to be connected with on-site legal advocates, social workers, and an infant food insecurity program. There was no significant relationship with preventive service completion or use. Conclusion A CRL embedded within a pediatric primary care center enhanced risk identification and resource connection.

The Volunteer Income Tax Assistance (VITA) program is an underutilized free taxpreparation service that directly addresses poverty by maximizing tax refunds. A pediatric medical home (PMH) with an embedded VITA site provides an excellent opportunity for a medical-financial partnership. We sought to assess the knowledge, attitudes, and practices of caregivers of children who used a PMH after embedding a VITA site. We found that a PMH-VITA site was a convenient, trusted, useful, and potentially tax-filing behaviorchanging intervention. Importantly, most caregivers who did not use the PMH-VITA site had no knowledge of availability of free tax filing services but would consider using one the following year. Improved marketing is needed to increase utilization in our target population.

OBJECTIVE The purpose of this study was to evaluate the poverty-related knowledge and attitudes of primary care providers and staff following an educational initiative focused on poverty and social determinants of health (SDoH). METHODS A descriptive posttest-only design was used. All providers and staff in three outpatient primary care clinics (including one medical home and one women's health clinic) received education (two sessions, one hour in length) on poverty and SDoH. The educational initiative's effectiveness was evaluated by measuring perceptions of (a) knowledge/understanding related to SDoH and low SES and (b) preparedness to serve patients of low SES. RESULTS Thirty-two of the 55 participants in the educational sessions completed the survey (58%). Average post-education ratings for perceptions of both preparedness and knowledge/understanding were significantly higher than for the corresponding pre-education items (p < .001), with large effect sizes. Study limitations and implications are presented.

Native Americans/American Indians (NA/AI) are perhaps the most disadvantaged population in the United States due to poverty, geographic isolation, and poor health care. The prevalence of diabetes mellitus and end-stage renal disease in NA/AI is higher compared with other racial/ethnic groups. Thus, a higher rate of kidney transplantation (KT) candidacy evaluation, wait-listing, and actual transplantation would be expected among NA/AI. However, KT is an underutilized life-saving therapy in this population. Half of the 20 poorest counties in the U.S. are within NA/AI reservations. Native Americans/American Indians residing on reservations are often isolated hundreds of miles from the nearest transplant center. Additionally, factors such as poor health literacy, distrust, and substance abuse contribute to low KT rates. However, collaboration between transplant centers and Indian Health Services, use of telemedicine, constructing socioculturally-competent educational strategies, and maintaining confidence-building measures to bridge the gap, create trust, and maintain patient autonomy could improve outcomes in this population.

Maternity care in the United States is characterized by racial and income disparities in maternal and infant outcomes. This article describes an innovative, hospital-based doula model serving a racially and ethnically diverse, low-income population. The program's history, program model, administration requirements, training, and evaluations are described.

Cost-related medication non-adherence (CRN) is a major population health concern in the United States, especially for patients with chronic conditions. It is associated with disease progression and increases the likelihood of emergency department utilization and hospitalization, thereby increasing overall health care expenditures. In this paper, we describe the prescription medication safety net in the United States and assess its reliability. We also introduce Dispensary of Hope (DoH), a charitable medication distribution network, as a reliable medication access program that is capable of filling gaps in medication coverage for low-income and uninsured Americans. Our critical assessment of the medication safety net in the United States suggests that an expansion of DoH could reduce CRN in the United States, improve chronic illness care, and help health systems achieve the triple aim of improving patient experiences and population health while reducing cost.

Objectives . We investigated the association of pre-existing economic variables with COVID-19 infections and mortality in New York City. Methods . We combined ZIP code-level data from New York City's Department of Health with five-year American Community Survey data. We estimated ordinary least squares models of the prevalence of positive COVID-19 test results and deaths per 100,000 population. Results . We found ZIP codes with higher concentrations of residents living in crowded living quarters, employees in high-risk occupations, and employees commuting more than half an hour were positively and significantly associated with higher infection rates. Higher rates of crowded housing were also significantly and positively related to mortality rates, though the positive point estimates for the other two economic variables were not statistically significant. Conclusions . Economic factors such as working and living conditions beyond common measures such as poverty generate significant public health effects. Policymakers should consider these associations while designing and modifying public health policies.

Children in low-income families are at risk for delayed diagnosis of autism spectrum disorder (ASD). The cascade-of-care model, which examines steps of care for quality and efficacy, can identify lesions in the process for evaluation and diagnosis for children at risk for ASD. Little is known about predictors that influence key steps in this process. We performed a retrospective chart review of 110 children under age five years from an academic medical center with social communication concerns. We assessed predictors of age of referral for ASD diagnostic evaluation, time to diagnosis, and likelihood of diagnostic completion. Children with continuity of primary care were referred at an earlier age than those receiving primary care at multiple centers. Compared with children with missed visits, children attending all well-child visits had a shorter median time to diagnosis. These findings illustrate a need for primary medical homes to facilitate early and timely ASD evaluations.

Health care expenditure (HCE) does not significantly vary by income in the U.S. However, health outcomes vary significantly by income. To understand the disconnection, we used the Medical Expenditure Panel Survey (MEPS) data and adjusted HCE for utilization and stratified it by income and age. We showed that the adjusted HCE is significantly higher among lower-income Americans, especially at older ages. At age 45-64, for example, the adjusted HCE for the poor, low-income, and high-income were $10,552; $7,118; and $5,300 in 2015 prices, respectively. We also found that children from lower-income families receive less nonurgent, preventive care than those from higher-income families. However, adults from lower-income families use much more urgent care than those from higher-income families. Our results, alongside the evidence of continuously widening gaps in mortality and morbidity rates among income groups, raise policy-relevant questions about the optimal age profile of health care provision, particularly among lower-income groups.

Millions of Americans are formerly or currently under correctional supervision and their involvement with the correctional system imposes collateral consequences beyond sentencing times. We explore the creation of extended punishment through the intersection of correctional system involvement, food insecurity, and two Supplemental Nutrition Assistance Program (SNAP) policies. Given the high prevalence of food insecurity, individuals with correctional supervision involvement are likely to need assistance from SNAP; however, they face more barriers accessing SNAP benefits than the general population. We highlight two policies in particular: the restrictions for individuals with drug felony convictions and the able-bodied adults without dependents work requirement. Due to challenges with securing gainful employment and the need for SNAP benefits, these two policies create disparities with participation in the program and increase risk for food insecurity and other poor health outcomes among this population.

Objectives To evaluate acceptability, feasibility, and short-term behavioral impact of an early childhood caries (ECC) intervention. Methods Predominantly low-income Hispanic parent/child (2-6 years) dyads attending a busy pediatric dental clinic in New York City completed a single administration of the iPad-based technology-assisted education, goal-setting, and behavior change MySmileBuddy program. Self-reported behavior change was assessed via telephone survey one month post-intervention. Results Of 113 parent/child dyads approached, 108 (95.6%) participated and all completed MySmileBuddy in its entirety. Over 96% (n = 76) of 79 parents reached for follow-up recalled MySmileBuddy; 63.3% (n = 50) recalled their diet-and/or oral hygiene-related behavioral goal; and 79.7% (n = 79) reported taking action to initiate behavior change. Conclusions Findings suggest that MySmileBuddy was feasibly implemented in a busy clinic, acceptable to this high-risk population, and effectively promoted preliminary ECC-related behavior changes. Larger, long-term studies are warranted to further investigate the impact of the MySmileBuddy program.

Introduction The Kenyan government launched a free maternity program in 2013. Kakamega County Government supplemented this through a conditional cash transfer program targeting poor women. This was to facilitate their access to maternal and child health services. This study looked at the impact of this intervention. Methods Deliveries, four antenatal attendances, and general antenatal attendance were analysed for level 4 hospitals in Kakamega, Bungoma, and Busia counties. Difference-in-differences treatment effects methods were used with Busia and Bungoma acting as controls. Population and poverty were controlled for. Results Monthly deliveries increased by 57, though this was not significant. Monthly antenatal clinic attendance and four antenatal clinic attendance increased significantly by 539 and 144 respectively. Poverty was a significant factor in influencing utilization of deliveries and antenatal clinic attendance. Conclusion This conditional cash transfer may have improved use of maternal health services, with greatest impact on antenatal attendance.

Almost two decades ago, the Institute of Medicine’s Clinical Research Roundtable commented on the major challenges of moving health related basic science discovery to the clinical setting. The roadblocks identified included challenges in evaluating a discovery’s application to human disease, and, if justified, getting that application out to the general population. The obstacles to achieving this translation of discovery to improvements in human health remain today and are most evident in populations at highest risk for inequitably poor health. We address four potential roadblocks which, if solved, will have a great impact on achieving health equity. They are expanding the definition of basic discovery to include all facets of health disparities science, understanding the daily factors that affect a community’s well-being, including diverse populations in clinical trials, and training the right scientists to perform the community-engaged research required to move discovery to application in the community.

People at higher risk of poverty or social exclusion are less likely to receive adequate prenatal care (PNC) and have a higher risk of poor perinatal outcomes. Appropriate PNC may help to reduce adverse outcomes. We conducted a systematic review of randomized controlled trials in high income countries on the impact of PNC delivery models targeting populations with low rates of PNC attendance on maternal and newborn outcomes. Searches in four scientific databases identified seven eligible studies. Interventions included group PNC and augmented PNC. The quality of the evidence was moderate to very low. We found insufficient evidence to conclude whether or not these interventions can reduce rates of PTB and SGA. We conclude there is limited high quality evidence regarding the effectiveness of PNC delivery models targeting populations with low rates of PNC attendance and more high-quality research on promising interventions such as mobile PNC clinics is needed.

BACKGROUND Women of color and people of low socioeconomic status continue to have poorer health outcomes than their counterparts. This study explored patientsatisfaction and perceptions of low-income African American women regarding access to care. METHODS The study took a mixed-methods approach. Ninety-five women were surveyed using the Short-form Patient Satisfaction Questionnaire (PSQ-18). Two sub-scales assessed satisfaction with access to care. Qualitative data were collected using one-on-one interviews (n=22) and two focus groups of community leaders. A thematic analysis was then conducted. RESULTS On a 5-point scale, patient-satisfaction with access was moderate (accessibility and convenience -2.99; financial aspects -3.35). Emerging themes included obtaining insurance, dynamics of insurance eligibility, adequacy and scope of insurance coverage, scheduling appointments, and transportation. CONCLUSION Providing insurance coverage for people with low incomes is not sufficient to close the racial/ethnic disparities gap in access to care. Understanding the challenges from patients' perspectives can help to make health care resources and services more accessible.

In the U.S., 54.8% of non-Hispanic Black women are obese, a rate that is 1.4 times greater than in White women. The drivers of this racial disparity are not yet clearly understood. We sought to disentangle race, household poverty, neighborhood racial composition, and neighborhood poverty to better understand the racial disparity in obesity among women. We used data from the 1999-2004 National Health and Nutrition Examination Survey and the 2000 U.S. Census to examine the role of individual race, individual poverty, neighborhood racial composition, and neighborhood poverty on women's risk of obesity. We found that individual race was the primary risk factor for obesity among women. Neighborhood effects did not account for the racial disparity. Understanding that race is a social, not a biologic construct, more work is needed to uncover what it is about race that produces racial disparities in obesity among women.

Black populations in the United States are disproportionately affected by HIV. This disparity may be affected by social and structural barriers to HIV testing, leading to undiagnosed infection and prolonged HIV transmissibility. Using data from a nationally representative sample of 1,727 Black men in the 2015 Behavioral Risk Factor Surveillance System we tested for differences in poverty, depression, and health care barriers between Black men who had been HIV tested in the past year and those who had not. We also tested a syndemic index of these factors. Number of syndemic factors was linearly associated with less HIV testing (aPR=0.79, 95% CI 0.66-0.95). Assumptions of unidimensionality were met. The use of a syndemic index was a superior approach to analyzing these factors individually, both in terms of model fit and associations detected. The accumulation of poverty, depression, and health care barriers has an adverse impact on HIV testing among Black men.

Introduction Prior research has shown that tobacco companies target point-of-sale (POS) marketing to low-income communities. This research assessed the association between demographic characteristics and venue type with purchasing tobacco products in response to marketing. Methods Using Population Assessment of Tobacco and Health (PATH) Study Wave 1 Adult data, this analysis compared promotion awareness and purchase influence among current smokers. Results Tobacco promotions were more likely to be noticed at convenience stores, gas stations, or tobacco stores than at other outlets. Smokers who bought their cigarettes at these outlets were more likely to purchase a brand other than their usual brand because of marketing. Smokers below the poverty level had greater odds than others to have noticed tobacco ads and to indicate purchase influence. Conclusions Point-of-sale marketing is effective in garnering the attention of low-income populations and influencing their tobacco purchases. Enforcing retailers' adherence to regulations is vital.

Objective Study occurrence and consequences of deductibles and medical debt among privately insured under the Affordable Care Act. Methods Analysis of 2012-2016 National Health Interview Survey data on privately insured adults younger than age 65 on the effect of deductibles on medical debt, deferred medical care, and office visits, by demographic characteristics, and treatable chronic diseases. Results Rates of medical debt and deferred care decreased. Medical debt is greater for those with any type of high deductible (HD) insurance, and among those more vulnerable (lower income, minority, treatable chronic diseases). Medical debt with HD's increased deferred needed medical care 6 fold and is highest for those with more treatable chronic diseases. Conclusion While medical debt and deferred care decreased for all privately insured, those HD-insured and vulnerable report higher medical debt rates markedly increasing deferred needed medical care. Highdeductible insurance risks adverse health and social consequences for those vulnerable.

Background Little is known about the relationship between food insecurity and depression among African American low-income single mothers living with HIV/AIDS in rural Alabama. Food insecurity is a neglected variable in bioethics, biomedical, behavioral, and health disparities research. Methods Regression analyses of data from a survey of African American single mothers living with HIV/AIDS in Alabama's Black Belt were used to evaluate the association between food insecurity and depression. Results As determined by the USDA food insecurity scale, about 53% of the sample was classified as food insecure. In the bivariate regression model, food insecurity was associated with depression. After controlling for sociodemographic variables, food insecurity remained positively associated with depression in this sample. Conclusions Food insecurity places low-income African American women at risk of depression. Given widespread poverty among HIV-positive individuals in the Black Belt, access to food should be considered in HIV-related prescriptions and in health disparities research.

The Mississippi Gulf Coast's Vietnamese community (MSGCVC) has repeatedly experienced physical, psychological, and economic hardship from natural and man-made disasters and economic downturn. Literature suggests that economic strain is the greatest contributor to Vietnamese population vulnerability. Previous literature focused on the aftermath of Hurricane Katrina, BP Deepwater Horizon oil spill, and urban communities. A photovoice project was conducted to measure causes and consequences of vulnerability and social resiliency by identifying sources of health strengths and health risks among individuals, families, and the community through generational and cultural perspectives. Content analysis was conducted to identify themes associated with vulnerability and resiliency and were subsequently grouped into six main categories. Findings will aid others exploring innovative approaches to addressing vulnerability and resiliency in underserved communities and applying photovoice as a research tool.

African American women living with HIV (WLWH) in the U.S. South encounter heightened marginalization due to the complex intersections of race, gender, poverty, and HIV status. Social vulnerabilities experienced by individuals and communities in daily life have the potential to sharpen ethical tensions in the context of research. Thus, conducting ethical research requires attention to the contextual challenges and concerns of diverse research populations to tailor participant protections to a particular sociocultural context. Using principles from the Belmont Report, the present report draws on data from a qualitative study with 42 African American WLWH in the South by highlighting the first author's accounts of ethical challenges that emerged during data collection. Findings suggest that engaging participants in their natural environments can inform the development of ethical research strategies germane to women's lived experiences. Study findings also contribute to empirical guidance for investigators engaging marginalized populations in scientific research.

We explored the role of dietary factors, as measured by individual behaviors and neighborhood produce availability, in the relationship between food insecurity and obesity among a representative sample of Latinos in California. We utilized data from the 2012, 2013/2014 California Health Interview Survey and included Latinos aged 18-65 years and under 200% of the federal poverty line (n=5,957). We conducted logistic regressions to first estimate the association between food insecurity and obesity and then examine whether this association remained significant after adjusting for soda and fast food consumption, perceived neighborhood fresh produce environment, and covariates. Latina women, and not men, were significantly more likely to be obese if they were very food insecure (OR=1.50, 95% CI=1.03-2.19). After adjusting for diet and neighborhood variables, only neighborhood affordability of fresh produce reduced this significant association. Policy efforts to remediate obesity among food insecurity households should focus on the affordability of neighborhood fresh produce.

This report describes the model of specialty clinics implemented at Stanford University's two student-run free clinics, Arbor Free Clinic and Pacific Free Clinic, in the San Francisco Bay Area. We describe our patient demographic characteristics and the specialty services provided. We discuss challenges in implementing specialty care at student-run free clinics.

African Americans experience poorer diabetes outcomes than non-Hispanic Whites. Few clinical trials of diabetes self-management interventions specifically target African Americans, perhaps due to well-documented barriers to recruitment in this population. This paper describes strategies used to successfully recruit 211 low-income African Americans from community clinics of a large, urban public hospital system to a randomized clinical trial of an 18-month diabetes self-management intervention. Diabetes-related physiological, psychosocial, and behavioral characteristics of the sample are reported. The sample was 77% female, mean age = 55, mean A1C = 8.5%, 39% low health literacy, 28.4% moderate/severe depression, and 48.3% low adherence. Participants ate a high-fat diet with low vegetable consumption. Relative to males, females had higher BMI, depression, and stress, and better glycemic control, less physical activity, and less alcohol consumption. Males consumed more daily calories, but females consumed a greater proportion of carbohydrates. Gender-specific diabetes self-management strategies may be warranted in this population.

Introduction. An estimated 5.6 million Kenyans defecate in the open. This exposes them to sanitation related diseases. This study analysed open defecation trends among the 47 counties in Kenya, newly created in 2013. Methods. The study used four data sets on open defecation, unimproved water supply coverage, poverty levels, and population density. Results. Mean open defecation rate across the 47 counties was 23.5% and the median rate 6.9%. The lowest rate was 0.1% and the highest 88.4%. Fifteen counties had open defecation rates of 40% and above. Another 21 counties had open defecation rates of less than 5%. Poverty was the most significant predictor accounting for 68.4% of the variance in open defecation after controlling for unimproved water supply and population density. Conclusion. Some counties have unacceptably high open defecation rates. Alleviating poverty may reduce open defecation in Kenya.

Diabetic retinopathy is the leading cause of preventable blindness in working-age American adults. This study hypothesized that patients with diabetes types I and II at St.Luke's Free Medical Clinic in Spartanburg, South Carolina were not being systematically referred for annual diabetic retinopathy screening. We evaluated the number of patients referred for screening, those patients who actually went for the screening, and the rate at which retinopathy was found in those who went. Of the 111 charts reviewed, only 49.5% of the patients were referred to an eye care professional between January 1, 2013 and December 31, 2014. Of those referred, 21.1% were found to have vision-threatening pathology. The median number of days to have an eye exam was 28.5. A standardized method to screen for diabetic retinopathy in the clinic would alleviate the referral burden and ultimately allow for detection of ocular pathology earlier in the course of disease.

HIV testing for some African American men remains a challenge, and effective interventions are lacking. We explored facilitators and barriers associated with HIV testing among heterosexual African American men in rural Florida. We conducted focus group interviews with 67 African American men who were low-income, and HIV-uninfected based on prior testing or had unknown HIV status. Using computer-assisted thematic analyses, we examined transcribed focus group responses for main themes. Thematic analyses revealed three main themes regarding facilitators of HIV testing: 1) using preferred HIV testing community locations (park, library, gym); 2) receiving incentives (food or money); and 3) the importance of peer-led messaging for free, rapid HIV testing. Barriers included HIV testing at the local health department, and perceived social and emotional consequences to testing and the possibility of receiving a positive result. Effective HIV testing interventions for heterosexual African American men in rural Florida may need to incorporate suggested facilitators and reduce perceived barriers in order to improve HIV testing strategies.

Enrolled patients at the free clinic in Dunedin, New Zealand were not just financially poor, but also vulnerable. Large social inequalities are present in the United States and New Zealand. The literature on vulnerability originates predominantly from sociology and public health. This commentary discusses the concept of vulnerability within clinical practice, and makes a case for the improved recognition of patient vulnerability. Vulnerability arises from an individual's susceptibility to harm and their exposure to risks and negative events. Biographical factors commonly regarded as social vulnerability characteristics such as homelessness, teenage parenthood, and childhood abuse do not necessarily lead to negative health and other outcomes because of a direct, causal effect, but because they are indicative of more upstream adversities. Health professionals should address vulnerability not just during clinical encounters, but also at an institutional and policy level.

Much of emergency department use is avoidable, and high-quality primary care can reduce it, but performance measures related to ED use may be inadequately risk-adjusted. To explore associations between emergency department (ED) use and neighborhood poverty, we conducted a secondary analysis of Massachusetts managed care network data, 2009-2011. For enrollees with commercial insurance (n = 64,623), we predicted any, total, and total primary-care-sensitive (PCS) ED visits using claims/enrollment (age, sex, race, morbidity, prior ED use), network (payor, primary care provider [PCP] type and quality), and census-tract-level characteristics. Overall, 14.6% had any visit; mean visits per 100 persons were 18.8 (±0.2) total and 7.6 (±0.1) PCS. Neighborhood poverty predicted all three outcomes (all Plt; .001). Holding providers accountable for their patients' ED use should avoid penalizing PCPs who care for poor and otherwise vulnerable populations. Expected use targets should account for neighborhood-level variables such as income, as well as other risk factors.

While smoking has declined, rates remain alarmingly high for people of low socioeconomic status. Funding community-based organizations to link low socioeconomic status smokers to cessation services holds promise for reaching this population. This approach also shows potential for elevating addressing tobacco use as a priority within these organizations.

The prevalence of tobacco smoking among people with HIV (PWH) ranges from 40% to 70%. Additionally, tobacco smoking is higher among low-income individuals, yet few studies have examined tobacco smoking in low socioeconomic status PWH. Using data from a cohort of PWH receiving care in an urban HIV clinic, we characterized factors associated with current and former smoking and with initiation/re-initiation and cessation of tobacco use. Among a study sample of 1,607 PWH, the prevalence of current smoking was 46.6% among men and 46.0% among women. Current smoking in men and women was associated with Medicaid insurance status, substance use, and panic symptoms. In women, but not men, hazardous alcohol use decreased the likelihood of quitting smoking and increased the risk of initiation/re-initiation. Smoking interventions for low-income, urban PWH may need to be tailored to address mental health and substance use comorbidities.

The cost-effectiveness of hepatitis C virus (HCV) screening and treatment was examined in low-income, primarily Hispanic baby boomers born 1945-1965 using a Markov model of the natural history of HCV. The model was parameterized using costs and diagnostic data from 2008-2016 and from literature on disease progression and effectiveness of screening and treatment using direct acting anti-viral (DAA) therapy. The incremental cost-effectiveness ratio (ICER) was computed from the perspective of Medicare as payer, calculated over 20 years, and discounted at 3% per year. In the base case, HCV screening cost $3,334 versus $3,797 for no screening, and yielded more quality-adjusted life years (QALYs; 14.08 vs 13.96, respectively). The ICER for screening was still less than $20,000 per additional QALY with drug costs up to $100,000. Among low-income Hispanics, HCV screening was less costly for Medicare and more effective than no screening under most assumptions. This analysis supports investment in screening and treatment in Hispanics.

Background Patient-centered discharge planning improves transitional care and health outcomes for vulnerable adults. The HOME Initiative was an educational intervention aiming to improve trainees' patient-centered discharge planning skills. Methods Using a quasi-experimental design, 52 internal medicine residents at an academic medical center were randomized to intervention or control in 2014-2015. Intervention interns visited recently discharged patients during inpatient rotations. Interns addressed patient deficits in understanding, rectified medication errors, and provided health education. Results Over three-quarters (77%) of intervention interns completed pre-and post-tests. Intervention interns reported significant improvements in patient-centered discharge planning skills and delivery of culturally sensitive care. Through improved communication skills, residents more effectively elicited patients' illness narratives and assessed their patients' safety (0.65; p=.05), functional status (0.79; p=.02) and health literacy (0.70; p=.01). Conclusion Structured home visitation with recently discharged patients is a valuable tool for medical residents to learn patient-centered discharge planning and improve delivery of culturally sensitive care.

OBJECTIVE To explore the association of maternal health literacy (MHL), parenting self-efficacy and early parenting practices among low-income mothers with infants. DESIGN A cross-sectional, descriptive correlational design. PARTICIPANTS Low-income mothers (N=186) with infants. METHODS Face-to-face interviews were conducted using English and Spanish versions of questionnaires by trained bilingual research assistants. The Newest Vital Sign (NVS) screening tool was used to measure MHL. RESULTS Nearly three-quarters (72%) of mothers were rated as having low MHL. In the bivariate analysis, MHL was positively correlated with education, household income, language, social support, parenting self-efficacy, and early parenting practices, but negatively correlated with number of children. The study findings demonstrate that parenting self-efficacy had a mediating effect on MHL and early parenting practices among mothers with infants. CONCLUSION Results suggest that future research is needed to advance MHL in low-income mothers and to inform potential HL interventions for this target population.

Objective . Tooth decay is related to poverty, measured at individual and neighbourhood levels. It is however uncertain if living in an advantaged neighbourhood reduces tooth decay similarly in Australian Indigenous and non-Indigenous children. Methods . This study describes tooth decay by neighbourhood characteristics and Indigenous status, and examines inequalities by Indigenous status. Results . In deciduous dentition the percentage of children with tooth decay and untreated decay decreased on average 26% and 20% respectively in the non-Indigenous sample from poor to affluent neighbourhoods. In Indigenous children tooth decay and untreated decay decreased on average 6% and 8%, respectively, from poor to affluent neighbourhoods. Conclusion . While all children from affluent areas had less tooth decay, the gap between non-Indigenous and Indigenous children remained significant across neighbourhood characteristics. This suggests that both universal and targeted prevention programs should be considered for all Indigenous children irrespective of where they live.

Physical inspections that assess how well affordable housing properties meet quality and safety standards help to ensure that low-income tenants live in a healthy built environment. This study was part of a larger Health Impact Assessment (HIA) conducted between January 2012 and November 2013 to inform policymakers about the potential health consequences of a proposed policy decision to align the physical inspections required by housing funding agencies, which would result in a reduction of the frequency of physical inspections. Key informant interviews (n=18) of property managers and tenants were used to explore the inspection process, identification of housing quality issues, and potential effects on the health of affordable housing tenants and the impact on property management practices. Results indicate that physical inspection frequency may be an important trigger for property managers and tenants to adhere to proper maintenance schedules.