The subjective nature of pain has always rendered it a point of entry for power and corresponding stratifying processes within biomedicine. The opioid crisis has further exacerbated these challenges by increasing the stakes of prescribing decisions for providers, which in turn has resulted in greater treatment disparities. Using the theoretical frame of cultural health capital (CHC) to account for these disparities in pain management as they unfold at both the macro- and the microlevel, we present findings from an interdisciplinary study of two complex care management programs in urban safety-net hospitals that serve high-utilizing patients. CHC, which considers the ways in which patient–provider interactions reflect and often reinforce broader social inequities, allows for a consideration of power as it circulates through and beyond the patient–provider encounter. Within the current sociopolitical era of pain management, attention must be paid to the stratifying processes that structure how suffering is addressed. Keywords: complex care management, cultural health capital, disparities, opiates, pain

Background: Neighborhood context plays a role in binge drinking, a behavior with major health and economic costs. Gentrification, the influx of capital and residents of higher socioeconomic status into historically-disinvested neighborhoods, is a growing trend with the potential to place urban communities under social and financial pressure. Hypothesizing that these pressures and other community changes resulting from gentrification could be tied to excessive alcohol consumption, we examined the relationship between gentrification and binge drinking in California neighborhoods.

We sought to examine the literature using the Patient Activation Measure (PAM) or the Patient Enablement Instrument (PEI) with high-need, high-cost (HNHC) patients receiving care in urban safety net settings. Urban safety net care management programs serve low-income, racially/ethnically diverse patients living with multiple chronic conditions. Although many care management programs track patient progress with the PAM or the PEI, it is not clear whether the PAM or the PEI is an effective and appropriate tool for HNHC patients receiving care in urban safety net settings in the United States. We searched PubMed, EMBASE, Web of Science, and PsycINFO for articles published between 2004 and 2015 that used the PAM and between 1998 and 2015 that used the PEI. The search was limited to English-language articles conducted in the United States and published in peer-reviewed journals. To assess the utility of the PAM and the PEI in urban safety net care settings, we defined a HNHC patient sample as racially/ethnically diverse, low socioeconomic status (SES), and multimorbid. One hundred fourteen articles used the PAM. All articles using the PEI were conducted outside the U.S. and therefore were excluded. Nine PAM studies (8%) included participants similar to those receiving care in urban safety net settings, three of which were longitudinal. Two of the three longitudinal studies reported positive changes following interventions. Our results indicate that research on patient activation is not commonly conducted on racially and ethnically diverse, low SES, and multimorbid patients; therefore, there are few opportunities to assess the appropriateness of the PAM in such populations. Investigators expressed concerns with the potential unreliability and inappropriate nature of the PAM on multimorbid, older, and low-literacy patients. Thus, the PAM may not be able to accurately assess patient progress among HNHC patients receiving care in urban safety net settings. Assessing progress in the urban safety net care setting requires measures that account for the social and structural challenges and competing demands of HNHC patients.

In this paper, we delineate how staff of two complex care management (CCM) programs in urban safety net hospitals in the United States understand trauma. We seek to (1) describe how staff in CCM programs talk about trauma in their patients’ lives; (2) discuss how trauma concepts allow staff to understand patients’ symptoms, health-related behaviors, and responses to care as results of structural conditions; and (3) delineate the mismatch between long-term needs of patients with histories of trauma and the short-term interventions that CCM programs provide. Observation and interview data gathered between February 2015 and August 2016 indicate that CCM providers define trauma expansively to include individual experiences of violence such as childhood abuse and neglect or recent assault, traumatization in the course of accessing health care and structural violence. Though CCM staff implement elements of trauma-informed care, the short-term design of CCM programs puts pressure on the staff to titrate their efforts, moving patients towards graduation or discharge. Trauma concepts enable clinicians to name structural violence in clinically legitimate language. As such, trauma-informed care and structural competency approaches can complement each other.

Increasing “patient engagement” has become a priority for health care organizations and policy-makers seeking to reduce cost and improve the quality of care. While concepts of patient engagement have proliferated rapidly across health care settings, little is known about how health care providers make use of these concepts in clinical practice. This paper uses 20 months of ethnographic and interview research carried out from 2015 to 2016 to explore how health care providers working at two public, urban, safety-net hospitals in the United States define, discuss, and assess patient engagement. We investigate how health care providers describe engagement for high cost patients—the “super-utilizers” of the health care system—who often face complex challenges related to socioeconomic marginalization including poverty, housing insecurity, exposure to violence and trauma, cognitive and mental health issues, and substance use. The health care providers in our study faced institutional pressure to assess patient engagement and to direct care towards engaged patients. However, providers considered such assessments to be highly challenging and oftentimes inaccurate, particularly because they understood low patient engagement to be the result of difficult socioeconomic conditions. Providers tried to navigate the demand to assess patient engagement in care by looking for explicit positive and negative indicators of engagement, while also being sensitive to more subtle and intuitive signs of engagement for marginalized patients.

This paper articulates how political ecology can be a useful tool for asking fundamental questions and applying relevant methods to investigate structures that impact relationship between neighborhood and health. Through a narrative analysis, we identify how political ecology can develop our future agendas for neighborhood-health research as it relates to social, political, environmental, and economic structures. Political ecology makes clear the connection between political economy and neighborhood by highlighting the historical and structural processes that produce and maintain social inequality, which affect health and well-being. These concepts encourage researchers to examine how people construct neighborhood and health in different ways that, in turn, can influence different health outcomes and, thus, efforts to address solutions. Keywords: Neighborhood; Political ecology

Introduction: Neighborhood factors are increasingly recognized as determinants of health. Neighborhood social cohesion may be associated with physical activity, but previous studies examined data aggregated across racial/ethnic groups. We assessed whether neighborhood social cohesion was associated with physical activity in a nationally representative data set and explored the role of race/ethnicity.

Background: The neighborhood built environment can have a strong influence on physical activity levels, particularly walking for transport. In examining racial/ethnic differences in physical activity, one important and understudied group is South Asians. This study aims to describe the association between neighborhood walkability and walking for transport among South Asian men and women in the United States in the Mediators of Atherosclerosis in South Asians Living in America (MASALA) Study.

BACKGROUND AND OBJECTIVES: The neighborhoods in which children live, play, and eat provide an environmental context that may influence obesity risk and ameliorate or exacerbate health disparities. The current study examines whether neighborhood characteristics predict obesity in a prospective cohort of girls.