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Khazanchi R, South EC, Cabrera KI, Winkelman TNA, Vasan A. Health Care Access and Use Among U.S. Children Exposed to Neighborhood Violence. Am J Prev Med 2024; 66:936-947. [PMID: 38416088 DOI: 10.1016/j.amepre.2024.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 01/17/2024] [Accepted: 01/18/2024] [Indexed: 02/29/2024]
Abstract
INTRODUCTION Neighborhood violence is an adverse childhood experience which impacts millions of U.S. children and is associated with poor health outcomes across the life course. These effects may be mitigated by access to care. Yet, the ways in which exposure to neighborhood violence shapes children's health care access have been understudied. METHODS This is a cross-sectional analysis of 16,083 children (weighted N=67,214,201) ages 1 to <18 years from the 2019 and 2021 National Health Interview Survey. Guardians were asked about preventive care access, unmet health needs, and health care utilization in the last year. Changes associated with exposure to neighborhood violence were estimated using marginal effects from multivariable logistic regression models adjusted for year, age, sex, race/ethnicity, parental education, family structure, rurality, income, insurance type, insurance discontinuity, and overall reported health. RESULTS Of 16,083 sample children, 863 (weighted 5.3% [95% CI 4.8-5.7]) reported exposure to neighborhood violence, representing a weighted population of ∼3.5 million. In adjusted analyses, exposure to violence was associated with forgone prescriptions (adjusted difference 1.2 percentage-points (pp) [95%CI 0.1-2.3]; weighted national population impact 42,833 children), trouble paying medical bills (7.7pp [4.4-11.0]; 271,735), delayed medical (1.5pp [0.2-2.9]; 54,063) and mental health care (2.8pp [1.1-4.6]; 98,627), and increased urgent care (4.5pp [0.9-8.1]; 158,246) and emergency department utilization (6.4pp [3.1-9.8]; 227,373). CONCLUSIONS In this nationally representative study, neighborhood violence exposure among children was associated with unmet health needs and increased acute care utilization. Evidence-based interventions to improve access to care and reduce economic precarity in communities impacted by violence are needed to mitigate downstream physical and mental health consequences.
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Affiliation(s)
- Rohan Khazanchi
- Harvard Internal Medicine-Pediatrics Residency Program at Brigham and Women's Hospital, Boston Children's Hospital, and Boston Medical Center, Boston, Massachusetts; FXB Center for Health and Human Rights, Harvard University, Boston, Massachusetts; Health, Homelessness, and Criminal Justice Lab, Hennepin Healthcare Research Institute, Minneapolis, Minnesota.
| | - Eugenia C South
- Urban Health Lab, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Keven I Cabrera
- Urban Health Lab, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Tyler N A Winkelman
- Health, Homelessness, and Criminal Justice Lab, Hennepin Healthcare Research Institute, Minneapolis, Minnesota; Division of General Internal Medicine, Department of Medicine, Hennepin Healthcare, Minneapolis, Minnesota
| | - Aditi Vasan
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia; PolicyLab, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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Jacoby SF, South EC. "Redlining" Maps and Contemporary Firearm Violence Research: Is It Time to Ask New Questions? Ann Intern Med 2024; 177:678-679. [PMID: 38648641 DOI: 10.7326/m24-0870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/25/2024] Open
Affiliation(s)
- Sara F Jacoby
- School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Eugenia C South
- Penn Medicine Center for Health Justice and Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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Ashcraft LE, Cabrera KI, Lane-Fall MB, South EC. Leveraging Implementation Science to Advance Environmental Justice Research and Achieve Health Equity through Neighborhood and Policy Interventions. Annu Rev Public Health 2024; 45:89-108. [PMID: 38166499 DOI: 10.1146/annurev-publhealth-060222-033003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2024]
Abstract
Environmental justice research is increasingly focused on community-engaged, participatory investigations that test interventions to improve health. Such research is primed for the use of implementation science-informed approaches to optimize the uptake and use of interventions proven to be effective. This review identifies synergies between implementation science and environmental justice with the goal of advancing both disciplines. Specifically, the article synthesizes the literature on neighborhood-, community-, and policy-level interventions in environmental health that address underlying structural determinants (e.g., structural racism) and social determinants of health. Opportunities to facilitate and scale the equitable implementation of evidence-based environmental health interventions are highlighted, using urban greening as an illustrative example. An environmental justice-focused version of the implementation science subway is provided, which highlights these principles: Remember and Reflect, Restore and Reclaim, and Reinvest. The review concludes with existing gaps and future directions to advance the science of implementation to promote environmental justice.
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Affiliation(s)
- Laura Ellen Ashcraft
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
- Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA;
| | - Keven I Cabrera
- Division of Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Urban Health Lab, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Meghan B Lane-Fall
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA;
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Penn Implementation Science Center (PISCE), University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Eugenia C South
- Urban Health Lab, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Nguemeni Tiako MJ, South EC. Lessons From an Urban Community Park Renovation Initiative. JAMA Netw Open 2024; 7:e241405. [PMID: 38598243 DOI: 10.1001/jamanetworkopen.2024.1405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/11/2024] Open
Affiliation(s)
- Max Jordan Nguemeni Tiako
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Eugenia C South
- Penn Medicine Center for Health Justice, Philadelphia, Pennsylvania
- Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
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Agarwal AK, Gonzales RE, Sagan C, Nijim S, Asch DA, Merchant RM, South EC. Perspectives of Black Patients on Racism Within Emergency Care. JAMA Health Forum 2024; 5:e240046. [PMID: 38457129 PMCID: PMC10924244 DOI: 10.1001/jamahealthforum.2024.0046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 01/01/2024] [Indexed: 03/09/2024] Open
Abstract
Importance Numerous Black individuals experience racism persistently throughout their lives, with repercussions extending into health care settings. The perspectives of Black individuals regarding emergency department (ED) care, racism, and patient-centered approaches for dismantling structural racism remain less explored. Objective To qualitatively explore the perspectives and experiences of Black patients related to race, racism, and health care following a recent ED visit. Design, Setting, and Participants In this qualitative study, the audio from semistructured interviews of Black patients discharged from an academic urban ED between August 2021 to April 2022 were recorded, transcribed, and analyzed using thematic analysis. Main Outcomes and Measures The main outcomes encompassed the main themes from the analysis of the interviews with Black patients regarding their perspectives on race, racism, and clinical care. Results A total of 25 Black patients (20 [80%] female; mean [SD] age, 44.6 [12.9] years) discharged from the ED were interviewed. Three broad domains were identified: (1) racism in health care; (2) ED clinical care; and (3) recommendations for improvement. Within these domains, the first 2 were grouped into specific themes. Within the first domain, racism in health care, 7 themes were identified using thematic analysis: (1) a history of medical racism; (2) dismissiveness; (3) patient expectations on encountering racism; (4) medical mistrust; (5) health literacy; (6) postencounter outcomes, and (7) discrimination beyond but associated with race. Within the second theme, ED clinical care, 5 themes were identified using the same thematic analysis method: (1) discharge plan; (2) patient experience; (3) waiting room perceptions; (4) medication treatment; and (5) pain management. The third domain, recommendations for improvement, incorporated patient-generated suggestions for enhancing the Black patient experience. Conclusions and Relevance In this qualitative study, the fabric of clinical care delivery in the ED was intricately woven with Black patients' experiences of racism. Patients expressed a pervasive sense of mistrust, skepticism, and dismissiveness at the system level. Instances of racism were consistently highlighted by patients from their entry to the ED to discharge. These perspectives illuminate the pervasive nature of racism in clinical care, providing valuable insights for exploring patient-centered approaches to foster antiracist cultures in the ED and throughout the broader medical landscape.
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Affiliation(s)
- Anish K. Agarwal
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Center for Health Care Transformation and Innovation, University of Pennsylvania, Philadelphia
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Rachel E. Gonzales
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Center for Health Care Transformation and Innovation, University of Pennsylvania, Philadelphia
| | - Charlotte Sagan
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Sally Nijim
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - David A. Asch
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Center for Health Care Transformation and Innovation, University of Pennsylvania, Philadelphia
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Raina M. Merchant
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Center for Health Care Transformation and Innovation, University of Pennsylvania, Philadelphia
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Eugenia C. South
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Center for Health Care Transformation and Innovation, University of Pennsylvania, Philadelphia
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Center for Health Justice, Penn Medicine, University of Pennsylvania, Philadelphia
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Burris HH, Yang N, Riis V, Valeri L, South EC, Ravel J, Elovitz MA. The role of neighborhood deprivation in the cervicovaginal microbiota. Am J Obstet Gynecol MFM 2024; 6:101291. [PMID: 38246324 PMCID: PMC10948309 DOI: 10.1016/j.ajogmf.2024.101291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 01/09/2024] [Accepted: 01/15/2024] [Indexed: 01/23/2024]
Abstract
BACKGROUND Lactobacillus-deficient cervicovaginal microbiota is associated with spontaneous preterm birth and is more common among Black individuals. Persistent racial segregation in the United States has led to differential neighborhood exposures by race that can affect pregnancy outcomes. The extent to which neighborhood exposures may explain racial differences in the cervicovaginal microbiota is unknown. OBJECTIVE This study aimed to determine whether neighborhood deprivation, defined as material community deprivation, is associated with a Lactobacillus-deficient cervicovaginal microbiota in a prospective cohort of pregnant individuals. Our hypothesis was that racial differences in neighborhood deprivation may explain the higher prevalence of Lactobacillus-deficient cervicovaginal microbiota in Black birthing people. STUDY DESIGN This study analyzed data from Motherhood and Microbiome, a prospective pregnancy cohort enrolled from prenatal clinics in a single hospital system 2013-2016 in which a Lactobacillus-deficient cervicovaginal microbiota was previously shown to be associated with spontaneous preterm birth. This study geocoded addresses to obtain census tract neighborhood deprivation data from the Brokamp Nationwide Community Deprivation Index that uses weighted proportions of poverty, income, public assistance, lack of health insurance, and vacant housing. Generalized linear mixed models quantified associations of deprivation with the cervicovaginal microbiota accounting for geographic clustering by census tract and potential confounders. Because of different distributions of neighborhood deprivation and the cervicovaginal microbiota, race-stratified models were used. Mediation analyses quantified the extent to which deprivation may contribute to racial differences in the cervicovaginal microbiota. RESULTS Higher neighborhood deprivation was associated with a Lactobacillus-deficient cervicovaginal microbiota. Per standard deviation increment of deprivation, participants had 28% higher adjusted odds (adjusted odds ratio, 1.28; 95% confidence interval, 1.04-1.58) of a Lactobacillus-deficient microbiota. Black participants had higher odds of a Lactobacillus-deficient microbiota than White participants (adjusted odds ratio, 4.00; 95% confidence interval, 2.05-8.26), and mediation analysis revealed that deprivation accounted for 22% (P=.046) of that disparity. CONCLUSION Neighborhood deprivation was associated with Lactobacillus-deficient cervicovaginal microbiota and may partially explain Black-White disparities in the cervicovaginal microbiota. Mechanistic studies to explore how environmental exposures modify the cervicovaginal microbiota are warranted to identify novel opportunities for future interventional strategies to prevent preterm birth. As the findings demonstrate a potential biological effect from neighborhood conditions, policies that drive urban planning should be explored to improve pregnancy outcomes.
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Affiliation(s)
- Heather H Burris
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA (Dr Burris); Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA (Dr Burris); Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia, PA (Dr Burris).
| | - Nancy Yang
- University of California San Francisco Medical School, San Francisco, CA (Ms. Yang)
| | - Valerie Riis
- Women's Biomedical Research Institute, Icahn School of Medicine, New York, NY (Ms. Riis and Dr. Elovitz)
| | - Linda Valeri
- Department of Biostatistics, Columbia University Mailman School of Public Health, New York, NY (Dr. Valeri)
| | - Eugenia C South
- Penn Urban Health Lab, Department of Emergency Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA (Dr. South)
| | - Jacques Ravel
- Institute for Genome Sciences and Department of Microbiology and Immunology, University of Maryland School of Medicine, Baltimore, MD (Dr. Ravel)
| | - Michal A Elovitz
- Women's Biomedical Research Institute, Icahn School of Medicine, New York, NY (Ms. Riis and Dr. Elovitz); Department of Obstetrics, Gynecology, and Reproductive Sciences, Icahn School of Medicine, New York, NY (Dr. Elovitz)
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Dolin CD, Mullin AM, Ledyard RF, Bender WR, South EC, Durnwald CP, Burris HH. Neighborhood Deprivation and Racial Disparities in Early Pregnancy Impaired Glucose Tolerance. Int J Environ Res Public Health 2023; 20:6175. [PMID: 37372761 PMCID: PMC10298257 DOI: 10.3390/ijerph20126175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 05/30/2023] [Accepted: 06/02/2023] [Indexed: 06/29/2023]
Abstract
OBJECTIVE There is mounting evidence that neighborhoods contribute to perinatal health inequity. We aimed (1) to determine whether neighborhood deprivation (a composite marker of area-level poverty, education, and housing) is associated with early pregnancy impaired glucose intolerance (IGT) and pre-pregnancy obesity and (2) to quantify the extent to which neighborhood deprivation may explain racial disparities in IGT and obesity. STUDY DESIGN This was a retrospective cohort study of non-diabetic patients with singleton births ≥ 20 weeks' gestation from 1 January 2017-31 December 2019 in two Philadelphia hospitals. The primary outcome was IGT (HbA1c 5.7-6.4%) at <20 weeks' gestation. Addresses were geocoded and census tract neighborhood deprivation index (range 0-1, higher indicating more deprivation) was calculated. Mixed-effects logistic regression and causal mediation models adjusted for covariates were used. RESULTS Of the 10,642 patients who met the inclusion criteria, 49% self-identified as Black, 49% were Medicaid insured, 32% were obese, and 11% had IGT. There were large racial disparities in IGT (16% vs. 3%) and obesity (45% vs. 16%) among Black vs. White patients, respectively (p < 0.0001). Mean (SD) neighborhood deprivation was higher among Black (0.55 (0.10)) compared with White patients (0.36 (0.11)) (p < 0.0001). Neighborhood deprivation was associated with IGT and obesity in models adjusted for age, insurance, parity, and race (aOR 1.15, 95%CI: 1.07, 1.24 and aOR 1.39, 95%CI: 1.28, 1.52, respectively). Mediation analysis revealed that 6.7% (95%CI: 1.6%, 11.7%) of the Black-White disparity in IGT might be explained by neighborhood deprivation and 13.3% (95%CI: 10.7%, 16.7%) by obesity. Mediation analysis also suggested that 17.4% (95%CI: 12.0%, 22.4%) of the Black-White disparity in obesity may be explained by neighborhood deprivation. CONCLUSION Neighborhood deprivation may contribute to early pregnancy IGT and obesity-surrogate markers of periconceptional metabolic health in which there are large racial disparities. Investing in neighborhoods where Black patients live may improve perinatal health equity.
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Affiliation(s)
- Cara D. Dolin
- Department of Obstetrics and Gynecology, Women’s Health Institute, Cleveland Clinic Lerner College of Medicine, Cleveland, OH 44195, USA
| | - Anne M. Mullin
- Tufts University School of Medicine, Boston, MA 02111, USA
| | - Rachel F. Ledyard
- Division of Neonatology, Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Whitney R. Bender
- Department of Obstetrics and Gynecology, Virginia Commonwealth University School of Medicine, Richmond, VA 23298, USA
| | - Eugenia C. South
- Urban Health Lab, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Celeste P. Durnwald
- Department of Obstetrics and Gynecology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA
| | - Heather H. Burris
- Division of Neonatology, Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA 19104, USA
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- Leonard Davis Institute, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
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Seeburger EF, Gonzales R, South EC, Friedman AB, Agarwal AK. Qualitative Perspectives of Emergency Nurses on Electronic Health Record Behavioral Flags to Promote Workplace Safety. JAMA Netw Open 2023; 6:e239057. [PMID: 37079303 PMCID: PMC10119742 DOI: 10.1001/jamanetworkopen.2023.9057] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 03/06/2023] [Indexed: 04/21/2023] Open
Abstract
Importance Emergency nurses experience high levels of workplace violence during patient interactions. Little is known about the efficacy of behavioral flags, which are notifications embedded within electronic health records (EHRs) as a tool to promote clinician safety. Objective To explore the perspectives of emergency nurses on EHR behavioral flags, workplace safety, and patient care. Design, Setting, and Participants In this qualitative study, semistructured interviews were conducted with emergency nurses at an academic, urban emergency department (ED) between February 8 and March 25, 2022. Interviews were audio recorded, transcribed, and analyzed using thematic analysis. Data analysis was performed from April 2 to 13, 2022. Main Outcomes and Measures Themes and subthemes of nursing perspectives on EHR behavioral flags were identified. Results This study included 25 registered emergency nurses at a large academic health system, with a mean (SD) tenure of 5 (6) years in the ED. Their mean (SD) age was 33 (7) years; 19 were women (76%) and 6 were men (24%). Participants self-reported their race as Asian (3 [12%]), Black (3 [12%]), White (15 [60%]), or multiple races (2 [8%]); 3 participants (12%) self-reported their ethnicity as Hispanic or Latinx. Five themes (with subthemes) were identified: (1) benefits of flags (useful advisory; prevents violence; engenders compassion), (2) issues with flags (administrative and process issues; unhelpful; unenforceable; bias; outdated), (3) patient transparency (patient accountability; damages patient-clinician relationship), (4) system improvements (process; built environment; human resources; zero-tolerance policies), and (5) difficulties of working in the ED (harassment and abuse; unmet mental health needs of patients; COVID-19-related strain and burnout). Conclusions and Relevance In this qualitative study, nursing perspectives on the utility and importance of EHR behavioral flags varied. For many, flags served as an important forewarning to approach patient interactions with more caution or use safety skills. However, nurses were skeptical of the ability of flags to prevent violence from occurring and noted concern for the unintended consequences of introducing bias into patient care. These findings suggest that changes to the deployment and utilization of flags, in concert with other safety interventions, are needed to create a safer work environment and mitigate bias.
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Affiliation(s)
- Emily F. Seeburger
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Center for Emergency Care Policy and Research, University of Pennsylvania, Philadelphia
- Penn Urban Health Lab, University of Pennsylvania, Philadelphia
| | - Rachel Gonzales
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Center for Emergency Care Policy and Research, University of Pennsylvania, Philadelphia
- Penn Medicine Center for Health Care Innovation, University of Pennsylvania, Philadelphia
| | - Eugenia C. South
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Center for Emergency Care Policy and Research, University of Pennsylvania, Philadelphia
- Penn Urban Health Lab, University of Pennsylvania, Philadelphia
| | - Ari B. Friedman
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Center for Emergency Care Policy and Research, University of Pennsylvania, Philadelphia
| | - Anish K. Agarwal
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Center for Emergency Care Policy and Research, University of Pennsylvania, Philadelphia
- Penn Medicine Center for Health Care Innovation, University of Pennsylvania, Philadelphia
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Unachukwu IC, Abrams MP, Dolan A, Oyekemi K, Meisel ZF, South EC, Aronowitz SV. "The new normal has become a nonstop crisis": a qualitative study of burnout among Philadelphia's harm reduction and substance use disorder treatment workers during the COVID-19 pandemic. Harm Reduct J 2023; 20:32. [PMID: 36906576 PMCID: PMC10008076 DOI: 10.1186/s12954-023-00752-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Accepted: 02/07/2023] [Indexed: 03/13/2023] Open
Abstract
BACKGROUND The COVID-19 pandemic worsened the ongoing overdose crisis in the United States (US) and caused significant mental health strain and burnout among health care workers (HCW). Harm reduction, overdose prevention, and substance use disorder (SUD) workers may be especially impacted due to underfunding, resources shortages, and chaotic working environments. Existing research on HCW burnout primarily focuses on licensed HCWs in traditional environments and fails to account for the unique experiences of harm reduction workers, community organizers, and SUD treatment clinicians. METHODS We conducted a qualitative secondary analysis descriptive study of 30 Philadelphia-based harm reduction workers, community organizers, and SUD treatment clinicians about their experiences working in their roles during the COVID-19 pandemic in July-August 2020. Our analysis was guided by Shanafelt and Noseworthy's model of key drivers of burnout and engagement. We aimed to assess the applicability of this model to the experiences of SUD and harm reduction workers in non-traditional settings. RESULTS We deductively coded our data in alignment with Shanafelt and Noseworthy's key drivers of burnout and engagement: (1) workload and job demands, (2) meaning in work, (3) control and flexibility, (4) work-life integration, (5) organizational culture and values, (6) efficiency and resources and (7) social support and community at work. While Shanafelt and Noseworthy's model broadly encompassed the experiences of our participants, it did not fully account for their concerns about safety at work, lack of control over the work environment, and experiences of task-shifting. CONCLUSIONS Burnout among healthcare providers is receiving increasing attention nationally. Much of this coverage and the existing research have focused on workers in traditional healthcare spaces and often do not consider the experiences of community-based SUD treatment, overdose prevention, and harm reduction providers. Our findings indicate a gap in existing frameworks for burnout and a need for models that encompass the full range of the harm reduction, overdose prevention, and SUD treatment workforce. As the US overdose crisis continues, it is vital that we address and mitigate experiences of burnout among harm reduction workers, community organizers, and SUD treatment clinicians to protect their wellbeing and to ensure the sustainability of their invaluable work.
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Affiliation(s)
- Ijeoma C Unachukwu
- Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA. .,Urban Health Lab, University of Pennsylvania, Philadelphia, PA, USA.
| | - Matthew P Abrams
- Center for Emergency Care Policy and Research, University of Pennsylvania, Philadelphia, PA, USA
| | - Abby Dolan
- Center for Emergency Care Policy and Research, University of Pennsylvania, Philadelphia, PA, USA
| | - Kehinde Oyekemi
- Urban Health Lab, University of Pennsylvania, Philadelphia, PA, USA
| | - Zachary F Meisel
- Center for Emergency Care Policy and Research, University of Pennsylvania, Philadelphia, PA, USA
| | - Eugenia C South
- Urban Health Lab, University of Pennsylvania, Philadelphia, PA, USA
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Agarwal AK, Seeburger E, O’Neill G, Nwakanma CC, Marsh LE, Soltany KA, South EC, Friedman AB. Prevalence of Behavioral Flags in the Electronic Health Record Among Black and White Patients Visiting the Emergency Department. JAMA Netw Open 2023; 6:e2251734. [PMID: 36656576 PMCID: PMC9857105 DOI: 10.1001/jamanetworkopen.2022.51734] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
IMPORTANCE Behavioral flags in the electronic health record (EHR) are designed to alert clinicians of potentially unsafe or aggressive patients. These flags may introduce bias, and understanding how they are used is important to ensure equitable care. OBJECTIVE To investigate the incidence of behavioral flags and assess whether there were differences between Black and White patients and whether the flags were associated with differences in emergency department (ED) clinical care. DESIGN, SETTING, AND PARTICIPANTS This was a retrospective cohort study of EHR data of adult patients (aged ≥18 years) from 3 Philadelphia, Pennsylvania, EDs within a single health system between January 1, 2017, and December 31, 2019. Secondary analyses excluded patients with sickle cell disease and high ED care utilization. Data were analyzed from February 1 to April 4, 2022. MAIN OUTCOMES AND MEASURES The primary outcome of interest was the presence of an EHR behavioral flag. Secondary measures included variation of flags across sex, race, age, insurance status, triage status, ED clinical care metrics (eg, laboratory, medication, and radiology orders), ED disposition (discharge, admission, or observation), and length of key intervals during ED care. RESULTS Participating EDs had 195 601 eligible patients (110 890 [56.7%] female patients; 113 638 Black patients [58.1%]; 81 963 White patients [41.9%]; median [IQR] age, 42 [28-60] years), with 426 858 ED visits. Among these, 683 patients (0.3%) had a behavioral flag notification in the EHR (3.5 flags per 1000 patients), and it was present for 6851 ED visits (16 flagged visits per 1000 visits). Patient differences between those with a flag and those without included male sex (56.1% vs 43.3%), Black race (71.2% vs 56.7%), and insurance status, particularly Medicaid insurance (74.5% vs 36.3%). Flag use varied across sites. Black patients received flags at a rate of 4.0 per 1000 patients, and White patients received flags at a rate of 2.4 per 1000 patients (P < .001). Among patients with a flag, Black patients, compared with White patients, had longer waiting times to be placed in a room (median [IQR] time, 28.0 [10.5-89.4] minutes vs 18.2 [7.2-75.1] minutes; P < .001), longer waiting times to see a clinician (median [IQR] time, 42.1 [18.8-105.5] minutes vs 33.3 [15.3-84.5] minutes; P < .001), and shorter lengths of stay (median [IQR] time, 274 [135-471] minutes vs 305 [154-491] minutes; P = .01). Black patients with a flag underwent fewer laboratory (eg, 2449 Black patients with 0 orders [43.4%] vs 441 White patients with 0 orders [36.7%]; P < .001) and imaging (eg, 3541 Black patients with no imaging [62.7%] vs 675 White patients with no imaging [56.2%]; P < .001) tests compared with White patients with a flag. CONCLUSIONS AND RELEVANCE This cohort study found significant differences in ED clinical care metrics, including that flagged patients had longer wait times and were less likely to undergo laboratory testing and imaging, which was amplified in Black patients.
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Affiliation(s)
- Anish K. Agarwal
- Department of Emergency Medicine, University of Pennsylvania, Perelman School of Medicine, Philadelphia
- Center for Emergency Care Policy and Research, Philadelphia, Pennsylvania
- Penn Medicine Center for Health Care Innovation, Philadelphia, Pennsylvania
| | - Emily Seeburger
- Department of Emergency Medicine, University of Pennsylvania, Perelman School of Medicine, Philadelphia
- Center for Emergency Care Policy and Research, Philadelphia, Pennsylvania
| | - Gerald O’Neill
- Department of Emergency Medicine, University of Pennsylvania, Perelman School of Medicine, Philadelphia
| | - Chidinma C. Nwakanma
- Department of Emergency Medicine, University of Pennsylvania, Perelman School of Medicine, Philadelphia
| | - Lillian E. Marsh
- Department of Emergency Medicine, University of Pennsylvania, Perelman School of Medicine, Philadelphia
| | | | - Eugenia C. South
- Department of Emergency Medicine, University of Pennsylvania, Perelman School of Medicine, Philadelphia
- Center for Emergency Care Policy and Research, Philadelphia, Pennsylvania
| | - Ari B. Friedman
- Department of Emergency Medicine, University of Pennsylvania, Perelman School of Medicine, Philadelphia
- Center for Emergency Care Policy and Research, Philadelphia, Pennsylvania
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11
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Barry F, Riis V, Ncube L, Elovitz MA, South EC, Burris HH. Self-reported greenspace exposure and perceived stress in a Black pregnancy cohort. Am J Obstet Gynecol 2023. [DOI: 10.1016/j.ajog.2022.11.836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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12
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South EC, MacDonald JM, Tam VW, Ridgeway G, Branas CC. Effect of Abandoned Housing Interventions on Gun Violence, Perceptions of Safety, and Substance Use in Black Neighborhoods: A Citywide Cluster Randomized Trial. JAMA Intern Med 2023; 183:31-39. [PMID: 36469329 PMCID: PMC9857286 DOI: 10.1001/jamainternmed.2022.5460] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 10/07/2022] [Indexed: 12/12/2022]
Abstract
Importance Structural racism has resulted in long-standing disinvestment and dilapidated environmental conditions in Black neighborhoods. Abandoned houses signal neglect and foster stress and fear for residents, weakening social ties and potentially contributing to poor health and safety. Objective To determine whether abandoned house remediation reduces gun violence and substance-related outcomes and increases perceptions of safety and use of outdoor space. Design, Setting, and Participants This cluster randomized trial was conducted from January 2017 to August 2020, with interventions occurring between August 2018 and March 2019. The study included abandoned houses across Philadelphia, Pennsylvania, and surveys completed by participants living nearby preintervention and postintervention. Data analysis was performed from March 2021 to September 2022. Interventions The study consisted of 3 arms: (1) full remediation (installing working windows and doors, cleaning trash, weeding); (2) trash cleanup and weeding only; and (3) a no-intervention control. Main Outcomes and Measures Difference-in-differences mixed-effects regression models were used to estimate the effect of the interventions on multiple primary outcomes: gun violence (weapons violations, gun assaults, and shootings), illegal substance trafficking and use, public drunkenness, and perceptions of safety and time outside for nearby residents. Results A master list of 3265 abandoned houses was randomly sorted. From the top of this randomly sorted list, a total of 63 clusters containing 258 abandoned houses were formed and then randomly allocated to 3 study arms. Of the 301 participants interviewed during the preintervention period, 172 (57.1%) were interviewed during the postintervention period and were included in this analysis; participants were predominantly Black, and most were employed. Study neighborhoods were predominantly Black with high percentages of low-income households. Gun violence outcomes increased in all study arms, but increased the least in the full remediation arm. The full housing remediation arm, compared with the control condition, showed reduced weapons violations by -8.43% (95% CI, -14.68% to -1.19%), reduced gun assaults by -13.12% (95% CI, -21.32% to -3.01%), and reduced shootings by a nonsignificant -6.96% (95% CI, -15.32% to 3.03%). The trash cleanup arm was not associated with a significant differential change in any gun violence outcome. Instances of illegal substance trafficking and use and public drunkenness outcomes were not significantly affected by the housing remediation or trash cleanup treatment. Perceptions of neighborhood safety and time spent outside were unaffected by the intervention. The study arms did differ in a baseline characteristic and some preintervention trends, which raises questions regarding other potential nonmeasured differences between study arms that could have influenced estimates. No evidence of displacement of gun violence outcomes was found. Conclusions and Relevance In this cluster randomized controlled trial among low-income, predominantly Black neighborhoods, inexpensive, straightforward abandoned housing remediation was directly linked to significant relative reductions in weapons violations and gun assaults, and suggestive reductions in shootings. Trial Registration isrctn.org Identifier: ISRCTN14973997.
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Affiliation(s)
- Eugenia C. South
- Urban Health Lab, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - John M. MacDonald
- Department of Criminology and Sociology, School of Arts and Sciences, University of Pennsylvania, Philadelphia
| | - Vicky W. Tam
- Data Science and Biostatistics Unit, Department of Biomedical and Health Informatics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Greg Ridgeway
- Department of Criminology, School of Arts and Sciences, University of Pennsylvania, Philadelphia
- Department of Statistics and Data Science, Wharton School, University of Pennsylvania, Philadelphia
| | - Charles C. Branas
- Department of Epidemiology, Center for Injury Science and Prevention, Mailman School of Public Health, Columbia University, New York, New York
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13
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Agarwal AK, Sagan C, Gonzales R, Nijim S, Merchant RM, Asch DA, South EC. Assessing experiences of racism among Black and White patients in the emergency department. J Am Coll Emerg Physicians Open 2022; 3:e12870. [PMID: 36570372 PMCID: PMC9772489 DOI: 10.1002/emp2.12870] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 10/25/2022] [Accepted: 11/22/2022] [Indexed: 12/24/2022] Open
Abstract
Objective The objective of this study was to investigate the differences in patient-reported experiences related to emergency department (ED) care using a post-discharge text messaging survey. Methods This was a prospective cohort study of patients discharged from the ED using an automated text messaging platform to assess patient experience and impact of race on ED care. The study was conducted for 7 weeks between August 6 and September 24, 2021. Participants included adults (aged ≥18 years) discharged from 2 urban, academic EDs with an active mobile phone number in the electronic health record. The primary outcome of interest was patient-reported impact of race on overall rating of ED care. Secondary outcomes included overall satisfaction with care and perceived impact of race on components of care, including respect, communication, and quality of care. A 6-point Likert scale was used, and chi-square and Wilcoxon rank sum tests were used to analyze responses. Results A total of 590 (14%) discharged patients consented, and 462 patients completed the entire survey; the mean age was 43 years (SD 17.3); 67% were women, and 60.0% were Black. Black patients reported a higher overall rating of ED care (median 5 [3, 5]; P = 0.013). Proportionately, when compared with White patients, more Black patients reported that race negatively impacted the rating of care (10.8% vs 1.4%; P = 0.002). More than a quarter of Black patients (27.4%) reported race highly impacting being treated with respect (P = 0.024), and 22.4% reported a high impact on quality of service (P = 0.003) when compared with White patients. Conclusion Health systems lack methods that specifically identify patient experiences of racism. We demonstrate the feasibility of using text messaging to collect patient-reported experiences of racism. For a significant number of Black patients, race negatively impacted their care, including communication, quality, and respect.
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Affiliation(s)
- Anish K. Agarwal
- Department of Emergency MedicinePerelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA,Leonard Davis Institute of Health EconomicsUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA,Center for Health Care InnovationUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA,Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Charlotte Sagan
- Department of Emergency MedicinePerelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Rachel Gonzales
- Department of Emergency MedicinePerelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Sally Nijim
- Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Raina M. Merchant
- Department of Emergency MedicinePerelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA,Leonard Davis Institute of Health EconomicsUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA,Center for Health Care InnovationUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA,Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - David A. Asch
- Leonard Davis Institute of Health EconomicsUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA,Center for Health Care InnovationUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA,Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Eugenia C. South
- Department of Emergency MedicinePerelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA,Leonard Davis Institute of Health EconomicsUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA,Center for Health Care InnovationUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA,Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
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14
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Jay J, Kondo MC, Lyons VH, Gause E, South EC. Neighborhood segregation, tree cover and firearm violence in 6 U.S. cities, 2015-2020. Prev Med 2022; 165:107256. [PMID: 36115422 PMCID: PMC10903784 DOI: 10.1016/j.ypmed.2022.107256] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 08/31/2022] [Accepted: 09/07/2022] [Indexed: 11/17/2022]
Abstract
Neighborhood segregation by race and income is a structural determinant of firearm violence. Addressing green space deficits in segregated neighborhoods is a promising prevention strategy. This study assessed the potential for reducing firearm violence disparities by increasing access to tree cover. Units of analysis were census tracts in six U.S. cities (Baltimore, MD; Philadelphia, PA; Richmond, VA; Syracuse, NY; Washington, DC; Wilmington, DE). We measured segregation using the index of concentration at the extremes (ICE) for race-income. We calculated proportion tree cover based on 2013-2014 imagery. Outcomes were 2015-2020 fatal and non-fatal shootings from the Gun Violence Archive. We modeled firearm violence as a function of ICE, tree cover, and covariates representing the social and built environment. Next, we simulated possible effects of "tree equity" programs, i.e., raising tract-level tree cover to a specified baseline level. In our fully-adjusted model, higher privilege on the ICE measure (1 standard deviation, SD) was associated with a 42% reduction in shootings (incidence rate ratio (IRR) = 0.58, 95% CI [0.54 0.62], p < 0.001). A 1-SD increase in tree cover was associated with a 9% reduction (IRR = 0.91, 95% CI [0.86, 0.97], p < 0.01). Simulated achievement of 40% baseline tree cover was associated with reductions in firearm violence, with the largest reductions in highly-deprived neighborhoods. Advancing tree equity would not disrupt the fundamental causes of racial disparities in firearm violence exposure, but may have the potential to help mitigate those disparities.
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Affiliation(s)
- Jonathan Jay
- Department of Community Health Sciences, Boston University School of Public Health, Boston, MA, USA.
| | - Michelle C Kondo
- USDA Forest Service, Northern Research Station, Philadelphia, PA, USA
| | - Vivian H Lyons
- Social Development Research Group, School of Social Work, University of Washington, Seattle, WA, USA
| | - Emma Gause
- Firearm Injury and Policy Research Program, Harborview Injury Prevention and Research Program, University of Washington, Seattle, WA, USA
| | - Eugenia C South
- Urban Health Lab, Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA, USA
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15
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South EC, Hemenway D, Webster DW. Gun violence research is surging to inform solutions to a devastating public health crisis. Prev Med 2022; 165:107325. [PMID: 36374716 PMCID: PMC9642971 DOI: 10.1016/j.ypmed.2022.107325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Eugenia C South
- Urban Health Lab, Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA, United States of America.
| | - David Hemenway
- Harvard Injury Control Research Center, Boston, MA, United States of America
| | - Daniel W Webster
- Johns Hopkins Center for Gun Violence Prevention and Policy, Baltimore, MD, United States of America
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16
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Nguemeni Tiako MJ, Meinhofer A, Friedman A, South EC, Epstein RL, Meisel ZF, Morgan JR. Buprenorphine uptake during pregnancy following the 2017 guidelines update on prenatal opioid use disorder. Am J Obstet Gynecol 2022; 227:544-546.e1. [PMID: 35613648 PMCID: PMC9420821 DOI: 10.1016/j.ajog.2022.05.041] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 05/18/2022] [Indexed: 11/01/2022]
Affiliation(s)
- Max Jordan Nguemeni Tiako
- Department of Internal Medicine, Brigham and Women's Hospital, 75 Francis St., Boston, MA 02134; Harvard Medical School, Boston, MA; Urban Health Lab, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Center for Emergency Care and Policy Research, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Center for Health Economics of Treatment Interventions for Substance Use Disorder, HCV, and HIV, Philadelphia, PA.
| | - Angelica Meinhofer
- Center for Health Economics of Treatment Interventions for Substance Use Disorder, HCV, and HIV, Philadelphia, PA; Weill Cornell School of Medicine, New York, NY
| | - Ari Friedman
- Center for Emergency Care and Policy Research, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute, Wharton School of Management, University of Pennsylvania, Philadelphia, PA
| | - Eugenia C South
- Urban Health Lab, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Center for Emergency Care and Policy Research, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute, Wharton School of Management, University of Pennsylvania, Philadelphia, PA
| | - Rachel L Epstein
- Section of Infectious Diseases, Department of Medicine, Boston University School of Medicine, Boston, MA
| | - Zachary F Meisel
- Center for Emergency Care and Policy Research, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Center for Health Economics of Treatment Interventions for Substance Use Disorder, HCV, and HIV, Philadelphia, PA; Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute, Wharton School of Management, University of Pennsylvania, Philadelphia, PA
| | - Jake R Morgan
- Center for Health Economics of Treatment Interventions for Substance Use Disorder, HCV, and HIV, Philadelphia, PA; Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, MA
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17
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Eberly LA, Julien H, South EC, Venkataraman A, Nathan AS, Anyawu EC, Dayoub E, Groeneveld PW, Khatana SAM. Association Between Community‐Level Violent Crime and Cardiovascular Mortality in Chicago: A Longitudinal Analysis. J Am Heart Assoc 2022; 11:e025168. [PMID: 35861831 PMCID: PMC9707824 DOI: 10.1161/jaha.122.025168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background
Violent crime has recently increased in many major metropolitan cities in the United States. Prior studies suggest an association between neighborhood crime levels and cardiovascular disease, but many have been limited by cross‐sectional designs. We investigated whether longitudinal changes in violent crime rates are associated with changes in cardiovascular mortality rates at the community level in one large US city‐Chicago, IL.
Methods and Results
Chicago is composed of 77 community areas. Age‐adjusted mortality rates by community area for cardiovascular disease, stroke, and coronary artery disease from 2000 to 2014, aggregated at 5‐year intervals, were obtained from the Illinois Department of Public Health Division of Vital Records. Mean total and violent crime rates by community area were obtained from the City of Chicago Police Data Portal. Using a 2‐way fixed effects estimator, we assessed the association between longitudinal changes in violent crime and cardiovascular mortality rates after accounting for changes in demographic and economic variables and secular time trends at the community area level from 2000 to 2014. Between 2000 and 2014, the median violent crime rate in Chicago decreased from 3620 per 100 000 (interquartile range [IQR], 2256, 7777) in the 2000 to 2004 period to 2390 (IQR 1507, 5745) in the 2010 to 2014 period (
P
=0.005 for trend). In the fixed effects model a 1% decrease in community area violent crime rate was associated with a 0.21% (95% CI, 0.09–0.33) decrease in cardiovascular mortality rates (
P
=<0.001) and a 0.19% (95% CI, 0.04–0.33) decrease in coronary artery disease mortality rates (
P
=0.01). There was no statistically significant association between change in violent crime and stroke mortality rates (−0.17% [95% CI, −0.42 to 0.08;
P
=0.18]).
Conclusions
From 2000 to 2014, a greater decrease in violent crime at the community area level was associated with a greater decrease in cardiovascular and coronary artery disease mortality rates in Chicago. These findings add to the growing evidence of the impact of the built environment on health and implicate violent crime exposure as a potential social determinant of cardiovascular health. Targeted investment in communities to decrease violent crime may improve community cardiovascular health.
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Affiliation(s)
- Lauren A. Eberly
- Cardiovascular Division Perelman School of Medicine at the University of Pennsylvania Philadelphia PA
- Center for Cardiovascular Outcomes, Quality, and Evaluative Research University of Pennsylvania Philadelphia PA
- Penn Cardiovascular Center for Health Equity and Social Justice University of Pennsylvania Philadelphia PA
- Leonard Davis Institute of Health Economics at the University of Pennsylvania Philadelphia PA
| | - Howard Julien
- Cardiovascular Division Perelman School of Medicine at the University of Pennsylvania Philadelphia PA
- Center for Cardiovascular Outcomes, Quality, and Evaluative Research University of Pennsylvania Philadelphia PA
- Penn Cardiovascular Center for Health Equity and Social Justice University of Pennsylvania Philadelphia PA
| | - Eugenia C. South
- Leonard Davis Institute of Health Economics at the University of Pennsylvania Philadelphia PA
- Urban Health Lab, Department of Emergency Medicine Perelman School of Medicine at the University of Pennsylvania Philadelphia PA
| | - Atheendar Venkataraman
- Leonard Davis Institute of Health Economics at the University of Pennsylvania Philadelphia PA
- Department of Medical Ethics and Health Policy, Perelman School of Medicine University of Pennsylvania Philadelphia PA
| | - Ashwin S. Nathan
- Cardiovascular Division Perelman School of Medicine at the University of Pennsylvania Philadelphia PA
- Center for Cardiovascular Outcomes, Quality, and Evaluative Research University of Pennsylvania Philadelphia PA
- Leonard Davis Institute of Health Economics at the University of Pennsylvania Philadelphia PA
| | - Emeka C. Anyawu
- Cardiovascular Division Perelman School of Medicine at the University of Pennsylvania Philadelphia PA
| | - Elias Dayoub
- Cardiovascular Division Perelman School of Medicine at the University of Pennsylvania Philadelphia PA
- Center for Cardiovascular Outcomes, Quality, and Evaluative Research University of Pennsylvania Philadelphia PA
- Leonard Davis Institute of Health Economics at the University of Pennsylvania Philadelphia PA
| | - Peter W. Groeneveld
- Center for Cardiovascular Outcomes, Quality, and Evaluative Research University of Pennsylvania Philadelphia PA
- Division of General Internal Medicine, Perelman School of Medicine University of Pennsylvania Philadelphia PA
| | - Sameed Ahmed M. Khatana
- Cardiovascular Division Perelman School of Medicine at the University of Pennsylvania Philadelphia PA
- Center for Cardiovascular Outcomes, Quality, and Evaluative Research University of Pennsylvania Philadelphia PA
- Leonard Davis Institute of Health Economics at the University of Pennsylvania Philadelphia PA
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18
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Nguemeni Tiako MJ, Ray V, South EC. Medical Schools as Racialized Organizations: How Race-Neutral Structures Sustain Racial Inequality in Medical Education-a Narrative Review. J Gen Intern Med 2022; 37:2259-2266. [PMID: 35710658 PMCID: PMC9202970 DOI: 10.1007/s11606-022-07500-w] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 03/23/2022] [Indexed: 11/26/2022]
Abstract
In 2021, The American Association of Medical Colleges released a framework addressing structural racism in academic medicine, following the significant, nationwide Movement for Black Lives. The first step of this framework is to "begin self-reflection and educating ourselves." Indeed, ample evidence shows that medical schools have a long history of racially exclusionary practices. Drawing on racialized organizations theory from the field of sociology, we compile and examine scholarship on the role of race and racism in medical training, focusing on disparities in educational and career outcomes, experiences along racial lines in medical training, and long-term implications. From the entrance into medical school through the residency application process, organizational factors such as reliance on standardized tests to predict future success, a hostile learning climate, and racially biased performance metrics negatively impact the careers of trainees of color, particularly those underrepresented in medicine (URiM). Indeed, in addition to structural biases associated with otherwise "objective" metrics, there are racial disparities across subjective outcomes such as the language used in medical trainees' performance evaluations, even when adjusting for grades and board exam scores. These disadvantages contribute to URIM trainees' lower odds of matching, steering into less competitive and lucrative specialties, and burnout and attrition from academic careers. Additionally, hostile racial climates and less diverse medical schools negatively influence White trainees' interest in practicing in underserved communities, disproportionally racial and ethnic minorities. Trainees' mental health suffers along the way, as do medical schools' recruitment, retention, diversity, and inclusion efforts. Evidence shows that seemingly race-neutral processes and structures within medical education, in conjunction with individuals' biases and interpersonal discrimination, may reproduce and sustain racial inequality among medical trainees. Medical schools whose goals include training a more diverse physician workforce towards addressing racial health disparities require a new playbook.
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Affiliation(s)
- Max Jordan Nguemeni Tiako
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
- Urban Health Lab, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
| | - Victor Ray
- Department of Sociology, University of Iowa, Iowa City, IA, USA
| | - Eugenia C South
- Urban Health Lab, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
- Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA, USA
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19
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Ortiz R, Joseph JJ, Branas CC, MacDonald JM, Nguemeni Tiako MJ, Oyekanmi K, South EC. Advancing health equity through integrated biology and population health research: A community-based sample cortisol feasibility and exploratory study. Comprehensive Psychoneuroendocrinology 2022; 11:100145. [PMID: 35757172 PMCID: PMC9228000 DOI: 10.1016/j.cpnec.2022.100145] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 05/20/2022] [Accepted: 05/20/2022] [Indexed: 12/21/2022] Open
Abstract
Background Community-based research inclusive of self-assessment and objective environmental metrics can be enhanced by the collection of biomarker data in unity toward assessing the health impacts of the totality of environmental stress driven by structural racism. Cortisol dynamic range (CDR), a measure of chronic stress burden, may underpin place-based connections to health, but a gap remains in elucidating community-based CDR methodology. Purpose To 1) assess the feasibility of cortisol collection and CDR measurement in a community-based study with home-based, participant-directed specimen collection, and 2) explore the association between CDR and other individual and environmental measures in a sample of predominantly Black participants. Methods: In this cross-sectional, observational study in predominantly Black urban neighborhoods, participants (n = 73) completed health assessments and in-home, self-collected salivary cortisol. For feasibility, CDR (peak-nadir) was compared to cortisol awakening response (CAR) slope over time. Comparisons of CDR quartile by person and place variables were explored (ANOVA). Results The cohort (77% Black, 39.7% <$15 k/year income, high perceived stress) completed 98.6% of cortisol collection timepoints. CDR was calculated in all participants without interruptions to sleep-wake cycle as seen with CAR collection. Participants in the lowest quartile of CDR were the oldest (p = 0.03) with lowest reported mental health (p = 0.048) with no associations seen for CAR. Conclusion Participant-collected 10.13039/501100011622CDR is more feasible than cortisol measures dependent on slopes over time in a community-based, predominately Black cohort with exploratory findings supporting relevance to outcomes of interest to future work. Future community-based studies should integrate CDR with environment and psychosocial measures. Biological and social metrics can enhance community studies of structural racism. Cortisol dynamic range (CDR) may reflect the burden of chronic stress in a community. In-home, participant-collected salivary cortisol is feasible with in-field guidance. CDR may be more feasible in community-based study than measures dependent on time. Greatest CDR is seen with youngest age and best self-reported mental health.
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Affiliation(s)
- Robin Ortiz
- Departments of Pediatrics and Population Health, New York University, Grossman School of Medicine, 180 Madison Ave, New York, NY, 10016, USA
- Institute for Excellence in Health Equity, New York University Langone Health, New York, Grossman School of Medicine, 180 Madison Ave, New York, NY, 10016, USA
- National Clinician Scholars Program, University of Pennsylvania Perelman School of Medicine, 1300 Blockley Hall, 423 Guardian Drive, Philadelphia, PA, 19104, USA
- Corresponding author. Departments of Pediatrics and Population Health, New York University, Grossman School of Medicine, 180 Madison Ave, New York, NY, 10016, USA
| | - Joshua J. Joseph
- The Ohio State University, Wexner Medical Center, Division of Endocrinology, Diabetes and Metabolism, 579 McCampbell Hall, Columbus, OH, 43210, USA
| | - Charlie C. Branas
- Department of Epidemiology, Mailman School of Public Health, Columbia University, 722 West 168th Street, Rm 1508, New York, NY, 10032, USA
| | - John M. MacDonald
- Department of Criminology, School of Arts and Sciences, University of Pennsylvania, 558 McNeil Building, Locus Walk, Philadelphia, PA, 19104, USA
| | | | - Kehinde Oyekanmi
- Department of Emergency Medicine, University of Pennsylvania, Perelman School of Medicine, 423 Guardian Drive, Philadelphia, PA, 19104, USA
- Urban Health Lab, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Eugenia C. South
- Department of Emergency Medicine, University of Pennsylvania, Perelman School of Medicine, 423 Guardian Drive, Philadelphia, PA, 19104, USA
- Urban Health Lab, University of Pennsylvania, Philadelphia, PA, 19104, USA
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20
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Burt CJ, Kondo MC, Hohl BC, Gong CH, Bushman G, Wixom C, South EC, Cunningham RM, Carter PM, Branas CC, Zimmerman MA. Community Greening, Fear of Crime, and Mental Health Outcomes. Am J Community Psychol 2022; 69:46-58. [PMID: 34333789 PMCID: PMC8803989 DOI: 10.1002/ajcp.12544] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
Unmaintained vacant land in urban areas is associated with a number of negative outcomes for residents of urban areas, including mental and physical health, safety, and quality of life. Community programs which promote land parcel maintenance in urban neighborhoods have been found to reverse some of the effects that unmaintained land has on nearby residents. We explored how land parcel maintenance is associated with mental health outcomes using data collected in Flint, MI in 2017-2018. Trained observers assessed the maintenance of approximately 7200 land parcels and surveyed 691 residents (57% Female, 53% Black, M age = 51). We aggregated resident and parcel rating data to 463 street segments and compared three structural equation models (SEM) to estimate the mediating effects of fear of crime on the association of parcel qualities on mental distress for residents. We found that fear of crime mediated the association between parcel maintenance values and mental distress indicating that poor maintenance predicted more fear of crime which was associated with mental distress. Our findings add to our understanding about the mechanism by which vacant lot improvements may operate to enhance psychological well-being of residents who live on streets with vacant and unkept lots.
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Affiliation(s)
- Cassidy J. Burt
- Department of Psychological Sciences, University of Connecticut, Storrs, CT, USA
| | - Michelle C. Kondo
- USDA Forest Service, Northern Research Station, Philadelphia Field Station, Philadelphia, PA, USA
| | - Bernadette C. Hohl
- Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, NJ, USA
| | | | - Gregory Bushman
- School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Caroline Wixom
- School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Eugenia C. South
- Urban Health Lab, Department of Emergency Medicine, Perelman School of Medicine, Philadelphia, PA, USA
| | - Rebecca M. Cunningham
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Patrick M. Carter
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Charles C. Branas
- Department of Epidemiology, Columbia Mailman School of Public Health, New York, NY, USA
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Nguemeni Tiako MJ, South EC, Burris HH. Lethality of racism for Black children in the USA: a primer. Arch Dis Child 2022; 107:212-213. [PMID: 33419724 DOI: 10.1136/archdischild-2020-320139] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Revised: 12/21/2020] [Accepted: 12/23/2020] [Indexed: 11/04/2022]
Affiliation(s)
| | - Eugenia C South
- Emergency Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Heather H Burris
- Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA .,Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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22
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Dolin CD, Mullin A, Ledyard R, Durnwald C, Bender W, South EC, Burris HH. Association between maternal neighborhood socioeconomic factors and early pregnancy glucose intolerance. Am J Obstet Gynecol 2022. [DOI: 10.1016/j.ajog.2021.11.1238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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23
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Nguemeni Tiako MJ, Meisel ZF, Friedman A, South EC, Epstein R, Meinhofer A, Jake morgan. Buprenorphine Uptake in Pregnancy Following the 2017 ACOG Guidelines Update on Perinatal Opioid Use Disorder. Am J Obstet Gynecol 2022. [DOI: 10.1016/j.ajog.2021.11.238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
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24
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Vasan A, Mitchell HK, Fein JA, Buckler DG, Wiebe DJ, South EC. Association of Neighborhood Gun Violence With Mental Health-Related Pediatric Emergency Department Utilization. JAMA Pediatr 2021; 175:1244-1251. [PMID: 34542562 PMCID: PMC8453357 DOI: 10.1001/jamapediatrics.2021.3512] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
IMPORTANCE Many children and adolescents in the United States are exposed to neighborhood gun violence. Associations between violence exposure and children's short-term mental health are not well understood. OBJECTIVE To examine the association between neighborhood gun violence and subsequent mental health-related pediatric emergency department (ED) utilization. DESIGN, SETTING, AND PARTICIPANTS This location-based cross-sectional study included 128 683 ED encounters for children aged 0 to 19 years living in 12 zip codes in Philadelphia, Pennsylvania, who presented to an urban academic pediatric ED from January 1, 2014, to December 31, 2018. Children were included if they (1) had 1 or more ED visits in the 60 days before or after a neighborhood shooting and (2) lived within a quarter-mile radius of the location where this shooting occurred. Analysis began August 2020 and ended May 2021. EXPOSURE Neighborhood violence exposure, as measured by whether a patient resided near 1 or more episodes of police-reported gun violence. MAIN OUTCOMES AND MEASURES ED encounters for a mental health-related chief complaint or primary diagnosis. RESULTS A total of 2629 people were shot in the study area between 2014 and 2018, and 54 341 children living nearby had 1 or more ED visits within 60 days of a shooting. The majority of these children were Black (45 946 [84.5%]) and were insured by Medicaid (42 480 [78.1%]). After adjusting for age, sex, race and ethnicity, median household income by zip code, and insurance, children residing within one-eighth of a mile (2-3 blocks) of a shooting had greater odds of mental health-related ED presentations in the subsequent 14 days (adjusted odds ratio, 1.86 [95% CI, 1.20-2.88]), 30 days (adjusted odds ratio, 1.49 [95% CI, 1.11-2.03]), and 60 days (adjusted odds ratio, 1.35 [95% CI, 1.06-1.72]). CONCLUSIONS AND RELEVANCE Exposure to neighborhood gun violence is associated with an increase in children's acute mental health symptoms. City health departments and pediatric health care systems should work together to provide community-based support for children and families exposed to violence and trauma-informed care for the subset of these children who subsequently present to the ED. Policies aimed at reducing children's exposure to neighborhood gun violence and mitigating the mental symptoms associated with gun violence exposure must be a public health priority.
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Affiliation(s)
- Aditi Vasan
- National Clinician Scholars Program, Perelman School of Medicine, University of Pennsylvania, Philadelphia,Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania,PolicyLab, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Hannah K. Mitchell
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Joel A. Fein
- Division of Emergency Medicine, Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania,Center for Violence Prevention, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - David G. Buckler
- The Urban Health Lab, Perelman School of Medicine, University of Pennsylvania, Philadelphia,Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Douglas J. Wiebe
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia,Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Eugenia C. South
- The Urban Health Lab, Perelman School of Medicine, University of Pennsylvania, Philadelphia,Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
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25
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South EC, Lee K, Oyekanmi K, Buckler DG, Tiako MJN, Martin T, Kornfield SL, Srinivas S. Nurtured in Nature: a Pilot Randomized Controlled Trial to Increase Time in Greenspace among Urban-Dwelling Postpartum Women. J Urban Health 2021; 98:822-831. [PMID: 34014451 PMCID: PMC8688635 DOI: 10.1007/s11524-021-00544-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/19/2021] [Indexed: 10/21/2022]
Abstract
Spending time in nature is associated with numerous mental health benefits, including reduced depression and improved well-being. However, few studies examine the most effective ways to nudge people to spend more time outside. Furthermore, the impact of spending time in nature has not been previously studied as a postpartum depression (PPD) prevention strategy. To fill these gaps, we developed and pilot tested Nurtured in Nature, a 4-week intervention leveraging a behavioral economics framework, and included a Nature Coach, digital nudges, and personalized goal feedback. We conducted a randomized controlled trial among postpartum women (n = 36) in Philadelphia, PA between 9/9/2019 and 3/27/2020. Nature visit frequency and duration was determined using GPS data. PPD was measured using the Edinburgh Postnatal Depression Scale (EPDS). Participants were from low-income, majority Black neighborhoods. Compared to control, the intervention arm had a strong trend toward longer duration and higher frequency of nature visits (IRR 2.6, 95%CI 0.96-2.75, p = 0.059). When analyzing women who completed the intervention (13 of 17 subjects), the intervention was associated with three times higher nature visits compared to control (IRR 3.1, 95%CI 1.16-3.14, p = 0.025). No significant differences were found in the EPDS scores, although we may have been limited by the study's sample size. Nurture in Nature increased the amount of time postpartum women spent in nature, and may be a useful population health tool to leverage the health benefits of nature in majority Black, low-resourced communities.
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Affiliation(s)
- Eugenia C South
- Department of Emergency Medicine, University of Pennsylvania, Blockley Hall, Room 408, 423 Guardian Drive, Philadelphia, PA, 19104, USA. .,Urban Health Lab, University of Pennsylvania, Philadelphia, PA, USA.
| | - Kathleen Lee
- Department of Emergency Medicine, University of Pennsylvania, Blockley Hall, Room 408, 423 Guardian Drive, Philadelphia, PA, 19104, USA
| | - Kehinde Oyekanmi
- Department of Emergency Medicine, University of Pennsylvania, Blockley Hall, Room 408, 423 Guardian Drive, Philadelphia, PA, 19104, USA.,Urban Health Lab, University of Pennsylvania, Philadelphia, PA, USA
| | - David G Buckler
- Department of Emergency Medicine, University of Pennsylvania, Blockley Hall, Room 408, 423 Guardian Drive, Philadelphia, PA, 19104, USA.,Urban Health Lab, University of Pennsylvania, Philadelphia, PA, USA
| | - Max Jordan Nguemeni Tiako
- Urban Health Lab, University of Pennsylvania, Philadelphia, PA, USA.,Yale School of Medicine, New Haven, CT, USA
| | - Tyler Martin
- Center for Healthcare Innovation, University of Pennsylvania, Philadelphia, PA, USA
| | - Sara L Kornfield
- Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, USA
| | - Sindhu Srinivas
- Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, PA, USA
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Abstract
IMPORTANCE Mortality across US counties varies considerably, from 252 to 1847 deaths per 100 000 people in 2018. Although patient satisfaction with health care is associated with patient- and facility-level health outcomes, the association between health care satisfaction and community-level health outcomes is not known. OBJECTIVE To examine the association between online ratings of health care facilities and mortality across US counties and to identify language specific to 1-star (lowest rating) and 5-star (highest rating) reviews in counties with high vs low mortality. DESIGN, SETTING, AND PARTICIPANTS This retrospective population-based cross-sectional study examined reviews and ratings of 95 120 essential health care facilities across 1301 US counties. Counties that had at least 1 essential health care facility with reviews available on Yelp, an online review platform, were included. Essential health care was defined according to the 10 essential health benefits covered by Affordable Care Act insurance plans. MAIN OUTCOMES AND MEASURES The mean rating of essential health care facilities was calculated by county from January 1, 2015, to December 31, 2019. Ratings were on a scale of 1 to 5 stars, with 1 being the worst rating and 5 the best. County-level composite measures of health behaviors, clinical care, social and economic factors, and physical environment were obtained from the University of Wisconsin School of Medicine and Public Health County Health Rankings database. The 2018 age-adjusted mortality by county was obtained from the Centers for Disease Control and Prevention Wide-ranging Online Data for Epidemiological Research database. Multiple linear regression analysis was used to estimate the association between mean facility rating and mortality, adjusting for county health ranking variables. Words with frequencies of use that were significantly different across 1-star and 5-star reviews in counties with high vs low mortality were identified. RESULTS The 95 120 facilities meeting inclusion criteria were distributed across 1301 of 3142 US counties (41.4%). At the county level, a 1-point increase in mean rating was associated with a mean (SE) age-adjusted decrease of 18.05 (3.68) deaths per 100 000 people (P < .001). Words specific to 1-star reviews in high-mortality counties included told, rude, and wait, and words specific to 5-star reviews in low-mortality counties included Dr, pain, and professional. CONCLUSIONS AND RELEVANCE This study found that, at the county level, higher online ratings of essential health care facilities were associated with lower mortality. Equivalent online ratings did not necessarily reflect equivalent experiences of care across counties with different mortality levels, as evidenced by variations in the frequency of use of key words in reviews. These findings suggest that online ratings and reviews may provide insight into unequal experiences of essential health care.
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Affiliation(s)
- Daniel C. Stokes
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles
- Center for Digital Health, Penn Medicine, University of Pennsylvania, Philadelphia
| | - Arthur P. Pelullo
- Center for Digital Health, Penn Medicine, University of Pennsylvania, Philadelphia
| | - Nandita Mitra
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Zachary F. Meisel
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Eugenia C. South
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Urban Health Lab, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - David A. Asch
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Raina M. Merchant
- Center for Digital Health, Penn Medicine, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
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27
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West‐Livingston LN, South EC, Mabins S, Landry A. When screens become mirrors: Black women in medicine find belonging through social media. AEM Educ Train 2021; 5:S98-S101. [PMID: 34616980 PMCID: PMC8480499 DOI: 10.1002/aet2.10669] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 05/27/2021] [Accepted: 06/14/2021] [Indexed: 05/25/2023]
Affiliation(s)
| | - Eugenia C. South
- Urban Health LabPerelman School of Medicine at the University of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | | | - Adaira Landry
- Brigham and Women’s HospitalHarvard Medical SchoolBostonMassachusettsUSA
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28
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Abstract
The year 2020 saw the largest social movement in response to the police killings of Black people and anti-Black racism in U.S. history. As a result, medical schools and professional societies such as the American Medical Association and the Association of American Medical Colleges are reckoning with their role in perpetuating racial inequality and the impact of structural racism on medical training. Whether these efforts will translate into meaningful change has yet to be determined. Success depends on a deep understanding of the fundamental role racism plays in how medical schools function and an acknowledgment that current organizational structures and processes often serve to entrench, not dismantle, racial inequities. Drawing on racialized organizations theory from the field of sociology, this article gives an overview of scholarship on race and racism in medical training to demonstrate how seemingly race-neutral processes and structures within medical education, in conjunction with individuals' biases and interpersonal discrimination, serve to reproduce and sustain racial inequality. From entrance into medical school through the residency application process, organizational factors such as reliance on standardized tests to predict future success, a hostile learning climate, and racially biased performance metrics ultimately stunt the careers of trainees of color, particularly those from backgrounds underrepresented in medicine (URM). These compounding disadvantages contribute to URM trainees' lower matching odds, steering into less competitive and lucrative specialties, and burnout and attrition from academic careers. In their commitment against structural racism in medical training and academic medicine, medical schools and larger organizations like the Association of American Medical Colleges should prioritize interventions targeted at these structural barriers to achieve equity.
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Affiliation(s)
- Max Jordan Nguemeni Tiako
- Yale School of Medicine, New Haven, Connecticut (M.J.N.).,Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania (M.J.N., E.C.S.)
| | - Eugenia C South
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania (M.J.N., E.C.S.)
| | - Victor Ray
- University of Iowa, Iowa City, Iowa (V.R.)
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Abstract
IMPORTANCE The root causes of violent crime in Black urban neighborhoods are structural, including residential racial segregation and concentrated poverty. Previous work suggests that simple and scalable place-based environmental interventions can overcome the legacies of neighborhood disinvestment and have implications for health broadly and crime specifically. OBJECTIVE To assess whether structural repairs to the homes of low-income owners are associated with a reduction in nearby crime. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study using difference-in-differences analysis included data from the City of Philadelphia Basic Systems Repair Program (BSRP) from January 1, 2006, through April 30, 2013. The unit of analysis was block faces (single street segments between 2 consecutive intersecting streets) with or without homes that received the BSRP intervention. The blocks of homes that received BSRP services were compared with the blocks of eligible homes that were still on the waiting list. Data were analyzed from December 1, 2019, to February 28, 2021. EXPOSURES The BSRP intervention includes a grant of up to $20 000 provided to low-income owners for structural repairs to electrical, plumbing, heating, and roofing damage. Eligible homeowners must meet income guidelines, which are set by the US Department of Housing and Urban Development and vary yearly. MAIN OUTCOMES AND MEASURES The main outcome was police-reported crime across 7 major categories of violent and nonviolent crimes (homicide, assault, burglary, theft, robbery, disorderly conduct, and public drunkenness). RESULTS A total of 13 632 houses on 6732 block faces received the BSRP intervention. Owners of these homes had a mean (range) age of 56.5 (18-98) years, were predominantly Black (10 952 [78.6%]) or Latino (1658 [11.9%]) individuals, and had a mean monthly income of $993. These census tracts compared with those without BSRP intervention had a substantially larger Black population (49.5% vs 12.2%; |D| = 0.406) and higher unemployment rate (17.3% vs 9.3%; |D| = 0.357). The main regression analysis demonstrated that the addition to a block face of a property that received a BSRP intervention was associated with a 21.9% decrease in the expected count of total crime (incidence rate ratio [IRR], 0.78; 95% CI, 0.76-0.80; P < .001), 19.0% decrease in assault (IRR, 0.81; 95% CI, 0.79-0.84; P < .001), 22.6% decrease in robbery (IRR, 0.77; 95% CI, 0.75-0.80; P < .001), and 21.9% decrease in homicide (IRR, 0.78; 95% CI, 0.71-0.86; P < .001). When restricting the analysis to blocks with properties that had ever received a BSRP intervention, a total crime reduction of 25.4% was observed for each additional property (IRR, 0.75; 95% CI, 0.73-0.77; P < .001). A significant dose-dependent decrease in total crime was found such that the magnitude of association increased with higher numbers of homes participating in the BSRP on a block. CONCLUSIONS AND RELEVANCE This study found that the BSRP intervention was associated with a modest but significant reduction in crime. These findings suggest that intentional and targeted financial investment in structural, scalable, and sustainable place-based interventions in neighborhoods that are still experiencing the lasting consequences of structural racism and segregation is a vital step toward achieving health equity.
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Affiliation(s)
- Eugenia C. South
- Urban Health Lab, Department of Emergency
Medicine, Perelman School of Medicine at the University of Pennsylvania,
Philadelphia
- Leonard Davis Institute, University of
Pennsylvania, Philadelphia
| | - John MacDonald
- Leonard Davis Institute, University of
Pennsylvania, Philadelphia
- Department of Criminology, School of Arts and
Sciences, University of Pennsylvania, Philadelphia
| | - Vincent Reina
- Department of City and Regional Planning,
Weitzman School of Design, University of Pennsylvania, Philadelphia
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30
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Affiliation(s)
- Eugenia C South
- Department of Emergency Medicine, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA.,Urban Health Lab, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Paris D Butler
- Department of Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | - Raina M Merchant
- Department of Emergency Medicine, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
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Affiliation(s)
- Raina M Merchant
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Penn Medicine Center for Digital Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Eugenia C South
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Urban Health Lab, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Nicole Lurie
- Coalition for Epidemic Preparedness Innovation, Washington, DC
- Massachusetts General Hospital, Boston
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Khatri UG, Pizzicato LN, Viner K, Bobyock E, Sun M, Meisel ZF, South EC. Racial/Ethnic Disparities in Unintentional Fatal and Nonfatal Emergency Medical Services-Attended Opioid Overdoses During the COVID-19 Pandemic in Philadelphia. JAMA Netw Open 2021; 4:e2034878. [PMID: 33475751 PMCID: PMC7821023 DOI: 10.1001/jamanetworkopen.2020.34878] [Citation(s) in RCA: 61] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
This cross-sectional study describes the differential associations of the coronavirus disease 2019 (COVID-19) pandemic with opioid-related overdoses among racial/ethnic groups in Philadelphia, Pennsylvania.
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Affiliation(s)
- Utsha G. Khatri
- National Clinician Scholars Program, Corporal Michael J. Crescenz Veterans Affairs Medical Center, University of Pennsylvania, Philadelphia
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Lia N. Pizzicato
- Substance Use Prevention and Harm Reduction Division, Philadelphia Department of Public Health, Philadelphia, Pennsylvania
| | - Kendra Viner
- Substance Use Prevention and Harm Reduction Division, Philadelphia Department of Public Health, Philadelphia, Pennsylvania
| | - Emily Bobyock
- Philadelphia Fire Department Emergency Medical Services, Philadelphia, Pennsylvania
| | - Monica Sun
- Substance Use Prevention and Harm Reduction Division, Philadelphia Department of Public Health, Philadelphia, Pennsylvania
| | - Zachary F. Meisel
- Center for Emergency Care Research and Policy, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Eugenia C. South
- Urban Health Lab, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
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South EC, Stillman K, Buckler DG, Wiebe D. Association of Gun Violence With Emergency Department Visits for Stress-Responsive Complaints. Ann Emerg Med 2020; 77:469-478. [PMID: 33342597 DOI: 10.1016/j.annemergmed.2020.10.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 10/14/2020] [Accepted: 10/19/2020] [Indexed: 11/25/2022]
Abstract
STUDY OBJECTIVE We evaluate the association between living near a neighborhood shooting and emergency department (ED) utilization for stress-responsive complaints. METHODS In this location-based before-and-after neighborhood study, we examined variability in ED encounter volume for stress-responsive complaints after neighborhood shooting incidents around 2 academic hospitals. We included patients residing within 1/8- and 1/2-mile-diameter buffers around a shooting (place) if their ED encounter occurred 7, 30, or 60 days before or after the shooting (time). Prespecified outcomes were stress-responsive complaints (chest pain, lightheadedness, syncope, hypertension, shortness of breath, asthma, anxiety, depression, and substance use) based on prior literature for stress-responsive diseases. Conditional logistic regression was used to calculate the odds of presentation to the ED with a stress-responsive complaint after, compared with before, a neighborhood shooting incident. RESULTS Between January 2013 and December 2014, 513 shooting incidents and 19,906 encounters for stress-responsive complaints were included in the analysis. Mean age was 50.3 years (SD 22.3 years), 61.5% were women, and 91% were black. We found increased odds of presenting with syncope in 2 place-time buffers: 30 days in the 1/8-mile buffer (odds ratio 2.61; 99% confidence interval 1.2 to 5.67) and 60 days in 1/8-mile buffer (odds ratio 1.56; 99% confidence interval 0.99 to 2.46). No other chief complaints met our statistical threshold for significance. CONCLUSION This study evaluated the relationship between objectively measured gun violence exposure and short-term health effect at a microspatial scale. Overall, this was a study with largely negative results, and we did not find any consistent dose-response pattern in time or space regarding neighborhood shootings and stress-responsive presentations to the ED. Theoretic links make this relationship plausible, however, and further investigation is needed to understand the short-term health consequences of violence exposure, and whether those vary based on the circumstances that are experienced inherently by residents of a given neighborhood.
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Affiliation(s)
- Eugenia C South
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Penn Urban Health Lab, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
| | - Kaytlena Stillman
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - David G Buckler
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Penn Urban Health Lab, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Douglas Wiebe
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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34
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South EC, Kondo MC, Razani N. Nature as a Community Health Tool: The Case for Healthcare Providers and Systems. Am J Prev Med 2020; 59:606-610. [PMID: 32654863 DOI: 10.1016/j.amepre.2020.03.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 03/26/2020] [Accepted: 03/31/2020] [Indexed: 10/23/2022]
Affiliation(s)
- Eugenia C South
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Center for Emergency Care Policy Research, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
| | | | - Nooshin Razani
- Department of Pediatrics, UCSF Benioff Children's Hospital, Oakland, California
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Kondo MC, Oyekanmi KO, Gibson A, South EC, Bocarro J, Hipp JA. Nature Prescriptions for Health: A Review of Evidence and Research Opportunities. Int J Environ Res Public Health 2020; 17:ijerph17124213. [PMID: 32545651 PMCID: PMC7344564 DOI: 10.3390/ijerph17124213] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 06/08/2020] [Accepted: 06/09/2020] [Indexed: 12/18/2022]
Abstract
Nature prescription programs have emerged to address the high burden of chronic disease and increasingly sedentary and screen-based lifestyles. This study examines the base of evidence regarding such programs. We conducted a narrative review of published literature using four electronic databases. We included case studies, research design articles, and empirical studies that discussed any type of outdoor exposure or activities initiated by a health-care provider from an outpatient clinic. We examined articles for information on target populations, health outcomes, and structural and procedural elements. We also summarized evidence of the effectiveness of nature prescription programs, and discussed needs and challenges for both practice and research. Eleven studies, including eight empirical studies, have evaluated nature prescription programs with either structured or unstructured formats, referring patients either to nearby parks or to formal outdoor activity programs. Empirical studies evaluate a wide variety of health behaviors and outcomes among the most at-risk children and families. Research is too sparse to draw patterns in health outcome responses. Studies largely tested program structures to increase adherence, or patient follow-through, however findings were mixed. Three published studies explore providers’ perspectives. More research is necessary to understand how to measure and increase patient adherence, short and long-term health outcomes for patients and their families, and determinants of provider participation and participation impacts on providers’ own health.
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Affiliation(s)
- Michelle C. Kondo
- USDA-Forest Service, Northern Research Station, 100 North 20th Street, Ste 205, Philadelphia, PA 19103, USA;
- Correspondence: ; Tel.: +1-215-988-1619
| | - Kehinde O. Oyekanmi
- USDA-Forest Service, Northern Research Station, 100 North 20th Street, Ste 205, Philadelphia, PA 19103, USA;
- Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, USA;
| | - Allison Gibson
- Schuylkill Center for Environmental Education, 8480 Hagys Mill Rd, Philadelphia, PA 19128, USA;
| | - Eugenia C. South
- Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, USA;
| | - Jason Bocarro
- Department of Parks, Recreation & Tourism Management, College of Natural Resources, Box 8004, 3028F Biltmore Hall, North Carolina State University, Raleigh, NC 27695-8004, USA; (J.B.); (J.A.H.)
| | - J. Aaron Hipp
- Department of Parks, Recreation & Tourism Management, College of Natural Resources, Box 8004, 3028F Biltmore Hall, North Carolina State University, Raleigh, NC 27695-8004, USA; (J.B.); (J.A.H.)
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Abstract
IMPORTANCE Neighborhood physical conditions have been associated with mental illness and may partially explain persistent socioeconomic disparities in the prevalence of poor mental health. OBJECTIVE To evaluate whether interventions to green vacant urban land can improve self-reported mental health. DESIGN, SETTING, AND PARTICIPANTS This citywide cluster randomized trial examined 442 community-dwelling sampled adults living in Philadelphia, Pennsylvania, within 110 vacant lot clusters randomly assigned to 3 study groups. Participants were followed up for 18 months preintervention and postintervention. This trial was conducted from October 1, 2011, to November 30, 2014. Data were analyzed from July 1, 2015, to April 16, 2017. INTERVENTIONS The greening intervention involved removing trash, grading the land, planting new grass and a small number of trees, installing a low wooden perimeter fence, and performing regular monthly maintenance. The trash cleanup intervention involved removal of trash, limited grass mowing where possible, and regular monthly maintenance. The control group received no intervention. MAIN OUTCOMES AND MEASURES Self-reported mental health measured by the Kessler-6 Psychological Distress Scale and the components of this scale. RESULTS A total of 110 clusters containing 541 vacant lots were enrolled in the trial and randomly allocated to the following 1 of 3 study groups: the greening intervention (37 clusters [33.6%]), the trash cleanup intervention (36 clusters [32.7%]), or no intervention (37 clusters [33.6%]). Of the 442 participants, the mean (SD) age was 44.6 (15.1) years, 264 (59.7%) were female, and 194 (43.9%) had a family income less than $25 000. A total of 342 participants (77.4%) had follow-up data and were included in the analysis. Of these, 117 (34.2%) received the greening intervention, 107 (31.3%) the trash cleanup intervention, and 118 (34.5%) no intervention. Intention-to-treat analysis of the greening intervention compared with no intervention demonstrated a significant decrease in participants who were feeling depressed (-41.5%; 95% CI, -63.6% to -5.9%; P = .03) and worthless (-50.9%; 95% CI, -74.7% to -4.7%; P = .04), as well as a nonsignificant reduction in overall self-reported poor mental health (-62.8%; 95% CI, -86.2% to 0.4%; P = .051). For participants living in neighborhoods below the poverty line, the greening intervention demonstrated a significant decrease in feeling depressed (-68.7%; 95% CI, -86.5% to -27.5%; P = .007). Intention-to-treat analysis of those living near the trash cleanup intervention compared with no intervention showed no significant changes in self-reported poor mental health. CONCLUSIONS AND RELEVANCE Among community-dwelling adults, self-reported feelings of depression and worthlessness were significantly decreased, and self-reported poor mental health was nonsignificantly reduced for those living near greened vacant land. The treatment of blighted physical environments, particularly in resource-limited urban settings, can be an important treatment for mental health problems alongside other patient-level treatments. TRIAL REGISTRATION isrctn.org Identifier: ISRCTN92582209.
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Affiliation(s)
- Eugenia C. South
- Department of Emergency Medicine, Perelman School of
Medicine, University of Pennsylvania, Philadelphia
- Center for Emergency Care Policy and Research,
Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Bernadette C. Hohl
- Department of Epidemiology, School of Public Health,
School of Criminal Justice, Rutgers University, Newark, New Jersey
| | - Michelle C. Kondo
- Northern Research Station, Forest Service, US
Department of Agriculture, Philadelphia, Pennsylvania
| | - John M. MacDonald
- Department of Criminology, School of Arts and
Sciences, University of Pennsylvania, Philadelphia
| | - Charles C. Branas
- Department of Epidemiology, Mailman School of Public
Health, Columbia University, New York, New York
- Department of Biostatistics and Epidemiology, Perelman
School of Medicine, University of Pennsylvania, Philadelphia
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Affiliation(s)
- Erik J. Blutinger
- Department of Emergency Medicine Center for Emergency Care and Policy Research University of Pennsylvania Health System Philadelphia PA
| | - Zachary F. Meisel
- Department of Emergency Medicine Center for Emergency Care and Policy Research University of Pennsylvania Health System Philadelphia PA
| | - Eugenia C. South
- Department of Emergency Medicine Center for Emergency Care and Policy Research University of Pennsylvania Health System Philadelphia PA
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Abstract
Violence is a widespread problem that affects the physical, mental, and social health of individuals and communities. Violence comes with an immense economic cost to its victims and society at large. Although violence interventions have traditionally targeted individuals, changes to the built environment in places where violence occurs show promise as practical, sustainable, and high-impact preventive measures. This review examines studies that use quasi-experimental or experimental designs to compare violence outcomes for treatment and control groups before and after a change is implemented in the built environment. The most consistent evidence exists in the realm of housing and blight remediation of buildings and land. Some evidence suggests that reducing alcohol availability, improving street connectivity, and providing green housing environments can reduce violent crimes. Finally, studies suggest that neither transit changes nor school openings affect community violence.
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Affiliation(s)
- Michelle C Kondo
- Northern Research Station, US Department of Agriculture (USDA) Forest Service, Philadelphia, Pennsylvania 19103, USA;
| | - Elena Andreyeva
- Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania 19104-6021, USA
| | - Eugenia C South
- Department of Emergency Medicine, Center for Emergency Care Policy Research, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA
| | - John M MacDonald
- Department of Criminology, School of Arts and Sciences, University of Pennsylvania, Philadelphia, Pennsylvania 19104-6286, USA
| | - Charles C Branas
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY 10032, USA
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Kondo MC, South EC, Branas CC, Richmond TS, Wiebe DJ. The Association Between Urban Tree Cover and Gun Assault: A Case-Control and Case-Crossover Study. Am J Epidemiol 2017; 186:289-296. [PMID: 28481962 DOI: 10.1093/aje/kwx096] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Accepted: 09/12/2016] [Indexed: 01/13/2023] Open
Abstract
Green space and vegetation may play a protective role against urban violence. We investigated whether being near urban tree cover during outdoor activities was related to being assaulted with a gun. We conducted geographic information systems-assisted interviews with boys and men aged 10-24 years in Philadelphia, Pennsylvania, including 135 patients who had been shot with a firearm and 274 community controls, during 2008-2011. Each subject reported a step-by-step mapped account of where and with whom they traveled over a full day from waking until being assaulted or going to bed. Geocoded path points were overlaid on mapped layers representing tree locations and place-specific characteristics. Conditional logistic regressions were used to compare case subjects versus controls (case-control) and case subjects at the time of injury versus times earlier that day (case-crossover). When comparing cases at the time of assault to controls matched at the same time of day, being under tree cover was inversely associated with gunshot assault (odds ratio (OR) = 0.70, 95% confidence interval (CI): 0.55, 0.88), especially in low-income areas (OR = 0.69, 95% CI: 0.54, 0.87). Case-crossover models confirmed this inverse association overall (OR = 0.55, 95% CI: 0.34, 0.89) and in low-income areas (OR = 0.54, 95% CI: 0.33, 0.88). Urban greening and tree cover may hold promise as proactive strategies to decrease urban violence.
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Branas CC, Kondo MC, Murphy SM, South EC, Polsky D, MacDonald JM. Urban Blight Remediation as a Cost-Beneficial Solution to Firearm Violence. Am J Public Health 2016; 106:2158-2164. [PMID: 27736217 DOI: 10.2105/ajph.2016.303434] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To determine if blight remediation of abandoned buildings and vacant lots can be a cost-beneficial solution to firearm violence in US cities. METHODS We performed quasi-experimental analyses of the impacts and economic returns on investment of urban blight remediation programs involving 5112 abandoned buildings and vacant lots on the occurrence of firearm and nonfirearm violence in Philadelphia, Pennsylvania, from 1999 to 2013. We adjusted before-after percent changes and returns on investment in treated versus control groups for sociodemographic factors. RESULTS Abandoned building remediation significantly reduced firearm violence -39% (95% confidence interval [CI] = -28%, -50%; P < .05) as did vacant lot remediation (-4.6%; 95% CI = -4.2%, -5.0%; P < .001). Neither program significantly affected nonfirearm violence. Respectively, taxpayer and societal returns on investment for the prevention of firearm violence were $5 and $79 for every dollar spent on abandoned building remediation and $26 and $333 for every dollar spent on vacant lot remediation. CONCLUSIONS Abandoned buildings and vacant lots are blighted structures seen daily by urban residents that may create physical opportunities for violence by sheltering illegal activity and illegal firearms. Urban blight remediation programs can be cost-beneficial strategies that significantly and sustainably reduce firearm violence.
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Affiliation(s)
- Charles C Branas
- Charles C. Branas is with the Department of Biostatistics and Epidemiology and the Leonard Davis Institute of Health Economics, University of Pennsylvania, Perelman School of Medicine, Philadelphia. Michelle C. Kondo is with the US Department of Agriculture-Forest Service, Northern Research Station, Philadelphia. Sean M. Murphy is with the Department of Health Policy and Administration, Washington State University, Spokane. Eugenia C. South is with the Department of Emergency Medicine, University of Pennsylvania, Perelman School of Medicine. Daniel Polsky is with the Leonard Davis Institute of Health Economics, the Wharton School of Business, and the Perelman School of Medicine, University of Pennsylvania. John M. MacDonald is with the Department of Criminology and the Leonard Davis Institute of Health Economics, University of Pennsylvania, School of Arts and Sciences, Philadelphia
| | - Michelle C Kondo
- Charles C. Branas is with the Department of Biostatistics and Epidemiology and the Leonard Davis Institute of Health Economics, University of Pennsylvania, Perelman School of Medicine, Philadelphia. Michelle C. Kondo is with the US Department of Agriculture-Forest Service, Northern Research Station, Philadelphia. Sean M. Murphy is with the Department of Health Policy and Administration, Washington State University, Spokane. Eugenia C. South is with the Department of Emergency Medicine, University of Pennsylvania, Perelman School of Medicine. Daniel Polsky is with the Leonard Davis Institute of Health Economics, the Wharton School of Business, and the Perelman School of Medicine, University of Pennsylvania. John M. MacDonald is with the Department of Criminology and the Leonard Davis Institute of Health Economics, University of Pennsylvania, School of Arts and Sciences, Philadelphia
| | - Sean M Murphy
- Charles C. Branas is with the Department of Biostatistics and Epidemiology and the Leonard Davis Institute of Health Economics, University of Pennsylvania, Perelman School of Medicine, Philadelphia. Michelle C. Kondo is with the US Department of Agriculture-Forest Service, Northern Research Station, Philadelphia. Sean M. Murphy is with the Department of Health Policy and Administration, Washington State University, Spokane. Eugenia C. South is with the Department of Emergency Medicine, University of Pennsylvania, Perelman School of Medicine. Daniel Polsky is with the Leonard Davis Institute of Health Economics, the Wharton School of Business, and the Perelman School of Medicine, University of Pennsylvania. John M. MacDonald is with the Department of Criminology and the Leonard Davis Institute of Health Economics, University of Pennsylvania, School of Arts and Sciences, Philadelphia
| | - Eugenia C South
- Charles C. Branas is with the Department of Biostatistics and Epidemiology and the Leonard Davis Institute of Health Economics, University of Pennsylvania, Perelman School of Medicine, Philadelphia. Michelle C. Kondo is with the US Department of Agriculture-Forest Service, Northern Research Station, Philadelphia. Sean M. Murphy is with the Department of Health Policy and Administration, Washington State University, Spokane. Eugenia C. South is with the Department of Emergency Medicine, University of Pennsylvania, Perelman School of Medicine. Daniel Polsky is with the Leonard Davis Institute of Health Economics, the Wharton School of Business, and the Perelman School of Medicine, University of Pennsylvania. John M. MacDonald is with the Department of Criminology and the Leonard Davis Institute of Health Economics, University of Pennsylvania, School of Arts and Sciences, Philadelphia
| | - Daniel Polsky
- Charles C. Branas is with the Department of Biostatistics and Epidemiology and the Leonard Davis Institute of Health Economics, University of Pennsylvania, Perelman School of Medicine, Philadelphia. Michelle C. Kondo is with the US Department of Agriculture-Forest Service, Northern Research Station, Philadelphia. Sean M. Murphy is with the Department of Health Policy and Administration, Washington State University, Spokane. Eugenia C. South is with the Department of Emergency Medicine, University of Pennsylvania, Perelman School of Medicine. Daniel Polsky is with the Leonard Davis Institute of Health Economics, the Wharton School of Business, and the Perelman School of Medicine, University of Pennsylvania. John M. MacDonald is with the Department of Criminology and the Leonard Davis Institute of Health Economics, University of Pennsylvania, School of Arts and Sciences, Philadelphia
| | - John M MacDonald
- Charles C. Branas is with the Department of Biostatistics and Epidemiology and the Leonard Davis Institute of Health Economics, University of Pennsylvania, Perelman School of Medicine, Philadelphia. Michelle C. Kondo is with the US Department of Agriculture-Forest Service, Northern Research Station, Philadelphia. Sean M. Murphy is with the Department of Health Policy and Administration, Washington State University, Spokane. Eugenia C. South is with the Department of Emergency Medicine, University of Pennsylvania, Perelman School of Medicine. Daniel Polsky is with the Leonard Davis Institute of Health Economics, the Wharton School of Business, and the Perelman School of Medicine, University of Pennsylvania. John M. MacDonald is with the Department of Criminology and the Leonard Davis Institute of Health Economics, University of Pennsylvania, School of Arts and Sciences, Philadelphia
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Abstract
Place-based programs are being noticed as key opportunities to prevent disease and promote public health and safety for populations at-large. As one key type of place-based intervention, nature-based and green space strategies can play an especially large role in improving health and safety for dwellers in urban environments such as US legacy cities that lack nature and greenery. In this paper, we describe the current understanding of place-based influences on public health and safety. We focus on nonchemical environmental factors, many of which are related to urban abandonment and blight. We then review findings from studies of nature-based interventions regarding impacts on health, perceptions of safety, and crime. Based on our findings, we suggest that further research in this area will require (1) refined measures of green space, nature, and health and safety for cities, (2) interdisciplinary science and cross-sector policy collaboration, (3) observational studies as well as randomized controlled experiments and natural experiments using appropriate spatial counterfactuals and mixed methods, and (4) return-on-investment calculations of potential economic, social, and health costs and benefits of urban greening initiatives.
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Affiliation(s)
- Michelle C Kondo
- USDA-Forest Service, Northern Research Station, 100 North 20th Street, Ste 205, Philadelphia, PA, 19103, USA.
| | - Eugenia C South
- Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Charles C Branas
- Department of Biostatistics and Epidemiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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South EC, Kondo MC, Cheney RA, Branas CC. Neighborhood blight, stress, and health: a walking trial of urban greening and ambulatory heart rate. Am J Public Health 2015; 105:909-13. [PMID: 25790382 DOI: 10.2105/ajph.2014.302526] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
We measured dynamic stress responses using ambulatory heart rate monitoring as participants in Philadelphia, Pennsylvania walked past vacant lots before and after a greening remediation treatment of randomly selected lots. Being in view of a greened vacant lot decreased heart rate significantly more than did being in view of a nongreened vacant lot or not in view of any vacant lot. Remediating neighborhood blight may reduce stress and improve health.
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Affiliation(s)
- Eugenia C South
- At the time of this study, Eugenia C. South was with the Robert Wood Johnson Clinical Scholars Program, Perelman School of Medicine, University of Pennsylvania, Philadelphia. Eugenia C. South is also with the Department of Emergency Medicine, Perelman School of Medicine. Michelle C. Kondo is with the Urban Health Lab, Perelman School of Medicine and the US Department of Agriculture Forest Service, Northern Research Station, Philadelphia, PA. Rose A. Cheney is with the Urban Health Lab, Perelman School of Medicine. Charles C. Branas is with the Urban Health Lab and the Department of Biostatistics and Epidemiology, Perelman School of Medicine
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