Low-income Participants Research Articles

Factors related to poor diet quality in food insecure populations.

It is well-known that consumption of nutrient-rich foods, especially fruits and vegetables, are low among food insecure populations. While cost is an important reason for these inadequate diets, underlying factors such as poor food purchase and management behaviors, and low levels of psychosocial factors that motivate dietary improvements, may exacerbate food insufficiency among the food-insecure. In this analysis, we examine these underlying factors across food-secure and food-insecure populations in Texas. Data on self-reported food insecurity, dietary practices, behaviors related to food purchase and management, and psychosocial factors related to food were obtained from a survey administered to a convenience sample of SNAP-eligible adults (n = 1,171) ages 18 and older, drawn from multiple low-income areas across the state of Texas in 2018 over two survey rounds. Mixed linear regression models adjusting for zip code as a random effect were used to compare mediators of diet across food-insecure and food-secure participants. Using the binary categories defined by the U.S. Household Food Security Survey Module scale 753 participants (64.3% of the sample collected) were classified as food insecure. Food insecure participants had notably unhealthier diet profiles, with significantly lower (p < .001) frequency and average serving size of fruit and vegetable consumption. They were also less likely to use food labels to make food choices (p < .001), and to cook a meal at home (p = .008). In contrast, differences across food secure and food insecure households in planning meals before going shopping, and making lists were much smaller. Finally, levels of various psychosocial precursors of healthy eating were also lower among food insecure participants, including self-efficacy for healthy eating (p = .014), self-efficacy to plan meals with vegetables (p = .048), and stage of change of fruit and vegetable consumption (p < .001). Overall, eating habits, specific food procurement and preparation practices, and levels of psychosocial precursors of healthy eating are significantly poorer among food insecure populations compared with food-secure low-income participants. Our results point to specific behaviors that can be targeted in educational and skill building interventions seeking to address poor dietary practices among the food insecure.

Entrepreneurial index for low-income households in Malaysia

Even though development organizations provide access to working capital and enterprise development training, they often fail to improve the socio-economic condition of low-income households. One of the factors contributing to the failure of development programs is their lack of capacity to measure the entrepreneurial potentials among the low-income participants. This study focused on the development of an entrepreneurial index that measures the entrepreneurial potentials among low-income households. Adopting a cross-sectional design, a total of 403 micro-entrepreneurs were approached from the list provided by ‘Majlis Amanah Rakyat’ and ‘Majlis Agama Islam Dan Adat Istiadat’, Kelantan. This study used formative hierarchial model to determine the local and global weights for all the items used to develop the index. Further, the nomological validity revealed a positive effect of entrepreneurial index on entrepreneurial competency, enterprise performance, and enterprise sustainability.

Housing Instability and HIV Risk: Expanding our Understanding of the Impact of Eviction and Other Landlord-Related Forced Moves

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.

Strengths and Weaknesses of Digital Diaries as a Means to Study Patient Pathways: Experiences With a Study of Hypertension in the Philippines

The rise of digital mobile communications has made possible novel research methods that can provide a better understanding of patients’ experience of non-communicable diseases. This study explores the opportunities and challenges in employing “digital diaries” via mobile phones to track the lived experiences of people with hypertension in the Philippines. Following in-depth interviews, 40 hypertensive adults were invited to submit digital diaries over 12 months. Mobile phones were found to be an efficient way of reaching participants, although it was difficult to collect in-depth narratives about their experiences using the medium beyond nominal responses about symptoms and treatment. Possible explanations include the asymptomatic nature of hypertension, which limited the participants’ experiences of the illness, as well as the platform itself, which our mostly-elderly, low-income participants may not be comfortable with. Despite these challenges, “digital diaries” hold potential for the study of other chronic conditions, provided that researchers engage in extensive co-production with participants to understand their preferences. Researchers also need more training in the use of these methods appropriately as part of a suite of methods for capturing the experience of people living with chronic illness.

Supplemental Material for Remotely Administered Incentive-Based Treatment for Alcohol Use Disorder With Participant-Funded Incentives is Effective but Less Accessible to Low-Income Participants

Supplemental Material for Remotely Administered Incentive-Based Treatment for Alcohol Use Disorder With Participant-Funded Incentives is Effective but Less Accessible to Low-Income Participants

Diabetes and liver cancer risk: A stronger effect in Whites than Blacks?

Both diabetes and liver cancer are overrepresented among African Americans, but limited information is available on the interrelationship of these two diseases among African Americans. We examined the association of diabetes with the incidence of liver cancer and whether this varied by participant self-reported race/ethnicity. Using the Southern Community Cohort Study, we conducted a cancer follow up (2002-2016) of a cohort of mostly low-income participants aged 40-79 with diabetes (n = 15,879) and without diabetes (n = 59,077) at study baseline. Cox regression was used to compute Hazard Ratios (HR) and 95% CIs for the risk of incident liver cancer. With 790,132 person years of follow up, 320 incident cases of liver cancer were identified. In analyses controlling for age, sex, race, BMI, current and former smoking, total alcohol consumption, family history of liver cancer, any hepatitis infection, hyperlipidemia and socioeconomic factors, the association between diabetes and risk of liver cancer differed significantly (pinteraction = 0.0001) between participants identifying as Black/African American (AA) or White/European American (EA). Diabetes was associated with 5.3-fold increased cancer risk among EAs (HR 5.4, 95% CI 3.2-9.3) vs an 80% increase (HR 1.8, 95% CI 1.3-2.5) among AAs. Furthermore, controlling for diabetes greatly attenuated the higher risk of liver cancer among AAs; indeed, while the cancer risk among those without diabetes was twice as high among AAs than EAs (HR = 2.0, 95% CI = 1.4-2.9), no excess in AAs was observed among those with diabetes (HR = 0.7, 95% CI = 0.4-1.1). While liver cancer risk in general is greater in AAs than EAs and diabetes increases this risk in both racial/ethnic groups, diabetes appears to impact liver cancer to a much greater extent among EAs. The findings raise the possibility of racially different mechanisms and impacts of diabetes on this often fatal cancer among AAs and EAs.

Income, inflammation and cancer mortality: a study of U.S. National Health and Nutrition Examination Survey mortality follow-up cohorts

BackgroundTo estimate the relationship between inflammatory biomarkers and cancer mortality in a nationally representative sample of the U.S. population while controlling for education, occupation, and income.MethodsData were obtained from the U.S. National Health and Nutrition Examination Survey from 1988 to 1994 (N = 7817) and 1999–2002 (N = 2344). We fit Cox proportional hazard models to examine the relationship between C-reactive protein (CRP) and fibrinogen with cancer mortality.ResultsIn the full Cox multivariate model, clinically raised CRP was associated with cancer mortality in NHANES 1988–1994 (> 0.99 mg/dL: 95%CI: 1.04–2.13). However, across two inflammatory biomarkers (CRP and Fibrinogen), two NHANES time periods (1998–1994 and 1999–2002) and three income levels (12 strata in total), Hazard ratio confidence intervals did not include the null only for one association: CRP and cancer mortality among low income participants from 1988 to 1994 (HR = 1.83, 95% CI: 1.10–3.04).ConclusionsWe find evidence that only in one unique stratum is earlier life CRP, and not fibrinogen, associated with prospective cancer mortality. After more complete control for socioeconomic confounding, CRP and fibrinogen do not predict cancer mortality in most subpopulations.

Incorporating local foods into low-income families' home-cooking practices: The critical role of sustained economic subsidies

Alternative food practices, including farmers markets and CSAs, are often inaccessible to low-income families. Subsidized CSAs and fruit and vegetable prescription programs have the potential to decrease food insecurity, increase fresh fruit and vegetable consumption, and generate better health outcomes. However, several challenges can limit the success of such programs, including the logis¬tics of distribution and an inability to cook from scratch due to a lack of kitchen infrastructure, time, or skills. In this paper, we investigate two diet-related health programs conducted with commu¬nity partners in Madison, Wisconsin, and Portland, Oregon. We used photovoice to evaluate and enhance these programs, which supplied low-income participants with free or subsidized weekly shares of local food, addressed transportation bar¬riers associated with access, and offered recipes and cooking education. Drawing on social practice theory, we demonstrate how these programs altered food provisioning practices for low-income individuals and families by building their competence in the kitchen, fostering meaningful social relationships, and cultivating new meanings related to fresh, local food. The short-term gains were positive, and such community-based nutrition pro¬grams warrant continued support as part of a broader strategy to address poverty and food insecurity.

The Effect of Integrating Primary Care and Mental Health Services on Diabetes and Depression: A Multi-site Impact Evaluation on the US-Mexico Border.

Health care delivery systems are increasingly integrating physical and mental health services to address patients' complex needs, contain costs, and improve satisfaction. Therefore, it is critical to understand whether adoption of integrated care models is effective in diverse settings. This study examined the effect of integrated care on physical and mental health outcomes among low-income Latino participants on the US-Mexico border. In this quasi-experimental multisite study, individual-level data were pooled from 8 studies of locally adapted integrated care models. Participants were 18 years or older and had 1 or more chronic conditions: diabetes, depression, hypertension, or obesity. The study enrolled 4226 participants with 2254 participants in the intervention group and 1972 in the comparison group. Primary outcomes were depressive symptoms as measured by the Patient Health Questionnaire-9 score and blood glucose measured by hemoglobin A1c (HbA1c). Blood pressure, body mass index, and quality of life were secondary outcomes. Multivariable linear regression analyses indicated intervention participants had significantly lower Patient Health Questionnaire-9 scores (β=-0.39, P=0.03) and HbA1c (β=-0.14, P=0.02) at 12 months compared with comparison group participants. Stratified analyses showed improvements in HbA1c were even greater among intervention participants who had diabetes, depression, severe and persistent mental illness, were older or female compared with their counterparts in the comparison group. Health care is constantly transforming, making it critical to study these changes across populations and settings. Findings from this study indicate that integrated care can significantly improve mental and physical health in an underserved Latino population.

A Pilot Study of a Comprehensive Financial Navigation Program in Patients With Cancer and Caregivers.

Few studies have engaged patients and caregivers in interventions to alleviate financial hardship. We collaborated with Consumer Education and Training Services (CENTS), Patient Advocate Foundation (PAF), and Family Reach (FR) to assess the feasibility of enrolling patient-caregiver dyads in a program that provides financial counseling, insurance navigation, and assistance with medical and cost of living expenses. Patients with solid tumors aged ≥18 years and their primary caregiver received a financial education video, monthly contact with a CENTS counselor and PAF case manager for 6 months, and referral to FR for help with unpaid cost of living bills (eg, transportation or housing). Patient financial hardship and caregiver burden were measured using the Comprehensive Score for Financial Toxicity-Patient-Reported Outcomes (COST-PRO) and Caregiver Strain Index (CSI) measures, respectively, at baseline and follow-up. Thirty patients (median age, 59.5 years; 40% commercially insured) and 18 caregivers (67% spouses) consented (78% dyad participation rate). Many participants faced cancer-related financial hardships prior to enrollment, such as work change or loss (45% of patients; 39% of caregivers) and debt (64% of patients); 39% of caregivers reported high levels of financial burden at enrollment. Subjects received $11,000 in assistance (mean, $772 per household); 66% of subjects with income ≤$50,000 received cost-of-living assistance. COST-PRO and CSI scores did not change significantly. Patient-caregiver dyads were willing to participate in a financial navigation program that addresses various financial issues, particularly cost of living expenses in lower income participants. Future work should address financial concerns at diagnosis and determine whether doing so improves patient and caregiver outcomes.

Awareness and Acceptability of Undetectable = Untransmittable Among a U.S. National Sample of HIV-Negative Sexual and Gender Minorities

While the "Undetectable = Untransmittable" (U=U) message is widely endorsed, little is known about its breadth and reach. Our study describes socio-demographic characteristics and sexual behaviors associated with having heard of and trusting in U =U in a U.S. national sample of HIV-negative participants. Data were derived from the Together 5,000 cohort study, an internet-based U.S. national cohort of cis men, trans men and trans women who have sex with men. Approximately 6months after enrollment, participants completed an optional survey included in the present cross-sectional analysis (n = 3286). Measures included socio-demographic and healthcare-related characteristics; questions pertaining to knowledge of and trust in U=U (dependable variable). We used descriptive statistics and multivariable logistic models to identify characteristics associated with these variables and explored patterns in willingness to engage in condomless anal sex (CAS) with regard to trust in U=U. In total, 85.5% of participants reported having heard of U=U. Among those aware of U=U, 42.3% indicated they trusted it, 19.8% did not, and 38.0% were unsure about it. Latinx, Asian, lower income, and Southern participants were less likely to have heard of U=U. Having had a recent clinical discussion about PrEP or being a former-PrEP user were associated with trust in U=U. Willingness to engage in CAS was positively associated with trust in U=U, and varied based on the partner's serostatus, PrEP use and viral load. Although we found high rates of awareness and low levels of distrust, our study indicated that key communities remain unaware and/or skeptical of U=U.

The Effect of the Housing Provident Fund on Income Redistribution: The Case of China

ABSTRACT Long-term collective saving schemes are widely adopted in many emerging economies to support residents’ housing consumption. This article evaluates the effect of the Housing Provident Fund (HPF), one of the most prominent housing policies in China, on income redistribution beyond its housing support role. Based on micro survey data, our results suggest that the current HPF policy design widens the income gap between HPF participants and nonparticipants and aggravates income inequality across the whole population; further simulation results suggest that expanding HPF coverage has an alleviating effect. However, in the event of housing purchases through HPF loans, lower income participants can leverage more benefits, and the floor-and-ceiling policy design decreases the marginal benefits for higher income participants, resulting in mitigated income inequality among HPF participants. One notable risk of the HPF’s widening of the income gap among participants is the unavailability of HPF loans for low-income participants. Our findings indicate that optimizing the HPF system might be a better option than its abolishment, from the perspective of its income redistribution function. We also provide some valuable recommendations for gradual future reform of the HPF.

Returning genomic results in a Federally Qualified Health Center: the intersection of precision medicine and social determinants of health

Purpose:This report describes the return of sequencing results to low-income Latino participants recruited through a Federally Qualified Health Center (FQHC). We describe challenges in returning research results secondary to social determinants of health and present lessons learned to guide future genomic medicine implementation studies in low resource settings.Methods:500 Latino adults (76% women) consented to research sequencing for a predetermined panel of actionable genes. Providers and staff from the FQHC were engaged to align processes with the practice and a Community Advisory Board grounded the project in the local community.Results:A pathogenic/likely pathogenic variant was present in 10 participants (2%). Challenges in return of results included the time lag (582±53 days) between enrollment and returning actionable results, difficulty reaching participants, missed appointments, low health literacy, lack of health insurance, and reconciling results with limited information on family history. Return of one actionable result was deferred due to acute emotional distress secondary to recent traumatic life events.Conclusion:The social determinants of health influence the implementation of genomic medicine in low-income populations in low-resource settings. Considering non-biological factors that contribute to disparities will be necessary to better appreciate how genomic medicine may fit within the context of health equity.

Intended and Unintended Consequences of a Community-Based Fresh Fruit and Vegetable Dietary Intervention on the Flathead Reservation of the Confederated Salish and Kootenai Tribes.

Tribal communities in the United States face disparities to accessing healthy foods including high-quality produce. A six-week fresh fruit and vegetable (FV) dietary intervention, Eat Fresh, was co-designed with a Community Advisory Board of local food and nutrition stakeholders on the Flathead Reservation of the Confederated Salish and Kootenai Tribes in Montana. Eat Fresh was implemented as a pilot study with low-income participants (n = 19) enrolled in the Food Distribution Program on Indian Reservations toward improving dietary quality and perceptions of well-being. We evaluated Eat Fresh at pre- and post-intervention on the basis on food procurement practices, dietary quality using the Healthy Eating Index (HEI), Body Mass Index (BMI), blood pressure, and participant perceptions of health. Participants reported consuming a greater number of types of FVs daily during the intervention (p < 0.005 for fruits and p > 0.19 for vegetables). Overall, participants found Eat Fresh moderately challenging to adhere to with the main barriers being access to ingredients in recipes (39.51% of responses), time constraints to cook (35.80%), and lack of financial resources (33.33%). Dietary quality improved during the intervention from a mean HEI score of 48.82 (± 11.88) out of 100–56.92 (± 11.88; (p > 0.12). HEI scores for fruit consumption significantly increased (p < 0.05) from 1.69 (out of 5 points) during the pre-intervention to 2.96 during the post-intervention. BMI and blood pressure increased for several participants, highlighting an unintended consequence. Most participants responded that FV consumption made them feel either very good (51.16%) or good about their health (43.02%) with the majority (83%) perceiving an improvement in energy. Findings of this pilot study highlight both intended and unintended consequences of a dietary intervention that provide lessons in co-designing community-based programs.

The Integrated Clinic-Parks and Recreation model of child obesity treatment: 2-year outcomes

Objective: To assess long-term outcomes and examine predictors of success among diverse, low-income participants in a childhood obesity intervention, and to examine participant expectations, motivators, facilitators, and barriers to program attendance and engagement. Methods: A sequential mixed-methods study design was employed: first, a retrospective analysis of an integrated clinic-community intervention cohort to identify predictors …

Socio-Emotional Learning among Low-Income Prekindergarteners: The Roles of Individual Factors and Early Intervention

ABSTRACT Research Findings: Previous research has indicated that low-income children are at increased risk for socio-emotional problems, which may contribute to socioeconomic disparities in wellbeing and academic achievement. The present study examines socio-emotional learning (SEL) across the prekindergarten year in a low-income, racially and ethnically diverse sample of Chicago Public School students (N = 2,630). The sample included participants of the Child-Parent Center early educational intervention program (N = 1,724) and a propensity-score matched comparison group (N = 906). At the beginning of the prekindergarten year, teachers rated boys and lower income participants as having relatively lower SEL skills, and CPC participants and older children as having slightly higher SEL skills. Over time, CPC participants exhibited significantly greater rates of SEL growth, ending the prekindergarten year with teacher-rated SEL scores that were an average 10.30% higher than control participants. There were no significant differences in SEL growth over time by sex or family income. Practice and Policy: Multicomponent, school-based early intervention programs (e.g., CPC) have the potential to promote SEL among at-risk populations.

“Good Luck Fixing the Problem”: Small Low-Income Community Participation in Collaborative Groundwater Governance and Implications for Drinking Water Source Protection

There is increasing interest in the potential of source water protection to address chronic challenges with small systems and rural drinking water provision. Such a planning and management approach to increasing safe drinking water access, however, will likely require leveraging multi-stakeholder collaborative governance venues to this effect. This paper investigates the prospects of doing so using the case of California’s groundwater reform process known as the Sustainable Groundwater Management Act or SGMA. Interviews with drinking water stakeholders from small low-income communities in the San Joaquin Valley show how existing power and resource disparities limit the prospects of integrating rural drinking water priorities into regional planning. Long-term, more fundamental changes will be needed to meaningfully transform water management in this direction. Short-term state intervention is needed to protect equity and public good goals, raising potential contradictions between devolved water management and improved drinking water access that need to be addressed.

How Neighborhood Effect Averaging Might Affect Assessment of Individual Exposures to Air Pollution: A Study of Ozone Exposures in Los Angeles

The neighborhood effect averaging problem (NEAP) can be a serious methodological problem that leads to erroneous assessments when studying mobility-dependent exposures (e.g., air or noise pollution) because people’s daily mobility could amplify or attenuate the exposures they experienced in their residential neighborhoods. Specifically, the NEAP suggests that individuals’ mobility-based exposures tend toward the mean level of the participants or population of a study area when compared to their residence-based exposures. This research provides an in-depth examination of the NEAP and how the NEAP is associated with people’s daily mobility through an assessment of individual exposures to ground-level ozone using the activity-travel diary data of 2,737 individuals collected in the Los Angeles metropolitan statistical area. The results obtained with exploratory analysis (e.g., a scatterplot and histograms) and spatial regression models indicate that the NEAP exists when assessing individual exposures to ozone in the study area. Further, high-income, employed, younger, and male participants (when compared to low-income, nonworking, older, and female participants) are associated with higher levels of neighborhood effect averaging because of their higher levels of daily mobility. Finally, three-dimensional interactive geovisualizations of the space-time paths and hourly ozone exposures of seventy-one selected participants who live in the same neighborhood corroborate the findings obtained from the spatial regression analysis.

The effect of the housing provident fund on housing consumption and inequity risks

Many emerging economies have established long-term collective saving schemes to support housing consumption. One of the most eminent schemes is the Housing Provident Fund (HPF) in China, whose policy effect is highly debated. Based on data from the 2013 China Household Finance Survey, this paper evaluates the heterogeneity of the HPF's effect on the housing consumption of households with different incomes from three dimensions: housing purchases, housing investment and age at first housing purchase. We further estimate the effect of the financial support of the HPF on the participants' housing pressure. Our results suggest that the HPF has an overall positive effect on housing consumption and that the financial support reduces households' housing pressure by 14% on average. However, the HPF provides insufficient financial support to low-income participants in housing purchases; in contrast, the HPF promotes housing investment and earlier purchases of houses among high-income households. Given the soaring housing prices in China, the HPF seems to not only entail inequity but also aggravate the inequality of wealth distribution and widen the gap between the rich and the poor. We conclude by proposing some valuable policy implications for China's HPF system reform in the future.

Enhanced Enrollment in the National Diabetes Prevention Program to Increase Engagement and Weight Loss for the Underserved: Protocol for a Randomized Controlled Trial.

BackgroundType 2 diabetes affects 9.4% of US adults with higher rates among racial and ethnic minorities and individuals of low socioeconomic status. The National Diabetes Prevention Program (NDPP) is an evidence-based and widely disseminated behavioral intervention to reduce diabetes incidence through modest weight loss. However, retention in the yearlong NDPP is problematic and leads to suboptimal weight loss, especially among diverse, underserved populations. Strategies to improve NDPP engagement and weight loss are needed urgently. Pilot results of the pre-NDPP, a novel enhancement to enrollment in the NDPP based on the Health Belief Model, were highly successful in a nonrandomized cohort study among 1140 racially diverse, predominately low-income participants. A total of 75 presession participants had doubled attendance and weight loss as compared with earlier participants who did not receive presessions. On the basis of these promising results, we are conducting a randomized controlled trial (RCT) to determine whether pre-NDPP reliably improves NDPP outcomes, as reported on ClinicalTrials.gov.ObjectiveThis study aims to (1) conduct an RCT comparing NDPP attendance and weight loss outcomes between participants who receive pre-NDPP versus direct enrollment into the NDPP (usual care), (2) examine potential effect mediators (perceived risk for developing diabetes and self-efficacy and readiness for weight control) and moderators (race and ethnicity; income level), and (3) evaluate implementation factors, including cost and projected return on investment.MethodsThis two-arm RCT will compare outcomes among diverse, predominately low-income participants who receive pre-NDPP versus direct enrollment into the NDPP (usual care). This is a type 1 hybrid effectiveness-implementation design to determine clinical effectiveness through an RCT, while assessing factors that may impact future pre-NDPP dissemination and implementation, including cost. Our primary research question is whether pre-NDPP improves NDPP attendance and weight loss compared with standard NDPP delivery.ResultsThis project was funded in April 2019. Recruitment is underway as of July 2019. Initial participants began the intervention in October 2019. Data analysis and results reporting are expected to be completed in 2024.ConclusionsThis RCT of pre-NDPP may lead to future dissemination of a scalable, evidence-based strategy to improve success of the NDPP, reduce disparities in NDPP effectiveness, and help prevent type 2 diabetes across the country.Trial RegistrationClinicalTrials.gov NCT04022499; https://clinicaltrials.gov/ct2/show/NCT04022499.International Registered Report Identifier (IRRID)PRR1-10.2196/15499