Journal of Urban Health-Bulletin of the New York Academy of Medicine最新文献

The fragile health system in Sierra Leone undermines healthcare, leading to substantial patient costs. We aimed to estimate the economic burden and inequalities in healthcare in urban informal settlements in Freetown, Sierra Leone. A cross-sectional survey was conducted in three informal settlements in Freetown in April and May 2023 to collect data on healthcare usage within and outside the boundaries of the informal settlements. Catastrophic expenditures were estimated using the payer's household budget. Logistic regression explored socioeconomic characteristics associated with catastrophic expenditures. Inequalities in healthcare expenditures were assessed through concentration curves and indices. A total of 2575 participants reported healthcare utilization. Dwarzark (US$6.9) and Moyiba (US$7.1) had higher costs than Cockle Bay (US$5.5) when utilizing healthcare within the communities. Households incurred higher costs when seeking healthcare outside their informal settlements than within (US$14 vs US$ 7). Over half of the households across the settlements incurred catastrophic expenditures when seeking care outside the communities (57%), with the poorest wealth quintile (poorest, 89%; wealthier, 12%) incurring in higher incidence. Attending informal healthcare had a protective effect against catastrophic expenditure for healthcare within the communities. Age + 35, residence in Dwarzark and Moyiba, and length of residence + 4 years were associated with catastrophic expenditures. Healthcare expenditure was progressive in Dwarzark and equally distributed across wealth quintiles in the other communities. Our findings indicate the need to provide accessible, affordable, and good-quality healthcare within communities to alleviate the catastrophic costs of healthcare utilization. The regulation of informal health providers and their integration into the formal health system should be considered.

Overdose deaths involving fentanyl represent a major public health crisis in the USA. This study investigates the spatiotemporal dynamics of fentanyl-involved deaths before, during, and after the COVID-19 pandemic and examines how sociodemographic factors influence these deaths across geographic regions. Using a retrospective ecological approach, we analyzed data on ZIP code-level fentanyl-related deaths in Cook County, IL, between 2018 and 2023, obtained from the Medical Examiner's Office and linked with sociodemographic data from the American Community Survey. We first mapped area-level death rates to assess their distribution and then conducted global and local clustering analyses to identify spatial autocorrelations and the locations of high- or low-death-rate areas. A geographically weighted Poisson regression (GWPR) model evaluated the associations between area-level fentanyl-related death rates and the area-level proportion of young adults, males, and individuals with at least a college degree, disability rate, and poverty rate. Spatial analyses found stronger spatial autocorrelations during (2020-2021) and after (2022-2023) the pandemic. Initially, high death rates were concentrated in the downtown area of Chicago, and they expanded to the surrounding areas during and after the pandemic. The GWPR model revealed that an increase in the area-level proportions of poverty, disability, and young adult residents increased the fentanyl-related death rates in most of the areas. Our findings highlight the urgent need to address the evolving dynamics of fentanyl-related overdoses through tailored public health interventions that account for the unique socioeconomic determinants of different regions. Importantly, a comprehensive approach to addressing differences in overdose death rates and their risk factors will be crucial to mitigating this public health crisis.

In the face of escalating climate-related challenges, the resilience of healthcare systems is paramount. As was seen during COVID-19, the climate crisis exemplifies the critical need for a resilient workforce and robust healthcare infrastructure amidst increasing impacts including infrastructure disruptions, rising costs, and exacerbated health disparities. Structurally vulnerable communities, particularly those of color, face disproportionate exposure to climate risks, highlighting the urgent need for equitable resilience strategies. A focus on multifaceted approaches to fortifying healthcare systems against climate change includes emphasizing decarbonization, adaptability, data-driven planning, and support of sustainable infrastructure and health workers. The importance of integrating climate awareness into clinical and public health practices is underscored, promoting proactive measures and community engagement. Strategies to mitigate carbon footprint and enhance healthcare delivery can be enacted including with some federal and philanthropic funding support. This comprehensive approach ensures that healthcare systems remain robust, equitable, and responsive in the face of ongoing and future climate crisis challenges.

Gun violence is a leading cause of death and injuries in the USA, adversely affecting physical and mental health among its survivors. Declared as a public health crisis in 2024, It disproportionately affects African Americans. It is linked to discriminatory policies like "redlining," which fostered racial segregation and systemic inequities, perpetuating cycles of violence and mental health disparities. This study explores the relationships between racial segregation, systemic inequities, gun violence, and mental health through a data-driven, longitudinal study (2005-2021) of Milwaukee, WI, a hyper segregated metropolitan region. Our investigation aims to inform evidence-based, place-sensitive policies to promote social justice, reduce disparities, and foster healthy communities. Utilizing location-based demographic and socio-economic data from the U.S. Census, gun violence data from the Wisconsin Incident-Based Reporting System, and mental health data from the CDC's PLACES dataset, we conduct spatial and temporal analyses and geovisualization in GIS. To understand trends and correlations, we conduct time series decomposition, Mann-Kendall trend tests, and entropy statistics. Our findings indicate that racially segregated neighborhoods experience higher rates of gun violence and poorer mental health outcomes. Predominantly African American neighborhoods exhibit patterns of "consecutive," "sporadic," and "new" hotspots of gun violence, while predominantly white neighborhoods are characterized as "cold spots." Physical and mental health disparities in Milwaukee indicate similar patterns. The results of this study highlight the profound impact of historical and systemic socioeconomic discrimination on contemporary public health issues.

Crowded living conditions are associated with negative health outcomes, particularly for children. Federal rental assistance may reduce household crowding by improving access to affordable housing for low-income families. We leveraged NHANES data linked with HUD administrative rental assistance records to examine relationships between different forms of HUD rental assistance and multiple measures of crowding for households with children. We found a statistically significant reduction in the odds of crowding for those currently receiving HUD assistance compared to a control group who entered rental assistance within 2 years of their NHANES interview (95% CI, 0.39 to 0.93). The specific relationships between rental assistance and crowding and the magnitude of these associations varied by rental assistance type (public housing, multi-family, and vouchers). Fewer than 1 in 4 eligible households receive rental assistance. Our findings suggest that expanding access to this resource can reduce household crowding and its adverse impacts on health and well-being.

Anti-Black mortgage lending discrimination (MLD) has resulted in homeownership disparities among White and Black households. This study examines the association between MLD and health opportunities, based on various neighborhood determinants of health (e.g., employment, education, and housing status), in Michigan's three largest metropolitan areas. Multilevel models using data from the Home Mortgage Disclosure Act and Census from 2015 to 2019 were used to examine the Black-White odds ratio of mortgage denial. An association analysis was performed to examine the relationship between the Black-White odds ratio of mortgage denial and neighborhood health opportunities. Loan denial for Black mortgage applicants was 1.99 (95% CI1.87, 2.12) times more likely than for White applicants. Neighborhoods with greater anti-Black MLD had fewer harmful environmental exposures, greater health insurance coverage, and better housing and socio-economic conditions. Anti-Black MLD remains a common practice and supports the assertion that Black home-seekers experience greater MLD in neighborhoods with better opportunities for health compared to White home-seekers, who access these benefits more freely. Greater protections against MLD-including increasing oversight of the data reporting requirements and improving mortgage access for Black households-are needed to promote health equity.

Randomized controlled trials (RCTs) aiming to address the multiple health and social challenges of people experiencing homelessness (PEH) are lacking. Here we report the findings from a multicenter, open, pilot RCT. The intervention involved independent prescriber pharmacist from the National Health Service working on outreach in partnership with dedicated workers from Homeless Voluntary Charity or Social Enterprises (HVCSEs) (Pharmacist and third sector charity worker integrated Homeless Outreach Engagement Non-medical Independent prescriber Rx'-PHOENIx) in low threshold HVCSE venues or temporary accommodation addressing PEH participants' health and wider needs through repeated outreach. The trial aimed to investigate whether sufficient numbers of participants could be recruited, retained, the intervention delivered as planned, and sufficient data collected to inform a subsequent definitive RCT. Clinical outcomes were also collected at follow-up (6 months). Participants were recruited from five community pharmacies and nearby venues in urban centers of Glasgow-Scotland and Birmingham-England, then randomized one-to-one into PHOENIx intervention in addition to usual care (UC) or UC only. A priori progression criteria were achieved: 55% of those assessed as eligible were recruited; at 6 months, 72% remained in the study, 91% had emergency department and mortality data available, and 72% completed questionnaire booklets. Fifty-three percent of participants received at least 50% of the planned PHOENIx intervention consultations (in-person or phone) at 6 months. Signs of improvement in clinical outcomes in the PHOENIx group included fewer ambulance call-outs, ED visits, and hospitalizations; higher outpatient attendances; and higher scores on self-reported health-related quality of life. A definitive RCT is merited.

Epidemiologic research has found worsening behavioral health in the USA since 2020. Local policies may have contributed to these patterns and associated disparities. However, scant research has systematically documented county-level COVID-19-era policymaking or empirically investigated its health impacts. To investigate this question, we linked the US COVID-19 County Policy Database-a novel database with weekly data from 2020 to 2021 on 26 policies for 309 primarily urban counties-to data on adult behavioral health from the cross-sectional 2021 National Survey on Drug Use and Health (N = 25,600). We created measures of policy comprehensiveness by aggregating individual policies into an overall score, and into three domains: containment/closure, economic response, and public health. Outcomes included any past-30-day use and frequency of use of multiple substances (alcohol, binge alcohol, cigarettes, marijuana, non-marijuana illicit drug use, and vaping) and past-30-day psychological distress. Models adjusted for individual covariates, county fixed effects, and time-varying county-level COVID-19 covariates. We found that increases in overall policy comprehensiveness-and comprehensiveness in each of three domains-over time were not associated with the behavioral health outcomes assessed. Meanwhile, stratified models found some variability in associations across sex, racial/ethnic, education, and urban subgroups. This study established the feasibility, utility, and potential challenges of linking newly available COVID-19-related county policy data with health data to examine county-level policy influences on behavioral health. Further research is needed to inform responses to current behavioral health needs and future public health emergencies.

People experiencing homelessness (PEH) face a high risk of opioid-related deaths, yet there is limited qualitative data on the barriers encountered when accessing buprenorphine treatment for opioid use disorder (OUD). To address this gap, we interviewed 28 clinicians, outreach workers, and administrators from organizations serving PEH with OUD. Our goal was to understand the barriers and facilitators at the patient, clinic, and institutional levels and gather recommendations for improvement. Interviews, conducted via Zoom and analyzed through thematic analysis, revealed several barriers. At the patient level, themes related to barriers included knowledge and experience (e.g., limited knowledge about buprenorphine options; rejection of buprenorphine due to prior experience with precipitated withdrawal); concerns about the medication and its administration (e.g., distrust of injectable medications; concerns about treatment control, and a prolonged informed consent process for extended-release injectable buprenorphine); and challenges due to homelessness (e.g., identification requirement to access medication at pharmacies, difficulties managing buprenorphine while unsheltered). At the clinic level, themes centered around staffing (e.g., lack of training and experience in treating PEH and staffing shortages) and health care-related stigma (e.g., discriminatory attitudes toward PEH with OUD). Institutional-level themes included state-regulatory factors (e.g., practice regulations limiting clinical pharmacists' ability to prescribe buprenorphine) and access factors (e.g., stigmatization of buprenorphine prescribing, limited low-barrier buprenorphine access, and care system complexity). Recommendations included educational programs for patients and clinicians to increase understanding and reduce stigma, integrating buprenorphine treatment into non-traditional settings, and providing housing with treatment.