Unstable Housing Research Articles

COVID-19 and Kidney Disease Disparities in the United States

Racial, ethnic, socioeconomic, age, and sex-related health disparities in kidney disease are prominent in the United States. The Coronavirus Disease 2019 (COVID-19) pandemic has disproportionately affected marginalized populations. Older adults, people experiencing unstable housing, racial and ethnic minorities, and immigrants are potentially at increased risk for infection and severe complications from COVID-19. The direct and societal effects of the pandemic may increase risk of incident kidney disease and lead to worse outcomes for those with kidney disease. The rapid transition to telemedicine potentially limits access to care for older adults, immigrants, and people experiencing unstable housing. The economic impact of the pandemic has had a disproportionate effect on women, minorities, and immigrants, which may limit their ability to manage kidney disease and lead to complications or kidney disease progression. We describe the impact of COVID-19 on marginalized populations and highlight how the pandemic may exacerbate existing disparities in kidney disease.

COVID-19 and Racial Disparities: Moving Towards Surgical Equity.

COVID-19 and Racial Disparities: Moving Towards Surgical Equity.

Tailoring a mobile health text-messaging intervention to promote antiretroviral therapy adherence among African Americans: A qualitative study.

African Americans are disproportionately affected by HIV and socio-structural barriers that impact antiretroviral (ART) adherence. Two-way text-messaging interventions have shown promise in supporting adherence in US studies of mostly White people living with HIV (PLWH). However, culturally-appropriate tailoring is necessary to maximize intervention effectiveness among other racial/ethnic groups. Thus, to refine an existing text-messaging intervention, we examined barriers and facilitators to ART adherence among African Americans and perspectives on features to integrate into the extant intervention. Three focus groups, two with African American PLWH (n = 5 and n = 7) and one with providers of care (n = 11) were conducted; transcripts of audio-recordings were thematically analyzed. Adherence supports operated at individual, interpersonal, and structural/environmental levels (e.g., using reminders and pill organizers, wanting to protect partners from HIV, and positive interactions with providers). Adherence barriers also operated at multiple ecological levels (e.g., poor mental health, fear of disclosure of HIV status, and unstable housing). Participant-suggested features for refinement included: i) matching content to participants’ comfort with receiving messages referencing HIV or medication-taking, ii) culturally-tailoring content for African Americans, iii) tracking adherence, and iv) encouraging adherence interactions between patients and providers. Feedback from both patients and providers is foundational to designing effective ART interventions among African American PLWH.

Housing stability and diabetes among people living in New York city public housing.

Public housing provides affordable housing and, potentially, housing stability for low-income families. Housing stability may be associated with lower incidence or prevalence and better management of a range of health conditions through many mechanisms. We aimed to test the hypotheses that public housing residency is associated with both housing stability and reduced risk of diabetes incidence, and the relationship between public housing and diabetes risk varies by levels of housing stability. Using 2004-16 World Trade Center Health Registry data, we compared outcomes (housing stability measured by sequence analysis of addresses, self-reported diabetes diagnoses) between 730 New York City public housing residents without prevalent diabetes at baseline and 730 propensity score-matched non-public housing residents. Sequence analysis found 3 mobility patterns among all 1460 enrollees, including stable housing (65%), limited mobility (27%), and unstable housing patterns (8%). Public housing residency was associated with stable housing over 12 years. Diabetes risk was not associated with public housing residency; however, among those experiencing housing instability, a higher risk of diabetes was found among public housing versus non-public housing residents. Of those stably housed, the association remained insignificant. These findings provide important evidence for a health benefit of public housing via housing stability among people living in public housing.

Residential satisfaction among low-income single-mother households: the case of residential welfare facilities in South Korea

PurposeThis paper examines residential satisfaction in welfare housing facilities exclusively built for low-income single-mother households in South Korea. The main objective is to identify predictors from among various domains such as sociodemographic and psychological characteristics of residents, as well as objective and subjective characteristics of their residential environment.Design/methodology/approachA mixed-method field study evaluates data obtained via structured questionnaires administered to 233 low-income single mothers in 23 residential welfare facilities across South Korea, supplemented by facility observations and interviews with housing staff from 16 facilities.FindingsResidential satisfaction was found to be a multidimensional construct predicted by a number of variables, with psychological characteristics being dominant. Significant predictors were also identified among physical and sociospatial environmental characteristics, such as plan type, management and service and personal space.Practical implicationsThe results of this study highlight the significance of the human aspects of management and the sociospatial quality of housing unit spaces to provide a sense of protection and privacy for the residents, which emphasizes the importance of management, design and policy improvements to increase satisfaction in welfare facility residents.Originality/valueCurrently, data for special housing conditions of female-headed households in unstable housing affordability are relatively few and outdated. A critical examination of the physical and sociospatial quality of short-term subsidized public housing for low-income single-mother households in South Korea expands the current knowledge in this field to various sociodemographic and cultural contexts.

Social and structural determinants of health associated with drug use patterns among female sex workers in Iran: A latent class analysis

BackgroundFemale sex workers (FSWs) experience adversities regarding social determinants of health (SDH) and behavioural factors including illicit drug use. This study aimed to assess the clustered impact of SDH on illicit drug use among FSWs in Iran. MethodsWe surveyed 1,347 FSWs in 13 major cities in 2015. Latent class analysis was conducted to identify distinct classes of five measured SDH including low education, unemployment, unstable housing, last-year incarceration and sexual violence. We examined the association of these classes with five illicit drug use patterns using multivariable generalized linear model with Poisson family and log link, and reported adjusted prevalence ratios (aPR) and their 95% confidence intervals (CI). ResultsWe identified five SDH classes: Class 1: no SDH adversities; Class 2: mainly unemployment; Class 3: low education and unemployment; Class 4: sexual violence and unemployment; and Class 5: multiple SDH adversities. The prevalence of last-month drug use ranged from 7.0% in Class 1 to 53.3% in Class 5. Compared to FSWs in Class 1, those in Class 2 (aPR: 2.47, 95% CI: 1.15, 5.27), Class 3 (aPR: 3.69, 95% CI: 1.62, 8.36), Class 4 (aPR: 4.49, 95% CI: 1.71, 11.78) and Class 5 (aPR: 6.35, 95% CI: 2.42, 16.69) were more likely to report last-month drug use. The same patterns were observed for specific drugs of opium use, crystal methamphetamine use, and heroin-crack use, as well as poly-drug use. ConclusionSocio-structural determinants are clustered together and elevate the likelihood of illicit drug use among FSWs. Our findings highlighted the significance of assessing and addressing such key determinants of health in drug use harm reduction programs targeting FSWs.

Syndemic theory, structural violence and HIV among African-Americans.

This paper will review recent use of syndemic frameworks in HIV research among African-Americans. Researchers have used syndemic theory in diverse African-American study populations, including MSM, cis-women, trans-women, heterosexual men and adolescents. These studies have evaluated the associations between syndemic conditions and a variety of outcomes, such as sexual behaviours, HIV and other sexually transmitted infections, HIV testing, adherence to antiretroviral therapy, HIV suppression and preexposure prophylaxis use. The most frequently evaluated syndemic conditions have been depression, substance use and personal experience of abuse or violence; a few studies have included experience of incarceration and unstable housing. These studies have yielded valuable insights into links between HIV-related outcomes and mental health, experience of violence and abuse, and substance use. But a key feature - and major utility - of the syndemics framework is its potential for examining not only synergistic individual-level risk factors but also the interactions with economic, political and social systems that influence these individual-level factors and thereby shape the HIV epidemic among African-Americans. Research that takes these systems into account is needed to inform policy changes that can help end the HIV epidemic in this population.

Experiences with Work and Participation in Public Programs by Low-Income Medicaid Enrollees Using Qualitative Interviews.

Centers for Medicare & Medicaid Services (CMS) began encouraging governors to implement work requirements for Medicaid enrollees using section 1115 waivers in 2018. Significant controversy surrounds such attempts, but we know little about the perceptions and experiences of enrollees. To characterize experiences of work and its relationship to participation in Medicaid and other public programs among potential targets of Medicaid work requirements. In-depth, semi-structured, one-time qualitative interviews. 35 very low-income, non-disabled Medicaid expansion enrollees participating in a county-sponsored Medicaid managed care plan as a part of a larger study. We used a biographical narrative interpretive method during interviews including questions about the use of employment and income support and other public programs including from state and federal disability programs. Our team iteratively coded verbatim transcripts allowing for emergent themes. Interview data revealed high motivation for, and broad participation in, formal and informal paid work. Eight themes emerged: (1) critical poverty (for example, "I'm not content, but what choices do I have?"); (2) behavioral and physical health barriers to work; (3) social barriers: unstable housing, low education, criminal justice involvement; (4) work, pride, and shame; (5)inflexible, unstable work (for example, "Can I have a job that will accommodate my doctor appointments?…Will my therapy have to suffer? You know? So it's a double edged sword."); (6) Medicaid supports the ability to work; (7) lack of transparency and misalignment of program eligibility (for example, "It's not like I don't want to work because I would like to work. It's just that I don't want to be homeless again, right?"); and (8) barriers, confusion, and contradictions about federal disability. We conclude that bipartisan solutions prioritizing the availability of well-paying jobs and planful transitions off of public programs would best serve very low-income, work-capable Medicaid enrollees.

Adaptation of Group-Based Suicide Intervention for Latinx Youth in a Community Mental Health Center

The purpose of this study was to better understand the sociocultural and logistical treatment needs and barriers of low-income Latinx suicidal youth; and to solicit feedback and identify best practices to adapt and implement a suicide treatment program for this population in a community mental health clinic. Working with the largest mental health care provider for urban area under- and uninsured patients, we conducted semi-structured interviews with Latinx suicidal youth (n = 6), their parents (n = 6), and clinical staff (n = 8). Interviews were audio-recorded, transcribed, and analyzed thematically using a deductively-driven codebook corresponding to interview domains. We supplemented semi-structured interview findings with knowledge gleaned from an exhaustive literature search, including best practice findings from other studies. We also conducted a brief provider survey to ensure a diverse sample. Many parents and providers focused on several unmet mental health needs and multiple barriers to accessing treatment that are common among uninsured populations: a need to prioritize parent and adolescent work schedules, lack of transportation, unstable housing, and unmet childcare needs. Additionally, participants described several factors that play a critical role in treatment: stigma, religion, fear related to immigration, gender roles, and acculturation. We mapped these findings, along with literature-identified best practices, to create components of a culturally-tailored adaptation. We combined primary and secondary evidence of Latinx suicidal youth and families’ mental health needs and barriers to treatment to propose a tailored adaption of an intensive outpatient program that provides transdiagnostic, suicide-specific care to Latinx adolescents and families in a community setting.

Criminal Justice-Involved Women Navigate COVID-19: Notes From the Field.

In March-April, 2020, we communicated with a cohort of criminal justice-involved (CJI) women to see how they were navigating COVID-19, chronic illness, homelessness, and shelter-in-place orders in Oakland, Birmingham, and Kansas City. We report on conversations with N = 35 women (out of the cohort of 474 women) and our own observations from ongoing criminal justice involvement studies. Women reported barriers to protecting themselves given widespread unstable housing and complex health needs, though many tried to follow COVID-19 prevention recommendations. Women expressed dissatisfaction with the suspension of research activities, as the pandemic contributed to a heightened need for study incentives, such as cash, emotional support, and other resources. COVID-19 is illuminating disparities between those who can follow recommended actions to prevent infection and those who lack resources to do so. Concerted efforts are required to reduce inequities that put the 1.3 million U.S. women under criminal justice supervision at risk for infection and mortality.

Improving Care Outcomes for PLWH Experiencing Homelessness and Unstable Housing: a Synthetic Review of Clinic-Based Strategies.

Singular interventions targeting vulnerable populations of people living with HIV (PLWH) are necessary for reducing new infections and optimizing individual-level outcomes, but extant literature for PLWH who experience homelessness and unstable housing (HUH) has not been compiled. To inform implementation of clinic-based programs that improve care outcomes in this population, we present a synthetic review of key studies examining clinic-based interventions, specifically case management, patient navigation, financial incentives, and the use of mobile technology. Results from unimodal interventions are mixed or descriptive, are limited by inability to address related multi-modal barriers to care, and do not address major challenges to implementation. Multi-component interventions are needed, but gaps in our knowledge base may limit widespread uptake of such interventions before further data are compiled. Future research evaluating interventions for PLWH experiencing HUH should include implementation outcomes in order to facilitate adaptation across diverse clinical settings.

National findings from the Tracks survey of people who inject drugs in Canada, Phase 4, 2017-2019.

The Tracks survey of people who inject drugs (PWID) collected data in 14 sentinel sites across Canada (2017-2019). To describe the prevalence of human immunodeficiency virus (HIV) and hepatitis C and associated risk behaviours and to examine trends over time. Information regarding socio-demographics, social determinants of health, use of prevention services and testing, drug use, risk behaviours, and HIV and hepatitis C testing, care and treatment was collected through interviewer-administered questionnaires. Biological samples were tested for HIV, hepatitis C antibodies and hepatitis C ribonucleic acid (RNA). Descriptive statistics were calculated and trends over time were assessed. Of the 2,383 participants, 65.6% were cisgender male, 42.2% were Indigenous, 48.0% completed some high school or less, 62.6% lived in unstable housing and 75.7% had ever been incarcerated. Average age was 40.1 years. The majority experienced stigma and discrimination (88.7%) and physical, sexual and/or emotional abuse in childhood (85.0%) or with a sexual partner (75.9%). The majority reported use of a needle/syringe distribution program (90.1%) and tested for HIV (90.5%) and hepatitis C (90.9%).Among participants who had ever had sex, the majority (59.2%) reported inconsistent condom use during vaginal and/or anal sex with a casual sex partner. Prevalence of HIV was 10.3% (82.9% were aware of infection status) and many (36.9%) were hepatitis C RNA-positive (50.1% were aware of infection status).Most surveillance indicators remained relatively stable from Phase 1 to Phase 4. Changes were found in substances used, and improvements were noted related to HIV and hepatitis C prevalence and care cascade indicators. Many PWID in Canada were living in unstable housing and experienced high levels of stigma and discrimination. Prevalence of HIV and hepatitis C was high in some areas. These findings contribute to the evidence base used to inform targeted prevention and control measures.

Hearing their voices: Youths’ experiences of unstable housing and homelessness post-care

Youths who age out of care face adverse health outcomes and high rates of homelessness. This study used content analysis to explore: “What are the post-care housing experiences of youth who have transitioned from care through an independent support program?” Semi-structured interviews were conducted with 10 youths who had aged out of care. Six service providers who worked with youth in care in various capacities were also interviewed. Data analysis revealed themes including: the experience of unstable housing and homelessness, lack of formal supports, and youth leaving care then wishing they could return. Another theme to emerge, I take responsibility for where I am now, adds new information to the literature. The research findings support that child welfare services should place greater emphasis on developing youths’ life skills while they are in care. In addition, allowing youths the option to return to care after discharge may reduce experiences of unstable housing and homelessness post-care.

Food insecurity and food pantry use among transgender and gender non-conforming people in the Southeast United States

BackgroundTransgender and gender non-conforming (TGNC) people face high rates of poverty, joblessness, and homelessness, rendering this population vulnerable to experiencing food insecurity. Yet, there is almost no empirical evidence concerning food insecurity and the use of local and federal food assistance resources in the TGNC community. Food insecurity, the use of local and Federal food assistance resources, and associations with gender-related minority stressors and resilience using the Gender Minority Stress and Resilience (GMSR) scale among TGNC individuals living in the Southeast United States (U.S.) were documented in this study.MethodsA cross-sectional online survey was conducted with TGNC people living in the Southeast U.S. Participants were recruited via targeted Facebook advertisements.ResultsIn total, 105 TGNC people completed the survey; 79% of survey participants experienced food insecurity, 19% utilized Federal, and 22% utilized local food assistance resources. High levels of minority stress and community resilience were reported. The GMSR resilience scale Pride (aOR = 1.09, 95% CI 1.00–1.19, p = .04) was significantly associated with the use of local food pantries, but minority stressors were not. No significant associations were found between GMSR and food security.ConclusionTGNC people living in the Southeast U.S. experienced food insecurity, unstable housing, low wages, and social stigma that were a barrier to using emergency food resources. Multi-level public health solutions that address discriminatory legislative policies and create linkages between TGNC people and local and federal food assistance are required to address issues of food insecurity in the TGNC population.

Rapid Implementation of a SARS-CoV-2 Diagnostic qRT-PCR Test with Emergency Use Authorization at a Large Academic Safety-Net Hospital

The coronavirus disease 2019 (COVID-19) pandemic, caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is now a major global public health crisis. In the United States, significant delays in the rapid development and distribution of diagnostic testing for SARS-CoV-2 infection have prevented adequate COVID-19 patient care and public health management of the pandemic, impacting the timely mapping of the dynamics of viral spread in the general population, and more topically, the conservation of personal protective equipment. Furthermore, vulnerable populations such as those served by Boston Medical Center (BMC), the largest safety net hospital in New England, represent a high-risk group across multiple dimensions, including a higher prevalence of pre-existing conditions and substance use disorders, lower general health maintenance, unstable housing, and a propensity for rapid community spread, highlighting the urgent need for rapid and reliable in-house testing infrastructure. Here, we report the rapid implementation of a SARS-CoV-2 diagnostic RT-PCR assay with Emergency Use Authorization (EUA) from the Food and Drug Administration (FDA). Our test offers a more rapid turnaround time in comparison to currently available commercial or state laboratory facilities, and enables clinicians and patients to make more informed decisions with personal and public health ramifications. The template and protocol that we have generated and validated could be useful for other smaller community hospitals lacking capital intensive automated clinical laboratory machinery to run molecular biology assays.

HEALTH DISPARITIES IN ADHERENCE WITH PRESCRIBED REHABILITATION FOLLOWING SURGICAL TREATMENT OF KNEE INJURIES IN PEDIATRIC PATIENTS

Background:Rehabilitation is paramount to recovery following surgery for ligamentous and meniscal knee injuries, but there exists little research regarding adherence with rehabilitation in pediatric populations, especially how this relates to health disparities in this population.Hypothesis/Purpose:Our study aimed to evaluate the effect of patient socioeconomic/demographic factors on adherence with physical therapy appointments following surgical repair or reconstruction of knee injuries. This information would be used to raise awareness of health disparities and potentially develop a set of predictors for a higher risk of non-adherence with prescribed rehabilitation.Methods:This study was a retrospective chart review of patients under the age of 18 who underwent physical therapy at the authors’ institution following initial surgical repair or reconstruction of a knee injury (ACL, MCL, LCL, PCL, meniscus, patellar tendon, and tibial eminence injuries included). Surgeries from 1 January 2015 to 31 December 2016 were considered, with physical therapy being considered for dates extending to 1 January 2018. Rate of adherence with physical therapy, reasons for lack of attendance, and socioeconomic/demographic variables were gathered. Data was evaluated utilizing bivariate and separate hierarchical linear regression analyses.Results:Our study population was comprised of 108 individuals with a mean age of 15.15 ± 2.04 years and a mean compliance rate with physical therapy of 80.2 ± 11.8%. Bivariate analysis revealed Hispanic/Latino patients were more likely to cancel/no show (18 ± 22.82) than non-Hispanic/Latino patients (7.55 ± 6.88, p = 0.010). Logistic regression revealed patients were significantly less likely to attend 85% of rehabilitation visits if in single-parent households (p = 0.024). The interaction of insurance type and residence stability (maintaining a single residence during treatment) found patients with public insurance and stable housing were less likely to reach the 85% compliance threshold (Table 1). At trend level, linear regression revealed an inverse relationship with distance and physical therapy attendance (p = 0.082), in addition to linear regression showing unstable residence (p = 0.052) and public insurance (p = 0.067) as significant at trend level of patients not reaching 85% compliance.Conclusion:Our study revealed single-parent households and Hispanic/Latino patients were significantly correlated with lower rehabilitation adherence, in addition to trends showing distance to physical therapy, unstable housing, and public insurance correlated with lower compliance. Our work highlights potential predictors of rehabilitation noncompliance and allows for targeted efforts to increase adherence in patients with these factors.Table 1. More Then 85% Compliance? Yes No Percent “Yes” Stable housing and private insurance 342845.2 Stable housing and public insurance 1019.1 Unstable housing and private insurance 16936.0 Unstable housing and public insurance 6333.3

Unstable Housing Associated with Lower Rate of HIV Suppression: U.S. Ryan White AIDS Program

The Ryan White HIV/AIDS Program (RWHAP) provides services to low-income persons living with HIV in the U.S. The RWHAP provides essential health

Housing Subsidies and Housing Stability are Associated with Better HIV Medical Outcomes Among Persons Who Experienced Homelessness and Live with HIV and Mental Illness or Substance Use Disorder.

Among 958 applicants to a supportive housing program for low-income persons living with HIV (PLWH) and mental illness or a substance use disorder, we assessed impacts of housing placement on housing stability, HIV care engagement, and viral suppression. Surveillance and administrative datasets provided medical and residence information, including stable (e.g., rental assistance, supportive housing) and unstable (e.g., emergency shelter) government-subsidized housing. Sequence analysis identified a "quick stable housing" pattern for 67% of persons placed by this program within 2years, vs. 28% of unplaced. Compared with unplaced persons not achieving stable housing quickly, persons quickly achieving stable housing were more likely to engage in care, whether placed (per Poisson regression, ARR: 1.14;95% CI 1.09-1.20) or unplaced (1.19;1.13-1.25) by this program, and to be virally suppressed, whether placed (1.22;1.03-1.44) or unplaced (1.26, 1.03-1.56) by this program. Housing programs can help homeless PLWH secure stable housing quickly, manage their infection, and prevent transmission.

Hepatitis C Care Continuum in a Human Immunodeficiency Virus (HIV) Positive Cohort: Data From the HIV Atlanta Veterans Affairs Cohort Study.

BackgroundHuman immunodeficiency virus (HIV) and hepatitis C virus (HCV) coinfection is associated with accelerated progression to cirrhosis, end-stage liver disease, and liver-associated death. It is fortunate that curative direct-acting antivirals for the treatment of HCV are widely available in the VA healthcare system. We attempted to identify, evaluate, and treat all HIV/HCV-coinfected persons at the Atlanta VA Healthcare System.MethodsHuman immunodeficiency virus/HCV-coinfected persons at Atlanta VA between 2015 and 2018 were identified using the HIV Atlanta Veterans Affairs Cohort Study and Hepatitis C VA Clinical Case Registry. Retrospective reviews of each electronic medical record were conducted by the hepatitis C clinical team for validation. The primary end point was achieving sustained virologic response.ResultsOne hundred thirty-eight veterans with HIV and hepatitis C viremia were identified. One hundred twenty-five (90%) were evaluated for treatment and 113 (91%) were initiated on direct-acting antiviral therapy. Median age at initiation of treatment was 60 years and the majority were black race (90%). Genotype 1a was most common (70%) and 41% had compensated cirrhosis. One hundred eight completed treatment and 96% achieved sustained virologic response. Six veterans had virologic relapse; 4 had treatment-emergent resistance mutations in the NS5a gene. Mean CD4 was 580 cells/mm3 with HIV viral suppression in 82% of the cohort. In those not treated, unstable housing (25%), active substance use (31%), and psychiatric conditions (42%) were identified barriers to care.ConclusionsThrough a concerted, systematic effort, over 80% of HIV/hepatitis C persons in the Atlanta VA have been initiated on treatment for hepatitis C, 96% of which have been cured.

Addressing disparities in the health of persons with HIV attributable to unstable housing in the United States: The role of the Ryan White HIV/AIDS Program.

Amy Griffin and co-authors discuss unstable housing and the response to HIV/AIDS in the United States.