Structural-level Interventions Research Articles

The social-structural contexts of cannabis consumption and harm reduction among young Nigerian women

BackgroundYoung women remain under-represented in the research literature on young people's cannabis use. This study explored cannabis use and harm reduction practices of young Nigerian women. MethodsThe study draws on 19 in-depth interviews conducted with young women aged 21–35 years who were recruited through time-location sampling in Uyo, Nigeria. Interview transcripts were subjected to thematic coding and analysis. ResultsAccounts highlighted a rapid progression from occasional consumption during hang-outs to regular and heavy consumption for most participants. Frequent and heavy cannabis use, shaped by trauma, stress and mental health problems linked to participants’ marginal social locations, established a context of risk for health harms. The participants sought to reduce harms by attempting to reduce frequency and quantity of cannabis consumed, often with limited success. They also micro-dosed to monitor drug effects, avoided mixing cannabis with more potent drugs, sought out cannabis strains with lower THC as well as consuming privately to reduce social harms such as violence and police arrest associated with using in street milieus. On the other hand, cannabis consumption was seen as helping to reduce harms by providing a relatively safer and less addictive alternative to drugs such as heroin and pharmaceutical opioids, preventing high-risk sexual exchanges often associated with opioid withdrawal among women, and relieving pain. ConclusionsCannabis was consumed recreationally at first, and harmful consumption patterns developed from using cannabis to treat the psychological symptoms of structural inequalities. The analysis supports the social-structural production of drug-related harms, foregrounding the importance of structural-level interventions for creating an enabling environment for safer consumption.

Race/ethnicity and socioeconomic position in emergency department utilization in patients with hepatocellular carcinoma.

Aim: Evaluate the association of race/ethnicity and socioeconomic position (SEP) on emergency department (ED) visits for patients with hepatocellular carcinoma (HCC), which may reflect access to and quality of cancer care. Materials & methods: Patients with HCC identified from a commercial multi-payer claims database between 2015 and2018 were matched to near-neighborhood social determinants of health (SDOH) and stratified by race/ethnicity and SEP (proxied by annual household income). Analyses evaluated the effect of race/ethnicity and SEP on ED utilization, adjusting for SDOH, demographic and clinical characteristics using multivariable regression methods. Results: A total of22,247 patients were included. Black and Hispanic patients had 43and 18% higher ED utilization than White patients at higher-income levels (p<0.01); these differences were nonsignificant at lower-income. Regardless of income level, Asian patients had lower ED utilization. Conclusion: Further research on the intersectionality between race/ethnicity, SEP and other SDOH may guide structural-level interventions to address health inequities.

A systematic review of national interventions and policies to optimize antibiotic use in healthcare settings in England.

To identify and assess the effectiveness of national antibiotic optimization interventions in primary and secondary care in England (2013-2022). A systematic scoping review was conducted. Literature databases (Embase and Medline) were used to identify interventions and evaluations. Reports included the UK AMR Strategy (2013-2018), National Action Plan (2019-2024) and English Surveillance Programme for Antimicrobial Utilisation and Resistance (ESPAUR) reports (2014-2022). The design, focus and quality of evaluations and the interventions' effectiveness were extracted. Four hundred and seventy-seven peer-reviewed studies and 13 reports were screened. One hundred and three studies were included for review, identifying 109 interventions in eight categories: policy and commissioning (n = 9); classifications (n = 1); guidance and toolkits (n = 22); monitoring and feedback (n = 17); professional engagement and training (n = 19); prescriber tools (n = 12); public awareness (n = 17); workforce and governance (n = 12).Most interventions lack high-quality effectiveness evidence. Evaluations mainly focused on clinical, microbiological or antibiotic use outcomes, or intervention implementation, often assessing how interventions were perceived to affect behaviour. Only 16 interventions had studies that quantified effects on prescribing, of which six reported reductions. The largest reduction was reported with structural-level interventions and attributed to a policy and commissioning intervention (primary care financial incentives). Behavioural interventions (guidance and toolkits) reported the greatest impact in hospitals. Many interventions have targeted antibiotic use, each pulling different levers across the health system simultaneously. On the basis of these studies, structural-level interventions may have the greatest impact. Collectively, the combination of interventions may explain England's decline in prescribing but direct evidence of causality is unavailable.

Residual design life-based evaluation of structural retrofitting on high-rise reinforced concrete buildings

The deteriorating structural performance of aging high-rise reinforced concrete (RC) buildings has brought increasing attention to the necessity of retrofitting in developed regions. In this context, the present paper introduces a novel approach by reversing the conventional service life-based structural design procedure. The proposed approach establishes a residual design life evaluation framework, enabling a comprehensive assessment of the performances of existing RC buildings both before and after retrofitting. This assessment framework takes into account various load scenarios, including wind and earthquake forces, etc., and yields an intuitive index based on design codes, termed "residual design life", which serves as valuable information for decision-makers. To exemplify the framework's application, a case study involving a high-rise RC building is presented. Initially, the influence of the adopted design codes on the residual life of the aging building is investigated. Subsequently, three commonly employed structural-level retrofit methods, namely steel bracing, RC wall addition, and exoskeleton, are examined. The findings reveal that the residual design life of the existing building decreases as the adopted design code transitions from an outdated version to the current one. However, the implementation of structural-level retrofit interventions proves highly effective in enhancing the building's residual life, particularly when failure is primarily governed by column capacities and storey drift. Nonetheless, it should be noted that certain structural-level interventions may increase the load on adjacent beams, potentially leading to a negative impact on the building's residual life when the condition of the beams becomes the predominant factor. Furthermore, the obtained residual life of the retrofitted building could be used to assist in conducting life-cycle analysis and further investigations and contribute to the understanding regarding structural performance and safety in the built environment.

Community- and individual-level correlates of HIV incidence in HPTN 071 (PopART).

Universal HIV testing and treatment aims to identify all people living with HIV and offer them treatment, decreasing the number of individuals with unsuppressed HIV and thus reducing HIV transmission. Longitudinal follow-up of individuals with and without HIV in a cluster-randomized trial of communities allowed for the examination of community- and individual-level measures of HIV risk and HIV incidence. HPTN 071 (PopART) was a three-arm cluster-randomized trial conducted between 2013 and 2018 that evaluated the use of two combination HIV prevention strategies implemented at the community level to reduce HIV incidence compared to the standard of care. The trial, conducted in 21 communities in Zambia and South Africa, measured HIV incidence over 36 months in a population cohort of ∼2000 randomly selected adults per community aged 18-44. Multilevel models were used to assess the association between HIV incidence and community- and individual-level socio-demographic and behavioural risk factors, as well as prevalence of detectable virus (PDV) defined as the estimated proportion of the community with unsuppressed viral load. Overall HIV incidence was 1.49/100 person-years. Communities with less financial wealth and communities with more individuals reporting having sex partners outside of the community or two or more sexual partners had higher HIV incidence. PDV at 2 years of study was 6.8% and was strongly associated with HIV incidence: for every 50% relative reduction in community PDV, there was a 49% (95% confidence interval [CI]: 37%-58%, p < 0.001) relative decrease in HIV incidence. At the individual level; socio-economic status, AUDIT score, medical male circumcision and certain sexual behaviours were associated with HIV risk. Using data from the PopART randomized trial, we found several associations of HIV incidence with community-level measures reflecting the sexual behaviour and socio-economic make-up of each community. We also found a strong association between community PDV and HIV incidence supporting the use of PDV as a tool for monitoring progress in controlling the epidemic. Lastly, we found significant individual-level factors of HIV risk that are generally consistent with previous HIV epidemiological research. These results have the potential to identify high high-incidence communities, inform structural-level interventions, and optimize individual-level interventions for HIV prevention. ClinicalTrials.gov number, NCT01900977, HPTN 071 [PopArt].

Testing the minority stress model across gender identity, race, and ethnicity among U.S. gender minority adolescents.

Gender minority (GM) youth are at heightened risk for psychopathology, purportedly due to their experiences of GM stressors. However, few studies have examined how GM stressors are associated with depression and anxiety among GM youth. Furthermore, no prior studies have investigated how experiences of GM stressors differ across gender identity and race/ethnicity within a diverse sample of GM youth. A nationwide online cross-sectional survey of 1,943 fourteen- to 18-year-old GM adolescents (66.91% White, 11.73% multiracial, 8.49% Latinx, 7.10% Black, 3.09% Asian, 1.49% American Indian/Alaskan Native) in the United States assessed GM stressors (prejudice events, expectations of rejection, internalized transnegativity, and concealment) and mental health. Structural equation modeling was used to examine how GM stressors and depressive and anxiety symptoms differ across gender identity and race/ethnicity. Higher levels of each GM stressor were related to higher depressive symptoms. Prejudice events, expectations of rejection, and concealment were related to higher anxiety symptoms. Transmasculine and transfeminine youth reported higher levels of GM prejudice events and expectations of rejection, and higher mental health symptoms, than nonbinary youth. Findings were relatively consistent across racial/ethnic identities, with the exception that Black GM adolescents reported fewer GM prejudice events and expectations of rejection and indirectly exhibited lower mental health symptoms as compared to White GM youth. Researchers and clinicians should be attuned to how intersectional identities are related to stress and mental health among diverse GM youth. Recommendations for individual and structural-level interventions are discussed. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

A Phenomenological Understanding of the Intersection-ality of Ageism and Racism Among Older Adults: Individual-Level Experiences.

Ageism is a prevalent, insidious social justice issue that has harmful effects on the health of older adults. Preliminary literature explores the intersectionality of ageism with sexism, ableism, and ageism experienced among LGBTQ+ older adults. Yet, the intersectionality of ageism with racism remains largely absent from the literature. Therefore, this study explores the lived experience of the intersectionality of ageism and racism among older adults. This qualitative study applied a phenomenological approach. Twenty participants 60+ years of age (M=69, standard deviation=8.84) in the U.S. Mountain West identifying as Black, Latino(a), Asian-American/Pacific Islander, Indigenous, or White engaged in a 1-hr interview between February and July 2021. A3-cycle coding process applied constant comparison methods. Five coders independently coded interviews, engaging in critical discussion to resolve disagreements. An audit trail, member checking, and peer debriefing enhanced credibility. This study focuses on individual-level experiences exemplified by 3 umbrella themes and 7 subthemes. The subthemes are (a) compounding oppression, (b) intersection of disparities, (c) White privilege, (d) racism and ageism: being tokenized or ignored, (e) ageism and racism: unspoken bias, (f) racism versus ageism: overt or covert? and (g) racism versus ageism: differentiated or ubiquitous? The findings indicate how ageism may be racialized through stereotypes related to mental (in)capability. Practitioners can apply the findings to enhance support for older adults by designing interventions aimed at reducing racialized ageist stereotypes and increasing collaboration through education across anti-ageism/anti-racism initiatives. Future research should focus on the impacts of the intersectionality of ageism and racism on specific health outcomes in addition to structural-level interventions.

Creating Cultures of Health in the Academy: Bringing Together Top-Down and Ground-Up Approaches.

This article reports on a 3-year longitudinal study focused on the impact of cross-sector, collective impact approaches to creating cultures of campus health. The study sought to understand the integration of health and well-being concepts into university operations, including business practices and policies, as well as the contribution of public health initiatives focused on health-promoting universities to creating cultures of campus health for students, staff, and faculty. Research was carried out from spring 2018 to spring 2020 via focus group data collection and rapid qualitative analysis involving template and matrix analysis. A total of 18 focus groups were conducted across the 3-year study, six with students, eight with staff, and four with faculty. The initial cohort included 70 participants: 26 students, 31 staff, and 13 faculty. Qualitative analysis findings indicate a general pattern of change over time from a primary focus on well-being characterized by programs and services (e.g., fitness classes) to policy and structural-level interventions (e.g., stairwell beautification and hydration stations) promoting well-being for all. Grass-top and grassroots leadership and action were instrumental to changes in working and learning environments, policies, and campus environment/infrastructure. This work contributes to the growing literature on health-promoting universities and colleges and demonstrates the critical role of both top-down and ground-up approaches and leadership efforts to create more equitable and sustainable cultures of campus health and well-being.

Correlates of maternal, newborn and child health services uptake, including male partner involvement: Baseline survey results from Bangladesh

ABSTRACT South Asia bears a substantial proportion of the global maternal mortality burden, with adolescents disproportionately affected. Bangladesh has one of the highest adolescent pregnancy rates in the world, with low utilisation of maternal newborn and child health (MNCH) services. This hampers the country’s efforts to achieve optimal health outcomes as envisioned by the Sustainable Development Goals. Male partner involvement is a recognised approach to optimise access to services and decision-making. In South Asia data on male involvement in MNCH service uptake is limited. Plan International’s Strengthening Health Outcomes for Women and Children was implemented across four districts in Bangladesh between 2016 and 2020 and aimed to address these issues. Study results (N = 1,724) found higher maternal education levels were associated with use of MNCH services. After controlling for maternal education, service uptake was associated with male partner support level and perceived joint decision-making. The positive association between male support level and MNCH scale was robust to stratification by maternal education level, and by age group (i.e. adolescent vs. adult mothers). These findings suggest that one path for achieving optimal MNCH outcomes might be through structural-level interventions centred on women, combined with components targeting male partners or male heads of households.

Seismic upgrading of RC structures through an optimization procedure based on Genetic Algorithm

Nowadays governments are encouraging the upgrading and the reuse (rather than the demolition) of older structures in order to reduce land use and environmental impact due to the construction of new buildings. The choice of the most suitable intervention for the seismic upgrading of existing structures could also be addressed combining member-level (e.g., FRP-confinement of single columns) and structural-level (e.g., insertion of steel bracing systems) techniques, although it may result in a complex technical challenge for engineers, since a huge number of combinations of technically feasible upgrading interventions are theoretically possible to accomplish the desired structural performance. In order to support the intervention choice, an “objective” approach could be implemented making use of recently-invented Artificial Intelligence (AI) procedures. Specifically, the application of Genetic Algorithms (GAs) is usually thought as a suitable optimization procedure in several civil engineering problems. By means of a Genetic Algorithm (GA), the design of upgrading interventions results to be based on one objective criterion related to the cost-effectiveness of the intervention, rather than on the highly subjective “engineering-judgement”. The present paper aims to highlight the capability of a Soft-Computing (SC) procedure in selecting the most cost-effective combination of the aforementioned member-level and structural-level interventions, among the technically consistent ones. To this aim a parametric study on a RC structure based on a similar GA procedure is reported, varying some “engineering parameters” related to the target seismic risk class of the upgraded structure. Relevant differences in the results are observed due to the variation of target of the analyses.

Structural interventions that affect racial inequities and their impact on population health outcomes: a systematic review

Structural racism is the historical and ongoing reinforcement of racism within society due to discriminatory systems and inequitable distribution of key resources. Racism, embedded within institutional structures, processes and values, perpetuates historical injustices and restricts access to structural factors that directly impact health, such as housing, education and employment. Due to the complex and pervasive nature of structural racism, interventions that act at the structural level, rather than the individual level, are necessary to improve racial health equity. This systematic review was conducted to evaluate the effects of structural-level interventions on determinants of health and health outcomes for racialized populations. A total of 29 articles are included in this review, analyzing interventions such as supplemental income programs, minimum wage policies, nutrition safeguard programs, immigration-related policies, and reproductive and family-based policies. Most studies were quasi-experimental or natural experiments. Findings of studies were largely mixed, although there were clear benefits to policies that improve socioeconomic status and opportunities, and demonstrable harms from policies that restrict access to abortion or immigration. Overall, research on the effects of structural-level interventions to address health inequities is lacking, and the evidence base would benefit from well-designed studies on upstream policy interventions that affect the structural determinants of health and health inequities and improve daily living conditions.

“We think about the quantity more”: factors influencing emerging adults’ food outlet choice in a university food environment, a qualitative enquiry

BackgroundIn recent decades, the food environment has seen rapid transformation globally, altering food availability and access along with how people interact with the food environment and make food-related choice.Objectives & methodThis explorative study aimed to identify the factors that shape the decision-making process for food outlet choices among emerging adults in a Ghanaian University food environment. The study uses focus group discussions in combination with novel dyadic interviews with best friend pairs. Verbatim transcripts were analysed thematically using NVivo 12.ResultsDrawing on socio-ecological model (SEM) of behaviour, the study used testimony from 46 participants aged 18–25, 47% female, including individuals from major ethnicities and religions in Ghana, and identified three interwoven levels of influence shaping emerging adults’ choices of food outlet. The main factors influencing food outlet choice were identified as food prices, spatial accessibility, budget, and food quantity/satiety with additional factors including hygiene, variety of foods, food quality and taste preferences as well as societal factors such as ambience and peer influence.ConclusionMulti-component approaches that combine structural level interventions in food retailing along with individual level components may be effective at changing emerging adult consumption behaviour in SSA, although this needs to be studied.

Addressing gaps in cardiovascular care for people with HIV: bridging scientific evidence and practice.

People with HIV continue to have an excess burden of cardiovascular disease compared to the general population. The reasons for these disparities in cardiovascular disease include HIV-specific risk enhancers, traditional atherosclerotic cardiovascular disease risk factors, and sociodemographic disparities, all of which are ripe targets for intervention. Accurate risk prediction of atherosclerotic cardiovascular disease remains difficult, and cardiovascular risk for people with HIV may be underestimated in the absence of HIV-specific risk enhancers. Despite this increased cardiovascular risk, people with HIV are undertreated and often placed on inadequate lipid lowering therapy. Structural racism and HIV-related stigma play a role, and provider-level and structural-level interventions to encourage early identification and treatment of persons at high risk are necessary. Persons with HIV should be screened with existing cardiovascular risk prediction tools, and those at high risk cardiovascular disease should be promptly referred for lifestyle and pharmacologic interventions as appropriate. System-level implementation research is ongoing in attempts to narrow the gap in cardiovascular care, particularly for vulnerable communities in low resource settings.

Prevalence and Predictors of Burnout Among Occupational Therapy Practitioners in the United States.

Identifying the extent and predictors of burnout among occupational therapy practitioners is important so strategies can be developed to reduce burnout and mitigate associated consequences within the profession. To investigate the prevalence and determinants of burnout reported by U.S. occupational therapy practitioners. Cross-sectional survey. Occupational therapy practitioners working in a wide range of clinical settings who spent at least 50% of their time in direct patient care and who had been employed continuously for more than 6 mo. The outcome of interest was burnout, which was measured using the Emotional Exhaustion, Depersonalization, and Personal Accomplishment subscales of the Maslach Burnout Inventory-Human Services Survey (MBI-HSS). Predictor variables included sociodemographic and workplace characteristics. The relationship between MBI-HSS subscale scores and predictor variables was jointly estimated using a multivariate multivariable linear regression analysis. One hundred seventy-eight occupational therapy practitioners completed the survey. Higher perceived level of supervisor support, satisfaction with income, and educational attainment were associated with lower MBI-HSS subscale scores (ps = .001, .002, and .005, respectively). Burnout among occupational therapy practitioners can be conceptualized as an issue of workplace health and safety. Various stakeholder groups can consider potential systematic interventions involving measures to promote positive supervisor support in the workplace and salary negotiation skills for early-stage clinicians. Future research should explore broad interventions to reduce burnout among clinicians. What This Article Adds: We estimated the extent and predictors of burnout among U.S. occupational therapy practitioners. Future research, advocacy, and policy should address structural-level interventions to promote workplace cultures and conditions that can protect the occupational therapy workforce from burnout.

Harmful Alcohol and Drug Use Is Associated with Syndemic Risk Factors among Female Sex Workers in Nairobi, Kenya.

Background: Female Sex Workers (FSWs) are at high risk of harmful alcohol and other drug use. We use quantitative data to describe the prevalence of alcohol and other drug use and identify associated occupational and socio-economic risk factors, and aim to elucidate patterns of alcohol and drug use through information drawn from qualitative data. Methods: Maisha Fiti was a mixed-method longitudinal study conducted in 2019 among a random sample of FSWs in Nairobi, Kenya. We used baseline date from the behavioural–biological survey, which included the WHO Alcohol, Smoking and Substance Involvement Screening Test that measures harmful alcohol and other drug use in the past three months (moderate/high risk score: >11 for alcohol; >4 for other drugs). In-depth interviews were conducted with 40 randomly selected FSWs. Findings: Of 1003 participants, 29.9% (95%CI 27.0–32.6%) reported harmful (moderate/high risk) alcohol use, 21.5% harmful amphetamine use (95%CI 19.1–24.1%) and 16.9% harmful cannabis use (95%CI 14.7–19.2%). Quantitative analysis found that harmful alcohol, cannabis and amphetamine use were associated with differing risk factors including higher Adverse Childhood Experience (ACE) scores, street homelessness, food insecurity (recent hunger), recent violence from clients, reduced condom use, depression/anxiety and police arrest. Qualitative interviews found that childhood neglect and violence were drivers of entry into sex work and alcohol use, and that alcohol and cannabis helped women cope with sex work. Conclusions: There is a need for individual and structural-level interventions, tailored for FSWs, to address harmful alcohol and other drug use and associated syndemic risks including ACEs, violence and sexual risk behaviours.

Mobilizing communities and families for child mental health promotion in Canada: Views of African immigrants

Available evidence in Canada suggests mental health disparities between immigrant and non-immigrant children. Children born to immigrants face a greater risk of poor mental health outcomes. However, these comparisons often mask important ethno-racial differences in mental health risks and outcomes among immigrant populations. Recent evidence suggests African immigrant children have some of the poorest social and mental health outcomes in Canada. Despite this awareness, research has yet to identify community-based strategies for addressing the stressors underpinning such outcomes. This study used data obtained from focus groups with African immigrant parents in Alberta, Canada, to identify child mental health stressors and child mental health promotion strategies in the African immigrant community. These strategies, thematically partitioned into family-, community-, and structural-level interventions, include building supportive parent–child relationships, strengthening resilience in childhood, economic empowerment of families, destigmatizing mental illness, influencing institutional policies and practices, supporting labour integration, and enhancing access to mental health supports. Ways in which policymakers and service providers can support child mental health promotion efforts in the African immigrant community are also discussed.

Balancing enhanced contraceptive access with risk of reproductive injustice: A United States comparative case study

We aimed to examine how peripartum contraceptive care quality improvement efforts address or perpetuate reproductive health injustices. We conducted a comparative case study of inpatient postpartum contraceptive care implementation in 2017 to 2018, using key informant interviews at 11 United States hospitals. After our primary analysis revealed tensions between enhancing access to contraceptive care and patient-centeredness, we conducted the current inductive content analysis guided by 4 questions developed post-hoc: (1) What are healthcare workers' aspirations for contraceptive quality improvement programs? (2) What are healthcare workers' biases regarding peripartum contraceptive care delivery? (3) Do care delivery processes center patients' needs? (4) Do healthcare workers recognize and engage with structural inequities? Seventy-eight key informants (i.e., clinicians, operations staff, administrators) participated. In nine study sites, we observed evidence of interviewees both mitigating and perpetuating reproductive injustice. Many aspired to provide compassionate, patient-centered care, avoid paternalism, and foster patient autonomy. Simultaneously, interviewees demonstrated biases, including implicit subscription to an ideology of stratified reproduction, stereotyping, and "othering." Even when interviewees endorsed goals of patient-centeredness, care delivery processes sometimes prioritized healthcare systems' needs, and patients were not included on quality improvement teams. Many interviewees recognized structural inequities as driving health outcome disparities, yet relied on individual-level solutions like long-acting reversible contraception, and not structural-level interventions, to address them. Alongside enthusiasm for delivering compassionate care exist biases, missed opportunities to center patients, and lack of curiosity about the appropriateness of solving structural-level problems with individual-level solutions. Our findings call for individual and institutional self-reflection, partnership with patients and communities, and other intentional efforts to mitigate potential for harm in initiatives enhancing access to contraceptive care.

Preventing Campus Sexual Violence

To reduce campus sexual violence, administrators must work with faculty experts in structural inequalities to develop, implement, evaluate, and share structural-level policy interventions.

Impact of race/ethnicity and socioeconomic status on emergency department visits in patients with hepatocellular carcinoma.

385 Background: Despite advances in diagnosis and treatment of hepatocellular carcinoma (HCC), disparities in care utilization and health outcomes persist. Few studies have evaluated the impact of race/ethnicity and socioeconomic status (SES) on incidence of emergency department (ED) visits, which may reflect access to and quality of cancer care. We investigated this relationship among patients (pts) with HCC. Methods: Using 100% Medicare Fee-for-Service claims and a commercial multi-payor claims database, pts diagnosed with HCC between 2014-2018 were identified. Using 9-digit ZIP code from enrollment records, pts were matched to near-neighborhood social determinants of health (SDOH) characteristics, including income, education, English language ability, living alone, vehicle ownership, rurality, and primary care shortages. We defined SES according to income level: low (≤2 times [x] federal poverty level [FPL]), middle (2-3x FPL), and high (&gt;3x FPL). We used generalized linear regressions to evaluate the effect of race/ethnicity on incidence rate ratios (IRR) of ED visits, adjusting for SDOH variables and demographic and clinical characteristics. We further stratified ED IRR by income level to examine how racial/ethnic differences in ED visits differ by SES. Results: 22,247 pts with HCC were identified (median age 69; 63% male; 69% White, 14% Black, 7% Hispanic, 6% Asian, 4% Other). The table summarizes adjusted IRR of ED visits for each racial/ethnic group compared with whites, overall and by income level. Overall, ED visits were higher for Blacks (IRR 1.27) and Hispanics (IRR 1.17) and lower for Asians (IRR 0.67). When stratified by income, Blacks and Hispanics had larger incidence of ED visits compared with Whites at higher income levels; these differences became insignificant at low income level. Asians had lower rate of ED visits regardless of income. Conclusions: Black and Hispanic pts with HCC demonstrated higher rates of ED visits compared with Whites. These differences were more pronounced at higher income levels, particularly for Blacks, suggesting racial disparities may differ by SES. Further research is needed to understand the intersectionality between race/ethnicity, SES and other SDOH, to guide structural-level interventions to address these disparities. [Table: see text]

The Social Determinants of Mental Health: A Descriptive Study of State Mental Health Agencies' Priorities.

Social determinants are receiving renewed attention as research demonstrates the effects of social factors on individuals’ physical and mental health and elucidates the biological and psychological mechanisms underlying those effects. Through spheres of influence from policy and regulation development to direct service provision, state mental health agencies are in a unique position to lead primary and secondary prevention efforts aimed at addressing social determinants with both client-level and structural-level interventions. A survey of social determinants-related activity was sent to the Medical Directors of the state offices of mental health in all 50 states. The survey results suggest consensus among respondents as to the importance of addressing specific social determinants. However, few state mental health agencies have taken on a comprehensive and intentional approach to addressing social determinants as a unique area of activity. Specific activities are reviewed, and implications for future work is discussed.