National Healthcare Quality and Disparities Report
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AHRQ Research Studies
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Research Studies is a compilation of published research articles funded by AHRQ or authored by AHRQ researchers.
Results
1 to 25 of 25 Research Studies DisplayedMehta S, Lyles CR, Rubinsky AD
Social determinants of health documentation in structured and unstructured clinical data of patients with diabetes: comparative analysis.
It is not clear how accurately Electronic health records (HER) data reflect patients' lived experience of social determinants of health (SDOH). The process of manually reviewing clinical notes to retrieve SDOH information is not feasible. The purpose of this study was to apply two tools, PatientExploreR and Electronic Medical Record Search Engine (EMERSE), to identify SDOH mappings for structured and unstructured patient data. The researchers included 4,283 adult patients receiving primary care for diabetes at UCSF. The study results revealed that SDOH may be more significant in the lives of patients with diabetes than is evident from structured data recorded on EHRs. When researchers applied EMERSE NLP rules, additional information was uncovered from patient clinical notes on problems related to social connections isolation, employment, financial insecurity, housing insecurity, food insecurity, education, and stress.
AHRQ-funded; HS026383.
Citation: Mehta S, Lyles CR, Rubinsky AD .
Social determinants of health documentation in structured and unstructured clinical data of patients with diabetes: comparative analysis.
JMIR Med Inform 2023 Aug 22; 11:e46159. doi: 10.2196/46159..
Keywords: Social Determinants of Health, Diabetes, Chronic Conditions, Electronic Health Records (EHRs), Health Information Technology (HIT)
Jackson P, Goodin BR, Long DL
The area deprivation index corresponds effectively with other measures of objective socioeconomic status in adults with chronic low back pain.
The purpose of this study was to compare the Area Deprivation Index (ADI) and other measures of socioeconomic status (SES), including income, education, and subjective social status (SSS), in their ability to predict pain severity/ interference in patients with chronic low back pain. The study found that pain severity/ interference correlated negatively with income and education and correlated positively with ADI. Criterion scores of the pain severity model indicate income performs best followed by ADI, with similar results with the pain interference model. The study concluded that when attempting to understand the impact of SES on chronic low back pain, neighborhood-level and individual-level factors should be considered.
AHRQ-funded; HS013852.
Citation: Jackson P, Goodin BR, Long DL .
The area deprivation index corresponds effectively with other measures of objective socioeconomic status in adults with chronic low back pain.
J Nurs Meas 2022 Sep 1;30(3):433-48. doi: 10.1891/jnm-d-20-00126..
Keywords: Back Health and Pain, Pain, Chronic Conditions, Social Determinants of Health
Kim B, Mulready-Ward C, Thorpe LE
Housing environments and asthma outcomes within population-based samples of adults and children in NYC.
This study assessed the relationship between housing type (i.e., home ownership, public housing, rental assistance, rent-controlled housing, and other rental housing) and asthma outcomes among New York City (NYC) adults and children (ages 1-13). The authors used the 2019 NYC Community Health Survey (CHS) and 2019 NYC KIDS survey to analyze associations between housing type and ever having been diagnosed with asthma (“ever asthma”) and experiencing an asthma attack within the past year. They also examined whether associations were modified by smoking status (among adults), smoking within the house (among children), and overweight/obesity. Among adults, living in public housing, compared to home ownership, was associated with higher odds of ever asthma and past-year asthma attack. Rental assistance housing living was also significantly associated with ever asthma. Public or rental assistance housing associations and ever asthma were marginally significant among children but were more pronounced among ever smokers than among never smokers.
AHRQ-funded; HS026120.
Citation: Kim B, Mulready-Ward C, Thorpe LE .
Housing environments and asthma outcomes within population-based samples of adults and children in NYC.
Prev Med 2022 Aug;161:107147. doi: 10.1016/j.ypmed.2022.107147..
Keywords: Children/Adolescents, Asthma, Respiratory Conditions, Social Determinants of Health, Vulnerable Populations, Urban Health, Chronic Conditions
McQueen A, Kreuter MW, Herrick CJ
Associations among social needs, health and healthcare utilization, and desire for navigation services among US Medicaid beneficiaries with type 2 diabetes.
The purpose of this study was to determine the number and types of social needs experienced by Medicaid beneficiaries with type 2 diabetes and how these social needs are associated with key health indicators. Findings showed that having more social needs was associated with a wide range of indicators of poor health and well-being. Study participants with the greatest social need burden were most open to intervention.
AHRQ-funded; HS019455.
Citation: McQueen A, Kreuter MW, Herrick CJ .
Associations among social needs, health and healthcare utilization, and desire for navigation services among US Medicaid beneficiaries with type 2 diabetes.
Health Soc Care Community 2022 May;30(3):1035-44. doi: 10.1111/hsc.13296..
Keywords: Diabetes, Chronic Conditions, Medicaid, Social Determinants of Health
Heller CG, Rehm CD, Parsons AH
The association between social needs and chronic conditions in a large, urban primary care population.
This study sought to understand the association between social needs and chronic health conditions using a screening tool and clinical data from Electronic Health Records. From April 2018 to December 2019, 33,550 adult patients completed a 10-item social needs screening tool during primary visits in Bronx and Westchester Counties, NY. A positive, cumulative association between social needs and each of the eight outcomes asked about was found. The relationship was strongest for elevated PHQ-2 (depression screening), alcohol/drug use disorder, and smoking. Those with 3 or greater social needs were 3.9 times more likely to have an elevated PHQ-2 than those without needs. Healthcare transportation challenges was associated with each condition and was the most strongly associated need with half of conditions in the fully-adjusted models. Examples included those with an alcohol/drug use disorder (84% more likely), and smokers (41% more likely).
AHRQ-funded; HS026396.
Citation: Heller CG, Rehm CD, Parsons AH .
The association between social needs and chronic conditions in a large, urban primary care population.
Prev Med 2021 Dec;153:106752. doi: 10.1016/j.ypmed.2021.106752..
Keywords: Chronic Conditions, Urban Health, Primary Care, Low-Income, Social Determinants of Health, Screening
Izadi Z, Li J, Evans M
Socioeconomic disparities in functional status in a national sample of patients with rheumatoid arthritis.
This longitudinal study looked at the association of socioeconomic disparities and functional status in a national sample of patients with rheumatoid arthritis (RA). This study used a cohort from the American College of Rheumatology’s Rheumatology Informatics System for Effectiveness (RISE) registry from 2016 to 2018. Analyses included all adult patients with a confirmed RA diagnosis and at least 1 functional status (FS) score documented. The Area Deprivation Index (ADI), a zip code-based indicator of poverty, was used as a proxy for socioeconomic status (SES). The cohort included 83,965 patients, of which 77% were women and 72% were non-Hispanic White. Mean age was 63.4 years. The probability of functional decline was 14.1% in the highest SES quintile and 18.9% in the lowest SES quintile. By all measures FS score was worse at lower SES levels.
AHRQ-funded; HS025638; HS024412.
Citation: Izadi Z, Li J, Evans M .
Socioeconomic disparities in functional status in a national sample of patients with rheumatoid arthritis.
JAMA Netw Open 2021 Aug 2;4(8):e2119400. doi: 10.1001/jamanetworkopen.2021.19400..
Keywords: Arthritis, Chronic Conditions, Disparities, Social Determinants of Health, Quality of Life
Nguyen KH, Fields JD JD, Cemballi AG
The role of community-based organizations in improving chronic care for safety-net populations.
Researchers conducted a multi-stakeholder qualitative study to capture the multi-level influences on health for those living in socio-economically deprived contexts. Participants were patients with chronic illnesses in San Francisco neighborhoods with high chronic disease rates, community leaders serving the same neighborhoods, or providers from San Francisco's public health care delivery system. The researchers identified several key themes. They concluded that their results contributed new evidence toward the community domain of the Chronic Care Model, and health care systems must intentionally partner with community-based organizations to address social determinants of health and improve community resources for chronic care management.
AHRQ-funded; HS026383.
Citation: Nguyen KH, Fields JD JD, Cemballi AG .
The role of community-based organizations in improving chronic care for safety-net populations.
J Am Board Fam Med 2021 Jul-Aug;34(4):698-708. doi: 10.3122/jabfm.2021.04.200591..
Keywords: Community Partnerships, Chronic Conditions, Social Determinants of Health, Care Management
Kim D, Lee Y, Thorsness R
Racial and ethnic disparities in excess deaths among persons with kidney failure during the COVID-19 pandemic, March-July 2020.
This national study estimated excess deaths for the kidney failure population by race and ethnicity from March 1 through August 1, 2020. Findings showed that, among the US kidney failure population, the number of excess deaths was 16% higher than expected, similar to reports for the general population. However, results showed that the relative increase in deaths among Black and Hispanic patients was more than 4-fold higher than that observed among White patients. The magnitude of these disparities was larger than corresponding relative ratios reported among COVID-19–associated deaths in the general population.
AHRQ-funded; HS028285.
Citation: Kim D, Lee Y, Thorsness R .
Racial and ethnic disparities in excess deaths among persons with kidney failure during the COVID-19 pandemic, March-July 2020.
Am J Kidney Dis 2021 May;77(5):827-29. doi: 10.1053/j.ajkd.2021.02.003..
Keywords: COVID-19, Racial and Ethnic Minorities, Disparities, Mortality, Kidney Disease and Health, Chronic Conditions, Social Determinants of Health
Loo S, Brochier A, Wexler MG
Addressing unmet basic needs for children with sickle cell disease in the United States: clinic and staff perspectives.
The purpose of this study was to assess pediatric hematology clinic staff's perspectives regarding barriers and facilitators in addressing unmet basic needs for children with sickle cell disease. Six focus groups were held at urban pediatric hematology clinics in the Northeastern region of the U.S. Four themes emerged: families of children with SCD have numerous unmet basic needs; clinic staff felt they had a role to play in addressing these needs; staff felt their ability to address these needs depended upon caregivers' capacity to act on staff recommendations; clinic staff's ability to address these needs was limited by organizational and systemic factors beyond their control. These findings have important implications for how best to address adverse social determinants of health for this vulnerable pediatric population so that urban-based pediatric hematology clinics can more equitably support families.
AHRQ-funded; HS022242.
Citation: Loo S, Brochier A, Wexler MG .
Addressing unmet basic needs for children with sickle cell disease in the United States: clinic and staff perspectives.
BMC Health Serv Res 2021 Jan 12;21(1):55. doi: 10.1186/s12913-020-06055-y..
Keywords: Children/Adolescents, Sickle Cell Disease, Chronic Conditions, Social Determinants of Health, Provider: Clinician, Provider: Physician, Provider, Urban Health
Chambers EC, McAuliff KE, Heller CG
Toward understanding social needs among primary care patients with uncontrolled diabetes.
This study examined the relationship between unmet social needs and diabetes among a predominantly Black and Hispanic patient population in a large urban hospital system in Bronx, New York. A total of 5846 patients with diabetes seen at a primary care visit between April 2018 and December 2019 were included and completed a social needs screener. Twenty-two percent of the patient sample had at least 1 unmet social need, with the most prevalent unmet needs being housing issues, food insecurity, and lack of healthcare transportation. Patients with more unmet needs had a greater likelihood of uncontrolled diabetes, with lack of healthcare transportation and food insecurity having the greatest likelihood.
AHRQ-funded; HS026396.
Citation: Chambers EC, McAuliff KE, Heller CG .
Toward understanding social needs among primary care patients with uncontrolled diabetes.
J Prim Care Community Health 2021 Jan-Dec;12:2150132720985044. doi: 10.1177/2150132720985044..
Keywords: Diabetes, Chronic Conditions, Primary Care, Vulnerable Populations, Social Determinants of Health
Vasan A, Morgan JW, Mitra N
Effects of a standardized community health worker intervention on hospitalization among disadvantaged patients with multiple chronic conditions: a pooled analysis of three clinical trials.
The purpose of this study was to analyze the effects of a standardized community health worker (CHW) intervention on hospitalization. The investigators concluded that data from three randomized clinical trials across multiple settings showed that a standardized CHW intervention reduced total hospital days and hospitalizations outside the primary health system. They indicated that this study was the largest analysis of randomized trials to demonstrate reductions in hospitalization with a health system-based social intervention.
AHRQ-funded.
Citation: Vasan A, Morgan JW, Mitra N .
Effects of a standardized community health worker intervention on hospitalization among disadvantaged patients with multiple chronic conditions: a pooled analysis of three clinical trials.
Health Serv Res 2020 Oct;55(Suppl 2):894-901. doi: 10.1111/1475-6773.13321..
Keywords: Hospitalization, Chronic Conditions, Vulnerable Populations, Social Determinants of Health, Community-Based Practice
Goto T, Yoshida K, Faridi MK
Contribution of social factors to readmissions within 30 days after hospitalization for COPD exacerbation.
This study examined whether adding social factors improved the predictive ability for 30-day hospital readmissions for COPD. Social factors include educational level and marital status. Out of 905 hospitalizations identified in the Medicare Current Beneficiary Survey from 2006 through 2012, 18.5% were readmitted within 30 days. The optimized model including social factors for prediction improved for early readmissions but not for late readmissions.
AHRQ-funded; HS023305.
Citation: Goto T, Yoshida K, Faridi MK .
Contribution of social factors to readmissions within 30 days after hospitalization for COPD exacerbation.
BMC Pulm Med 2020 Apr 29;20(1):107. doi: 10.1186/s12890-020-1136-8..
Keywords: Respiratory Conditions, Hospital Readmissions, Hospitalization, Social Determinants of Health, Chronic Conditions
Phillips AZ, Rodriguez HP
Adults with diabetes residing in "food swamps" have higher hospitalization rates.
This study examined the relationship between ‘food swamps’ and hospitalization rates among adults with diabetes. Food Swamps are defined and measured by a ratio of fast food outlets to grocery stores within a given area. Data resources for this study included the Blue Cross Blue Shield Association Community Health Management Hub(R), AHRQ’s Health Care Cost and Utilization Project State Inpatient Databases, and HHS’s Area Health Resources File. The study concludes that higher hospitalization rates among adults with diabetes are significantly associated with food swamps, more so in rural than urban communities, and that improvements to local food environments may help to reduce this disparity.
AHRQ-funded; HS022241.
Citation: Phillips AZ, Rodriguez HP .
Adults with diabetes residing in "food swamps" have higher hospitalization rates.
Health Serv Res 2019 Feb;54(Suppl 1):217-25. doi: 10.1111/1475-6773.13102..
Keywords: Chronic Conditions, Diabetes, Disparities, Nutrition, Healthcare Cost and Utilization Project (HCUP), Hospitalization, Social Determinants of Health
Tung EL, Johnson TA, O'Neal Y
Experiences of community violence among adults with chronic conditions: qualitative findings from Chicago.
The purpose of this study was to explore and characterize, using a qualitative study design, self-described experiences of community violence among adults with chronic health conditions. Investigators found that patients often struggled to balance the challenges imposed by community violence with the demands of living with and managing their chronic conditions.
AHRQ-funded; HS023007.
Citation: Tung EL, Johnson TA, O'Neal Y .
Experiences of community violence among adults with chronic conditions: qualitative findings from Chicago.
J Gen Intern Med 2018 Nov;33(11):1913-20. doi: 10.1007/s11606-018-4607-3..
Keywords: Chronic Conditions, Disparities, Social Determinants of Health
Cardet JC, Louisias M, King TS
Income is an independent risk factor for worse asthma outcomes.
The authors investigated whether low income, low education, and high perceived stress were independent risk factors for treatment failure and asthma exacerbations in the context of a randomized controlled trial. They found that participants with lower income were more likely to experience adverse asthma outcomes independent of education, perceived stress, race, and medication adherence.
AHRQ-funded; HS022986.
Citation: Cardet JC, Louisias M, King TS .
Income is an independent risk factor for worse asthma outcomes.
J Allergy Clin Immunol 2018 Feb;141(2):754-60.e3. doi: 10.1016/j.jaci.2017.04.036..
Keywords: Asthma, Chronic Conditions, Low-Income, Outcomes, Patient-Centered Outcomes Research, Risk, Social Determinants of Health
Hewner S, Casucci S, Sullivan S
Integrating social determinants of health into primary care clinical and informational workflow during care transitions.
Care continuity during transitions between the hospital and home requires reliable communication between providers and settings and an understanding of social determinants that influence recovery. This paper describes the coordinating transitions intervention which uses real time alerts, delivered directly to the primary care practice for complex chronically ill patients discharged from an acute care setting, to facilitate nurse care coordinator led telephone outreach.
AHRQ-funded; HS022575.
Citation: Hewner S, Casucci S, Sullivan S .
Integrating social determinants of health into primary care clinical and informational workflow during care transitions.
eGEMS 2017 Jul 4;5(2):2. doi: 10.13063/2327-9214.1282..
Keywords: Care Coordination, Chronic Conditions, Patient-Centered Healthcare, Social Determinants of Health, Transitions of Care
Jackson BE, Oates GR, Singh KP
Disparities in chronic medical conditions in the Mid-South.
This study examined differences in socio-demographic characteristics and health behaviors relevant to chronic medical conditions (CMCs) in the Mid-South region (Alabama, Mississippi, Louisiana, Kentucky, Tennessee, and Arkansas), and identified subpopulations with increased burden of chronic disease. It concluded that in the Mid-South, race and gender disparities in the top five chronic conditions are more prominent among higher-income rather than lower-income individuals.
AHRQ-funded; HS023009.
Citation: Jackson BE, Oates GR, Singh KP .
Disparities in chronic medical conditions in the Mid-South.
Ethn Health 2017 Apr;22(2):196-208. doi: 10.1080/13557858.2016.1232805.
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Keywords: Chronic Conditions, Disparities, Health Status, Racial and Ethnic Minorities, Social Determinants of Health
Oates GR, Jackson BE, Partridge EE
Sociodemographic patterns of chronic disease: how the mid-south region compares to the rest of the country.
This descriptive study examines sociodemographic differences in the distribution of chronic diseases and health-related behaviors in the Mid-South versus the rest of the U.S., identifying subgroups at increased risk of chronic disease. It finds that the Mid-South population had increased rates of chronic disease and worse health-related behaviors than the rest of the U.S. Mid-South blacks had the highest percentages of obesity, diabetes, high blood pressure, and stroke of all subgroups.
AHRQ-funded; HS023009.
Citation: Oates GR, Jackson BE, Partridge EE .
Sociodemographic patterns of chronic disease: how the mid-south region compares to the rest of the country.
Am J Prev Med 2017 Jan;52(1s1):S31-s39. doi: 10.1016/j.amepre.2016.09.004.
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Keywords: Chronic Conditions, Health Status, Lifestyle Changes, Social Determinants of Health
Cockerham WC, Hamby BW, Oates GR
The social determinants of chronic disease.
This review article addresses the concept of the social determinants of health (SDH), selected theories, and its application in studies of chronic disease. The health effects of SDH are initially discussed with respect to smoking and the social gradient in mortality. The article concludes with an examination of neighborhood disadvantage, social networks, and perceived discrimination in SDH research.
AHRQ-funded; HS023009.
Citation: Cockerham WC, Hamby BW, Oates GR .
The social determinants of chronic disease.
Am J Prev Med 2017 Jan;52(1s1):S5-s12. doi: 10.1016/j.amepre.2016.09.010.
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Keywords: Chronic Conditions, Health Status, Lifestyle Changes, Social Determinants of Health
Sohn MW, Kang H, Park JS
Disparities in recommended preventive care usage among persons living with diabetes in the Appalachian region.
This study examined disparities in the receipt of preventive care recommended by the American Diabetes Association (ADA) between Appalachian and non-Appalachian counties and within Appalachian counties. It concluded that there are significant disparities in the uptake of many recommended preventive services between less and more affluent counties in the Appalachian region.
AHRQ-funded; HS018542.
Citation: Sohn MW, Kang H, Park JS .
Disparities in recommended preventive care usage among persons living with diabetes in the Appalachian region.
BMJ Open Diabetes Res Care 2016 Dec;4(1):e000284. doi: 10.1136/bmjdrc-2016-000284.
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Keywords: Diabetes, Disparities, Prevention, Chronic Conditions, Social Determinants of Health
Whittle HJ, Palar K, Hufstedler LL
Food insecurity, chronic illness, and gentrification in the San Francisco Bay Area: an example of structural violence in United States public policy.
This study sought to explore the experiences and structural determinants of food insecurity among a group of low-income PLHIV in the San Francisco Bay Area. It found that the lived experience of food insecurity among participants included periods of insufficient quantity of food and resultant hunger, as well as long-term struggles with quality of food that led to concerns about the poor health effects of a cheap diet.
AHRQ-funded; HS000046.
Citation: Whittle HJ, Palar K, Hufstedler LL .
Food insecurity, chronic illness, and gentrification in the San Francisco Bay Area: an example of structural violence in United States public policy.
Soc Sci Med 2015 Oct;143:154-61. doi: 10.1016/j.socscimed.2015.08.027..
Keywords: Chronic Conditions, Policy, Social Determinants of Health, Nutrition, Vulnerable Populations
Buys DR, Howard VJ, McClure LA
Association between neighborhood disadvantage and hypertension prevalence, awareness, treatment, and control in older adults: results from the University of Alabama at Birmingham Study of Aging.
The investigators evaluated the effect of neighborhood disadvantage (ND) on older adults' prevalence, awareness, treatment, and control of hypertension. Using data from the University of Alabama at Birmingham Study of Aging along with US Census data, they created tertiles of ND and found that living in mid-ND and high-ND tertiles was associated with higher hypertension prevalence, and living in high-ND tertiles was further associated with lower odds of controlled hypertension.
AHRQ-funded; HS019465; HS013852.
Citation: Buys DR, Howard VJ, McClure LA .
Association between neighborhood disadvantage and hypertension prevalence, awareness, treatment, and control in older adults: results from the University of Alabama at Birmingham Study of Aging.
Am J Public Health 2015 Jun;105(6):1181-8. doi: 10.2105/ajph.2014.302048.
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Keywords: Elderly, Blood Pressure, Low-Income, Social Determinants of Health, Cardiovascular Conditions, Chronic Conditions
Witt WP, Park H, Wisk LE
Neighborhood disadvantage, preconception stressful life events, and infant birth weight.
This study investigated the impact of neighborhood conditions on the association between stressful life events prior to pregnancy and birth weight in a national sample of women living in the United States. It found that women who experienced preconception stressful life events, who had chronic conditions, or were racial/ethnic minorities had the greatest risk of having very low birth weight infants if they lived in disadvantaged neighborhoods.
AHRQ-funded; HS000083; HS000063
Citation: Witt WP, Park H, Wisk LE .
Neighborhood disadvantage, preconception stressful life events, and infant birth weight.
Am J Public Health 2015 May;105(5):1044-52. doi: 10.2105/ajph.2015.302566.
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Keywords: Pregnancy, Social Determinants of Health, Chronic Conditions
Thorpe RJ, Jr., Bell CN, Kennedy-Hendricks A
Disentangling race and social context in understanding disparities in chronic conditions among men.
This study compared survey data collected in 2003 from black and white men with similar incomes living in a racially integrated neighborhood of Baltimore to data from the 2003 National Health Interview Survey. The researchers found no race disparities in chronic conditions among low-income, urban men living in the same social environment, and they recommended that policies and interventions aiming to reduce disparities in chronic conditions focus on modifying social aspects of the environment.
AHRQ-funded; HS000029.
Citation: Thorpe RJ, Jr., Bell CN, Kennedy-Hendricks A .
Disentangling race and social context in understanding disparities in chronic conditions among men.
J Urban Health 2015 Feb;92(1):83-92. doi: 10.1007/s11524-014-9900-9.
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Keywords: Chronic Conditions, Disparities, Health Status, Racial and Ethnic Minorities, Social Determinants of Health
Chambers C, Chiu S, Scott AN
Factors associated with poor mental health status among homeless women with and without dependent children.
The researchers estimated the prevalence of mental health problems among homeless women as well as the effects of risk factors on those problems. They found that, in a group of 522 homeless women in Toronto, Canada, poor mental health was associated with low perceived access to social support, physical/sexual assault in the past 12 months, presence of a chronic health condition, and presence of a drug use problem.
AHRQ-funded; HS014129
Citation: Chambers C, Chiu S, Scott AN .
Factors associated with poor mental health status among homeless women with and without dependent children.
Community Ment Health J. 2014 Jul;50(5):553-9. doi: 10.1007/s10597-013-9605-7..
Keywords: Behavioral Health, Chronic Conditions, Social Determinants of Health, Risk