Low-income Minority Communities Research Articles

Therapy deserts: A call to action to address inequitable access to therapy services among pediatric orthopaedic patients

Background"Food deserts" are areas with limited access to affordable and healthy foods, disproportionately affecting low-income and ethnic minority communities in the United States. Analogous disparities exist in other disciplines. Our interprofessional team observed "therapy deserts” in orthopaedic and rehabilitation settings, wherein pediatric patients (particularly those with Medicaid-type insurance) appeared to lack equal access to physical therapy (PT), occupational therapy (OT), and speech-language pathology (SLP) services. Inadequate access to therapy services places patients at risk for worse outcomes. MethodsWe conducted a quality improvement project to assess pediatric patients’ access to therapy care in our region. We surveyed all local PT, OT, and SLP clinics identified from a comprehensive listserv maintained by pediatric therapy teams in our institution. Using a scripted questionnaire, we contacted 113 PT, 38 OT, and 82 SLP clinics external to our institution, collecting data on accepted conditions, appointment waitlist periods, and accepted insurance types. Our primary objective was to determine the percentage of clinics that accepted patients with Medicaid-type insurance. We supplemented our survey with an examination of the Area Deprivation Index (ADI) for each clinic location. Results59 PT clinics (52%), 15 OT clinics (39%), and 36 SLP clinics (44%) completed the survey. Clinics often had limited capacity to care for medically complex conditions. Waitlist times varied, with a median wait of 1 week for PT services, 1 month for OT services, and immediate availability for SLP services. Only 14% of responding PT clinics, 53% of OT clinics, and 22% of SLP clinics accepted patients with Medicaid-type insurance. Insufficient reimbursement rates were frequently cited as the reason for not accepting Medicaid-type insurance. Waitlist times were longer for PT and SLP clinics that accepted Medicaid-type insurance compared to those that did not. Moreover, clinics that accepted Medicaid-type insurance were, on average, in more disadvantaged locations. ConclusionsOur findings suggest the existence of “therapy deserts,” where limited access to therapy services is influenced by insurance type and patient complexity. These restrictions likely exacerbate existing health disparities and illustrate a systemic problem rooted in complex social drivers of health. Addressing "therapy deserts" requires collaborative efforts from multidisciplinary teams. Level of EvidenceLevel III

Heterogeneity in COVID-19 vaccine uptake within low-income minority communities: evidence from the watts neighborhood health study

BackgroundThe literature on disparities in COVID-19 vaccine uptake focuses primarily on the differences between White versus non-White individuals or differences by socioeconomic status. Much less is known about disparities in vaccine uptake within low-income, minority communities and its correlates.MethodsThis study investigates disparities in COVID-19 vaccination uptake within racial and ethnic minoritized communities with similar socioeconomic backgrounds and built environments, specifically focusing on Black-Hispanic disparities and disparities within the Hispanic community by country of origin. Data are analyzed from the fourth wave (June 2021- May 2022) of the Watts Neighborhood Health Study, a cohort study of public housing residents in south Los Angeles, CA. Linear probability models estimated the association between vaccine uptake and participants’ race/ethnicity, sequentially adding controls for sociodemographic characteristics, health care access and insurance, prior infection, and attitudes towards COVID-19 vaccines. Differences in reasons for vaccination status by race/ethnicity were also tested.ResultsMexican Hispanic and non-Mexican Hispanic participants were 31% points (95% CI: 0.21, 0.41, p < 0.001) and 44% points (95% CI: 0.32, 0.56, p < 0.001) more likely to be vaccinated than non-Hispanic Black participants, respectively. The disparity between Black and Hispanic participants was reduced by about 40% after controlling for attitudes towards COVID-19 vaccines. Among Hispanic participants, non-Mexican participants were 13% points (95% CI: 0.03, 0.24, p = 0.01) more likely to be vaccinated than Mexican participants, however, these differences were no longer significant after controlling for individual and household characteristics (β = 0.04, 95% CI: -0.07, 0.15, p = 0.44).ConclusionThere are sizeable racial and ethnic COVID-19 vaccination disparities even within low-income and minoritized communities. Accounting for this heterogeneity and its correlates can be critically important for public health efforts to ensure vaccine equity.

Monday-Enhanced CEASE Program for Underserved Ethnic Minorities: a Mixed-Methods Study.

Due to the persistence of tobacco-related health disparities in the U.S., there is a need for innovative strategies to reach the underserved ethnic minority populations who are most at risk. As contemplations for health behavior modification tend to surge on Mondays, we explored the feasibility and effect of a Monday-enhanced smoking cessation program on quitting outcomes in a low-income ethnic minority community. To compare a Monday-enhanced with a standard Communities Engaged and Advocating for a Smoke-free Environment (CEASE) program and understand the overall experiences of participants in the program. In this mixed-methods study, affordable housing complexes (n = 4) and a church were randomly assigned either a Monday-enhanced (n = 3) or standard (n = 2) CEASE smoking cessation program. CEASE comprised twelve weekly group counseling sessions facilitated by trained peer motivators plus nicotine replacement products. Participants in the Monday-enhanced arm were encouraged to pick Mondays as a quitting day. Quantitative and qualitative data were collected during the program and at 3-month post-graduation. Seventy-seven participants were enrolled in the study arms. In both groups combined, tobacco consumption reduced from 7.7 to 5.6 cig/day (mean reduction, 2.1; 95% CI: 0.9 to 5.1, p = 0.08). Although no significant difference in quit rate was observed between the two arms, more participants completed the follow-up survey in the Monday-enhanced than standard CEASE program [82.4% vs. 36.0%, p < 0.05]. While qualitative data suggested an overall satisfaction of participants with the program, motivation for quitting was higher in the Monday-enhanced CEASE program compared to the standard CEASE program. The Monday-enhanced program is promising and may enhance participants' engagement and willingness to quit smoking, particularly in low-income ethnic minority communities. Further research should include larger sample sizes to better assess the efficacy of a Monday-enhanced program across diverse populations.

Effectiveness variation of different census outreach activities: An empirical analysis from the state of Illinois using machine learning and user interface technologies for participatory data collection

Major social changes stem from policies that their developments heavily rely on public participation in the decennial U.S. Census. For individual states, the population counts determine representation in the U.S. House of Representatives and the amount of federal funding each state receives, leading to state outreach efforts to encourage participation in the census. The present empirical study uses advanced data collection technologies based on a user interface (UI) and machine learning techniques (k-means clustering, random forest, gradient boosting) to analyze the effectiveness of the outreach activities organized by the State of Illinois. As a result, we assess various types of outreach activities in different geographic areas with distinct socio-economic and demographic characteristics. Findings from the models in this study show that outreach activities classified as “direct engagement (1-on-1)” and “single events” bear the highest impact, especially in predominantly low-income minority communities in metropolitan areas. However, socio-demographic characteristics are found to be generally more influential on response rates than outreach activities performed in the area, and in many underperforming areas, a high number of activities does not correlate with an increase in response rates. The findings of this research could assist in structuring outreach efforts in different countries and the U.S.

Understanding drivers of micro-level disparities in childhood body mass index, overweight, and obesity within low-income, minority communities

The focus of childhood obesity disparities has been mainly on macro-level disparities, such as, between lower versus higher socioeconomic groups. But, less is known about micro-level disparities, that is disparities within minority and low-income populations. The present study examines individual and family level predictors of micro-level obesity disparities. We analyze data on 497 parent–child dyads living in public housing communities in Watts, Los Angeles. Cross-sectional multivariable linear and logistic regression models were estimated to examine whether individual and family level factors predict children’s BMI z-scores, overweight, and obesity in the sample overall and separately by child’s gender and age group. Child characteristics of our study sample included mean age 10.9 years, 74.3% Hispanic, 25.7% Non-Hispanic Black, 53.1% female, 47.5% with household income below $10,000, 53.3% with overweight or obesity, and 34.6% with obesity. Parental BMI was the strongest and most consistent predictor of child zBMI, overweight, and obesity, even after controlling for parent’s diet and activity behaviors and home environment. The parenting practice of limiting children’s screentime was also protective of unhealthy BMI in younger children and females. Home environment, parental diet and activity behaviors, and parenting practices related to food and bedtime routines were not significant predictors. Overall, our findings show that there is considerable heterogeneity in child BMI, overweight, and obesity even within low-income communities with similar socioeconomic and built environments in their neighborhoods. Parental factors play an important role in explaining micro-level disparities and should be an integral part of obesity prevention strategies in low-income minority communities.

Prevention Strategies for Policing Gun Violence

The police have the unique capacity to preempt and deter violence and to reduce the use of firearms in violent encounters. But overly aggressive policing tactics have contributed to a fraught relationship with low-income minority communities in which gun violence is heavily concentrated. Increased resources should be devoted to policing gun violence, but efforts of this sort must be targeted and disciplined. Effective policing requires a focus on the places and people that are at greatest risk; and there is a strong case for police agencies to increase the resources devoted to investigations of all criminal shootings, not just homicides. Successful policing of gun violence requires a productive working relationship with victims and their neighbors, which can be facilitated through observing community policing principles and respect for residents’ interests.

Dissociation and misdiagnosis of schizophrenia in populations experiencing chronic discrimination and social defeat

ABSTRACT As recently as the late 20th century, Schizophrenia, a category of mental illness with widely varying phenotypic symptoms, was believed by psychobiologists to be a genetically based disorder in which the environment played a limited etiological role. Yet a growing body of evidence indicates a strong correlation between schizophrenia and environmental factors. This theoretical paper explores the relationship between highly elevated rates of schizophrenia in some low-income minority communities worldwide and trauma-related dissociative symptoms that often mimic schizophrenia. Elevated rates of schizophrenia in racially and ethnically isolated, inner-city Black populations are well documented. This paper contains evidence proposing that this amplification in the rate of schizophrenia is mediated by childhood trauma, disorganized attachment, and social defeat. Further, evidence demonstrating how these three variables combine in early childhood to incubate dissociative disorders will also be conveyed. The misdiagnosis of dissociative disorders as schizophrenia is theorized to partially mediate the increased rate of schizophrenia in communities that experience high levels of racial/ethnic discrimination. It is argued that this misdiagnosis is often attributable to cultural misunderstanding and/or a lack of knowledge about dissociative disorders

The environmental and traffic impacts of warehouses in southern California

Economic growth over the last few decades along with increasing household consumption has led to a rapid expansion of the warehousing industry. Research has shown that warehouse facilities tend to be disproportionately sited in low-income minority communities. Warehouses can generate significant environmental externalities making the siting of warehouses a major environmental justice concern. We investigate the relationship between the warehouse activity in southern California and a range of health-based risks for communities residing nearby, after controlling for important socio-demographic characteristics. Our results reveal a significant association between warehouse activity and air pollution, noise levels and traffic collisions.

Assessing impacts of redeveloping public housing communities on obesity in low-income minority residents: Rationale, study design, and baseline data from the Watts Neighborhood Health Study

IntroductionObesogenic built- and social-environments in low-income and minority communities are often blamed for the higher rates of obesity in this population, but existing evidence is based largely on observational studies. This study leverages a natural experiment created by the redevelopment of a public housing community to examine the impact of major improvements to the housing, built, and social environments on obesity among residents. Methods/designThe study design is a natural experiment where residents from the redeveloped community (treatment group) will be compared to those from a similar community (control group) in terms of their pre/post changes in primary outcomes using annual longitudinal data on a cohort of residents. Quasi-experimental variation in the timing of exposure to various redevelopment components within the treated community will be further leveraged within a stepped-wedge research design to assess the impact of the redevelopment components. Primary outcome measures include body mass index, overweight, and obese status. ResultsA cohort of 868 adults and 704 children (ages 2–17 years) was recruited during 2018–2019 with up to two waves of baseline data. At baseline, the prevalence of obesity (overweight or obesity) was 57.2% (81.3%) in adults and 33.1% (52.4%) among children, with no significant differences by treatment status. No differential trends in primary outcomes were observed by treatment status during the two years of baseline. DiscussionThis natural experiment study offers a unique opportunity to assess whether improvements to housing, built, and social environment in low-income minority communities can lead to reductions in obesity.

Geographic variation of iPLEDGE-participating pharmacies across major metropolitan cities in the United States

To the Editor: Treatment with isotretinoin poses many challenges for patients, including locating an iPLEDGE-participating pharmacy.1Shah N. Smith E. Kirkorian A.Y. Evaluating the barriers to isotretinoin treatment for acne vulgaris in pediatric patients.J Am Acad Dermatol. 2020; https://doi.org/10.1016/j.jaad.2020.11.055Abstract Full Text Full Text PDF Scopus (8) Google Scholar We demonstrated in Washington, District of Columbia, that iPLEDGE pharmacies are substantially limited in low-income and racial minority communities.2Shah N. Truong M. Kirkorian A.Y. Relationship between sociodemographic factors and geographic distribution of pharmacies dispensing isotretinoin in Washington, DC.J Am Acad Dermatol. 2020; 83: 930-933https://doi.org/10.1016/j.jaad.2020.01.014Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar The current study expands the geographic analysis of iPLEDGE pharmacies across metropolitan cities in the United States. Four cities with a population greater than 500,000 residents, based on the US Census Bureau's 2010 estimates, were randomly selected per geographic region of the country (Northeast, Southeast, Midwest, West, and Southwest). A list of active outpatient pharmacies was obtained from the state's Board of Pharmacy and public sources and verified for iPLEDGE enrollment. A list of dermatologists was obtained from the American Academy of Dermatology. Zip code-specific demographics were extracted from the 2013-2017 American Community Survey estimates. iPLEDGE pharmacy distribution was compared with community demographics and dermatologist density using Poisson regression and simple linear regression, respectively. Of 737 zip codes surveyed across 20 cities, 5470 pharmacies were identified, of which 2961 (54.1%) were enrolled in iPLEDGE. The Southeast had the highest iPLEDGE pharmacy density, whereas the West had the lowest (Fig 1). For every $1000 increase in median household income, the number of iPLEDGE pharmacies increased by 12% and 10% in the West (95% CI 1.10-1.15) and Midwest (95% CI 1.08-1.13), respectively (Fig 2). For every 1% increase in the percentage of individuals living below the poverty line, the overall number of iPLEDGE pharmacies decreased by 22% (95% CI 0.71-0.85), with the largest decrease in the Southwest, ie, 30% (95% CI 0.57-0.86). For every 1% increase in the percentage of non-White individuals, the overall number of iPLEDGE pharmacies decreased by 9% (95% CI 0.87-0.96), with the largest decrease in the Southwest, ie, 30% (95% CI 0.59-0.83). Overall, the iPLEDGE pharmacy density increased by 0.66 units for every unit increase in the dermatologist density (per 10,000 residents) (95% CI 0.64-0.68). The total number of pharmacies was not associated with changes in sociodemographic factors; however, non-iPLEDGE pharmacy distribution decreased by 8% and 13% for every 1% increase in the percentage of non-White individuals and individuals living below the poverty line, respectively.Fig 2Association of the distribution of iPLEDGE-participating pharmacies with sociodemographic variables. The data represent changes in the number of iPLEDGE pharmacies for every $1000 increase in median household income, 1% increase in non-White population, and 1% increase in the percentage of people living below the poverty line. ∗Represents a statistically significant change.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Our study demonstrates the maldistribution of iPLEDGE pharmacies across the United States, with restricted availability in low-income and racial minority communities. Limited access to iPLEDGE pharmacies is associated with poor isotretinoin treatment outcomes, such as more missed prescription windows and early termination of treatment, and contributes to racial and socioeconomic disparities in acne treatment.1Shah N. Smith E. Kirkorian A.Y. Evaluating the barriers to isotretinoin treatment for acne vulgaris in pediatric patients.J Am Acad Dermatol. 2020; https://doi.org/10.1016/j.jaad.2020.11.055Abstract Full Text Full Text PDF Scopus (8) Google Scholar,3Barbieri J.S. Shin D.B. Wang S. Margolis D.J. Takeshita J. Association of race/ethnicity and sex with differences in health care use and treatment for acne.JAMA Dermatol. 2020; 156: 312-319https://doi.org/10.1001/jamadermatol.2019.4818Crossref PubMed Scopus (22) Google Scholar Further, Black women have been reported to face restricted access to pharmacies that have contraception.4Barber J.S. Ela E. Gatny H. et al.Contraceptive desert? Black-white differences in characteristics of nearby pharmacies.J Racial Ethn Heal Disparities. 2019; 6: 719-732https://doi.org/10.1007/s40615-019-00570-3Crossref PubMed Scopus (13) Google Scholar The disproportionate distribution of iPLEDGE pharmacies and dermatologists, coupled with a “contraception desert,” not only places racial minorities at a disadvantage of accessing isotretinoin but also jeopardizes the safe use of isotretinoin. Our results are limited to urban settings and may not be generalizable to rural communities. iPLEDGE presents multiple challenges for pharmacies, such as recertification and retraining requirements, gaining access to the iPLEDGE online portal, and using an interactive voice system.5Barlas S. FDA intensifies drive to reduce REMS burdens.http://dailymed.nlm.nih.gov/Date accessed: December 17, 2020Google Scholar Methods to reduce the regulatory burden of iPLEDGE requirements on pharmacies, such as streamlining the iPLEDGE verification process, may encourage pharmacies with limited resources to enroll in the program and expand access. Supplementary Material are available on Mendeley at https://doi.org/10.17632/wybgpbcbzd.3. None disclosed.

Who gets access to fast broadband? Evidence from Los Angeles County

Regulatory and market changes in residential (fixed) broadband have raised concerns about Internet Service Providers (ISPs) prioritizing investments in the most profitable areas, thus relegating low-income and minority communities to fewer broadband options and legacy networks. This study examines these concerns for Los Angeles (LA) County during the 2014–18 period. The analysis uses rollout data collected by the California Public Utilities Commission (CPUC) in combination with demographic information from the American Community Survey (ACS). Because the spatial distribution of broadband investments cannot be directly observed, competition and the availability of FTTH services are used as proxies. The findings indicate that competition and fiber-based services are less likely in low-income areas and minority communities, with the most severe deficits observed in census block groups that combine poverty and a large share of Black residents. We outline alternative policy tools to address intracity inequalities in broadband investments in the conclusion.

Social Determinants of Pharmacy Deserts in Los Angeles County

As medications are commonly used to prevent and mitigate chronic diseases and their associated complications and outcomes, limited geographic access to medications in communities that are already plagued with health inequity is a growing concern. This is especially important because low-income urban minority communities often have high prevalence and incidence of cardiometabolic and respiratory chronic conditions. Community pharmacy deserts have been established in Chicago, New York, and other locales. In part because the definition was originally adapted from the concept of food deserts, existing studies have either utilized the distance of 1 mile or greater to the nearest community pharmacy solely, or used distance along with the same predefined social indicator thresholds that define food deserts (i.e., income and vehicle ownership), to define and identify areas as pharmacy deserts. No full analysis has been conducted of the social determinants that define and characterize medication shortage areas within a given locale, even though medication and food are usually accessed independently. Therefore, to address this gap in the literature, this study was designed to identify all potential “pharmacy deserts” in Los Angeles County based on distance alone and then characterize them by their social determinants of health (SDOH) indicators. Geographic pharmacy deserts were identified as census tracts where the nearest community pharmacy was 1 mile or more away from a tract centroid. K-means clustering was applied to group pharmacy deserts based on their composition of social determinants of health indicators. Twenty-five percent (571/2323) of LA County census tracts were pharmacy deserts and 75% (1752/2323) were pharmacy non-deserts. Within the desert areas, two statistically distinct groups of pharmacy deserts (type one and type two) emerged from the analysis. In comparison to type two pharmacy deserts, type one pharmacy deserts were characterized by a denser population, had more renters, more residents that speak English as a second language, less vehicle ownership, more residents living under the federal poverty level, more Black and Hispanic residents, more areas with higher crime against property and people, and less health professionals to serve the area. Residing in type one desert areas, potentially compounds the geographic shortage of pharmacies and pharmacy services. As such, residents in Los Angeles County pharmacy deserts might benefit greatly from equitable, innovative, community-based interventions that increase access to medications, pharmacy services, and pharmacists.

Neighborhood Composition and Community Garden Locations: The Effect of Ethnicity, Income, and Education

Community gardens provide food, health, and sustainability benefits to surrounding communities. Research demonstrates that low-income or ethnic minority communities develop gardens to resist divestment and provide access to healthy food, whereas white or highly educated communities develop gardens to address local sustainability concerns. Missing from this discussion is a comprehensive picture of the relationship between neighborhood composition and community garden locations. Using GrowNYC and GreenThumb’s 2014 survey of New York City community gardens, this study employs negative binomial and spatial regression methods to examine this relationship. Findings reveal increased numbers of gardens in communities with higher aggregate concentrations of (1) black and/or Latino residents, (2) lower income residents, and (3) well-educated residents, regardless of ethnicity or income. In keeping with qualitative research on motivations for garden development, this study provides crucial quantitative metrics suggesting the diversity of neighborhoods with community gardens and supports their inclusion in urban public policy and city planning.

Trauma-Responsive Care in a Pediatric Setting: Feasibility and Acceptability of Screening for Adverse Childhood Experiences.

Adverse childhood experiences (ACEs) have demonstrable negative effects on long-term physical and mental health. Low-income and ethnic minority communities face significant disparities in exposure to ACEs. Pediatric settings offer an opportune context to identify and address ACEs, with the potential to reduce barriers in access to resources and services. The current study examined the feasibility and acceptability of screening infants and their parents for ACEs at a community medical clinic. Feasibility data indicated that 151 (92%) of the 164 unique patients that presented for well-child visits for infants (4- to 12-months) across a 13-month period were screened for infant and parent ACEs. Of these 151 patients, 47% met eligibility (infants with 1+ACEs, parents with 2+ACEs) deemed intermediate risk and indicated referral to prevention services. The majority of referred families (77%) accepted prevention services, including appointments with bilingual and bicultural wellness navigators who provided a cultural bridge and access to resources that could address patients' social determinants of health. Qualitative interviews with providers expand upon screening acceptability. Implications for integrated behavioral health, ACEs screening, and trauma-responsive prevention in a pediatric setting are discussed.

Program Capacity to Deliver Prevention Services to Children of Adult Clients Receiving Substance Use Disorder Treatment.

Children whose parents have a history of substance use are at elevated risk of developing substance use disorders (SUDs) and related debilitating behaviors. Although specialty treatment programs are uniquely positioned to deliver prevention care to children of adult clients, these programs may have limited capacity to implement prevention and early intervention care services, particularly in racial and ethnic minority communities. We merged data from program surveys and client records collected in 2015 to examine the extent to which program capacity factors are associated with the odds of delivering prevention and early intervention services for children of adult clients attending outpatient SUD treatment in low-income minority communities in Los Angeles County, California. Our analytic sample consisted of 16,712 clients embedded in 82 programs. Our results show that 85% of these programs reported delivering prevention care services, while 71% of programs delivered early intervention services. Programs with organizational climates supporting change and those that served a high number of clients annually were more likely to implement both prevention and early intervention practices. Programs accepting Medicaid payments and serving clients whose primary drug was marijuana were more than three times as likely to implement prevention services. Overall, our findings suggest both program- and client-level characteristics are associated with delivering preventive care offered to children of adult clients receiving SUD treatment in communities of color. As Medicaid has become a major payor of SUD treatment services and marijuana use has been legalized in California, findings identify capacity factors to deliver public health prevention interventions in one of the nation's largest public SUD treatment systems.

Place-Making Practices for Park Improvements to Support Environmental Justice in a Low-Income African American Neighborhood

Place-making practices can facilitate effective place and park design. This study explores the importance of inclusive place-making practices for supporting procedural justice in park design. Place-making is a multifaceted approach to space design and management that seeks to integrate a community’s needs for the space. The incorporation of such practices in design is particularly important for low-income minority communities and for promoting environmental justice. While it has been shown that place-making practices can help facilitate social justice and place attachment, research regarding the use of these practices in park design is lacking. As such, this study sought to examine park user perceptions that could be used to facilitate better place-making practices in relation to ongoing design changes at a historically significant park in a low-income, predominantly African American neighborhood. Semi-structured interviews were conducted with park users (n = 30) in June 2015. Interview questions examined community members’ use of the park, history and connections to the park, and feelings towards the park changes, which were planned at the time of the interviews but have since been completed. Six overall themes emerged: everyday activities, organized events, belonging, dependence, safety, and political processes. An emphasis on park changes and youth emerged throughout the themes. Interviews revealed a heavy reliance on park features that were scheduled to be removed from the park, with participants questioning how these changes would affect park users and overall park use. While park changes seemed to prioritize green space and a skate park designed to promote physical activity, many park users spoke of a desire to maintain social gathering spaces, including a parking lot and large picnic shelter. This highlights a potential mismatch between the goals of the design changes and neighborhood priorities. A better understanding of how park users connect to and use this park can inform park changes that more appropriately accommodate the community’s needs. Such findings suggest that changes to a place necessitate greater understanding of its cultural significance to a community, how changes can positively or negatively influence the community and the use of the space, and how officials can better include the community in the decision-making process. This study provides a foundation for future place-making research aimed at better understanding the unique concerns of low-income minority communities.

Increasing Home Smoking Restrictions Boosts Underserved Moms' Bioverified Quit Success.

Objectives: Standard smoking cessation treatments remain relatively ineffective in vulnerable populations. This study tested whether efforts to restrict residential smoking mediated the counseling treatment - smoking cessation association in a child tobacco smoke exposure (TSE) reduction trial. Methods: Maternal smokers (N = 300) with young children from low-income minority communities were randomized to counseling or standard care control to promote child TSE reduction. Secondary mediation analyses controlled for factors associated with smoking cessation. Results: Counseling group mothers were more likely than controls to increase home smoking restrictions (OR = 1.9, 95% CI 1.1-3.4) and quit smoking (OR = 11.0, 95% CI 6.3-19.2). As hypothesized, increasing home smoking restrictions improved likelihood of bioverified quit status at end of treatment (OR = 2.5, 95% CI 1.1-5.9) and partially mediated the association between counseling intervention and quit status. Conclusions: Results suggest that among maternal smokers known to experience increased challenges to quitting smoking, encouraging efforts to protect children from TSE by increasing home smoking restrictions may be an important counseling intervention element that facilitates smoking cessation.

BBRF Honors Leaders Who Are Forwarding the Cause of MH

BBRF Honors Leaders Who Are Forwarding the Cause of MH

Assessment of Exposure to High-Performing Schools and Risk of Adolescent Substance Use

Although school environments are thought to influence health behaviors, experimental data assessing causality are lacking, and which aspects of school environments may be most important for adolescent health are unknown. To test whether exposure to high-performing schools is associated with risky adolescent health behaviors. This natural experiment used admission lotteries, which mimic random assignment, to estimate the association of school environments and adolescent health. A survey of 1270 students who applied to at least 1 of 5 high-performing public charter schools in low-income minority communities in Los Angeles, California. Schools had an academic performance ranked in the top tertile of Los Angeles County public high schools, applicants outnumbered available seats by at least 50, and an admissions lottery was used. Participants included lottery winners (intervention group [n = 694]) and lottery losers (control group [n = 576]) from the end of 8th grade and beginning of 9th grade through the end of 11th grade. Intention-to-treat (ITT) and instrumental variable techniques estimated the association of winning the lottery and attending high-performing schools with health behaviors and whether the association varied by sex. Data were collected from March 11, 2013, through February 22, 2017, and analyzed from October 1, 2017, through July 1, 2018. Schools were considered high performing if they placed in the top tercile of public high schools in LA County on 2012 state standardized tests. Most students attended that same school for 3 years (9th-11th grades). Primary self-reported outcomes were 30-day and high-risk self-reported marijuana use. Additional health outcomes included 30-day alcohol use, alcohol misuse, ever being in a fight, ever having sex, and past-year delinquency. Potential intermediate factors (time studying, truancy, school mobility, school culture, school order, teacher support for college, and proportion of substance-using peers in students' social networks) were also examined. Among the 1270 participating students (52.6% female; mean [SD] age at enrollment, 14.3 [0.5] years), ITT analysis showed that the intervention group reported less marijuana misuse than the control group (mean marijuana misuse score, 0.46 vs 0.71), as well as fewer substance-using peers (9.6% vs 12.7%), more time studying (mean, 2.63 vs 2.49 hours), less truancy (84.3% vs 77.3% with no truancy), greater teacher support for college (mean scores, 7.20 vs 7.02), more orderly schools (mean order score, 7.06 vs 6.83), and less school mobility (21.4% vs 28.4%) (all P < .05). Stratified analyses suggest that among boys, intervention participants had significantly lower marijuana use (mean misuse score, 0.43 vs 0.88; difference, -0.45; 95% CI, -0.78 to -0.13) and alcohol misuse (mean misuse score, 0.52 vs 0.97; difference, -0.44; 95% CI, -0.80 to -0.09) scores compared with control participants, whereas no significant health outcomes were noted for girls. This natural experiment provides evidence that school environments can improve risky behaviors for low-income minority adolescents.

Inequities in the quality of urban park systems: An environmental justice investigation of cities in the United States

A growing body of research shows affluent White neighborhoods have more acres of parks and more park facilities than low-income ethnic minority communities in many Global North cities. Most of these investigations focused on neighborhood-level differences and did not analyze broader inequities across cities. This is a particularly significant limitation in the U.S., where changes in the political economy of parks due to a reduced local tax base have led cities to compete against each other to secure park funding from national nonprofits and public agencies. To address this gap, we examined whether the quality of urban park systems – measured through The Trust for Public Land’s ParkScore – varies depending on a city’s median income and ethnic composition. Based on multivariate regressions in which we control for features of the urban fabric, we found U.S. cities with higher median incomes and lower percentages of Latino and Non-Hispanic Black residents have higher ParkScores than other cities. Some inequities also emerged for park coverage, park spending per person, and park facilities, with majority-Latino cities being particularly disadvantaged. These findings echo the results of neighborhood-level studies in Global North contexts, suggesting neighborhood-level inequities in park provision might scale up to inequities across cities. This study contributes to environmental justice theory and advocacy by demonstrating the importance of scaling up analyses of park provision to cross-city comparisons. Implications for landscape planning, public policy, and grant-making are discussed.