Search

Objectives. To summarize data collection on anti–Asian American and Native Hawaiian/Pacific Islander (AANHPI) experiences during COVID-19 and measure the associations of anti-AANHPI hate incidents with mental health, health access, and public safety among AANHPI adults. Methods. We cataloged COVID-19 surveys conducted in 2020 and 2021 on anti-AANHPI experiences. We then analyzed the 2020 California Health Interview Survey (CHIS) AANHPI COVID-19 module by constructing a variable of experiencing or witnessing a hate incident and estimating its associations with serious psychological distress, forgone care, and perceived neighborhood safety. Results. Estimates of being a victim of a hate incident ranged from 6% to 30%. In the CHIS, 28% of respondents experienced or witnessed a hate incident. Experiencing or witnessing a hate incident was significantly associated with serious psychological distress (adjusted odds ratio [AOR] = 5.33), forgoing care (AOR = 2.27), and not feeling safe in one’s neighborhood (AOR = 2.70). Conclusions. Evidence from a multitude of data sources corroborates the toll of hate incidents suffered by AANHPIs. Findings regarding the negative effects of anti-AANHPI hate on mental health, health access, and public safety compel public and private investment to end victimization of AANHPI communities. (Am J Public Health. 2022;112(10):1446–1453. https://doi.org/10.2105/AJPH.2022.306977 )

Background: Neighborhood socioeconomic status (nSES) has been found to be associated with breast cancer risk. It remains unclear whether this association applies across racial/ethnic groups independent of individual-level factors and is attributable to other neighborhood characteristics.Methods: We examined the independent and joint associations of education and nSES with odds of breast cancer. Residential addresses were geocoded for 2,838 cases and 3,117 controls and linked to nSES and social and built environment characteristics. We estimated ORs and 95% confidence intervals (CI) using multilevel logistic regression controlling for individual-level breast cancer risk factors and assessed the extent to which nSES associations were due to neighborhood characteristics.Results: Women living in the highest versus lowest nSES quintile had a nearly 2-fold greater odds of breast cancer, with elevated odds (adjusted ORs, 95% CI) for non-Hispanic whites (NHWs; 2.27; 1.45–3.56), African Americans (1.74; 1.07–2.83), U.S.-born Hispanics (1.82; 1.19–2.79), and foreign-born Hispanics (1.83; 1.06–3.17). Considering education and nSES jointly, ORs were increased for low education/high nSES NHWs (1.83; 1.14–2.95), high education/high nSES NHWs (1.64; 1.06–2.54), and high education/high nSES foreign-born Hispanics (2.17; 1.52–3.09) relative to their race/ethnicity/nativity-specific low education/low nSES counterparts. Adjustment for urban and mixed-land use characteristics attenuated the nSES associations for most racial/ethnic/nativity groups except NHWs.Conclusions: Our study provides empirical evidence for a role of neighborhood environments in breast cancer risk, specifically social and built environment attributes.Impact: Considering the role of neighborhood characteristics among diverse populations may offer insights to understand racial/ethnic disparities in breast cancer risk. Cancer Epidemiol Biomarkers Prev; 26(4); 541–52. ©2017 AACR.

Associations between neighborhood contextual characteristics and breast cancer risk by race/ethnicity and nativity, the Neighborhoods and Breast Cancer Study, 1995-2002.

Background The number of Californians covered by Medi-Cal increased more than 50% between 2013 and 2018, largely due to expansion under the Affordable Care Act (ACA). This rapid expansion of Medicaid rolls prompted concerns that Medi-Cal enrollees would face greater difficulty accessing health care. Objective Examine whether gaps in access to care between Medi-Cal and employer-sponsored insurance (ESI) present in 2013 (prior to ACA implementation) had changed by 2018 (several years post implementation). Design Secondary analysis of data from the 2013 and 2018 California Health Interview Survey. The sample included adults of ages 18–64 insured all year and covered by ESI or Medi-Cal at time of interview. Logistic regressions were used to examine variation across years in the association between access to care and insurance type. Main Measures Five access to care outcomes were assessed: no usual source of care, not accepted as new patient in past year, insurance not accepted in past year, delayed medical care in past year, and difficulty getting timely appointment. The main predictors of interest were type of insurance (Medi-Cal or ESI) and survey year (2013 or 2018). Key Results The association between insurance type and access to care changed significantly over time for three outcomes: not accepted as new patient in past year (OR = 0.55, 95% CI = 0.32–0.97), delayed medical care in past year (OR = 1.55, 95% CI = 1.06–2.25), and difficulty getting timely appointment (OR = 0.41, 95% CI = 0.23–0.74). Predicted probabilities indicate gaps between Medi-Cal and ESI narrowed for not accepted as new patient in past year and difficulty getting timely appointment, but widened for delayed medical care. Conclusions Despite the rapid expansion in the number of Californians covered by Medi-Cal, most gaps in access to care between Medi-Cal and ESI enrollees improved or did not significantly change between 2013 and 2018.

Youth psychiatric emergencies have increased at alarming rates, and disproportionately so for youth of color. Outpatient follow-up care is critical for positive youth outcomes, but rates of follow-up remain low, especially for racial/ethnic minoritized youth. Mobile crisis response can initiate care connection. The current study (1) describes the population who received mobile crisis response (MCR) within the nation's largest county public mental health system, (2) assesses rates of follow-up outpatient services after MCR, and (3) examines racial/ethnic disparities in outpatient services and correlates of receipt of therapy dose (≥8 sessions).Administrative claims for MCR and outpatient services for youth ages 0 to 18 were abstracted from the Los Angeles County Department of Mental Health.From October 2016-2019, 20,782 youth received a MCR, 52.5% of youth were female, and youth mean age was 13.41 years. The majority of youth (91.8%) received some outpatient services after their first MCR. However, only 56.7% of youth received ≥1 therapy session. In a logistic regression, youth age, gender, race/ethnicity, primary language, primary diagnosis, insurance status, MCR call location, and MCR disposition significantly predicted receipt of ≥8 therapy sessions.Findings highlight disparities in therapy receipt for Asian American Pacific Islander, Black, and White youth (relative to Latinx youth), older youth, youth whose MCR was initiated from a police station call, and youth whose MCR did not result in hospitalization. We discuss priorities for quality improvement for MCR processes and strategies to promote linkage to care to achieve mental health equity.

Latinxs are vulnerable to experiencing housing insecurity and less likely to receive public benefits, such as health insurance, which can impact a household’s economic resources. We inform homelessness prevention by examining the association of social risks and healthcare access with housing insecurity for Latinxs. Our sample consisted of 120,362 participants under the age of 65, of which 17.3% were Latinx. Weighted chi-squared tests and logistic regression were used to examine predictors of housing insecurity. Housing insecurity was measured as worry about paying for housing. Latinxs were almost twice as likely as non-Latinxs to worry about paying for housing. Excellent/fair health status, health service use, and having health insurance decreased the likelihood of housing insecurity for Latinxs. Access to health insurance, regardless of citizenship status, and use of preventative healthcare to maintain good health can be protective against housing insecurity. Supplementary Information The online version contains supplementary material available at 10.1007/s10903-021-01258-9.

Filipinxs are the second-largest Asian subgroup in the USA. While Filipinxs are most often considered Asian when constructing aggregate ethnic categories, recent research has identified a trend of a small portion of Filipinxs identifying as Latinx or multiracial. However, little research had addressed how identification with different aggregate ethnic categories may have implications for identifying health disparities among Filipinxs and how these compare to non-Hispanic whites. Bivariate and multivariable regression analyses using 2011–2018 California Health Interview Survey data, comparing Asian Filipinxs, Latinx Filipinxs, and multiracial Filipinxs. In bivariate analyses, Asian Filipinxs had a higher prevalence of diabetes than Latinx or multiracial Filipinxs. After controlling for sociodemographics, Latinx Filipinxs had significantly lower odds of having diabetes or heart disease than Asian Filipinxs. Compared to non-Latinx Whites, Asian Filipinxs reported higher odds of being in fair/poor health, obese or overweight, high blood pressure, and diabetes, multiracial Filipinxs reported higher odds of being obese or overweight, and Latinx Filipinxs reported lower odds of heart disease. These findings suggest emerging differences in health linked to identification with different ethnic categories, underscoring the need to investigate nuances among Filipinxs in future research as well as highlighting the utility of emerging sociological insights in health research.

More than any other racial group, American Indian/Alaska Natives (AIAN) face the risk of imprecise survey estimates due to survey processes regarding the classification, tabulation, and weighting of race/ethnicity. Variations in approaches to classifying racial and ethnic populations in federal and state health statistics have substantial implications for how we measure health status, access to healthcare, healthcare quality, and health equity. We identify strategies to improve data capacity for AIAN in federal health surveys by exploring current approaches to collecting and coding of AIANs across eight population-based health surveys (seven federal surveys and the California Health Interview Survey). Our analysis assesses how different coding and weighting decisions affect the classification and measurement of the AIAN population by comparing single-race non-Hispanic/Latino AIAN to more expansive classifications that include not only those reporting AIAN race alone, but also individuals reporting AIAN race in combination with other races and/or in combination with Hispanic/Latino ethnicity. Our results provide insight into the representativeness of each survey on the AIAN population and our ability to draw conclusions about the health of the AIAN population and the health disparities they face. The results show considerable variation across surveys in their measurement of the AIAN population based on survey classification, tabulation, and weighting approaches.

As the fastest-growing racial/ethnic group in the U.S., Asian Americans, Native Hawaiians, and Pacific Islanders (AANHPI) make up about 7% of the U.S. population. AANHPIs represent more than 50 ethnic groups and speak over 100 different languages, but national health data rarely collect information needed to disaggregate AANHPI into smaller groups to capture this diversity. This study reviewed AANHPI disaggregated data collection methods in large, U.S. population-based surveys, summarized disaggregated data reporting practices in the peer-reviewed literature, and conducted key informant interviews with 23 members of the National Network of Health Surveys who lead state/local and national surveys to identify challenges to data collection. We found that while large national surveys may include AANHPI subpopulation in data collection, sample sizes are often too small to permit meaningful data analysis. In our interviews, barriers cited included the lack of stakeholder interest, inadequate funding, lack of space on questionnaires, as well as methodologic challenges, such as the inability to obtain an adequate sample size and poor questionnaire design. Survey administration efforts to improve disaggregated health data are challenging, but when done, have led to a proliferation of new population-representative knowledge on the health of AANHPI subgroups. This study provides evidence of the population health value of disaggregating AANHPI data to identify the needs of vulnerable subpopulations. It also advances the field by offering key informants’ insights in overcoming implementation challenges.

A growing body of literature has indicated that disaggregated analyses using distinct Asian subgroups allow for identification of varying mental health challenges and health services utilization. In this study, we examined the associations between distress and health services utilization among five Asian subgroups: Chinese, Korean, Japanese, Filipino, and Vietnamese adults in California. Using a combined dataset using the 2011–2018 cross-sectional cycles of the California Health Interview survey, we assessed moderate and serious distress and four health services utilization indicators in a set of disaggregated analyses among adults 18 years of age and older in five Asian subgroups. We performed bivariate and multivariable analyses. The prevalence of and associations between moderate and serious distress and gaps in health services utilization varied among each Asian subgroup. Koreans had the highest prevalence of moderate and serious distress and the most gaps in health services utilization. Compared to those without moderate distress (p

Little is known about the effects of the ACA's coverage expansion among immigrant groups of differing immigration status. Using data from the California Health Interview Survey (2003-2016), we compare changes in health coverage and access to care among immigrants in California before and after implementation of the ACA. We find that the ACA has led to major gains in coverage for lawful permanent residents in California, similar in scope to changes among citizens. However, unauthorized immigrants have experienced only modest increases in coverage, with the result disparity in uninsured rates for this group relative to citizens and permanent residents widening considerably since 2014. Findings indicate a significant increase in having a usual source of care across all groups, but without a significant change in disparities for this outcome. Our results have important implications for the intersection of health policy, immigration, and health equity.

ImportanceUnaffordable housing is associated with adverse health-related outcomes, but little is known about the associations between moving due to unaffordable housing and health-related outcomes.ObjectiveTo characterize the association of recent cost-driven residential moves with health-related outcomes.Design, Setting, and ParticipantsThis cross-sectional study involved a weighted multivariable regression analysis of California Health Interview Survey data from January 1, 2011, to December 31, 2017. A population-based sample of 52 646 adult renters and other nonhomeowners in California were included. Data were analyzed from March 2, 2021, to January 6, 2023.ExposureCost-driven moves in the past 3 years relative to no move and to non–cost-driven moves.Main Outcomes and MeasuresFive outcomes were assessed: psychological distress (low, moderate, or severe, as categorized by the 6-item Kessler Psychological Distress Scale), emergency department [ED] visits in the past year (any vs none), preventive care visits in the past year (any vs none), general health (poor or fair vs good, very good, or excellent), and walking for leisure in the past 7 days (in minutes).ResultsAmong 52 646 adult renters and other nonhomeowners, 50.3% were female, 85.2% were younger than 60 years, 45.3% were Hispanic, and 55.1% had income lower than 200% of the federal poverty level. Overall, 8.9% of renters reported making a recent cost-driven move, with higher prevalence among Hispanic (9.9%) and non-Hispanic Black (11.3%) renters compared with non-Hispanic White renters (7.2%). In multivariable models, compared with not moving, cost-driven moving was associated with a 4.2 (95% CI, 2.6-5.7) percentage point higher probability of experiencing moderate psychological distress; a 3.2 (95% CI, 1.9-4.5) percentage point higher probability of experiencing severe psychological distress; a 2.5 (95% CI, 0-4.9) percentage point higher probability of ED visits; a 5.1 (95% CI, 1.6-8.6) percentage point lower probability of having preventive care visits; a 3.7 (95% CI, 1.2-6.2) percentage point lower probability of having good, very good, or excellent general health; and 16.8 (95% CI, 6.9-26.6) fewer minutes of walking for leisure. General health, psychological distress, and walking for leisure were also worse with cost-driven moves relative to non–cost-driven moves, with a 3.2 (95% CI, 1.7-4.7) percentage point higher probability of experiencing moderate psychological distress; a 2.5 (95% CI, 1.2-3.9) percentage point higher probability of experiencing severe psychological distress; a 4.6 (95% CI, 2.1-7.2) percentage point lower probability of having good, very good, or excellent general health; and 13.0 (95% CI, 4.0-21.9) fewer minutes of walking for leisure. However, the incidence of preventive care and ED visits did not differ between those who made cost-driven vs non–cost-driven moves.Conclusions and RelevanceIn this study, cost-driven moves were associated with adverse health-related outcomes relative to not moving and to non–cost-driven moves. These findings suggest that policies to improve housing affordability, prevent displacement, and increase access to health care for groups vulnerable to cost-driven moves may have the potential to improve population health equity, especially during the current national housing affordability crisis.

This cross-sectional study examines the association of avoidance of public programs among California immigrants with delayed access to health care services and prescriptions owing to concerns about how their interaction with these services may affect their immigration status.

Data on the health and social determinants for Native Hawaiians and Pacific Islanders (NHPIs) in the United States are hidden, because data are often not collected or are reported in aggregate with other racial/ethnic groups despite decades of calls to disaggregate NHPI data. As a form of structural racism, data omissions contribute to systemic problems such as inability to advocate, lack of resources, and limitations on political power. The authors conducted a data audit to determine how US federal agencies are collecting and reporting disaggregated NHPI data. Using the COVID-19 pandemic as a case study, they reviewed how states are reporting NHPI cases and deaths. They then used California's neighborhood equity metric—the California Healthy Places Index (HPI)—to calculate the extent of NHPI underrepresentation in communities targeted for COVID-19 resources in that state. Their analysis shows that while collection and reporting of NHPI data nationally has improved, federal data gaps remain. States are vastly underreporting: more than half of states are not reporting NHPI COVID-19 case and death data. The HPI, used to inform political decisions about allocation of resources to combat COVID-19 in at-risk neighborhoods, underrepresents NHPIs. The authors make recommendations for improving NHPI data equity to achieve health equity and social justice.

Background There has been little research on the relationship between education and healthcare utilization, especially for racial/ethnic minorities. This study aimed to examine the association between education and hospitalizations, investigate the mechanisms, and disaggregate the relationship by gender, race/ethnicity, and age groups. Methods A retrospective cohort analysis was conducted using data from the 1992-2016 US Health and Retirement Study. The analytic sample consists of 35,451 respondents with 215,724 person-year observations. We employed a linear probability model with standard errors clustered at the respondent level and accounted for attrition bias using an inverse probability weighting approach. Results On average, compared to having an education less than high school, having a college degree or above was significantly associated with an 8.37 pp (95% CI, -9.79 pp to -7.95 pp) lower probability of being hospitalized, and having education of high school or some college was related to 3.35 pp (95% CI, -4.57 pp to -2.14 pp) lower probability. The association slightly attenuated after controlling for income but dramatically reduced once holding health conditions constant. Specifically, given the same health status and childhood environment conditions, compared to those with less than high school degree, college graduates saw a 1.79 pp (95% CI, -3.16 pp to -0.42 pp) lower chance of being hospitalized, but the association for high school graduates became indistinguishable from zero. Additionally, the association was larger for females, whites, and those younger than 78. The association was statistically significantly smaller for black college graduates than their white counterparts, even when health status is held constant. Conclusions Educational attainment is a strong predictor of hospitalizations for middle-aged and older US adults. Health mediates most of the education-hospitalization gradients. The heterogeneous results across age, gender, race, and ethnicity groups should inform further research on health disparities.

Author(s): Tran, Linda Diem | Advisor(s): Ponce, Ninez | Abstract: Gentrification is a dynamic process that changes the physical, economic, social, and cultural characteristics of historically underserved neighborhoods. This neighborhood transition process can improve the material and environmental circumstances of some residents and bring forth harmful consequences such as heightened financial stress and residential displacement for other community members. The subsequent impact of gentrification on population health is understudied, and little is known about how gentrification influences the mental wellness of residents.This dissertation advances the small but growing literature on the relationship between gentrification and adult mental health. Using multiple data sources, we identified Southern California neighborhoods that gentrified between 2010 and 2015 and investigated the impact of living in a gentrified neighborhood on mental health distress. Econometric techniques such as instrumental variables estimation and propensity score analyses were applied to reduce bias arising from residential selection and reverse causality.The first study compared three quantitative approaches for identifying gentrified neighborhoods and demonstrated that each approach generated a different set of results. Findings highlighted the importance of the strategy used for identifying gentrified neighborhoods, especially when assessing gentrification’s effects on health outcomes. The second study used five years of pooled data from the California Health Interview Survey to examine the causal relationship between gentrification and adult mental health. Relative to living in a low-income and not gentrified neighborhood, living in a gentrified neighborhood was associated with increased likelihood of serious psychological distress among longtime residents, renters, and people with low incomes. In the third study, we evaluated reasons for moving between residents who moved within gentrified and not gentrified neighborhoods and found evidence that people in gentrified neighborhoods were more likely to experience within-neighborhood displacement. Residents who experienced within-neighborhood displacement had greater likelihoods of having serious psychological distress.Taken together, findings suggest that gentrification imposes a mental health cost on longtime residents and the most financially vulnerable residents, which has important implications for population health. By elevating levels of mental health distress of population groups who are already disproportionately exposed to stressors, gentrification can exacerbate mental health inequities.

There has been mounting evidence for the beneficial effect of green space on mental health among adults, but studies on the same topics are lacking for teens in the US. This study aimed to fill in this research gap by utilizing data from California Health Interview Survey (CHIS) 2011–2014. A total of 81,102 households (composed of 4538 teens and 81,102 adults) were retained for main analyses. Surrounding greenness was assessed by the Normalized Difference Vegetation Index (NDVI) within varying buffers of home residence. Survey logistic regressions accounted for sampling weights and design were conducted to examine the effects of greenness on serious psychological distress (SPD), adjusted for major socio-demographic factors, neighborhood socioeconomic status (SES) and co-respondent's psychological distress level within the same household. An inter-quartile increment of NDVI in 350 m buffer predicted decreased odds of SPDs by 36% in teens (OR = 0.64, 95% CI = [0.46, 0.91]). Mediation analyses revealed that this association remained almost unchanged even after adjusting for social cohesion. The NDVI-SPD association of adults was found to be significant only in the older group (OR = 0.81, 95% CI = [0.68, 0.95]). This study is one of the first population-based US studies extending the epidemiological evidence for benefits of green space on mental health from adults to teens.

As of March 2021, Native Hawaiians and Pacific Islanders (NHPIs) in the United States have lost more than 800 lives to COVID-19—the highest per capita death rate in 18 of 20 US states reporting NHPI deaths. However, NHPI risks are overlooked in policy discussions. We discuss the NHPI COVID-19 Data Policy Lab and dashboard, featuring the disproportionate COVID-19 mortality burden for NHPIs. The Lab democratized NHPI data, developed community infrastructure and resources, and informed testing site and outreach policies related to health equity.

Little data exist on the well-being of older adults from Asian American (AA) communities.Using data from the 2018 California Health Interview Survey, we examined 2 well-being metrics among AAs and AA subgroups (Korean, Filipino, Vietnamese, Chinese) 65 years and older.AA older adults reported lower life satisfaction and not having needed social and emotional support compared with all other race/ethnicities. Current life satisfaction among AA older adults was 54% compared with 80% for all other race/ethnicities; 56% of AA older adults reported usually or always receiving social/emotional compared with 80% for all other race/ethnicities. Within the AA category, life satisfaction was 40% for Korean, 48% for Chinese, 47% for Vietnamese, and 77% for Filipino older adults. Among Korean older adults, 30% reported receiving needed social/emotional support, 57% among Chinese, 59% among Filipino, and 65% among Vietnamese older adults.

Background: Filipinx Americans working in healthcare in the U.S. are particularly at risk for COVID-19 death, but lack of consistent data on healthcare worker deaths and lack of mortality data disaggregated by Asian subgroup hamper further research into this topic. This cross-sectional study aims to examine how the overrepresentation of Filipinxs in healthcare contributes to COVID-19 mortality among Asian American populations. Methods: To overcome the lack of COVID-19 mortality data among Filipinxs and Filipinx healthcare workers, we merged data from several sources: Kanlungan website (the only known public-facing source of systematically collected mortality data on Filipinx healthcare workers), National Center for Health Statistics, and 2014-2018 American Community Survey. We examined county-level associations using t-tests, scatterplots, and linear regression. Findings: Higher percentage of Filipinxs among Asian Americans was correlated with a higher percentage of COVID-19 decedents who are Asian Americans. Moreover, the percentage of Filipinx in healthcare remained a strong predictor of COVID-19 deaths among Asian Americans even after adjusting for age, poverty, and population density. Interpretation: Our study shows that the overrepresentation of Filipinxs in healthcare contributes to COVID-19 mortality disparities among Asian Americans. Such findings support a targeted approach to address factors that exacerbate the threat of COVID-19 death among frontline workers in all healthcare settings, especially in U.S. counties with high percentages of healthcare workers at increased risk. Funding: N.A. Ponce’s work was partially supported by the Robert Wood Johnson Foundation grant #76329: Advancing the disaggregation of ethnic/racial data through technical assistance, training, and case-making. Declaration of Interests: All authors have no conflicts of interest.

Background and Objectives The US housing market has experienced considerable fluctuations over the last decades. This study aimed to investigate the impacts of housing price dynamics on physical health, mental health, and health-related behaviors for older American outright owners, mortgaged owners, and renters. Research Design and Methods We drew longitudinal data from the 1992–2016 Health and Retirement Study and merged it to the 5-digit zip code–level Housing Price Index. The analytic sample comprised 34 182 persons and 174 759 person-year observations. We used a fixed-effects model to identify the health impacts of housing price dynamics separately for outright owners, mortgaged owners, and renters. Results A 100% increase in Housing Price Index was associated with a 2.81 and 3.50 percentage points (pp) increase in the probability of reporting excellent/very good/good health status for mortgage owners and renters, respectively. It was also related to a lower likelihood of obesity (1.82 pp) for outright owners and a lesser chance of obesity (2.85 pp) and smoking (3.03 pp) for renters. All of these relationships were statistically significant (p < .05). Renters also experienced significantly decreased depression scores (−0.24), measured by the Center for Epidemiologic Studies—Depression scale, associated with the same housing price changes. Discussion and Implications Housing price dynamics have significant health impacts, and renters are more sensitive to fluctuations in the housing market. Our study rules out the wealth effect as the mechanism through which changes in housing prices affect older adults’ health. Our findings may inform policies to promote older adults’ health by investing in local area amenities and improving socioeconomic conditions.

A growing body of literature has indicated that disaggregated analyses using distinct Asian subgroups allow for identification of varying mental health challenges and health services utilization. In this study, we examined the associations between distress and health services utilization among five Asian subgroups: Chinese, Korean, Japanese, Filipino, and Vietnamese adults in California.Using a combined dataset using the 2011-2018 cross-sectional cycles of the California Health Interview survey, we assessed moderate and serious distress and four health services utilization indicators in a set of disaggregated analyses among adults 18 years of age and older in five Asian subgroups. We performed bivariate and multivariable analyses.The prevalence of and associations between moderate and serious distress and gaps in health services utilization varied among each Asian subgroup. Koreans had the highest prevalence of moderate and serious distress and the most gaps in health services utilization. Compared to those without moderate distress (p .05), Japanese adults were more likely to delay care. Compared to those without serious distress (p .05), Chinese adults who experienced serious distress were more likely to delay both medications and care, whereas Filipino and Vietnamese adults were more likely to delay medications.Disaggregating health data elucidates the impact of mental distress on healthcare-seeking behaviors among specific Asian subgroups. Identifying these influences can facilitate future tailored interventions, yet fully understanding the mechanism linking mental distress and healthcare usage will necessitate a comprehensive assessment of structural influences and Asian American experiences without otherization.

BACKGROUND The diverse Asian American population has been impacted by the COVID-19 pandemic, but due to limited data and other factors, disparities experienced by this population are hidden. OBJECTIVE This study aims to describe the Asian American community’s experiences during the COVID-19 pandemic, focusing on the Greater San Francisco Bay Area, California, and to better inform a Federally Qualified Health Center’s (FQHC) health care services and response to challenges faced by the community. METHODS We conducted a cross-sectional survey between May 20 and June 23, 2020, using a multipronged recruitment approach, including word-of-mouth, FQHC patient appointments, and social media posts. The survey was self-administered online or administered over the phone by FQHC staff in English, Cantonese, Mandarin, and Vietnamese. Survey question topics included COVID-19 testing and preventative behaviors, economic impacts of COVID-19, experience with perceived mistreatment due to their race/ethnicity, and mental health challenges. RESULTS Among 1297 Asian American respondents, only 3.1% (39/1273) had previously been tested for COVID-19, and 46.6% (392/841) stated that they could not find a place to get tested. In addition, about two-thirds of respondents (477/707) reported feeling stressed, and 22.6% (160/707) reported feeling depressed. Furthermore, 5.6% (72/1275) of respondents reported being treated unfairly because of their race/ethnicity. Among respondents who experienced economic impacts from COVID-19, 32.2% (246/763) had lost their regular jobs and 22.5% (172/763) had reduced hours or reduced income. Additionally, 70.1% (890/1269) of respondents shared that they avoid leaving their home to go to public places (eg, grocery stores, church, and school). CONCLUSIONS We found that Asian Americans had lower levels of COVID-19 testing and limited access to testing, a high prevalence of mental health issues and economic impacts, and a high prevalence of risk-avoidant behaviors (eg, not leaving the house) in the early months of the COVID-19 pandemic. These findings provide preliminary insights into the impact of the COVID-19 pandemic on Asian American communities served by an FQHC and underscore the longstanding need for culturally and linguistically appropriate approaches to providing mental health, outreach, and education services. These findings led to the establishment of the first Asian multilingual and multicultural COVID-19 testing sites in the local area where the study was conducted, and laid the groundwork for subsequent COVID-19 programs, specifically contact tracing and vaccination programs.

Background Real-time, rapid assessment of barriers to care experienced by patients can be used to inform relevant health care legislation. In recent years, online communities have become a source of support for patients as well as a vehicle for discussion and collaboration among patients, clinicians, advocates, and researchers. The Breast Cancer Social Media (#BCSM) community has hosted weekly Twitter chats since 2011. Topics vary each week, and chats draw a diverse group of participants. Partnering with the #BCSM community, we used Twitter to gather data on barriers to care for patients with metastatic breast cancer and potential policy solutions. Metastatic breast cancer survival rates are low and in large part conditioned by time-sensitive access to care factors that might be improved through policy changes. Objective This study was part of an assessment of the barriers to care for metastatic breast cancer with the goal of offering policy solutions for the legislative session in California. Methods We provided 5 questions for a chat specific to metastatic breast cancer care barriers and potential policy solutions. These were discussed during the course of a #BCSM chat on November 18, 2019. We used Symplur (Symplur LLC) analytics to generate a transcript of tweets and a profile of participants. Responses to the questions are presented in this paper. Results There were 288 tweets from 42 users, generating 2.1 million impressions during the 1-hour chat. Participants included 23 patient advocates (most of whom were patients themselves), 7 doctors, 6 researchers or academics, 3 health care providers (2 nurses, 1 clinical psychologist), and 2 advocacy organizations. Participants noted communication gaps between patient and provider especially as related to the need for individualized medication dosing to minimize side effects and maximize quality of life. Timeliness of insurance company response, for example, to authorize treatments, was also a concern. Chat participants noted that palliative care is not well integrated into metastatic breast cancer care and that insurance company denials of coverage for these services were common. Regarding financial challenges, chat participants mentioned unexpected copays, changes in insurance drug formularies that made it difficult to anticipate drug costs, and limits on the number of physical therapy visits covered by insurance. Last, on the topic of disability benefits, participants expressed frustration about how to access disability benefits. When prompted for input regarding what health system and policy changes are necessary, participants suggested a number of ideas, including expanding the availability of nurse navigation for metastatic breast cancer, developing and offering a guide for the range of treatment and support resources patients with metastatic breast cancer, and improving access to clinical trials. Conclusions Rapid assessments drawing from online community insights may be a critical source of data that can be used to ensure more responsive policy action to improve patient care.

Filipinxs are the second-largest Asian subgroup in the USA. While Filipinxs are most often considered Asian when constructing aggregate ethnic categories, recent research has identified a trend of a small portion of Filipinxs identifying as Latinx or multiracial. However, little research had addressed how identification with different aggregate ethnic categories may have implications for identifying health disparities among Filipinxs and how these compare to non-Hispanic whites.Bivariate and multivariable regression analyses using 2011-2018 California Health Interview Survey data, comparing Asian Filipinxs, Latinx Filipinxs, and multiracial Filipinxs.In bivariate analyses, Asian Filipinxs had a higher prevalence of diabetes than Latinx or multiracial Filipinxs. After controlling for sociodemographics, Latinx Filipinxs had significantly lower odds of having diabetes or heart disease than Asian Filipinxs. Compared to non-Latinx Whites, Asian Filipinxs reported higher odds of being in fair/poor health, obese or overweight, high blood pressure, and diabetes, multiracial Filipinxs reported higher odds of being obese or overweight, and Latinx Filipinxs reported lower odds of heart disease.These findings suggest emerging differences in health linked to identification with different ethnic categories, underscoring the need to investigate nuances among Filipinxs in future research as well as highlighting the utility of emerging sociological insights in health research.

Objectives. To determine the impact of data disaggregation on the ability to identify health disparities and needs for future research for Filipino, Vietnamese, Chinese, Japanese, and Korean adults in California. Methods. Using available data from the 2011–2017 California Health Interview Survey, we conducted bivariate and multivariable analyses to assess disparities in health conditions, outcomes, and service access compared with non-Hispanic Whites for Asians as an overall group and for each individual subgroup. Results. As an aggregate category, Asians appeared healthier than did non-Hispanic Whites on most indicators. However, every Asian subgroup had at least 1 disparity disguised by aggregation. Filipinos had the most disparities, with higher prevalence of fair or poor health, being obese or overweight, and having high blood pressure, diabetes, or asthma compared with non-Hispanic Whites (P Conclusions. Failure to disaggregate health data for individual Asian subgroups disguises disparities and leads to inaccurate conclusions about needs for interventions and research.

BACKGROUND: To address concerns that the Hospital Readmissions Reduction Program (HRRP) unfairly penalized safety net hospitals treating patients with high social and functional risks, Medicare recently modified HRRP to compare hospitals with similar proportions of high-risk, dual-eligible patients (“peer group hospitals”). Whether the change fully accounts for patients’ social and functional risks is unknown. OBJECTIVE: Examine risk-standardized readmission rates (RSRRs) and hospital penalties after adding patient-level social and functional and community-level risk factors. DESIGN: Using 2000-2014 Medicare hospital discharge, Health and Retirement Study, and community-level data, latent factors for patient social and functional factors and community factors were identified. We estimated RSRRs for peer groups and by safety net status using four hierarchical logistic regression models: “base” (HRRP model); “patient” (base plus patient factors); “community” (base plus community factors); and “full” (all factors). The proportion of hospitals penalized was calculated by safety net status. PATIENTS: 20,255 fee-for-service Medicare beneficiaries (65+) with eligible index hospitalizations MAIN MEASURES: RSRRs KEY RESULTS: Half of safety net hospitals are in peer group 5. Compared with other hospitals, peer group 5 hospitals (most dual-eligibles) treated sicker, more functionally limited patients from socially disadvantaged groups. RSRRs decreased by 0.7% for peer groups 2 and 4 and 1.3% for peer group 5 under the patient and full (versus base) models. Measured performance improved after adjusting for patient risk factors for hospitals in peer group 4 and 5 hospitals, but worsened for those in peer groups 1, 2, and 3. Under the patient (versus base) model, fewer safety net hospitals (48.7% versus 51.3%) but more non-safety net hospitals (50.0% versus 49.1%) were penalized. CONCLUSIONS: Patient-level risk adjustment decreased RSRRs for hospitals serving more at-risk patients and proportion of safety net hospitals penalized, while modestly increasing RSRRs and proportion of non-safety net hospitals penalized. Results suggest HRRP modifications may not fully account for hospital variation in patient-level risk. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s11606-020-06222-1) contains supplementary material, which is available to authorized users.

To examine whether changes in food prices are associated with changes in obesity prevalence among women in developing countries, and assess effect modification by individual socioeconomic status (SES). Longitudinal study of country-level food price inflation temporally and geographically linked to anthropometric data on non-pregnant adult women (n = 295,984) in 31 low-income and middle-income countries over the 2000–2014 time period, using separate multivariable multilevel growth models of five SES indicators. Post-estimation analysis computed the relationship between food price inflation and predicted mean probabilities of being obese, by SES. Rising food price inflation was strongly associated with women’s obesity prevalence, and SES consistently modified the relationship. Regardless of indicator used, higher food price inflation was positively associated with obesity among women in top SES categories, but was flat or negative among women in low SES categories, averaging over time. The SES differences were widest across educational strata and were most pronounced when food price inflation was highest. Overall, for every 1-unit increase in food price inflation, predicted mean obesity prevalence was between 0.02 and 0.06 percentage points greater in women of high SES compared to low SES women. There is a strong link between food price inflation and obesity in adult women in developing countries which is clearly modified by individuals’ SES. Greater food price inflation was associated with greater obesity prevalence only among women in higher SES groups, who may be net food buyers most at risk of obesity in low-income and middle-income countries.

Current approaches to health care quality have failed to reduce health care disparities. Despite dramatic increases in the use of quality measurement and associated payment policies, there has been no notable implementation of measurement strategies to reduce health disparities. The National Quality Forum developed a road map to demonstrate how measurement and associated policies can contribute to eliminating disparities and promote health equity. Specifically, the road map presents a four-part strategy whose components are identifying and prioritizing areas to reduce health disparities, implementing evidence-based interventions to reduce disparities, investing in the development and use of health equity performance measures, and incentivizing the reduction of health disparities and achievement of health equity. To demonstrate how the road map can be applied, we present an example of how measurement and value-based payment can be used to reduce racial disparities in hypertension among African Americans.

Objective To assess racial/ethnic differential impacts of the ACA's Medicaid expansion on low-income, nonelderly adults' access to primary care. Data sources Behavioral Risk Factor Surveillance System, State Physicians Workforce Data Book, and Bureau of Labor Statistics, in 2013 and 2015. Study design Quasi-experimental design with difference-in-differences analyses. Outcomes included health insurance coverage, having personal doctor(s), being unable to see doctors because of cost, and receiving a flu shot. We tested racial/ethnic differential impacts using the "Seemingly unrelated estimation" method. Multiple imputations and survey weights were used. Data collection/extraction methods Low-income, nonelderly adults were identified based on age, household income, and family size. Principal findings Among the low-income, nonelderly adults, Medicaid expansion was associated with statistically significant gains in health insurance coverage, having personal doctors, and affordability. Hispanics got the fewest benefits, which significantly widened racial/ethnic disparities for the Hispanic group. Racial/ethnic disparity in having personal doctors narrowed for non-Hispanic black and non-Hispanic others, although not statistically significant. Conclusion Medicaid expansion improved access to primary care, but it had differential effects among racial/ethnic groups resulting in mixed effects on disparities. Further research is necessary to develop tailored policy tools for racial/ethnic groups.

Summary In small area estimation, non-parametric models with penalized spline regression have been demonstrated to be a useful tool in creating granular area estimates to provide supplemental information where samples are few or non-existent. This study further examines the ability of a semiparametric generalized linear mixed model to produce conforming estimates for multiple area levels. A mosaic analogy is used to describe this process. A design-based jackknife method is employed for variance calculation.

Background and Objectives Growing literature documents that where you live has an impact on your health, due in part to social capital. Building on social capital literature, we assess how subjective appraisals of neighborhood quality are associated with self-reported health (SRH) for older adults. Research Design and Methods Cross-sectional analysis of the 2014 California Health Interview Survey, a representative survey of diverse, noninstitutionalized California residents. We use three measures of neighborhood quality: trustworthy neighbors, helpful neighbors, and feeling safe. Using weighted ordinary least squares regression, we assess the associations of trust, helpfulness, and safety to SRH, controlling for neighborhood, demographic, and health care variables. We then examine how these associations vary by household income. Results We find that characterizing neighbors as helpful and feeling safe are associated with better SRH, even controlling for community, demographic, and health care variables. However, the importance of these dimensions varies across household income: helpfulness is positively associated, whereas trust is negatively associated with SRH for lower income residents; safety is positively associated with SRH in all but the lowest income residents. These findings show that social capital dimensions work differently from one another, and differentially affect the health of older adults. Discussion and Implications Scholarly analyses of neighborhood effects should include a range of social capital measures and stratify by household income. Our findings may also inform priority setting for social capital programs, especially for older adults with limited economic resources. Policies and programs should consider actions that raise perceptions of helpfulness and safety.

Concern is growing in the United States regarding the potential for health insurance benefit designs to discriminate against persons living with HIV as research demonstrates that such practices are occurring. A recent complaint filed against health insurers in seven states alleges that some health insurance companies have been using benefit designs that discourage enrollment of people living with HIV either by not covering essential HIV medications or by requiring cost-sharing for these prohibitively expensive medications. Legislators across the country have reacted by introducing legislation to address these growing problems. This paper describes Assembly Bill 339, legislation passed in California in 2015 and going into effect on 1 January 2017, which provides protection for people living with HIV by requiring coverage for single-tablet regimens to manage HIV while placing a cap on patient cost-sharing. Given California's size and influence, and the uncertainty of the future of the Affordable Care Act, this legislation has the potential to influence the national policy debate.

BACKGROUND School climate is an integral part of a comprehensive approach to improving the well-being of students; however, little is known about the relationships between its different domains and measures. We examined the relationships between student, staff, and administrative measures of school climate to understand the extent to which they were related to each other and student outcomes. METHODS The sample included 33,572 secondary school students from 121 schools in Los Angeles County during the 2014-2015 academic year. A multilevel regression model was constructed to examine the association between the domains and measures of school climate and 5 outcomes of student well-being: depressive symptoms or suicidal ideation, tobacco use, alcohol use, marijuana use, and grades. RESULTS Student, staff, and administrative measures of school climate were weakly correlated. Strong associations were found between student outcomes and student reports of engagement and safety, while school staff reports and administrative measures of school climate showed limited associations with student outcomes. CONCLUSIONS As schools seek to measure and implement interventions aimed at improving school climate, consideration should be given to grounding these efforts in a multidimensional conceptualization of climate that values student perspectives and includes elements of both engagement and safety.