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University of Pennsylvania School of Dental Medicine and the University of Pennsylvania School of Social Policy and Practice (SP2) designed an asynchronous online course about racism and cultural competence to address student concerns about harmful interactions with peers across race/ethnicity. The Penn Experience Course establishes common language and concepts to facilitate difficult conversations about racism in the classroom and clinical spaces.The course included six modules addressing the history of racism in the Philadelphia area and at the University of Pennsylvania: implicit bias and microaggressions; racism and other forms of oppression; gender identity and sexuality; construction of whiteness and white supremacy ideology; cultural humility, disparities, and equity; and access in healthcare. Students completed pre- and post-course surveys about their likelihood of engaging with the neighborhood surrounding Penn, confidence discussing the topics covered, and general experience with the course.Four hundred forty-nine students completed post-course surveys, 220 of which could be linked to precourse survey responses. Overwhelmingly, students reported a positive experience with the course, an increase in their likelihood to engage with the Penn neighborhood, and increased confidence in discussing course topics with peers. Many students suggested incorporating synchronous discussion, while a smaller group expressed resentment about the focus on whiteness, white fragility, and anti-Black racism. Several students of color expressed concern that the course centered the learning needs of white students.Asynchronous online content offers an effective and efficient way of teaching dental students about the basics of cultural competence. Educators should anticipate resistance from some white students and the distinct learning needs of students of color.

The coronavirus disease 2019 (COVID-19) pandemic has upended every aspect of life in the United States and forced Americans to rethink their daily activities, including how they work, attend school, secure food, obtain health care, and maintain social connections. For vulnerable populations that were already facing significant barriers to health, such as people experiencing homelessness, the pandemic has only generated new hardships and exacerbated existing inequities. (Am J Public Health. Published online ahead of print November 19, 2020: e1-e3. https://doi.org/10.2105/AJPH.2020.305961).

Without clear federal mandates protecting the rights of transgender and gender nonconforming people, local governments are drafting their own legislation that either protects or limits these populations’ rights. This leaves street-level bureaucrats situated in between competing auspices, conflicting mandates, and a constrained sense of self-determination when they are tasked with applying emerging legislation in a policy gray area. This paper considers the policy logic of an intersectional approach to LGBTQ policy, as well as the implementation barriers street-level bureaucrats may face when operationalizing LGBTQ policy in a politically complex environment. First, we use a piece of local legislation designed by transgender and LGB youth as an implementation case study focused on policy logic and policy triggers. Second, we employ thematic analysis for analyzing open-ended responses to 281 surveys completed by teachers and other school staff after training around implementation of a new district-wide policy anchored in an intersectional approach. Beyond normative, protracted implementation timelines, even when front-line workers were in full support of LGBTQ rights, tension still surfaces around the internalization of bureaucracy, fear of disciplinary sanctions, a perception of competing rights, and ambivalence with mediating between personal, familial, and youth agency. Even when using equity-focused policy approaches, stakeholders can expect to encounter implementation barriers with street-level bureaucrats (SLBs) while trying to influence higher orders of government through local advocacy and action. Altering the discourse on gender identity remains difficult in the current political environment surrounding LGBTQ rights. Electronic supplementary material The online version of this article (10.1007/s42972-020-00010-1) contains supplementary material, which is available to authorized users.

Research on the experiences of trans youth has generally emphasized their disparate risk for negative educational, housing, and health outcomes. While drawing attention to very real vulnerabilities...

Supplemental Nutrition Assistance Program (SNAP) participation has been associated with obesity in women. The objective of this pilot study was to describe the caloric intake and dietary qu...

Objective:The present study explored chronic disease management over the monthly benefit cycle among primary food shoppers from households receiving Supplemental Nutrition Assistance Program (SNAP) benefits in Philadelphia, PA, USA.Design:In-depth interviews, participant observation and surveys were conducted with the primary food shopper of SNAP households.Setting:Interviews and surveys were conducted in a clinical setting at Children’s Hospital of Philadelphia, at participants’ homes, and in food procurement settings including grocery stores, food pantries and soup kitchens.Participants:Eighteen adults who received SNAP; five with a diet-related chronic condition, five managing the chronic condition of a family member and thirteen with overweight or obesity.Results:All households had at least one member with a chronic disease or condition. Households reported that the dietary demands of managing chronic illnesses were expensive and mentally taxing. Food and financial shortfalls at the end of the benefit cycle, as well as reliance on charitable food assistance programmes, often had negative impacts on chronic disease self-management.Conclusions:Drawing from nearly 50 h of in-depth qualitative interviews with SNAP participants, the study highlights the dual cognitive burden of poverty and chronic disease and elucidates the particular challenges of food procurement and maintenance of diet quality throughout the benefit month faced by SNAP households with diet-related chronic diseases. Interventions targeted at reducing the cost of medically appropriate, healthy foods may help to improve chronic disease self-management within SNAP populations.

Objectives Numerous U.S. state legislatures have proposed bills to ban gender-affirming medical interventions for minors. Parents and caregivers play a critical role in advocating for and supporting their transgender and gender-diverse youth (TGDY). We aimed to understand parent and caregiver perspectives about this potential legislation and perceived effects on their TGDY’s mental health. Methods We developed and launched a social-media based, anonymous online survey in February 2020 to assess parent and caregiver perspectives on proposed laws to ban gender-affirming medical interventions for minors. Participants were asked to respond to two open-ended questions about these laws; responses were coded to identify key themes. Results We analyzed responses from 273 participants from 43 states. Most identified as white (86.4%) female (90.0%) mothers (93.8%), and 83.6% of their TGDY had received gender-affirming medical interventions before age 18 years. The most salient theme, which appeared in the majority of responses, described parent and caregiver fears that these laws would lead to worsening mental health and suicide for their TGDY. Additional themes included a fear that their TGDY would face increased discrimination, lose access to gender-affirming medical interventions, and lose autonomy over medical decision-making due to government overreach. Conclusions In this convenience sample, parents and caregivers overwhelmingly expressed fear that the proposed legislation will lead to worsening mental health and increased suicidal ideation for their TGDY. They implored lawmakers to hear their stories and to leave critical decisions about gender-affirming medical interventions to families and their medical providers.

Public health interventions to increase supermarket access assume that shopping in supermarkets is associated with healthier food purchases compared to other store types. To test this assumption, we compared purchasing patterns by store-type for certain higher-calorie, less healthy foods (HCF) and lower-calorie, healthier foods (LCF) in a sample of 35 black women household shoppers in Philadelphia, PA. Data analyzed were from 450 food shopping receipts collected by these shoppers over four-week periods in 2012. We compared the likelihood of purchasing the HCF (sugar-sweetened beverages, sweet/salty snacks, and grain-based snacks) and LCF (low-fat dairy, fruits, and vegetables) at full-service supermarkets and six other types of food retailers, using generalized estimating equations. Thirty-seven percent of participants had household incomes at or below the poverty line, and 54% had a BMI >30. Participants shopped primarily at full-service supermarkets (55%) or discount/limited assortment supermarkets (22%), making an average of 11 shopping trips over a 4-week period and spending mean (SD) of $350 ($222). Of full-service supermarket receipts, 64% included at least one HCF item and 58% at least one LCF. Most trips including HCF (58%) and LCF (60%) expenditures were to full-service or discount/limited assortment supermarkets rather than smaller stores. Spending a greater percent of total dollars in full-service supermarkets was associated with spending more on HCF (p = 0.03) but not LCF items (p = 0.26). These findings in black women suggest a need for more attention to supermarket interventions that change retailing practices and/or consumer shopping behaviors related to foods in the HCF categories examined., Highlights • In the study, most (55%) food shopping trips were to full-service supermarkets. • Lower- vs. higher-income shoppers spent a higher share at limited-assortment stores. • Most (65%) full-service supermarket trips included at least 1 higher-calorie food. • Higher- but not lower-calorie food spending was greater in full-service supermarkets.

Objective To describe maternal morbidity, birth outcomes, and neighborhood characteristics of urban women from a racially segregated city with the use of a geographic information system (GIS). Design Exploratory neighborhood-level study. Existing birth certificate data were linked and aggregated to neighborhood-level data for spatial analyses. Setting Southern city in New Jersey. Sample Women and their 7,858 live births that occurred between 2009 and 2013. Methods Secondary analyses of extant sources were conducted. Maternal health and newborn birth outcomes were geocoded and then aggregated to the neighborhood level for further exploratory spatial analyses through our GIS database. An iterative process was used to generate meaningful visual representations of the data through maps of maternal and infant health in 19 neighborhoods. Results The racial and ethnic residential segregation and neighborhood patterns of associations of adverse birth outcomes with poverty and crime were illustrated in GIS maps. In 43% of the births, women had a documented medical risk. Significantly more preterm births occurred for Black women ( p p = .01). The rate of diabetes was greater in Hispanic women, and the rate of pregnancy-related hypertensive disorders was greater in Black women. Conclusion Data-driven maps can provide clear evidence of maternal and infant health and health needs based on the neighborhoods where mothers live. This research is important so that maternity care providers can understand contextual factors that affect mothers in their communities and guide the design of interventions.

Purpose: Parent support is considered crucial for the health of transgender and gender-nonconforming (trans/GNC) children, yet little research has focused on how to support parents and caregivers. This study considered the experience of participation in a support group for parents of transgender children on families. Methods: Online surveys were conducted with parents whose children were receiving clinical care at a gender specialty clinic and who participated at least once in a monthly support group. Close-ended questions addressed the importance of participation and open-ended questions addressed the specific ways it was helpful, how it impacted them and their trans/GNC child, and if they faced barriers to participating. Results: The majority of the 48 participants (77.1%) identified as female. The mean age of their trans/GNC child was 13.9 years (standard deviation 5.1, range 5–22 years); just over half (n=25) of their trans/GNC children identified as male. Participants overwhelmingly reported positive experiences with the support group, with 72.9% reporting that the group was either important or critically important to them and 66.7% reporting that it was important or critically important to their trans/GNC child. Perceived benefits included the opportunity to learn about legal, medical, and school issues and receive emotional support. Conclusion: Support groups provide an important complement to specialized clinical care for families with trans/GNC children. Logistical challenges, lack of age peers, and lack of people of color all served as limitations of the group. Further research is needed to understand the experiences of fathers and to determine if the support group model would be effective with racially/ethnically and economically diverse populations.

One in seven Americans participates in the Supplemental Nutrition Assistance Program (SNAP), making it the largest federally funded food assistance program. SNAP benefits are distributed once per month and both food spending and calorie consumption tend to decrease as time from benefit distribution increases. The monthly SNAP benefit cycle has serious implications for the health and financial stability of low-income families, a growing number of whom rely on SNAP as their sole source of income. Relatively little is known about the specific coping strategies households use to manage the SNAP cycle. The purpose of this study is to provide a critical exploration of the nature and timing of coping strategies for managing the SNAP cycle, including implications these coping mechanisms have for health and financial stability. This paper presents data from a prospective cohort study of mothers (n = 12) receiving SNAP benefits in Philadelphia between 2016 and 17. Both in-depth qualitative and survey methods were used. Participants reported on a variety of coping strategies they used to manage the SNAP cycle, including adjustments to shopping and eating patterns, mental accounting, emotional resilience, and social support. Instrumental social support was particularly vital in the final days of the benefit cycle, as were skipping meals and purchasing less expensive, energy-dense foods. Constant vigilance was required throughout the month to manage financial instability. The coping strategies for managing the SNAP cycle have short-term benefits, such as buffering against hunger and financial instability, however these survival strategies may have negative long-term repercussions for physical and financial health., Highlights • Coping strategies included adjusting shopping/eating, mental accounting, and social support. • SNAP was divided by trip type; first trip for essential food items, later trips for fill-in items. • End-of-month diet changes included skipping meals and buying cheaper, more energy-dense foods. • Instrumental social support was most critical in final days of the benefit cycle. • Constant vigilance was required throughout the month to manage financial instability.

Supplemental Nutrition Assistance Program (SNAP) benefits, which are distributed monthly, help low-income families put food on their tables. Both food spending and caloric intake among recipients decrease over the month following benefit receipt. This pattern, termed the "SNAP-cycle," has serious implications for health and food security of low-income households. To understand better the SNAP-cycle, this study explored (1) differences in diet quality between SNAP and non-SNAP households and (2) the association between the SNAP-cycle and diet quality.Multivariate linear regression with SNAP households in the U.S. Department of Agriculture's Food Acquisition and Purchase Survey to evaluate changes in diet quality as time from SNAP distribution increased. Diet quality of food purchases was measured by Healthy Eating Index-2010 total and component scores. Data were collected 2012-2013 and analyzed 2016-2017.Overall dietary quality was low throughout the SNAP-cycle (n=1,377, mean Healthy Eating Index 46.14 of 100). SNAP households had significantly lower Healthy Eating Index scores compared with eligible and ineligible nonparticipants (p

Research evaluating the impact of new food stores in “food deserts” have reported limited impact on eating and health outcomes of residents who live nearby. Few studies have reported on shoppers' food store choices and experiences in these new stores. This study focused on residents' experience with a new non-profit food market in Chester, PA and analyzes spatial patterns regarding who did and did not choose to shop at the new store. Phone surveys (n = 135) and in-person interviews (n = 13) were conducted with the primary food shopper for households living in Chester 1–2 years, respectively, after the opening of a store. Participants who shopped at the new market reported positive experiences in regard to convenience, customer service, food quality, and prices and believed that the new market had a positive impact on the community. But most participants had not shopped at the new market, citing many of the same factors in their decision to shop at supermarkets outside the city. Our findings underscore the need to combine new food retail strategies with community engagement and other interventions, such as in-store promotions and health education programs, to maximize the number of people who shop at new food outlets designed to improve access to healthful foods.

Youth participatory action research (YPAR) provides a model for youth leadership in research aimed at tangible improvements to their lives. We employed YPAR with queer and trans young adults in a qualitative study about trans high school youth. In this paper, we highlight the importance of relationships, dialog and reflexivity to ensuring ongoing critical reflection on the ethical nature of what often appear as methodological and operational issues. Our research underscores the tensions, contradictions, and limitations of sharing power that emerge in collaborations across age, race, educational attainment, and lived experience.

We analysed observations from 31 neighbourhood parks, with each park mapped into smaller target areas for study, across five US cities generated using the System for Observing Play and Recreation in the Community (SOPARC). In areas where at least two people were observed, less than one-third (31.6%) were populated with at least one white and one non-white person. Park areas that were supervised, had one or more people engaged in vigorous activity, had at least one male and one female present, and had one or more teens present were significantly more likely to involve interracial groups (p < 0.01 for each association). Observations in parks located in interracial neighbourhoods were also more likely to involve interracial groups (p < 0.05). Neighbourhood poverty rate had a significant and negative relationship with the presence of interracial groups, particularly in neighbourhoods that are predominantly non-white. Additional research is needed to confirm the impact of these interactions. Urban planning and public health practitioners should consider the health benefits of interracial contact in the design and programming of neighbourhood parks.

PURPOSE: To determine individual- and park-related characteristics associated with adults visiting their closest neighborhood park and involvement in sports, walking, and sedentary activities. DESIGN: Cross-sectional study. SETTING: Neighborhoods surrounding 24 parks in four United States metropolitan areas. SUBJECTS: Adults (N = 3,815) (25% African American, 12% Hispanic, and 56% Non-Hispanic White) living within .5 mile of one of 24 public parks. MEASURES: Anonymous surveys and park observations. ANALYSIS: Chi-square statistics and logistic regression including individual and park characteristics. RESULTS: Thirty-seven percent reported never having visited their park; 16% reported using it for regular exercise. Respondents who perceived the parks as safe or very safe had 4.6 times the odds of visiting the parks. Active sports participation was associated with being male, ages 18 to 24, and of African American heritage. Walking was associated with being female, age 47+, and reporting fair or poor health. Females, Hispanics, and those reporting fair/poor health were more likely to report sedentary activities. Park characteristics associated with park use included fewer physical incivilities, closer proximity to homes, more facilities, and organized activities. CONCLUSIONS: Perceptions of park safety were strongly associated with ever having visited a respective park, while park characteristics appeared to influence the types of activities performed. Increasing the number of organized activities and offering a variety of different facilities may encourage park use.

Regardless of whether we live in urban, suburban, or rural areas, we all “read” landscapes for indications of whether we fit in and are welcome. Identities relating to race, ethnicity, class, gender and sexuality all contribute to the lenses through which we interpret these signs. This chapter considers how we make sense of public and private places and what elements of the built and social environment we can change to make a wider range of people feel welcome. Specific examples focus on how people navigate food stores and neighborhood parks based on their intersecting identities.

BACKGROUND Previous analyses identified specific geographic areas in Philadelphia (hotspots) associated with negative outcomes along the HIV care continuum. We examined individual and community factors associated with residing in these hotspots. METHODS Retrospective cohort of 1404 persons newly diagnosed with HIV in 2008-2009 followed for 24 months after linkage to care. Multivariable regression examined associations between individual (age, sex, race/ethnicity, HIV transmission risk, and insurance status) and community (economic deprivation, distance to care, access to public transit, and access to pharmacy services) factors and the outcomes: residence in a hotspot associated with poor retention-in-care and residence in a hotspot associated with poor viral suppression. RESULTS In total, 24.4% and 13.7% of persons resided in hotspots associated with poor retention and poor viral suppression, respectively. For persons residing in poor retention hotspots, 28.3% were retained in care compared with 40.4% of those residing outside hotspots (P < 0.05). Similarly, for persons residing in poor viral suppression hotspots, 51.4% achieved viral suppression compared with 75.3% of those outside hotspots (P < 0.0.05). Factors significantly associated with residence in poor retention hotspots included female sex, lower economic deprivation, greater access to public transit, shorter distance to medical care, and longer distance to pharmacies. Factors significantly associated with residence in poor viral suppression hotspots included female sex, higher economic deprivation, and shorter distance to pharmacies. CONCLUSIONS Individual and community-level associations with geographic hotspots may inform both content and delivery strategies for interventions designed to improve retention-in-care and viral suppression.

Assessments of access to healthful food frequently use GIS to measure the distance and concentration of food outlets relative to where residents live. These descriptive approaches do not account for food shopping behavior, which may vary based on the attributes of food shoppers and their activity space—places where they live, work, access resources, and socialize. Building on transportation research about accessibility, we reframe the issue of food access and equity from one about ‘what is nearby?’ to ‘where do people shop?’. We use a conditional logit model to analyze disaggregate data from a door-to-door survey of food shopping choice and food store surveys conducted in a predominantly non-Hispanic Black and middle-income and low-income section of Philadelphia. Our results highlight the importance of distance from home to food stores, overall, but they also emphasize the influence on food store choice of the race and sex of food shoppers, travel mode, and where they spend time other than at home, as well as food prices and the availability of healthful foods. This approach to understanding food access holds promise for future research that can link store choice to specific food purchases and health outcomes as well as for refining place-based strategies for improving access to healthful foods. Keywords: food access, supermarkets, GIS, discrete choice, Philadelphia, food deserts, NEMS-S

Food shopping decisions are pathways between food environment, diet and health outcomes, including chronic diseases such as diabetes and obesity. The choices of where to shop and what to buy are interrelated, though a better understanding of this dynamic is needed. The U.S. Department of Agriculture's nationally representative Food Acquisitions and Purchase Survey food-at-home dataset was joined with other databases of retailer characteristics and Healthy Eating Index-2010 (HEI) of purchases. We used linear regression models with general estimating equations to assess relationships between trip, store, and shopper characteristics with trip HEI scores. We examined HEI component scores for conventional supermarkets and discount/limited assortment retailers with descriptive statistics. Overall, 4962 shoppers made 11,472 shopping trips over one-week periods, 2012–2013. Trips to conventional supermarkets were the most common (53.6%), followed by supercenters (18.6%). Compared to conventional supermarkets, purchases at natural/gourmet stores had significantly higher HEI scores (β = 6.48, 95% CI = [4.45, 8.51], while those from “other” retailers (including corner and convenience stores) were significantly lower (−3.89, [−5.87, −1.92]). Older participants (versus younger) and women (versus men) made significantly healthier purchases (1.19, [0.29, 2.10]). Shoppers with less than some college education made significantly less-healthy purchases, versus shoppers with more education, as did households participating in SNAP, versus those with incomes above 185% of the Federal Poverty Level. Individual, trip, and store characteristics influenced the healthfulness of foods purchased. Interventions to encourage healthy purchasing should reflect these dynamics in terms of how, where, and for whom they are implemented.

Where households across income levels shop for food is of central concern within a growing body of research focused on where people live relative to where they shop, what they purchase and eat, and how those choices influence the risk of obesity and chronic disease. We analyzed data from the National Household Food Acquisition and Purchase Survey (FoodAPS) using a conditional logit model to determine where participants shop for food to be prepared and eaten at home and how individual and household characteristics of food shoppers interact with store characteristics and distance from home in determining store choice. Store size, whether or not it was a full-service supermarket, and the driving distance from home to the store constituted the three significant main effects on store choice. Overall, participants were more likely to choose larger stores, conventional supermarkets rather than super-centers and other types of stores, and stores closer to home. Interaction effects show that participants receiving Supplemental Nutrition Assistance Program (SNAP) were even more likely to choose larger stores. Hispanic participants were more likely than non-Hispanics to choose full-service supermarkets while White participants were more likely to travel further than non-Whites. This study demonstrates the value of explicitly spatial discrete choice models and provides evidence of national trends consistent with previous smaller, local studies.

Cities are by definition complex and dynamic physical and social systems. Professionals charged with planning for and building our constantly-changing cities, including urban planners and designers, depend upon a wide range of maps and spatial technologies to make decisions. Planning is essentially a visual and spatial discipline where ideas, plans, arguments and empirical analyses are all expressed through paper and digital maps, including GIS (geographic information systems). This chapter critically explores the way professional and academic planners who work in transportation, community and economic development, international development, environmental conservation, real estate and urban use maps at all scales. Maps will continue to be critical in planners’ efforts to understand the spatial form of cities and how residents conceive of places, make and analyze plans, model social and environmental impacts, engage citizens and hold government officials accountable. The interdisciplinary fields of public health, energy and sustainability and civic engagement are examined as opportunities for future collaboration.

To respond to the high prevalence of obesity and its associated health consequences, recent food research and policy have focused on neighborhood food environments, especially the links between health and retail mix, proximity of food outlets, and types of foods available. In addition, the social environment exerts important influences on food-related behaviors, through mechanisms like role-modeling, social support, and social norms. This study examined the social dynamics of residents' health-related food-shopping behaviors in 2010-11 in urban Philadelphia, where we conducted 25 semi-structured resident interviews-the foundation for this paper-in addition to 514 structured interviews and a food environment audit. In interviews, participants demonstrated adaptability and resourcefulness in their food shopping; they chose to shop at stores that met a range of social needs. Those needs ranged from practical financial considerations, to fundamental issues of safety, to mundane concerns about convenience, and juggling multiple work and family responsibilities. The majority of participants were highly motivated to adapt their shopping patterns to accommodate personal financial constraints. In addition, they selectively shopped at stores frequented by people who shared their race/ethnicity, income and education, and they sought stores where they had positive interactions with personnel and proprietors. In deciding where to shop in this urban context, participants adapted their routines to avoid unsafe places and the threat of violence. Participants also discussed the importance of convenient stores that allowed for easy parking, accommodation of physical disabilities or special needs, and integration of food shopping into other daily activities like meeting children at school. Food research and policies should explicitly attend to the social dynamics that influence food-shopping behavior. In our social relationships, interactions, and responsibilities, there are countless opportunities to influence-and also to improve-health.

OBJECTIVES: This study explored chronic disease self-management over the monthly benefit cycle among primary food shoppers from households receiving Supplemental Nutrition Assistance Program (SNAP) benefits in Philadelphia, Pennsylvania. METHODS: In-depth interviews, participant observation and surveys were conducted with the primary food shopper of SNAP households (n = 18). Interviews and surveys were conducted in a clinical setting, at participants’ homes, and in food procurement settings including grocery stores, food pantries and soup kitchens. RESULTS: All households had at least one member with a chronic disease or condition; 5 with a diet-related chronic condition, 5 managing the chronic condition of a family member, and 13 with overweight or obesity. Households reported that the dietary demands of managing chronic illnesses were expensive and mentally taxing. Food and financial shortfalls at the end of the benefit cycle, as well as reliance on charitable food assistance programs, often had negative impacts on chronic disease self-management. CONCLUSIONS: Drawing from nearly 50 hours of in-depth qualitative interviews with SNAP participants, this study highlights the dual cognitive burden of poverty and chronic disease and elucidates the particular challenges of food procurement and maintenance of diet quality throughout the benefit month faced by SNAP households with diet-related chronic diseases. Interventions targeted at reducing the cost of medically appropriate, healthy foods may help to improve chronic disease self-management within SNAP populations. FUNDING SOURCES: This work was supported by the University of Pennsylvania Leonard Davis Institute of Health Economics, the University of Pennsylvania Graduate and Professional Student Assembly Provost Award for Interdisciplinary Innovation, the NIH NIDDK Pediatric Endocrine Fellowship Training in Diabetes Research, and the Investment for the Future Initiative in Community Practices, University of Pennsylvania School of Nursing. The sources of financial support had no role in the design, analysis, or writing of this abstract.

Background Food environments may promote or undermine healthy behaviors, but questions remain regarding how individuals interact with their local food environments. Purpose This study incorporated an urban food environment audit as well as an examination of residents’ food shopping behaviors within that context. Methods In 2010, the research team audited the variety and healthfulness of foods available in 373 Philadelphia stores, using the validated Nutrition Environment Measures Survey in Stores (NEMS-S); higher scores indicate more diverse and healthful food inventories. The team also surveyed urban residents (n=514) regarding their food shopping. Descriptive and multivariate analyses (conducted in 2012) assessed variation in retail food environments and in shoppers’ store choices. Results Corner and convenience stores were common (78.6% of food retail outlets) and had the lowest mean NEMS-S scores of any store type. Most participants (94.5%) did their primary food shopping at higher-scoring chain supermarkets, and the majority of participants did not shop at the supermarket closest to home. Supermarket offerings varied, with significantly fewer healthful foods at supermarkets closest to the homes of disadvantaged residents. In multivariate analyses, participants were significantly more likely to shop at supermarkets closest to home if those supermarkets had higher NEMS-S scores. Conclusions These data suggest that, when possible, shoppers chose supermarkets that offered more variety and more healthful foods. Findings from this study also reinforce concern regarding unhealthy immediate food environments for disadvantaged residents, who disproportionately relied on nearby stores with more limited food items. Interventions to improve nutrition and health should address not only food store proximity but also diversity of healthful foods available.

AB Purpose: Parks offer a free option for physical activity in many communities. How much time people spend using parks and the contribution that parks makes to their physical activity is not known. This study describes patterns of park use and physical activity among a diverse adult sample. Methods: From five US states, 248 adults enrolled in or near 31 study parks. Participants wore a global positioning system (GPS) monitor (Qstarz BT-Q1000X) and an ActiGraph accelerometer (GT1M) concurrently for 3 wk. Parks were mapped from local and national park shape files. Park visits and travel to and from the parks were derived from the objective data. Results: Participants visited parks a median of 2.3 times per week, and park visits lasted a median of 42.0 min. Overall, participants engaged in a median of 21.7 min[middle dot]d-1 of moderate activity and 0.1 min[middle dot]d-1 of vigorous activity, with an average of 8.2% of all moderate and 9.4% of all vigorous activity occurring within the parks. Among those with at least one park visit (n = 218), counts per minute, moderate, moderate-to-vigorous physical activity (MVPA), number and time in MVPA bouts per day, and sedentary behavior were all higher on days when a park was visited compared with days when a park was not visited. Considering several definitions of active travel, walking or bicycling to and from the park added an additional 3.7-6.6 mean minutes of MVPA per park visit. Conclusions: Parks contributed as a place and destination for physical activity but were underused. One of the next steps in this line of inquiry is to understand characteristics of parks used more often as a place and destination for physical activity.

This paper describes the longstanding, naturally emergent model of curbside vending of whole fruit and vegetable produce across several low-income, low-health Philadelphia neighborhoods. We conducted open-ended interviews with managers of 11 curbside produce vendors and compared prices and varieties of fruits and vegetables with the 11 closest conventional outlets. We find that produce trucks offer significantly lower prices on common fruit and vegetable items and they carry a variety of items comparable to that carried by limited-assortment grocery stores. We conclude with recommendations regarding zoning, licensing, and Supplemental Nutrition Assistance Program (SNAP) authorization that could stabilize and expand this model of healthy food access.

Background The effectiveness of initiatives to increase healthy food access may be affected by where people decide to shop. People with poor neighborhood access to large grocery stores develop shopping patterns that require traveling to other areas, and some people who do have neighborhood access also travel elsewhere for food shopping. We sought to gain an understanding of household food shopping patterns in a sample of Black women in terms of where they shopped and why. Methods All food shopping trips of 35 low- or middle/high-income black mothers or caregivers living with at least one child were identified from grocery shopping receipts collected over four consecutive weeks. Food shopping locations were mapped along with locations of participants’ homes and other places they visited during weekly routine travels (e.g. work, child’s school). Semi-structured individual interviews elicited narrative information about whether and how grocery shopping trips were linked to routine travels. Inductive content analysis was utilized to identify emergent themes from interviews. Themes were considered in relation to geospatial distances and travel patterns identified through mapping of participants’ shopping. Results Participants shopped at an average of six different stores, traveling on average a total of 35 miles (sd = 41) (Euclidian distance) over the four weeks. The most frequented store was within a mile of home (57 %) or home or another place visited in the weekly routine for about 77 % of participants. Interview results emphasized the concept of convenience which referred to geographical proximity to the home or routine destinations and also to potential to save time because several stores were co-located or because the store layout was easy to navigate and familiar. Store selection also related to mode of transportation, pricing, and family preference for certain foods. Conclusion People have specific reasons for consistently shopping in areas outside of their neighborhood of residence. Incorporating considerations other than proximity (e.g. time saving while shopping, promoting less familiar foods, pricing) into food environment interventions may facilitate use of new stores by neighborhood residents and thereby increase the viability of these stores as health-promoting food environment interventions.

This paper argues that door-to-door surveys are a valuable tool for collecting information about health and the environment in urban areas in a manner consistent with community-based participatory research principles. We describe in detail how a door-to-door survey on food shopping and physical activity was conducted with the primary food shopper in 514 households on 30 randomly selected blocks in West and Southwest Philadelphia over seven weeks during the summer of 2010. We identify the elements of our door-to-door protocol that had benefits for the quality of the data collected, flow of data collection, the perceived safety of interviewers and residents, and that informed subsequent phases of this multimethod four-year study of urban food and physical activity environments. We conclude that door-to-door surveys are appropriate and valuable in certain research contexts, when spending time in a community, conducting observations and building relationships are central to the goals and success of a study.

Research on the impact of the built environment on obesity and access to healthful foods often fails to incorporate information about how individuals interact with their environment. A sample of 198 low-income WIC recipients from two urban neighborhoods were interviewed about where they do their food shopping and surveys were conducted of food stores in their neighborhoods to assess the availability of healthful foods. Results indicate that participants rarely shop at the closest supermarket, traveling on average 1.58 miles for non-WIC food shopping and 1.07 miles for WIC shopping. Findings suggest that access to healthful foods is not synonymous with geographic proximity.

Urban and planning historians frequently focus on inherently spatial topics such as migration, segregation, gentrification, and suburbanization and rely on historical maps as primary sources, but they rarely use geographic information systems (GIS) as a research method for analyzing spatial patterns. This article considers the reasons that GIS is not used more, including longstanding ambivalence about quantitative methods and limited training opportunities. It then outlines ways in which GIS can uniquely inform historical research—by emphasizing underlying spatial processes, making spatial patterns visible, and transforming mapping into a process—in ways that can refine and challenge existing urban historical narratives. Finally, recommendations for overcoming existing barriers to historical GIS are presented.

Using GPS devices and digital cameras, we surveyed outdoor advertisements in Austin, Los Angeles and Philadelphia. GIS and hot spot analysis revealed that unhealthy ads were clustered around child-serving institutions in Los Angeles and Philadelphia but not in Austin. Multivariate generalized least square (GLS) regression models showed that percent black (p

Background All available ARV (antiretroviral) agents can cause hepatotoxicity. Many case reports of ARV-induced hepatotoxicity have been described in patients with confounding viral hepatitis. This case series is comprised 23 HIV-positive patients with hepatic enzyme abnormalities but without the evidence of viral hepatitis. The data available for these 23 patients were assessed with an effort to establish any correlation between ARV therapy and abnormal liver function tests (LFTs) as well as the histologic findings on liver biopsies. Methods The 23 participants included in this study were referred to a hepatology/gastrointestinal clinic that catered specifically to HIV patients. The patients were referred by their HIV providers for evaluation of elevated LFTs, gastrointestinal symptoms or cirrhosis. The data surveyed included variables associated with hepatotoxicity and HIV infection. Results Liver biopsies were obtained in 21 out of 23 participants. The remaining two participants had evidence of cirrhosis based on imaging studies. The LFT elevations were definitely or possibly attributed to ARV therapy in 17 out of 23 participants. Specifically, the biochemical hepatotoxicity was definitely related to ARV therapy in six and possibly related to ARV medications in 11 participants. Nine out of 17 participants had evidence of nonalcoholic steatohepatitis, whereas four out of 17 had clinical features of lipodystrophy. Six participants had elevated LFTs before starting ARV therapy. The participants with nonalcoholic fatty liver diseases had normal LFTs for many years after which a steep rise was noted. All participants with nonalcoholic fatty liver diseases were exposed to nucleoside reverse transcriptase inhibitors. Conclusion ARV medications, particularly the nucleoside reverse transcriptase inhibitors, can cause a dose-dependent hepatotoxicity that occurs after several months of exposure and possibly result in increasing the adverse effects of alcohol and obesity. Owing to the overlap of ARV medications, the contribution of each class of drugs toward the observed hepatotoxicity is not entirely clear. Liver biopsies should be considered in patients receiving ARV therapy with elevated LFTs and/or evidence of fatty liver.

The changing nature of how children engage with their physical environment is one factor in the dramatic increase in childhood overweight. Children today are engaging much less with the world outside their homes in terms of physical activity and much more in terms of eating. Technological innovations in media have contributed to these changes, keeping children inside and sedentary during more of their playtime and exposing them to highly coordinated advertising campaigns. But researchers are increasingly looking to technology for solutions to understand how children interact with their built environments and to make changes that promote healthy living. This article reviews many of these innovations, including the use of geospatial technologies, accelerometers, electronic food and travel diaries, and video games to promote physical activity and healthy eating. It also explores some of the other possibilities for harnessing the potential of technology to combat the childhood overweight epidemic.

The prevalence of HIV infection in HCV patients is much lower than the prevalence of HCV infection in HIV patients. Whereas the higher prevalence of HCV infection in HIV is clearly related to drug abuse, the reasons for the lower prevalence of HIV infection in HCV patients has not been reported. The prevalence of non-sexual and sexual risk factors associated with acquisition of hepatitis C and HIV were studied in HIV-mono-infected, HCV-mono-infected, and HCV/HIV-co-infected individuals. None of the 114 HCV-mono-infected patients tested positive for HIV and this finding was associated with a significantly lower number of men who have sex with men (MSM) among the HCV-mono-infected subjects than among either the HIV-mono-infected or HCV/HIV-co-infected individuals. Unprotected anal intercourse and sex for money or drugs were reported less often by HCV-mono-infected individuals than by HIV-mono-infected and HCV/HIV-co-infected subjects. Having sex with an intravenous-drug user (IVDU) was reported more frequently by both HCV-mono-infected and HCV/HIV-co-infected individuals than by HIV-mono-infected individuals. Sub-analysis of the group of MSM revealed that IVDU differentiated between HIV-mono-infected and HCV/HIV-co-infected subjects. These results reveal that the lower prevalence of HIV in HCV patients is related to a lower number of MSM in this group and that sex with an IVDU is a surrogate marker for drug abuse related to acquiring HCV but not HIV. The guidelines should include strategies for testing for HCV and HIV in patients with these infections.

METHODS A sample of patients with HIV completed a questionnaire identifying their demographic characteristics and risk factors for hepatitis C virus (HCV). A chart review was conducted to confirm the information obtained using the questionnaire. Risk factors associated with coinfection status at alpha level of 0.1 in univariate analysis were entered into a multivariate Cox regression model. RESULTS Of the 242 HIV-positive patients analyzed, 168 were HIV-infected and 74 were HIV/HCV-coinfected. Risk factors that were significantly different between HIV-monoinfected and HIV/HCV-coinfected subjects included intravenous drug use, snorting drugs, sharing razors or toothbrushes, being in prison, the presence of one or more tattoos, sex for money or drugs, sex with an intravenous drug user and man who has sex with men. In a multivariate regression model, only intravenous drug use remained as a significant risk factor/predictor of HCV/HIV coinfection. A subanalysis identified risk factors more prevalent among coinfected men who have sex with men, including intravenous drug use, sharing razors/toothbrushes, tattoos, sex for money or drugs, sex with an intravenous drug user, and a history of having 11 or more sexual partners. A history of having had a sexually transmitted disease and 11 or more sex partners was more prevalent among HIV-monoinfected men who have sex with men. CONCLUSIONS HIV/HCV coinfection was associated with intravenous drug use but not with sexual risk factors.

Using the Philadelphia Congregations Census, the Neighborhood Change Database, the U.S. Census, and geographic information systems (GIS) software, this study compared characteristics of congregations made up of members who live nearby their congregation’s building to those with more members who commute from outside the immediate area or outside the city. We considered whether the neighborhood characteristics in which the “commuter” versus “resident” congregations were located differed in regard to racial composition, socioeconomic status, and residential stability. The study found that where the pastor lives in relation to the building, denomination, racial composition of membership, and the stability of the neighborhood were related to members’ residential proximity to the congregation building.

Relative to other fields, social work has been slow to adopt geographic information systems (GIS) as a tool for research and practice. This paper argues that GIS can benefit social work by: (1) continuing and strengthening the social survey tradition; (2) providing a framework for understanding human behavior; (3) identifying community needs and assets; (4) improving the delivery of social services; and (5) empowering communities and traditionally disenfranchised groups. Examples from a social work course on GIS and published social work research help illustrate these points. The paper concludes by considering the ways that social work can contribute to the development of GIS.