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CONTEXT: In-person home visiting programs that provide evidence-based parenting and child development support improve outcomes for low-income children and families. The COVID-19 pandemic led to a shift from primarily in-person to virtual home visiting services, and little is known about clients experience of home visiting in this context. OBJECTIVE: To describe the experience of clients in the California Work Opportunity and Responsibility to Kids (CalWORKs) Home Visiting Program (HVP) across California during the first 2 years of the pandemic. DESIGN: Three repeated cross-sectional surveys over a 2-year period. Clients free-text responses to open-ended questions were analyzed using a directed content analysis approach. SETTING: Forty-one counties in California. PARTICIPANTS: Current CalWORKs HVP clients and those who left the program in the 6 months prior to each survey. MAIN OUTCOME MEASURES: Clients experience of the CalWORKs HVP. RESULTS: Five main themes emerged: (1) benefits received from the program; (2) life challenges; (3) COVID-19-related or other program changes; (4) client dissatisfaction and suggestions for improvement; and (5) appreciation for the program. Clients valued the practical, financial, parenting, and interpersonal support provided to themselves and their children. Almost three-quarters commented on life challenges experienced during the program. Significant programmatic changes related to COVID-19 pandemic public health safety and organizational constraints impacted clients both positively and negatively. Very few clients experienced overt dissatisfaction with the program. Many clients expressed appreciation for the program, particularly the individualized and relational support offered by a consistent home visitor. CONCLUSIONS: The findings provide insights into the benefits and challenges experienced by clients receiving evidence-based home visiting services. The findings highlight the ongoing life challenges faced by clients who experience poverty, and how those challenges were exacerbated by a global pandemic. The CalWORKs HVP may buffer the substantial personal stresses clients experience related to parenting in the context of poverty and major public health challenges.

Living with extremely low-income is an important risk factor for HIV/AIDS and can be mitigated by conditional cash transfers. Using a cohort of 22.7 million low-income individuals during 9 years, we evaluated the effects of the worlds largest conditional cash transfer, the Programa Bolsa Família, on HIV/AIDS-related outcomes. Exposure to Programa Bolsa Família was associated with reduced AIDS incidence by 41% (RR:0.59; 95%CI:0.57-0.61), mortality by 39% (RR:0.61; 95%CI:0.57-0.64), and case fatality rates by 25% (RR:0.75; 95%CI:0.66-0.85) in the cohort, and Programa Bolsa Família effects were considerably stronger among individuals of extremely low-income [reduction of 55% for incidence (RR:0.45, 95% CI:0.42-0.47), 54% mortality (RR:0.46, 95% CI:0.42-0.49), and 37% case-fatality (RR:0.63, 95% CI:0.51 -0.76)], decreasing gradually until having no effect in individuals with higher incomes. Similar effects were observed on HIV notification. Programa Bolsa Família impact was also stronger among women and adolescents. Several sensitivity and triangulation analyses demonstrated the robustness of the results. Conditional cash transfers can significantly reduce AIDS morbidity and mortality in extremely vulnerable populations and should be considered an essential intervention to achieve AIDS-related sustainable development goals by 2030.

BACKGROUND: Early childhood health development is positively associated with income, but the strength of this relationship with ethnoracial background remains unclear. This study examined the extent of health development inequities among California kindergarteners based on ethnoracial backgrounds and neighborhood-level income. METHODS: This cross-sectional study assessed health development inequities by analyzing neighborhood-level income, ethnoracial background, and health development data for California kindergarteners. Student-level data (n = 106,574) were collected through teacher report between 2010-2020 across 52 school districts and 964 schools. Student addresses were geocoded and linked to American Community Survey neighborhood income levels. Health development was measured using the Early Development Instrument, a population-level measure which includes physical health and well-being, social competence, emotional maturity, language and cognitive development, and communication skills and general knowledge domains. Outcomes included being on-track in each domain as well as overall health development. RESULTS: Using a Generalized Estimation Equation with a log-link function, while accounting for interactions between ethnoracial background, income, and income-squared, we found significant health development inequities by ethnoracial background and neighborhood-level income. Regarding overall health development, as well as the physical, social and emotional domains, Black students had a lower likelihood of being on-track compared to the weighted average across income levels, whereas Asian students surpassed the weighted average. White students exhibited the steepest slope, and at the lowest income levels, their health development scores were akin to their Black and Hispanic/Latino/a low-income counterparts but resembled their Asian counterparts at higher income levels. For the general knowledge and communication domain, white students consistently had the highest likelihood of being on-track, while Hispanic/Latino/a students had the lowest likelihood across all income levels. CONCLUSION: This study examines health development inequities among California kindergarteners in diverse communities. Our analysis shows that the relationship between neighborhood-level income and kindergartners health development varies by domain and is weaker for students of color. Given the scarcity of population-level data on health development outcomes, these analyses offer valuable insights for identifying ecosystems necessitating support in promoting equitable early childhood health development.

INTRODUCTION: Access to primary care has been a long-standing priority for improving population health. Asian Americans, who often settle in ethnic enclaves, have been found to underutilize health care. Understanding geographic primary care accessibility within Asian American enclaves can help to ensure the long-term health of this fast-growing population. METHODS: U.S. Census data from five states (California, Florida, New Jersey, New York, and Texas) were used to develop and describe census-tract level measures of Asian American enclaves and social and built environment characteristics for years 2000 and 2010. The 2-step floating catchment area method was applied to National Provider Identifier data to develop a tract-level measure of geographic primary care accessibility. Analyses were conducted in 2022-2023, and associations between enclaves (versus nonenclaves) and geographic primary care accessibility were evaluated using multivariable Poisson regression with robust variance estimation, adjusting for potential area-level confounders. RESULTS: Of 24,482 census tracts, 26.1% were classified as Asian American enclaves. Asian American enclaves were more likely to be metropolitan and have less poverty, lower crime, and lower proportions of uninsured individuals than nonenclaves. Asian American enclaves had higher primary care accessibility than nonenclaves (adjusted prevalence ratio=1.23, 95% CI=1.17, 1.29). CONCLUSIONS: Asian American enclaves in five of the most diverse and populous states in the U.S. had fewer markers of disadvantage and greater geographic primary care accessibility. This study contributes to the growing body of research elucidating the constellation of social and built environment features within Asian American enclaves and provides evidence of health-promoting characteristics of these neighborhoods.

OBJECTIVE: To use evidence on addressing racism in social care intervention research to create a framework for advancing health equity for all populations with marginalized social identities (e.g., race, gender, and sexual orientation). Such groups have disproportionate social needs (e.g., food insecurity) and negative social determinants of health (SDOH; e.g., poverty). We recommend how the Agency for Healthcare Research and Quality (AHRQ) could advance health equity for marginalized populations through social care research and care delivery. DATA SOURCES AND STUDY SETTING: This commentary is informed by a literature review of social care interventions that were affiliated with healthcare systems; input from health equity researchers, policymakers, and community leaders attending the AHRQ Health Equity Summit; and consensus of the authors. PRINCIPAL FINDINGS: We recommend that AHRQ: (1) create an ecosystem that values research on SDOH and the effectiveness and implementation of social care interventions in the healthcare sector; (2) work with other federal agencies to (a) develop position statements with actionable recommendations about racism and other systems that perpetuate marginalization based on social identity and (b) develop aligned, complementary approaches to research and care delivery that address social marginalization; (3) advance both inclusive care delivery and inclusive research teams; (4) advance understanding of racism as a social determinant of health and effective strategies to mitigate its adverse impact on health; (5) advance the creation and scaling of effective strategies for addressing SDOH in healthcare systems, particularly in co-creation with community partners; and (6) require social care intervention researchers to use methods that advance our understanding of social health equity. CONCLUSIONS: AHRQ, as a federal agency, could help advance health equity using a range of strategies, including using the agencys levers to ensure AHRQ stakeholders examine and address the unique experiences of socially marginalized populations in SDOH and social care intervention research.

Using  6 years of data from the National Survey of Drug Use and Health, the present study investigated ethnic minority-White disparities in self-rated health and community functioning for persons with untreated mental illness. Comparing minority and White persons with untreated severe mental illness (SMI) and mild and moderate mental illness (MMMI), the study sought evidence of double jeopardy: that minority persons with mental illness suffer an added burden from being members of ethnic minority groups. For African Americans with SMI and MMMI, results indicated that the odds were greater of living in poverty, being unemployed, and being arrested in the past year, and for African Americans with SMI, the odds were greater of reporting fair/poor health. For Native Americans/Alaska Native persons with MMMI, the odds were greater of living in poverty and being arrested in the past year. For Latinx persons with SMI and MMMI, the odds were greater of living in poverty and for Latinx persons with SMI the odds were greater of reporting fair/poor health. Results indicate that African Americans with mental illness suffer pervasive adversity relative to Whites and Native Americans/Alaska Natives and Latinx persons do so selectively.

Associations between household social needs, acculturation, and emotional health remain understudied, particularly among Latinx mothers. We analyzed baseline survey data from 455 Latinx mothers in a previous study. Using multinomial regression, we examined whether emotional problems and perceived stress were associated with household social needs and acculturation. Almost half the sample reported four or more household social needs. Social needs cumulatively and independently predicted increased odds of frequent emotional problems or perceived stress. Lower acculturation predicted lower odds of frequent emotional problems. There is increased risk for emotional problems and stress in low-income Latinx mothers who experience high social need. Integrated social service and mental health care models may be one way to improve health outcomes. More research is needed to understand how clinical settings can leverage unique cultural protective factors to address the social and emotional health needs of Latinx mothers.

BACKGROUND: Social determinants of health (SDoHs) are receiving growing attention and are particularly relevant to persons with schizophrenia-spectrum psychotic disorders (SSPDs), considering their heightened risk of comorbidities, cognitive and functional decline, and early mortality. Yet, we did not find any comprehensive review of multiple SDoHs in SSPD. STUDY DESIGN: We conducted a scoping review of meta-analyses and systematic reviews of nine major SDoHs in SSPD. STUDY RESULTS: Childhood abuse, parental psychopathology, parental communication problems, bullying, and urban settings with lower socioeconomic status were major risk factors for the greater incidence of SSPD and/or worse health. Social network size was inversely associated with overall psychopathology and negative symptoms. Experiences of racial/ethnic discrimination correlated with the prevalence of psychotic symptoms and experiences. Compared to native populations, the risk of psychosis was higher in immigrants, refugees, and asylees. Social fragmentation was associated with an increased prevalence of schizophrenia. Homeless populations had a 30-fold higher prevalence of schizophrenia than the general population. Seriously mentally ill people were 2.7 times more likely to report food insecurity than controls. The prevalence of non-affective psychosis in prisoners was 2.0%-6.5%, compared to 0.3% in the general population. Certain potentially positive factors like family and community resilience remain poorly studied. CONCLUSIONS: SDoHs are associated with higher rates of and worse outcomes in SSPD. Well-designed longitudinal studies are needed to understand SDoHs contribution to health in persons with SSPD, to develop interventions, and to implement changes in clinical care and public health policies that would reduce adverse health impacts of SDoHs. Positive SDoHs deserve greater attention.

BackgroundNutrition during pregnancy is important for maternal and infant health. The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) provides nutritional support for low-income pregnant and postpartum individuals and children under the age of 5 y. However, WIC participation was in decline in the decade leading up to 2019.ObjectivesThis study examined individual and state predictors associated with WIC uptake among eligible individuals so as to identify subgroups for targeted intervention to improve participation.MethodsData came from the 2004-2019 waves of the Pregnancy Risk Assessment Monitoring System (PRAMS), a national survey of individuals who recently gave birth (N = 288,531). Multivariable logistic regressions were used to examine individual- and state-level and temporal predictors of WIC uptake among WIC-eligible respondents.ResultsAmong WIC-eligible respondents, ages of >35 (OR: 0.68; 95% CI: 0.66, 0.70), more than high school education (OR: 0.63; 95% CI: 062, 0.65), English language proficiency (OR: 0.71; 95% CI: 0.68, 0.74), being married (OR: 0.70; 95% CI: 0.69, 0.72), White race, smaller family size, not having prepregnancy diabetes, and higher income were associated with lower odds of WIC uptake. Respondents in states with higher earned income tax credit rates and in the Northeast, Midwest, and West (compared with the South) had lower WIC uptake. Respondents in states with higher gross domestic product, higher unemployment rates, higher Supplemental Nutrition Assistance Program, Temporary Assistance for Needy Families, and Medicaid caseloads, and Democrat governors had higher uptake; however, effect estimates were small and may not represent a meaningful change. Associations were the strongest during 2009-2015 than during other years, particularly for race/Hispanic origin, language, marital status, prepregnancy diabetes, family size, and prepregnancy.ConclusionsThis study identified several individual- and state-level characteristics associated with WIC uptake among low-income eligible respondents, paving the way for future interventions to target key subgroups to improve program participation.

COVID-19 testing is an important risk mitigation strategy for COVID-19 prevention in school settings, where the virus continues to pose a public health challenge for in-person learning. Socially vulnerable school communities with the highest proportion of low-income, minority, and non-English speaking families have the least testing access despite shouldering a disproportionate burden of COVID-19 morbidity and mortality. Through the Safer at School Early Alert (SASEA) program, we investigated community perceptions of testing in San Diego County schools, with a focus on barriers and facilitators from the perspective of socially vulnerable parents and school staff. Using a mixed-methods approach, we administered a community survey and conducted focus group discussions (FGDs) with staff and parents from SASEA-affiliated schools and childcares. We recruited 299 survey respondents and 42 FGD participants. Protecting one's family (96.6%) and protecting one's community (96.6%) were marked as key motivators to testing uptake. School staff in particular reported that the reassurance of a negative status mitigated concerns about COVID-19 infection in schools. Participants expressed that COVID-19-related stigma, loss of income as a result of isolation/quarantine requirements, and lack of multilingual materials were the most significant barriers to testing. Our findings suggest that the testing barriers faced by school community members are predominantly structural. Testing uptake efforts must provide support and resources to manage the social and financial consequences of testing while continuously communicating its benefits. There is a clear need to continue to incorporate testing as a strategy to maintain school safety and facilitate access for vulnerable community members.

In the United States, the coronavirus disease-2019 (COVID-19) pandemic has disproportionally affected Black, Latinx, and Indigenous populations, immigrants, and economically disadvantaged individuals. Such historically marginalized groups are more often employed in low-wage jobs without health insurance and have higher rates of infection, hospitalization, and death from COVID-19 than non-Latinx White individuals. Mistrust in the health care system, language barriers, and limited health literacy have hindered vaccination rates in minorities, further exacerbating health disparities rooted in structural, institutional, and socioeconomic inequities. In this article, we discuss the lessons learned over the last 2 years and how to mitigate health disparities moving forward.

PurposeSince 2011, US authorities have supported the following 2 approaches to healthier body fat composition: the Centers for Disease Control and Prevention National Diabetes Prevention Program's calorie counting (CC) approach and the US Department of Agriculture's MyPlate (adherence to federal nutrition guidelines). The purpose of this study was to compare the effect of CC vs MyPlate approaches on satiety/satiation and on achieving healthier body fat composition among primary care patients.MethodsWe conducted a randomized controlled trial comparing the CC and MyPlate approaches from 2015 to 2017. The adult participants were overweight, of low income, and were mostly Latine (n = 261). For both approaches, community health workers conducted 2 home education visits, 2 group education sessions, and 7 telephone coaching calls over a period of 6 months. Satiation and satiety were the primary patient-centered outcome measures. Waist circumference and body weight were the primary anthropometric measures. Measures were assessed at baseline, 6 months, and 12 months.ResultsSatiation and satiety scores increased for both groups. Waist circumference was significantly decreased in both groups. MyPlate, but not CC, resulted in lower systolic blood pressure at 6 months but not at 12 months. Participants for both MyPlate and CC reported greater quality of life and emotional well-being and high satisfaction with their assigned weight-loss program. The most acculturated participants showed the greatest decreases in waist circumference.ConclusionsA MyPlate-based intervention might be a practical alternative to the more traditional CC approach to promoting satiety and facilitating decreases in central adiposity among low-income, mostly Latine primary care patients.

BackgroundThe COVID-19 pandemic has disproportionately impacted disabled people, especially those who are members of marginalized communities that were already denied access to the resources and opportunities necessary to ensure health equity before the pandemic.ObjectiveCompare COVID-19 impact on basic needs access among households with and without disabled adults.MethodsAn online survey was distributed to households with children enrolled in one of 30 socially vulnerable elementary or middle schools in San Diego County, California. We measured disability using the single-item Global Activities Limitations Indicator. We measured pandemic impacts on basic needs access using the RADx-UP common data elements toolkit. We then assessed number of impact items reported by household disability using multivariable linear regression, adjusting for household income, household size, education, parent gender, and child's ethnicity.ResultsOf 304 participants, 41% had at least one disabled household member. Participants reporting a disabled household member were more likely to report challenges accessing basic needs, such as food, housing, healthcare, transportation, medication, and stable income during the pandemic (all p

Most older adults reside in low- and middle-income countries (LMICs) but most research dollars spent on interventions to improve the lives of older adults are awarded to researchers in high-income countries (HICs). One approach to improve the implementation of evidence-based innovations for older adults in LMICs is designing interventions that are relevant to LMICs and HICs simultaneously. We propose that researchers in HICs could partner with stakeholders in an LMIC throughout the intervention design process to better position their intervention for the implementation in that LMIC. We provide an example study from an adaptation of the Resources for Enhancing Caregiver Health II in Vietnam, which did not use this strategy but may have benefited from this strategy. We then turn to several considerations that are important for researchers to contemplate when incorporating this strategy. Finally, we explore incentives for creating interventions that are relevant to both HICs and LMICs for funders, intervention designers, and intervention receivers. Although this is not the only strategy to bring interventions to LMICs, it may represent another tool in researchers' toolboxes to help expedite the implementation of efficacious interventions in LMICs.

Rapid identification and isolation/quarantine of COVID-19 cases or close contacts, respectively, is a vital tool to support safe, in-person learning. However, safe isolation or quarantine for a young child also necessitates home confinement for at least one adult caregiver, as well as rapid learning material development by the teacher to minimize learning loss. The purpose of this study is to better understand barriers and supports to student home confinement. We conducted a mixed-methods study using focus group discussions and a self-administered online survey with parents and staff members from 12 elementary schools and childcare sites across San Diego County serving low-income and socially vulnerable families. Focus group participants reported that mental distress and loneliness, learning loss, childcare, food, income loss, and overcrowded housing were major barriers related to home confinement. The experiences described by FGD participants were prevalent in a concurrent community survey: 25% of participants reported that isolation would be extremely difficult for a household member who tested positive or was exposed to COVID-19, and 20% were extremely concerned about learning loss while in isolation or quarantine. Our findings suggest that there are serious structural impediments to safely completing the entire recommended course of isolation or quarantine, and that the potential for isolation or quarantine may also lead to increased hesitancy to access diagnostic testing.

ObjectivesLow-income, first-time mothers generally breastfeed exclusively and, overall, for a shorter average duration than high-income, multiparous mothers. A potential barrier to breastfeeding success is access to a breast pump for home use. In this pilot study, we estimated the effect of providing a manual breast pump during birth hospitalization for home use on any/exclusive breastfeeding and investigated participant attitudes about manual pumps and their breastfeeding experiences.MethodsSixty low-income, first-time mothers were enrolled in a pilot randomized controlled trial. One-half received a manual breast pump and the other half received an attention control. Breastfeeding exclusivity, duration, and use of the manual pump were assessed at 6 and 12 weeks. Qualitative interviews regarding the breastfeeding experience were completed. Thirty-one women answered 13 questions that were then transcribed, coded, and grouped into themes.ResultsParticipants who were randomized to manual breast pump receipt during birth hospitalization had increased manual pump use at 6 weeks (13/19 [68%] versus controls 5/17 [29%]), there was no effect of pump receipt on any nor exclusive breastfeeding at 12 weeks. In qualitative analysis of the overall breastfeeding experience, participants expressed a need for additional support and had conflicting attitudes regarding breastfeeding and the pumping experience.ConclusionsManual breast pump receipt in hospital among low-income, first-time mothers did not affect breastfeeding exclusivity or duration. Participants reported that early and ongoing lactation support is essential. Strategies to improve breastfeeding outcomes low-income, first-time mothers are needed.

Quality improvement (QI) work is critical, particularly in federally qualified health centers (FQHCs) that treat underserved populations. In a national sample of 45 FQHCs, we examined how patients' sociodemographic characteristics were associated with employee engagement in QI, via innovation contests that solicited ideas for improving care and offered opportunities to vote on ideas. We posited that patients' sociodemographic characteristics influence the complexity and intensity of clinical work and thus employees' capacity to engage in QI. Regression results indicated that the percentage of patients living in poverty was negatively associated with employee participation in idea submission and voting. Moreover, the percentage of Hispanic patients was negatively associated with participation in voting. The percentage of Black patients, however, was not associated with either outcome. FQHCs that serve a higher share of low income and/or Hispanic patients may face resource and personnel constraints that reduce employees' capacity to contribute to QI efforts.

Research on discrimination and risks for violence and mental health issues under the pandemic is notably absent. We examined the relative effects of perceived everyday discrimination (e.g., poorer service, disrespectful treatment in a typical week) and major experiences of race-based discrimination (e.g., racial/ethnic discrimination in housing or employment at any point in the lifetime) on experiences of violence and the PHQ-4 assessment of symptoms of depression and anxiety under the pandemic. We analyzed state-representative cross-sectional survey data from California adults (N = 2114) collected in March 2021. We conducted multivariate regression models adjusting for age, race/ethnicity, gender, sexual identity, income, and disability. One in four Californians (26.1%) experienced everyday discrimination in public spaces, due most often to race/ethnicity and gender. We found that everyday discrimination was significantly associated with past year physical violence (single form Adjusted Odds Ratio [AOR] 5.0, 95% CI 2.5-10.3; multiple forms AOR 2.6, 95% CI 1.1-5.8), past year sexual violence (multiple forms AOR 2.5, 95% CI 1.4-4.4), and mental health symptoms (e.g., severe symptoms, multiple forms AOR 3.3, 95% CI 1.6-6.7). Major experiences of race-based discrimination (reported by 10.0% of Californians) were associated with past year sexual violence (AOR 2.0, 95% CI 1.1-3.8) and severe mental health symptoms (AOR 2.7, 95% CI 1.2-6.2). Non-race-based major discrimination (reported by 23.9% of Californians) was also associated with violence and mental health outcomes Everyday discrimination, more than major experiences of discrimination, was associated with higher risk for violence and poor mental health outcomes during the pandemic. Non-race-based forms of major discrimination independently were also associated with these negative outcomes. Findings indicate that efforts to reduce and ultimately eliminate discrimination should be a focus of public health and COVID-19 rebuilding efforts.

Child protective services (CPS) contact occurs at substantially higher rates among Black than White families. The present study considers systemic racism as a central driver of this disparity and emphasizes racialized poverty as a possible mechanism. We used data from the Fragile Families and Child Wellbeing Study and logistic regression analyses to assess the associations between income poverty, a racialized experience, and CPS contact, separately among Black and White families. Results indicated that income poverty was a significant predictor of CPS contact among White families, who were protected by higher income. In contrast, income per se was not a significant predictor of CPS contact among Black families, who were instead impacted by racialized family regulation and consequences of poverty, such as poor health and depression. Refundable state Earned Income Tax Credit (EITC) policies were protective for Black families, and more expansive Temporary Assistance for Needy Families (TANF) programs decreased CPS contact for Black and White families. Implications include centering systemic racism and specifically racialized poverty as causes of racial inequities in CPS contact and rethinking the role of CPS in protecting children.

Exposure to adversity (e.g., poverty, bereavement) is a robust predictor of disruptions in psychological functioning. However, people vary greatly in their responses to adversity; some experience severe long-term disruptions, others experience minimal disruptions or even improvements. We refer to the latter outcomes-faring better than expected given adversity-as psychological resilience. Understanding what processes explain resilience has critical theoretical and practical implications. Yet, psychology's understanding of resilience is incomplete, for two reasons: (a) We lack conceptual clarity, and (b) two major approaches to resilience-the stress and coping approach and the emotion and emotion-regulation approach-have limitations and are relatively isolated from one another. To address these two obstacles,we first discuss conceptual questions about resilience. Next, we offer an integrative affect-regulation framework that capitalizes on complementary strengths of both approaches. This framework advances our understanding of resilience by integrating existing findings, highlighting gaps in knowledge, and guiding future research.

PURPOSE: Understanding parental experiences with managing their toddlers screen use is important to inform the design of interventions addressing early childhood screen use, yet current evidence is limited. To enhance our understanding of the context of toddler screen use, this study characterizes the screen-related discord and dismay parents experience in families with toddlers. DESIGN AND METHODS: In-depth interviews were conducted to explore everyday experiences with screen use among low-income Mexican American caregivers of toddlers (21 mothers, 10 fathers, 1 grandmother). Transcripts were content analyzed to identify prominent themes. RESULTS: Three themes were identified. Experiences of screen-related discord and dismay arose (1) between parent and child, (2) between parents, and (3) surfaced as parental internal dissonance about toddler screen use. Parent-child discord resulted from parental limit setting and child reactions to parental screen use, which often included tantrums. Parent-partner discord included patterns of agreeing to disagree and direct disagreement between partners. Parents also reported their own feelings of ambivalence and dismay as they struggled to reconcile their preferences against their toddlers actual screen use, while living in a screen-saturated world. CONCLUSIONS: Findings offer insight into types of screen-related discord and dismay low-income Mexican American parents experience as they attempt to manage their toddlers screen use. PRACTICE IMPLICATIONS: Although discord in families is normal, the screen-specific discord reported by participants warrants consideration in efforts promoting healthy screen use in families. Providers can tailor their counseling to consider the range of screen-related discord families of toddlers may experience.

OBJECTIVE: Health disparities in juvenile idiopathic arthritis (JIA) remain poorly understood. Social disadvantage may have a cumulative impact on health, with recent analyses using combined scoring systems to measure their impact on outcomes. Our aim was to investigate cumulative social disadvantage on childhood arthritis by using a cumulative score to analyze its association with arthritis among a nationally representative sample of children. METHODS: A cross-sectional analysis of the National Survey of Childrens Health (2016-2019) was performed. A cumulative social disadvantage score was generated (1 point each, with a maximum score of 4): low guardian education (high school or less), low household income level (0-199% of federal poverty level), underinsured status (public or uninsured), and high adverse childhood experience (ACE) score (≥4). Univariate and multivariable (adjusting for age, sex, and race and ethnicity) logistic regression models were used to measure the association between cumulative social risk and the odds of an arthritis diagnosis and moderate-to-severe parent-reported arthritis severity. RESULTS: Of 131,774 surveys completed, a total of 365 children reported current arthritis. Cumulative social disadvantage was associated with an arthritis diagnosis, with the highest odds among those with a score of 4 (adjusted odds ratio [ORadj ] 12.4 [95% confidence interval (95% CI) 2.9-53.3]). Cumulative social disadvantage also was associated with increased odds of moderate-to-severe arthritis severity (ORadj 12.4 [95% CI 1.8-82.6]). CONCLUSION: In this nationally representative sample, accumulated social disadvantage, measured via a cumulative social disadvantage score based on income level, guardian education, insurance status, and ACE exposure, was associated with an arthritis diagnosis and moderate-to-severe arthritis severity.

BACKGROUND: Economic inequity systematically affects Black emerging adults (BEA), aged 18-24, and their healthy trajectory into adulthood. Guaranteed income (GI)-temporary, unconditional cash payments-is gaining traction as a policy solution to address the inequitable distribution of resources sewn by decades of structural racism and disinvestment. GI provides recipients with security, time, and support to enable their transition into adulthood and shows promise for improving mental and physical health outcomes. To date, few GI pilots have targeted emerging adults. The BEEM trial seeks to determine whether providing GI to BEA improves financial wellbeing, mental and physical health as a means to address health disparities. METHODS/DESIGN: Using a randomized controlled crossover trial design, 300 low-income BEA from San Francisco and Oakland, California, are randomized to receive a $500/month GI either during the first 12-months of follow-up (Phase I) or during the second 12-months of a total of 24-months follow-up (Phase II). All participants are offered enrollment in optional peer discussion groups and financial mentoring to bolster financial capability. Primary intention-to-treat analyzes will evaluate the impact of GI at 12 months among Phase I GI recipients compared to waitlist arm participants using Generalized Estimating Equations (GEE). Primary outcomes include: (a) financial well-being (investing in education/training); (b) mental health status (depressive symptoms); and (c) unmet need for mental health and sexual and reproductive health services. Secondary analyzes will examine effects of optional financial capability components using GEE with causal inference methods to adjust for differences across sub-strata. We will also explore the degree to which GI impacts dissipate after payments end. Study outcomes will be collected via surveys every 3 months throughout the study. A nested longitudinal qualitative cohort of 36 participants will further clarify how GI impacts these outcomes. We also discuss how anti-racism praxis guided the intervention design, evaluation design, and implementation. DISCUSSION: Findings will provide the first experimental evidence of whether targeted GI paired with complementary financial programming improves the financial well-being, mental health, and unmet health service needs of urban BEA. Results will contribute timely evidence for utilizing GI as a policy tool to reduce health disparities. CLINICAL TRIAL REGISTRATION: https://clinicaltrials.gov, identifier NCT05609188.

Prenatal depression is prevalent and adversely impacts maternal and infant health. This study addresses a critical literature gap and investigates the association between maternal diet quality and prenatal depressive symptoms, as well as the moderating effect of economic well-being on this link. A cross-sectional design was used, including 43 healthy pregnant women in the second trimester aggregated from two research projects. Prenatal depressive symptoms were assessed using the Edinburgh Postnatal Depression Scale. Dietary quality was evaluated using two non-consecutive 24 h dietary recalls, from which the Adapted Dietary Inflammatory Index (ADII) and the Healthy Eating Index (HEI)-2015 were derived. Economic well-being was indicated by the income-to-poverty ratio. A higher HEI-2015 (adherence to dietary guidelines; β = -0.53, p = 0.01) and negative ADII (anti-inflammatory diet; β = 0.40, p = 0.06) were associated with fewer prenatal depressive symp-toms. Among pregnant women with worse economic well-being, a pro-inflammatory diet was as-sociated with more prenatal depressive symptoms (b = 1.69, p = 0.004), but among those with better economic well-being, the association was not significant (b = 0.51, p = 0.09). Dietary interventions aimed at reducing dietary inflammation might hold some promise for improving mental health among pregnant women who are economically vulnerable.

IntroductionSalivary bioscience has found increased utilization within pediatric research, given the non-invasive nature of self-collecting saliva for measuring biological markers. With this growth in pediatric utility, more understanding is needed of how social-contextual factors, such as socioeconomic factors or status (SES), influence salivary bioscience in large multi-site studies. Socioeconomic factors have been shown to influence non-salivary analyte levels across childhood and adolescent development. However, less is understood about relationships between these socioeconomic factors and salivary collection methodological variables (e.g., time of saliva collection from waking, time of day of saliva collection, physical activity prior to saliva collection, and caffeine intake prior to saliva collection). Variability in salivary methodological variables between participants may impact the levels of analytes measured in a salivary sample, thus serving as a potential mechanism for non-random systematic biases in analytes.MethodsOur objective is to examine relationships between socioeconomic factors and salivary bioscience methodological variables within the Adolescent Brain Cognitive Development Study© cohort of children aged 9-10 years old (n = 10,567 participants with saliva samples).ResultsWe observed significant associations between household socioeconomic factors (poverty status, education) and salivary collection methodological variables (time since waking, time of day of sampling, physical activity, and caffeine intake). Moreover, lower levels of household poverty and education were significantly associated with more sources of potential bias in salivary collection methodological variables (e.g., longer times since waking, collections later in the day, higher odds of caffeine consumption, and lower odds of physical activity). Consistent associations were not observed with neighborhood socioeconomic factors and salivary methodological variables.DiscussionPrevious literature demonstrates associations between collection methodological variables and measurements of salivary analyte levels, particularly with analytes that are more sensitive to circadian rhythms, pH levels, or rigorous physical activity. Our novel findings suggest that unintended distortions in measured salivary analyte values, potentially resulting from the non-random systematic biases in salivary methodology, need to be intentionally incorporated into analyses and interpretation of results. This is particularly salient for future studies interested in examining underlying mechanisms of childhood socioeconomic health inequities in future analyses.

The US Congress temporarily expanded the Child Tax Credit (CTC) during the COVID-19 pandemic to provide economic assistance for families with children. Although formerly the CTC provided $2,000 per child for mostly middle-income parents, during July-December 2021 it provided up to $3,600 per child. Eligibility criteria were also expanded to reach more economically disadvantaged families. There has been little research evaluating the effect of the policy expansion on mental health. Using data from the Census Bureau's Household Pulse Survey and a quasi-experimental study design, we examined the effects of the expanded CTC on mental health and related outcomes among low-income adults with children, and by racial and ethnic subgroup. We found fewer depressive and anxiety symptoms among low-income adults. Adults of Black, Hispanic, and other racial and ethnic backgrounds demonstrated greater reductions in anxiety symptoms compared to non-Hispanic White adults with children. There were no changes in mental health care use. These findings are important for Congress and state legislators to weigh as they consider making the expanded CTC and other similar tax credits permanent to support economically disadvantaged families.

A key element of risk assessment is accounting for the full range of variability in response to environmental exposures. Default dose-response methods typically assume a 10-fold difference in response to chemical exposures between average (healthy) and susceptible humans, despite evidence of wider variability. Experts and authoritative bodies support using advanced techniques to better account for human variability due to factors such as in utero or early life exposure and exposure to multiple environmental, social, and economic stressors.This review describes: 1) sources of human variability and susceptibility in dose-response assessment, 2) existing US frameworks for addressing response variability in risk assessment; 3) key scientific inadequacies necessitating updated methods; 4) improved approaches and opportunities for better use of science; and 5) specific and quantitative recommendations to address evidence and policy needs.Current default adjustment factors do not sufficiently capture human variability in dose-response and thus are inadequate to protect the entire population. Susceptible groups are not appropriately protected under current regulatory guidelines. Emerging tools and data sources that better account for human variability and susceptibility include probabilistic methods, genetically diverse in vivo and in vitro models, and the use of human data to capture underlying risk and/or assess combined effects from chemical and non-chemical stressors.We recommend using updated methods and data to improve consideration of human variability and susceptibility in risk assessment, including the use of increased default human variability factors and separate adjustment factors for capturing age/life stage of development and exposure to multiple chemical and non-chemical stressors. Updated methods would result in greater transparency and protection for susceptible groups, including children, infants, people who are pregnant or nursing, people with disabilities, and those burdened by additional environmental exposures and/or social factors such as poverty and racism.

We investigated the impact of State-level Earned Income Tax Credit (SEITC) generosity on HIV risk behavior among single mothers with low education. We merged individual-level data from the Behavioral Risk Factor Surveillance System (2002-2018) with state-level data from the University of Kentucky Center for Poverty Research and conducted a multi-state, multi-year difference-in-differences (DID) analysis. We found that a refundable SEITC ≥ 10% of the Federal Earned Income Tax Credit was associated with 21% relative risk reduction in reporting any high-risk behavior for HIV in the last year, relative to no SEITC. We also found that a 10-percentage point increase in SEITC generosity was associated with 38% relative risk reduction in reporting any high-risk HIV behavior in the last year. SEITC policy may be an important strategy to reduce the burden of HIV infections among women with low socioeconomic status, particularly single mothers.

Science education and research have the potential to drive profound change in low- and middle-income countries (LMICs) through encouraging innovation, attracting industry, and creating job opportunities. However, in LMICs, research capacity is often limited, and acquisition of funding and access to state-of-the-art technologies is challenging. The Alliance for Global Health and Science (the Alliance) was founded as a partnership between the University of California, Berkeley (USA) and Makerere University (Uganda), with the goal of strengthening Makerere University's capacity for bioscience research. The flagship program of the Alliance partnership is the MU/UCB Biosciences Training Program, an in-country, hands-on workshop model that trains a large number of students from Makerere University in infectious disease and molecular biology research. This approach nucleates training of larger and more diverse groups of students, development of mentoring and bi-directional research partnerships, and support of the local economy. Here, we describe the project, its conception, implementation, challenges, and outcomes of bioscience research workshops. We aim to provide a blueprint for workshop implementation, and create a valuable resource for bioscience research capacity strengthening in LMICs.

OBJECTIVE: To study the impact of Medicaid funding structures before and after the implementation of the Affordable Care Act (ACA) on health care access for Latinos in New York (Medicaid expansion), Florida (Medicaid non-expansion), and Puerto Rico (Medicaid block grant). DATA SOURCES: Pooled state-level data for New York, Florida, and Puerto Rico from the 2011-2019 Behavioral Risk Factor Surveillance System and data from the 2011-2019 American Community Survey and Puerto Rico Community Survey. STUDY DESIGN: Cross-sectional study using probit with predicted margins to separately compare four health care access measures among Latinos in New York, Florida, and Puerto Rico (having health insurance coverage, having a personal doctor, delayed care due to cost, and having a routine checkup). We also used difference-in-differences to measure the probability percent change of having any health insurance and any public health insurance before (2011-2013) and after (2014-2019) the ACA implementation among citizen Latinos in low-income households. DATA COLLECTION: The sample consisted of Latinos aged 18-64 residing in New York, Florida, and Puerto Rico from 2011 to 2019. PRINCIPAL FINDINGS: Latinos in Florida had the lowest probability of having health care access across all four measures and all time periods compared with those in New York and Puerto Rico. While Latinos in Puerto Rico had greater overall health care access compared with Latinos in both states, health care access in Puerto Rico did not change over time. Among citizen Latinos in low-income households, New York had the greatest post-ACA probability of having any health insurance and any public health insurance, with a growing disparity with Puerto Rico (9.7% any [1.6 SE], 5.2% public [1.8 SE]). CONCLUSIONS: Limited Medicaid eligibility (non-expansion of Floridas Medicaid program) and capped Medicaid funds (Puerto Ricos Medicaid block grant) contributed to reduced health care access over time, particularly for citizen Latinos in low-income households.

Firearm violence is a major threat to global public health and safety. Several individual, family, peer, community, and societal risk and protective factors determine or modify the risk of firearm violence. Specifically, there is a strong relationship between poverty, income inequality, and firearm violence; as such, interventions that influence upstream determinants of health by providing income support may hold much promise in affecting multiple domains of risk that are on the causal pathway to firearm violence. Guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews, we conducted a scoping review to examine the current state of evidence on the relationship between income support policies and risk of firearm violence. We searched 8 databases related to health and social sciences from inception through March 30, 2022, and placed no time, language, setting, or other publication restrictions on our search, as long as the study was quantitative or mixed-methods and addressed firearm violence specifically, rather than violence more broadly, as an outcome in relation to income support policies. We found 4 studies; of those, 3 were conducted in the United States and 1 in Brazil. All 4 found associations of policy-relevant magnitude between income support policies and reductions in risk of inter-personal firearm violence. We propose future opportunities to enhance the substantive scope and methodologic rigor of this field of research and inform policy and practice for greater impact.

OBJECTIVE: To estimate the avoidance of Medicaid enrollment among Latino and Asian immigrants due to fears about immigration status. In 2019, changes to the public charge rule made it difficult for immigrants to receive a green card or permanent residence visa, particularly for those who used health and nutrition benefits. Despite the Biden administrations reversal of these changes, fear and misinformation persist among immigrants. DATA SOURCES: Pooled data from the 2017 to 2020 California Health Interview Survey. STUDY DESIGN: We used adjusted predicted probability models to estimate differences in access to and use of health care and health insurance coverage among Latino and Asian immigrant adults with and without green cards, using US citizens as the reference. We estimated the avoidance of Medicaid enrollment among immigrants without a green card, the immigrant population subject to the public charge rule. DATA COLLECTION/EXTRACTION METHODS: Population stratified by race/ethnicity and green card status. PRINCIPAL FINDINGS: Latino immigrants without a green card were -23.1% (CI: -27.8, -18.4) less likely to be insured, -9.2% (CI: -12.8, -5.5) less likely to have Medicaid coverage, -9.3% (CI: -14.5, -4.1) less likely to have a usual source of care, and -8.4% (CI: -13.2, -0.3) less likely to have a physician visit relative to citizens. Asian immigrants without a green card were -11.7% (CI: -19.7, -3.72) less likely to be insured, -8.8% (CI: -11.6, -6.1) less likely to have Medicaid coverage, -11.6% (CI: -19.3, -3.9) less likely to have a usual source of care, and -11.0% (CI: -19.2, -2.3) less likely to have a physician visit. Between 107,956 and 192,905 Latino immigrants and 1294 and 4702 Asian immigrants in California likely avoided Medicaid enrollment due to fears about their immigration status. CONCLUSION: While our estimates are lower than those of previous studies, our findings highlight barriers to health care for immigrants despite the reversal of the changes in the public charge rule. Since the public charge rule was not abolished, immigrants with low incomes might choose not to seek health care, despite recent efforts in California to expand Medicaid coverage to all eligible immigrants regardless of documentation statuses.

Prior research has shown collective efficacy to be a key determinant of women's well-being. However, much of the work around measuring this construct has been done in high-income geographies, with very little representation from low- and middle-income countries (LMIC). To fill this gap, and guide future research in low resource settings, we aim to summarize best evidence measures of collective efficacy for women and girls from LMICs. Following PRISMA guidelines, we systematically searched five databases for English language peer-reviewed literature on measures of collective efficacy, published between 1 January 2009 and 25 August 2020. In addition, we sought expert input for relevant papers in this area. Research staff screened titles, abstracts, and full-text articles in a double-blind review. Inclusion criteria were: (i) original quantitative analysis, and (ii) sample limited to women/girls only (≥ 100), residing in LMICs. We identified 786 unique articles, 14 of which met inclusion criteria. Eligible studies captured a diversity of population groups, including pregnant women, recent mothers, adolescent girls, and female sex workers, from across national settings. Two broad constructs of collective efficacy were captured by the measures: (i) group dynamics, and (ii) collective action. All 14 studies included items on group dynamics in their measures, whereas seven studies included items on collective action. Four studies validated new measures of collective efficacy, and seven provided evidence supporting the relationship between collective efficacy and outcomes related to women's well-being. Overall, measures demonstrated good reliability and validity when tested, and those testing for associations or effects found a positive relationship of collective efficacy with women's health behaviors. The past decade has resulted in a number of new collective efficacy measures demonstrating good validity in terms of their associations with key health outcomes among women and girls from across LMIC settings, but there remains no standard measure in the field. Those that exist focus on group dynamics, but less often on collective action. A standard measure of collective efficacy inclusive of group dynamics and collective action can support better understanding of the value of women's collectives across national settings and populations.

BackgroundCommunity health centers (CHCs) provide comprehensive primary and preventive care to medically underserved, low-income, and racially/ethnically diverse populations. CHCs also offer enabling services, non-clinical assistance to reduce barriers to healthcare due to unmet social and material needs, to improve access to healthcare and reduce health disparities. For patients with modifiable cardiometabolic risk factors, including obesity, hypertension, and diabetes, enabling services may provide additional support to improve disease management. However, little is known about the relationship between enabling services and healthcare accessibility and utilization among patients with cardiometabolic risk factors.MethodsThis study uses data from the 2014 Health Center Patient Survey to examine the relationship between enabling services use and delayed/foregone care, routine check-ups, and emergency room visits, among adult community health center patients in the United States with cardiometabolic risk factors (N = 2358). Outcomes of enabling services users were compared to nonusers using doubly robust propensity score matching methods and generalized linear regression models.ResultsOverall, enabling service users were 15.4 percentage points less likely to report delayed/foregone care and 29.4 percentage points more likely to report routine check-ups than nonusers. Enabling service users who lived in urban areas, younger and middle-aged adults, and those with two cardiometabolic risk factors were also less likely to report delayed/foregone care and/or more likely to report routine check-ups in comparison with nonusers. However, among adults with three or more cardiometabolic risk factors, enabling services use was associated with a 41.3 percentage point increase in emergency room visits and a 7.6 percentage point decrease in routine check-ups.ConclusionsThe findings highlight the value in utilizing enabling services to improve timeliness and receipt of care among CHC patients with heightened cardiometabolic risk. There is a need for targeting high-risk populations with additional enabling services to support management of multiple chronic conditions.

BackgroundPolicy debates over anti-poverty programs are often marked by pernicious stereotypes suggesting that direct cash transfers to people residing in poverty encourage health-risking behaviors such as smoking, drinking, and other substance use. Causal evidence on this issue is limited in the U.S. Given the prominent role of child allowances and other forms of cash assistance in the 2021 American Rescue Plan and proposed Build Back Better legislation, evidence on the extent to which a monthly unconditional cash gift changes substance use patterns among low-income mothers with infants warrants attention, particularly in the context of economic supports that can help improve early environments of children.MethodWe employ a multi-site, parallel-group, randomized control trial in which 1,000 low-income mothers in the U.S. with newborns were recruited from hospitals shortly after the infant's birth and randomly assigned to receive either a substantial ($333) or a nominal ($20) monthly cash gift during the early years of the infant's life. We estimate the effect of the unconditional cash transfer on self-report measures of maternal substance use (i.e., alcohol, cigarette, or opioid use) and household expenditures on alcohol and cigarettes after one year of cash gifts.ResultsThe cash gift difference of $313 per month had small and statistically nonsignificant impacts on group differences in maternal reports of substance use and household expenditures on alcohol or cigarettes. Effect sizes ranged between - 0.067 standard deviations and + 0.072 standard deviations. The estimated share of the $313 group difference spent on alcohol and tobacco was less than 1%.ConclusionsOur randomized control trial of monthly cash gifts to mothers with newborn infants finds that a cash gift difference of $313 per month did not significantly change maternal use of alcohol, cigarettes, or opioids or household expenditures on alcohol or cigarettes. Although the structure of our cash gifts differs somewhat from that of a government-provided child allowance, our null effect findings suggest that unconditional cash transfers aimed at families living in poverty are unlikely to induce large changes in substance use and expenditures by recipients.Trial registrationRegistered on Clinical Trials.gov NCT03593356 in July of 2018.

ObjectiveThe COVID-19 pandemic has forced many human subjects research to halt in-person activities and pivot to virtual engagement, including Focus Groups (FGs). We highlight learnings from our experience of hosting virtual FGs from our BEhavioral EConomics for Oral health iNnovation (BEECON) study focusing on oral hygiene behaviors among low-income, predominantly Hispanic families, including practical tips and potential pitfalls to avoid for researchers considering virtual engagement.ResultsThere can be particular benefits to holding virtual sessions among minority parents of young children-to provide flexibility, comfort, and reduced logistical barriers for participation-while still facilitating friendly conversation with minimal distractions. However, extensive preparation is needed to ensure smooth execution and minimal distractions.

BackgroundOlder adults are the least active population in the U.S. Low-income communities have fewer physical activity (PA) resources, contributing to less PA and increased chronic disease risk. This study assessed the effect of the multilevel, peer-led, Peer Empowerment Program 4 Physical Activity (PEP4PA) on moderate-to-vigorous PA (MVPA) and health outcomes, over 2 years of follow up.MethodsIn a cluster-randomized controlled trial, 12 senior or community centers serving low-income older adults were assigned to a PA intervention (n = 6) or usual programming (n = 6) condition. PEP4PA included self-monitoring, health coaching, group walks, social support, and community advocacy to improve walking conditions. The primary outcome was daily minutes of MVPA (7-day accelerometer). Secondary outcomes included Perceived Quality of Life (PQoL), 6-Minute Walk Test (6-MWT), blood pressure (BP), and depressive symptoms at baseline, 6, 12, 18 and 24 months. Mixed effects regression models estimated the effects on outcomes between groups over time and included random effects for repeated measures and center clustering. Effect modification by sex and income status was assessed. We calculated the incremental cost per daily minute of MVPA gained in the intervention group relative to the control group to assess cost effectiveness.ResultsWe enrolled 476 older adults (50 + years). Participants were on average 71 years old, 76% female, 60% low income, and 38% identified as racial or ethnic minorities. Compared to the control group, intervention participants sustained roughly a 10 min/day increase in MVPA from baseline at all time points and increased mean PQoL scores from unsatisfied at baseline to satisfied at 12, 18 and 24 months. Males and higher-income groups had greater improvements in MVPA. No significant effects were observed for 6-MWT or depressive symptoms, and BP results were mixed. The incremental cost per minute MVPA gained per person was $0.25, $0.09, $0.06, and $0.05 at 6, 12, 18 and 24 months, respectively.ConclusionsPEP4PA achieved increases in MVPA and PQoL in low-income older adults, over 2 years of follow up. The peer-led, community-based intervention provides a sustainable and cost-effective model to improve health behaviors in underserved, aging populations.Trial registrationClinicalTrials.gov ( NCT02405325 ) March 20, 2015.

BackgroundAssess the associations between ten severe maternal hardships and food insecurity experienced during pregnancy.MethodsData on 14,274 low-income/lower-income women (below 400% of the income to federal poverty guideline ratio) from the statewide-representative 2010-2012 California Maternal and Infant Health Assessment were used to estimate food security status prevalence. Prevalence of severe maternal hardships by food security status was estimated. Multinomial logistic regression was used to assess the associations between severe maternal hardship and food security status, adjusting for sociodemographic characteristics.ResultsFood insecurity was common among low- and lower-income pregnant women in California; 23.4% food insecure and an additional 11.5% marginally secure. In adjusted analysis, nine of ten hardships were associated with food security status. Only the respondent or someone close to the respondent having a problem with alcohol or drugs was not associated with food security status after adjusting for socioeconomic factors. Husband/partner losing a job, depressive symptoms, not having practical support and intimate partner violence were consistently associated with marginal, low and very low food security status. Each additional severe maternal hardship a woman experienced during pregnancy was associated with a 36% greater risk of reporting marginal food security (Relative Risk Ratio 1.36, 95% CI: 1.27, 1.47), 54% for low food security (Relative Risk Ratio 1.54, 95% CI: 1.44, 1.64), and 99% for very low food security (Relative Risk Ratio 1.99, 95% CI: 1.83, 2.15).ConclusionsFood security status was strongly linked with several maternal hardships that could jeopardize maternal and/or infant health. Services-including prenatal care and nutritional assistance-for a large proportion of pregnant women should address a wide range of serious unmet social needs including food insecurity.

BACKGROUND: The complex multifactorial nature of childhood obesity makes community interventions difficult to evaluate using traditional approaches; innovative methods are needed. OBJECTIVE: To evaluate the impact of various interventions targeting childhood obesity-related behaviours, and classified as using a micro-level (e.g., home visitation programs) or macro-level (e.g., business practices) strategy, on obesity among children enrolled in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). METHODS: We simulated a population of 1500 children enrolled in WIC, with specific diet, physical activity, breastfeeding behaviours and body mass index z-scores (BMIz), following them from age 2 to 5 years. RESULTS: Combined interventions targeting breastfeeding appeared to be moderately effective, reducing BMIz by 0.03 (95% CI -005, -0.01). Two strategy-specific interventions, home visitation programs and business practices targeting obesity-related behaviours, appeared to be moderately effective at reducing BMIz by 0.04 (95% CI -0.06, -0.02) and 0.02 (95% CI -0.04, 0.00), respectively. Contrary to expectation, combining all micro and macro interventions appeared to have no impact or moderately increased the proportion of obesity/overweight among children. CONCLUSION: Interventions targeting breastfeeding behaviour were most effective when both micro and macro strategies were implemented. Interventions targeting obesity-related behaviours in general were effective for two strategies, home visitation and business practices.

BackgroundHousehold food insecurity persists in the United States and has important implications for health and well-being. Food insecurity in female-identified caregivers is particularly concerning, given its association with their mental health and adverse health outcomes for their children. Food insecurity is associated with disordered eating but, to our knowledge, no prior studies have examined an association between food insecurity and food addiction.ObjectiveOur aim was to examine whether food insecurity is associated with higher food addiction symptom endorsement in low-income female adults.DesignSecondary analysis of baseline data from a quasi-experimental study of a mindfulness-based intervention on gestational weight gain among low-income pregnant individuals and an observational study of low-income families.Participants/settingParticipants in study 1 (n = 208) were English-speaking, low-income pregnant individuals with overweight or obesity, recruited in California from 2011 to 2013. Participants in study 2 (n = 181) were English-speaking, low-income female caregivers for children aged 8 through 10 years, recruited in Michigan from 2018 to 2019. Both studies recruited participants from community health clinics, social service agencies, and online advertisements.Main outcome measuresThe primary outcome measure was food addiction symptoms, assessed by the Yale Food Addiction Scale.Statistical analysisMultivariate Poisson regression was used to examine the association between household food insecurity and food addiction symptoms in each sample, adjusted for sociodemographic characteristics.ResultsIn study 1, pregnant individuals in food-insecure households reported 21% higher food addiction symptoms than pregnant individuals in food-secure households (incidence rate ratio 1.21; 95% CI 1.00 to 1.47; P = .047). In study 2, caregivers in food-insecure households had 56% higher food addiction symptoms than caregivers in food-secure households (incidence rate ratio 1.56; 95% CI 1.01 to 2.40; P = .045).ConclusionsThese findings provide preliminary support for a relationship between household food insecurity and food addiction. Future research should examine potential mechanisms and whether interventions to reduce food insecurity lower risk of food addiction.

Residential racial segregation is a key manifestation of anti-Black structural racism, thought to be a fundamental cause of poor health; evidence has shown that it yields neighborhood disinvestment, institutional discrimination, and targeting of unhealthy products like tobacco and alcohol. Yet research on the long-term impacts of childhood exposure to residential racial segregation is limited. Here, we analyzed data on 1823 Black participants in the Panel Study of Income Dynamics, estimating associations between childhood segregation trajectories and young adult health. Black young adults who consistently lived in high-segregation neighborhoods throughout childhood experienced unhealthier smoking and drinking behaviors and higher odds of obesity compared to other trajectory groups, including children who moved into or out of high-segregation neighborhoods. Results were robust to controls for neighborhood and family poverty. Findings underscore that for Black children who grow up in segregated neighborhoods, the roots of structurally-determined health inequities are established early in life.

ObjectivesTo determine the socioeconomic consequences of receipt versus denial of abortion.MethodsWomen who presented for abortion just before or after the gestational age limit of 30 abortion facilities across the United States between 2008 and 2010 were recruited and followed for 5 years via semiannual telephone interviews. Using mixed effects models, we evaluated socioeconomic outcomes for 813 women by receipt or denial of abortion care.ResultsIn analyses that adjusted for the few baseline differences, women denied abortions who gave birth had higher odds of poverty 6 months after denial (adjusted odds ratio [AOR] = 3.77; P

Hundreds of millions of poor families receive some form of targeted social assistance. Many of these antipoverty programs involve some degree of geographic targeting, where aid is prioritized to the poorest regions of the country. However, policy makers in many low-resource settings lack the disaggregated poverty data required to make effective geographic targeting decisions. Using several independent datasets from Nigeria, this paper shows that high-resolution poverty maps, constructed by applying machine learning algorithms to satellite imagery and other nontraditional geospatial data, can improve the targeting of government cash transfers to poor families. Specifically, we find that geographic targeting relying on machine learning-based poverty maps can reduce errors of exclusion and inclusion relative to geographic targeting based on recent nationally representative survey data. This result holds for antipoverty programs that target both the poor and the extreme poor and for initiatives of varying sizes. We also find no evidence that machine learning-based maps increase targeting disparities by demographic groups, such as gender or religion. Based in part on these findings, the Government of Nigeria used this approach to geographically target emergency cash transfers in response to the COVID-19 pandemic.

Understanding the burden of gun violence among youth is a public health imperative. While most estimates are based on direct and witnessed victimization, living nearby gun violence incidents may be consequential too. Yet detailed information about these broader experiences of violence is lacking. We use data on a population-based cohort of youth merged with incident-level data on deadly gun violence to assess the prevalence and intensity of community exposure to gun homicides across cross-classified categories of exposure distance and recency, overall and by race/ethnicity, household poverty, and neighborhood disadvantage. In total, 2-18% of youth resided within 600 m of a gun homicide occurring in the past 14-365 days. These percentages were 3-25% for incidents within 800 m and 5-37% for those within a 1300-m radius. Black and Latinx youth were 3-7 times more likely, depending on the exposure radius, to experience a past-year gun homicide than white youth and on average experienced incidents more recently and closer to home. Household poverty contributed to exposure inequities, but disproportionate residence in disadvantaged neighborhoods was especially consequential: for all racial/ethnic groups, the difference in the probability of exposure between youth in low vs high poverty households was approximately 5-10 percentage points, while the difference between youth residing in low vs high disadvantage neighborhoods was approximately 50 percentage points. Given well-documented consequences of gun violence exposure on health, these more comprehensive estimates underscore the importance of supportive strategies not only for individual victims but entire communities in the aftermath of gun violence.

BackgroundNeighborhood poverty has been associated with poor health outcomes. Previous studies have also identified adverse respiratory effects of long-term ambient ozone. Factors associated with neighborhood poverty may accentuate the adverse impact of ozone on respiratory health.ObjectivesTo evaluate whether neighborhood poverty modifies the association between ambient ozone exposure and respiratory morbidity including symptoms, exacerbation risk, and radiologic parameters, among participants of the SPIROMICS AIR cohort study.MethodsSpatiotemporal models incorporating cohort-specific monitoring estimated 10-year average outdoor ozone concentrations at participants' homes. Adjusted regression models were used to determine the association of ozone exposure with respiratory outcomes, accounting for demographic factors, education, individual income, body mass index (BMI), and study site. Neighborhood poverty rate was defined by percentage of families living below federal poverty level per census tract. Interaction terms for neighborhood poverty rate with ozone were included in covariate-adjusted models to evaluate for effect modification.Results1874 participants were included in the analysis, with mean (± SD) age 64 (± 8.8) years and FEV1 (forced expiratory volume in one second) 74.7% (±25.8) predicted. Participants resided in neighborhoods with mean poverty rate of 9.9% (±10.3) of families below the federal poverty level and mean 10-year ambient ozone concentration of 24.7 (±5.2) ppb. There was an interaction between neighborhood poverty rate and ozone concentration for numerous respiratory outcomes, including COPD Assessment Test score, modified Medical Research Council Dyspnea Scale, six-minute walk test, and odds of COPD exacerbation in the year prior to enrollment, such that adverse effects of ozone were greater among participants in higher poverty neighborhoods.ConclusionIndividuals with COPD in high poverty neighborhoods have higher susceptibility to adverse respiratory effects of ambient ozone exposure, after adjusting for individual factors. These findings highlight the interaction between exposures associated with poverty and their effect on respiratory health.

BackgroundLeadership development programs are integral to the future success of public health and healthcare organisations. Despite low-and middle-income countries (LMICs) bearing a greater burden of unmet medical needs, fewer professional development opportunities exist in these settings. This study aims to provide a comprehensive understanding of available leadership development programs for healthcare professionals in LMICs.MethodsThis study conforms to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis-P systematic review and traditional meta-analyses guidelines. Articles were identified through five academic databases: Embase, PubMed, Web of Science, ERIC, and Business Source Complete. Eligibility criteria included original research published in peer-reviewed journals on non-clinical, leadership development programs offered to healthcare professionals in LMICs worldwide.ResultsForty-one peer-reviewed articles met inclusion criteria, of which physicians, nurses, and public health professionals were the most common types of providers to attend leadership development programs; no programs exclusively targeted surgeons. The greatest proportion of programs were short-term interventions (ranging from 1 day to 12 weeks). Communication, organizational structure and leadership, and personal development were identified as the three most common leadership themes in the review. Regionally, leadership programs were reported most commonly in Africa, specifically in Anglophone countries. Other regions worldwide, including Latin America and the Caribbean, were underrepresented in the review.ConclusionsThe findings from this review identify gaps in leadership development programs for certain groups of healthcare professionals from certain geographical regions, supporting the need for further provision of and participation in these opportunities in LMICs.

Policy Points Clarifications to Senate Bill (SB) 1152 are necessary to address the differences between inpatient and emergency department (ED) discharge processes, determine how frequently an ED must deliver the SB 1152 bundle of services to a single patient, and establish expectations for compliance during off-hours when social services are unavailable. Because homelessness cannot be resolved in a single ED visit, the state should provide funding to support housing-focused case workers that will follow patients experiencing homelessness (PEH) through the transition from temporary shelters to permanent supportive housing. Medi-Cal could fund the delivery of the SB 1152 bundle of services to defray the costs to public hospitals that provide care for high numbers of PEH. California legislators should consider complementary legislation to increase funding for shelters so that sufficient capacity is available to accept PEH from EDs and hospitals, and to fund alternative strategies to prevent poverty and the upstream root causes of homelessness itself.ContextPrompted by stories of "patient dumping," California enacted Senate Bill (SB) 1152, which mandates that hospitals offer patients experiencing homelessness (PEH) a set of resources at discharge to ensure safety and prevent dumping.MethodsTo evaluate interventions to meet the requirements of SB 1152 across three emergency departments (EDs) of a Los Angeles County public hospital system with a combined annual census of 260,000 visits, we used an explanatory sequential mixed methods approach, focusing first on quantitative evaluation and then using information from qualitative interviews to explain the quantitative findings.FindingsIn total, 2.9% (1,515/52,607) of encounters involved PEH. Documentation of compliance with the eight required components of SB 1152 was low, ranging from 9.0% to 33.9%. Twenty-five provider interviews confirmed support for providing assistance to PEH in the ED, but the participants described barriers to compliance, including challenges in implementing universal screening for homelessness, incongruity of the requirements with the ED setting, the complexity of the patients, and the limitations of SB 1152 as a health policy.ConclusionsDespite operationalizing universal screening for homelessness, we found poor compliance with SB 1152 and identified multiple barriers to implementation.

ObjectiveTo describe the National Heart Lung and Blood Institute (NHLBI) sponsored Disparities Elimination through Coordinated Interventions to Prevent and Control Heart and Lung Disease (DECIPHeR) Alliance to support late-stage implementation research aimed at reducing disparities in communities with high burdens of cardiovascular and/or pulmonary disease.Study settingNHBLI funded seven DECIPHeR studies and a Coordinating Center. Projects target high-risk diverse populations including racial and ethnic minorities, urban, rural, and low-income communities, disadvantaged children, and persons with serious mental illness. Two projects address multiple cardiovascular risk factors, three focus on hypertension, one on tobacco use, and one on pediatric asthma.Study designThe initial phase supports planning activities for sustainable uptake of evidence-based interventions in targeted communities. The second phase tests late-stage evidence-based implementation strategies.Data collection/extraction methodsNot applicable.Principal findingsWe provide an overview of the DECIPHeR Alliance and individual study designs, populations, and settings, implementation strategies, interventions, and outcomes. We describe the Alliance's organizational structure, designed to promote cross-center partnership and collaboration.ConclusionsThe DECIPHeR Alliance represents an ambitious national effort to develop sustainable implementation of interventions to achieve cardiovascular and pulmonary health equity.

The COVID-19 pandemic caused widespread non-essential business closures in the U.S., which may have disproportionately impacted food consumption in lower-income communities, in part due to reduced access to healthy and affordable foods, as well as occupations that may have required working outside the home. The aims of this study were to examine restaurant dining behaviors (including drive-through, takeout, and delivery) at fast-food and non-fast-food (i.e., fast casual and full-service ['other']) restaurants and the impact on diet quality among racially/ethnically diverse low-income adults during the early months of the pandemic. Participants completed an online survey using CloudResearch regarding restaurant dining behaviors in the past week (during June 2020) and during a typical week prior to the pandemic. Diet quality was measured using the Prime Diet Quality Score (PDQS). Surveys from 1,756 low-income adults (incomes

ObjectiveTo determine if low household income is associated with disease severity following emergency department (ED) discharge in children with acute gastroenteritis (AGE).MethodsWe conducted a secondary analysis employing data collected in 10 US-based tertiary-care, pediatric EDs between 2014 and 2017. Participants were aged 3 to 48 months and presented for care due to AGE. Income status was defined based on 1) home ZIP Code median annual home income and 2) percentage of home ZIP Code households below the poverty threshold. The primary outcome was moderate-to-severe AGE, defined by a post-ED visit Modified Vesikari Scale (MVS) score ≥9. Secondary outcomes included in-person revisits, revisits with intravenous rehydration, hospitalization, and etiologic pathogens.ResultsAbout 943 (97%) participants with a median age of 17 months (interquartile range 10, 28) completed follow-up. Post-ED visit MVS scores were lower for the lowest household income group (adjusted: -0.60; 95% confidence interval [CI]: -1.13, -0.07). Odds of experiencing an MVS score ≥9 did not differ between groups (adjusted odds ratio: 0.91; 95% CI: 0.54, 1.52). No difference in the post-ED visit MVS score or the proportion of participants with scores ≥9 was observed using the national poverty threshold definition. For both income definitions, there were no differences in terms of revisits following discharge, hospitalizations, and intravenous rehydration. Bacterial enteropathogens were more commonly identified in the lowest socioeconomic group using both definitions.ConclusionsLower household income was not associated with increased disease severity or resource use. Economic disparities do not appear to result in differences in the disease course of children with AGE seeking ED care.