Health Disparities, Transportation Equity and Complete Streets: a Case Study of a Policy Development Process through the Lens of Critical Race Theory

Disparities in Pedestrian and Cyclist Crashes by Social Vulnerability Across South Carolina

BACKGROUND

Little crash equity research has controlled for active transportation rates, examined the Southeastern United States, or used composite sociodemographic metrics. This study analyzed disparities in pedestrian and cyclist crashes and crash severity according to level of social vulnerability (SV) across South Carolina.

METHODS

Data about SV and its 4 dimensions (socioeconomic status, household composition and disability, minority status and language, and housing type and transportation) were compiled for all census tracts (N = 1103) within South Carolina. Data for all crashes involving a pedestrian (n = 10,688) and/or cyclist (n = 4802) from 2011 to 2021 were obtained from the South Carolina Department of Transportation and geocoded to the respective census tract. Total average pedestrian and cyclist crash severity (Equivalent Property Damage Only) were also calculated for each tract. Crash frequency and severity scores were adjusted using the average number of walking and cycling trips in the census tract per year using StreetLight Data. Mixed-model linear regression analyzed the relationships between overall SV and the 4 SV dimensions and 4 crash measures-pedestrian and cyclist frequency and severity. Stratified analyses were conducted for urban and rural tracts.

RESULTS

Overall SV was positively and significantly associated with all 4 crash outcomes in urban areas: pedestrian crashes per trip (B = 0.048, SE = 0.012, P < .001), pedestrian crash severity per trip (B = 9.018, SE = 2.516, P < .001), cyclist crashes per trip (B = 0.093, SE = 0.029, P < .01), and cyclist crash severity per trip (B = 16.370, SE = 5.482, P < .01). In urban areas, greater SV was associated with more severe pedestrian and cyclist crash outcomes.

CONCLUSIONS

Targeted policy and programmatic and infrastructure interventions are needed to improve active transportation safety and public health.

Bridging the Gap in Policy Implementation through a Health Equity Lens: Insights from a 2-Year Study on Measurement Development

Background: Policy implementation measurement lacks an equity focus, which limits understanding of how policies addressing health inequities, such as Universal School Meals (USM) can elicit intended outcomes. We report findings from an equity-focused measurement development study, which had two aims: (1) identify key constructs related to the equitable implementation of school health policies and (2) establish face and content validity of measures assessing key implementation determinants, processes, and outcomes. Methods: To address Aim 1, study participants (i.e., school health policy experts) completed a survey to rate the importance of constructs identified from implementation science and health equity by the research team. To accomplish Aim 2, the research team developed survey instruments to assess the key constructs identified from Aim 1 and conducted cognitive testing of these survey instruments among multiple user groups. The research team iteratively analyzed the data; feedback was categorized into "easy" or "moderate/difficult" to facilitate decision-making. Results: The Aim 1 survey had 122 responses from school health policy experts, including school staff (n = 76), researchers (n = 22), trainees (n = 3), leaders of non-profit organizations (n = 6), and others (n = 15). For Aim 2, cognitive testing feedback from 23 participants was predominantly classified as "easy" revisions (69%) versus "moderate/difficult" revisions (31%). Primary feedback themes comprised (1) comprehension and wording, (2) perceived lack of control over implementation, and (3) unclear descriptions of equity in questions. Conclusions: Through adaptation and careful dissemination, these tools can be shared with implementation researchers and practitioners so they may equitably assess policy implementation in their respective settings.

Effects of mode of transportation on PrEP persistence among urban men who have sex with men

Little is known about the effect of travel-related factors, such as mode of transportation, on retention in PrEP care, or PrEP persistence. We used data from the 2020 American Men's Internet Survey and conducted multilevel logistic regression to estimate the association between mode of transportation used for healthcare access and PrEP persistence among urban gay, bisexual, and other men who have sex with men (MSM) in the U.S. MSM using public transportation were less likely to report PrEP persistence (aOR: 0.51; 95% CI: 0.28-0.95) than MSM using private transportation. There were no significant associations between PrEP persistence and using active transportation (aOR: 0.67; 95% CI: 0.35-1.29) or multimodal transportation (aOR: 0.85; 95% CI: 0.51-1.43) compared to using private transportation. Transportation-related interventions and policies are needed to address structural barriers to accessing PrEP services and to improve PrEP persistence in urban areas.

Scoping Conceptions of Equity: Reviewing a Decade of Physical Activity Research

Lee and Cubbin's (2009) call for a "socially just" Ecological Model of Physical Activity (EMPA) prompted an inquiry into physical activity (PA), active living (AL) research that advances social justice framed as a set of equity-centered principles for research. In response to the call, we conducted a scoping review to explore how PAAL research has operationalized equity to advance a socially-just EMPA. We searched for original research, published between 2010 and 2020, using key terms for 'physical activity' and 'equity' that produced 5,152 non-duplicated records. Title-abstract screening for exclusion/inclusion criteria disqualified 4,392 records. A review protocol and coding guide was developed, piloted, and revised by team members. The remaining 760 abstracts were reviewed and consensus coded for PA Variable (dependent or independent) and Factor (individual outcome or contextual exposure), Equity (population demographic or social-environmental determinant), and Social Ecological Milieu (SEM) (PAAL-specific or SEM-general policy, system, or environment (PSE) operations. Of the 463 studies selected, PA codified as an individual outcome (67%) more often than as a contextual-exposure (33%) factor. Equity codified more frequently as a population demographic (69%) rather than as a social-environmental determinant (31%). The SEM codified as PAAL-specific (44%) or as SEM-general (56%) PSE factors. Based on multistep study abstract reviews, the selected studies more often missed the opportunity to center equity in PAAL research by examining social, environmental, political, and systemic factors as institutionalized inequities at the root of PAAL disparities. We will not achieve a socially-just EMPA without shared conceptualizations of equity followed by intentional action.

Health Equity Cannot Be Sought Without the Consideration of Racism In Equity-Focused Urban Health Initiatives

Given that racism is present worldwide, we believe it is imperative to address racism in the pursuit of health equity in cities. Despite the strengths of global urban health efforts in improving health equity, these initiatives can be furthered by explicitly considering systemic racism. Because racism is a major contributor to health issues, utilizing critical race theory (CRT) and taking an anti-racist perspective can help key players understand how racial health differences are initiated and sustained, which will subsequently inform solutions in seeking to address urban health inequities. Applying CRT within policymaking can happen in a variety of ways that are explored in this article. Ultimately, by acknowledging and responding to the effect of racism on groups within cities and the increased difficulties racialized minorities face, international players may use their power to transfer data and resources to cities that could benefit from specialized support.

Characterizing vulnerabilities to climate change across the United States

Climate change will cause a range of related risks, including increases in infectious and chronic disease, intensified social and economic stresses, and more frequent extreme weather events. Vulnerable groups will be disproportionately affected due to greater exposure to climate risks and lower ability to prepare, adapt, and recover from their effects. Better understanding of the intersection of vulnerability and climate change risks is required to identify the most important drivers of future climate risks and effectively build resilience and deploy targeted adaptation efforts. Incorporating community stakeholder input, we identified and integrated available public health, social, economic, environmental, and climate data in the United States (U.S.), comprising 184 indicators, to develop a Climate Vulnerability Index (CVI) composed of four baseline vulnerabilities (health, social/economic, infrastructure, and environment) and three climate change risks (health, social/economic, extreme events). We find that the vulnerability to and risks from climate change are highly heterogeneous across the U.S. at the census tract scale, and geospatially cluster into complementary areas with similar climate risks but differing baseline vulnerabilities. Our results therefore demonstrate that not only are climate change risks both broadly and variably distributed across the U.S., but also that existing disparities are often further exacerbated by climate change. The CVI thus lays a data-driven, scientific foundation for future research on the intersection of climate change risks with health and other inequalities, while also identifying health impacts of climate change as the greatest research gap. Moreover, given U.S. government initiatives surrounding climate and equity, the CVI can be instrumental in empowering communities and policymakers to better prioritize resources and target interventions, providing a template for addressing local-scale climate and environmental justice globally.

Transportation Barriers and Health-Related Quality of Life in a Sample of Middle-Aged and Older Adults Living with HIV in the Deep South

Access to reliable transportation is a social determinant of health imperative for disease management for those aging with HIV/AIDS. To what degree transportation barriers are associated with health-related quality of life (HRQOL) in middle-aged and older people living with HIV (PWH) in the Deep South region of the United States is presently unknown. PWH (n = 261, age range = 39 to 73 years old, 80.1% African American, 64.4% male) were recruited from an academic medical center in the Deep South. Variables included sociodemographics, HIV characteristics, depressive symptoms, HRQOL, and perceived transportation barriers. Spearman rho correlations and linear regressions accounting for covariates were conducted. After accounting for covariates, greater perceived transportation barriers were associated with worse health perceptions, pain, social functioning, health distress, and health transitions. Access to reliable transportation is a key factor in improving health for PWH. Considerations for healthcare and traffic safety are discussed.