Culturally tailored interventions for ethnic minorities: A scoping review

AIM

This scoping review identifies strengths and weakness of culturally tailored interventions for ethnic minorities' care in the United States. It reviews recently published studies to improve understanding of these interventions for future research and practice.

DESIGN

Scoping review.

METHODS

By searching five electronic databases-CINAHL, PubMed, Ovid, Scopus and Web of Science, this review located 58 empirical studies published between 2015-2019. This review was guided by the PRISMA statements.

RESULTS

The review identified four weaknesses and five strengths of culturally tailored interventions. Weaknesses included unclear guidelines, low attention and retention rates, failure to measure processes and inadequate training for healthcare providers. The intervention strengths were culturally respectful and patient-centred care, healthy lifestyle promotion, increased family and community supports, technology use for efficient and timely care and increased knowledge of disease by participants.

Racial Disparities and Upward Trend in Bowel Preparation for Elective Colectomy in the National Surgical Quality Improvement Program Procedure Targeted Dataset: 2012 to 2018

Objective

The primary objective of this study was to assess trends in bowel preparation among patients who had elective colectomy between 2012 and 2018. The secondary objective was to assess patient and procedure-related factors predictive of bowel preparation use or lack thereof.

Background

Numerous studies have demonstrated that bowel preparation before elective colorectal surgery can reduce the risk of postoperative complications. Studies of surgeon practices found 75% to 98% prescribe bowel preparation to their patients, although biases in the study design may lead to overestimation of bowel preparation practice.

Methods

Cross-sectional study of the National Surgical Quality Improvement Program colectomy procedure targeted dataset. We included patients from 18 to 90 years old who underwent elective colectomy (n = 101,096). The primary outcomes were bowel preparation before elective colectomy, including oral antibiotic only, mechanical only, both oral and mechanical, or none.

Results

Twenty percent of patients did not do any bowel preparation before elective colectomy. Almost all covariates were independently associated with any bowel preparation, although some were not clinically relevant. The odds that Black/African American or Hispanic patients had any bowel preparation were lower than that of White patients. Additionally, the odds minimally invasive colectomy patients completed any bowel preparation was 1.46 times that of open surgery patients.

Conclusions

This study is the first of its kind to assess trends in bowel preparation using an objective dataset. Our study highlights disparities in bowel preparation. Further studies should focus on delineating the root cause of this disparity, identifying the barriers, and finding solutions.

Association between housing type and accelerated biological aging in different sexes: moderating effects of health behaviors

Introduction: Despite associated with multiple geriatric disorders, whether housing type, an indicator of socioeconomic status (SES) and environmental factors, is associated with accelerated biological aging is unknown. Furthermore, although individuals with low-SES have higher body mass index (BMI) and are more likely to smoke, whether BMI and smoking status moderate the association between SES and biological aging is unclear. We examined these questions in urbanized low-SES older community-dwelling adults.

Methods: First, we analyzed complete blood count data using the cox proportional hazards model and derived measures for biological age (BA) and biological age acceleration (BAA, the higher the more accelerated aging) (N = 376). Subsequently, BAA was regressed on housing type, controlling for covariates, including four other SES indicators. Interaction terms between housing type and BMI/smoking status were separately added to examine their moderating effects. Total sample and sex-stratified analyses were performed.

Results: There were significant differences between men and women in housing type and BAA. Compared to residents in ≥3 room public or private housing, older adults resided in 1–2 room public housing had a higher BAA. Furthermore, BMI attenuated the association between housing type and BAA. In sex-stratified analyses, the main and interaction effects were only significant in women. In men, smoking status instead aggravated the association between housing type and BAA.

Conclusion: Controlling for other SES indicators, housing type is an independent socio-environmental determinant of BA and BAA in a low-SES urbanized population. There were also sex differences in the moderating effects of health behaviors on biological aging.

COVID-19 Deaths in the United States: Shifts in Hot Spots over the Three Phases of the Pandemic and the Spatiotemporally Varying Impact of Pandemic Vulnerability

The geographic areas most impacted by COVID-19 may not remain static because public health measures/behaviors change dynamically, and the impacts of pandemic vulnerability also may vary geographically and temporally. The nature of the pandemic makes spatiotemporal methods essential to understanding the distribution of COVID-19 deaths and developing interventions. This study examines the spatiotemporal trends in COVID-19 death rates in the United States from March 2020 to May 2021 by performing an emerging hot spot analysis (EHSA). It then investigates the effects of the COVID-19 time-dependent and basic social vulnerability factors on COVID-19 death rates using geographically and temporally weighted regression (GTWR). The EHSA results demonstrate that over the three phases of the pandemic (first wave, second wave, and post-vaccine deployment), hot spots have shifted from densely populated cities and the states with a high percentage of socially vulnerable individuals to the states with relatively relaxed social distancing requirements, and then to the states with low vaccination rates. The GTWR results suggest that local infection and testing rates, social distancing interventions, and other social, environmental, and health risk factors show significant associations with COVID-19 death rates, but these associations vary over time and space. These findings can inform public health planning.

The African American experience in reproductive medicine: provider, patient, and pipeline perspectives

The goal of this Views and Reviews is to let colleagues and leaders well versed in the African American experience in reproductive medicine address the problems of racism affecting our trainees and patients and, more significantly, propose solutions. The areas in reproductive medicine that will be explored from the African American perspective include the pipeline of providers, health disparities, and access to infertility treatment.

Urinary PGE-M in Men with Prostate Cancer

Simple Summary

Elevated levels of urinary prostaglandin E metabolite (PGE-M), a marker of inflammation, have previously been associated with cancer incidence and metastasis. Studies investigating PGE-M in prostate cancer are lacking even though chronic inflammation is a candidate risk factor for the disease. We investigated the association of PGE-M with lethal prostate cancer. We measured PGE-M in the urine of men with prostate cancer and in men without prostate cancer (population controls). Our participants included African American and European American men. Because African American men die more frequently from prostate cancer than European American men, we investigated whether high PGE-M may contribute to the increased mortality among African American prostate cancer patients. We did not observe a relationship between PGE-M and prostate cancer aggressiveness or prostate cancer-specific mortality in our study population, neither in the combined cohort nor in the race/ethnicity stratified analysis. Interestingly, however, we observed a significant relationship between high PGE-M and all-cause mortality in African American men with prostate cancer. Yet, there was no association between high PGE-M and all-cause mortality when these men were regular aspirin users.

Abstract

Urinary PGE-M is a stable metabolite of prostaglandin E2 (PGE2). PGE2 is a product of the inflammatory COX signaling pathway and has been associated with cancer incidence and metastasis. Its synthesis can be inhibited by aspirin. We investigated the association of PGE-M with lethal prostate cancer in a case–control study of African American (AA) and European American men. We measured urinary PGE-M using mass-spectrometry. Samples were obtained from 977 cases and 1022 controls at the time of recruitment. We applied multivariable logistic and Cox regression modeling to examine associations of PGE-M with prostate cancer and participant survival. Median survival follow-up was 8.4 years, with 246 deaths among cases. Self-reported aspirin use over the past 5 years was assessed with a questionnaire. Race/ethnicity was self-reported. Urinary PGE-M levels did not differ between men with prostate cancer and population-based controls. We observed no association between PGE-M and aggressive disease nor prostate-cancer-specific survival. However, we observed a statistically significant association between higher (>median) PGE-M and all-cause mortality in AA cases who did not regularly use aspirin (HR = 2.04, 95% CI 1.23–3.37). Among cases who reported using aspirin, there was no association. Our study does not support a meaningful association between urinary PGE-M and prostate cancer. Moreover, PGE-M levels were not associated with aggressive prostate cancer. However, the observed association between elevated PGE-M and all-cause mortality in AA non-aspirin users reinforces the potential benefit of aspirin to reduce mortality among AA men with prostate cancer.

Telehealth amid the COVID-19 pandemic: perception among Asian, Native Hawaiian and Pacific Islander cancer patients

Aim: To assess the perception of telehealth visits among a multiracial cancer population during the coronavirus disease 2019 pandemic. Methods: This cross-sectional study was conducted at outpatient cancer clinics in Hawaii between March and August 2020. Patients were invited to participate in the survey either by phone or email. Results: Of the 212 survey respondents, 61.3% were Asian, 23.6% were White and 15.1% were Native Hawaiians or Pacific Islanders. Asians, Native Hawaiians and Pacific Islanders were less likely to desire future telehealth visits compared with Whites. Predictors with regard to preferring future telehealth visits included lower income and hematopoietic cancers. Conclusion: The authors found racial differences in preference for telehealth. Future studies aimed at overcoming these racial disparities are needed to provide equitable oncology care.

Health-Care Utilization Due to Suicide Attempts Among Homeless Youth in New York State

Suicide remains the leading cause of death among homeless youth. We assessed differences in health-care utilization between homeless and nonhomeless youth presenting to the emergency department or hospital after a suicide attempt. New York Statewide Inpatient and Emergency Department Databases (2009-2014) were used to identify homeless and nonhomeless youth aged 10-17 who utilized health-care services following a suicide attempt. To evaluate associations with homelessness, we used logistic regression models for use of violent means, intensive care unit utilization, log-transformed linear regression models for hospitalization cost, and negative binomial regression models for length of stay. All models adjusted for individual characteristics with a hospital random effect and year fixed effect. We identified 18,026 suicide attempts with health-care utilization rates of 347.2 (95% confidence interval (CI): 317.5, 377.0) and 67.3 (95% CI: 66.3, 68.3) per 100,000 person-years for homeless and nonhomeless youth, respectively. Length of stay for homeless youth was statistically longer than that for nonhomeless youth (incidence rate ratio = 1.53, 95% CI: 1.32, 1.77). All homeless youth who visited the emergency department after a suicide attempt were subsequently hospitalized. This could suggest a higher acuity upon presentation among homeless youth compared with nonhomeless youth. Interventions tailored to homeless youth should be developed.

Urinary Thromboxane B2 and Lethal Prostate Cancer in African American Men

BACKGROUND

Thromboxane A2 (TXA2) is a platelet- and cyclooxygenase-derived eicosanoid that has been linked to metastasis. We investigated the role of TXA2 in the development of lethal prostate cancer in African American (AA) and European American (EA) men.

METHODS

We measured urinary 11-dehydrothromboxane B2 (TXB2), a stable metabolite of TXA2, with mass-spectrometry. Samples were obtained from 977 cases and 1022 controls at time of recruitment. We applied multivariable logistic and Cox regression modeling to examine associations of TXB2 with prostate cancer and patient survival. Median survival follow-up was 8.4 years with 246 deaths among cases. Aspirin use was assessed with a questionnaire. Race/ethnicity was self-reported.

RESULTS

Urinary TXB2 was inversely associated with aspirin use. High (> median) TXB2 was associated with prostate cancer in AA (adjusted odds ratio [OR] = 1.50, 95% confidence interval [CI]= 1.13-2.00) but not EA men (OR = 1.07, 95% CI = 0.82-1.40), suggesting upregulated TXA2 synthesis in AA men with prostate cancer. High TXB2 was positively associated with metastatic prostate cancer (OR = 2.60, 95%CI = 1.08-6.28), compared with low (≤ median) TXB2. Furthermore, high TXB2 was also associated with all-cause (adjusted hazard ratio = 1.59, 95% CI = 1.06-2.40) and prostate cancer-specific mortality (hazard ratio = 4.74, 95%CI = 1.62-13.88 in AA men only.

CONCLUSION

We report a distinct association of TXB2 with prostate cancer outcomes in AA men. In this high-risk group of men, upregulation of TXA2/TXB2 synthesis may promote metastasis and lethal disease. Our observation identifies a potential benefit of aspirin in preventing lethal prostate cancer through inhibition of TXA2 synthesis.

Risk Factors for Recurrent Staphylococcus aureus Bacteremia

BACKGROUND

To understand the clinical, bacterial, and host characteristics associated with recurrent Staphylococcus aureus bacteremia (R-SAB), patients with R-SAB were compared to contemporaneous patients with a single episode of SAB (S-SAB).

METHODS

All SAB isolates underwent spa genotyping. All isolates from R-SAB patients underwent pulsed-field gel electrophoresis (PFGE). PFGE-indistinguishable pairs from 40 patients underwent whole genome sequencing (WGS). Acute phase plasma from R-SAB and S-SAB patients was matched 1:1 for age, race, sex, and bacterial genotype, and underwent cytokine quantification using 25-analyte multiplex bead array.

RESULTS

R-SAB occurred in 69 (9.1%) of the 756 study patients. Of the 69 patients, 30 experienced relapse (43.5%) and 39 reinfection (56.5%). Age, race, hemodialysis dependence, presence of foreign body, methicillin-resistant Staphyloccus aureus, and persistent bacteremia were individually associated with likelihood of recurrence. Multivariate risk modeling revealed that black hemodialysis patients were nearly 2 times more likely (odds ratio [OR] = 9.652 [95% confidence interval [CI], 5.402-17.418]) than white hemodialysis patients (OR = 4.53 [95% CI, 1.696-10.879]) to experience R-SAB. WGS confirmed PFGE interpretations in all cases. Median RANTES (regulated on activation, normal T cell expressed and secreted) levels in acute phase plasma from the initial episode of SAB were higher in R-SAB than in matched S-SAB controls (P = .0053, false discovery rate < 0.10).

CONCLUSION

This study identified several risk factors for R-SAB. The largest risk for R-SAB is among black hemodialysis patients. Higher RANTES levels in R-SAB compared to matched controls warrants further study.

The Longitudinal Association Between Exposure to Violence and Patterns of Health Risk Behaviors Among African American Youth

PURPOSE

We investigate whether exposure to violence (ETV) during adolescence and emerging adulthood predicts engagement in chronic disease-related health risk behaviors years later among African Americans.

DESIGN

A longitudinal study following youth from mid-adolescence (mean age = 14.8 years) to young adulthood (mean age = 32.0 years).

SETTING

Flint, Michigan.

SAMPLE

Four hundred forty-two African American (96.2%) and mixed African American and White (3.8%) participants.

MEASURES

Outcomes were diet, smoking, drinking, and physical inactivity. Covariates were ETV, sex, mother's educational attainment, and substance use by siblings, peers, and parents.

ANALYSIS

Latent profile analysis was conducted to identify distinct patterns of adult health risk behaviors and assess the association of youth ETV and identified patterns.

RESULTS

Four latent profiles were identified: high substance use (n = 46; 10.41%), high overall risk (n = 71; 16.06%), low overall risk (n = 140; 31.67%) and inactive (n = 185, 41.86%). Relative to the low overall risk profile, ETV was associated with being in the high overall risk profile (b = 0.37, p = 0.04), but not other profiles. Female gender and higher maternal education were associated with being in the inactive profile compared to the low overall risk profile. Peer alcohol and tobacco use were associated with being in the high substance use profile.

CONCLUSION

ETV during adolescence and emerging adulthood increased the risk of engagement in multiple health risk behaviors later in life.

Inequities in people with gout: a focus on Māori (Indigenous People) of Aotearoa New Zealand

Health equity can be defined as the absence of systematic disparities in health between more and less advantaged social groups. Gout is one of the most common forms of arthritis and disproportionally affects Indigenous peoples, including Māori in Aotearoa New Zealand. Inequities in gout management are well documented and clearly evidenced in Indigenous populations. For example, while gout occurs at a younger age and is more severe in Māori, there is less regular dispensing of urate-lowering therapies. Indigenous peoples are also under-represented in clinical trials. Herein, we will review inequities in gout using Aoteoaroa New Zealand as an example. We will explore reasons for health inequities and challenges that need to be faced to achieve health equity.

Association Between Race/Ethnicity and Survival in Women With Advanced Ovarian Cancer

Introduction

Ovarian cancer is the fifth-leading cause of cancer-related mortality in US women. There are survival disparities between non-Hispanic black (NHB) and non-Hispanic white (NHW) women. We assessed if insurance status or extent of disease modified the effect of race/ethnicity on survival for ovarian cancer.

Methods

A historical cohort was assembled using the 2007-2015 National Cancer Institute’s Surveillance, Epidemiology, and End Result (SEER) dataset. Adult NHB and NHW (>18 years) diagnosed with regional and distant ovarian cancer were included. The outcome was five-year cause-specific mortality. Multivariable Cox regression models were fitted, including race by the extent of disease and race by insurance status interaction terms.

Results

For each significant interaction, separate Cox models were fitted. In total 8,043 women were included. The insurance status/race interaction was not statistically significant, but the extent of disease modified the effect of race on survival. NHB survival was lower in regional disease (adjusted hazard ratio (HR) =1.6; 95% confidence interval (CI) 1.1-2.4), while there was no difference in survival between women with distant disease (adjusted HR =1.0; 95%CI 0.9-1.2).

Conclusions

Ovarian cancer mortality is similar between NHB and NHW women with the distant disease but higher in NHB women with regional disease. Further research should clarify whether this difference is due to access to quality cancer treatment or other factors affecting treatment response.

The ARIC (Atherosclerosis Risk In Communities) Study: JACC Focus Seminar 3/8

ARIC (Atherosclerosis Risk In Communities) initiated community-based surveillance in 1987 for myocardial infarction and coronary heart disease (CHD) incidence and mortality and created a prospective cohort of 15,792 Black and White adults ages 45 to 64 years. The primary aims were to improve understanding of the decline in CHD mortality and identify determinants of subclinical atherosclerosis and CHD in Black and White middle-age adults. ARIC has examined areas including health disparities, genomics, heart failure, and prevention, producing more than 2,300 publications. Results have had strong clinical impact and demonstrate the importance of population-based research in the spectrum of biomedical research to improve health.

Time to reopen schools: COVID-19, health disparity and education

Weighing the dilemma of reopening schools during the pandemic is no longer a matter of self-determination but harm. Coronavirus disease 2019 has shown gross health inequality and, by extension, the inequality of society per se. The assertion that ‘education continues despite the pandemic’ using access to technological means is a privileged position.

Immune Inflammation Pathways as Therapeutic Targets to Reduce Lethal Prostate Cancer in African American Men

Despite substantial improvements in cancer survival, not all population groups have benefitted equally from this progress. For prostate cancer, men of African descent in the United States and England continue to have about double the rate of fatal disease compared to other men. Studies suggest that when there is equal access to care, survival disparities are greatly diminished. However, notable differences exist in prostate tumor biology across population groups. Ancestral factors and disparate exposures can lead to altered tumor biology, resulting in a distinct disease etiology by population group. While equal care remains the key target to improve survival, additional efforts should be made to gain comprehensive knowledge of the tumor biology in prostate cancer patients of African descent. Such an approach may identify novel intervention strategies in the era of precision medicine. A growing body of evidence shows that inflammation and the immune response may play a distinct role in prostate cancer disparities. Low-grade chronic inflammation and an inflammatory tumor microenvironment are more prevalent in African American patients and have been associated with adverse outcomes. Thus, differences in activation of immune-inflammatory pathways between African American and European American men with prostate cancer may exist. These differences may influence the response to immune therapy which is consistent with recent observations. This review will discuss mechanisms by which inflammation may contribute to the disparate outcomes experienced by African American men with prostate cancer and how these immunogenic and inflammatory vulnerabilities could be exploited to improve their survival.

Coronavirus Disease 2019 (COVID-19) and HIV Spotlight the United States Imperative for Permanent Affordable Housing

Job loss and evictions tied to the COVID-19 pandemic are expected to significantly increase homelessness in the coming months. Reciprocally, homelessness and the many vulnerabilities that inevitably accompany it are driving COVID-19 outbreaks in U.S. shelters and other congregate living situations. Unless we intervene to address homelessness, these co-existing and synergistic situations will make the current public health crisis even worse.

Preventing homelessness and providing permanent affordable housing has reduced the ravages of the HIV epidemic. We must take the lessons learned in 40 years of fighting HIV to respond effectively to the COVID-19 crisis. Housing is an investment that will curb the spread of COVID-19 and help protect all of us from future pandemics.

Breastfeeding Disparities and Their Mediators in an Urban Birth Cohort of Black and White Mothers

Background: Black mothers in the United States have shorter breastfeeding (BF) durations and less exclusive breastfeeding (EBF) than others. The factors underlying these disparities require investigation. Methods: Using longitudinal data from a CDC-sponsored birth cohort in Cincinnati, Ohio, we analyzed the factors mediating racial disparity in BF outcomes. Study mothers were enrolled in prenatal clinics associated with two large birth hospitals. Analysis was restricted to racial groups with sufficient numbers in the cohort, non-Hispanic Black (n = 92) and White (n = 113) mothers, followed to at least 6 months postpartum. Results: Black mothers were 25 times more likely to reside in socioeconomically deprived neighborhoods and 20 times more likely to have an annual household income <$50,000/year than White mothers (p < 0.001). The gap in EBF for 6 weeks was 45 percentage points by racial group (13%-Black mothers versus 58%-White mothers, p < 0.001); in any BF at 6 months was 37 percentage points (28%-Black mothers versus 65%-White mothers, p < 0.001); and in mothers meeting their own intention to BF at least 6 months was 51 percentage points (29%-Black mothers versus 80%-White mothers, p < 0.001). Racial disparity in EBF at 6 weeks was mediated in logistic regression models by inequities in socioeconomic position, maternal hypertension, and BF intention. Racial disparities in BF at 6 months or meeting 6-month BF intention were mediated by inequities in socioeconomic position, maternal obesity, and EBF at 6 weeks. Not all BF disparities could be explained by models used in these analyses. Conclusions: Efforts to lessen BF disparities should address the underlying structural inequities that disproportionately affect Black mothers and children, should incorporate maternal health, and focus on breastfeeding exclusivity and duration. Few Black mothers achieved EBF at 6 weeks, which contributed to disparity in BF duration. Greater attention to Black mother-infant pairs is a public health priority.

Race as a Contributor to Stromal Modulation of Tumor Progression

Stromal cells play crucial roles in tumor development and are increasingly attractive targets for therapy. There are considerable racial disparities in the incidence and progression of many tumors, reflecting both environmental exposure and genetic differences existing between races. Tumorigenesis and tumor progression are linked to both the propensity to suffer an initiating event and the host response to such an event once it occurs, contributing to incidence and outcomes. In this review, we focused on racial disparities in the tumor microenvironment (TME) of different cancers as potential modulators of growth, metastasis, and response to treatment. Several studies suggest that the TME in AA has a distinct tumor biology and may facilitate both early onset and aggressive tumor growth while inhibiting anti-tumorigenic properties. The TME of AA patients often exhibits an immunosuppressive microenvironment with a substantial enrichment of immune inflammatory pathways and genes. As a result, AA patients can potentially benefit more from treatment strategies that modulate the immune system. Focusing on TME components for diagnostic and therapeutic purposes to address racial disparities is a promising area of investigation. Future basic and clinical research studies on personalized cancer diagnosis and treatment should acknowledge the significance of TME in racial disparities.

Late presentation and suboptimal treatment of breast cancer among Syrian refugees: a retrospective study

Objectives

The crisis in Syria has had a profound impact on the entire region. In this study, we report the patterns of presentation and management of Syrian patients with breast cancer treated at our institution.

Methods

We retrospectively collected data on Syrian refugees treated for breast cancer over the past 10 years at our center. Management was compared against our approved clinical practice guidelines.

Results

A total of 113 patients were eligible and included. The median age (range) at diagnosis was 47 (21–84) years and most women presented with locally advanced or metastatic disease (n = 74, 65.5%). Breast-conserving surgery and breast reconstruction were performed in 27 (33.8%) and 11 (35.4%) patients, respectively. Only a few patients received targeted (35.5%) or advanced endocrine therapy (30.0%). In total, 37 (32.7%) patients had considerable deviations from our institutional treatment guidelines and had worse outcomes.

Conclusions

Syrian refugees with breast cancer present late, have more advanced-stage disease, and are more likely to receive delayed and suboptimal therapy. An international systematic approach for cancer care among such vulnerable populations is urgently needed.

State-Level Health Disparity Is Associated with Sarcoidosis Mortality

BACKGROUND

Sarcoidosis is associated with significant morbidity and rising health care utilization, which contribute to the health care burden and disease outcome. In the United States (US), evaluation of sarcoidosis mortality by individual states has not been investigated.

METHODS

We examined sarcoidosis mortality data for 1999-2018 from the Centers for Disease Control and Prevention (CDC). America's Health Rankings (AHR) assesses the nation's health on a state-by-state basis to determine state health rankings. The numbers of certified Sarcoidosis Clinics within the US were obtained from World Association for Sarcoidosis and Other Granulomatous Disorders (WASOG) and Foundation for Sarcoidosis Research (FSR). The associations between sarcoidosis mortality and state health disparities were calculated by linear regression analyses.

RESULTS

From 1999 to 2018, the mean age-adjusted mortality rate (AAMR) in all populations, African Americans and European Americans were 2.9, 14.8, and 1.4 per 1,000,000 population, respectively. South Carolina had the highest AAMR for all populations (6.6/1,000,000) and African Americans (20.8/1,000,000). Both Utah and Vermont had the highest AAMR for European Americans (2.6/1,000,000). New York State and South Atlantic had the largest numbers of FSR-WASOG Sarcoidosis Clinics (6 and 13, respectively). States with better health rankings were significantly associated with lower AAMR in all population (R² = 0.170, p = 0.003) but with higher AAMR in European Americans (R² = 0.223, p < 0.001).

CONCLUSIONS

There are significant variations in sarcoidosis mortality within the US. Sarcoidosis mortality was strongly associated with state health disparities. The current study suggests sarcoidosis mortality could be an indicator to reflect the state-level health care disparities in the US.

Trends and Inequalities in Overall and Abdominal Obesity by Sociodemographic Factors in Korean Adults, 1998-2018

Few studies have comprehensively examined the nationwide trends in overall and abdominal obesity prevalence and related sociodemographic inequalities in Korea. In the Korea National Health and Nutrition Examination Survey 1998–2018, we estimated the age-standardized prevalence of overall (body mass index ≥ 25 kg/m²) and abdominal obesity (waist circumference ≥ 90 cm men, ≥85 cm women) in each sociodemographic subgroup of Korean adults (aged 19–79 years). For each survey year, weighted logistic regression was performed to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for the associations between obesity prevalence and sociodemographic factors. During the study period, the prevalence of overall and abdominal obesity increased in men (24.8% to 42.4%; 20.1% to 32.1%; respectively) but only a small change was observed in women (26.5% to 26.0%; 22.7% to 20.9%; respectively). Obesity prevalence increased in all sociodemographic groups of men but varied across groups in women. In women, income (4th vs. 1st quartiles in 2016–2018: OR (95% CI) = 0.66 (0.56–0.78) overall obesity; 0.60 (0.51–0.71) abdominal obesity) and education (college or higher vs. high school or less: 0.62 (0.54–0.72) overall obesity; 0.58 (0.50–0.68) abdominal obesity) were inversely associated with obesity prevalence, and the gaps became more pronounced since 2007. Our data suggest that the inequalities in obesity prevalence by sex and by socioeconomic status have become more apparent over time in Korea.

Sex and Race-Related DNA Methylation Changes in Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is the sixth most common cancer and fourth leading cause of cancer-related death worldwide. The number of HCC cases continues to rise despite advances in screening and therapeutic inventions. More importantly, HCC poses two major health disparity issues. First, HCC occurs more commonly in men than women. Second, with the global increase in non-alcoholic fatty liver diseases (NAFLD), it has also become evident that HCC is more prevalent in some races and/or ethnic groups compared to others, depending on its predisposing etiology. Most studies on HCC in the past have been focused on genetic factors as the driving force for HCC development, and the results revealed that genetic mutations associated with HCC are often heterogeneous and involve multiple pathogenic pathways. An emerging new research field is epigenetics, in which gene expression is modified without altering DNA sequences. In this article, we focus on reviewing current knowledge on HCC-related DNA methylation changes that show disparities among different sexes or different racial/ethnic groups, in an effort to establish a point of departure for resolving the broader issue of health disparities in gastrointestinal malignancies using cutting-edge epigenetic approaches.

Incidence of and Trends in the Leading Cancers With Elevated Incidence Among American Indian and Alaska Native Populations, 2012-2016

Cancer incidence varies among American Indian and Alaska Native (AI/AN) populations, as well as between AI/AN and White populations. This study examined trends for cancers with elevated incidence among AI/AN compared with non-Hispanic White populations and estimated potentially avoidable incident cases among AI/AN populations. Incident cases diagnosed during 2012-2016 were identified from population-based cancer registries and linked with the Indian Health Service patient registration databases to improve racial classification of AI/AN populations. Age-adjusted rates (per 100,000) and trends were calculated for cancers with elevated incidence among AI/AN compared with non-Hispanic White populations (rate ratio of >1.0) according to region. Trends were estimated using joinpoint regression analyses. Expected cancers were estimated by applying age-specific cancer incidence rates among non-Hispanic White populations to population estimates for AI/AN populations. Excess cancer cases among AI/AN populations were defined as observed minus expected cases. Liver, stomach, kidney, lung, colorectal, and female breast cancers had higher incidence rates among AI/AN populations across most regions. Between 2012 and 2016, nearly 5,200 excess cancers were diagnosed among AI/AN populations, with the largest number of excess cancers (1,925) occurring in the Southern Plains region. Culturally informed efforts could reduce cancer disparities associated with these and other cancers among AI/AN populations.

Perspectives of Urban Adolescent Black Males and Their Parents on Well Care

OBJECTIVE

Adolescents have fewer well-care visits than all other age groups. Males and ethnic minorities are seen least often. We elicited from Black adolescent males and their parents key drivers of teen well-care seeking.

METHODS

We conducted separate semistructured interviews with Black adolescent males and their parents. We recruited parent-teen dyads from West Philadelphia. Eligible teens were age 13 to 18, with no complex chronic health conditions. We purposively sampled teens who had not received preventive care in at least 2 years, some of whom had since returned to care and some not. Interviews were recorded, transcribed, and coded by 2 coders using the constant comparative method, resolving discrepancies by consensus. Interviews continued until thematic saturation.

RESULTS

We interviewed 23 Black adolescent males (mean age 15) and 22 parents (20 mothers). Participants understood that teens should routinely receive preventive care. Four themes emerged: receiving preventive care is important to knowing teens are mentally and physically well; remembering to schedule/attend visits is challenging - participants find appointment reminders helpful; mothers noted that males of all ages are generally disengaged from health care; teens and parents felt that a "good" parent ensures teens receive preventive care.

CONCLUSIONS

Black adolescent males and their parents value regular preventive care as an opportunity to ensure the teen is physically and mentally well, but competing priorities interfere with care receipt. Results support testing the impact of reminders on receipt of care in this population. These reminders may be most effective if directed at mothers and focused on "good parenting."

Barriers and Challenges to Cervical Cancer Screening, Follow-Up, and Prevention Measures among Korean Immigrant Women in Hawaii

OBJECTIVE

Despite being the fastest-growing population in the United States, Asian American women have one of the lowest cancer screening rates and the least attention given to cancer-related research. Cervical cancer screening disparities among Korean immigrant women (KIWs) in Hawaii have been reported.

METHODS

The qualitative ethnographic study was to explore the health barriers and challenges of cervical cancer prevention among KIWs in Hawaii. The Social Ecological Model was used to guide the study. Data were collected using individual structured interviews with 20 KIWs aged 21-65 years. The data were coded and analyzed to identify themes in exploring health barriers.

RESULTS

The findings revealed that participants (a) lacked knowledge about the U.S. health-care system; (b) lacked access; (c) had limited resources regarding cervical cancer screening communicated in Korean; (d) lacked an understanding of cultural and psychosocial beliefs on preventive care; (e) lacked female and Korean-speaking providers; and (f) experienced language barriers and limited coverage of health insurance.

CONCLUSIONS

A multicomponent intervention combining individual and community-based, Internet-accessible, culturally, and linguistically appropriate approaches may enhance effective cervical cancer screening rates and positive health outcomes among KIWs in Hawaii.

Characteristics and Factors Associated with COVID-19 Infection, Hospitalization, and Mortality Across Race and Ethnicity

Background

Data on the characteristics of COVID-19 patients disaggregated by race/ethnicity remain limited. We evaluated the sociodemographic and clinical characteristics of patients across racial/ethnic groups and assessed their associations with COVID-19 outcomes.

Methods

This retrospective cohort study examined 629,953 patients tested for SARS-CoV-2 in a large health system spanning California, Oregon, and Washington between March 1 and December 31, 2020. Sociodemographic and clinical characteristics were obtained from electronic health records. Odds of SARS-CoV-2 infection, COVID-19 hospitalization, and in-hospital death were assessed with multivariate logistic regression.

Results

570,298 patients with known race/ethnicity were tested for SARS-CoV-2, of whom 27.8% were non-White minorities. 54,645 individuals tested positive, with minorities representing 50.1%. Hispanics represented 34.3% of infections but only 13.4% of tests. While generally younger than White patients, Hispanics had higher rates of diabetes but fewer other comorbidities. 8,536 patients were hospitalized and 1,246 died, of whom 56.1% and 54.4% were non-White, respectively. Racial/ethnic distributions of outcomes across the health system tracked with state-level statistics. Increased odds of testing positive and hospitalization were associated with all minority races/ethnicities. Hispanic patients also exhibited increased morbidity, and Hispanic race/ethnicity was associated with in-hospital mortality (OR: 1.39 [95% CI: 1.14-1.70]).

Conclusion

Major healthcare disparities were evident, especially among Hispanics who tested positive at a higher rate, required excess hospitalization and mechanical ventilation, and had higher odds of in-hospital mortality despite younger age. Targeted, culturally-responsive interventions and equitable vaccine development and distribution are needed to address the increased risk of poorer COVID-19 outcomes among minority populations.

The Effects of Childhood Circumstances on Health in Middle and Later Life: Evidence From China

Background: This study examined the relationship between childhood circumstances and health in middle and later life. We quantified how childhood circumstances contribute to health in later life, both directly and indirectly, through their effects on potential mediators.

Methods: This study used three waves of data from the national longitudinal survey of the China Health and Retirement Longitudinal Study (CHARLS). The final model in this study included 7,476 eligible respondents aged 45 years and above. We constructed a simple health status measure based on the first principal component of CHARLS survey responses with 25 health-related information. It is a multi-dimensional measurement that comprehensively reflects the individual's healthy aging. We formulated childhood circumstances factors into five domains: childhood health and nutrition, childhood socioeconomic status, access to health care, parental genetics, and adverse childhood experiences. Ordered logit regression was conducted to analyze the relationship between health in middle and later life and childhood circumstances, with other explanatory variables controlled.

Results: Controlling for educational attainment, personal income, and health status in the last wave, adults who experience good childhood health (poor as the base, coefficient 0.448, p < 0.01), and better family financial status (worse as the base, coefficient 0.173, p < 0.01) have significantly better health during their middle and later life, in comparison, being inconvenient to visit a doctor (coefficient −0.178, p < 0.01), and having two or three adverse childhood experiences (0 as the base, coefficient −0.148, p < 0.01) are significantly associated with poorer health. Childhood circumstances appear to act both through a lasting effect of initial health and financial status in childhood and through their impact on achievements in adulthood.

Conclusion: Our findings suggest that investments in health during childhood not only contribute to health in later life but also dynamically improve an individual's educational attainment and personal income, as well as other life prospects. All these returns may extend far beyond childhood and continue throughout the lifespan.

The Role of Place in Disparities Affecting Black Men Receiving Hemodialysis

INTRODUCTION

Black men are over-represented in the end stage kidney disease population and are at disproportionate risk of unfavorable outcomes. There is a paucity of investigation to elucidate the mediators of this risk. This study attempts to identify residential community attributes as a possible contributor.

METHODS

A post-hoc analysis of prospectively collected data from a cohort of Black men enrolled in the US Dialysis Outcomes and Practice Patterns Study (DOPPS), 2010--2015, linked to the American Community Survey, by dialysis facility zip codes was undertaken. The exposure variable was the dialysis facility community composition as defined by percent Black residents. Negative binomial regression was used to estimate incidence rate ratio (IRR) of hospitalization (first outcome) for Black men in crude and adjusted models. Similarly, Cox proportional hazards modeling was used to estimate mortality (second outcome) for Black men by type of community.

RESULTS

A total of 702 Black men receiving chronic hemodialysis were included in the study. Black men receiving hemodialysis in communities with greater proportions of Black residents had lower Charlson scores and fewer comorbidities, but a higher rate of hypertension. They had equivalent adherence to dialysis treatments, but a lower rate of arteriovenous fistula use and fewer dialysis minutes prescribed. Black men receiving dialysis in communities with a greater proportion of Black residents (per 10% increase) had higher adjusted hospitalization rates (IRR 1.09, 95% confidence interval [CI] 1.00-1.19) and mortality (hazard ratio [HR] 1.29, 95% CI 1.05-1.59).

CONCLUSIONS

This study supports the unique role of residential community as a risk factor for Black men with end stage kidney disease, showing higher hospitalization and mortality in those treating in Black versus non-Black communities, despite equivalent adherence and fewer comorbidities.

How Comorbidities Shape Cancer Biology and Survival

Comorbid chronic diseases affect cancer patients with an increasing frequency as populations get older. They negatively and disproportionately impact underserved populations and influence cancer diagnosis, tumor biology and metastasis, and choice of treatment. Many comorbidities are associated with a delayed cancer diagnosis. Although the relationship between comorbidities and cancer risk and survivorship has been studied extensively, we still lack knowledge on how they affect tumor biology and the metastatic process. Here, we will discuss our current understanding of mechanisms linking comorbidities to an adverse tumor biology and lethality and introduce thoughts of how we can close existing gaps in this knowledge. We argue that research into comorbidity-induced alterations in cancer metastasis, immunity, and metabolism should be prioritized.

African American Patients Have Improved Functional Gains and Comparable Clinical Outcomes to Caucasian Patients After Total Hip and Knee Arthroplasty

BACKGROUND

With the increasing popularity of alternative payment models, minorities who use more postacute care resources may face difficulties with access to quality total hip arthroplasty (THA) and total knee arthroplasty (TKA) care. The purpose of this study is to compare differences in perioperative complications and functional outcomes between African American and Caucasian patients undergoing THA and TKA.

METHODS

We reviewed a consecutive series of all primary THA and TKA patients at our institution from 2015 to 2018. Demographics, comorbidities, 90-day complications, readmissions, Veterans Rand 12-Item Health Survey (VR-12), Hip disability Osteoarthritis Outcome Score (HOOS), and Knee injury and Osteoarthritis Outcome Scores (KOOS) were compared between African American and Caucasian patients. A multivariate analysis was performed to control for confounding variables.

RESULTS

Of the 5284 patients included in the study, 1041 were African American (24.5%). Although African American patients had lower preoperative HOOS/KOOS (33.5 vs 45.1, P < .001) and mental VR-12 scores (37.8 vs 51.5, P < .001) compared with Caucasian patients, there was no clinical difference at 1 year in HOOS/KOOS (50.2 vs 50.4), mental VR-12 (55.0 vs 52.6), or physical VR-12 scores (39.5 vs 39.8). When controlling for demographics and medical comorbidities, African American race was associated with increased rehabilitation facility discharge (odds ratio, 1.69; P < .001) but no difference in readmissions or complications.

CONCLUSION

Although African American patients had lower preoperative functional scores, they made improved postoperative gains when compared with Caucasian patients. Although there was no difference in postoperative complications, further studies should assess social causes for the increase in rehabilitation utilization rates in minority patients.

Socioeconomic status relates to exercise habits and cardiorespiratory fitness among workers in the Tokyo area

OBJECTIVES

This survey aims to investigate consciousness regarding habitual exercise among workers in urban areas and to analyze the associations of workers' socioeconomic status with their habitual exercise and cardiorespiratory fitness (CRF).

METHODS

Ten thousand participants, who worked in the Tokyo area of Japan, were recruited for the questionnaire-based survey. The questionnaire elicited participant's characteristics, socioeconomic status (eg, employment status and annual income), habitual exercise status, and consciousness regarding exercising. After the data-cleaning procedure, 9406 participants were selected for analyses. CRF was estimated by a validated equation model.

RESULTS

Some (32.9%) participants had an exercise habit, and 93% recognized that exercise is good for health. Of the nonexercise habit group (n = 6308), 73% wanted to develop an exercise habit, and "spare time (40%)" and "financial capability (16%)" were the two most necessary conditions for habituating exercise. As socioeconomic statuses increased, the odds ratios (ORs) for engaging in habitual exercise increased among full-time (1.22) versus part-time (reference) employees and those having high (1.76) versus low (reference) incomes, whereas the ORs for low CRF risk decreased among full-time (0.78) versus part-time (reference) employees and those having high (0.53) versus low (reference) incomes.

CONCLUSIONS

Although most workers recognized the benefits of exercise, many were unable to develop exercise habits and believed that they could develop exercise habits if they had the time and financial capabilities. The survey suggests that workers with a higher socioeconomic status more likely to obtain favorable physical fitness, indicating a health disparity among workers in urban areas.

A Data Science Approach to Analyze the Association of Socioeconomic and Environmental Conditions With Disparities in Pediatric Surgery

Background: Scientific evidence confirm that significant racial disparities exist in healthcare, including surgery outcomes. However, the causal pathway underlying disparities at preoperative physical condition of children is not well-understood. Objectives: This research aims to uncover the role of socioeconomic and environmental factors in racial disparities at the preoperative physical condition of children through multidimensional integration of several data sources at the patient and population level. Methods: After the data integration process an unsupervised k-means algorithm on neighborhood quality metrics was developed to split 29 zip-codes from Memphis, TN into good and poor-quality neighborhoods. Results: An unadjusted comparison of African Americans and white children showed that the prevalence of poor preoperative condition is significantly higher among African Americans compared to whites. No statistically significant difference in surgery outcome was present when adjusted by surgical severity and neighborhood quality. Conclusions: The socioenvironmental factors affect the preoperative clinical condition of children and their surgical outcomes.

Time to Authorized Clearance from Sport-Related Concussion: The Influence of Healthcare Provider and Medical Facility

CONTEXT

Return-to-play following sport-related concussion(SRC) requires authorized clearance from a healthcare provider(HCP). Variability in HCPs and facilities where athletes seek care may influence return time.

OBJECTIVE

Determine the initial examiner, HCPs that authorize clearance, and medical facilities authorizing clearance among high school student-athletes following SRC, and compare authorized clearance time by HCPs and medical facilities.

DESIGN

Prospective Cohort Study.

SETTING

High school.

PATIENTS OR OTHER PARTICIPANTS

Student-athletes(n=16,001) with SRC participating in STATE-XXX High School Athletic Association(XHSAA)-sponsored athletics.

MAIN OUTCOME MEASURE(S)

Frequencies of initial examiner and authorized clearance for each HCP(Doctor of Osteopathic Medicine(DO), Doctor of Medicine(MD), Nurse Practitioner(NP), Physician Assistant(PA)) and medical facility (Neurologist's Office, Team Physician, Primary Care Physician or Pediatrician's Office(PCP), Hospital, Urgent/Ready Care) for each SRC case. Kaplan-Meier curves and Peto tests evaluated differences in median time to authorized clearance between HCPs and facilities. Only cases with a follow-up authorized clearance date(80.3%, n=12,856) were included in authorized clearance and time to return analyses.

RESULTS

An athletic trainer was at least one of the initial examiners for 71.3%(n=11,404) of cases; 80.2%(n=12,990) had only one initial examiner. There was an association between initial examiner and medical facility providing clearance for athletic director(χ2=52.6, p≤.001, V=.06), athletic trainer(χ2=172.0, p≤.001, V=.12), coach(χ2=161.5, p≤.001, V=.11), DO(χ2=59.4, p≤.001, V= 07), and NP(χ2=10.0, p .03, V=.12). The majority(n=8,218, 63.9%) received clearance by an MD; 70.8%(n=9,099) were cleared at a PCP. Median time to authorized clearance varied by facility(Urgent/Ready Care: 7 days[4,11], Hospital: 9 days[6,14], PCP: 10 days[6,14], Team Physician: 12 days[8,16], Neurologist Office: 13 days[9,20]; p ≤ .001).

CONCLUSIONS

Clearance was frequently provided by an MD and at a PCP. Median time to return to unrestricted participation following SRC varied by HCP and medical facility. Future research should elucidate why differences exist and determine why athletes seek care at different medical facilities.

The Impact of African Ancestry on Prostate Cancer Disparities in the Era of Precision Medicine

Prostate cancer disproportionately affects men of African ancestry at nearly twice the rate of men of European ancestry despite the advancement of treatment strategies and prevention. In this review, we discuss the underlying causes of these disparities including genetics, environmental/behavioral, and social determinants of health while highlighting the implications and challenges that contribute to the stark underrepresentation of men of African ancestry in clinical trials and genetic research studies. Reducing prostate cancer disparities through the development of personalized medicine approaches based on genetics will require a holistic understanding of the complex interplay of non-genetic factors that disproportionately exacerbate the observed disparity between men of African and European ancestries.

Wilms Tumor in Sub-Saharan Africa: Molecular and Social Determinants of a Global Pediatric Health Disparity

Wilms tumor (WT) is the most common renal malignancy of childhood. Global disparities in WT have been reported with the highest incidence and lowest overall survival occurring in sub-Saharan African nations. After a detailed search of PubMed, we reviewed available literature on WT in sub-Saharan Africa and summarized findings that explore biologic and social factors contributing to this alarming cancer health disparity. Access to care and treatment abandonment are the most frequently reported factors associated with decreased outcomes. Implementation of multidisciplinary teams, collaborative networks, and financial support has improved overall survival in some nations. However, treatment abandonment remains a challenge. In high-income countries globally, WT therapy now is risk-stratified according to biology and histology. To a significantly lesser extent, biologic features have been studied only recently in sub-Saharan African WT, yet unique molecular and genetic signatures, including congenital anomaly-associated syndromes and biomarkers associated with treatment-resistance and poor prognosis have been identified. Together, challenges with access to and delivery of health care in addition to adverse biologic features likely contribute to increased burden of disease in sub-Saharan African children having WT. Publications on biologic features of WT that inform treatment stratification and personalized therapy in resource-limited regions of sub-Saharan Africa have lagged in comparison to publications that discuss social determinants of health. Further efforts to understand both WT biology and social factors relevant to appropriate treatment delivery should be prioritized in order to reduce health disparities for children residing in resource-limited areas of sub-Saharan Africa battling this lethal childhood cancer.

Factors Associated with Self-Reported Hypertension Among Black Women

A Black woman has an 85.7% chance of developing hypertension in her lifetime, yet she is less likely to be optimally treated. The purpose of this research report is to describe the factors associated with self-reported hypertension in a sample of Black women. A descriptive study was conducted using a researcher-developed survey. Responses were obtained from 201 adult Black women from 19 to 92 years of age. Descriptive and comparative analyses were performed. The frequency of self-reported hypertension in the sample was low (n = 54, 27%). The self-report hypertension group was significantly older (p < 0.05) and obese (61%). There were significant associations between self-report hypertension and greater income (c2 = 9.24, p = 0.002, f = 0.232), self-report hypertension and higher education (c2 = 5.66, p = 0.017, phi = 0.182), and self-report hypertension and not having Medicaid (c2 = 5.05, p = 0.025, f = 0.174). APRNs should stress the importance of routine health screenings and healthy lifestyle behaviors in accordance with patient needs.

Time-to-event modeling of hypertension reveals the nonexistence of true controls

Given a lifetime risk of ~90% by the ninth decade of life, it is unknown if there are true controls for hypertension in epidemiological and genetic studies. Here, we compared Bayesian logistic and time-to-event approaches to modeling hypertension. The median age at hypertension was approximately a decade earlier in African Americans than in European Americans or Mexican Americans. The probability of being free of hypertension at 85 years of age in African Americans was less than half that in European Americans or Mexican Americans. In all groups, baseline hazard rates increased until nearly 60 years of age and then decreased but did not reach zero. Taken together, modeling of the baseline hazard function of hypertension suggests that there are no true controls and that controls in logistic regression are cases with a late age of onset.

Understanding the Heterogeneity of Obesity and the Relationship to the Brain-Gut Axis

Obesity is best understood as a multifactorial metabolic imbalances disorder. In a cross-sectional study, we aimed to explore sociodemographic and dietary determinants of obesity in relation to brain-gut homeostasis among overweight and obese individuals. Multivariate logistic regression models were used to examine obesity and its association with sociodemographic and dietary factors. Biological variables examined included the gut microbiome, fecal amino acid metabolites and brain structural volumes. Among 130 participants, there were higher odds of obesity if individuals were Hispanic (adjusted odds ratio (aOR) 1.56, p = 0.014). Compared to non-Hispanics, Hispanics differed in gut microbial composition (p = 0.046) with lower microbial species richness (Chao1) (p = 0.032) and evenness (Shannon) (p = 0.0029). Fourteen of the twenty fecal amino acids including branch-chain- and aromatic- amino acids were increased among Hispanics (q < 0.05). Brain structural volumes in reward regions were decreased in Hispanics (pallidum, q = 0.036; brainstem, q = 0.011). Correlation patterns suggest complex brain-gut interactions differ by Hispanic ethnicity. In conclusion, Hispanics expressed a unique brain-gut microbial signature, which was associated with obesity despite sociodemographic and dietary differences. Addressing ethnic disparities guided by biologic phenotypes may unlock novel understanding of obesity heterogeneity and treatment strategies.

Health Disparities among Australia's Remote-Dwelling Aboriginal People: A Report from 2020

BACKGROUND

Australia has 2 distinct indigenous groups, Torres Strait Islanders and Aborigines. The Aborigines, described in this report, first colonized the continent 65 millennia ago. Those still living in the Northern Territory (NT) retain much ancestrally derived genetic complement but also are the most health-challenged by environment and lifestyle in 21st century. Reports providing overviews of these disparities are, as yet, rare.

CONTENT

This review defines the studied population and then describes and attempts to explain contemporary clinical findings among Australia's remote-dwelling Aborigines, principally in the NT. The report is structured by life stage and then by organ system. Finally, a brief synthesis is advanced concerning the disparities that Australia's Aboriginals face.

SUMMARY

In 2015-2017, NT aboriginal life expectancy for people then born was 66.6 years for men and 69.9 years for women compared with 78.1 and 82.7 years, respectively, among nonindigenous Territorians. Principal causes of the reduced longevity, with nonindigenous comparisons, include adolescent pregnancy, with maternal use of alcohol and tobacco (each 7-fold greater); fetal alcohol spectrum disorder and attention deficit hyperactivity disorder; skin infections, both scabies and impetigo (50-fold greater); rheumatic heart disease (260-fold greater); premature acute myocardial infarction (9-fold greater); bronchiectasis (40-fold greater); lung cancer (2-fold greater); diabetes mellitus (10-fold greater); renal failure (30-fold greater); and suicide (2-fold greater). Some disease has genetic roots, secondary to prolonged genetic drift. Much arises from avoidable stressors and from contemporary environmental disparities in housing. The Europid diet is also not helpful.

Health Literacy in Korean Adults and Korean American Immigrants: Implications for Achieving Health Equity

Health literacy is necessary to understand health information and make appropriate decisions regarding one's health. This study aims to investigate (1) the health literacy level of Korean citizens and Korean American (KA) immigrants in the United States and (2) factors that influence health literacy across three age groups. A quota sampling method was used to collect cross-sectional survey data from 404 Korean participants and 404 KA immigrants. Andersen's behavioral model was used as the theoretical framework for this study. Overall, Korean participants had a higher mean score on health literacy than did the KA immigrants. Only one of predisposing and enabling factors were significant variables influencing health literacy in KA immigrants, while several predisposing, enabling and need factors were significantly associated with health literacy in Korean adults. Our findings indicate that both countries need to have a community-based health literacy educational program that is tailored to each age group.

COVID-19 Pandemic: Disparate Health Impact on the Hispanic/Latinx Population in the United States

In December 2019, a novel coronavirus known as SARS-CoV-2, emerged in Wuhan, China, causing the Coronavirus disease 2019 we now refer to as COVID-19. The World Health Organization declared COVID-19 a pandemic on March 12th, 2020. In the United States, the COVID-19 pandemic has exposed pre-existing social and health disparities among several historically vulnerable populations, with stark differences in the proportion of minority individuals diagnosed with and dying from COVID-19. In this article we will describe the emerging disproportionate impact of COVID-19 on the Hispanic/Latinx (henceforth: Hispanic or Latinx) community in the U.S., discuss potential antecedents and consider strategies to address the disparate impact of COVID-19 on this population.

Disparities of indoor temperature in winter: A cross-sectional analysis of the Nationwide Smart Wellness Housing Survey in Japan

The WHO Housing and health guidelines recommend a minimum indoor temperature of 18°C to prevent cold-related diseases. In Japan, indoor temperatures appear lower than in Euro-American countries because of low insulation standards and use of partial intermittent heating. This study investigated the actual status of indoor temperatures in Japan and the common characteristics of residents who live in cold homes. We conducted a nationwide real-world survey on indoor temperature for 2 weeks in winter. Cross-sectional analyses involving 2190 houses showed that average living room, changing room, and bedroom temperatures were 16.8°C, 13.0°C, and 12.8°C, respectively. Comparison of average living room temperature between prefectures revealed a maximum difference of 6.7°C (Hokkaido: 19.8°C, Kagawa: 13.1°C). Compared to the high-income group, the odds ratio for living room temperature falling below 18°C was 1.38 (95% CI: 1.04-1.84) and 2.07 (95% CI: 1.28-3.33) for the middle- and low-income groups. The odds ratio was 1.96 (95% CI: 1.19-3.22) for single-person households, compared to households living with housemates. Furthermore, lower room temperature was correlated with local heating device use and a larger amount of clothes. These results will be useful in the development of prevention strategies for residents who live in cold homes.

Effectiveness of Patient Navigation to Increase Cancer Screening in Populations Adversely Affected by Health Disparities: a Meta-analysis

BACKGROUND

This study evaluates the effectiveness of patient navigation to increase screening for colorectal, breast, and cervical cancer in populations adversely affected by health care disparities.

METHODS

Eligible studies were identified through English-language searches of Ovid® MEDLINE®, PsycINFO®, SocINDEX, and Veterans Affairs Health Services database (January 1, 1996, to July 5, 2019) and manual review of reference lists. Randomized trials and observational studies of relevant populations that evaluated the effectiveness of patient navigation on screening rates for colorectal, breast, or cervical cancer compared with usual or alternative care comparison groups were included. Two investigators independently abstracted study data and assessed study quality and applicability using criteria adapted from the U.S. Preventive Services Task Force. Discrepancies were resolved by consensus with a third reviewer. Results were combined using profile likelihood random effects models.

RESULTS

Thirty-seven studies met inclusion criteria (28 colorectal, 11 breast, 4 cervical cancers including 3 trials with multiple cancer types). Screening rates were higher with patient navigation for colorectal cancer overall (risk ratio [RR] 1.64; 95% confidence interval [CI] 1.42 to 1.92; I² = 93.7%; 22 trials) and by type of test (fecal occult blood or immunohistochemistry testing [RR 1.69; 95% CI 1.33 to 2.15; I² = 80.5%; 6 trials]; colonoscopy/endoscopy [RR 2.08; 95% CI 1.08 to 4.56; I² = 94.6%; 6 trials]). Screening was also higher with navigation for breast cancer (RR 1.50; 95% CI 1.22 to 1.91; I² = 98.6%; 10 trials) and cervical cancer (RR 1.11; 95% CI 1.05 to 1.19; based on the largest trial). The high heterogeneity of cervical cancer studies prohibited meta-analysis. Results were similar for colorectal and breast cancer regardless of prior adherence to screening guidelines, follow-up time, and study quality.

CONCLUSIONS

In populations adversely affected by disparities, colorectal, breast, and cervical cancer screening rates were higher in patients provided navigation services. Registration: PROSPERO: CRD42018109263.

Examination of Racial Disparities in Adolescents Seen in the Emergency Department for Head, Neck, or Brain Injury

BACKGROUND

Given the frequency, severity, and attention of traumatic brain injury in children, benchmarking disparities and injury characteristics for adolescent patients is pivotal in understanding and enhancing both clinical care and outcomes.

OBJECTIVES

The purpose of this study was to investigate racial disparities on mechanism of injury, clinical outcomes, and social-health factors among adolescents treated in the emergency department (ED) for a head, neck, or brain injury.

METHODS

This study is the result of a retrospective chart review of head-, neck-, and brain-injured adolescent patients (n = 2857) treated at three community hospital EDs and one stand-alone ED. Outcome measures included patient demographics (gender, race/ethnicity, age), Glasgow Coma Scale score, hospital length of stay, intensive care unit length of stay, mechanism of injury, primary diagnosis, secondary diagnosis of a concussion, ventilation days, discharge disposition, and primary insurance.

RESULTS

There were racial differences in primary diagnosis, mechanism of injury, and insurance status. Results indicated that a higher proportion of white patients were diagnosed with a concussion compared with black patients (p < 0.001). Moreover, a higher proportion of white patients were seen in the ED for head, neck, or brain injury as a result of a sports or motor vehicle incident, whereas a leading mechanism among black patients was assault (p = 0.01). More white patients had private insurance, whereas more black patients had Medicaid (p < 0.001).

CONCLUSION

The disparities in mechanisms for which black and white adolescent patients are seeking care at the ED for head, neck, or brain injury help to identify social-health risks of sustaining a head, neck, or brain injury. These racial disparities between black and white adolescents seen at the ED for head, neck, or brain injury suggest the need for further research to better understand the national representation of these disparities.

Social Determinants of Health and Patient-Reported Outcomes Following Total Hip and Knee Arthroplasty in Veterans

BACKGROUND

Social determinants of health (SDOH) are the conditions in which people are born, grow, live, work, and age. They are associated with disparities in outcomes following total joint arthroplasty (TJA). These disparities occur even in equal-access healthcare systems such as the Veterans Health Administration (VHA). Our goal was to determine whether SDOH affect patient-reported outcome measures (PROMs) following TJA in VHA patients.

METHODS

Patients scheduled to undergo total hip or knee arthroplasty at VHA Hospitals in Minneapolis, MN, Palo Alto, CA, and San Francisco, CA, prospectively completed PROMs before and 1 year after surgery. PROMs included the Hip disability and Osteoarthritis Outcome Score, the Knee injury and Osteoarthritis Outcome Score, and their Joint Replacement subscores. SDOH included race, ethnicity, marital status, education, and employment status. The level of poverty in each patient's neighborhood was determined. Medical comorbidities were recorded. Univariate and multivariate analyses were performed to determine whether SDOH were significantly associated with PROM improvement after surgery.

RESULTS

On multivariate analysis, black race was significantly negatively correlated with knee PROM improvement and Hispanic ethnicity was significantly negatively correlated with hip PROM improvement compared to whites. Higher baseline PROM scores and lower age were significantly associated with lower PROM improvement. Significant associations were also found based on education, gender, comorbidities, and neighborhood poverty.

CONCLUSION

Minority VHA patients have lower improvement in PROM scores after TJA than white patients. Further research is required to identify the reasons for these disparities and to design interventions to reduce them.

Sociocultural Influences on Disparities in United States Children with Atopic Dermatitis: A Narrative Review of the Literature

Approximately 13% of United States (US) children have atopic dermatitis (AD), also known as eczema. AD is a chronic skin condition associated with significant burdens on quality of life and both individual and overall health-care system costs. The pathogenesis of AD is considered to be multifactorial, with biologic factors such as family history and genetics often reported as influencing risk. Some lesser discussed determinants of AD prevalence and severity are sociocultural, such as race/ethnicity, neighborhood, housing type, income level, and family structure. While several factors appear to contribute to disparities in childhood AD, black or African American race/ethnicity most significantly predicts AD prevalence, severity, disease control, access to care, and family impact. There is a shortage of research related to disparities in AD, an important topic considering the large percentage of families that are affected by the disease. This article is a narrative literature review of sociocultural influences on AD disparities in US children. The purpose of this review is to increase awareness of these important risk factors and to suggest related, future areas of research that may positively impact overall outcomes in children with AD. Much work remains to be done in order to ensure equitable care and outcomes among all children with AD.

Psychosocial and Clinical Risk Factors Associated with Substance Use in Observational Cohort of Patients with Sickle Cell Disease

BACKGROUND

Patients with sickle cell disease (SCD) experience high rates of chronic pain, and have a high burden of mental health comorbidities shown to negatively influence health. There is limited research on substance use among individuals with SCD. Objective: The aim of this study is to measure the prevalence of substance use in patients with SCD and determine whether psychosocial or clinical risk factors are associated with substance use. Methods: This study was conducted as part of an observational study of patients with SCD at two academic medical centers. We asked participants (ages 15 and older) about the lifetime use of heroin, cocaine, amphetamines, and marijuana/cannabis. We measured stigma, depression, urban life stress, pain catastrophizing, and asked about a brief pain inventory. Results: Of 258 participants, 24.9% (n = 71) reported substance use. Marijuana was the most common substance used (22.5%; n = 65). The mean depressive score met criteria for positive screen amongst individuals who reported a history of substance use (mean 10.7(5.76)). Adjusting for age, sex, yearly family income, and education level, odds of substance use increased with higher levels of internalized stigma (aOR: 1.38; 95% CI: 1.07, 1.77; p = 0.012); higher urban life stress scores (aOR 1.06; 95% CI: 1.01, 1.12; p = 0.017) and higher pain catastrophizing scores (aOR: 1.03; 95% CI: 1.01, 1.06; p = 0.008). Conclusions: Among individuals with SCD who endorse substance use, there was markedly more stress and distress with higher rates of depression and poorer quality of life. Interventions focusing on improving distress tolerance and coping to not only pain, but also social stressors, might reduce substance use.

Can Health Disparity Be Eliminated? The Role of Family Doctor Played in Shanghai, China

Background: Globally, the elimination of health disparity is a significant policy target. Primary health care has been implemented as a strategy to achieve this target in China for almost 10 years. This study examined whether family doctor (FD) policy in Shanghai contributed to eliminating health disparity as expected. Methods: System dynamics modeling was performed to construct and simulate a system of health disparity formation (business-as-usual (BAU) scenario, without any interventions), a system with FD intervention (FD scenario), and three other systems with supporting policies (Policy 1/Policy 2/Policy hybrid scenario) from 2013 to 2050. Health disparities were simulated in different scenarios, making it possible to compare the BAU results with those of FD intervention and with other policy interventions. Findings: System dynamics models showed that the FD policy would play a positive role in reducing health disparities in the initial stage, and medical price control—rather than health management—was the dominant mechanism. However, in this model, the health gap was projected to expand again around 2039. The model examined the introduction of two intervention policies, with findings showing that the policy focused on socioeconomic status improvement would be more effective in reducing health disparities, suggesting that socioeconomic status is the fundamental cause of these disparities. Conclusions: The results indicate that health disparities could be optimized, but not eliminated, as long as differences in socioeconomic status persists.