Structural Racism, the Social Determination of Health, and Health Inequities: The Intersecting Impacts of Housing and Mass Incarceration

Inequity in US Racial/Ethnic Infant Health and Birth Outcomes: The Role of the Adult Sex Ratio as a Potential Indicator of Structural Anti-Black Racism

BACKGROUND

Structural racism accounts for inequity in health outcomes in ways that are difficult to measure. To conduct more actionable research and measure the impact of intervention programs, there is a need to develop indicator measures of structural racism. One potential candidate is the Adult Sex Ratio (ASR), which was identified by Du Bois as an important indicator of social life functioning over 100 years ago and has remained significant up to the present day. This study investigated the utility of this measure.

METHODS

We compared birth/infant health outcomes using the US 2000 Linked Birth/Infant Death Cohort Data Set matched with 2000 Census data on adult sex ratios in multilevel logistic regression models, stratified by the racial/ethnic category of the mothers.

RESULTS

In an adjusted model, the odds of infant death was 21% higher among non-Hispanic Black (NHB) women living in counties in the lowest ASR tertile category when compared to their counterparts in counties in the highest ASR tertile. Similarly, the odds of giving birth to a preterm or a low birth weight infant were each 20% higher among NHB women living in counties in the lowest ASR tertile compared to their counterparts in counties in the highest ASR tertile.

CONCLUSION

ASRs may serve as a useful indicator of anti-Black structural racism at the local level. More research is needed to determine the circumstances under which this factor may serve to improve assessment of structural racism and facilitate health equity research.

Impact of COVID-19 Pandemic on Social Determinants of Health Issues of Marginalized Black and Asian Communities: A Social Media Analysis Empowered by Natural Language Processing

PURPOSE

This study aims to understand the impact of the COVID-19 pandemic on social determinants of health (SDOH) of marginalized racial/ethnic US population groups, specifically African Americans and Asians, by leveraging natural language processing (NLP) and machine learning (ML) techniques on race-related spatiotemporal social media text data. Specifically, this study establishes the extent to which Latent Dirichlet Allocation (LDA) and Gibbs Sampling Dirichlet Multinomial Mixture (GSDMM)-based topic modeling determines social determinants of health (SDOH) categories, and how adequately custom named-entity recognition (NER) detects key SDOH factors from a race/ethnicity-related Reddit data corpus.

METHODS

In this study, we collected race/ethnicity-specific data from 5 location subreddits including New York City, NY; Los Angeles, CA; Chicago, IL; Philadelphia, PA; and Houston, TX from March to December 2019 (before COVID-19 pandemic) and from March to December 2020 (during COVID-19 pandemic). Next, we applied methods from natural language processing and machine learning to analyze SDOH issues from extracted Reddit comments and conversation threads using feature engineering, topic modeling, and custom named-entity recognition (NER).

RESULTS

Topic modeling identified 35 SDOH-related topics. The SDOH-based custom NER analyses revealed that the COVID-19 pandemic significantly impacted SDOH issues of marginalized Black and Asian communities. On average, the Social and Community Context (SCC) category of SDOH had the highest percent increase (366%) from the pre-pandemic period to the pandemic period across all locations and population groups. Some of the detected SCC issues were racism, protests, arrests, immigration, police brutality, hate crime, white supremacy, and discrimination.

CONCLUSION

Reddit social media platform can be an alternative source to assess the SDOH issues of marginalized Black and Asian communities during the COVID-19 pandemic. By employing NLP/ML techniques such as LDA/GSDMM-based topic modeling and custom NER on a race/ethnicity-specific Reddit corpus, we uncovered various SDOH issues affecting marginalized Black and Asian communities that were significantly worsened during the COVID-19 pandemic. As a result of conducting this research, we recommend that researchers, healthcare providers, and governments utilize social media and collaboratively formulate responses and policies that will address SDOH issues during public health crises.

A Systems Perspective of How Community-Engaged Public Health Addresses Social Determinants of Health: A Case Study of a Population-Based COVID-19 Testing Program

CONTEXT

Despite the recognition that social determinants of health (SDOH) are key to improving the health of all communities, the causality and specific mechanisms through which SDOH impacts health behaviors and outcomes are often ambiguous.

OBJECTIVE

The aim of this study was to use systems thinking to document pathways through which SDOH affected health-seeking behaviors and identify how community engagement strategies intervened to address SDOH barriers.

DESIGN

We leveraged the case context of a large federal initiative (Rapid Acceleration of Diagnostics-Underserved Populations [RADx-UP]) designed to improve COVID-19 testing for underserved populations through community-engaged and participatory approaches. First, we used structured sessions with RADx-UP partners to create causal maps that documented relationships between factors relevant to SDOH, a health-seeking behavior (COVID-19 testing), and community engagement strategies. Second, we searched, reviewed, and tied evidence from RADx-UP peer-reviewed literature to contextualize the causal maps.

RESULTS

We identified 17 unique pathways that linked SDOH to COVID-19 testing. The map also highlighted 3 mechanisms through which the community engagement addressed SDOH: (1) improving access to testing, (2) addressing health and digital literacy, and (3) conducting social needs screening and assistance.

CONCLUSIONS

Our findings highlighted the complexity of public health issues such as COVID-19 and how community engagement is critical to addressing SDOH and health equity. Importantly, dedicating resources to community engagement created positive reinforcing dynamics to improve the health of communities; however, as COVID-19 became better managed, funding also diminished and decreased the capacity for community-engaged efforts. Research in public health needs to focus on understanding and reshaping systems that better support community-engaged efforts.

Examining variation within Hispanic ethnicity: An intersectional multilevel analysis of individual heterogeneity and discriminatory accuracy (MAIHDA) of birthweight inequities in New York City, 2012-2019

Birthweight inequities in the United States have been persistent with variations observed across maternal age, race/ethnicity, education, and nativity status. However, the Hispanic/Latino population is often treated as a monolithic category, ignoring within-group diversity and heterogeneity of health outcomes. This study employed an intersectional MAIHDA (multilevel analysis of individual heterogeneity and discriminatory accuracy) to examine birthweight inequities among singleton births in New York City from 2012 to 2019 (n = 819,920 records of singleton births) by maternal age, race/ethnicity, education, and nativity status, with particular attention to within-group heterogeneity among Hispanic/Latino mothers. Birthweight was measured in grams and was considered continuous for analytical purposes. The analysis was conducted using both the aggregate "Hispanic" category and disaggregated into Hispanic subgroups, based on the country/region of birth as part of the racial/ethnic categories. We found that 2.7%-3.2% of the variation in birthweight means among NYC women lies between intersectional strata, suggesting both meaningful between-stratum birthweight inequities and a high-degree of between-person birthweight variation. The finding of between-stratum inequities is consistent with a difference of 384.7g. between strata with the highest and lowest predicted birthweight means. We found consistent additive inequity patterns in birthweight by maternal age, race/ethnicity, educational attainment, and nativity status. The latter explained 81.2% of the variation in birthweight inequities. While attention to subgroup differences is often limited by sample size, intersectional MAIHDA allows for the identification of between- and within-strata variations regardless of whether Hispanic ethnicity was treated as an aggregate or subgroup based on country/region of origin.

The Role of Social Determinants in Racial and Ethnic Mental Health Disparities: Getting It Right

ABSTRACT

Despite increased research on and attention to mental health, significant racial and ethnic disparities in this area persist. We propose that racial and ethnic disparities in mental health should be examined through the lens of social determinants of mental health (SDoMH). In this perspective article, we review current definitions and frameworks of SDoMH, discuss their strengths and shortcomings, and provide recommendations for a framework to better capture the causal pathways of mental health for racially and ethnically minoritized populations. We also discuss efforts to address SDoMH, focusing on policy-level SDoMH interventions, and review progress and challenges in integrating SDoMH approaches into mental health care.

Institutional, neighborhood, and life stressors on loneliness among older adults

BACKGROUND

Loneliness is a public health epidemic in the United States (US), with older adults being vulnerable to experiencing loneliness. Predictors of loneliness are less understood among racial/ethnic groups of US older adults, and few studies have included perceived institutional discrimination (PID), stressful life events (SLE), and perceived neighborhood characteristics (PNC) as antecedent stressors of loneliness in diverse older adult samples. Our study assessed the relationship between these stressors and loneliness among specific racial/ethnic groups of older adults.

METHODS

We used the Health and Retirement Study data (n = 9,904) to examine whether PID, SLE, and PNC were associated with loneliness. Loneliness was measured using the 11-item UCLA Loneliness Scale. PID included unfairly not hired for a job, unfairly prevented from moving into a neighborhood, and unfairly treated by the police. SLE included moving to a worse neighborhood/residence, being robbed or burglarized, and unemployed/looking for a job. PNC were measured as discohesion and disorder. Lagged multivariate linear regression models regressed loneliness (2014/2016 HRS waves) on PID, SLE and PNC (2010/2012 HRS waves) measured as cumulative totals and individual items. Models were stratified by Black (BOAs), Hispanic/Latinx (HOAs), and White (WOAs) older adults.

RESULTS

Cumulative totals of PID, SLE, and neighborhood discohesion were associated with loneliness among BOAs while only discohesion was associated with loneliness among HOAs. Cumulative totals for PID, SLE, and PNC were associated with loneliness among WOAs. Individual stressors predicting loneliness for BOAs were moving to a worse residence and being robbed/burglarized. For HOAs, being prevented from moving to a neighborhood was associated with greater loneliness while being robbed/burglarized was associated with less loneliness. Individual stressors predicting greater loneliness for WOAs were being unfairly not hired for a job, receiving unfair treatment during police encounters, and moving to a worse residence.

CONCLUSIONS

Our study finds racial/ethnic variation in psychosocial stressors predicting loneliness four years later. Nevertheless, neighborhood discohesion was the most salient stressor and was associated with greater loneliness across all racial/ethnic groups. Future research and interventions should consider the differing stress appraisal processes across groups and to support the development of resources and policies to ameliorate loneliness among diverse older adults.

Pathways to maternal health inequities: Structural racism, sleep, and physiological stress

Racial inequities in health are vast and well-documented, particularly regarding maternal and infant health. Sleep health, including but not limited to duration and quality, is central to overall health and well-being. However, research has not adequately addressed how racism embedded in structures and systems, in addition to individual experiences, may affect maternal health by impacting sleep. In this critical review, we aim to 1) synthesize findings, emphasizing collaborative studies within our group, 2) highlight gaps in knowledge, and 3) propose a theoretical framework and methodological approach for moving the field forward. Specifically, we focus on findings and future directions linking perinatal sleep, cardiovascular and immune function, and racial disparities in maternal health. Because too few studies look beyond individual-level determinants of sleep deficiencies among Black Americans, we assert a critical need for research that bridges multiple levels of analysis (e.g., individual, community, society) and provides recommendations for specific health parameters that researchers in this area can target. Although the need to understand and address perinatal health disparities is clear, the goal of identifying multilevel mechanisms underlying how racism in one's environment and daily life may interact to affect health extends far beyond pregnancy research.

Association between lifetime criminal legal involvement and acute healthcare utilization in middle-aged and older US adults, 2015-2019

BACKGROUND

Five decades into the era of mass incarceration, a growing number of older adults have experienced criminal legal involvement (CLI) in their lifetime. Studies have shown that prior incarceration is associated with substantial disease burden, but little is known about the distinct needs and utilization patterns of middle-aged and older adults with lifetime CLI compared to those without. Using a nationally representative data set, we tested the association between lifetime CLI exposure and use of acute care services among middle-aged and older adults.

METHODS

Our sample included 44,007 US adults (25,074 middle-aged-50-64 years; 18,709 older- ≥65 years) who participated in the National Survey of Drug Use and Health (2015-2019). The data is publicly available. Our independent variable was lifetime CLI. Using separate negative binomial regression models for middle-aged and older adults, we tested the association between lifetime CLI and acute healthcare utilization (ED visits and nights spent inpatient) controlling for relevant sociodemographic covariates.

RESULTS

For middle-aged respondents, 19.1% reported lifetime CLI; for older adults, the rate of exposure was 9.6%. In multivariate models, CLI was associated with increased ED visits in middle-aged adults (IRR 1.18, 95% CI 1.06-1.31) but not older adults (IRR 0.99, 95% CI 0.85-1.16). CLI was associated with increased nights hospitalized in both groups (middle-aged: IRR 1.33, 95% CI 1.08-1.62; older adults: IRR 1.26, 95% CI 1.01, 1.57).

CONCLUSION

Middle-aged and older adults with lifetime CLI experience higher rates of acute care utilization than their peers with no lifetime CLI, even after adjustment for confounders. As the cohort of adults from the era of mass incarceration ages, understanding the mechanisms by which lifetime CLI impacts health outcomes is crucial in designing interventions to improve outcomes and reduce unnecessary acute healthcare utilization.

From Striving to Thriving: Mitigating Anti-Black Family Racism to Maximize Health Outcomes in Black Children

Certain inequities and injustices represent long-standing, recurring challenges that disproportionately affect many Black communities in the United States. Despite decades of efforts to eliminate these problems and improve outcomes in health, housing, education, and employment, a significant number of Black families are still "surviving" and not "thriving." The effects of historical and ongoing discriminatory policies continue to increase risk for adverse outcomes among Black people and their families. These systemic conditions also help perpetuate negative myths and stereotypes associated with the Black family unit, and particularly, Black fathers. In striving to achieve equitable child health outcomes, it is vital for health care professionals to comprehend the tangible traumas that result from experiencing racism. This specific type of harm also acts as a driver for manifestation of developmental, physical, behavioral, and mental health issues in Black children. This review highlights the intersecting dynamics of structural racism, Black family units, and adverse outcomes on child health, development, and behavior. Health care professionals seeking to provide culturally attuned and appropriate anticipatory guidance need to address the effects of racism on social-emotional, language, and cognitive development in children. This includes centering Black family perspectives and advocating for antiracist programs and policies that protect Black children, such as increased support of Black children with special education needs, more equitable funding for neighborhoods where Black families reside, and meaningful efforts to reform criminal justice system practices that unfairly target Black men. By actively mitigating anti-Black racism, Black children and families can shift from surviving to thriving.

Integrating developmental neuroscience with community-engaged approaches to address mental health outcomes for housing-insecure youth: Implications for research, practice, and policy

One in three children in the United States is exposed to insecure housing conditions, including unaffordable, inconsistent, and unsafe housing. These exposures have detrimental impacts on youth mental health. Delineating the neurobehavioral pathways linking exposure to housing insecurity with children's mental health has the potential to inform interventions and policy. However, in approaching this work, carefully considering the lived experiences of youth and families is essential to translating scientific discovery to improve health outcomes in an equitable and representative way. In the current paper, we provide an introduction to the range of stressful experiences that children may face when exposed to insecure housing conditions. Next, we highlight findings from the early-life stress literature regarding the potential neurobehavioral consequences of insecure housing, focusing on how unpredictability is associated with the neural circuitry supporting cognitive and emotional development. We then delineate how community-engaged research (CEnR) approaches have been leveraged to understand the effects of housing insecurity on mental health, and we propose future research directions that integrate developmental neuroscience research and CEnR approaches to maximize the impact of this work. We conclude by outlining practice and policy recommendations that aim to improve the mental health of children exposed to insecure housing.

Critical Self-reflection on Racism by Hospital Physicians in Large German Cities. A Qualitative Reconstructive Study Using Episodic Interviews

Racism permeates healthcare institutions and interpersonal interactions, impacting both staff and patients. The role of doctors, given their influential position in the healthcare system, is particularly crucial in this context. Despite this, there is a scarcity of evidence regarding the manifestation of racism among healthcare professionals in Germany. Critical whiteness studies emphasize the importance of white* individuals engaging in critical self-reflection to mitigate racism. This study aimed to explore the attitudes of white* physicians in hospitals in major German cities towards racism and their critical reflection on personal attitudes and actions concerning racism in interactions with staff members and patients. Data was collected through six episodic interviews with physicians, analyzed using the reconstructive qualitative procedure of the documentary method, leading to a sense-genetic typology. The sense-genetic typology revealed three distinct attitudes towards racism: acknowledging, individualistic, and ignoring. Four types emerged concerning the self-reflection of white doctors: self-critical, socially critical, worried, and defensive. The most promising potential for interventions to reduce racism lies within the self-critical and socially critical types, both demonstrating an acknowledging attitude. Conversely, the worrying and defensive types may present challenges in deconstruction. This suggests that interventions aimed at reducing racism should be tailored and implemented with a nuanced approach.

Association Between Rental Assistance Programs and Undiagnosed Diabetes Among U.S

BACKGROUND

Rental assistance programs have been linked to better housing quality, stability, healthcare access, and reduced likelihood of uncontrolled diabetes. However, its direct association with diabetes screening is uncertain.

OBJECTIVE

To determine whether federal rental assistance programs are associated with lower odds of undiagnosed diabetes.

DESIGN

We used a quasi-experimental approach, comparing outcomes among adults receiving rental assistance to those who entered assisted housing within 2 years after their health data were collected. We test the a priori hypothesis that rental assistance will be associated with decreased odds of undiagnosed diabetes.

PARTICIPANTS

Participants in the National Health and Nutrition Examination Survey 1999-2018 who received rental assistance and who had diabetes.

INTERVENTION

Current rental assistance participation, including specific housing programs.

MAIN MEASURES

Undiagnosed diabetes based on having hemoglobin A1c ≥ 6.5% but answering no to the survey question of being diagnosed with diabetes.

KEY RESULTS

Among 435 eligible adults (median age 54.5 years, female 68.5%, non-Hispanic white 32.5%), 80.7% were receiving rental assistance programs at the time of the interview, and 19.3% went on to receive rental assistance within 2 years. The rates of undiagnosed diabetes were 15.0% and 25.3% among those receiving rental assistance programs vs. those in the future assistance group (p-value = 0.07). In an adjusted logistic regression model, adults receiving rental assistance had lower odds of undiagnosed diabetes (OR 0.52, 95% CI 0.28-0.94) than those in future assistance groups. Sex, race and ethnic group, educational level, and poverty ratio were not significantly associated with having undiagnosed diabetes, but individuals aged 45-64 years had significantly lower odds of undiagnosed diabetes (OR 0.21, 95% CI 0.08-0.53) compared with those aged 18-44.

CONCLUSIONS

Rental assistance was linked to lower odds of undiagnosed diabetes, suggesting that affordable housing programs can aid in early recognition and diagnosis, which may improve long-term outcomes.

Prevalence and risk factors of low birth weight in the United States: An analysis of 2016-2021 data

BACKGROUND

Low birthweight (LBW), infants weighing less than 2,500 g, is a global health concern associated with high infant morbidity and mortality rates. This study investigates LBW prevalence and its relation to maternal sociodemographic characteristics and lifestyle behaviors factors in the United States (US).

METHODS

This analysis used the National Survey of Children's Health (NSCH) data from 2016 to 2021, including n = 225,443 children aged 0-17 years. 18,131 had LBW (<2,500 g), and 2810 had very LBW (VLBW) (<1,500 g). Logistic regression calculated odds ratios (OR) using LBW as the dependent variable, adjusting for various factors.

RESULTS

Between 2016 and 2021 in the United States, LBW prevalence averaged 9.31%, with VLBW at 1.50%. Mothers aged 18-35, White, had the lowest LBW (7.63%) and VLBW (1.17%) rates. Mothers aged ≤18 years, black, had the highest LBW (15.45%) and VLBW infants (4.70%). Maternal age emerged as a significant LBW factor, with an OR of 1.27 for ≤18 and 1.19 for >35. Children in poor health had the highest OR (2.87). Race/ethnicity and other disparities were observed.

CONCLUSION

Our study highlights LBW risk among non-White mothers with specific criteria, emphasizing the need for continued exploration of intersectional targets for change that are exacerbating LBW disparities among marginalized populations which may be artificially attributed to biologic determinants and individual-level risk factors. In-depth analysis of repressive structures at the root of inequalities demand continued research on macro levels of influence. Customized healthcare reform holds the greatest potential to disrupt the patterns contributing to poor health outcomes among LBW children, and will ultimately maximize the reach and effectiveness of health promotion strategies and clinical practices aimed to improve universal maternal and infant health.

Associations of Subjective Memory with Life Space and Neighborhood Built Environment in Older Adults in the ACTIVE Study

Objectives: To investigate the longitudinal association of life space and neighborhood and built environment (NBE) with subjective memory among individuals 65 and older, and the mediating role of depressive symptoms, a major correlate of life space mobility, NBE, and subjective memory. Methods: We examined community-dwelling participants in the Advanced Cognitive Training for Independent and Vital Elderly study (N = 2,622, Mean age = 73.7 years, 24.9% Black) across annual assessments of up to 3 years. Results: Baseline life space and NBE were positively associated with subjective memory, and these associations were partly mediated by depressive symptoms. Over time, higher baseline life space predicted a better subjective memory as one aged. Life space was concurrently associated with subjective memory across time, mediated by concurrent depressive symptoms. Discussion: Potentially modifiable environmental factors such as life space and NBE appear to influence level and change in subjective memory as we age. Interventions supporting movement in our environments may help offset subjective memory problems, a potential early sign of dementia.

Eviction as a community health exposure

Evidence suggests that being evicted harms health. Largely ignored in the existing literature is the possibility that evictions exert community-level health effects, affecting evicted individuals' social networks and shaping broader community conditions. In this narrative review, we summarize evidence and lay out a theoretical model for eviction as a community health exposure, mediated through four paths: 1) shifting ecologies of infectious disease and health behaviors, 2) disruption of neighborhood social cohesion, 3) strain on social networks, and 4) increasing salience of eviction risk. We describe methods for parsing eviction's individual and contextual effects and discuss implications for causal inference. We conclude by addressing eviction's potentially multilevel consequences for policy advocacy and cost-benefit analyses.

The Affordable Rental Housing Crisis and Population Health Equity: a Multidimensional and Multilevel Framework

The US is facing a severe affordable rental housing crisis that contributes to multiple forms of housing insecurity including homelessness, crowded and poor quality housing conditions, unstable housing arrangements, and cost burdens. A considerable body of evidence finds that housing insecurity is an important determinant of health. However, the existing literature may fall short of conceptualizing and measuring the full impact of housing insecurity on population health and on racial health equity. In this paper, we seek to expand the conceptualization of housing as a determinant of population health equity by considering housing insecurity as a manifestation of structural racism that intersects with other manifestations and impacts of structural racism to affect, not only the health of housing insecure individuals, but also the health of the networks and communities in which these individuals live. First, we situate the current housing crisis within larger systems of structural racism. We extend prior work documenting the confluence of ways that racist policies and practices have created unequal burdens of housing insecurity to also discuss the ways that the meanings and impacts of housing insecurity may be shaped by racism. Next, we consider how the health impacts of this unequal burden of housing insecurity can extend beyond individual households to affect networks and communities. Ultimately, we provide a multilevel framework that can inform research, policy, and practice to address housing and health equity.

Using nursing science to advance policy and practice in the context of social and structural determinants of health

BACKGROUND

Social and structural determinants of health play a large role in health inequities.

PURPOSE

To highlight how nursing science can be used to advance policy and practice in the context of social and structural determinants of health.

METHODS

This paper reports on the author's keynote presentation from the 2022 State of The Science Conference on Social and Structural Determinants of Health presented by the Council for the Advancement of Nursing Science. Key concepts are overviewed and defined, followed by examples of two community-engaged research projects with findings that inform practice and policy. The author concludes with individual-, social- and structural-level recommendations as a clarion call for nurses to use research to eliminate health inequities and promote justice for all.

CONCLUSION

What we know is, in part, only as good as what we do with that knowledge. When lives are at stake, gone are the days of knowing something and failing to act on that knowledge.

Disparities in property insurance relief among socially vulnerable Texas communities after Winter Storm Uri

Property insurance is an important tool for resiliency from the accelerating impacts of climate-intensified extreme weather events. However, disparities in property insurance payouts may reduce their potential protective effects. The objective of this study was to quantify disparities in insurance payouts by Texas' insurers after the 2021 Winter Storm Uri, and to understand if any socioeconomic factors were associated with higher rates of declined relief. We extracted data from the Texas Department of Insurance on rates of denied insurance claims by zip code and county at 1 month and 13 months into the recovery period. We then linked these data to community-level socioeconomic information. Finally, we produced separate linear regressions for each predictor and covariate. Across both time points, communities with a higher proportion of Hispanic people, primary Spanish speakers, people who did not graduate high school, and people living below the federal poverty line were significantly more likely to experience denied claims. Communities with higher social vulnerability scores also experienced more denied claims. While financial security is a critical social determinant of health, findings suggest that insurers may be engaging in structurally discriminatory practices and failing to provide relief for people from socially vulnerable communities in the wake of climate-intensified events.

"A Little Bit of a Security Blanket": Renter Experiences with COVID-19-Era Eviction Moratoriums

Policy makers at the federal, state, and local levels responded to the COVID-19 pandemic with a broad array of policies that were intended to prevent housing instability among renters. Eviction moratoriums were an important part of this policy landscape. Recent evidence indicates that these moratoriums were effective in reducing eviction-filing rates, but many questions remain about the impacts of these policies. Drawing on qualitative interviews (N = 60) with renters in three states (Connecticut, Florida, and Ohio) who had experienced eviction or eviction risk during the pandemic, we examine how renters interpreted, experienced, and navigated the moratoriums; how moratoriums shaped their well-being and housing security; how racism may have shaped policy effects; and how these experiences differed across a varied policy landscape. Our findings demonstrate how moratoriums supported renters and how they fell short, offering important lessons for future eviction-prevention and civil-legal policy making.