Hospital-based violence intervention programs (HVIP) are a public-health approach to violence that seek to intervene with victims in the hospital and break the cycle of violence. While there are published blueprints for launching an HVIP, limited evidence and guidance exist about how to sustain HVIPs. To fill this gap, we conducted a three-round Delphi study (June 2024–March 2025) with leaders and founders of established HVIPs to prioritize factors critical for achieving long-term program sustainability. Participants (n = 32) submitted 108 candidate factors influencing their program’s sustainability in Round 1. These submissions were synthesized into 28 unique factors in Round 2 through an iterative refinement process between the research team and study participants. In Round 3, we used maximum-difference (MaxDiff) scaling with hierarchical Bayes estimation to rank the 28 factors in order of priority for achieving long-term HVIP sustainability based on their relative importance to study participants. Factors related to support for frontline violence prevention professionals represented six of the top nine factors. Funding sources (e.g., government) and funding allocation (e.g., general operating support) received moderate to above average priority. Administrative factors (e.g., hospital leadership) and factors related to community stakeholders (e.g., community champions) received lower priority, with those related to external systems and institutions (e.g., law enforcement) prioritized lowest for program sustainability. Sustainability priorities differ from those in existing blueprints for launching a program. These results indicate the likely need for programs to adapt during their implementation journey. HVIP leaders may need to recalibrate priorities over time and acquire new skills.
Socioeconomic disadvantage is associated with higher obesity risk in older adults, but whether walkable neighborhoods modify these inequalities remains unclear. We examined whether neighborhood walkability moderates the association between area-level socioeconomic status (SES) and adiposity among older adults with overweight or obesity living in Mediterranean cities. This cross-sectional study analyzed baseline data from 1286 urban-dwelling adults aged 55 to 75 years with overweight or obesity and metabolic syndrome residing in six Andalusian cities. Area-level SES was assessed using the 2011 Spanish Deprivation Index, and neighborhood walkability was derived from an open-source index incorporating population density, street intersection density, and access to daily amenities. Adiposity outcomes included waist circumference, waist-to-hip ratio, and a body shape index, all objectively measured. Two-level linear regression models, with individuals nested within census tracts, evaluated SES-walkability interactions while adjusting for demographic and lifestyle factors. No overall differences in adiposity were observed between higher- and lower-SES neighborhoods. However, walkability significantly modified the SES-adiposity association. In highly walkable and dense neighborhoods, participants living in more deprived areas had larger waist circumference and higher body shape index compared with those in less deprived areas, indicating a steeper SES gradient in central adiposity. In low-walkability neighborhoods, SES differences in central adiposity were minimal. No interaction was observed for body mass index. Highly walkable urban environments may therefore amplify socioeconomic inequalities in abdominal obesity among older Mediterranean adults with overweight or obesity. Urban planning strategies promoting walkability should incorporate equity-focused, age-friendly approaches to ensure benefits reach socioeconomically disadvantaged populations.
India has experienced rapid urbanisation, straining the healthcare system. The National Urban Health Mission was launched in 2013 to improve access to public healthcare, particularly among socio-economically disadvantaged urban populations. This study aimed to assess whether inequalities in maternal and newborn health (MNH) service coverage and outcomes between richer and poorer groups have improved at public and private sources across urban India in the last two decades. We used pooled data from four national cross-sectional surveys, the District Level Household Surveys from 2002 to 2008 and National Family Health Surveys from 2015 to 2021, covering 94,826 and 108,152 births in urban India, respectively. We analysed trends in coverage of antenatal, delivery, and postnatal care services and neonatal mortality by source across wealth deciles, and summarised inequalities using the slope index of inequality, concentration index, and inequality pattern index. The study found that coverage of all MNH services, and to a lesser extent neonatal survival, increased substantially between 2002-2008 and 2015-2021 in urban India. Improvements were steeper among the poorest groups. Coverage by public health facilities notably increased, and neonatal mortality rates were lower at public than private facilities, particularly among the poorest. However, the poorest decile remained well behind all other groups, reflecting bottom inequalities. Rapid improvements with reduced inequalities in MNH service coverage appear to be driven by increased access to public sector services in urban India. It remains critical for the public healthcare system to understand and address the particular needs of the poorest groups to reduce ongoing bottom MNH inequalities in urban India.
Extreme heat is a significant and growing health hazard in urban locations around the world, particularly in the Southeastern United States (U.S.). While most extreme heat research and interventions are focused on ambient outdoor conditions and the neighborhood environment, the indoor residential environment is where the most severe heat-health consequences occur. The aim of this study was to characterize the indoor thermal environments and identify predictors of high indoor temperatures for residents of heat-vulnerable neighborhoods within New Orleans, Louisiana, within the context of current heat adaptation measures and issues of energy insecurity. We conducted surveys with both open- and closed-ended questions and measured indoor temperature over 2-week sampling periods in 114 households across two heat vulnerable New Orleans wards during the warm seasons of 2023 and 2024. Our study found that a combination of AC type and use, along with outdoor daily maximum temperature, were significant predictors of indoor maximum overnight temperature. Our results indicate that households without AC, using window AC units, or those not running central AC all or most of the time struggled to maintain 80 degrees Fahrenheit overnight (a threshold deemed appropriate by a recent healthy homes ordinance) once outdoor daily maximum temperatures exceeded 90 degrees Fahrenheit. Homeownership, compared to renting, was associated with higher overnight indoor temperatures, greater variability in typical AC use patterns, and greater sensitivity of summer monthly energy expenditures to differences in AC use patterns, potentially indicating that this group is practicing energy limiting behavior. This paper contributes to limited literature on indoor thermal environments, particularly in the Southeastern U.S., and underscores the importance of housing and energy burden in heat adaptation.
This study examined the nutritional environments of restaurants offering children’s menus and their association with neighborhood-level factors in a southern United States city with disproportionately high childhood obesity rates. On-site assessments were conducted to generate nutrition environment scores for restaurants offering children’s menus in New Orleans, Louisiana (n = 191). Restaurants were geocoded and linked to neighborhood characteristics, including racial/ethnic composition and socioeconomic opportunity measured by the Social and Economic Child Opportunity Index (COI-SE). Multivariate linear regressions assessed associations between nutrition environment scores and neighborhood characteristics, adjusting for restaurant-specific attributes. Restaurants located in neighborhoods with COI-SEs above the median had significantly higher nutrition environment scores (+ 2.41 points; 95
Over the past three decades, court-mandated drug treatment has emerged as a popular strategy to manage drug-related crime and substance use disorder (SUD). These programs offer dismissal or reduction of criminal charges upon satisfactory completion of drug treatment and additional conditions such as negative urine screenings, as determined by the criminal-legal system. Treatment modalities utilized via mandated treatment programs vary substantially across jurisdictions in the intensity and format of treatment. This variation can be explained in part by differences in state-level sentencing policies and the landscape of drug treatment and social services. We analyzed 27 qualitative individuals with Black and Hispanic individuals recruited from metropolitan areas in 3 US states who had received court-mandated treatment. Interviews were analyzed using a hybrid deductive-inductive approach to examine common challenges and diverging experiences of mandated treatment. Our analysis highlights intrinsic motivation, perceived agency, and perceived quality of care as key determinants of the effectiveness of mandated treatment on long-lasting behavioral change. Findings suggest there is a need to increase the emphasis on service quality within mandated treatment, including the utilization of evidence-based practices. This will require reframing success within mandated treatment programs from quantitative metrics, such as treatment attendance, to include qualitative metrics, such as level of therapeutic engagement.
The United States has responded to multiple societal ills, from substance use to homelessness to mental health, with criminalization. A new analysis using City and County of San Francisco data shows jails disproportionately harm people with serious mental illness (SMI). In addition to longer periods of incarceration and higher rates of repeat jail bookings, people with SMI also experience higher rates of homelessness, co-occurring substance use disorder, and urgent and emergent health services utilization before and after incarceration compared to their peers without SMI. The study provides a much-needed spotlight on jail research, as well as demonstrating the power of data when not siloed in multiple, disparate departments. Investing in community-based mental health resources, housing, and substance use disorder services can address the upstream determinants of incarceration and may benefit people with SMI.
Housing insecurity and substance use disorder (SUD) are critical public health issues in the USA, with significant implications for health outcomes. This study evaluated the intersection of housing insecurity, SUD, and psychosis among Medicaid enrollees in an urban center in Oregon. Using data from Health Share of Oregon, we identified three distinct cohorts-individuals with housing insecurity, those with SUD/psychosis, and those with both conditions. Key outcomes included inpatient admission rates, average lengths of stay, and 30-day readmissions. The findings indicate that housing-insecure individuals with SUD/psychosis show greater acute care utilization than the other two cohorts. Inpatient admissions for housing-insecure individuals with SUD/psychosis were over twice as high as those without housing insecurity (29.7% vs. 12.4%), nearly three times as high as those without SUD/psychosis (29.7% vs. 9.5%), and almost ten times higher than those without either (29.7% vs. 3.0%). There were likewise corresponding increases in ambulatory-sensitive hospitalizations, 30-day readmissions, and longer hospital stays. Effective interventions should address both housing and healthcare needs, including comprehensive case management and improved access to physical, behavioral, and mental health services integrated with housing programs and services. These strategies could mitigate acute care utilization and improve overall health outcomes for these vulnerable populations.
Exposure to lethal or non-lethal police-involved shootings within communities has been shown to negatively impact individual mental health. Most literature has found this association through survey data that cannot speak to contemporaneous and cumulative impacts of police shootings. Given heterogeneity in both policing and community characteristics, immediate and granular mental health outcomes related to police-involved shootings must be explored. Our study examines how temporal community-level exposure to police shootings influences rates of mental health condition diagnosis at the ZCTA (ZIP code tabulation area) and month level using hospital discharge data from Minneapolis, Minnesota. For our exposures, we created a cumulative counter of police-involved shootings within ZCTAs and a lagged exposure indicator of police-involved shootings in the previous month. Using two-way fixed effect panel models, we find a nonlinear relationship between cumulative shooting exposure and rate of mental health diagnosis. As cumulative shootings increase, their effect on overall mental health diagnosis rate in Minneapolis increases until reaching a peak and then diminishes. This trend is similar across racial groups. This may be due to sensitization (increases in response to a certain point) and desensitization (diminishing responses after that point) as police shootings accumulate. In contrast, the effect of recent shooting exposures is null and weak, suggesting that it is the initial compounding, concentrated nature of police violence that exacts the greatest toll on community mental health. Findings highlight the need to investigate temporal exposure to police violence at granular levels to further understand its negative mental health impacts on community health.
Our study objective was to describe the match between community safety needs and resources in Cleveland, Ohio from 2015–2019. We conducted an extensive review of online sources, agency websites, and implementation documents to identify violence prevention and community safety activities. We coded each census tract based on the presence or absence of each specific activity type and explored cross-sectional associations with crime frequency and type, including violent, property, and firearm crime, using Besag-York-Mollie (BYM) spatial autoregressive models. We identified 1,147 activities taking place in 1,625 locations. Efforts to improve the physical environment and after-school and out-of-school programs were the most common activity types. The total number of activities per population was positively associated with crime frequency (Relative Risk (RR) = 1.14; 95
Geographic differences in drug overdose patterns across the rural-urban continuum are well documented. Few studies utilize remote sensing data to assess environmental and structural factors influencing overdose risk across different geographic scales. We performed a retrospective ecological study analyzing fatal opioid overdoses within census block groups in Cook County, Illinois, from 2018 to 2023. Urbanicity was classified using the Global Human Settlement Layer Model (GHSL-MOD), which employed satellite data to measure built-up intensity, vegetative greenness, and nighttime light intensity (NLI). Environmental indicators were combined with census-based measures of neighborhood deprivation to characterize spatial variation in physical and social conditions. A Bayesian spatiotemporal model was estimated to account for spatial dependence, temporal trends, and environmental exposures, yielding neighborhood-level estimates of overdose risk. Overdose risk exhibited significant spatial clustering and strong associations with both social and environmental factors. Neighborhood disadvantage had a dose-response relationship, with fatal overdose risk in areas with the most deprivation, experiencing over seven times the risk, compared to the least deprived. NLI was strongly associated with increased overdose risk, while vegetative greenness and park access showed no significant protective effects. Increasing trends were detected in rural and transitional zones despite a higher risk in urban centers. Demographic characteristics of overdose victims varied across the county, suggesting potential geographic disparities in risk. The physical and social features of neighborhoods underscore the need for early surveillance and intervention within and outside urban centers. These factors should be incorporated into targeted, place-based strategies to lower opioid-related deaths.
Police violence is increasingly recognized as a public health crisis, disproportionately affecting Black, Indigenous, and other communities of color due to long-standing patterns of racialized surveillance and disinvestment. Environmental stressors such as heat have also been linked to increased aggression, stress reactivity, and violence, suggesting that as climate change drives more frequent and intense extremes in temperature, these conditions may amplify existing risks of fatal police encounters. This study evaluated whether extreme ambient temperatures were associated with fatal police violence and whether structural neighborhood deprivation modified this relationship. Our nationwide case-crossover analysis examined daily maximum temperature and fatal police violence in the United States (2013–2024) using data from Mapping Police Violence. We estimated odds ratios across percentiles of the temperature distribution and analyses were stratified by neighborhood-level measures of deprivation, using Index of Concentration at the Extremes metrics for education, income, racialized income, and homeownership. Our main analysis revealed that compared to the median temperature (23.5 °C), the odds of fatal police violence at the 5th temperature percentile were reduced by 12
To elucidate the role of housing status in observed racial disparities in opioid overdose mortality, we conducted a cross-sectional study using vital statistics, medical, and housing records in San Francisco, California from 2021 to 2023. We reported standardized mortality ratio (SMR); indirectly age- and sex-standardized mortality rate; and observed, expected, and excess deaths for each race or ethnicity group among people experiencing homelessness, using adult Californians as the standard population. Forty-seven percent (812/1727) of overdose decedents were recently homeless, and people experiencing homelessness had 33 times the rate of opioid overdose mortality (SMR 33.2, CI 29.1-37.3) compared to the general population, standardized by age, race, and sex. There were a minimum of 244 excess deaths per year in San Francisco due to the increased risk of overdose among people experiencing homelessness, which disproportionally affected Black people. Reducing opioid overdose mortality and related disparities requires addressing the housing crisis.
Extreme, high indoor temperatures in urban slums of tropical regions pose significant health risks, particularly for vulnerable populations. This study investigates the influence of housing construction materials on indoor temperatures in Dhaka, Bangladesh, in the context of rising global temperatures. A longitudinal prospective survey was conducted between January and December 2022 in five urban slums of Dhaka, covering 44 dwellings purposively selected to ensure good spatial coverage and to reflect predominant construction materials. Temperature data loggers were placed unobtrusively to record hourly indoor temperatures. Housing construction materials, including cement, tin, or a combination of both, were examined. Negative binomial models were employed to analyze the impact of construction materials on hours per day exceeding 32 °C and 35 °C. Descriptive statistics showed wide temperature variations based on construction materials, with tin-tin dwellings exhibiting the widest temperature range (19.1 °C to 47.2 °C). Negative binomial models showed that houses with tin elements, especially those with both tin roofs and walls, experienced significantly more hours above 35 °C compared to cement-cement houses. Tin-tin dwellings had the greatest risk of extreme, high indoor temperatures. The study underscores the substantial influence of housing construction materials on indoor temperatures, with tin sheeting contributing to rapid temperature increases. This has critical implications, particularly for vulnerable populations, as mean temperatures continue to rise. Policies addressing building materials and climate resilience are essential to mitigate heat-related health risks in urban slums.
Brazil has historically seen higher mortality among urban residents compared to rural counterparts, despite better self-reported health among urban residents and better access to healthcare services. However, recent trends in these urban-rural mortality differentials and the specific causes of death contributing to them have not been well documented. We address this gap by analyzing trends in adult life expectancy in Brazil's five macro-regions from 2006 to 2023. We decompose changes in the life expectancy gap by age, sex, and cause of death. Our findings reveal an emerging urban advantage in male life expectancy in Brazil, beginning in the mid-2000s and continuing until the start of the COVID-19 pandemic. For females, a small initial urban survival penalty had shifted to an urban advantage by 2019. The North and Northeast regions showed larger urban penalties for both sexes than the southern regions. For males, the emerging urban life expectancy advantage was primarily driven by a more rapid decrease in mortality from external causes among urban residents aged 20-39. For females, the urban advantage was fueled by relative gains in mortality from neoplasms, respiratory diseases, and external causes. The COVID-19 pandemic initially widened the urban mortality penalty or narrowed the urban advantage in 2020 due to higher COVID-19 mortality in urban areas. However, this trend reversed from 2021 to 2023, as the urban penalty in COVID-19 mortality turned into an urban advantage, reversing the relative gains seen in rural areas.
Geographic access to healthcare remains a critical barrier to health equity in low- and middle-income countries, where infrastructure and service provision are unevenly distributed. Using the UN-endorsed Degree of Urbanisation framework, we assessed disparities in geographic healthcare accessibility across Nigeria and Zambia in 2020. Travel times to health facilities were modeled for both walking and motorized transport at 1 km resolution, and stratified by settlement type and demographic group. Results showed marked urban–rural disparities: while city residents could typically reach hospitals within minutes, rural populations faced journeys exceeding 4 h on foot. Motorized transport substantially improved accessibility but remained unavailable to many, leaving only 8
Disparities in health services remain one of the pressing issues engaging the attention of many stakeholders. Although this issue is more prevalent in developing countries, the impact of limited hospital beds on healthcare for residents in informal communities remains largely unexplored. This study aims to examine this phenomenon. Within the framework of structural violence and health systems resilience, the study employed a triangulation approach, combining newspaper publications, reconnaissance, and in-depth interviews, all centered on a qualitative approach to inform the conclusions reached. Results show that the lack of hospital beds led to delayed access to emergency care, financial exploitation, and preventable deaths. It further indicates that residents perceive the phenomenon as a discriminatory, unjust health system and a loss of confidence in health governance. Overall, the findings highlight the importance of strengthening health governance equitably to enhance public trust in the healthcare system. It supports the Ministry of Health and Ghana Health Service in developing policies and strategies that enhance health governance, focusing on the low-income population. The findings fill the gaps in the context of the ignored voices of informal residents in a developing country, Ghana.
The present study investigated the extent to which the relationship between perceptions of neighborhood unsafety and disorder and self-assessed health (SAH) is explained by mediation, interaction, or a combination of both through perceived neighborhood social cohesion. We analyzed data on 5650 respondents over a 10-year follow-up using the GLOBE study, a prospective cohort study in the Netherlands. Log-linear regression analyses were used to estimate the total effects of feeling unsafe and perceived neighborhood disorder with poor SAH. A four-way decomposition approach was used to decompose the total effects into four components: controlled direct effect (neither mediation nor interaction), pure indirect effect (mediation only), reference interaction effect (interaction only), and mediated interaction effect (both mediation and interaction). The results indicate that feeling unsafe had a positive estimated total effect on poor SAH (RR = 1.05; 95
Social network diffusion interventions are a promising strategy for promoting health behavior change at the community level. Individuals impacted by the criminal legal system (CLS) experienced disproportionately high morbidity and mortality during the COVID-19 pandemic. As part of the National Institutes of Health Rapid Acceleration of Diagnostics–Underserved Populations (RADX-UP) initiative, we evaluated a group-level social network diffusion intervention incorporating motivational interviewing strategies to increase COVID-19 testing and vaccination among CLS-impacted individuals and their social networks across four urban cities. Between January 2023 and February 2024, participants were randomized by cohort to either a Motivational Interviewing–based intervention (MI) or a Prevention Education (PE) comparison condition. The MI intervention incorporated motivational interviewing–informed strategies to support participants in engaging and influencing members of their social networks, whereas PE participants received COVID-19 prevention education. The primary outcome was uptake of COVID-19 testing or vaccination within 90 days among previously unvaccinated primary participants, with testing and vaccination outcomes for social network members assessed based on participant report. Secondary outcomes included COVID-19 testing and vaccination knowledge among primary participants and reported resource sharing within social networks. A total of 810 primary participants were enrolled (MI: n = 403; PE: n = 407), with most identifying as Black or African American (89.8
Tolerance to increasingly frequent, intense, and prolonged heatwaves depends on vulnerability, with elderly people being among the most vulnerable groups. However, many elderly people do not perceive themselves as vulnerable to heat. Vulnerability results from exposure, sensitivity, and adaptive capacity. This paper explores the factors influencing perceived vulnerability and aims to understand why elderly women often report low perceived vulnerability. For this purpose, semi-structured interviews were conducted with seven elderly women during the summers of 2022 and 2023. The analysis of interview transcripts aligns with existing literature: low perceived vulnerability is linked to a limited knowledge of heat-related risks, the relativisation of vulnerability through peer comparison, and the unrealistic optimism bias. Moreover, the factors influencing perceived vulnerability differ from those identified in epidemiological studies in their nature, effects, importance, and methods of assessment. Perceived vulnerability is shown to be personal, nuanced, and variable, and its study could offer insights for rethinking prevention.
