"I just wanted money for food": a qualitative study of the experiences of Australians during the COVID-19 pandemic.

Aim: The social and economic impacts that have occurred during the COVID-19 pandemic can disproportionally affect those already experiencing poverty or at risk of poverty. Therefore, this study sought to explore the relationship between well-being and social determinants of health among Australian adults during the pandemic. Subject and Methods: Semi-structured interviews were undertaken with 20 participants, aged 21-65 years, from various socioeconomic areas. Results: Three main themes emerged from the analysis of the data: food security; housing outcomes; and psychological and emotional impact. Participants in low socioeconomic areas struggled with food security, having to access food banks, which was precipitated by employment loss during the pandemic. Some female participants experienced worsening inequalities and lack of financial and housing stability, affecting their overall well-being. Conclusion: This study identified that there was a clear social divide between adults living in low socioeconomic areas compared with those living in high socioeconomic areas, with participants in low socioeconomic areas faring worse in terms of exacerbated social determinants of health and consequent impacts on well-being.

Protecting the Most Vulnerable: Policy Response and Eviction Filing Patterns During the COVID-19 Pandemic

The COVID-19 pandemic and resulting economic crisis exposed the U.S. rental housing market to extraordinary stress. Policymakers at the federal, state, and local levels established eviction moratoria and a number of additional direct and indirect renter-supportive measures in a bid to prevent a surge in evictions and associated public health risks. This article assesses the net efficacy of these interventions, analyzing changes in eviction filing patterns in 2020–2021 in thirty-one cities across the country. We find that eviction filings were dramatically reduced over this period. The largest reductions were in places that previously experienced highest eviction filing rates, particularly majority-Black and low-income neighborhoods. Although these changes did not ameliorate racial, gender, and income inequalities in relative risk of eviction, they did significantly reduce rates across the board, resulting in especially large absolute gains in previously high-risk communities.

Addressing the unmet social needs of gynecologic oncology patients as identified by a universal screening tool in a safety net hospital

Objectives: To identify the unmet, actionable social needs of gynecologic oncology patients using a self-administered social needs assessment tool and quantify the interventions subsequently provided to our patients. Method(s): This is a study of data collected in an ongoing performance improvement initiative in a gynecologic oncology clinic at a safety net hospital and was determined to be exempt from review by the institutional IRB. Eligible patients completed the social needs screening tool from October 2021 to March 2022. The following social needs domains were assessed: food insecurity, utility insecurity, housing insecurity, transportation insecurity, need for childcare, exposure to violence, lack of companionship, difficulty reading, or difficulty accessing medical care due to fear of losing job. Patients were asked if they desired to speak with a social worker and if any needs were urgent. Data from the screening tool was collected and supplemented by data from the EMR. Univariate descriptive statistics were used to report the patient demographic information, prevalence of social needs, and referral rates for social needs identified. Result(s): There were 475 patients seen in the gynecologic oncology clinic since October 2021. 286 (60%) patients completed the screening tool. 139 (49%) screened positive for at least 1 social need;of those 98 (70%) were Hispanic with a median age of 56 years. 27 (6%) patients were receiving treatment for a gynecologic malignancy, of whom 19 (70%) had at least 1 social need. 25 (92%) patients were insured through Medi-Cal. 12 (44%) patients were being treated for endometrial cancer, followed by ovarian (7, 26%) and cervical (4, 15%). The social needs identified in all patients and in patients actively receiving cancer treatment are summarized in Fig. 1. Patients reporting lack of companionship were referred to mental health or cancer support groups through the American Cancer Society or the Los Angeles County Department of Public Health. Those needing transportation or utility services were linked with services available through their insurance or LA County, ride share vouchers, low-income energy assistance programs, COVID rent/mortgage relief programs. Patients with food and housing insecurity were assisted in applying for public housing or food stamps;local food banks were provided. Patients were assisted with applying for disability insurance as needed. To date, all actively treated patients reporting lack of companionship, need for transportation, avoiding medical care for fear of losing their job, and utility insecurity were provided resources;80% received resources for food insecurity. Conclusion(s): Universal screening for social needs in gynecologic cancer patients identifies a high rate of unmet needs within a safety net hospital. Cancer care navigators can successfully provide these patients community-based resources tailored to their individual social needs. Our next steps will be to determine if and how these resources impact our patients' experiences and treatment outcomes.[Formula presented]Copyright © 2022 Elsevier Inc.

Risks and opportunities for children's well-being in resource-constrained multigenerational households during COVID-19: Implications for school psychology interventions

The coronavirus disease (COVID-19) pandemic had a global impact on family social and economic well-being. Individuals and families sought alternative living arrangements as a result of the financial crisis, health implications, and housing insecurity, with many joining multigenerational households. However, it is unknown how multigenerational family life affects children's well-being. Therefore, this qualitative study explored risks and resilience-building opportunities for children's psychological and social well-being in resource-constrained multigenerational households during the COVID-19 pandemic in South Africa. Five multigenerational families were selected through snowball sampling and case design. The three generations of participants were grandparents (n = 5), parents (n = 7), and children (n = 4). Data were gathered through a questionnaire and interviews. The study received institutional ethics approval. After thematic analysis, two themes and six sub-themes were identified. Risks were related to interpersonal conflict, family collective fear of COVID-19, and children's multiple other fears. Opportunities were identified as academic support, shared responsibilities, life skills and values acquisition, and family cohesion. Results demonstrated the potential risks and resilience-building opportunities multigenerational households present for children's psychosocial well-being. Multisystemic influences in a multigenerational household contribute to children's adjustment. These outcomes necessitate systemic school psychology interventions. Longitudinal studies are recommended to explore child well-being trends in multigenerational households in varying socioeconomic contexts.

Factors Associated with Food Insecurity Among Health Sciences Students During the COVID-19 Pandemic

This web-based survey explored factors associated with food insecurity (FI) among health sciences students during the COVID-19 pandemic. FI was assessed using the USDA 6-item tool. Multivariable logistic regression was used for data analyses. Of the 816 respondents, 74.7% were female and 22.1% were food insecure. An annual income of <$25,000, housing instability, use of a food pantry over the past 12 months, and receiving financial support from family were independently associated with increased odds of being food insecure even after adjusting for other covariates. Further research exploring FI screening and interventions among health sciences university students is needed.

A Developing Crisis in Hunger: Food Insecurity within 3 Public Colleges before and during the COVID-19 Pandemic

During the COVID-19 pandemic, food insecurity increased across the United States, with college students being particularly vulnerable. This study surveyed 1989 undergraduates attending three public colleges before and during the first year of the pandemic. At all times, students' food insecurity was related to worse academic performance, greater housing insecurity, poorer psychological and physical health, and less access to healthcare. Compared to pre-pandemic students, during-pandemic students reported greater use of and fewer barriers to food programs, spending more on and and receiving more government aid for food, experiencing more academic difficulties due to food insecurity, having greater housing insecurity, and enduring less access to healthcare. © 2022 Taylor & Francis Group, LLC.

Community health needs bus tour: understanding social determinants of health and racism

Purpose of Study: Racism, the social system in which certain groups of people are afforded opportunity while others are limited, based on race, is a social determinant of health (SDOH) that contributes greatly to health inequity. An interactive Community Health Needs Bus Tour at Arkansas Children's Hospital served to: (1) increase intern knowledge of SDOH and racially-driven health inequity, while providing context to the patients and community we serve;and (2) connect residents to the organizations working to overcome these disparities. Methods Used: Key SDOH were identified including food and housing insecurity, education, literacy, community and personal violence, and racism. Community organizations and landmarks were identified as "tour stops" to illustrate each SDOH and its impact. Each stop connected residents to a place where they would soon be referring patients with such needs in the future. A detailed script was developed. At each tour stop residents were given demographic data that highlighted the impact of health inequity. They also learned the positive impact of the organization. At "Hop On" tour stops, speakers from the individual organizations were invited on board the bus to share the specific impact of their work. The tour was also designed with two "Hop Off" stops, chosen to illustrate how Little Rock's unique history and racial division created much of the health inequity of today. At the Mosaic Templars Cultural Center, residents toured exhibits to learn and celebrate African American history and culture. At the Central High School Visitor Center, residents studied the history of the "Little Rock 9." These stops highlighted the impact of public policy and racism and sought to expand residents' cultural competency. The tour took place during Intern Orientation in June 2019 and 2022, with a gap due to COVID. Summary of Results: All participants were surveyed anonymously at the conclusion of the bus tour. 96% felt that the experience met its core objectives. 100% of all participants agreed or strongly agreed that they can apply what they learned on the Bus Tour to their work as a resident. Further, 100% of all participants agreed or strongly agreed that they had identified an organization or person they can collaborate with in the future. One resident reported the tour led to "better understanding the history and current socioeconomic context that may color interactions with future patients." Another resident reflected the experience was a "great reminder to keep in mind that regardless of patients' background, they all deserve the same standard of care." Conclusion(s): This type of interactive, community-based programming is effective in teaching SDOH, raciallydriven health inequity, and connecting residents to the patients and communities they serve. Further study could identify if these experiences specifically impact residents' perception on racism, health inequity, and bias. Copyright © 2023 Southern Society for Clinical Investigation.

Syrian Refugees' Experiences of the Pandemic in Canada: Barriers to Integration and Just Solutions

Research has shown high levels of housing precarity among government-assisted refugees (GARs) connected to difficult housing markets, limited social benefits, and other social and structural barriers to positive settlement (Lumley-Sapanski, 2021). The COVID-19 pandemic has likely exacerbated this precarity. Research to date demonstrates the negative consequences of the COVID-19 pandemic for refugees and low-income households, including both health-related issues and economic challenges, that may exacerbate their ability to obtain affordable, suitable housing (Jones & Grigsby-Toussaint, 2020;Shields & Alrob, 2020). In this context, we examined Syrian government-assisted refugees' experiences during the pandemic, asking: how the COVID-19 pandemic has impacted Syrian refugees' experiences of housing stability. To examine this issue, we interviewed 38 families in Calgary, London, and Fredericton. Using a qualitative descriptive methodology for analysis and interpretation (Thorne et al., 1997), we found the liminality of settling as a GAR has been compounded by isolation, further economic loss, and new anxieties during the pandemic. Ultimately, for many participants, the pandemic has thwarted their housing stability goals and decreased their likelihood of improving their housing conditions. Based on our findings, we discuss potential policy and practice relevant solutions to the challenges faced by refugees in Canada during the pandemic and likely beyond.

Antiretroviral (ART) Virologic Suppression (VS) and Patient Reported Outcomes (PROs) at 6 Months in the Clinical Opportunities and Management to Exploit Bictegravir/Emtricitabine/Tenofovir Alafenamide (B/F/TAF) an Asynchronous Connection Key (COMEBACK) Study

Background. Effectively interrupting the source of transmission is a critical step in ending the HIV epidemic. COMEBACK (NCT04519970) is a 48-week single-center study in Chicago implemented in September 2020, with its main objectives to reengage lost-to-care patients and rapidly reinitiate ART to promote VS and favorable PROs. Methods. Adults off ART >=2 weeks, without history of significant B/F/TAF resistance or renal impairment, were rapidly started on B/F/TAF upon reengagement after same day collection of baseline labs and PROs. A retention screening assessment was used to stratify participants into case management (CM) tiers: Minimal, Moderate, or Advanced. An acuity assessment tool was adapted to determine whether participants needed additional support based on retention and VS. Currently, 80 of the expected 100 subjects are enrolled and 55 have reached the 24-week timepoint. Baseline and 6-month endpoints were analyzed for these participants. Results. At baseline (N=55), median age was 34 years (range, 24-62), with 92.6% Black and 72.2% cisgender male. Median CD4+ was 338 cells/mm3, with a median viral load 7,402copies/mL, (range, < 40-333,350, 16.3% VS). Median time off ART was 2.6 months (range, 0.5-243). For CM, participants were stratified into Minimal (71%) and Moderate (29%) tiers;none were identified as Advanced. Table 1 reflects tier shifts through 24 weeks. Shifts inCMintensity differs from the HIV adherence self-efficacy PRO completed within 24 weeks, indicating that at least 50% underestimated their need to integrate and maintain adherence to ART treatment. Forty of 55 participants (72.7%) were retained-in-care at 6 months, with VS in 61.8% (N=34/55) by intention-to-treat and 85% (N=34/40) by observed analysis. No resistance to B/F/TAF was detected through 6 months. Note: The table reflects patients retained on study at their week 24 endpoint. Conclusion. VS was high for participants retained-in-care, but lapses in retention and shifts toward more intense CM were likely due to social determinants of health challenges, including incarceration, housing insecurity, and COVID-19-related disruptions in healthcare.

Social Determinants of Health Associated with Intimate Partner Violence in an Urban Obstetric Population

Objective: Intimate partner violence (IPV) is pervasive and can lead to severe health consequences. In the US, 25% of women have experienced sexual violence, physical violence, and/or stalking by an intimate partner. However, less is known about the frequency and risk factors for IPV in the obstetric population. Study Design: Nested case-control study from a prospective cohort survey study of 606 parturients at a single academic medical center from 2011-2022. Structured surveys were administered to consented patients during their postpartum hospital stay to gather information on social determinants of health (SDoH) and birth outcomes. The case group included participants who reported forced sex causing pregnancy, verbal abuse before or during pregnancy, or physical abuse during pregnancy. The control group reported none of these. Odds ratios were used to quantify the relationship between IPV and maternal sociodemographic characteristics, pregnancy factors, and levels of perceived support and discrimination. Result(s): Of 606 study participants, 568 (94%) had data on IPV. Of those, 20.4% reported IPV (case) and 80.6% reported no IPV (control). 74.6% of the study population was enrolled pre-pandemic. Unmarried status, low income, food insecurity, housing insecurity, substance use during pregnancy, higher gravidity, unintended pregnancy, low social support, and racial and gender discrimination were all significantly associated with IPV;maternal race and pregnancy during the COVID-19 pandemic were not. Conclusion(s): IPV is common, reported by 1 in 5 parturients in our population. Although maternal race was not associated with IPV in this perinatal cohort, experiencing racism was. Initiatives aimed to address SDoH such as substance use, family planning, and access to food and housing remain key opportunities to support pregnant patients experiencing IPV. The connection between perceived discrimination and IPV found here highlight the importance of addressing the influence of racism and gender-based violence on adverse birth outcomes in the US. [Formula presented] [Formula presented] Copyright © 2022

Providers' reflections on infrastructure and improvements to promote access to care for Veterans experiencing housing instability in rural areas of the United States: A qualitative study.

Veterans in rural areas of the United States face barriers to accessing healthcare and other services, which are intensified for those experiencing housing instability. Recent legislative acts have the potential to address obstacles faced by rural patients in the U.S. This study explores how infrastructure-including features related to the physical and digital environment-impacts the ability of rural Veterans experiencing housing instability to access healthcare and related services from the perspective of homeless service providers within the Veterans Health Administration (VHA). We conducted semi-structured telephone interviews (n = 22) with providers in high/low performing and/or resourced communities across the U.S. in May and June 2021 and analysed transcripts using template analysis. Themes described by providers highlight how infrastructure limitations in rural areas can exacerbate health disparities for Veterans experiencing housing instability, the impact of COVID-19 on service access, and recommendations to enhance service delivery. Providers suggested that VHA reconfigure where and how staff work, identify additional resources for transportation and/or alternative transportation models, and increase Veterans' access to technology and broadband Internet. Federal infrastructure investments should address challenges faced by Veterans experiencing housing instability in rural areas and the concerns of providers connecting them with care.

Vulnerability and resilience in the metropolitan area of Munich during the pandemic: a qualitative assessment of environment, housing, tolerance, and inclusion

Einleitung The EU project SonarGlobal was conducted in five countries, including Germany, to reveal contributing factors to vulnerability and resilience in the context of the COVID-19 pandemic. The data obtained in Munich indicated that the characteristics of the city and its suburban districts are crucial determinants of vulnerability. This study questions the aspects of environment, housing, tolerance, and inclusion of the Munich metropolitan area to explore the mechanisms that increase vulnerabilities or resilience during the pandemic. Methoden In this qualitative study, in-depth interviews were performed with 82 people living in Munich and its suburban districts and who were faced with at least one mechanism that has the potential to create a biological or social disadvantage, such as age, gender, disability, health problems, occupation, or immigration status. We also interviewed 19 experts and community representatives on specific vulnerability and resilience mechanisms. Living conditions were questioned according to the physical and social environment, housing, stigma, discrimination, and support for inclusion. After the first round of coding, subcodes were created and the second round of coding was done as. This was followed by developing categories covering challenges and resilience factors. Ergebnisse 29 participants were from rural districts surrounding Munich while 53 were living inside urban districts. They originated from 22 different countries. Nine challenges (1. Common places for socialization and inclusion being closed;2. Interruption of organized support for inclusion;3. Isolation in over-centralized institutions and shelters;4. Limited access to IT technology;5. Limited solidarity between neighbours;6. Worsened housing conditions;7. Housing insecurity;8. Increased racism;9. Discrimination and stigma regarding adherence to COVID-19 rules) and four resilience factors (1. Being close to green places;2. Having outdoor spaces at home;3. Solidarity initiatives and strong relationships in neighbourhoods;4. Alternative means for organized support) were determined. For international students, refugees, seasonal workers and other immigrants, the challenges were more intense, while they reported the only significant resilience factor as being close to nature. The alternative support ways developed by the organizations could not be strong in the face of challenges. Stigma towards the disabled, immigrants and Muslims has increased, against which a significant resilience factor did not develop. In rural districts, challenges played a minor role while resilience factors were more effective. Schlussfolgerung The COVID-19 pandemic has deepened the inequalities in people living in the metropolitan area of Munich and with a greater extent in people living in the urban district in terms of environment and housing, reduced the tolerance towards and inclusion of the most disadvantaged segments of society, and aggravated discrimination.

Families' housing experiences within contexts of stress

Experiences of homelessness and housing instability have implications for child and family well-being across the life course. In this three-paper dissertation, I explore a variety of housing experiences for families within additionally stressful contexts. First, I review the existing literature regarding infants' and toddlers' experiences of homelessness, a consequential developmental time period, and a critical gap in homelessness scholarship. Second, using qualitative analyses, I investigate families' descriptions of their experiences of housing instability and homelessness in addition to experiencing the incarceration of a parent, addressing family-identified challenges and supports. Lastly, I address relations between parents' well-being and children's stress within families living doubled-up during the COVID-19 pandemic, comparing across doubled-up status for parent mental health symptoms, emotions, behaviors, and employment, and child stress and adaptive behaviors. Following the three papers, I discuss implications for future research, policy, and practice within the field of family homelessness and housing instability. (PsycInfo Database Record (c) 2022 APA, all rights reserved)

Social Determinants of Health in Children with Severe and Non-severe sars-cov-2 Infection

Background: The COVID-19 pandemic has been shown to have a compounding effect on families across various social and healthcare needs. However, the impact of social determinants of health (SDOH) on COVID-19 disease severity in children is unknown. Our objectives were to describe the SDOH in children with SARS-CoV-2 infection and determine their association with severity of the infection Methods: This prospective observational study was supported by the National Institutes of Health RADx program and conducted in the emergency department (ED) of two large children's hospitals. Children ≤ 18 years of age with symptoms due to SARS-CoV-2 infection (positive RT PCR test, serology or epidemiological link) were enrolled between 03/29/2021 and 05/30/2021. Data collected from electronic medical records included demographics, clinical features, treatment, disposition, and outcomes. Severe cases were defined as the following within 30 days of test positivity: diagnosis of Multisystem inflammatory syndrome in children or Kawasaki disease, requirement for oxygen > 2L, inotropes, mechanical ventilation, extracorporeal membrane oxygenation (ECMO), or death. Following informed consent, caregivers were surveyed via an electronic device on previously validated PhenX questions. Aligned with the Healthy People 2020 SDOH framework, caregivers reported on economic stability, education, social and community context, health and health care, and neighborhood and built environment. Stata was used to analyze descriptive statistics, and unadjusted comparisons between groups were assessed using two sample t-tests for continuous variables and Fisher's exact test for categorical variables due to small sizes. Results: A total of 107 children (mean age 6.9 (±5.9) years, 44.9% males), with SARS-CoV-2 infection were enrolled, and 85 caregivers (79.4%) completed the survey (71.4% Black). In this sample, 97% of children were RT PCR positive, 3% had an epidemiological link, and 23 (27.1%) were categorized as severe. Almost half of caregivers (47.6%) reported employment or income loss due to COVID-19. The three most common SDOH needs identified were that of childcare (22.0%), housing instability (22.0%), and food insecurity (21.7%). Children with severe COVID-19 were significantly more likely to have a caregiver who was single, including never married, separated/divorced, and widowed (82.6% vs. 52.5%;Table 1). Although not statistically significant, children with severe COVID-19 tended to have higher levels of social needs including housing instability, poor caregiver mental health, and lower levels of social support compared to children with nonsevere infection (Table 2). Conclusion: Our preliminary data on SDOH suggest that among children with SARS-CoV-2 infection, housing instability, food insecurity and childcare needs are particularly prevalent. Children with severe SARS-CoV-2 infection were more likely to have single caregivers. Family structure may influence severe COVID-19 in children and programming and supports for single parent households should be considered. Larger studies in the ED setting will help confirm these findings and to direct resources to address these social needs.

DEMOGRAPHIC, SOCIAL DETERMINANTS, AND CLINICAL FACTORS ASSOCIATED WITH COVID-19 VACCINATION COMPLETION AMONG 6.2 MILLION VETERANS IN THE VETERANS HEALTH ADMINISTRATION FROM JANUARY 1, 2020 TO DECEMBER 22, 2021

BACKGROUND: Despite COVID-19 vaccines' demonstrated effectiveness in mitigating COVID-related hospitalizations and death, large numbers of Americans, including U.S. veterans, have not completed the primary vaccine series or the third/booster dose. The Veterans Health Administration (VHA) is the largest integrated health care system in the U.S. Identifying subgroups of veterans that have not completed COVID-19 vaccination and booster/third doses may inform targeted interventions to decrease disparities and promote vaccine completion. METHODS: We included veterans enrolled at VHA facilities from Jan 1, 2021 (first COVID-19 vaccinations available for highest risk veterans per CDC guidelines) through December 22, 2021. The VA COVID-19 Shared Data Resource was linked to the Corporate Data Warehouse to provide vaccination and other COVID-related clinical information, as well as demographic and social determinants data. The main study outcome was completion of the COVID-19 primary vaccine series (two doses of either mRNA vaccine or one dose of the viral vector vaccine). Secondary outcome was completion of the booster or third dose among eligible veterans. Univariate descriptive statistics determined the proportion of veterans completing vaccination by subgroup of interest;relative risks calculated statistical significance. RESULTS: Of 6,235,555 veterans, 9.5% were women;mean age was 62.9 years (+/-16.8 years);31.2% were of non-White racial/ethnic minority groups;6.7% were Hispanic. Of these, 61.7% completed primary vaccination series. Primary vaccination rates were significantly lower in younger veterans ≤ 49 years (47.2%) compared to those >50 years (67.7%). In addition, lower primary vaccination rates were found in women vs. men (57.1% vs. 62.5%);those residing in highly rural vs. urban locations (53.9% vs. 64.5%);Native Americans (56%) compared to Black/African American (64.8%), Hispanic (63.9%) or White (61.6%) veterans;those reporting food insecurity vs. not (54.9% vs. 64.3%);housing insecurity vs. not (51.6% vs. 65.1%);having had a positive vs. negative COVID-19 test prior to vaccination (45.5% vs. 71.6%);and not assigned a primary care team vs. assigned (45.2% vs. 64.5%), (all pvalues < 0.001). Of 3,672,322 eligible veterans, 33.5% received their booster/ third doses as of 12/22/21. Subgroups at risk for not having received booster/ third doses were the same as for the primary series, with the youngest veterans (18-49 years) having the lowest rates of booster/third doses compared to veterans > 50 years (16.1% vs. 36.9%). CONCLUSIONS: Based on VA data, substantial proportions of veterans remain unvaccinated-or under-vaccinated, especially younger veterans, women, Native Americans, those with food or housing insecurity, prior COVID-19, and those not assigned to primary care. Impactful interventions, including health care staff encouraging vaccine completion among more vulnerable subgroups, are needed to avoid further disparities related to adverse COVID19 outcomes.

LEPTOSPIROSIS IN THE CITY: A CASE REPORT

CASE: A 58 year-old undomiciled man with no medical history presented with three days of anorexia, malaise, abdominal pain, and decreased urination. Exam was notable for scleral icterus. Lab-work revealed sodium 133 mEq/L, BUN 132mg/dL, creatinine 8.82 mg/dL, platelet 64 K/uL, total bilirubin 6.4 mg/dL, direct bilirubin 5 mg/dL. Lab-work two years prior was normal. HCV antibody was reactive, urinalysis revealed microscopic hematuria, and cocaine was detected on toxicology. Abdominopelvic CT, MRCP and renal sonogram were non-pathologic. On hospital day 5 his creatinine downtrended but total bilirubin continued to rise to a peak of 11.2 mg/dL and a leukocytosis without fever developed (peak 21.2 K/uL). Ceftriaxone was started empirically and a workup of blood cultures, viral serologies, ANA, alpha-1 antitrypsin, complement, cryoglobulin, ceruloplasmin level, microsomal, smooth muscle and antimitochondrial antibodies was normal. Review of his history suggested exposure to rodents as he slept close to a dumpster. Pending Leptospirosis serology, the antibiotics were adjusted to doxycycline. At discharge, the WBC and platelet counts normalized while the bilirubin and creatinine downtrended. IgM serology for leptospira later resulted positive. IMPACT/DISCUSSION: Leptospirosis is a worldwide zoonotic disease commonly associated with moist environments, poor housing and inadequate sanitation. Rodents are important reservoirs, shedding spirochetes through urine. Human infection results from exposure to animal urine, contaminated soil or water, or infected animal tissue. Portals of entry include cuts, mucous membranes or conjunctivae. Person-toperson transmission is rare. The incubation period is 5-14 days and illness severity ranges from subclinical to life-threatening. Disease manifestations include jaundice with acute kidney failure (Weil's disease), rash, conjunctival suffusion, hyponatremia, thrombocytopenia, microscopic hematuria, myocarditis, pulmonary hemorrhage, and meningitis. A biphasic illness, the acute febrile bacteremic phase can last 2-9 days followed by a period of apparent improvement. An “immune” phase then follows characterized by development of complications, as in our patient. During this phase, leptospires are absent from blood but may appear in the urine. While human cases of leptospirosis are rarely reported in the US outside of Puerto Rico and Hawaii (in the absence of travel), there was a significant rise reported to the NYC DOH in 2021. A potential explanation is an increase in housing insecurity and disruptions to waste management as a consequence of the COVID-19 pandemic. CONCLUSION: Leptospirosis is an important consideration in at-risk populations who may unknowingly be exposed due to living conditions. Our case of unexpected Weil's disease in an urban setting underscores the importance of a thorough social history as well as timely recognition of uncommon infections as possible reversible causes of multi- organ failure in the context of a changing world climate.

MIXEDMETHODS EVALUATIONOF THE INITIAL IMPLEMENTATION OF A MEDICAID ACCOUNTABLE CARE ORGANIZATION PROGRAM TO ADDRESS FOOD AND HOUSING INSECURITY

BACKGROUND: States and health systems are investing in programs to address patients' unmet social needs, such as food and housing insecurity, but there has been limited evaluation of the implementation of these programs. In 2020, Massachusetts initiated the Flexible Services (Flex) program to provide funding to Medicaid accountable care organizations (ACOs) to address food and housing insecurity through community resources. The study objective was to examine initial implementation of Flex (March 2020-July 2021), using the Reach, Efficacy, Adoption, Implementation, Maintenance (RE-AIM) framework. METHODS: This mixed-methods evaluation was part of LiveWell, a longitudinal study assessing the impact of Flex on community health center patients aligned with two large hospitals within Mass General Brigham (MGB) in Boston, MA. ACO participants were screened annually for food and housing insecurity. To assess reach, we examined Flex enrollment using electronic health record data of enrollees ≥21 years old. Eligibility criteria for Flex included: 1) enrollment in MGB Medicaid ACO, 2) food or housing insecurity identified by screening or clinical encounter, and 3) a complex health condition (e.g., uncontrolled diabetes, depression). To assess implementation, adoption, and effectiveness, we conducted qualitative interviews with Flex enrollees (N=16) and health system staff (N=15). Interviews were analyzed using the Framework Method. RESULTS: Of 44,417 ACO enrollees, 693 (2%) were enrolled in Flex in the first 17 months. A total of 19,275 (43%) of ACO enrollees and 521 (75%) of Flex enrollees completed annual screening for food/housing insecurity. Mean ACO participant age was 40 years (SD: 14);62% were female;32% were Hispanic. Mean Flex enrollee age was 46 years (SD: 13);81% were female;54% were Hispanic. Implementation challenges included complex eligibility requirements, administrative burden (e.g., tracking, documentation), COVID- 19 factors (e.g., reduced clinic visits), and coordinating with community organizations. Facilitators included raising staff awareness to increase referrals, administrative funding for enrollment staff, adaptive strategies to identify eligible patients, and streamlined communication with community organizations. Flex enrollees reported improvements in healthy eating and food security. Patients who were able to select food or meals based on their preferences reported higher satisfaction. Patient-reported housing support included assistance with utility bills and affordable housing applications. CONCLUSIONS: To improve reach, adoption, and effectiveness in diverse populations, states and health systems implementing programs to address social needs should consider expanding screening for food and housing insecurity, minimizing administrative burden, providing funding for enrollment staff, and tailoring programs to patient preferences.

LONGITUDINAL PATTERNS OF POPULATION AND INDIVIDUAL-LEVEL HEALTH-RELATED SOCIAL NEEDS

BACKGROUND: While almost half of US adults report a health-related social need (HRSN), little is known about how an individual's HRSNs change over time. Existing research on HRSNs has mostly focused on cross-sectional studies and has been geographically localized. To overcome these limitations, we examined longitudinal patterns of HRSNs among a large nationwide cohort of Medicare beneficiaries. METHODS: We used data from a longitudinal nationwide cohort of individuals ≥65 years of age enrolled in Humana Medicare Advantage plans. Four surveys were administered approximately quarterly between Q4 2019 to Q4 2020 and asked validated questions about financial strain, food insecurity, loneliness or social isolation, housing insecurity, poor housing quality, utility insecurity, and unreliable transportation. We restricted our analyses to those who responded at least in part to all 4 surveys. We used Sankey plots to visualize transitions in individual patients' total number of reported HRSNs over time. We also used baseline patient characteristics drawn from medical and pharmacy claims data to characterize 3 distinct groups: 1) no HRSN across all quarters, 2) any fluctuation between 0 and ≥1 HRSN, and 3) ≥1 HRSN across all quarters. RESULTS: Of 18,881 individuals, the overall number reporting HRSNs was relatively consistent over time. Specifically, financial (29.6-31.3%), food (18.7-19.8%), and housing quality (15.9-17.3%) were the most frequent needs across each quarter. However, when characterized at the individual level, patients reported substantial fluctuations in need: 27.7% reported no HRSNs in all four quarters;45.5% fluctuated between having 0 and ≥1 HRSN across the four quarters;26.8% reported ≥1 HRSN in all 4 quarters. For example, of those who reported one HRSN in Q1, 44.8% transitioned to no need in Q2. Demographic and clinical characteristics differed across the three groups. For example, female gender, Black race/ethnicity, residence in the South, and higher comorbidity burden were disproportionately represented in those reporting ≥1 HRSN in each quarter, followed by those with fluctuating needs. CONCLUSIONS: In this nationwide survey of health-related social needs among Medicare beneficiaries, while the overall prevalence of HRSNs was consistent over time, we observed marked fluctuation in individuals' needs during the year observed. This fluctuation occurred over all quarters and did not change after the COVID-19 pandemic began. Our findings have important ramifications for health systems or communities that wish to offer support for these patients. In some populations, screening for needs may have to happen more frequently than typically done at present. Support may need to be offered rapidly as patients experience a change in need. Key demographic and clinical characteristics also appear to differ for patients experiencing consistent or fluctuating needs, which could be used as potential identifiers for those at greatest need.

Exploring financial stress and resource deprivation as barriers to preferred contraceptive use in Wisconsin in 2021.

OBJECTIVE: This study assessed a broad array of socioeconomic barriers in relation to preferred contraceptive use during a time of exacerbated personal and social financial strain (the COVID-19 pandemic). STUDY DESIGN: Using statewide data collected in early 2021 through the Survey of the Health of Wisconsin, we conducted bivariate analyses exploring the relationship between socioeconomic resources and preferred contraceptive use among Wisconsin women. RESULTS: The survey garnered 1889 responses, with a response rate of 34%. The sample for the current study (N = 247) included only adult women of reproductive age who reported current contraceptive use. Nearly one-third (32.8%) of contraceptive users reported that they were not using their preferred method. We found that greater resource deprivation, including housing instability (had to relocate: p = 0.004; unable to pay rent and/or mortgage: p = 0.008), food insecurity (ran out of food: p = 0.003; worried about running out of food: p = 0.008), and greater financial stress (p < 0.001), were significantly associated with lowered likelihood of using one's preferred contraceptive method. CONCLUSIONS: Findings indicated that people lacking socioeconomic resources, including adequate food and housing, may be unable to access their preferred contraceptive method(s). Amidst competing demands on time and resources, the inability to obtain preferred contraceptive method(s) may represent system-wide barriers as well as people's lowered ability to prioritize and access care in light of socioeconomic struggles. IMPLICATIONS: Health care providers and health systems should work to address structural barriers to care and bolster community resources in ways that promote patients' reproductive autonomy. There is also a need for continued research on specific socioeconomic determinants of preferred contraceptive use and potential solutions that bolster community resources.

COVID-19 AND THE PRECARIOUS SITUATION OF LESBIANS, GAYS AND BISEXUALS IN ETHIOPIA

The burden of the pandemic is more pronounced among vulnerable and marginalized groups in the society, who, in the context of complex disadvantages, do not have the means to cope with the multifaceted disruptions in the labour market, food and health system, and their social networks. The pandemic and different measures taken by the Ethiopian government including State of Emergency (SOE) and strategies to contain COVID-19 affect all citizens in general and LGB in particular. This mixed methods study seeks to assess the impact of COVID-19 and the wide socio-economic and political upheaval associated with the State of Emergency Proclamation on the lives of LGBs in Ethiopia. The research combines phone surveys involving 200 LGB and qualitative interviews with 12 LGB. Most of the participants reported experiencing drastic changes in their lives since the advent of COVID-19. The most reported as well as the worst experiences include unemployment/ reduced income and food/housing insecurity;fear of COVID-19 infection or death;inability to continue normal daily life, social and intimate relationship;and change in living arrangement. A small proportion of participants also mentioned violence. The study confirmed the precarious situation of sexual minorities in times of crisis. The ongoing war since Nov.2020 and resulting insecurity have led to disruption and destruction of the economy, social and health services;and deterioration of peace and security with significant bearing on marginalized groups. Long standing and entrenched stigma and widely held notions of heteronormativity have relegated LGB in Ethiopia to the margins of society. The pandemic and subsequent SOE and internet interruptions have pushed LGB into further physical, social, and economic vulnerabilities and marginalization. Within the LGB group, the impact varies across individuals based on their socioeconomic and health standing. The situation calls for concerted policy measures to address economic, social, and health determinants.