American Community Research Articles

Geospatial insights into social determinants and financial toxicity among patients with gynecologic malignancies: A perspective from the American Community Survey data

Geospatial insights into social determinants and financial toxicity among patients with gynecologic malignancies: A perspective from the American Community Survey data

Multidimensional structural racism and estimated cancer risk from traffic-related air pollution.

Traffic-related air pollutants have been associated with a variety of adverse human health impacts, including cancers. In the United States, numerous studies have documented racial inequities in neighborhood exposures to traffic-related air pollution. Emerging evidence suggests that structural racism may influence neighborhood exposures to air pollutants. However, existing research has largely focused on residential racial segregation, one indicator of structural racism. This study developed a multidimensional measure of structural racism to examine the relationship between structural racism and estimated cancer risk from air pollutants in Georgia. Carcinogenic air toxics data were obtained from the US Environmental Protection Agency's 2019 Air Toxics Screening Assessment and sociodemographic data from the American Community Survey. Guided by stakeholder input, county-level data on residential segregation, education, employment, incarceration, economic status, political participation, and homeownership were used to create a multidimensional county-level structural racism index. Relative risks (RRs) were estimated for associations between structural racism and elevated (top 10% in Georgia) estimated cancer risk from air toxics. Multilevel analyses revealed a significant association between multidimensional structural racism and exposure to carcinogenic traffic-related air pollutants. Neighborhoods in the highest quartile of structural racism exhibited an elevated cancer risk from traffic-related air pollutants (RR,7.84; 95% CI,5.11-12.05) compared to neighborhoods with lower levels of structural racism. Multidimensional structural racism was associated with estimated cancer risk from traffic-related air pollution in Georgia. Findings can inform future studies and policy interventions that address racial inequalities in exposure to traffic-related air pollution.

Cognitive Difficulty in Middle Eastern and North African Adults Living in the United States Compared With Other Racial and Ethnic Categories, 2017-2021.

Objectives. To estimate the odds of having cognitive difficulties among Middle Eastern and North African (MENA) American adults and compare these odds with those of White, Black, Hispanic/Latino, Asian, American Indian or Alaska Native (AI/AN), and Native Hawaiian/Other Pacific Islander adults nationally and in the 4 states with the largest MENA populations (California, New York, Michigan, and Texas) after adjusting for sociodemographic factors. Methods. We analyzed 2017-2021 American Community Survey data (aged ≥ 45 years; n = 7 284 988), comparing presence of cognitive difficulties by race/ethnicity. Results. MENA adults had greater odds of reporting cognitive difficulties than did White (odds ratio [OR] = 1.49; 95% confidence interval [CI] = 1.42, 1.56), Black (OR = 1.20; 95% CI = 1.14, 1.26), Hispanic (OR = 1.46; 95% CI = 1.39, 1.53), Asian (OR = 1.31; 95% CI = 1.25, 1.38), and AI/AN (OR = 1.07; 95% CI = 1.01, 1.14) adults. In all 4 states, odds of having cognitive difficulties were higher among MENA than Asian adults. Other racial/ethnic comparisons differed by state. Conclusions. A separate checkbox for MENA Americans approved by the Office of Management and Budget is important so health outcomes can be studied in more detail and funds can be allocated for research and resources at state and national levels. (Am J Public Health. 2024;114(11):1265-1274. https://doi.org/10.2105/AJPH.2024.307803).

Cardiovascular risk factors and disease mortality among asian american subgroups

Abstract Background Asian Americans are the fastest growing racial group in the United States. Although Asian subgroups have distinct cardiovascular (CV) risk profiles, they are often aggregated together for public health surveillance. Purpose We provide the first comprehensive national estimates of CV and CV risk factor mortality in Asian American subgroups to assess differences in CV risk. Methods We used CDC WONDER, which captures all death certificates in the US (2018-2020), as well as the American Community Survey for demographic data. Adults aged ≥18 years were included. Estimates of age-adjusted overall CV mortality, as well as heart disease, hypertension, and stroke-related mortality, were determined by ICD-10 codes. To compare the contribution of each cause of mortality among subgroups with different baseline all-cause mortality rates, proportional mortality rates were determined by race. Proportional mortality was defined as the mortality rate of each condition divided by the all-cause mortality for that race group. Differences in proportional mortality by race and ethnicity, compared with White American adults, were assessed with age-sex adjusted linear regression. Results The US population consisted of 12,950,565 Asian Americans (53.7% female). Among the Asian American subgroups, 25.4% were Asian Indian, 28.5% Chinese, 19.7% Filipino, 5.3% Japanese, 9.6% Korean, and 11.8% Vietnamese. A total of 160,282,147 adults were White. Age-adjusted baseline mortality rates are shown in the Table. Compared with White adults, Asian Indian (34.5% vs 29.3%; adjusted difference 5.2%, [95% CI: 1.8%, 8.6%], P=0.009) and Filipino (32.8% vs 29.3%; adjusted difference 3.5%, [95% CI: 0.1%, 6.9%], P=0.04) adults had significantly higher proportional mortality from all CV causes. Asian Indian (26.0% vs 22.6%; adjusted difference 3.2%, [95% CI: 0.3%, 6.2%], P=0.04) adults had higher proportional mortality from heart disease than White adults, while Korean (17.3% vs 22.6%; adjusted difference -5.2%, [95% CI: -8.1%, -2.2%], P=0.01) and Vietnamese (17.5% vs 22.6%; adjusted difference -5.1%, [95% CI: -8.0%, -2.1%], P=0.01) adults had lower proportional mortality. Every Asian American subgroup had higher proportional mortality from hypertension causes compared with White adults, except for Asian Indians (Figure). In addition, every Asian American subpopulation had higher proportional mortality from stroke compared with White adults (Figure). Conclusions CV risk factor and disease-related mortality varies substantially among Asian American subgroups. Public health efforts targeted to address CV health disparities among the diverse group of Asian Americans are needed.

Overlapping markets and quality competition among community health centers.

To examine the response of community health center (CHC) quality to quality levels at neighboring CHCs in the presence of non-price competition. A quasi-experimental study of US community health centers. Outcome variables were indices that measured overall quality of CHC care. Using patient flow data, we constructed CHC-specific Hirschman-Herfindahl index (HHI) and competitors' composite quality measure. The plausibly exogenous change in characteristics of "competitors' competitors" was exploited to identify the relationship between competition and quality of care, using a generalized two-stage least square model with instrumental variables. Using the Health Center Program Uniform Data System (2014-2018), linked with American Community Survey and Medical Expenditure Panel Survey, we analyzed 1098 unique federally funded CHCs in 50 states and District of Columbia which had at least one neighboring CHC and had non-missing data for 2015-2018 (4226 CHC-years). Most of CHCs served populations in overlapping geographic markets, with median market concentration decreasing during the study period. A one-percent increase in competitors' quality was associated with a 0.71-percent increase in an index CHC's composite quality (p < 0.01), consisting of a 0.59-percent increase in chronic condition control rates (p < 0.01); a 0.68-percent increase in the screening and assessment rates (p < 0.01); and a 0.78-percent increase in medication management rates (p < 0.01). The association was stronger at CHCs serving a smaller proportion of uninsured patients. No significant quality reaction was observed at CHCs with a percentage of uninsured patients larger than the 75th percentile. We observed no significant associations between HHI and quality. Increasing competition does not harm quality of care at CHCs. A CHC appears to improve its quality if its competitors improved quality. The beneficial quality effect was less pronounced in CHCs providing a significant proportion of care to uninsured patients, suggesting lack of incentives faced by these CHCs.

Spatially varying associations between community-level predictors and COVID-19 outcomes in NYC

Abstract Background The cumulative impacts of COVID-19 on hospitalization and mortality were not uniformly distributed across New York City (NYC). To better understand potential drivers of this observed geospatial disparity, we explored the associations between community-level sociodemographic characteristics and cumulative COVID-19 hospitalizations and mortality using geographically weighted Poisson regression (GWPR). Methods Cumulative COVID-19 hospitalization and mortality rates in 177 NYC modified ZIP code tabulation areas as of Dec 2022 were taken from the NYC Department of Health and Mental Hygiene, and sociodemographic predictors were taken from the 2018 American Community Survey. GWPR was applied using both non-multiscale (single bandwidth) and multiscale (flexible bandwidth) models to assess which predictors were significant and which associations varied spatially (allowing them to potentially act as both risk and protective factors, depending on the location). Results Multiscale GWPR models outperformed non-multiscale models in rendering residual spatial autocorrelation insignificant. Although multiscale GWPR allowed flexible bandwidths for each predictor, most yielded global bandwidths, suggesting geographically consistent effects. For mortality, the percent of residents without health insurance acted solely as a risk factor. Similarly, for hospitalizations, the percent of residents with a disability acted solely as a risk factor. The percent of residents with a bachelors degree or higher acted solely as a protective factor against both outcomes. Conclusions Even when associations were allowed to vary spatially in GWPR models, we still found geographically consistent associations between many sociodemographic predictors and cumulative COVID-19 outcomes in NYC. Consistent risk factors, such as prevalence of disability, or protective factors, such as prevalence of higher education, highlight potential areas for city-wide policies to reduce the burden of future epidemics. Key messages • For cumulative COVID-19 outcomes across NYC communities, geographically consistent risk factors include disability prevalence for hospitalization and lack of health insurance for mortality. • Increasing prevalence of higher education acted as a geographically consistent protective factor against both hospitalization and mortality due to COVID-19.

Empowering Early Career Researchers: The Jackson Heart Study Smith Scholars Program.

The University of Mississippi Medical Center Graduate Training and Education Center houses the Robert E. Smith, MD, Scholars Program, a two-year certificate program that equips predoctoral trainees from five Mississippi universities with advanced research skills in cardiovascular epidemiology. Funded by the National Heart, Lung, and Blood Institute (NHLBI), the program focuses on addressing health disparities, minority health, and health inequities in underserved communities. Trainees receive mentorship, career coaching, and a $7,500 annual stipend, building a foundation for postdoctoral opportunities and expanding professional networks. The Smith Scholars Program emphasizes population health and provides interdisciplinary training in areas such as biostatistics, scientific communication, and cardiovascular health. It is uniquely positioned to address systemic challenges, particularly in Mississippi, a state with high cardiovascular disease prevalence and limited research funding. The program's regional advantage and its partnership with the Jackson Heart Study offer scholars exposure to health disparities in Black/African American communities, preparing them to contribute to innovative, community-based research. Additionally, it fosters collaborative science, enabling participants to overcome academic barriers and engage with large-scale health equity research efforts. The Smith Scholars Program has been instrumental in shaping the career trajectories of its participants, facilitating their transition to postdoctoral positions and independent research roles.

The Influence of Prenatal Vitamin use and Community Health Programs on Reducing Teratogenic Medication Exposure and Improving Perinatal Nutrition among African American Adolescents with Limited Access to Healthcare

This review paper examines the critical influence of prenatal vitamin use and community health programs on reducing teratogenic medication exposure and improving perinatal nutrition among African American adolescents with limited access to healthcare. African American adolescents face disproportionate barriers to healthcare access, including socioeconomic challenges and systemic healthcare inequities, which contribute to heightened risks of teratogenic exposure and poor prenatal nutrition. The paper explores the role of prenatal vitamins such as folic acid, iron, and calcium in preventing congenital disabilities and enhancing maternal health. It also highlights the impact of community-based health programs and education initiatives that aim to bridge healthcare gaps for vulnerable populations. By focusing on adolescent pregnancy in African American communities, this review identifies key challenges such as limited healthcare access, inadequate educational resources, and socio-economic constraints. Furthermore, the paper assesses the effectiveness of current health interventions and policies, offering recommendations for improving healthcare access and expanding community programs. The review underscores the necessity for long-term research to address gaps in the intersection of race, adolescent health, and prenatal care, ultimately aiming to inform policy and program development that promotes equitable maternal and fetal health outcomes.

The role of ethnic enclaves and neighborhood socioeconomic status in invasive breast cancer incidence rates among Asian American, Native Hawaiian, and Pacific Islander females in California.

Few studies have examined whether the incidence rates of invasive breast cancer among Asian American, Native Hawaiian, and Pacific Islander (AANHPI) populations differ by the neighborhood social environment. Thus, we examined associations of ethnic enclave and neighborhood socioeconomic status (nSES) with breast cancer incidence rates among AANHPI females in California. A total of 14,738 AANHPI females diagnosed with invasive breast cancer in 2008-2012 were identified from the California Cancer Registry. AANHPI ethnic enclaves (culturally distinct neighborhoods) and nSES were assessed at the census tract level using 2007-2011 American Community Survey data. Breast cancer age-adjusted incidence rates and incidence rate ratios (IRRs) were estimated for AANHPI ethnic enclave, nSES, and their joint effects. Subgroup analyses were conducted by stage of disease. The incidence rate of breast cancer among AANHPI females living in lowest ethnic enclave neighborhoods (quintile (Q)1) were 1.21 times (95% Confidence Interval (CI) 1.11, 1.32) that of AANHPI females living highest ethnic enclave neighborhoods (Q5). In addition, AANHPI females living in highest vs. lowest SES neighborhoods had higher incidence rates of breast cancer (Q5 vs. Q1 IRR = 1.30, 95% CI 1.22 to 1.40). The incidence rate of breast cancer among AANHPI females living in low ethnic enclave + high SES neighborhoods was 1.32 times (95% CI 1.25, 1.39) that of AANHPI females living in high ethnic enclave + low SES neighborhoods. Similar patterns of associations were observed for localized and advanced stage disease. For AANHPI females in California, incidence rates of breast cancer differed by nSES, ethnic enclave, when considered independently and jointly. Future studies should examine whether the impact of these neighborhood-level factors on breast cancer incidence rates differ across specific AANHPI ethnic groups and investigate the pathways through which they contribute to breast cancer incidence.

Feasibility of the MIND+SOUL Culturally Tailored Brain Healthy Diet: A Pilot Study

Alzheimer’s disease (AD) disproportionately impacts Black Americans, who are three times more likely to develop AD. While heart-healthy diets have shown potential in reducing AD risk, research on adapted dietary interventions for Black American communities remains limited. This pilot study assessed the feasibility and acceptability of an adapted brain healthy diet intervention (MIND + SOUL) and explored changes in cardiometabolic risk and cognition. Twenty-nine participants completed the 12-week intervention, which included culturally tailored health education, cooking classes, health coaching, and groceries. Feasibility was assessed by attendance and retention rates, while acceptability was measured by two questionnaires. Participants had a mean age of 70.3, with 10.3% male. The intervention demonstrated high feasibility (89.3% retention) and acceptability (mean = 71.9, SD = 8.59), with meaningful improvements in body mass index (estimate = −0.54, P = 0.009), dietary intake (estimate = 28.39, P = 0.042), and executive function (estimate = 3.32, P &lt; 0.001). However, no significant changes in blood-based biomarkers were observed. The MIND + SOUL intervention demonstrated high feasibility and acceptability, improvements in body composition, cognitive function, and dietary behaviors, despite no significant changes in blood-based biomarkers. Findings suggest potential benefits for reducing AD risk factors and promoting healthy aging. Clinical Trials Registry: ClinicalTrials.Gov; NCT05414682.

Exploring the Association Between Minimum Wage Policy, Income Inequality, and Obesity Rates in US Counties.

To examine the interaction between minimum wage policy, income inequality, and obesity rates among U.S. counties, and how this relationship is shaped by policy, place, and racial/ethnic composition in a county. We used the County Health Rankings Data for obesity ratio (measured by Body Mass Index ≥ 30kg/m2) in US counties and combined it with the American Community Survey to include the Gini coefficient (GC) and population characteristics. The analytical sample included 3129 counties between 2015 and 2019. We ran several sets of regression analyses, controlling for county characteristics, access to healthy foods, and minimum wage categories as a policy influencer on the obesity ratio. In total, 31.7% of the population were obese, with wide variations across counties; during this time, counties' average GC was 0.442. Our findings showed that in the lack of any other predictors, GC has a positive association with the county obesity ratio (OLS 0.147, CI 0.122-0.173). Counties with minimum wage between $7.26-$9.0 and $9 + had lower obesity ratios by - 0.6 and - 2.8 percentage points, respectively, and counties with lower access to healthy foods had higher obesity ratio (Coeff = 0.022, CI 0.019-0.025). Income inequality is positively associated with the obesity ratio in counties. Access to healthy foods and state minimum wage policy predict obesity rates, with a lack of healthy foods increasing the ratio, while a higher minimum wage reduces it.

State-level trends in access to Medicaid family planning services, 2008-2023.

To characterize the landscape of policies that determine eligibility for family planning services through Medicaid programs and describe trends in eligibility and its determinants over time. Secondary data were collected for all states in the United States for the years 2008 through 2023. Data on economic and demographic characteristics came from the American Community Survey (ACS). Our descriptive study characterized state adoptions of Medicaid family planning section 1115 waivers and state plan amendments (SPA) and their eligibility criteria. We then estimated the proportion of women aged 19-44 years who were eligible for family planning services through Medicaid and identified the key determinants of changes in eligibility, by state and year. Information on state Medicaid policies was extracted from documentation on the Centers for Medicare & Medicaid Services website. When estimating the eligible population sizes, the denominator was women aged 19-44 years, the group most likely to be eligible for Medicaid family planning programs. Supplemental data on program enrollment or utilization were collected from states' websites and reports. Though eligibility limits for family planning through Medicaid generally increased over time, the proportion of women aged 19-44 years eligible for at least limited benefits decreased from 45.0% in 2012 to 39.4% in 2022, largely because of increases in household income. Trends varied considerably across states and by eligibility pathway. Among women with incomes below the poverty level, the proportion who were not eligible for Medicaid family planning services decreased from 6.3% in 2013 to 1.5% in 2022. Our data demonstrated substantial geographic and temporal variation in eligibility for family planning services through Medicaid. We identified key drivers of eligibility changes that may have important implications for health services analyses of means-tested public programs.

A COVID-19 Memoir: Using the Co-Occupation of Crafting and Spirituality to Promote Health and Wellness in the United States.

The occupational therapist authors explored the evolution of co-occupation during their experiences of social distancing related to the COVID-19 pandemic and times of ongoing civil unrest. The research method used is auto-ethnography to describe and analyze their personal experiences juxtaposed with their cultural experiences. The authors, one white and one African American shared a desire to promote emotional and spiritual wellness during isolation, healthcare disparities, and social unrest. This collaboration led to a creative partnership aimed at promoting health and wellness for both themselves and sectors of their local African American spiritual community. Through designing, creating, giving, and receiving cycles, they worked cooperatively to interweave craftwork with social ministry. Intrigued by the traditions of African kente cloth, they designed and carried out a handwoven kente-style liturgical stole ministry focused on encouraging African American pastors who experienced difficulty engaging in their usual worship and fellowship, which serves as their respite from civil unrest and providing comfort during illness and death.

Prevalence of Hearing Loss and Hearing Aid Use Among Persons Living With Dementia in the US

Dementia and hearing loss are prevalent and represent public health priorities, but little is known about the prevalence of hearing loss among persons living with dementia at a population level. To estimate the prevalence of hearing loss and hearing aid use among a nationally representative sample of persons living with dementia. In this cross-sectional study, we analyzed data from Medicare beneficiaries who participated in round 11 of the National Health and Aging Trends Study (NHATS). The analytic sample included participants who had complete audiometric data and a dementia classification, and survey weights were applied to yield nationally representative estimates. Data were collected from June to November 2021, and analyzed from October 12, 2023, to February 27, 2024. Audiometric measures of hearing loss and self-reported hearing aid use. National prevalence estimates of possible and probable dementia and hearing loss were estimated by applying NHATS survey weights of sex and age to the population aged 71 years or older based on the US Census Bureau's 2020 American Community Survey data. The analytic sample comprised 2613 NHATS participants (74.6% aged 71-79 years and 25.4% aged ≥80 years; 52.9% female). Overall prevalence of hearing loss among participants with dementia was estimated at 79.4% (95% CI, 72.1%-85.3%). The prevalence of hearing loss increased with age, from 61.1% (95% CI, 37.7%-80.2%) among participants aged 71 to 74 years to 94.2% (95% CI, 88.8%-97.0%) among those aged 85 years or older. Among participants with hearing loss, 21.7% (95% CI, 16.2%-28.3%) reported hearing aid use. In this cross-sectional study, the findings suggest that hearing loss is highly prevalent among individuals with dementia, with a low prevalence of hearing aid use. These findings reveal a potential opportunity for intervention.

Exploring Neighborhood-Level Environmental Justice to Tackle County-Level Disparities in Breast Cancer Outcomes

Breast cancer is a disease in which cells, originating from the breast epithelium, grow out of control and form tumors. The progression of breast cancer can vary, and its severity is often categorized by stages ranging from early, localized forms to more advanced stages involving widespread dissemination. Breast cancer cases can be hereditary or non-hereditary; Hereditary cases are caused by a penetrant gene mutation: one that is pathogenic and has the potential to promote the development of cancer whereas non-hereditary cases can be caused by a variety of day-to-day exposures affected by socioeconomic disparities and health literacy rates. Despite scientific and technological advancements, researchers and health officials still do not know enough about the disease and breast cancer incidence rates in the United States have steadily increased. This literature review aims to synthesize the relationship between breast cancer health outcomes and environmental justice, health literacy, and socioeconomic disparities. This relationship was first examined from a county-level in the state of Florida. We first examined three Florida counties with varying socioeconomic profiles (Broward, Miami-Dade, and Palm Beach) and then examined neighborhoods within the county of Miami-Dade (selected because it has the highest breast cancer rates out of all Florida counties). This examination revealed higher incidences of breast cancer in Latinx and African American communities with high environmental exposures and lower socioeconomic statuses. The identification of specific neighborhoods primarily affected by environmental exposures and low socioeconomic statuses emphasizes the need for neighborhood level modeling to inform future breast cancer research and intervention strategies.

Effectiveness of an Infection Control Program Among the Ysleta del Sur Pueblo in Preventing COVID-19-Related Hospitalizations and Deaths.

In response to the SARS-CoV-2 pandemic, the United States declared a state of emergency and implemented large-scale shutdowns and public health initiatives to prevent overwhelming public resources. The success of these prevention methods remains unresolved as restrictions and implementation varied from national, state, and local levels. Despite national and local regulations, individual adherence to preventative guidelines presented an additional layer of variability. Cases of COVID-19 continued to rise and fall over a two-year period on a national level, despite masking recommendations, ease of testing, and availability of vaccines. The Ysleta del Sur Pueblo is a Native American tribal community and sovereign nation located in El Paso, Texas. Speaking Rock Entertainment Center is a major business operated by the tribe, employing many tribal and non-tribal members from the El Paso area. Following nationwide re-openings of non-essential businesses, Speaking Rock implemented an infection control program with strict adherence to recommendations provided by the Center for Disease Control and Prevention (CDC) and additional disease control. This response would result in a fully vaccinated workforce within the wider community of El Paso, where the vaccination rate was less than 80%. Herein, we examine the efficacy of these measures and report on the success of the program resulting in zero hospitalizations or deaths compared with rates of 1 in 250 and 1 in 40, respectively, in the surrounding community.

Using the 12-item short-form health survey (SF-12) to evaluate self-rated health in an environmental justice community

The Greater Fifth Ward (GFW) is a Northeast Houston, Texas, neighborhood with a legacy of industrial contamination and a confirmed cancer cluster. To understand self-rated health in the GFW, community-based participatory research (CBPR), was used to promote the inclusion of all partners. CBPR involves the community during each stage of the research process from design to research dissemination. A complete census was conducted, and 114 surveys were obtained in the environmental justice (EJ) community from July to November 2021. EJ communities shoulder an unfair burden of environmental exposures, pollution, and poor built environments. Mental and physical health were measured using the validated 12-item Short Form Health Survey (SF-12v2). We posited that the Black or African American (Black/AA) community would have lower mental composite scores (MCS) and physical composite scores (PCS) compared to the nation and their White counterparts. The MCS and PCS were calculated and compared against the national mean. Overall, participants had higher MCS and lower PCS than the national mean. Black/AA males and females had lower MCS compared to their White counterparts. White females had the lowest PCS among all respondents, significantly lower than the national average. MCS was lower among those who lived in the neighborhood longer. Burdens from pollution may impact residents’ health and perceived health. Targeted interventions or programs that improve mental or physical health would benefit this community and other inequitably burdened neighborhoods.

Increasing expenditures on home- and community-based services: Do home care workers benefit?

To examine the association of Medicaid home- and community-based services (HCBS) expenditures on the home care workforce. We use two national, secondary data sources from 2008 to 2019: state-level Medicaid HCBS expenditures and the American Community Survey, in which we identify direct care workers in the home (i.e., home care workers), defined as nursing, psychiatric, and home health aides or personal care aides working in home health care services, individual and family services, and private households. Our key explanatory variable is HCBS expenditures per state per year. To estimate the association between changes in Medicaid HCBS expenditures and the workforce size, hourly wages and hours worked, we use negative binomial, linear, and generalized ordered logit regression, respectively. All models include demographic and socioeconomic characteristics, the number of potential HCBS beneficiaries (individuals with a disability and income under the federal maximum income eligibility limits), indicators for minimum wage and/or overtime protections for direct care workers, wage pass-through policies, and state and year fixed effects. We exclude states with incomplete reporting of expenditures. States' HCBS expenditures increased between 2008 and 2019 after adjusting for inflation and the number of potential HCBS beneficiaries. Yet, home care workers' wages remained stagnant at $11-12/h. We find no association between changes in Medicaid HCBS expenditures and wages. For every additional $1 million in Medicaid HCBS expenditures, the expected number of workers increases by 1.2 and the probability of working overtime increased (0.0015% points; p < 0.05). Results are largely robust under multiple sensitivity analyses. We find no evidence of a statistically significant relationship between changes in state-level changes in Medicaid HCBS expenditures and worker wages but do find a significant, but small, association with hours worked and workforce size.

Association of Racial Residential Segregation and Other Social Determinants of Health with HIV Late Presentation.

Understanding social determinants of HIV late presentation with advanced disease (LPWA) beyond individual-level factors could help decrease LPWA and improve population-level HIV outcomes. This study aimed to examine county-level social determinants of health (SDOH) with HIV late presentation. We aggregated datasets for analysis by linking statewide HIV diagnosis data from the South Carolina (SC) Enhanced HIV/AIDS Reporting System and multiple social contextual datasets (e.g., the American Community Survey). All adult (18 years and older) people with HIV diagnosed from 2014 to 2019 in SC were included. Linear mixed models with forward selection were employed to explore the association of county-level SDOH with the county-level three-year moving average percentage of LPWA and average delay time from HIV infection to diagnosis. Around 30% of new HIV diagnoses were LPWA in SC, and the mean delay time for people with LPWA was approximately 13 years. Counties with more racial residential segregation had longer average delay time (Adjusted beta = 5.079, 95% CI: 0.268 ~ 9.889). Regarding other SDOH, the increased percentage of LPWA was associated with fewer Ryan White centers per 100,000 population (Adjusted beta = -0.006, 95% CI: -0.011~-0.001) and higher percentages of the population with less than a high school education (Adjusted beta = 0.008, 95% CI: 0 ~ 0.015). Reducing county-level disparities in LPWA requires multifaceted interventions addressing multiple dimensions of SDOH. Targeted interventions are needed for counties with more Black residential segregation, fewer Ryan White centers, and higher percentages of less than high school education.

The Challenges and Rewards of Carrying Out Qualitative Research on the Police in the African American Community

In this paper, we discuss the challenges and rewards of carrying out qualitative research on the police in the African American1 community. Using data drawn from interviews with seventy-seven African American adults in Durham, NC, we found that community member hostility toward research(ers) and fear of both neighbors and the police lowered African Americans’ willingness to be interviewed about their perceptions of and experiences with U.S. police. These findings were observed primarily in public housing and middle-income communities. On a positive note, we found that greater awareness of policing issues increased African Americans’ willingness to participate in research about the police. This finding was more common among upper-middle-income African Americans. The implications of our findings for future research and improved policing in the African American community are discussed.