Research

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                    [post_content] => In school, Samantha was always afraid of being called on in class even when she knew the answers.  Her hands would get clammy and her heart would pound. She skips class frequently, sits in the back of the classroom and avoids participation in lectures and presentations. She wants to go to class, learn the material, and interact with her peers but is afraid her instructor and peers won’t think she is smart enough.

Social anxiety is characterized by intense fear and avoidance social situations because we fear we are being judged. Socially anxious individuals tend to exhibit physical symptoms like trembling, sweating, and fidgeting when they perceive a social interaction as threatening. High social anxiety often results in severe avoidance of social interactions that interferes with work, school, and personal life. In addition to the immediate effects on quality of life, the experience of social anxiety has been shown to undermine educational achievement, predict significantly lower earned wages and workplace productivity, and be associated with taking more days off of work.

Traditional psychological research to understand social anxiety has fallen short, relying on laboratory-based methods that don’t capture the in-the-moment, real-life experience of individuals with social anxiety. Exciting recent advances in sensing technology have made it possible to monitor how activities and social behaviors unfold in natural social settings. Social patterns can be monitored using sensors embedded in personal smartphones and other devices.

Our team at the University of Virginia was interested in understanding how social anxiety symptoms manifest in the ‘wild.’ Our collaboration between engineers and psychologists  aimed to discover how socially anxious individuals’ fine-grained behaviors manifest as their daily life unfolds. We analyzed data that is constantly being gathered by sensors embedded in our cell phones (see figure below). Accelerometers, light sensors, global positioning system (GPS), and other programs track our internet search history, the places we go, the people with whom we interact, just to name a few. These sensors are increasingly used to understand health. For example, accelerometers can tell us how active a person is in a given day by measuring how many steps an individual took, how many flights of stairs they climbed, or if they missed their morning run.


Sensors embedded in smartphones (image courtesy of the author)
Apps like Google Maps and Waze already use this data to suggest the most efficient routes to our destinations. We repurposed this data to understand and predict mental health states. In this study, we leveraged location data as captured from GPS sensors to extract meaningful patterns that enhance our understanding of behaviors of socially anxious individuals.  We set out to answer the following questions: Does an individual regularly visit the same locations during specific hours? Are they visiting their friends? Are they socially isolating themselves?

We recruited 228 undergraduate university student participants with varying social anxiety levels. Students were recruited through email advertisements and an undergraduate study participant pool. We decided to focus on university students for two reasons: (1) high social anxiety levels among young adults are well-documented, and (2) recruiting young adults in a university setting provides a relatively homogeneous sample in terms of life phase, psychological stressors, and life experiences, thereby eliminating a wide variety of potential confounding factors.
Traditional psychological research to understand social anxiety has fallen short, relying on laboratory-based methods that don’t capture the in-the-moment, real-life experience of individuals with social anxiety.

 
We installed a custom mobile app for studying human behavior in natural settings (Sensus) on participants’ personal IOS or Android phones. The app collected GPS location data from participants continuously and uploaded them to a cloud for analysis.

After the 2-week study was complete, we used advanced computational techniques and OpenStreetMap (OSM) geodatabase to translate GPS coordinates into meaningful classes of locations such as home, coffee shop, supermarket, friend’s house. From these labels, we computed how long an individual participant stayed in each location, how their time was distributed at each location, how often they moved between locations, and the diversity of locations. We then used these mobility metrics to predict an individual’s social anxiety using a neural network.

We found that, by combining passively sensed location data with advance computational methods, it is possible to accurately predict an individual’s social anxiety levels. We integrated semantic labels  indicating different types of locations (where we relax, exercise, socialize, study, or work) into prediction models to provide a nuanced picture of the behavioral patterns of socially anxious individuals. Consistent with the existing theory and psychological research, we found that socially anxious students avoided locations that contain a threat of social evaluation, such as restaurants, bars, or dormitory common rooms. They also  engaged in fewer leisure activities during evenings and weekends than students with low social anxiety.

These study results demonstrate the potential utility of leveraging mobility patterns to understand how social anxiety symptoms manifest in real-life situations. Future research will need to look at how this and other sensor data can be used to develop interventions for people who experience high social stress. This is the first work to demonstrate the connection between fine-grained behaviors as measured by smartphone sensors and social anxiety disorder.
Acknowledgements
The study was supported by the Hobby Postdoctoral and Predoctoral Fellowships in Computational Science and the National Institutes of Health’s National Institute of Mental Health (MH113752).

Photo by inbal marilli on Unsplash
                    [post_title] => Does My Smartphone Know I’m Anxious?
                    [post_excerpt] => Researchers used an app to map mobility patterns among undergraduate students to understand how social anxiety symptoms manifest in real-life situations.
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                    [post_content] => Of the over three million workers a year seriously injured on the job, only a small fraction receive any workers’ compensation. Compared to the general population, Latinx immigrant workers, especially if undocumented, are highly vulnerable to workplace injury. In fact, workplace fatality rates for Latinx immigrants are 50% higher than for all other workers. Immigrant workers are also more likely to have their workers’ compensation claims contested.

Latinx immigrant workers face barriers to reporting workplace injuries and filing worker compensation claims. In collaboration with Fuerza Laboral, a worker center in Rhode Island, I analyzed interviews with Latinx workers injured at work, medical practitioners who see workers’ compensation patients, and legal professionals who work in the compensation system. This research found that the gauntlet workers must run to file claims in Rhode Island includes uncertainty about their rights; misleading information from employers; threats of retaliation, dismissal, or being reported to immigration; and language barriers. My analysis of injured workers’ stories also make it clear that medical providers act as sentinel gatekeepers to healthcare and benefits.

People who make a worker compensation claim are not seen as fully trustworthy because they have motives to gain from reporting pain or damages. Physicians are thus required to serve as impartial and scientific arbiters who evaluate employee injuries. Consequently, the medical and legal systems create additional barriers for patients and medical professionals. The Injured workers I interviewed reported missing treatments, feeling uncertainty about the loyalty of their physicians, and confusion about their treatment options. They are overwhelmed with contradictory opinions from a tangle of providers.
The physicians I interviewed, in turn, acknowledged frustration with the requirements of “impartial” exams, delayed patient treatment, additional work communicating with insurance companies, and increased difficulty building rapport with patients.

A doctor’s report can support a patient claim, but if a worker’s reported symptoms diverge from the doctor’s conclusions, the legitimacy of their need for compensation may be questioned. And, while judges have the ultimate say, the assumed objectivity of biomedical information can make judges feel dependent on physicians’ conclusions.
Compared to the general population, Latinx immigrant workers, especially if undocumented, are highly vulnerable to workplace injury.

 
Supplanting injured workers’ testimonies with medical reports complicates recovery and medical treatment, and leaves courts susceptible to influence by physician’s opinions about a claimant. Physicians described how they decide what to emphasize or play down in a report and their methods of trying to decipher the validity of patients’ pain. The effects of physician bias are being increasingly documented. That research begs a reevaluation of legal systems that rely on medicine being objective. A workers’ compensation claim, like any claim for public assistance, is stigmatized. Claimants are typecast as abusing the system or lazy. For low-wage immigrant workers, their value to society is deeply intertwined with their productive capacity, or their ability to work. These popular narratives are reinforced by the mass media, and medical providers are not immune. In worker compensation systems, the perceptions physicians hold will likely shape their actions in response to treating or evaluating an immigrant worker injured on the job.

Analysis of injured Latinx immigrants’ experiences within the RI workers’ compensation system also calls for evaluation of medical education. For example, the orthopedic surgeons I interviewed reported a widespread belief among physicians that Latinx patients expressed or experienced more pain due to “cultural or ethnic” differences. These same doctors acknowledged they often lack interpreters and have difficulties communicating with the same patient population. Still, they believed culture was the main driving factor of Latinx patients’ longer recoveries, and overlooked the impact of structural issues like safety, language barriers, lack of transportation, and the effects of racism.

Analyzing the experiences of those affected by workplace injury exposes pitfalls in coupling medical evaluation and access to healthcare. This research demands a reevaluation of the workers’ compensation system in light of growing data on the effects of physician bias. It also calls for medical education reform that gives priority attention to structural barriers to health.

Image from Balazs Gari, GB.USA.07.0028 (detail), CC BY-NC-ND 2.0
                    [post_title] => Physicians as Gatekeepers in Workers’ Compensation
                    [post_excerpt] => Analysis of injured Latinx immigrants’ experiences within Rhode Island's workers’ compensation system also calls for evaluation of medical education.
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                    [post_content] => In many cultures, a woman giving birth is attended by other women—family members, neighbors, and others who bring their own experience to assist the laboring woman through her birth experience. This was the tradition in the United States until the 20th century, when birth became medicalized. Women began to have their babies in hospitals rather than at home, and family and friends were forbidden to stay with them. A backlash against these restrictions led to men’s being allowed to accompany their female partners in labor, but their lack of experience with childbirth often limited the support they could provide.

Enter the doula. A childbirth assistant, trained and experienced in birth, she (or sometimes, he) provides physical, informational, and emotional support to the laboring woman and any support person(s) who may be with her. The word “doula” derives from a Greek term for “female helper.” A doula may provide comforting touch to help her client deal with labor pains. She may help interpret the hospital environment, explaining the mysterious beeps and supporting her client in asking for more information or more time to make a decision. She may reassure the mother that what she’s experiencing is normal, and that she’s making great progress. Research has shown that doula support is associated with reduced cesarean birth, anesthesia use, postpartum depression, and preterm birth, as well as increased breastfeeding and birth satisfaction.

Too often, however, the services of a doula are not covered by insurance, meaning that the support is restricted to women who know about it and can afford to pay for it. The practical result has been that some of the people who would most benefit from the service—women of color and those living in areas of high poverty, who experience disproportionately high rates of poor birth outcomes—have been unable to obtain it.

The By My Side Birth Support Program (BMS) was created to address this issue. Operated by Healthy Start Brooklyn, a federally funded program based in the New York City Department of Health and Mental Hygiene’s Center for Health Equity, By My Side serves low-income Black and Latina women in central and eastern Brooklyn, who bear a disproportionate burden of infant mortality, preterm birth, low birthweight, and other challenges.
In many cultures, a woman giving birth is attended by other women—family members, neighbors, and others who bring their own experience to assist the laboring woman through her birth experience.

 
My colleagues and I recently published an article examining data from the program’s beginning in 2010 through 2015. In that time, BMS served more than 560 women, and 489 infants were born to program clients; 84.7% of these births were attended by a doula. Attrition was relatively low: 83.2% of the mothers remained in the program through graduation (defined as completing at least two postpartum visits), and in follow-up interviews with 244 clients, 96% said they would recommend the program or use it in a future pregnancy.

The results of our study were intriguing. Compared with overall outcomes in the program neighborhoods, By My Side clients had significantly lower rates of preterm birth (6.3% vs. 12.4%) and low birthweight (6.5% vs. 11.1%). However, contrary to many results in the literature, the rate of Cesarean birth was statistically similar (33.5% vs. 36.9%). Possible reasons for this include routine hospital practices in the program area, such as confining a woman to bed during labor, which may limit the influence a doula can have on mode of delivery. Other factors may include the challenges of pervasive poverty, community violence, and structural racism, which often show themselves in high levels of stress and chronic disease, such as obesity, high blood pressure, and diabetes.

We hypothesize that the relationship forged with a doula during prenatal home visits may lessen some of the stress a woman naturally experiences in challenging circumstances. This in turn may make her less likely to give birth prematurely, when her baby is less likely to survive and thrive.

The By My Side experience shows that low-income Black and Latina women in Brooklyn neighborhoods benefit from having doula support during pregnancy, childbirth, and the postpartum period. Providing access to free doula services may thus be an important way to address inequities in birth outcomes.

Image from David Mooring, 23 Weeks (detail), CC BY-NC-ND 2.0
                    [post_title] => Doula Support for Women in Underserved Communities
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                    [post_content] => Under the recently announced Migrant Protection Protocols, also known as “Remain in Mexico,” people fleeing violence across Central America are being returned to Mexico while they wait out asylum determinations from the US government. Much of the ensuing discussion leaves out that the US and European countries are not the only nations that grant asylum. Among many other countries, Mexico does too. However, aslyum in Mexico offers only tenuous protection. As practitioners and researchers, we have spent time with asylum seekers in Mexico, people like Magda who continue to face acute dangers after being officially recognized as refugees by the Mexican government. Magda’s story speaks to some of the dangers associated with the Migrant Protection Protocols.

Magda is a survivor of intimate partner violence. At fifteen years old she became the mother of a beautiful baby girl by a man who abused her over the course of their two-year relationship. Magda and her daughter escaped to family in a nearby town, but the father of her daughter responded by intimidating Magda and her family so that she would return to him.

On the cusp of her eighteenth birthday, Magda left her daughter with her mother and fled El Salvador. As with many women escaping intimate partner violence across Central America, Magda left home suddenly. Upon reaching Mexico, she hopped freight trains—a relatively cheap but dangerous means of travel—until arriving at the migrant shelter where we were both working. In 2014, the Mexican government intensified policing along railways in the name of protecting unaccompanied minors like Magda. Instead of protecting young people, this policing has made the journey through Mexico more dangerous and circuitous. People become “stuck” in Mexico after running out of money or suffering abuses. In this context, a growing number of Central Americans like Magda seek formal humanitarian recognition from the Mexican government as a “plan B.”

As a survivor of intimate partner violence, Magda petitioned Mexico’s refugee commission for asylum. Historically, Mexico’s shelters have helped people who are just passing through. Many shelters lack the resources needed to sufficiently support people pursuing refugee status, a process that can last several months. Applying for asylum is distressing. It means putting your life on hold, often without the means to support family back home. As a result, people often abandon asylum cases and continue their journeys, prioritizing the chance to reach the US over the uncertainty of waiting out bureaucracies in Mexico.
After three months of waiting, Magda received word from the Mexican government that her petition for refugee status had been approved. But when she was told that she would have to wait several more weeks for official immigration documents to be processed, she left the shelter and we didn’t hear from her for several months.

A few weeks ago, Magda messaged both of us over Facebook. She explained that, after leaving the shelter, she eventually made it to the US-Mexico border. There, she was kidnapped by traffickers, smuggled across the border, and forced into prostitution in Los Angeles for several months until being arrested and detained by ICE. Traumatized by what had happened to her, Magda did not inform US officials that she had been recognized as an asylee in Mexico. As a result, she was deported back to El Salvador.

The chain of traumas Magda has experienced points to the health implications of policies like the Migrant Protection Protocols that trap people in Mexico. Seeking asylum should offer relief from persecution. But, for many, navigating bureaucracies while in Mexico is a form of persecution. Policies like the Migration Protection Protocols are likely to exacerbate existing traumas as people like Magda navigate the dangers of daily life in Mexico. The associated traumas are long-lasting and they ripple through communities. These policies will likely discourage people from seeking help from institutions that purport to “protect” them. As opposed to policies like the Migrant Protection Protocols, we need an asylum system that provides affordable housing, work authorization, and a safe environment while awaiting asylum determinations, conditions that are often difficult to find in Mexico.

Editor's Note: The authors include a translation of the article from English to Spanish below.
Version en español: Los Nuevos “Protocoloes de Protección al Migrante” No “Protegen,” Agravan Peligros 
Bajo los nuevos Protocolos de Protección a Migrantes, también conocido como “Queda en México,” el gobierno de los EEUU está devolviendo Centroamericanos huyendo de violencia en Centroamérica mientras esperan determinaciones en sus casos. Mucha gente no se da cuenta que además de los EEUU y países de Europa, México, junto con varias otras naciones, también ofrece asilo. Sin embargo, para muchas personas, recibir asilo en México ofrece una forma de protección sumamente tenue. Como coloboradores con una casa de migrante en México, hemos convivido con personas siguiendo el proceso de pedir asilo en México, gente como Magda quienes enfrentan peligros en México aún despues de ser reconocidos como refugiados por el gobierno Mexicano. La experiencia de Magda muestra algunos de los peligros implicados en una política de ‘queda en México.’

Magda es sobreviviente de la violencia de género. A los quince años fue madre de una hermosa niña, producto de una relación violenta que duró dos años. Ante esta situación, Magda junto con su hija decide escapar y pedir ayuda a su familia cercana, pero el papá de su hija siempre la intimidó a Magda para que regresara con él.

Poco antes de cumplir 18 años, Magda se vio forzada a dejar a su hija en las manos de su madre y huyó de El Salvador. Como muchas mujeres que escapan violencia de pareja en centroámerica, Magda se fue de su casa de repente. Al llegar a México, viajó en tren—un camino relativamente barato, aunque peligroso—hasta llegar a la casa de migrante donde trabajábamos. En 2014, el gobierno Mexicano intensificó operativos en las vías a nombre de proteger menores no acompañados como Magda. En vez de proteger, los operativos han resultado en viajes más peligrosos y más largos. Muchas personas vuelven atorados en México al quedarse sin dinero o después de sufrir abusos. En esto contexto, más y más centroamericanos como Magda buscan reconocimiento humanitaria del gobierno mexicano como un “plan B.”

Como sobreviviente de violencia de pareja, Magda tramitó asilo con el gobierno de México. Históricamente, las casas de migrante en México han apoyado gente de paso. Muchos albergues faltan recursos suficientes para apoyar a personas en trámites, un proceso que puede tardar varios meses. Pedir asilo es estresante. Implica frenar tu vida por varios meses sin la manera de apoyar a familiares en su país de origen. Como resultado, es común que gente como Magda abandonan sus casos para seguir sus viajes. Priorizan la posibilidad de ganar dólares en los EEUU ante los hostigamientos del proceso de tramitar asilo.

Después de tres meses en espera, Magda le avisaron a Magda que le habían aprobado su caso. Pero cuando la dijeron que todavía tendría que esperar varias semanas mientras procesaron sus papeles de migración, Magde se desesperó y se fue del albergue. Pasamos varios meses sin comunicarse con Magda. Hace unas semanas, Magda nos mensajeó por Facebook. Nos explicó que después de salir del albergue llegó a la frontera con los EEUU. Allí le secuestraron, la cruzaron a Los Ángeles, y fue prostituida por varios meses hasta ser detenido por policías. Traumatizada, Magda no les informó a los oficiales de los EEUU que era refugiado en México así que le deportaron a El Salvador.

La cadena de traumas que Magda ha vivido tiene implicaciones de salud para programas como los Protocolos que atrapan a migrantes en México. Pedir asilo debe ser un alivio de persecución. Para muchas personas, el proceso de navegar burocracias se siente como una forma de persecución. Programas como los Protocolos de Protección a Migrantes solo van a agravar las traumas que personas como Magda experimenten. Estos traumas tienen impactos de largo plazo que extienden por comunidades y familias. También disuaden a personas como Magda de pedir apoyo de instituciones que pretenden “proteger.” En vez de programas como los Protocolos, necesitamos un sistema de asilo que ofrece vivienda accesible, autorización para trabajar, y un ambiente seguro mientras personas como Magda esperan determinaciones, condiciones que en muchos casos son difíciles de encontrar en México.

Image courtesy of the author
                    [post_title] => “Migrant Protection Protocols” Don't Protect
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                    [post_content] => A recent study found that aggressive marketing by insurance companies of short-term health plans may cause confusion among individuals shopping for health insurance online. Short-term plans don’t have to meet now standard requirements to cover pre-existing conditions or essential health benefits, and could lead to more Americans not having adequate protection if health crises arise.

Short-term health plans were originally designed to cover individuals with gaps in coverage–between jobs, for example–and were limited to 90 days under the Obama Administration and the Affordable Care Act (ACA). New rules issued in August 2018 extended the limit of short-term plans to 364 days and allow them to be renewed for up to 36 months. In effect, these “short-term” plans could serve as long-term alternatives but without the ACA’s comprehensive coverage. Short-term plans are enticing because they often have relatively low costs due at least in part to the limited benefits they provide.

The study was conducted in two phases last October and November, before and after open enrollment, the time when individuals can enroll in or change health insurance plans through the online Marketplace established under the ACA. Researchers looked for health insurance options online using search terms such as “cheap health insurance,” “short-term health insurance,” “Obamacare plans,” and “ACA enroll.” Before open enrollment, more than 99% of search results led to sites selling plans that may not cover pre-existing conditions or include the essential health benefits. During open enrollment, the advertising improved, but not by much: 81% of search results led to websites selling plans that may not meet ACA requirements.

Researchers found many of the websites prompted potential customers to enter contact information and some personal data, such as income or smoking status that could influence the cost of insurance. These sites then redirected customers to sites where they could buy insurance products or connected them to insurance brokers, who also sometimes called directly.

When prompted to provide information online, researchers posed as healthy 29-year-olds expecting to earn $29,000 in 2019, making them potentially eligible for premium subsidies that could reduce the cost of comprehensive coverage.
Short-term health plans were originally designed to cover individuals with gaps in coverage– between jobs, for example – and were limited to 90 days under the Obama Administration and the Affordable Care Act (ACA).

 
In some cases, researchers answered phone calls from brokers who used aggressive phone tactics, urging consumers to purchase coverage on the spot with little information about the plan. When asked to provide written materials about the plan, brokers either refused or hung up.

The Centers for Medicare and Medicaid Services (CMS) estimate that 2 million people will take-up short-term plans by 2022. These consumers should be on the lookout for skimpy plans and aggressive sales tactics, neither of which will serve them well if they become ill.

If you are considering short-term plans as an alternative to comprehensive, but cost-prohibitive coverage, it’s important to understand what your plan covers. This fact-sheet from the Kaiser Family Foundation lists features of short-term plans that could differ from ACA-compliant coverage, but because short-term plans take many forms it’s best to confirm benefits with your insurer directly.

Understanding how short-term plans are marketed is important for both consumers and state regulators. Several states (California, Hawaii, Massachusetts, New Jersey, Rhode Island, Vermont, Washington, Oregon, and New York) have banned the sale of short-term plans because, among other limitations, they do not cover pre-existing conditions. Some state regulators say that purchasing a short-term plan is better than nothing, while others are concerned consumers won’t know what they’re getting into. Needless to say, individuals shopping for health insurance online should proceed with caution.

Image: admakz/iStock
                    [post_title] => On Short-Term Health Plans
                    [post_excerpt] => Understanding how short-term plans are marketed is important for both consumers and state regulators now that the limit of short-term plans is extended. 
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                    [post_date] => 2019-03-07 07:00:00
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                    [post_content] => The massive surge of unaccompanied minors from El Salvador, Honduras, and Guatemala is a humanitarian crisis. Beginning in October 2011, the United States government reported a dramatic rise in the number of unaccompanied children arriving from the Northern Triangle. The initial influx of 3,933 unaccompanied Central American children crossing the southwest border of the Rio Grande increased steadily to a high of 50,036 in 2018.

United States foreign policy and the ravages of civil war in the region during the 1980s have contributed to the socio-economic conditions underlying this crisis. Extreme poverty, malnutrition, sexual violence, gang violence, and family reunification are the primary reasons these children are fleeing their homes. Many of these kids are re-victimized or trafficked on their journey from Central America. Female migrants make the journey knowing they will likely be raped along the way. Unaccompanied migrant children are in desperate need of medical and mental health services when they arrive, services that are sorely lacking in most communities.

These kids are utterly traumatized when they arrive. Once apprehended at the border, they are placed in shelters for approximately three months before being reunited with family or placed in foster care. While in the shelters they have access to health and mental health services. However, once released to family members those services are no longer available and families must fend for themselves.
The pain does not go away when they are reunited with their parents who work long hours outside the home. As a result, children who have migrated on their own in search of their families, security, and stability end up feeling neglected all over again.

 
Navigating the morass of social services is exacerbated by language barriers, lack of transportation, and undocumented immigration status. In New York, unaccompanied minors are eligible for Child Health Plus which provides free medical care and access to a private therapist. But many immigrant families are unaware of this program. The Mid-Hudson Valley – where I conducted research on the collective response to the crisis by service providers, educators, activists, and immigration lawyers – has just one Spanish speaking therapist. In the region where I work and beyond there are few bilingual medical or counseling services.

Given the enormous trauma suffered by these youth, the lack of services is devastating. The decision to migrate with only some of your children is excruciating. Unfortunately, the kids who are left behind do not understand the pain their parents go through when making this decision or the underlying the socioeconomic reasons. They do not grasp the complexities of immigration policy or the reasons why their parents left. Many haven’t seen their parents for years and are angry about being abandoned. All they know is that they were left behind.

The pain does not go away when they are reunited with their parents who work long hours outside the home. As a result, children who have migrated on their own in search of their families, security, and stability end up feeling neglected all over again. They are relieved to be reunited, but the transition is extremely difficult and they need intensive health care and counseling. Their trauma is compounded by the racist and xenophobic public discourse from news outlets and President Trump describing their violent nature and destruction of their new communities.

These children need long-term mental health care to deal with their anger and the trauma they experienced in their home countries and on their journey. They also need medical care for malnutrition, untreated illness, and physical harm. The lack of services is unconscionable. The first step to meaningful social policy is to recognize these children and their families as human beings and not demonize them as dangerous others. In addition, communities must make access to bilingual medical and mental health care for unaccompanied minors a priority.

Feature image: akinshin/iStock
                    [post_title] => The Humanitarian Crisis of Unaccompanied Minor Children from Central America
                    [post_excerpt] => Unaccompanied children undergo tremendous trauma.
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                    [post_date] => 2019-03-05 06:30:52
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                    [post_content] => The recent revelation that FamilyTreeDNA is sharing all of its customers’ genetic information with the FBI without the need for a warrant or a court order emphasizes one of our genetic privacy concerns. As the Golden State Killer investigation recently demonstrated, these concerns will be of interest not only to the customers of FamlyTreeDNA, but to their relatives as well.

Unlocking the information hidden in one’s genetic code has clear appeal. One can claim or clarify heritage, diagnose current disease, and learn about the risk of future disease. Since the first direct-to-consumer (DTC) genetic testing company opened its doors, business has expanded in terms of both the number of companies and diversity of genetic information services.

The underreported detriment of DTC genetic testing is that it can be used for unapproved information gathering and population surveillance. Just as law enforcement officers can compel compulsory genetic testing for identification, data submitted to public databases (e.g., GEDmatch, where individuals voluntarily submit genetic information with full knowledge that their information is viewable by the public) and the genetic information gathered as part of clinical or research studies may be at risk for use by law enforcement.
The underreported detriment of DTC genetic testing is that it can be used for unapproved information gathering and population surveillance.

 
What the FamilyTreeDNA revelation reinforces is that consumers lack control of the information uncovered by DTC genetic testing companies. Some of these companies are setting policies that promise a separate consent for release of information outside the company, but these policies currently lack the force of law.

There are also reasons to be concerned about genetic testing done in clinical settings. The results of genetic testing are protected similarly to other information in an individual’s medical record through the Genetic Information Non-Discrimination Act (GINA) which protects against discrimination in the health insurance market. GINA does not, however, protect individuals in long-term care insurance or life insurance markets. Given that long-term care and life insurers routinely require medical records before they offer coverage, an individual's genetic information becomes a potential source for raising rates or the denial of coverage.
Given that long-term care and life insurers routinely require medical records before they offer coverage, an individual's genetic information becomes a potential source for raising rates or the denial of coverage.

 
Genetic information gathered through research studies may be more protected than information gathered in routine clinical care. When researchers get a Certificate of Confidentiality, which ensures that investigators can never be compelled to re-identify research study participants, additional privacy protections beyond the protection typically afforded to medical records is provided. Genetic information obtained through research can, however, still be used for re-identification purposes even with the added protection of a Certificate of Confidentiality.

Since 2015, the National Institutes of Health has promoted the sharing of de-identified human genomic data and associated phenotypic data for NIH-funded studies to vetted databases through the Genomic Data Sharing Policy. Traditionally de-identified genetic datasets (from which personal identifiers have been removed as required by federal law) afford some privacy protection. However, when de-identified genetic datasets are combined with public databases such as phone book data, an individual’s genetic data can be revealed.
However, when de-identified genetic datasets are combined with public databases such as phone book data, an individual’s genetic data can be revealed.

 
Relatives of consumers, patients, and research subjects who share genetic data are also at risk. As the use of genetic databases to identify and apprehend the Golden State Killer showed, close genetic relatives can be identified through available genetic information.

An individual’s decision to undergo genetic testing can affect the lives of their genetic relatives, as well as future descendants. These effects will arise most frequently from compulsory genetic testing in law enforcement scenarios, but will also arise when an individual submits genetic samples to public databases. At present, these identifications are most likely to involve law enforcement, but the applications readily apply to other areas including long-term care insurance and life insurance.

Feature image: Scharvik/iStock
                    [post_title] => Your DNA Could Imprison Your Child
                    [post_excerpt] => Questions about confidentiality have risen as genetic testing companies may share your family information on public databases.
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                    [post_content] => Food insecurity is an important economic and policy issue, both globally and in the United States. Food insecurity reduces individual performance, limits cognitive development, and increases risk for developing nutrition-related chronic diseases such as hypertension, obesity, and type II diabetes. While food insecurity across the US is in relative decline, pockets of particularly vulnerable Americans remain very food insecure. Residents in the US South and Appalachian regions continue to struggle with food security in particular.

These persistent pockets of food insecurity are a result of larger structural issues such as unemployment, pay inequity, inter-generational poverty, and poor food environment. Additionally, many of the social safety-nets these communities must use, such as social security and disability payments, place them on a fixed income, well below the federal poverty level, making it hard to manage household expenses and food purchases.

Food environment plays a monumental role in creating and perpetuating food insecurity. Food environment includes the types of and distance to stores, restaurants, or other venues available to purchase or access food. Food environment also includes the quality of foods available. The nature of food environment dictates how affordable food is for households, especially nutritionally-dense foods such as vegetables. While food affordability is measured in many ways, this measure examines the money households spend as a percentage of household income.

Nationally, Americans spend roughly 10% of their income on food, spread evenly across food prepared at home and food eaten outside of the home. However, our recent study suggests this may not be the case. We used data from grocery store scans and estimated a percentage of household income spent on food for all 3,142 counties in the US. On average, using this model of food affordability, households spent 18% of their income on food nationally.
Average expenditures on food were nearly double the USDA-predicted 10%. And rural households spent a significantly larger portion of their income on food, compared to urban counties.

 
Average expenditures on food were nearly double the USDA-predicted 10%. And rural households spent a significantly larger portion of their income on food (18.84%), compared to urban counties (16.86%). This difference is due, in large part, to the lower incomes of rural households and higher rates of poverty. Rural communities also tend to have higher food prices due to inaccessibility and lack of competition between retailers. The remoteness of rural retailers means these stores pay higher shipping and transportation costs and have lower product turnover. Two rural regions had notably lower food affordability when compared to all other counties: the Delta and Appalachia.



This analysis shows us that rural areas suffer disproportionately from poor food environments and are much more likely to have unaffordable food. There are many ways to address this inequity. Local grocery cooperatives, community-based food projects, rural development programs that focus on building social interconnectedness, and advocacy to influence state and regional planning or policy.

Maps courtesy of the authors. 
                    [post_title] => National Food Affordability: A County-Level Analysis
                    [post_excerpt] => Food insecurity across the US is in relative decline, but pockets of particularly vulnerable Americans remain very food insecure.
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                    [post_date] => 2019-03-01 05:30:18
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                    [post_content] => A housing crisis does not only carry economic weight, but also has implications for health and wellness. Cities in the United States have been facing rapid gentrification as the increase in wages of lower and middle-income residents lags behind steep and continuously rising rents. Families who cannot keep up with rent hikes may opt for smaller spaces in their cities, or move to less expensive exurbs and suburbs. But when these families make such decisions, they may have to deal with crowded households or longer commutes to work, both of which have a direct impact on children.

Over 10 million children in the US live in crowded homes, or households in which multiple family members share bedrooms. Sometimes, common spaces like the kitchen and living room are converted into places for sleeping. Kids in these overcrowded settings may be more likely to struggle academically and socially, receiving poor grades and fighting peers. When adults’ commute times to work lengthen, parents themselves face a greater risk of hypertension and decreased sleep quality, but the commute may also cut into the time they have to spend with their children.

Researchers at the University of California Los Angeles examined how overcrowded homes and longer commute times may be associated with early child development. They hypothesized that this impact may be of greater magnitude for lower-income families, compared to those in high-income neighborhoods.
Residential crowding was also linked decreases in children’s cognitive development, as well as language and communication skills.

 
To measure child development, the researchers used a tool called the Early Development Instrument: teachers evaluate whether a child is ready, somewhat ready, or not ready to attend school, basing their decisions on the children’s physical, social, emotional, and cognitive wellbeing. The researchers gathered materials from eight states, including California, Texas, and New York, as well as Washington DC from 2010 to 2017.

The study found that children being deemed “not ready” for school was related to living in overcrowded households –defined as the number family members exceeding the number of rooms in a home—regardless of income level. Residential crowding was also linked decreases in children’s cognitive development, as well as language and communication skills. But the researchers found no link between crowded homes and children’s ability to socialize and mature emotionally. Children in low-income neighborhoods with parents who had longer commute times, however, exhibited greater social difficulties and struggled more with emotional maturity, compared to children in more affluent areas.

While the magnitude of the changes in child development related to household conditions in this study was small, the researchers emphasize the importance of the potential for home environments and family dynamics to impact health at a population level. From a policy perspective, the researchers encourage considering the health of children during decisions on urban planning and transportation.

Feature image: Thomas Hawk, Little Pink Houses, used under CC BY-NC 2.0
                    [post_title] => Crowding, Commutes, and Children
                    [post_excerpt] => Rising rents are causing families to move to small spaces or into suburbs. These crowded households and long commutes may directly impact children. 
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                    [post_content] => In January, Arkansas announced it had disenrolled more than 18,000 adults from Medicaid who had not submitted the required paperwork to prove they were working, a new requirement for continuing to receive coverage. The Trump administration has encouraged states to restrict coverage this way (a “waiver” of previous practice) under the Social Security Act. The administration has approved such waivers, imposing work requirements, in six other states and is considering applications in eight more. Two lawsuits are challenging the administration’s approval of waivers in Arkansas and Kentucky on the grounds that cutting off Medicaid is inconsistent with the program’s goal of providing access to health care for those who are eligible by law.

Tens of thousands of Arkansans enrolled in Medicaid must now go online monthly to report at least 80 work hours or equal time spent on job training, community service, or caring for a dependent child. Failure to comply for three months locks you out of Medicaid until the next year. It is unlikely that many of the 18,000 people who have already lost their Medicaid coverage will easily gain another source of insurance.
It is unlikely that many of the 18,000 people who have already lost their Medicaid coverage will easily gain another source of insurance.

 
Over the two-year period beginning in January 2014 and ending in December 2015, a Commonwealth Fund analysis of federal data shows that one-third of non-disabled adults enrolled in Medicaid nationwide at the beginning of the period had disenrolled by the end of the period. Of those, just over one-quarter left Medicaid for another coverage source, including job-based insurance or Medicare. But nearly three-quarters became uninsured and remained so until the end of the two-year period. This suggests that, because the 18,000 people who lost Medicaid in Arkansas this year did so involuntarily, most will likely experience either a temporary or extended period of time without insurance. Indeed, Arkansas reported that only 1,452 people of the 18,000 reenrolled in January.

Even short gaps in coverage can disrupt health care and economically distress poor families. The Commonwealth Fund Biennial Health Insurance Survey has found that working-age adults who experience gaps in their health insurance report not getting health care because of cost at nearly the same rate as people who are without coverage for the entire year. The two groups also report similar rates of problems paying medical bills and the accumulation of medical debt.
Income eligibility rules in Medicaid increase this dynamic—even a small change in income can make someone eligible or ineligible for benefits.

 
Insurance coverage in the United States is highly dynamic. People move in and out of employer coverage, individual coverage, Medicaid, and Medicare because of life changes as simple as a birthday, moving to a new city, getting a new job, or getting married. This phenomenon is often referred to as “churn.” Income eligibility rules in Medicaid increase this dynamic—even a small change in income can make someone eligible or ineligible for benefits. Medicaid enrollees also face significant documentation requirements at the time of enrollment and during re-enrollment. Prior research by Benjamin Sommers suggests that administrative barriers, particularly renewal, are the primary reason people become disenrolled from Medicaid.

The Affordable Care Act attempted to reduce coverage gaps by making it easier for people to move between coverage options and maintain their coverage once enrolled. Several reforms were made to Medicaid aimed at simplifying enrollment, including the elimination of in-person interviews, limiting information requested from Medicaid applicants, and electronic information verification that uses data from other federal and state agencies. But these earlier enrollment reforms are being undercut by the new enrollment barriers such as work requirements. States that establish new eligibility criteria for Medicaid will accelerate churn and leave hundreds of thousands of people without access to health care.

Feature image: zimmytws/iStock
                    [post_title] => Medicaid Work Requirements Increase Coverage Gaps
                    [post_excerpt] => Arkansas disenrolled more than 18,000 adults from Medicaid who had not proved they were working. Most will likely experience either a temporary or extended period of time without insurance.
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