Recent Selected Publications

Housing is a key social determinant of health and health care utilization. Although stigmatized due to poor quality, public housing may provide stability and affordability needed for individuals to engage in health care utilization behaviors. For low-income women of reproductive age (15–44 y), this has implications for long-term reproductive health trajectories. In a sample of 5,075 women, we used electronic health records (EHR) data from 2006 to 2011 to assess outpatient and emergency department (ED) visits across six public housing sites in San Francisco, CA. Non-publicly housed counterparts were selected from census tracts surrounding public housing sites. Multivariable regression models adjusted for age and insurance status estimated incidence rate ratios (IRR) for outpatient visits (count) and odds ratios (OR) for ED visit (any/none). We obtained race/ethnicity-specific associations overall and by public housing site. Analyses were completed in December 2020. Public housing was consistently associated with health care utilization among the combined Asian, Alaskan Native/Native American, Native Hawaiian/Pacific Islander, and Other (AANHPI/Other) group. Public housing residents had fewer outpatient visits (IRR: 0.86; 95% Confidence Interval [CI]: 0.81, 0.93) and higher odds of an ED visit (OR: 1.81; 95% CI: 1.32, 2.48). Black women had higher odds of an ED visits (OR: 1.32; 95% CI: 1.07, 1.63), but this was driven by one public housing site (site-specific OR: 2.34; 95% CI: 1.12, 4.88). Variations by race/ethnicity and public housing site are integral to understanding patterns of health care utilization among women of reproductive age to potentially improve women’s long-term health trajectories.

Keywords: housing, reproductive health, health care utilization, racial/ethnic disparities, social determinants

Background: Low-income U.S. adults experiencing food insecurity have a disproportionately high prevalence of cigarette smoking, and quantitative studies suggest that food insecurity is a barrier to quitting. To guide effective tobacco control strategies, this study aimed to understand the experiences, perceptions, and context of tobacco use and cessation among low-income populations experiencing food insecurity. Methods: We conducted in-depth, semi-structured interviews with 23 adults who were currently smoking cigarettes and were experiencing food insecurity, mostly living in rural settings. Participants were recruited through food-pantry-based needs assessment surveys and study flyers in community-based organizations. The interview guide explored participants’ histories of smoking, the role and function of tobacco in their lives, their interest in and barriers to quitting, as well as lived experiences of food insecurity. We used reflexive thematic analysis to analyze transcribed interviews. Results: Within a broader context of structural challenges related to poverty and financial strain that shaped current smoking behavior and experiences with food insecurity, we identified the following five themes: smoking to ignore hunger or eat less; staying addicted to smoking in the midst of instability; smoking being prioritized in the midst of financial strain; life stressors and the difficulty of quitting smoking and staying quit; and childhood adversity at the intersection of food insecurity and tobacco use. Conclusion: The context of tobacco use among adults with food insecurity was highly complex. To effectively address tobacco-related disparities among those who are socially and economically disadvantaged, tobacco control efforts should consider relevant lived experiences and structural constraints intersecting smoking and food insecurity. Findings are applied to a conceptualization of clustering of conditions contributing to nicotine dependence, food insecurity, and stress.

Keywords: tobacco use, food insecurity, poverty, disparities, qualitative

We share findings from a larger ethnographic study of two urban complex care management programs in the Western United States. The data presented stem from in-depth interviews conducted with 17 complex care management RNs and participant observations of home visits. We advance the concept of social literacy as a nursing attribute that comprises an RN’s recognition and responses to the varied types of hinderances to self-management with which patients must contend in their lived environment. It is through social literacy that complex care management RNs reconceptualize and understand health literacy to be a product born out of the social circumstances in which patients live and the stratified nature of the health care systems that provide them care. Social literacy provides a broader framework for health literacy—one that is situated within the patient’s social context through which complex care management RNs must navigate for self-management goals to be achieved.

Keywords: complex care management, chronic disease, nursing, health inequalities, Western United States

As medicine integrates social and structural determinants into health care, some health workers redefine housing as medical treatment. This article discusses how health workers in two U.S. urban safety-net hospitals worked with patients without stable housing. We observed ethnographically how health workers helped patients seek housing in a sharply stratified housing economy. Analyzing in-depth interviews and observations, we show how health workers: (1) understood housing as health care and navigated limits of individual care in a structurally produced housing crisis; and (2) developed and enacted practices of biomedical and sociopolitical stabilization, including eligibilizing and data-tracking work. We discuss how health workers bridged individually focused techniques of clinical care with structural critiques of stratified housing economies despite contradictions in this approach. Finally, we analyze the implications of providers’ extension of medical stabilization into social, economic, and political realms, even as they remained caught in the structural dynamics they sought to address.

Health care systems in the United States are experimenting with a form of surveillance and intervention known as “hot spotting,” which targets high-cost patients—the so-called “super-utilizers” of emergency departments—with intensive health and social services. Through a calculative deployment of resources to the costliest patients, health care hot spotting promises to simultaneously improve population health and decrease financial expenditures on health care for impoverished people. Through an ethnographic investigation of hot spotting’s modes of distribution and its workings in the lives of patients and providers, we find that it targets the same individuals and neighborhoods as the police, who maintain longer-standing practices of hot spotting in zones of racialized urban poverty. This has led to a convergence of caring and punitive strategies of governance. The boundaries between them are shifting as a financialized logic of governance has come to dominate both health and criminal justice.

Keywords: health care, chronic illness, governance, policing, poverty, United States

Objectives: Individuals increasingly experience delays or interruptions in schooling; we evaluate the association between these non-traditional education trajectories and mental health. Methods: Using year-by-year education data for 7,501 National Longitudinal Survey of Youth 1979 participants, ages 14-48 (262,535 person-years of education data), we applied sequence analysis and a clustering algorithm to identify educational trajectory groups, incorporating both type and timing to credential. Linear regression models, adjusted for early-life confounders, evaluated relationships between educational trajectories and mental health component scores (MCS) from the 12-item short form instrument at age 50. We evaluated effect modification by race, gender, and race by gender. Results: We identified 24 distinct educational trajectories based on highest credential and educational timing. Compared to high school (HS) diplomas, < HS (beta=-3.41, 95%CI:-4.74,-2.07) and general educational development credentials (GEDs) predicted poorer MCS (beta=-2.07,95%CI:-3.16,-0.98). The following educational trajectories predicted better MCS: some college immediately after High School (beta=1.52, 95%CI:0.68,2.37), Associate degrees after long interruptions (beta=1.73, 95%CI:0.27,3.19), and graduate school soon after Bachelor's completion (beta=1.13, 95%CI:0.21,2.06). Compared to White men, Black women especially benefited from educational credentials higher than HS in predicting MCS. Conclusions: Both type and timing of educational credential predicted mental health. Black women's mental higher especially benefited from higher educational credentials.

Keywords: education; educational trajectories; health disparities; mental health; sequence analysis.

The Supplemental Nutrition Assistance Program (SNAP) is critical to alleviating food insecurity, but low diet quality among program participants is a concern. Nutrition-related interventions have focused on SNAP-authorized food retailers, but the perspectives of small food store owners and managers have not been represented in national policy discussions. This study aimed to explore the opinions of store owners/managers of SNAP-authorized small food stores about their overall perceptions of the program and the stricter stocking standards previously proposed in 2016. We conducted in-depth, semi-structured interviews with 33 small food store owners and managers in San Francisco and Oakland, California in 2016. Interviews were analyzed for thematic content using the general inductive approach. Four themes emerged from owners/managers’ discussion of their overall perceptions of SNAP: the beneficial impact of SNAP on their business, how SNAP enables them to connect with the broader community, the importance of SNAP in preventing hunger, and the nutrition-related struggles that SNAP participants face. Store owners/managers had a generally favorable response towards the proposed stricter stocking standards. Additional themes discussed pertained to the concern about whether stocking changes would lead SNAP participants to purchase more healthful food and some logistical challenges related to sourcing and storing perishable foods.

Keywords: community-based participatory research, food insecurity, nutrition policy, poverty, urban health

The vast majority of studies investigating participation in, persistence through, and consequences of postsecondary education focus on educational attainment status among the so-called traditional population of collegegoers between the ages of 18 and 24. This narrow focus leaves largely invisible the role that an expanding set of educational trajectories throughout adulthood plays in shaping social stratification. Using 35-plus and 20 years of follow-up data from the US National Longitudinal Survey of Youth (NLSY)’s 1979 and 1997 cohorts, we found that a substantial share within each cohort is attaining education well into adulthood, and that these trajectories are patterned according to key social and demographic characteristics. In both cohorts, racial/ethnic differences in educational attainment grew over time and, for those attaining the same degree, members of historically disadvantaged groups did so at an older age. Cohort differences in trajectories emerged, however, when considering the intersection of race/ethnicity and socialized gender. Through careful descriptive analysis of two generational cohorts, our study makes clear the role of educational trajectories in the process of cumulative (dis)advantage across the life course, as well as across generations.

Background: Higher educational attainment predicts lower hypertension. Yet, associations between non-traditional educational trajectories (e.g., interrupted degree programs) and hypertension are less well understood, particularly among structurally marginalized groups who are more likely to experience these non-traditional trajectories. Methods: In National Longitudinal Survey of Youth 1979 cohort data (N = 6 317), we used sequence and cluster analyses to identify groups of similar educational sequences—characterized by timing and type of terminal credential—that participants followed from age 14–48 years. Using logistic regression, we estimated associations between the resulting 10 educational sequences and hypertension at age 50. We evaluated effect modification by individual-level indicators of structural marginalization (race, gender, race and gender, and childhood socioeconomic status [cSES]). Results: Compared to terminal high school (HS) diploma completed at traditional age, terminal GED (OR: 1.32; 95%CI: 1.04, 1.66) or Associate degree after <HS (OR: 1.93; 95%CI: 1.11, 3.35) was associated with higher hypertension. There was some evidence of effect modification. Hypertension associated with delayed HS diploma versus HS diploma at a traditional age (the reference) was lower for Black men than White men (interaction term: 0.44; 95%CI: 0.21, 0.91); similarly, hypertension associated with <HS versus completing HS at a traditional age was lower for people with low cSES than people with high cSES (interaction term: 0.52; 95%CI: 0.30, 0.90). Conclusions: Both type and timing to terminal credential matter for hypertension but effects may vary by experiences of structural marginalization. Documenting the nuanced ways in which complex educational trajectories are associated with health could elucidate underlying mechanisms and inform systems-level interventions for health equity.

Nontraditional education trajectories are common, but their influence on physical health is understudied. We constructed year-by-year education trajectories for 7,501 National Longitudinal Survey of Youth 1979 participants aged 14 to 48 years (262,535 person-years of education data from 1979 to 2014). We characterized trajectory similarity using sequence analysis and used hierarchical clustering to group similar educational trajectories. Using linear regression, we predicted physical health summary scores of the participants at age 50 years from the 12-item Short-Form Survey, adjusting for available confounders, and evaluated effect modification by sex, race/ethnicity, and childhood socioeconomic status. We identified 24 unique educational sequence clusters on the basis of highest level of schooling and attendance timing. General education development credentials predicted poorer health than did high school diplomas (β = −3.07, 95% confidence interval: −4.07, −2.07), and bachelor’s degrees attained at earlier ages predicted better health than the same degree attained at later ages (β = 1.66, 95% confidence interval: 0.05, 3.28). Structurally marginalized groups benefited more from some educational trajectories than did advantaged groups (e.g., Black vs. White Americans with some college; those of low vs. high childhood socioeconomic status who received an associate’s or bachelor’s degree). Both type and timing of educational credentials may influence physical health. Literature to date has likely underestimated the impact of educational trajectories on health.

Keywords: education, educational credential, educational timing, educational trajectories, sequence analysis