The moderating role of housing quality on concentrated poverty and asthma-related emergency department visits among Hispanics/Latinos.

BACKGROUND: Rates of asthma-related emergency department visits have been shown to vary significantly by place (i.e. neighborhood) and race/ethnicity. The moderating factors of asthmatic events among Hispanic/Latino-specific populations are known to a much lesser degree. OBJECTIVE: To assess the extent to which housing moderates the effect of poverty on Hispanic/Latino-specific asthma-related emergency department (ED) visits at an ecological level. METHODS: Using data from the Office of Statewide Health Planning and Development (OSHPD) and the 2016-2017 U.S. Census, a cross-sectional ecological analysis at the census tract-level was conducted. Crosswalk files from the U.S. Department of Housing and Urban Development were used to associate zip codes to census tracts. Negative binomial regression was used to estimate rate ratios. RESULTS: The effect of poverty on asthma-related ED visits was significantly moderated by the median year of housing structures built. The effect of mid-level poverty (RR = 1.57, 95% CI 1.27, 1.95) and high-level poverty (RR = 1.47, 95% CI 1.22, 1.78) in comparison to low-level poverty, was significantly greater among census tracts with housing built prior to 1965 in comparison to census tract with housing built between 1965 and 2020. CONCLUSION: Communities with older housing structures tend to be associated with increased Hispanic/Latino ED visits apart from affluent communities.

Using Community-Based Participatory Research to Design a Patient and Practitioner-Centered Group Prenatal Care Model.

In response to disproportionately high rates of infant mortality and preterm birth among women of color and women in poverty in Fresno County, California, community and academic partners coordinated a community-based participatory research (CBPR) project with local residents. Social isolation and stress, inaccessible prenatal care, and dissatisfaction with care experiences were identified as leading predictors of poor birth outcomes. The PRECEDE-PROCEED framework was used to lead the CBPR effort that resulted in the development of a model of group prenatal care, named Glow! Group Prenatal Care Program (Glow! Program). Group prenatal care (GPNC), which focuses on pregnancy health assessments, education, and peer support, has the potential to address the health and social priorities of women during pregnancy. As a result of the employed CBPR process and the extensive participation from stakeholders, this modified GPNC model responds to the unique needs of the at-risk community members, the agencies aiming to improve maternal-child health experiences and outcomes, and the prenatal care providers offering it to their patients. The methods from this study can be applied in the design and implementation of community-based health care interventions. Returning to community partners throughout the design, implementation, and evaluation phases underscored that health care interventions cannot be designed in silos, and require flexibility to respond to factors that promote improved maternal and infant outcomes, which affect the end goal for the intervention.

Risk Factors for Acute Urticaria in Central California.

At least 15-20% of the population in the world suffers from urticaria. Allergy triggers contribute to the development of urticaria. Not much is known about the demographic and environmental risk factors that contribute to the occurrence of acute urticaria. Methods: We utilized emergency department data on acute urticaria-related visits managed by the California Office of Statewide Planning and Operations for 201 zip codes located in southern central California (San Joaquin Valley) collected during the years 2016 and 2017. Census data from the same zip codes were considered as a population at risk. Socioeconomic and environmental parameters using CalEnviroScreen (Office of Environmental Health Hazard Assessment, Sacramento, CA, USA) database for the zip codes were evaluated as risk factors. Results: The incidence rate of acute urticaria in San Joaquin Valley during 2016-2017 was 1.56/1000 persons (n = 14,417 cases). Multivariate Poisson analysis revealed that zip codes with high population density (RR = 2.81), high percentage of farm workers (RR = 1.49), and the composite of those with high and medium percentage of poverty and those with high and medium percentage of non-white residents (RR = 1.59) increased the likelihood of the occurrence of acute urticaria. Conclusion: High population density, farm work, poverty and minority status is associated with a high risk of having acute urticaria.

Cumulative Impact of Environmental Pollution and Population Vulnerability on Pediatric Asthma Hospitalizations: A Multilevel Analysis of CalEnviroScreen.

The CalEnviroScreen created by the Office of Environmental Health Hazard Assessment, Sacramento, USA, is a place-based dataset developed to measure environmental and social indicators that are theorized to have cumulative health impacts on populations. The objective of this study was to examine the extent to which the composite scores of the CalEnviroScreen tool are associated with pediatric asthma hospitalization. This was a retrospective analysis of California hospital discharge data from 2010 to 2012. Children who were hospitalized for asthma-related conditions, were aged 0-14 years, and resided in California were included in analysis. Rates of hospitalization for asthma-related conditions among children residing in California were calculated. Poisson multilevel modeling was used to account for individual- and neighborhood-level risk factors. Every unit increase in the CalEnviroScreen Score was associated with an increase of 1.6% above the mean rate of pediatric asthma hospitalizations (rate ratio (RR) = 1.016, 95% confidence interval (CI) = 1.014-1.018). Every unit increase in racial/ethnic segregation and diesel particulate matter was associated with an increase of 1.1% and 0.2% above the mean rate of pediatric asthma, respectively (RR = 1.011, 95% CI = 1.010-1.013; RR = 1.002, 95% CI = 1.001-1.004). The CalEnviroScreen is a unique tool that combines socioecological factors and environmental indicators to identify vulnerable communities with major health disparities, including pediatric asthma hospital use. Future research should identify mediating factors that contribute to community-level health disparities.

Poor People Are Hospitalized Three Times More for Mental Health Services than the Non-Poor in Central Valley California.

Introduction: Providing health insurance to the poor has become a standard policy response to health disparities between the poor and the non-poor. It is often assumed that if the poor people are given health insurance, they will use preventative care, which will prevent more expensive emergency visits and inpatient hospitalization, and in turn, it will save healthcare cost in the long run. This paper presents the findings from our study in California about what happens to the poor when they are given health insurance. The purpose of the study was to understand how the healthcare system in California treats the poor patients differently than the non-poor. Method: Using multivariate logistic regressions, this study analyzed a large patient discharge data (PDD) from the California Office of Statewide Planning and Development (OSHPD) for eight counties in the Central Valley California (N = 423,640). First, utilizing International Classification of Diseases (ICD 10) as diagnostic criteria, mental-health vs. non-mental health hospitalization rates were estimated. Second, health insurance status was used as a proxy measure of poverty of the patients. Using chi-Square, the probability of hospitalization for mental health services was estimated based on their insurance types. Finally, using step-wise logistic regression, the odds of mental health hospitalization was estimated conditional on individual characteristics, health insurance types, and geographic characteristics. Findings: When the poor people were given health insurance, they were three times more likely to be hospitalized for mental health services than the non-poor. The more than three-fold variation in mental health hospitalization was not driven by demographic or geographic characteristics. The findings are new and have important implications for the healthcare policies for the poor. Further studies are needed to understand the extent to which the disproportionately high rate of mental health hospitalizations of the poor are driven by the provider-induced needs.

The Association Between the Intersection of Immigrant Status and Insurance with Adverse Birth Outcomes Among Mexican Women Residing in the San Joaquin Valley: A Mediation Analysis of Late Initiation or No Prenatal Care.

Latinos are the largest growing population and have the highest fertility rates in the US. In response, this study assessed if late initiation of or no prenatal care (PNC) mediated the relationship among adverse birth outcomes and interactions between immigrant and insurance status. This study used cross-sectional data (2002-2004) limited to 109,399 women of Mexican ethnicity who had singleton births in the San Joaquin Valley, California. We conducted hierarchical mediation analyses. US-born Mexican women who used private or public insurance for PNC were more likely to have infants born at low-birth weight and premature compared to Mexican first generation immigrant women. Nonetheless, initiation of late or no PNC positively mediated the relationship between infants born premature to Mexican first generation immigrant women who used public insurance (ab/se(ab) = 2.123, p = .034). Findings from this study support acculturation theory and the need for multilevel approaches to address PNC among women of Mexican ethnicity.

Health care access, concentrated poverty, and pediatric asthma hospital care use in California's San Joaquin Valley: A multilevel approach.

BACKGROUND: California's San Joaquin Valley is a region with a history of poverty, low health care access, and high rates of pediatric asthma. It is important to understand the potential barriers to care that challenge vulnerable populations. OBJECTIVE: The objective was to describe pediatric asthma-related utilization patterns in the emergency department (ED) and hospital by insurance coverage as well as to identify contributing individual-level indicators (age, sex, race/ethnicity, and insurance coverage) and neighborhood-level indicators of health care access. METHODS: This was a retrospective study based on secondary data from California hospital and ED records 2007-2012. Children who used services for asthma-related conditions, were aged 0-14 years, Hispanic or non-Hispanic white, and resided in the San Joaquin Valley were included in the analysis. Poisson multilevel modeling was used to control for individual- and neighborhood-level factors. RESULTS: The effect of insurance coverage on asthma ED visits and hospitalizations was modified by the neighborhood-level percentage of concentrated poverty (RR = 1.01, 95% CI = 1.01-1.02; RR = 1.03, 95% CI = 1.02-1.04, respectively). The effect of insurance coverage on asthma hospitalizations was completely explained by the neighborhood-level percentage of concentrated poverty. CONCLUSIONS: Observed effects of insurance coverage on hospital care use were significantly modified by neighborhood-level measures of health care access and concentrated poverty. This suggests not only an overall greater risk for poor children on Medi-Cal, but also a greater vulnerability or response to neighborhood social factors such as socioeconomic status, community cohesiveness, crime, and racial/ethnic segregation.

Pollution, Poverty, and Potentially Preventable Childhood Morbidity in Central California.

OBJECTIVE: To measure ecological relationships between neighborhood pollution burden, poverty, race/ethnicity, and pediatric preventable disease hospitalization rates. STUDY DESIGN: Preventable disease hospitalization rates were obtained from the 2012 California Office of Statewide Health Planning and Development database, for 8 Central Valley counties. US Census Data was used to incorporate zip code level factors including racial diversity and poverty rates. The pollution burden score was calculated by the California Office of Environmental Health Hazard Assessment using 11 indicators. Poisson-based negative binomial regression was used for final analysis. Stratification of sample by age, race/ethnicity, and insurance coverage was also incorporated. RESULTS: Children experiencing potentially preventable hospitalizations are disproportionately low income and under the age of 4 years. With every unit increase in pollution burden, preventable disease hospitalizations rates increase between 21% and 32%, depending on racial and age subgroups. Although living in a poor neighborhood was not associated with potentially avoidable hospitalizations, children enrolled in Medi-Cal who live in neighborhoods with lower pollution burden and lower levels of poverty, face 32% lower risk for ambulatory care sensitive condition hospitalization. Children living in primary care shortage areas are at increased risk of preventable hospitalizations. Preventable disease hospitalizations increase for all subgroups, except white/non-Hispanic children, as neighborhoods became more racially diverse. CONCLUSIONS: Understanding the geographic distribution of disease and impact of individual and community level factors is essential to expanding access to care and preventive resources to improve the health of children in California's most polluted and underserved region.

Achieving excellence in community health centers: implications for health reform.

BACKGROUND: Existing studies tell us little about care quality variation within the community health center (CHC) delivery system. They also tell us little about the organizational conditions associated with CHCs that deliver especially high quality care. The purpose of this study was to examine the operational practices associated with a sample of high performing CHCs. METHODS: Qualitative case studies of eight CHCs identified as delivering high-quality care relative to other CHCs were used to examine operational practices, including systems to facilitate care access, manage patient care, and monitor performance. RESULTS: Four common themes emerged that may contribute to high performance. At the same time, important differences across health centers were observed, reflecting differences in local environments and CHC capacity. CONCLUSIONS: In the development of effective, community-based models of care, adapting care standards to meet the needs of local conditions may be important.

Implementation challenges and functional outcome predictors for elder community-based disability prevention programs.

BACKGROUND AND PURPOSE: Strategies to foster elder well-being and reduce long-term care costs include efficacious community disability prevention programs. However, it is often difficult to replicate clinical trials into real-world practice settings. We (a) compared replication and clinical trial functional changes, (b) compared replication and clinical trial program structures and processes of care, and, additionally, (c) examined how replication client and site features are associated with function. METHODS: We used secondary longitudinal data on 719 elder clients, and primary data through interviews with nurses, social workers, and site managers for the replication, and compared this to original trial data. We analyzed associations between baseline self-efficacy and functional outcomes and between site features and functional outcomes using multivariate and logistic models for the replication. RESULTS: Replication functional outcome changes were lower and structures and processes were less intense than in the original clinical trial. Baseline client higher self-efficacy positively influenced 12-month function, and smaller sites and urban sites had better functional outcomes than larger sites and rural sites for the replication. DISCUSSION AND CONCLUSION: Exploring systemic strategies for using available resources to improve research translation is essential. In addition, practitioners need to focus on client self-efficacy enhancement techniques, which may be more important in replication studies to improve function.

Can more use of supporting primary care health practitioners increase efficiency of health clinics? Evidence from California's San Joaquin Valley.

This study examined 67 primary health care centers operating in the San Joaquin Valley, California, and explored the factors that may have contributed to productive efficiency gains. The study used the data envelopment analysis (DEA) technique to measure efficiency of the clinics and then used tobit regression analysis to understand the factors that affected efficiency. It was found that clinics that employed relatively more "unlicensed" supporting practitioners compared to "licensed" practitioners were more likely to be efficient. The results also showed that clinics that employed fewer physicians compared to all "licensed" practitioners were likely to be more efficient. In addition, providing transportation services to patients also enhanced clinics' efficiency.

Policy barriers to health care access fuel discriminatory treatment: the role of Promotoras in overcoming malos tratos.

This article demonstrates that policy barriers resulting in access to health care inequities were significantly decreased by 2 Promotora interventions for 416 legal and undocumented Latino immigrants in the California Central Valley. Promotoras conducted baseline/follow-up assessments and referrals/phone-calls/visits during a 3-month period. In-depth interviews with Promotoras and a policy analysis on policy-driven access programs were carried out. Access to care was significantly increased between legal and undocumented immigrant from baseline to follow-up. Systemic barriers to access (malos tratos) reflected on personal barriers such as affordability of care. Promotoras help participants overcome barriers but do not change the policies determining access and procedures.

Lay health mentors in community-based older adult disability prevention programs: provider perspectives.

In this study, we explored provider perspectives on the benefits of and implementation challenges in using lay health mentor peers in a community-based replication of an efficacious 12-month older adult disability prevention program. In addition, we describe the association of the mentor program with site features and program completion. We conducted semi-structured telephone interviews with nurses, social workers, and site managers and obtained primary data on site features and secondary data on program completion. Major themes included the importance of the health mentor program and implementation challenges. Sites with mentor programs were more likely to have older adults complete the program compared with sites without mentor programs. Rural, small, and less diverse sites were more likely to have health mentor programs than urban, large, and more diverse sites. Implications include a need to fund more lay health mentor programs, obtain adequate staffing including minority staff for health mentor support, and implement strategies to improve program efficiency.

A systematic review and meta-analysis of racial disparities in prenatal care in California: How much? Does insurance matter?

This meta-analysis compares California to 13 states with regard to adequacy of prenatal care in the context of the major Medicaid expansion. It shows a reduction in prenatal care inadequacy after 1992, especially in California. It also shows persistent racial ethnic disparities. By examining how California differed from other states, this study provides not only benchmarks for attaining the Healthy People 2010 goal of 90% adequacy but also possible strategies for achieving this goal. Attaining the Healthy People 2010 objective for prenatal care for California as a whole will require further efforts to understand and address racial/ethnic and insurance-related inequalities.

The Central California Regional Obesity Prevention Program: changing nutrition and physical activity environments in California's heartland.

The goals of the Central California Regional Obesity Prevention Program (CCROPP) are to promote safe places for physical activity, increase access to fresh fruits and vegetables, and support community and youth engagement in local and regional efforts to change nutrition and physical activity environments for obesity prevention. CCROPP has created a community-driven policy and environmental change model for obesity prevention with local and regional elements in low-income, disadvantaged ethnic and rural communities in a climate of poor resources and inadequate infrastructure. Evaluation data collected from 2005-2009 demonstrate that CCROPP has made progress in changing nutrition and physical activity environments by mobilizing community members, engaging and influencing policymakers, and forming organizational partnerships.

Community-based disability prevention programs for elders: predictors of program completion.

Strategies to foster elder well-being and reduce long-term care costs include efficacious community disability prevention programs. Program completion remains an important barrier to their effectiveness. We examined the association between provider relationships and client variables, and program completion in senior centers. Our mixed methods design used secondary data for 719 clients and primary data through telephone interviews with 20 nurses, 23 social workers, and 18 site managers. Quantitative data showed that higher client baseline self-efficacy positively influenced completion and minority status negatively influenced completion. Qualitative data showed that higher focus on provider-client relationships was associated with high completion.

Disparities in initiation and adherence to prenatal care: impact of insurance, race-ethnicity and nativity.

We used the intersectionality framework to examine impact of racial/ethnic, immigration, and insurance differences on the timing of initiation of prenatal care (PNC) and subsequent adherence. In this cross sectional study independent variables were women's race/ethnicity; nativity; age; education; and insurance. The dependent variables were late initiation and non-adherence to recommended number of PNC visits. We used multivariate analysis to evaluate the impact of the independent variables on late initiation and non-adherence. Analysis revealed that race/ethnicity/nativity (RE-N) was more consistently associated with late initiation and non-adherence for privately insured than publicly insured persons. While private insurance had a positive impact on initiation and adherence overall, its impact was greater for White women. Having private insurance coverage was most beneficial to White women. We contend that the intersectional approach provides promising avenues for expanding our knowledge of health disparities and of identifying new ways of going about eliminating the persistent and pervasive social inequalities and informing efforts to reduce them.

Met needs and unmet needs, and satisfaction among Social HMO members.

This article reports on a survey of 800 members of four Social HMO demonstration sites, who were receiving home-based, community-based, and short-term institutional services under the demonstration's expanded community care benefits. The survey asked whether members needed help in 11 areas, whether they received help in each area from an informal caregiver, whether they wanted more help from the Social HMO, and whether help provided by both was adequate. Satisfaction with the program and with service coordination was also assessed. The adequacy of informal care differed by problem area, as did the help desired from the Social HMO and its responsiveness. Members were less satisfied when they had weaker informal care, were African American, and when they received inadequate help from the plan with ADLs, transportation, medical access, and managing money. Members were more satisfied when they were professionals, home owners, knew their service coordinator's name (or how to contact her), and received help with their problems. The findings point to the importance of clarifying divisions of labor with informal caregivers, as well as possible expansions in responsibilities for service coordinators and benefits beyond traditional boundaries.

Socioeconomic differences in adolescent stress: the role of psychological resources.

PURPOSE: To investigate whether psychological resources influenced the association between parent education (PE), a marker of socioeconomic status (SES), and perceived stress. METHODS: Cross-sectional analyses were conducted in a sample of 1167 non-Hispanic black and white junior and senior high school students from a Midwestern public school district in 2002-2003. Hierarchical multivariable regression analyses examined relationships between PE (high school graduate or less = E1, > high school, < college = E2, college graduate = E3, and professional degree = E4), and psychological resources (optimism and coping style) on teens' perceived stress. Greater optimism and adaptive coping were hypothesized to influence (i.e., mediate or moderate) the relationship between higher PE and lower stress. RESULTS: Relative to adolescents from families with a professionally educated parent, adolescents with lower parent education had higher perceived stress (E3 beta = 1.70, p < .01, E2 beta = 1.94, p < .01, E1 beta = 3.19, p < .0001). Both psychological resources were associated with stress: higher optimism (beta = -.58, p < .0001) and engagement coping (beta = -.19, p < .0001) were associated with less stress and higher disengagement coping was associated with more stress (beta = .09, p < .01). Adding optimism to the regression model attenuated the effect of SES by nearly 30%, suggesting that optimism partially mediates the inverse SES-stress relationship. Mediation was confirmed using a Sobel test (p < .01). CONCLUSIONS: Adolescents from families with lower parent education are less optimistic than teens from more educated families. This pessimism may be a mechanism through which lower SES increases stress in adolescence.