In addition, most cities cited incomplete sidewalks and missing or unmarked crosswalks within their industrial areas that need repair. However, while biking and walking to work may sound attractive, cities must thoroughly examine whether or not active commutes are suited for their industrial districts and employees. Bicyclists and pedestrians may face a series of challenges in doing so, and the supporting infrastructure may also pose challenges for the industry’s goods movement system. For instance, many industrial shifts occur during off-hours; biking to or from the night shift may not be an attractive or safe option. Also, bicyclists and pedestrians may simply feel unsafe traveling in an aesthetically unpleasant environment and in close proximity with trucks. From the goods movement perspective, bicyclists and pedestrian infrastructure may stifle their operations. For instance, the West Oakland specific plan includes bulb outs and bicycle boulevards on truck routes. Going forward, decisions about bicycle infrastructure placement must be intentional and clear about who they are intended to benefit. The PPA program provides an opportunity to address last-mile access for workers traveling to industrial businesses that operate within the regional economy. The following recommendations, which were developed based on conversations with city staff, could inform a transportation component of the PPA program. Require comprehensive, multi-modal planning that would acknowledge the trade offs between different types of last-mile options. In some places,cannabis growing supplies shuttle services may be a better option than active transportation, and vice versa. A comprehensive plan would require cities to prioritize between modes. Set guidelines based on lessons learned from case studies. These guidelines could encourage institutional arrangements for last-mile shuttles that would provide targeted services that meet the needs of industrial businesses and employees. The regional framework of the PPA program would allow for a more holistic set of guidelines that cities on their own would not necessarily recognize. Provide funding for at least some aspect of last-mile access improvements.
Although the specific opportunities available for funding are not yet clear, funding opportunities such as planning and technical assistance grants, similar to those provided through Plan Bay Area’s Priority Development Area , could be linked to the PPA program. In addition, given ABAGMTC’s role as a transportation planning and financing agency, some of the agency’s federally allocated transportation funds could be directed towards transportation connections that facilitate improved access for workers commuting to industrial employment centers. Going forward, the PPA program should consider last-mile solutions in the context of a comprehensive transportation plan that examines the needs for both people and goods, as well in the context of the PPA’s broader goals. Shuttle services and bicycle and pedestrian improvements are just a few approaches to last-mile connectivity; other solutions should be considered. Furthermore, a focus on last-mile connections alone will not address the needs of those who do not live near transit. Also, the last-mile approach also may not be suitable for more suburban areas that lack robust regional transit options. In addition, all jurisdictions reported that workers travel to jobs in their jurisdiction from faraway places since they cannot afford to live nearby. This challenge brings up the inter connectedness of the high cost of living and workforce challenges across the Bay Area. Given the broader economic development goals of the PPA program, the policy could attempt to address this challenge by aligning with a jobs to housing goal for communities with a large share of affordable suburban housing, but whose workforce commutes long distances to find middle-wage jobs. Overall, the PPA program could support the planning for and provision of improved last-mile access as one element of a transportation component that should acknowledge broader accessibility and policy goals.People living with HIV experience high rates of mental illness, including elevated rates of depression and anxiety . In the United States , poverty and social deprivation are concentrated among PLHIV , and may contribute to poor mental health. An important challenge that low-income PLHIV in the USA frequently face is food insecurity , which includes food insufficiency and hunger, poor quality diets, persistent uncertainty around access to food and having to engage in personally or socially unacceptable food procurement .
Food insecurity has been associated with a range of poor mental health outcomes including depression , anxiety , symptoms of post-traumatic stress disorder , substance use and suicidality. While people who experience mental illness likely face more barriers to accessing healthy food, evidence from longitudinal and qualitative studies indicates that food insecurity contributes to symptoms of common mental illness . Provision of food support to food-insecure individuals in a manner consistent with the preservation of dignity has been shown to reduce symptoms of depression . These findings raise questions about how symptoms of common mental illness occurring in the setting of adverse social and structural factors should be addressed. Mental illness and its treatment are often formulated according to a ‘bio-psychosocial’ model in which multidimensional influences on mental health are addressed concurrently through psychotropic medications, psychological interventions and services aimed at improving social circumstances. Yet, in practice, psychotropic medications often predominate. In the USA, data have shown significant upward trends over the past two decades for the use of psychotropic medications alone, compared to significant downward trends for the use of psychotherapy and psychotropic medications together or psychotherapy alone . One in six US adults is now prescribed a psychotropic medication, rising to one in five among non-Hispanic White adults and one in four among adults aged 60–85 years . Pharmaceutical drugs are prominent for several reasons. Psychotropic medications have the most extensive evidence base among mental health interventions, as their effects can be measured through randomised controlled trials more easily than other forms of intervention. In meta-analyses of trials, common classes of psychotropic medications including antidepressants and antipsychotics show modest but significant therapeutic effects for their respective indications . Prescribing drugs is also less labour-intensive than psychological or social interventions, and often more accessible and time-efficient for service users. In the USA specifically, the market-based structure of the healthcare system may contribute to higher rates of psychotropic medications, which have the financial and promotional backing of for-profit pharmaceutical companies . Conversely, reimbursement rates for non-pharmacological treatments by Medicare have been falling steadily for many years, driving psychologists and other allied professionals away from low-income service users .
Furthermore, psychotropic medications adhere to a medical model of intervention that accords with the clinical education of prescribers. The paucity of social science training in clinical curricula leaves clinicians lacking the intellectual tools and frameworks to fully understand how social-structural issues may drive distress . Consequently,cannabis indoor growing social interventions may be placed at lower priority than pharmaceutical drugs by default, principally through unfamiliarity and misunderstanding on the part of clinicians. The vulnerability of public funding for social support to changes in fiscal policies and political ideologies may also contribute to the primacy of pharmacologic interventions. In the USA, public spending on social safety net institutions has undergone a sustained reduction since the 1980s . The welfare reforms of 1996 had a particularly detrimental effect on the provision of social support, significantly curtailing access to government income for non-disabled adults, with the most severe restrictions targeting those without dependent children . Notably, this development has left federal disability income as one of the last forms of substantial government assistance available to many indigent adults in the USA . Recent studies have suggested that this shift may be fuelling a ‘medicalisation of poverty’, as diagnoses of chronic illness – and particularly mental illness – play an increasingly important economic role for struggling adults to obtain income security through disability status . In this respect, diagnoses of mental illness, accompanied by treatment with psychotropic medications, can act as an important gateway to a level of income stability otherwise unobtainable for many in the current US context of widespread working poverty under welfare reform . Identifying these social and economic realities does not imply that disabled individuals are malingering, or that clinicians are prescribing for non-clinical reasons, but suggests instead that we consider the impact, at a population level, of structural factors that incentivise the prescription of psychotropic drugs for socially deprived individuals. These arguments raise the question of whether social adversity might drive higher rates of psychotropic prescriptions, independent of psychiatric symptoms. Few empirical studies have attempted to investigate this possibility. We used data from the Women’s Interagency HIV Study , an ongoing prospective cohort study at nine sites across the USA, to investigate the associations between food insecurity and psychotropic medication use among a broadly representative population of women living with HIV in the USA. Our previous studies in the WIHS cohort have demonstrated dose–response relationships between food insecurity and poor mental health outcomes, including depression , anxiety, stress, symptoms of post-traumatic stress disorder , substance use and mental health-related quality of life . Here we used a cross sectional sub-sample of the WIHS cohort for which data on psychotropic medication use were available to test two successive hypotheses: food insecurity would be associated with psychotropic medication use in a dose–response relationship among women living with HIV, mirroring the dose–response relationships between food insecurity and symptoms of common mental illness found in previous studies; and if we additionally adjusted for symptoms of common mental illness, any positive associations between food insecurity and psychotropic medication use would remain significant.Our study was a cross-sectional analysis of data from the WIHS, a prospective cohort study of HIV-seropositive women and demographically similar HIV-seronegative women in the USA. Cohort recruitment, demographics and retention are described elsewhere .
WIHS participants undergo structured interviews and physical examinations every 6 months at nine sites across the USA and have blood and other biological samples taken. The WIHS began with baseline recruitment in 1994 and has undergone three recruitment waves since. Beginning in 2009, a standardised and detailed neurocognitive assessment was added to the WIHS Core exams and administered every 2 years. From April 2013 through March 2016, the Food Insecurity Sub-study collected data every 6 months on food security, nutrition and other key socio-economic variables from all WIHS participants. For the current analysis, women living with HIV who participated in the Food Insecurity Sub-study from April 2013 through March 2015 and also had neurocognitive and psychiatric variables during the same time period were included . Data collection for psychotropic medication use was staggered across four WIHS visits during this period, at five study sites: San Francisco, CA; Chicago, IL; Washington, DC; Bronx, NY and Brooklyn, NY.Food security was the primary explanatory variable, measured using the Household Food Security Survey Module . The HFSSM is an 18-item survey designed to capture the experience of anxiety around household food supplies, inadequate quality of food and/or reduced food intake. Originally developed from in-depth qualitative and survey data among women in the USA , it has since been validated in multiple diverse contexts . Respondents are classified as having high, marginal, low or very low FS. Very low FS corresponds to reduced food intake and hunger, while marginal FS implies persistent anxiety and uncertainty around food. The internal consistency of the HFSSM in this sample was high .The primary outcomes were four categories of prescribed psychotropic medication use . WIHS participants are asked to bring a list of medications to each visit and are also asked specifically whether they are using any medications ‘for psychological conditions or depression’ and for the name of the medication. Self-reported psychotropic medications were coded as antidepressants , sedatives/hypnotics/tranquilisers/anxiolytics or antipsychotics as appropriate. Using these data, we constructed a pooled outcome for any psychotropic medication use and made three separate binary outcomes corresponding to each individual drug class. Other outcomes included symptoms of depression, generalised anxiety disorder and mental health-related quality of life. Symptoms of depression were measured using the Center for Epidemiologic Studies Depression score, a widely used self-report instrument that asks participants how often they experience symptoms of depression including low mood, low self esteem, poor concentration, sleeping difficulties, poor appetite and others . Scores range from 0 to 60, with higher scores indicating greater depressive symptoms.The internal consistency of the CESD in our sample was high.We measured symptoms of generalised anxiety disorder using the Generalised Anxiety Disorder-7 scale, a 7-item self-report instrument used to screen for and categorise the severity of GAD in primary care .