Josalin Hunter-Jones

The aftermath of public housing relocation: Relationship to substance misuse

INTRODUCTION Several cross-sectional studies have examined relationships between neighborhood characteristics and substance misuse. Using data from a sample of African-American adults relocating from U.S. public housing complexes, we examined relationships between changes in exposure to local socioeconomic conditions and substance misuse over time. We tested the hypothesis that adults who experienced greater post-relocation improvements in local economic conditions and social disorder would have a lower probability of recent substance misuse. METHODS Data were drawn from administrative sources to describe the census tracts where participants lived before and after relocating. Data on individual-level characteristics, including binge drinking, illicit drug use, and substance dependence, were gathered via survey before and after the relocations. Multilevel models were used to test hypotheses. RESULTS Participants (N=172) experienced improvements in tract-level economic conditions and, to a lesser degree, in social disorder after moving. A one standard-deviation improvement in tract-level economic conditions was associated with a decrease in recent binge drinking from 34% to 20% (p=0.04) and with a decline in using illicit drugs weekly or more from 37% to 16% (p=0.02). A reduction in tract-level alcohol outlet density of >3.0 outlets per square mile predicted a reduction in binge drinking from 32% to 18% at p=0.05 significance level. DISCUSSION We observed relationships between improvements in tract-level conditions and declines in substance misuse, providing further support for the importance of the local environment in shaping substance misuse. These findings have important implications for public housing policies and future research.

Public housing relocations in Atlanta, Georgia, and declines in spatial access to safety net primary care.

This analysis investigates changes in spatial access to safety-net primary care in a sample of US public housing residents relocating via the HOPE VI initiative from public housing complexes to voucher-subsidized rental units; substance misusers were oversampled. We used gravity-based models to measure spatial access to care, and used mixed models to assess pre-/post-relocation changes in access. Half the sample experienced declines in spatial access of ≥ 79.83%; declines did not vary by substance misuse status. Results suggest that future public housing relocation initiatives should partner with relocaters, particularly those in poor health, to help them find housing near safety-net clinics.

Impact of public housing relocations: are changes in neighborhood conditions related to STIs among relocaters?

Background Cross-sectional and ecologic studies suggest that place characteristics influence sexual behaviors and sexually transmitted infections (STIs). Using data from a predominately substance-misusing cohort of African American adults relocating from US public housing complexes, this multilevel longitudinal study tested the hypothesis that participants who experienced greater postrelocation improvements in neighborhood conditions (i.e., socioeconomic disadvantage, social disorder, STI prevalence, and male/female sex ratios) would have reduced the odds of testing positive for an STI over time. Methods Baseline data were collected in 2009 from 172 public housing residents before relocations occurred; 3 waves of postrelocation data were collected every 9 months thereafter. Polymerase chain reaction methods were used to test participants’ urine for Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis. Individual-level characteristics were assessed via survey. Administrative data described the census tracts where participants lived at each wave (e.g., sex ratios, violent crime rates, and poverty rates). Hypotheses were tested using multilevel models. Results Participants experienced improvements in all tract-level conditions studied and reductions in STIs over time (baseline: 29% tested STI positive; wave 4: 16% tested positive). Analyses identified a borderline statistically significant relationship between moving to tracts with more equitable sex ratios and reduced odds of testing positive for an STI (odds ratio, 0.16; 95% confidence interval, 0.02–1.01). Changes in other neighborhood conditions were not associated with this outcome. Discussion Consonant with past research, our findings suggest that moving to areas with more equitable sex ratios reduces the risk of STI infection. Future research should study the extent to which this relationship is mediated by changes in sexual network dynamics.

Access to health services and sexually transmitted infections in a cohort of relocating African American public housing residents: an association between travel time and infection.

Background: High incidence and prevalence of sexually transmitted infection (STI) in blacks have been attributed to multiple factors. However, few articles have discussed spatial access to healthcare as a driver of disparities. The objective of this analysis was to evaluate the relationship between travel time to a healthcare provider and the likelihood of testing positive for 1 of 3 STIs in a sample of adults living in public housing. Methods: One hundred and eight black adults in Atlanta, GA from November 2008 to June 2009, completed a survey that queried sexual behavior and healthcare use and had urine tested for Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis by molecular methods. Travel time was a continuous variable capturing the number of minutes it took to reach the place where participants received most of their care. Multivariate analyses tested the hypothesis that individuals reporting longer travel times would be more likely to test positive for an STI. Travel time was squared to linearize its relationship to the outcome. Results: Thirty-six residents (37.5%) tested positive for ≥1 STI. A curvilinear relationship existed between travel time and STI status. When travel time was <48 minutes, a positive relationship existed between travel time and the odds of testing positive for an STI. An inverse relationship existed when travel time was ≥48 minutes. Conclusion: Residents of impoverished communities experience a curvilinear relationship between travel time and STI status. We discuss possible factors that might have created this curvilinear relationship, including voluntary social isolation.

Risk Environments, Race/Ethnicity, and HIV Status in a Large Sample of People Who Inject Drugs in the United States.

Introduction We analyzed relationships between place characteristics and being HIV-negative among black, Latino, and white people who inject drugs (PWID) in the US. Methods Data on PWID (N = 9077) were from the Centers for Disease Control and Prevention’s 2009 National HIV Behavioral Surveillance. Administrative data were analyzed to describe the 968 ZIP codes, 51 counties, and 19 metropolitan statistical areas (MSAs) where they lived. Multilevel multivariable models examined relationships between place characteristics and HIV status. Exploratory population attributable risk percents (e-PAR%s) were estimated. Results Black and Latino PWID were more likely to be HIV-negative if they lived in less economically disadvantaged counties, or in MSAs with less criminal-justice activity (i.e., lower drug-related arrest rates, lower policing/corrections expenditures). Latino PWID were more likely to be HIV-negative in MSAs with more Latino isolation, less black isolation, and less violent crime. E-PAR%s attributed 8–19% of HIV cases among black PWID and 1–15% of cases among Latino PWID to place characteristics. Discussion Evaluations of structural interventions to improve economic conditions and reduce drug-related criminal justice activity may show evidence that they protect black and Latino PWID from HIV infection.

Contextual Predictors of Injection Drug Use Among Black Adolescents and Adults in US Metropolitan Areas, 1993–2007

OBJECTIVES We sought to determine whether contextual factors shape injection drug use among Black adolescents and adults. METHODS For this longitudinal study of 95 US metropolitan statistical areas (MSAs), we drew annual MSA-specific estimates of the prevalence of injection drug use (IDU) among Black adolescents and adults in 1993 through 2007 from 3 surveillance databases. We used existing administrative data to measure MSA-level socioeconomic status; criminal justice activities; expenditures on social welfare, health, and policing; and histories of Black uprisings (1960-1969) and urban renewal funding (1949-1974). We regressed Black IDU prevalence on these predictors by using hierarchical linear models. RESULTS Black IDU prevalence was lower in MSAs with declining Black high-school dropout rates, a history of Black uprisings, higher percentages of Black residents, and, in MSAs where 1992 White income was high, higher 1992 Black income. Incarceration rates were unrelated. CONCLUSIONS Contextual factors shape patterns of drug use among Black individuals. Structural interventions, especially those that improve Black socioeconomic security and political strength, may help reduce IDU among Black adolescents and adults.

Changing Places and Partners: Associations of Neighborhood Conditions With Sexual Network Turnover Among African American Adults Relocated From Public Housing

Neighborhood conditions and sexual network turnover have been associated with the acquisition of HIV and other sexually transmitted infections (STIs). However, few studies investigate the influence of neighborhood conditions on sexual network turnover. This longitudinal study used data collected across 7 visits from a predominantly substance-misusing cohort of 172 African American adults relocated from public housing in Atlanta, Georgia, to determine whether post-relocation changes in exposure to neighborhood conditions influence sexual network stability, the number of new partners joining sexual networks, and the number of partners leaving sexual networks over time. At each visit, participant and sexual network characteristics were captured via survey, and administrative data were analyzed to describe the census tracts where participants lived. Multilevel models were used to longitudinally assess the relationships of tract-level characteristics to sexual network dynamics over time. On average, participants relocated to neighborhoods that were less economically deprived and violent, and had lower alcohol outlet densities. Post-relocation reductions in exposure to alcohol outlet density were associated with fewer new partners joining sexual networks. Reduced perceived community violence was associated with more sexual partners leaving sexual networks. These associations were marginally significant. No post-relocation changes in place characteristics were significantly associated with overall sexual network stability. Neighborhood social context may influence sexual network turnover. To increase understanding of the social–ecological determinants of HIV/STIs, a new line of research should investigate the combined influence of neighborhood conditions and sexual network dynamics on HIV/STI transmission over time.

Public Housing Relocations and Relationships of Changes in Neighborhood Disadvantage and Transportation Access to Unmet Need for Medical Care

Introduction. Cross-sectional research suggests that neighborhood characteristics and transportation access shape unmet need for medical care. This longitudinal analysis explores relationships of changes in neighborhood socioeconomic disadvantage and trans- portation access to unmet need for medical care. Methods. We analyzed seven waves of data from African American adults (N = 172) relocating from severely distressed public housing complexes in Atlanta, Georgia. Surveys yielded individual-level data and admin- istrative data characterized census tracts. We used hierarchical generalized linear models to explore relationships. Results. Unmet need declined from 25% pre-relocation to 12% at Wave 7. Post-relocation reductions in neighborhood disadvantage were inversely associated with reductions in unmet need over time (OR = 0.71, 95% CI = 0.51-0.99). More frequent transportation barriers predicted unmet need (OR = 1.16, 95% CI = 1.02-1.31). Conclusion. These longitudinal findings support the importance of neighborhood environments and transportation access in shaping unmet need and suggest that improvements in these exposures reduce unmet need for medical care in this vulnerable population.

Identifying Barriers and Facilitators to Breast Health Services among Women with Disabilities

Women with disabilities experience significant disparities in accessing breast health services. Many studies have focused on barriers, but few have explored facilitators to improving breast health services. This study used a participatory-research approach involving women with physical, mobility, sensory, and developmental disabilities to explore facilitators and barriers affecting the access and quality of breast health services. Findings confirmed commonly cited barriers including attitudinal, environmental, financial, and structural issues but also identified multiple facilitators such as enhancing accessibility of breast health facilities and equipment, improving information sources, and increasing training of health professionals. Findings from this study can be used in improving breast health services among women with disabilities by targeting not only the removal of barriers but also the increase in proven facilitators.

Changes in healthcare access and utilization among participants in a public housing relocation program in Atlanta, Georgia

Using survey data from participants in a public housing relocation program in Atlanta, Georgia, we examine post-relocation changes in healthcare access (having a usual source of care, having an unmet need) and utilization (receiving a medical exam). Although participants moved to safer, less impoverished neighborhoods, some participants experienced improvements in access and utilization whereas others experienced declines. The supply of healthcare providers in the new neighborhood and having health insurance were associated with improvements in access for this population. Future relocation efforts may seek to assist individuals with choosing a new neighborhood that has accessible healthcare resources for low-income populations.