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Shaylen Foley,1 Danya E Keene,1 Roman Shrestha,2– 4 Shan-Estelle Brown,5 Kamal Gautam,2 Ryan A Sutherland,3 Francesca Maviglia,3 Rumana Saifi,4 Jeffrey A Wickersham3,4 1Department of Social and Behavioral Sciences, Yale School of Public Health, Yale University, New Haven, CT, USA; 2Department of Allied Health Sciences, University of Connecticut, Storrs, CT, USA; 3Section of Infectious Diseases, Department of Internal Medicine, Yale School of Medicine, Yale University, New Haven, CT, USA; 4Centre of Excellence for Research in AIDS (CERiA), Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia; 5Department of Anthropology, Rollins College, Winter Park, FL, USACorrespondence: Shaylen Foley, 135 College Street, Suite 323, New Haven, CT, 06510, USA, Tel +419 343-4606, Email shaysf@gmail.comIntroduction: Pre-exposure prophylaxis (PrEP) is an effective method for prevention of HIV transmission. Female sex workers (FSW) in Malaysia are at substantially increased risk of acquiring HIV compared to the general female population, yet little is known about this population’s current HIV prevention practices or acceptance of PrEP. This study aims to inform the culturally relevant implementation of PrEP through the qualitative exploration of (1) the potential need for PrEP in this population and (2) the factors that determine FSW willingness to use oral PrEP.Methods: In-depth, semi-structured interviews (n = 30) were conducted with FSW in English, Malay, or Tamil. Transcribed and translated interviews were analyzed using a grounded theory approach.Results: FSW express positive interest in PrEP but prefer it as a supplement to condoms, not a replacement. Perceived challenges to PrEP use include cost, adherence, and side effects.Conclusion: The findings suggest that in combination with condom use, PrEP may be an acceptable method of HIV prevention. Effective PrEP rollout may also include condom promotion using a peer-driven model, cost subsidies, and sex work harm reduction and empowerment components.Keywords: sex work, HIV, pre-exposure prophylaxis, Malaysia

HOPE VI has funded the demolition of public housing developments across the United States and created in their place mixed-income communities that are often inaccessible to the majority of former tenants. This recent uprooting of low-income, urban, and predominantly African American communities raises concern about the health impacts of the HOPE VI program for a population that already shoulders an enormous burden of excess morbidity and mortality. In this paper, we rely on existing literature about HOPE VI relocation to evaluate the program from the perspective of weathering-a biosocial process hypothesized by Geronimus to underlie early health deterioration and excess mortality observed among African Americans. Relying on the weathering framework, we consider the effects of HOPE VI relocation on the material context of urban poverty, autonomous institutions that are health protective, and on the broader discourse surrounding urban poverty. We conclude that relocated HOPE VI residents have experienced few improvements to the living conditions and economic realities that are likely sources of stress and illness among this population. Additionally, we find that relocated residents must contend with these material realities, without the health-protective, community-based social resources that they often rely on in public housing. Finally, we conclude that by disregarding the significance of health-protective autonomous institutions and by obscuring the structural context that gave rise to racially segregated public housing projects, the discourse surrounding HOPE VI is likely to reinforce health-demoting stereotypes of low-income urban African American communities. Given the potential for urban and housing policies to negatively affect the health of an already vulnerable population, we argue that a health-equity perspective is a critical component of future policy conversations. [ABSTRACT FROM AUTHOR]

In this paper, we explore how the stigmatization of place is transported to new destinations and negotiated by those who carry it. Additionally, we discuss the implications of 'spatial stigmatization' for the health and well-being of those who relocate from discursively condemned places such as high-poverty urban neighborhoods. Specifically, we analyze in-depth interviews conducted with 25 low-income African American men and women who have moved from urban neighborhoods in Chicago to predominantly white small town communities in eastern Iowa. These men and women, who moved to Iowa in the context of gentrification and public housing demolition, describe encountering pervasive stigmatization that is associated not only with race and class, but also with defamed notions of Chicago neighborhoods. [ABSTRACT FROM AUTHOR]

Objectives: The number of older adults struggling to maintain adequate housing is growing. Prior studies have used various criteria to measure housing insecurity; however, no standardized definition exists to date. Using a multidimensional approach, our study sought to calculate population-based estimates of various forms of housing insecurity among community-living older Americans and determine how these estimates differ across key characteristics., Methods: This study utilized data from the 2011 round of the National Health and Aging Trends Study (NHATS), a prospective longitudinal study of Medicare beneficiaries aged 65 years or older. Three key forms of housing insecurity were operationalized: poor housing affordability (PHA), poor housing quality (PHQ), and poor neighborhood quality (PNQ). Population-based estimates of these forms of housing insecurity were calculated using analytic sampling weights and stratified by age, gender, race and ethnicity, frailty status, and dementia status., Results: Totally 6466 participants were included in the analysis, representing 29,848,119 community-living older Americans. The mean (standard deviation) age was 77.3 (7.7) years; by weighted percentages, 56.0% identified as female, 81.3% as White, 8.2% Black, and 7.1% Hispanic. At least one form of housing insecurity was identified in 38.5% of older Americans. Individually, the prevalence of PHA was 14.8%, PHQ 24%, and PNQ 12.5%. The prevalence of at least one form of housing insecurity was higher among persons of color (62.9% Black and 66% Hispanic vs White; p < 0.001), those with frailty (40.9% pre-frail and 49.4% frail vs robust; p < 0.001), and those with cognitive impairment (48.1% possible and 51% probable dementia vs no dementia; p < 0.001)., Discussion: Nearly one in three community-living older Americans experience at least one form of housing insecurity. This was most common among vulnerable subgroups. Our multidimensional approach to defining various forms of housing insecurity can be used for future studies focused on improving social determinants of health among high-risk older adults., (© 2024 The American Geriatrics Society.)

The US is facing a severe affordable rental housing crisis that contributes to multiple forms of housing insecurity including homelessness, crowded and poor quality housing conditions, unstable housing arrangements, and cost burdens. A considerable body of evidence finds that housing insecurity is an important determinant of health. However, the existing literature may fall short of conceptualizing and measuring the full impact of housing insecurity on population health and on racial health equity. In this paper, we seek to expand the conceptualization of housing as a determinant of population health equity by considering housing insecurity as a manifestation of structural racism that intersects with other manifestations and impacts of structural racism to affect, not only the health of housing insecure individuals, but also the health of the networks and communities in which these individuals live. First, we situate the current housing crisis within larger systems of structural racism. We extend prior work documenting the confluence of ways that racist policies and practices have created unequal burdens of housing insecurity to also discuss the ways that the meanings and impacts of housing insecurity may be shaped by racism. Next, we consider how the health impacts of this unequal burden of housing insecurity can extend beyond individual households to affect networks and communities. Ultimately, we provide a multilevel framework that can inform research, policy, and practice to address housing and health equity., (© 2023. The New York Academy of Medicine.)

Policy makers at the federal, state, and local levels responded to the COVID-19 pandemic with a broad array of policies that were intended to prevent housing instability among renters. Eviction moratoriums were an important part of this policy landscape. Recent evidence indicates that these moratoriums were effective in reducing eviction-filing rates, but many questions remain about the impacts of these policies. Drawing on qualitative interviews ( N = 60) with renters in three states (Connecticut, Florida, and Ohio) who had experienced eviction or eviction risk during the pandemic, we examine how renters interpreted, experienced, and navigated the moratoriums; how moratoriums shaped their well-being and housing security; how racism may have shaped policy effects; and how these experiences differed across a varied policy landscape. Our findings demonstrate how moratoriums supported renters and how they fell short, offering important lessons for future eviction-prevention and civil-legal policy making.

The U.S. is experiencing a severe housing affordability crisis, resulting in households having to make difficult trade-offs between paying for a place to live and basic health necessities such as food. Rental assistance may mitigate these strains, improving food security and nutrition. However, only one in five eligible individuals receive assistance, with an average wait time of two years. Existing waitlists create a comparable control group, allowing us to examine the causal impact of improved housing access on health and well-being. This national quasi-experimental study utilizes linked NHANES-HUD data (1999-2016) to investigate the impacts of rental assistance on food security and nutrition using cross-sectional regression. Tenants with project-based assistance were less likely to experience food insecurity (B = -0.18, p = 0.02) and rent-assisted individuals consumed 0.23 more cups of daily fruits and vegetables compared the pseudo-waitlist group. These findings suggest that the current unmet need for rental assistance and resulting long waitlists have adverse health implications, including decreased food security and fruit and vegetable consumption., Competing Interests: Declaration of Competing Interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: W. Denary reported receiving grants from the NIDDK, NIH during the conduct of the study. A. Fenelon reported receiving grants from the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), National Institutes of Health (NIH) during the conduct of the study. S. Whittaker reported receiving grants from the NIMHD and Robert Wood Johnson Foundation Health Policy Research Fellowship during the conduct of the study. D. Esserman reported receiving grants from the NIH during the conduct of the study. K. Lipska reported receiving grants from the NIDDK, NIH during the conduct of the study and receiving grants from the NIH, the Patient-Centered Outcomes Research Institute, and the centers for Medicare & Medicaid Services and personal fees from UpToDate outside the submitted work. D. Keene reported receiving grants from the NIDDK, NIH during the conduct of the study and outside the submitted work. No other disclosures were reported., (Copyright © 2023 Elsevier Inc. All rights reserved.)

In 2016, only one in five eligible U.S. households received rental assistance and waiting lists averaged two years nationally. The gap between available rental assistance and need requires systems to allocate this scarce resource. The way potential rental assistance recipients experience and navigate these systems is likely to shape who ultimately receives assistance. We draw on repeated qualitative interviews (N=238) with low-income New Haven residents (N=54) to examine how participants understand and navigate rental assistance applications and waiting lists. Participants encountered multiple challenges in their search for rental assistance. They described an opaque and complex application and waiting process requiring significant knowledge to navigate. They also described considerable labor associated with monitoring waiting lists, a challenge made more difficult for some by their lack of a stable address. Additionally, participants described significant labor and knowledge required to strategically navigate prioritization systems that often required them to advocate for their deservingness of scarce housing resources. Our findings suggest that the allocation of rental assistance through complex processes that depend on applicant knowledge, labor, and advocacy may create barriers to housing, particularly for more vulnerable and marginalized housing seekers.

Background: Workplace legal protections are important for perinatal health outcomes. Black birthing people are disproportionally affected by pregnancy discrimination and bias in the employment context and lack of family-friendly workplace policies, which may hinder their participation in the labor force and lead to gender and racial inequities in income and health. We aimed to explore Black pregnant women's experiences of pregnancy discrimination and bias when looking for work, working while pregnant, and returning to work postpartum. Additionally, we explored Black pregnant women's perspectives on how these experiences may influence their health., Methods: Using an intersectional framework, where oppression is based on intersecting social identities such as race, gender, pregnancy, and socioeconomic status, we conducted an analysis of qualitative data collected for a study exploring the lived experience of pregnancy among Black pregnant women in New Haven, Connecticut, United States. Twenty-four women participated in semi-structured interviews (January 2017-August 2018). Interview transcripts were analyzed using grounded theory techniques., Results: Participants expressed their desire to provide a financially secure future for their family. However, many described how pregnancy discrimination and bias made it difficult to find or keep a job during pregnancy. The following three themes were identified: 1) "You're a liability"; difficulty seeking employment during pregnancy; 2) "This is not working"; experiences on the job and navigating leave and accommodations while pregnant and parenting; and 3) "It's really depressing. I wanna work"; the stressors of experiencing pregnancy discrimination and bias., Conclusion: Black pregnant women in this study anticipated and experienced pregnancy discrimination and bias, which influenced financial burden and stress. We used an intersectional framework in this study which allowed us to more fully examine how racism and economic marginalization contribute to the lived experience of Black birthing people. Promoting health equity and gender parity means addressing pregnancy discrimination and bias and the lack of family-friendly workplace policies and the harm they cause to individuals, families, and communities, particularly those of color, throughout the United States., (© 2023. The Author(s).)

Public health researchers have directed increasing attention to structural racism and its implications for health equity. The conceptualization of racism as historically rooted in systems, structures, and institutions of US society has important implications for addressing social determinants of health (SDOH). It requires theorizing SDOH as embedded in and expressions of racially oppressive historical structures that are manifested in and maintained by policies, programs, and practices in multiple domains that dynamically intersect to reinforce and reproduce in new ways: race inequities in health. We develop this argument using housing, a SDOH recognized as reflecting longstanding racist practices and policies that, among other things, have restricted the affordable housing options of Black people to segregated neighborhoods with limited resources. We argue that understanding and addressing the health inequities resulting from structural racism associated with housing requires simultaneously understanding and addressing how housing intersects with mass incarceration, another SDOH and manifestation of structural racism. We suggest that unless these intersections are intentionally analyzed and confronted, efforts to address the impacts of housing on racial health disparities may produce new forms of health inequities. ( Am J Public Health . 2023;113(S1):S58-S64. https://doi.org/10.2105/AJPH.2022.307116).

Social determinants of health are the economic and environmental conditions under which people are born, live, work, and age that affect health. These structural factors underlie many of the long-standing inequities in cancer care and outcomes that vary by geography, socioeconomic status, and race and ethnicity in the United States. Housing insecurity, including lack of safe, affordable, and stable housing, is a key social determinant of health that can influence-and be influenced by-cancer care across the continuum, from prevention to screening, diagnosis, treatment, and survivorship. During 2021, the National Cancer Policy Forum of the National Academies of Science, Engineering, and Medicine sponsored a series of webinars addressing social determinants of health, including food, housing, and transportation insecurity, and their associations with cancer care and patient outcomes. This dissemination commentary summarizes the formal presentations and panel discussions from the webinar devoted to housing insecurity. It provides an overview of housing insecurity and health care across the cancer control continuum, describes health system interventions to minimize the impact of housing insecurity on patients with cancer, and identifies challenges and opportunities for addressing housing insecurity and improving health equity. Systematically identifying and addressing housing insecurity to ensure equitable access to cancer care and reduce health disparities will require ongoing investment at the practice, systems, and broader policy levels., (© The Author(s) 2022. Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

We sought to examine whether and how landlord-related forced moves (inclusive of, but not limited to, legal eviction) were associated with emergency department (ED) use over time. We used survey data collected between 2017 and 2019 among 283 low-income participants in New Haven, CT to examine whether experiencing a legal eviction or other landlord-related forced move (T 0 ) was associated with increased odds of ED use 6 months (T 1 ) and 12 months (T 2 ) later. We conducted bootstrapped mediation analyses to examine indirect effects of post-traumatic stress symptoms. One-fifth of participants (n = 61) reported a recent forced move at baseline (T 0 ); half of these were legally evicted. Landlord-related forced moves were associated with ED use at T 1  (AOR = 2.06, 95 % CI: 1.04-4.06) and T 2  (AOR = 3.05, 95 % CI: 1.59-5.88). After adjustment for sociodemographic factors and other health-related confounders, legal eviction was not significantly associated with ED use at T 1 (AOR = 1.61, 95 % CI: 0.68-3.81), but was significantly associated with ED use at T 2 (AOR = 3.58, 95 % CI: 1.58-8.10). Post-traumatic stress symptoms accounted for 15.1% of forced moves' association with ED use (p <.05). Landlord-related forced moves are positively associated with subsequent ED use, and post-traumatic stress symptoms are one factor that may help explain this association. Structural interventions that promote housing stability are needed to advance health equity, and they may also help to reduce preventable ED use. Such interventions are imperative in the context of the COVID-19 pandemic, which has strained health system capacity and exacerbated housing instability for many low-income renters. Results underscore the relevance of trauma-informed care and integrated care management to clinical practice in emergency settings., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2022 The Authors.)

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

Over 2 million renters in the United States are legally evicted annually, and even more renters experience other landlord-related forced moves each year. While past research has documented an association between legal eviction and HIV risk, no studies have examined the relationship between forced moves and sexual partnership dynamics longitudinally, or the pathways through which forced moves impact such risk. Addressing this gap is imperative, particularly given inequities that place Black renters and women at disproportionate risk of eviction. This study leverages data from a longitudinal cohort study of 282 adults in New Haven to examine whether landlord-related forced moves reported at baseline (including, but not limited to, legal eviction) is associated with HIV sexual risk reported six months later. We use bootstrapped path analyses to examine intimate partner violence (IPV) victimization and perpetration as potential mediators. One-fifth of participants (21.2%) had experienced a landlord-related forced move at baseline. At follow up, nearly two-thirds (63.8%) reported at least one HIV sexual risk factor, one in seven (14.2%) reported IPV victimization, and one in ten (10.3%) reported IPV perpetration. Individuals who reported landlord-related forced moves were more likely to report IPV victimization (standardized β = 0.19, SE = 0.08, p = .02) and IPV perpetration (β = 0.25, SE = 0.09, p = .003). Both IPV victimization and perpetration mediated the association between landlord-related forced moves and HIV sexual risk (indirect victimization effect, β = 0.09, SE = 0.05, p = .06; indirect perpetration effect, β = 0.16, SE = 0.07, p = .02), though IPV victimization was only marginally significant. In conclusion, IPV is itself a negative consequence of forced moves that also contributes to other negative health effects, like HIV risk. Therefore, providers should offer violence screening and referral for clients who have recently faced a forced move. Simultaneously, policy-level solutions to prevent eviction and increase housing affordability are urgently needed to address the rising burden - and inequitable distribution - of evictions among low-income renters., (Copyright © 2022 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: A disproportionate number of people who are killed by police each year are Black. While much attention rightly remains on victims of police brutality, there is a sparse literature on police brutality and perinatal health outcomes. We aimed to explore how Black pregnant women perceive police brutality affects them during pregnancy and might affect their children., Methods: This qualitative study involved semi-structured interviews among 24 Black pregnant women in New Haven, Connecticut (January 2017 to August 2018). Interview questions explored neighborhood factors, safety, stressors during pregnancy, and anticipated stressors while parenting. Grounded theory informed the analysis., Results: Participants, regardless of socioeconomic status, shared experiences with police and beliefs about anticipated police brutality, as summarized in the following themes: (1) experiences that lead to police distrust - "If this is the way that mommy's treated [by police]"; (2) anticipating police brutality - "I'm always expecting that phone call"; (3) stress and fear during pregnancy - "It's a boy, [I feel] absolutely petrified"; and (4) 'the talk' about avoiding police brutality - "How do you get prepared?" Even participants who reported positive experiences with police anticipated brutality towards their children., Conclusions: Interactions between Black people and police on a personal, familial, community, and societal level influenced how Black pregnant women understand the potential for police brutality towards their children. Anticipated police brutality is a source of stress during pregnancy, which may adversely influence maternal and infant health outcomes. Police brutality must be addressed in all communities to prevent harming the health of birthing people and their children., (© 2022. The Author(s).)

The authors examine the experiences of informal housing providers, defined as those who provide housing and shelter to family, friends, and acquaintances in the context of a severe affordable rental housing crisis. Forty-five semistructured interviews were conducted with informal housing providers in and around New Haven, Connecticut, in 2021. The data describe the critical role informal housing providers play in addressing gaps in the housing safety net. Interviews also show the ways informal housing provision can strain already vulnerable households and threaten providers' own housing security, with implications for their health and well-being. As such, the data illustrate how widespread unmet housing needs can reverberate across networks and communities. Given the multiple ways structural racism has constrained housing access for nonwhite Americans, this burden of housing provision is also likely to be unequal, with implications for population health equity.

We contrast a typical "social determinants of health" framing with a more dynamic and complex "social determination of health" framing to analyze HIV-related sexual risk among women in low-income, segregated neighborhoods in New Haven, CT. Using an abductive approach, we analyze repeated, longitudinal qualitative interviews conducted over a 2-year period with a sample of 14 HIV-negative women who engaged in sex with men during the study period. Three case studies are presented to demonstrate how behaviors and sexual practices typically described as HIV "risks" can be understood as part of the work of establishing and maintaining monogamous committed relationships, which we call "relationship work," shaped in a context characterized by housing vulnerabilities and the many manifestations of mass incarceration and the surveillance state. We conclude by suggesting that for these women, their relationship work is the work of HIV prevention and life in low-income segregated neighborhoods is their HIV-related risk., (© 2021. The Author(s).)

Almost half of renters in the United States are rent-burdened, meaning that they pay more than 30% of their income toward housing costs. Rental assistance through programs administered by the U.S. Department of Housing and Urban Development, alleviates these financial strains for around 5 million households. However, due to budgetary constraints, fewer than one in four eligible households actually receive this assistance and waitlists average two years nationally. Using longitudinal data from a cohort of 400 low-income adults living in New Haven, CT, this paper investigates how access to rental assistance affects mental health through two analytical methods that address selection into rental assistance. First, we performed a cross-sectional analysis to identify how psychological distress differs among those receiving and those on a waitlist for rental assistance. Second, we used a within-person fixed-effects analysis to compare changes in individuals following entry into rental assistance. We find that those receiving rental assistance report significantly less psychological distress than those on waiting lists and that transitions into rental assistance are associated with statistically non-significant decreases in psychological distress. Our findings suggest that expanding rental assistance may be one potential step toward improving the mental health of low-income individuals in the United States., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

The study purpose is to comprehensively measure landlord-related forced moves (inclusive of, but not restricted to, legal eviction), and to examine whether landlord-related forced moves is associated with HIV risk. Baseline survey data was collected between 2017 and 2018 among 360 low-income participants in New Haven, Connecticut. We used multivariable logistic regression analyses to examine associations between landlord-related forced moves and HIV sexual risk outcomes. Seventy seven out of three hundred and sixty participants reported a landlord-related forced move in the past 2 years, of whom 19% reported formal eviction, 56% reported informal eviction and 25% reported both. Landlord-related forced moves were associated with higher odds of unprotected sex (AOR 1.98), concurrent sex (AOR 1.94), selling sex for money or drugs (AOR 3.28), exchange of sex for a place to live (AOR 3.29), and an HIV sexual risk composite (ARR 1.46) (p < .05 for all). We found robust associations between landlord-related forced moves and HIV sexual risk. Findings suggest that the social and economic consequences of landlord-related forced moves may impact sexual vulnerability.

Gay and bisexual men (GBM) are incarcerated at nearly twice the rate as the general United States male population. Minority stress, namely the unique social stressors related to anti-GBM stigma and discrimination, is central to GBM's experiences in ways that might put them at risk of incarceration and psychosocial risks during and after incarceration. In this qualitative study, we examined how GBM navigate minority stress and how this navigation influences their psychosocial health before, during, and after incarceration. We conducted semi-structured, in-depth interviews with 20 formerly incarcerated GBM in New York City, diverse in terms of race and time since last release. Our findings document the many ways in which GBM manage their identities in the context of minority stress and how such management exposes them to, or helps them avoid, minority stress and associated psychosocial health risks surrounding their incarcerations. Here, we report dominant themes before, during, and after incarceration for GBM, including minority stress: 1) as catalyzing incarceration-related experiences, 2) as motiving identity management techniques to survive the hegemonic masculinity and normative anti-GBM stigma of incarceration, and 3) as a determinant to reentry support and sexual expression after incarceration. These findings suggest potential changes to public health policy and practice to better serve the needs of currently and formerly incarcerated GBM and to prevent such incarceration in the first place., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Housing is central to health equity, and mass incarceration is an important but understudied aspect of housing vulnerability and health inequity. One way in which housing can be linked to health and health inequity is through ontological security. Ontological security, or a sense of feeling at home, is comprised of constancy, daily routines, privacy, and a basic security that enables the development of one's identity. It has been theorized as a mechanism by which people reap the health benefits of housing. Based on two waves of interviews in 2017-2018 with a sample of 27 people returning from incarceration in a northeast U.S. city, we describe participants' residential experiences during the first two years after release. Participants lived in residential group settings, with friends, partners and family, or were homeless. They experienced impermanence, punitive place rules, surveillance, and a lack of control. In contrast, participants spoke about their idea of home, imagined from the past or for the future, as a place of privacy, control, and wellbeing. This analysis expands the study of ontological security by detailing its absence among people returning from incarceration. The concept of ontological security holds promise in delineating the ways in which housing provides health benefits, and is particularly useful for understanding the needs and experiences of those returning from prison and seeking to restart their lives in the community. Relatedly, participant narratives point to the expansion of the carceral state beyond prison, including into residential space, with implications for the intersection of housing and health equity., (Copyright © 2021. Published by Elsevier Ltd.)

The COVID-19 pandemic precipitated catastrophic job loss, unprecedented unemployment rates, and severe economic hardship in renter households. As a result, housing precarity and the risk of eviction increased and worsened during the pandemic, especially among people of color and low-income populations. This paper considers the implications of this eviction crisis for health and health inequity, and the need for eviction prevention policies during the pandemic. Eviction and housing displacement are particularly threatening to individual and public health during a pandemic. Eviction is likely to increase COVID-19 infection rates because it results in overcrowded living environments, doubling up, transiency, limited access to healthcare, and a decreased ability to comply with pandemic mitigation strategies (e.g., social distancing, self-quarantine, and hygiene practices). Indeed, recent studies suggest that eviction may increase the spread of COVID-19 and that the absence or lifting of eviction moratoria may be associated with an increased rate of COVID-19 infection and death. Eviction is also a driver of health inequity as historic trends, and recent data demonstrate that people of color are more likely to face eviction and associated comorbidities. Black people have had less confidence in their ability to pay rent and are dying at 2.1 times the rate of non-Hispanic Whites. Indigenous Americans and Hispanic/Latinx people face an infection rate almost 3 times the rate of non-Hispanic whites. Disproportionate rates of both COVID-19 and eviction in communities of color compound negative health effects make eviction prevention a critical intervention to address racial health inequity. In light of the undisputed connection between eviction and health outcomes, eviction prevention, through moratoria and other supportive measures, is a key component of pandemic control strategies to mitigate COVID-19 spread and death.

Background: Outpatient heart failure (HF) care involves intensive self-management (SM). Effective HF SM is associated with improved outcomes. Homelessness poses challenges to successful SM., Objectives: To identify the ways in which homelessness may impede successful SM of HF and engagement with the healthcare system., Methods: We conducted open-ended, semi-structured interviews with homeless adults with HF. Data were analyzed by a multidisciplinary team using a grounded theory approach., Results: We interviewed 19 participants, 11 (58%) of whom were homeless at the time of interview. Interviews revealed a combination of influences on HF SM. Major themes included instability and lack of routine, tradeoffs between basic necessities and HF SM, and stigmatization by healthcare providers., Conclusions: Anticipatory guidance aimed at the unique challenges faced by homeless individuals with HF may aid successful SM. HF providers should simlpify medication regimes and engage in non-stigmatizing discourse. Larger-scale interventions include the creation of medical respite programs., Competing Interests: Declaration of Competing Interest The authors have no relationships or competing interests to disclose., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Pronounced racial disparities in maternal and infant health outcomes persist in the United States. Using an ecosocial and intersectionality framework and biopsychosocial model of health, we aimed to understand Black pregnant women's experiences of gendered racism during pregnancy., Methods: We conducted semistructured interviews with 24 Black pregnant women in New Haven, Connecticut. We asked women about their experience of being pregnant, experiences of gendered racism, and concerns related to pregnancy and parenting Black children. Transcripts were coded by three trained analysts using grounded theory techniques., Results: Women experienced gendered racism during pregnancy-racialized pregnancy stigma-in the form of stereotypes stigmatizing Black motherhood that devalued Black pregnancies. Women reported encountering assumptions that they had low incomes, were single, and had multiple children, regardless of socioeconomic status, marital status, or parity. Women encountered racialized pregnancy stigma in everyday, health care, social services, and housing-related contexts, making it difficult to complete tasks without scrutiny. For many, racialized pregnancy stigma was a source of stress. To counteract these stereotypes, women used a variety of coping responses, including positive self-definition., Conclusions: Racialized pregnancy stigma may contribute to poorer maternal and infant outcomes by way of reduced access to quality health care; impediments to services, resources, and social support; and poorer psychological health. Interventions to address racialized pregnancy stigma and its adverse consequences include anti-bias training for health care and social service providers; screening for racialized pregnancy stigma and providing evidence-based coping strategies; creating pregnancy support groups; and developing a broader societal discourse that values Black women and their pregnancies., (Copyright © 2020 Jacobs Institute of Women's Health. Published by Elsevier Inc. All rights reserved.)

Gay and bisexual men might face unique, status-based competitive pressures given that their social and sexual relationships often occur with other men, who are known to compete for social and sexual gain. In a multistage study, we delineated intraminority gay community stress theory-that status-focused elements of the gay community challenge the mental health of gay and bisexual men. We first created a measure of gay community stress with items derived from qualitative interviewing ( n = 49); calculated its psychometric properties, including 1-year temporal stability ( n = 937); and confirmed its structural stability in distinct samples ( n = 96; n = 1,413). Being stressed by perceiving the gay community's focus on sex, focus on status, focus on competition, and exclusion of diversity predicted gay and bisexual men's mental health over-and-above a comprehensive battery of traditional minority stressors (β = .17, p < .01) and mediated the association between one's gay community status and mental health. To examine the impact of individual differences in status concerns (i.e., about masculinity, attractiveness, and wealth) on gay and bisexual men's feelings of within-community exclusion, a series of experiments manipulated (a) the sexual orientation (gay vs. heterosexual) of rejecters ( n = 103), (b) the social status of gay rejecters ( n = 83), and (c) whether rejection from gay and bisexual rejecters was status-based or nonstatus-based ( n = 252). Overall, these experiments provide partial support for the possibility that gay and bisexual men's status concerns underlie their experience of gay community stress. Together, these studies advance psychological and sociological accounts of gay and bisexual men's mental health beyond minority stress theory, with implications for intervention. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Background : Competency-based assessment is an important but challenging aspect of residency education but determines trainees' progression towards the ultimate goal of graduation. Entrustment decision making has been proposed as a supplementary metric to assess trainee competence. This study explores the process by which Program Directors (PDs) make entrustment decisions in Internal Medicine (IM) training programs. Study Design : Purposive sampling was used to recruit PDs from ACGME-accredited IM training programs to participate in a semi-structured interview. We analyzed interviews using an iterative, grounded theory-based approach to allow identification of themes that define the process of trainee entrustment. Results : Sixteen PDs were interviewed. Qualitative analysis showed that PDs use a dynamic process to understand trainee entrustability and progression towards competence, including construction of assessment networks, comparing performance to expected trajectory of trainee competence development, and bidirectional filtering and weighing of assessment data. Conclusions : PDs serve as a central processor by which assessment data on trainees is filtered, weighted, and compared an expected trajectory, all to gain understanding of trainee performance. Assessment networks are crucial to understanding trainee competence. While expected trajectory is an important tool to determine how trainees are progressing, its continued use may inject bias into the assessment process and slow transition to true competency-based assessment., (Copyright ©2020, Yale Journal of Biology and Medicine.)

Background: Housing is a growing challenge for US adults in an increasingly unaffordable housing market. These housing challenges can create barriers to effective management and control of Type II Diabetes. However, little is known about how housing challenges are perceived and navigated by clinicians who care for patients with Type II Diabetes., Objective: To examine how primary care clinicians perceive and navigate their patients' housing challenges in the context of Type II Diabetes management., Methods: We conducted semi-structured interviews with 18 primary care clinicians practising in four clinical settings in New Haven, Connecticut. Two investigators systematically coded the interviews. Analysis of coded data was used to determine themes., Results: Participants considered housing as significant to their patients' health and a potential barrier to optimal diabetes management. Participants sought to improve their patients' housing through advocacy, referrals and interdisciplinary collaborations. They also adjusted clinical decisions to adapt to patients' housing challenges. In making clinical adjustments, participants struggled to find a balance between what they perceived to be feasible for unstably housed patients and maintaining a standard of care. Some participants navigated this balanced by employing creative strategies and individualized care., Conclusion: In highlighting the challenges that clinicians face in maintaining a standard of care for unstably housed diabetes patients, our findings speak to the need for more guidance, resources and support to address housing in a clinical setting., (© The Author(s) 2019. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: The process of entrustment-placing trust in a trainee to independently execute a task-has been proposed as a complementary metric to assess competence. However, entrustment decision-making by trainee supervisors is not well understood in surgical training. We aim to explore processes underlying entrustment decision-making (EDM) by general surgery program directors., Materials and Methods: Purposive sampling was used to recruit 20 program directors from Accreditation Council for Graduate Medical Education-accredited general surgery training programs to participate in a one-hour semistructured interview. We analyzed interviews using an iterative and inductive approach to identify novel themes associated with the process of trainee entrustment., Results: Qualitative analysis identified that program directors rely on a network of faculty to make entrustment decisions regarding trainees. Perceived trainee competence to perform independent clinical tasks varies significantly in and out of the operating room (OR), with a strong emphasis on entrustment for technical competencies to the exclusion of cognitive competencies. In the OR, entrustment is informed by an attending's reflexive trust and physical presence, trainee labels, and presumed discernment. Outside of the OR, trainee labels, presumed discernment, and transference of competence were identified as critical themes., Conclusions: Modifiable components of entrustment are equally dependent on trainee and faculty behavior. Entrustment is more heavily informed by trainee performance in the OR, despite program directors uniformly stating that judgment outside of the OR is the most critical component of resident training. The inclusion of EDM to evaluate trainee progression should be considered as an important adjunct to established Accreditation Council for Graduate Medical Education milestones., (Copyright © 2019 Elsevier Inc. All rights reserved.)

A recent study by the Legal Services Corporation reported that 71% of low-income U.S. households experienced at least one civil legal problem in 2017 and that 86% of these needs went unresolved. In this article, we examine the potential for medical-legal partnerships (MLPs) to address this "justice gap." We draw on qualitative interviews, conducted with 20 parents and guardians in one pediatric MLP, to identify barriers to legal access and examine how the MLP model may uniquely address these barriers. Our data suggest that MLPs can (1) identify legal needs and create awareness of legal rights among individuals who would not have sought legal services; (2) create an access point for legal services; (3) improve access to legal advice and brief intervention; (4) support ongoing relationships between patients and lawyers that allow for the timely identification of subsequent legal needs; (5) foster trust and confidence in the legal system; and (6) address affordability concerns. These findings suggest that by improving access to justice, MLPs can address critical social and legal determinants of health and, ultimately, advance health equity.

Intimate partner violence (IPV) is associated with pre-exposure prophylaxis (PrEP) acceptability among US women, but whether IPV influences other steps along the PrEP care continuum remains unclear. This study estimated the causal effects of IPV on the early stages of the PrEP care continuum using doubly robust (DR) estimation (statistical method allowing causal inference in non-randomized studies). Data were collected (2017-2018) from a cohort study of 124 US women without and 94 women with IPV experiences in the past 6 months (N = 218). Of the 218 women, 12.4% were worried about getting HIV, 22.9% knew of PrEP, 32.1% intended to use PrEP, and 40.4% preferred an "invisible" PrEP modality. IPV predicts HIV-related worry (DR estimate = 0.139, SE = 0.049, p = 0.004). IPV causes women to be more concerned about contracting HIV. Women experiencing IPV are worried about HIV, but this population may need trauma-informed approaches to help facilitate their PrEP interest and intentions.

Background: Vulnerability to human immunodeficiency virus (HIV) infection is a significant public health issue for women experiencing intimate partner violence (IPV). Despite the increased risk of human immunodeficiency virus infection, women only represent 4.6% of pre-exposure prophylaxis (PrEP) users in the United States. IPV may present additional difficulties to PrEP access. In this qualitative study, we examined how IPV and the relational context shaped women's decisions, attitudes, and engagement in the PrEP care continuum., Methods: We conducted semistructured interviews with 19 women residing in Connecticut who participated in a prospective cohort study. We purposively recruited our sample to include women who reported physical and/or sexual IPV in the past 6 months, and used a grounded theory approach to analyze the qualitative data., Results: Our findings suggest multiple ways that the relational context can affect women's decisions, attitudes, and engagement in the PrEP care continuum. We identified five aspects of women's relationships that can shape women's interest, intentions, and access to PrEP: 1) relationship power struggles, 2) infidelity, 3) trust and monogamy, 4) male partner's reactions, and 5) "season of risk" (i.e., PrEP use only during times of perceived human immunodeficiency virus risk). Collectively, these findings suggest that women experiencing IPV might face additional relational challenges that need to be adequately addressed in settings administering PrEP., Conclusions: Communication on sexual risk reduction strategies should address relational factors and promote women's autonomy. Future research on long-acting and invisible forms of PrEP may help to circumvent some of the relational barriers women experiencing IPV may face when considering PrEP care., (Copyright © 2019 Jacobs Institute of Women's Health. Published by Elsevier Inc. All rights reserved.)

Rental assistance, in the form of vouchers and project-based subsidized housing, is a primary source of affordable housing for low-income Americans, given a growing and severe shortage of private-market rental units. However, due to supply constraints, fewer than one in four eligible households receive this kind of assistance. In this paper, we examine associations between receipt of rental assistance and self-rated health among a sample of 400 low-income adults in one U.S. city. We find that individuals who currently receive rental assistance have lower odds of reporting poor or fair self-rated health than individuals who are currently on rental assistance waiting lists. These relationships persist after adjusting for factors that affect access to rental assistance and are not significantly modified by criminal justice history. Our findings suggest that the current unmet need for rental assistance may contribute to poor health among low-income Americans.

The criminal justice system has become a major pathway to drug treatment across the USA. Millions of criminal justice dollars are spent on an array of treatment programs for justice-involved populations, from pre-sentence diversionary programs to outpatient services for those on community supervision. This study uses 235 qualitative, longitudinal interviews with 45 people convicted of drug offenses to describe participants' perspectives on criminal justice-related drug treatment (programs within correctional facilities; court, probation, or parole-ordered mandates and referrals; and self-referrals made with the goal of reducing criminal justice involvement), beyond discourses about help with addiction. Interviews took place in New Haven, CT, between 2011 and 2014 every 6 months, for a maximum of five interviews with each participant. Many participants who were referred to drug treatment did not consider these programs appropriate for their needs, as many did not perceive themselves to have a drug problem, or did not consider substance use to be their primary problem. Frustrations regarding the ill-fitting nature of mandated programs were coupled with theories about non-health-related policy goals of criminal justice-mandated drug treatment, such as prison overflow management and increased profit for the state. Nonetheless, participants used drug treatment to advance their own goals of coping with life's challenges, reducing their criminal justice system involvement, proving worthiness through rehabilitation, and accessing other resources. These participants' perspectives offer a wide lens through which to view the system of criminal justice-related drug treatment, a view that can guide us in critically evaluating provision of drug treatment and developing more effective systems of appropriate rehabilitative services for people who are justice involved.

Racial and ethnic disparities in adverse birth outcomes have persistently been wide and may be explained by individual and area-level factors. Our primary objective was to determine if county-level black-white segregation modified the association between maternal race/ethnicity and adverse birth outcomes using birth records from the National Center for Health Statistics (2012). Based on maternal residence at birth, county-level black-white racial residential segregation was calculated along five dimensions of segregation: evenness, exposure, concentration, centralization, and clustering. We conducted a two-stage analysis: (1) county-specific logistic regression to determine whether maternal race and ethnicity were associated with preterm birth and term low birth weight; and (2) Bayesian meta-analyses to determine if segregation moderated these associations. We found greater black-white and Hispanic-white disparities in preterm birth in racially isolated counties (exposure) relative to non-isolated counties. We found reduced Hispanic-white disparities in term low birth weight in racially concentrated and centralized counties relative to non-segregated counties. Area-level poverty explained most of the moderating effect of segregation on disparities in adverse birth outcomes, suggesting that area-level poverty is a mediator of these associations. Segregation appears to modify racial/ethnic disparities in adverse birth outcomes. Therefore, policy interventions that reduce black-white racial isolation, or buffer the poor social and economic correlates of segregation, may help to reduce disparities in preterm birth and term low birth weight.

Background: In the United States, women represent less than 5% of all pre-exposure prophylaxis (PrEP) users. Social networks may promote and/or inhibit women's PrEP awareness, which could influence PrEP intentions. Furthermore, women experiencing intimate partner violence (IPV) may have smaller, less supportive networks, which could deter or have no impact on PrEP care engagement. This study examined associations between network characteristics and women's PrEP awareness, interest, uptake, and perceived candidacy and analyzed IPV as an effect modifier., Setting/methods: From 2017 to 2018, data were collected from a prospective cohort study of 218 PrEP-eligible women with (n = 94) and without (n = 124) IPV experiences in Connecticut. Women completed surveys on demographics, IPV, social networks, and PrEP care continuum outcomes., Results: Adjusted analyses showed that PrEP awareness related to having more PrEP-aware alters. PrEP intentions related to having more alters with favorable opinions of women's potential PrEP use and a smaller network size. Viewing oneself as an appropriate PrEP candidate related to having more PrEP-aware alters and more alters with favorable opinions of women's potential PrEP use. IPV modified associations between network characteristics and PrEP care. Having members who were aware of and/or used PrEP was positively associated with PrEP care engagement for women without IPV experiences but had either no effect or the opposite effect for women experiencing IPV., Conclusion: Improving PrEP attitudes might improve its utilization among women. Social network interventions might be one way to increase PrEP uptake among many US women but may not be as effective for women experiencing IPV.

Background and Objectives: Reverse mortgages are loans that allow older homeowners to borrow from their home equity with no repayment due until the borrower dies or moves out of the home. We currently know very little about how homeowners evaluate and experience reverse mortgages as solutions to their financial and housing needs in later life. Furthermore, despite an increasingly diverse population of reverse mortgage borrowers, we know little about how social inequalities may contribute to reverse mortgage decisions and their outcomes. In this paper, we examine reverse mortgage decision-making and experiences in a racially and economically diverse sample of older US homeowners., Research Design and Methods: We conducted 44 in-depth interviews with older homeowners who were considering or who had obtained a reverse mortgage loan. We inductively and iteratively developed a thematic coding scheme that was applied to all interview transcripts., Results: Our analysis produced a dichotomous schema of reverse mortgage decision making that was shaped by social and economic opportunities and constraints. For some participants, reverse mortgages represented strategic tools used to maximize home equity and its benefits. For others, it was an option of last resort to which participants turned when faced with the imminent loss of their home., Discussion and Implications: Focusing on reverse mortgages, our analysis suggests way that social inequalities may be reproduced through financial decisions and the unequal landscapes of opportunity in which they are made., (© The Author(s) 2018. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Housing instability is linked to numerous health outcomes, but the specific impact of eviction from renter-occupied households, an event that has immediate implications for residential stability for low-income individuals, on sexually transmitted infections (STI) rates has not been adequately studied., Methods: We examined county-level associations between eviction rates in 2014 and rates of chlamydia and gonorrhea in the following year using publicly available data sources (Eviction Lab National Database and AtlasPlus, respectively). Descriptive statistics compared medians and nonparametric distributions with Krusal-Wallis tests. Linear regression was used to compare tertile categories of eviction rates and STI rates while controlling for potential confounders., Results: Median rates of chlamydia in counties with low, medium, and high rates of eviction were 229, 270, and 358 cases per 100,000 population, respectively (P < 0.001). The corresponding median rates of gonorrhea were 25, 37, and 75 cases per 100,000 population (P < 0.001). These associations remained statistically significant after controlling for all covariates in adjusted models. The beta coefficients and 95% confidence intervals (95% CI) for chlamydia and gonorrhea comparing high to low county-level eviction rates were 63.8 (95% CI, 45.1-82.5) and 20.4 (95% CI, 13.5-27.4), respectively. Similar associations were observed across levels of poverty and in both metropolitan and nonmetropolitan counties., Conclusions: County-level eviction rates are associated with chlamydia and gonorrhea rates in a significant and robust way independent of other known predictors of STI. These results suggest that evictions result in residential instability in a way that may increase STI risk.

We explore race differences in how individuals experience mass incarceration, as well as in mass incarceration's impacts on measures of well-being that are recognized as major social determinants of health. We draw on baseline data from a sample of 302 men and women recently released from prison/jail or placed directly onto probation in New Haven, Connecticut (CT) for drug related offenses and followed at 6-month intervals for two years (2011-2014). We describe race differences in experiences of mass incarceration and in its impacts on well-being; and we conduct mediation analyses to analyze relationships among race, mass incarceration, and well-being. Blacks reported fewer adult convictions than whites, but an average of 2.5 more adult incarcerations. Blacks were more likely to have been incarcerated as a juvenile, spent time in a juvenile facility and in an adult facility as a juvenile, been on parole, and experienced multiple forms of surveillance. Whites were more likely to report being caught by the police doing something illegal but let go. Blacks were more likely to report any impact of incarceration on education, and dropping out of school, leaving a job, leaving their longest job, and becoming estranged from a family member due to incarceration. Whites were more likely to avoid getting needed health or social services for fear of arrest. Overall, Blacks reported a larger number of impacts of criminal justice involvement on well-being than whites. Number of adult incarcerations and of surveillance types, and being incarcerated as a juvenile, each mediated the relationship among race, mass incarceration, and well-being. Though more research is necessary, experiences of mass incarceration appear to vary by race and these differences, in turn, have implications for interventions aimed at addressing the impacts of mass incarceration on health and well-being., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Purpose: The burden of syndemics-which are clusters of overlapping risk factors that adversely impact health-has been previously evaluated among high-risk individuals, yet little is known regarding syndemics within the relationship context., Methods: We evaluated concordant and discordant syndemic profiles among 296 pregnant couples and their actor-partner effects longitudinally from pregnancy to 1-year postpartum., Results: Syndemic score and severity were correlated across all time points for men and women. There was a significant difference in syndemic score (β Men - Women  = .2736, p = <.0001) and severity (β Men - Women  = .4282, p = <.0001) during pregnancy. For actor effects, we found score (β T1 - T2  = .273, p = .002; β T2 - T3  = .300, p = .005) and severity (β T1 - T2  = .253, p = .004; β T2 - T3  = .418, p = .001) were significantly associated across all time points for women. For men, only syndemic score predicted subsequent score at later time points (β T1 - T2  = .393, p = <.001; β T2 - T3  = .421, p = <.001). Severity was not significantly associated across time (β T1 - T2  = .043, p = .566; β T2 - T3  = .172, p = .066). For partner effects, we found women's syndemic risk to influence men's syndemic risk, while men had no significant effect on women's syndemic risk., Conclusions: Pregnancy provides an opportunity to reduce syndemic burden among men and women. Couples-based prevention programs may serve to reduce syndemic risk for both partners, particularly during the postpartum period., (Copyright © 2018 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Existing research suggests that individuals who are released from prison face considerable challenges in obtaining access to safe, stable, and affordable places to live and call home. This article draws on repeated qualitative interviews (conducted every 6 months over a period of 3 years) with 44 formerly incarcerated individuals, to understand how these individuals experience the search for a home after their prison release. The interviews show that the quest for a home is central to participants' reintegration projects as they seek to establish themselves as 'decent' and economically self-sufficient citizens, and shed stigmatized identities associated with incarceration, poverty, homelessness, and place. Interviews also suggest that their quest for a home is an arduous one as they encounter numerous barriers to housing arising from both structural and interpersonal forms of incarceration stigma. Somewhat paradoxically, the challenges that they face in accessing housing seem to hinder their ability to shed the stigmatized identities associated with their incarceration. Ultimately, the narratives presented here show how stigma can restrict access to a valuable material and symbolic resource (housing), resulting in ongoing stigmatization, and contributing to the enduring and discrediting mark of incarceration. In this way, the study illustrates how stigma that is enacted by both individuals and the state, that is embodied in place, and that is internalized and managed by stigmatized individuals themselves, can work to reproduce power and serve as justification for inequality.

Perceptions of neighborhood safety shape the well-being of individuals and communities, affecting neighborhood walkability, associated physical activity behaviors, and health conditions. However, less is known about the factors that determine perceptions of safety. One factor that may affect perceptions of neighborhood safety is the length of time someone has lived in their neighborhood. We use a representative, adult sample of urban low-income residents from the 2015 New Haven Health Survey (n = 1189) to investigate the associations between length of residence (new residents of < 1 year in neighborhood versus longer-term residents of 1 or more years in neighborhood) and perceptions of neighborhood safety (whether feeling unsafe to walk at night). We then examine the potential moderating effect of exposure to neighborhood violence on these associations. We find that the association between length of residence and perceived safety differs by exposure to neighborhood violence. Among those unexposed to neighborhood violence, longer-term neighborhood residents were more likely to feel unsafe compared to new residents (OR = 2.03, 95% CI 1.19, 3.45). Additionally, the effect of exposure to violence on feelings of safety was larger for new residents (OR = 9.10, 95% CI 2.72, 30.44) compared to longer-term residents (OR = 1.88, 95% CI 1.28, 2.77). Our findings suggest that length of residence may have implications for feelings of safety, and that experiences of violence may uniquely contribute to feelings of unsafety among new residents. These findings hold implications for interventions and policy efforts aimed at neighborhood safety improvements through community development, housing, or city urban planning initiatives, particularly for new neighborhood residents or those who experience neighborhood violence.

An emerging literature has documented the challenges that formerly incarcerated individuals face in securing stable housing. Given the increasingly unaffordable rental market, rental subsidies represent an important and understudied source of stable housing for this population. The existing literature has described substantial discretion and a varied policy landscape that determine former prisoners' access to housing subsidies, or subsidized housing spaces that are leased to members of their social and family networks. Less is known about how former prisoners themselves interpret and navigate this limited and uncertain access to subsidized housing. Drawing on data from repeated qualitative interviews with 44 former prisoners, we describe the creative and often labor-intensive strategies that participants employed to navigate discretion and better position themselves for subsidized housing that was in high demand, but also largely out of reach. Our findings also illustrate the potential costs associated with these strategies for both participants and members of their social and family networks., Competing Interests: Disclosure Statement No potential conflict of interest was reported by the authors.

Lack of affordable housing access represents a significant and growing problem for low-income households in the United States and these housing challenges may present barriers to the management of chronic diseases such as type 2 diabetes. In this qualitative study, we examined how both housing challenges and housing resources shaped diabetes self-management behaviors. We conducted semi-structured interviews with 40 low-income residents of one US city, New Haven, Connecticut, who had a diagnosis of type 2 diabetes and either resided in or qualified for subsidized housing. We purposively constructed our sample to include a range of housing experiences (subsidized, unsubsidized, homeless) and treatment regimes. We analyzed the data using grounded theory techniques of inductive coding and memo writing. Our findings suggest multiple ways that housing access can affect diabetes self-management with implications for blood glucose levels and future complications. Specifically, we describe the ways that housing access affected participants' ability to: 1) prioritize their diabetes care, 2) establish and maintain diabetes routines, and 3) afford diabetes-related expenses. Together, our findings show how housing challenges increased the cost of adherence to diabetes management regimes such that inadequately housed individuals had to both invest and sacrifice more for the same outcomes. Our findings suggest that improved affordable housing access may represent an opportunity to improve outcomes and reduce socioeconomic disparities among those living with type 2 diabetes., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Objective: This study draws on qualitative interview data to examine transitions into rent-assisted housing as they relate to diabetes self-management behaviors., Methods: We conducted qualitative interviews with low-income residents of New Haven, Connecticut, who had a diagnosis of type 2 diabetes. To examine experiences of transition into rent-assisted housing, we drew on interviews with those participants who were living in rent-assisted housing at the baseline interview (n = 18) and participants (n = 5) who transitioned into rent-assisted housing between baseline and a 9-month followup. Interviews probed participants' housing and diabetes experiences. Analysis followed an inductive grounded theory approach., Results: Our data suggest that improvements in diabetes self-management accompanied the receipt of rental assistance. By providing housing access to those participants who previously had no place of their own, rental assistance facilitated environmental control that supported diabetes routines. By making housing more affordable, rental assistance also improved some participants' ability to afford diabetes-related expenses and mitigated health-demoting financial stress. Additionally, for some participants, rental assistance provided residential stability that facilitated access to health-promoting local social support., Conclusions: Although more research is needed, these data suggest that expanded access to rental assistance could both improve population health and reduce healthcare spending associated with preventable diabetes-related complications.

While the number of HIV cases in the Middle East and North Africa region is low compared to other regions, recent studies show that incidence is increasing especially among high-risk populations; in particular, little is known about women and HIV in the region. Through semi-structured interviews with sexual healthcare providers and staff at non-governmental organisations, we sought to understand barriers to HIV testing among women in Lebanon. Using snowball sampling, key informants were recruited from greater Beirut (12 physicians, 9 non-governmental organisation staff). Data were analysed using a grounded theory framework. Findings identified barriers to HIV testing among women at each level of an adapted social-ecological model (i.e. social-cultural barriers, policy barriers, interpersonal healthcare provider barriers and intrapersonal barriers). Primary findings include the culture of sex as taboo; lack of sexual health education among women; fear of disclosing HIV testing and diagnosis; financial barriers linked to stigmatising insurance policies; and provider attitudes towards women. Findings can be used to inform HIV-related sexual health interventions at multiple levels for women in Lebanon and the greater region.

Social-sexual networking technologies have been reported to yield both psychosocial benefits and sexual risks for gay and bisexual men, yet little research has explored how technology interacts with the social-geographical environment to shape the health of gay and bisexual men in the relatively understudied environment of small cities. This article draws on 29 semistructured interviews examining the use of social-sexual networking technologies among racially diverse gay and bisexual men in two small cities. Questions probed participants' use of technology to meet sexual partners, engagement in the gay community, and the role of virtual and nonvirtual spaces in relation to health. Findings suggest that social networking technologies can help men navigate the challenges of small cities, including small and insular gay communities, lack of dedicated gay spaces, and sexual minority stigma. However, participants also describe declines in gay community visibility and cohesion, which they attribute to technology use. The article concludes by discussing the intersections of virtual and physical space in small cities as sites for the production of health and illness.