The association between neighborhood residential rehabilitation and injection drug use in Baltimore, Maryland, 2000-2011

Enhanced Cohort Methods for HIV Research and Epidemiology (ENCORE): Protocol for a Nationwide Hybrid Cohort for Transgender Women in the United States

BACKGROUND

In the United States, transgender women are disproportionately impacted by HIV and prioritized in the national strategy to end the epidemic. Individual, interpersonal, and structural vulnerabilities underlie HIV acquisition among transgender women and fuel syndemic conditions, yet no nationwide cohort monitors their HIV and other health outcomes.

OBJECTIVE

Our objective is to develop a nationwide cohort to estimate HIV incidence, identify risk factors, and investigate syndemic conditions co-occurring with HIV vulnerability or acquisition among US transgender women. The study is informed by the Syndemics Framework and the Social Ecological Model, positing that stigma-related conditions are synergistically driven by shared multilevel vulnerabilities.

METHODS

To address logistical and cost challenges while minimizing technology barriers and research distrust, we aim to establish a novel, hybrid community hub-supported digital cohort (N=3000). The digital cohort is the backbone of the study and is enhanced by hubs strategically located across the United States for increased engagement and in-person support. Study participants are English or Spanish speakers, are aged ≥18 years, identify as transgender women or along the transfeminine spectrum, reside in 1 of the 50 states or Puerto Rico, and do not have HIV (laboratory confirmed). Participants are followed for 24 months, with semiannual assessments. These include a questionnaire and laboratory-based HIV testing using self-collected specimens. Using residential zip codes, person-level data will be merged with contextual geolocated data, including population health measures and economic, housing, and other social and structural factors. Analyses will (1) evaluate the contribution of hub support to the digital cohort using descriptive statistics; (2) estimate and characterize syndemic patterns among transgender women using latent class analysis; (3) examine the role of contextual factors in driving syndemics and HIV prevention over time using multilevel regression models; (4) estimate HIV incidence in transgender women and examine the effect of syndemics and contextual factors on HIV incidence using Poisson regression models; and (5) develop dynamic, compartmental models of multilevel combination HIV prevention interventions among transgender women to simulate their impact on HIV incidence through 2030.

RESULTS

Enrollment launched on March 15, 2023, with data collection phases occurring in spring and fall. As of February 24, 2024, a total of 3084 individuals were screened, and 996 (32.3%) met the inclusion criteria and enrolled into the cohort: 2.3% (23/996) enrolled at a hub, and 53.6% (534/996) enrolled through a community hub-supported strategy. Recruitment through purely digital methods contributed 61.5% (1895/3084) of those screened and 42.7% (425/996) of those enrolled in the cohort.

CONCLUSIONS

Study findings will inform the development of evidence-based interventions to reduce HIV acquisition and syndemic conditions among US transgender women and advance efforts to end the US HIV epidemic. Methodological findings will also have critical implications for the design of future innovative approaches to HIV research.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/59846.

Cross-classified multilevel models (CCMM) in health research: A systematic review of published empirical studies and recommendations for best practices

Recognizing that health outcomes are influenced by and occur within multiple social and physical contexts, researchers have used multilevel modeling techniques for decades to analyze hierarchical or nested data. Cross-Classified Multilevel Models (CCMM) are a statistical technique proposed in the 1990s that extend standard multilevel modeling and enable the simultaneous analysis of non-nested multilevel data. Though use of CCMM in empirical health studies has become increasingly popular, there has not yet been a review summarizing how CCMM are used in the health literature. To address this gap, we performed a scoping review of empirical health studies using CCMM to: (a) evaluate the extent to which this statistical approach has been adopted; (b) assess the rationale and procedures for using CCMM; and (c) provide concrete recommendations for the future use of CCMM. We identified 118 CCMM papers published in English-language literature between 1994 and 2018. Our results reveal a steady growth in empirical health studies using CCMM to address a wide variety of health outcomes in clustered non-hierarchical data. Health researchers use CCMM primarily for five reasons: (1) to statistically account for non-independence in clustered data structures; out of substantive interest in the variance explained by (2) concurrent contexts, (3) contexts over time, and (4) age-period-cohort effects; and (5) to apply CCMM alongside other techniques within a joint model. We conclude by proposing a set of recommendations for use of CCMM with the aim of improved clarity and standardization of reporting in future research using this statistical approach.

"Clear action requires clear thinking": A systematic review of gentrification and health research in the United States

Gentrification is a process in which formerly declining, under-resourced, neighborhoods experience reinvestment and in-migration of increasingly affluent new residents, with understudied implications for individual health and health-protective community resources for low-income and minority residents. Increased attention on urban health inequities have propelled research on the relationship between gentrification and health. Yet, there are significant challenges inherent in the study of gentrification given its non-linear process occurring at multiple levels and via various mechanisms in a complex web of urban systems. How then have empirical studies addressed questions regarding the relationship between gentrification and health and wellness from a conceptual and methodological standpoint? Applying key search terms to PubMed and Web of Science, we identified 546 papers published in the United States. This review is guided by three foundational premises informing the inclusion and exclusion of articles. These include: 1. a clear definition of gentrification and explicit health outcome; 2. identification of a specific geographic context (United States) in which gentrification occurs, and 3. use of a social determinants of health framework to identify potential health outcomes of interest. 17 papers met our inclusion criteria. Through systematic content analysis using MaxQDA software, we evaluated the included studies using three critical frames: 1. conceptualization of gentrification; 2. mechanisms linking gentrification and health; and 3. spatio-temporal considerations. Based on this analysis, we identify the strengths and limitations of existing research, and offer three methodological approaches to strengthen the current literature on gentrification and health. We recommend that future studies: 1. explicitly identify the mechanisms and levels at which processes can occur and systems are organized; 2. incorporate space and time into the analytical strategy and 3. articulate an epistemological standpoint driven by their conceptualization of the exposure and identification of the relevant mechanism and outcome of interest.

Personal and Socioeconomic Determinants in Medication-assisted Treatment of Opioid Use Disorder in Adolescents and Young Adults

Opioid use disorder (OUD) is a pediatric and adolescent problem as most young adults (aged <25 years) in treatment programs report initiating use before 25 years of age, and there are lifelong impacts from early substance use necessitating early screening for opioid use and subsequent treatment. Medication-assisted treatment (MAT) is a highly effective intervention for OUD, and there is strong evidence for its use with adolescents; however, most adolescents with OUD are unable to access MAT or remain in MAT long term to achieve substantial recovery. Using case examples drawn from a pediatric and adolescent physician's experiences proving MAT to adolescents and young adults (ages 16-24 years), this article explores the personal and socioeconomic determinants in MAT of OUD in adolescents and young adults and provides suggestions for advocacy areas and resources to improve MAT with this population.

Negotiating space & drug use in emergency shelters with peer witness injection programs within the context of an overdose crisis: A qualitative study

Vancouver, Canada is experiencing an overdose crisis due to the proliferation of fentanyl and related analogues and novel overdose response interventions are being implemented across multiple high overdose risk environments, including emergency shelters. We draw on ethnographic fieldwork and qualitative interviews to examine how social, structural, and physical contexts at two emergency shelters implementing a peer-based supervised injection intervention influenced injection drug use and overdose risks. Findings reveal that the implementation of this intervention reduced stigma and shame through the normalization of drug use in shelter spaces, and yet underlying social norms and material constraints led people to inject alone in non-designated injecting spaces. Whereas these spatial dynamics of injection drug use potentially increased overdose vulnerability, an emerging sense of collective responsibility in relation to the overdose crisis led to the routinization of peer witnessing practices across the shelter environment to extend the impact of the intervention.

Mapping child maltreatment risk: a 12-year spatio-temporal analysis of neighborhood influences

Background

‘Place’ matters in understanding prevalence variations and inequalities in child maltreatment risk. However, most studies examining ecological variations in child maltreatment risk fail to take into account the implications of the spatial and temporal dimensions of neighborhoods. In this study, we conduct a high-resolution small-area study to analyze the influence of neighborhood characteristics on the spatio-temporal epidemiology of child maltreatment risk.

Methods

We conducted a 12-year (2004–2015) small-area Bayesian spatio-temporal epidemiological study with all families with child maltreatment protection measures in the city of Valencia, Spain. As neighborhood units, we used 552 census block groups. Cases were geocoded using the family address. Neighborhood-level characteristics analyzed included three indicators of neighborhood disadvantage—neighborhood economic status, neighborhood education level, and levels of policing activity—, immigrant concentration, and residential instability. Bayesian spatio-temporal modelling and disease mapping methods were used to provide area-specific risk estimations.

Results

Results from a spatio-temporal autoregressive model showed that neighborhoods with low levels of economic and educational status, with high levels of policing activity, and high immigrant concentration had higher levels of substantiated child maltreatment risk. Disease mapping methods were used to analyze areas of excess risk. Results showed chronic spatial patterns of high child maltreatment risk during the years analyzed, as well as stability over time in areas of low risk. Areas with increased or decreased child maltreatment risk over the years were also observed.

Conclusions

A spatio-temporal epidemiological approach to study the geographical patterns, trends over time, and the contextual determinants of child maltreatment risk can provide a useful method to inform policy and action. This method can offer a more accurate description of the problem, and help to inform more localized prevention and intervention strategies. This new approach can also contribute to an improved epidemiological surveillance system to detect ecological variations in risk, and to assess the effectiveness of the initiatives to reduce this risk.

Social causation and neighborhood selection underlie associations of neighborhood factors with illicit drug-using social networks and illicit drug use among adults relocated from public housing

Theories of social causation and social influence, which posit that neighborhood and social network characteristics are distal causes of substance use, are frequently used to interpret associations among neighborhood characteristics, social network characteristics and substance use. These associations are also hypothesized to result from selection processes, in which substance use determines where people live and who they interact with. The potential for these competing selection mechanisms to co-occur has been underexplored among adults. This study utilizes path analysis to determine the paths that relate census tract characteristics (e.g., economic deprivation), social network characteristics (i.e., having ≥ 1 illicit drug-using network member) and illicit drug use, among 172 African American adults relocated from public housing in Atlanta, Georgia and followed from 2009 to 2014 (7 waves). Individual and network-level characteristics were captured using surveys. Census tract characteristics were created using administrative data. Waves 1 (pre-relocation), 2 (1st wave post-relocation), and 7 were analyzed. When controlling for individual-level sociodemographic factors, residing in census tracts with prior economic disadvantage was significantly associated with illicit drug use at wave 1; illicit drug use at wave 1 was significantly associated with living in economically-disadvantaged census tracts at wave 2; and violent crime at wave 2 was associated with illicit drug-using social network members at wave 7. Findings from this study support theories that describe social causation and neighborhood selection processes as explaining relationships of neighborhood characteristics with illicit drug use and illicit drug-using social networks. Policies that improve local economic and social conditions of neighborhoods may discourage substance use. Future studies should further identify the barriers that prevent substance users from obtaining housing in less disadvantaged neighborhoods.

Salutogenesis: Contextualising place and space in the policies and politics of recovery from drug dependence

This commentary seeks to make a contribution to applied and academic debates concerning recovery from drug dependence. This involves a discussion of various commonalities relating to the places and spaces of substance use/treatment; the identification of various tensions relating to 'structure and agency' in current service provision and the way in which environmentally disparate settings may be synthesised to establish enabling environments of recovery. At the centre of this discussion is Aaron Antonovsky's (1984) model of 'salutogenesis' (and 'salutogenic environments') and how this conceptual framework may be considered and/or applied in the field of recovery from dependent substance use. Whereas public health, clinical intervention and epidemiology each attempt to identify the underlying causation of illness and ill health, salutogenesis is an agency-led concept that seeks to identify the factors and mechanisms that foster good health and the principles of 'keeping well'. It is suggested that a salutogenic approach to recovery options would draw upon the guiding principles of the framework towards advancing, individual level, recovery capital. These principles being (i) the development of social/cultural capital within socially-constructed environments; in which (ii) individual action (or agency) seeks to (iii) manage ill health; recognise the challenges underlying illness and identify the resources that are available to improve health. The author suggests that opportunities for a more 'salutogenic approach' to recovery may be noted within a grassroots model burgeoning throughout parts of the UK (and known as Recovery Cafés). This design is in stark contrast to the State's more structurally-focused treatment options that may not fully appreciate the influence of agency (and the role of place) in attempts to garner recovery capital. In order to demonstrate the academic and applied value of the proposed salutogenic framework to the issue of recovery from dependence (including the centrality of space and place in debate surrounding substance use/treatment), the author draws upon empirical research as well as theoretical and hypothetical frameworks from the discipline of sociology to illustrate throughout.