More than Tuskegee: understanding mistrust about research participation

Exploration of Experiences and Perpetration of Identity-Based Bullying Among Adolescents by Race/Ethnicity and Other Marginalized Identities

IMPORTANCE

Race-based discrimination represents an ongoing public health crisis in the US, manifested by wide-ranging disparities in youth health, mental health, and violence exposure. However, studies of racial discrimination often neglect experiences of identity-based bullying (IBB) stemming from other marginalized identities, such as gender identity and sexual orientation.

OBJECTIVE

To examine associations between experiences of IBB based on race/ethnicity/national origin and other social identities and youth health, mental health, and violence outcomes.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study analyzed responses from an anonymous survey conducted at 13 public high schools in Pittsburgh, Pennsylvania, between October 15, 2018, and October 19, 2018. Participants included in the study were in the 9th through 12th grades. Data were analyzed from October 15, 2020, to February 14, 2021.

EXPOSURES

Experiences of bullying and bullying perpetration based on race/ethnicity/national origin and other social identities (ie, gender identity, sexual orientation, religion, physical or mental disability, immigration status, other unspecified reason).

MAIN OUTCOMES AND MEASURES

Youth health (delayed well care; forgone medical care; physical, mental, or emotional limitations), mental health (nonsuicidal self-injury, suicidal ideation), and violence involvement (weapon perpetration or survivorship, fighting, sexual assault, adolescent relationship abuse, experiencing homicide of friend or family member) were assessed using self-reported items modeled on the Centers for Disease Control and Prevention Youth Risk Behavior Survey.

RESULTS

Among 3939 participants, the mean (SD) age was 15.7 (1.3) years; 1380 students (36.3%) identified as Black/African American, 2086 (53.7%) as assigned female at birth, 1021 (32.6%) as belonging to a sexual minority group, and 313 (10.0%) as gender diverse. Among reported social identities, race/ethnicity-based experiences of bullying (375 students [9.5%]) and bullying perpetration (209 students [5.8%]) were the most common. Youth with multiple stigmatized identities experienced even higher rates of experiences of IBB and IBB perpetration. Specifically, the highest rates of IBB were reported by gender diverse Black and Hispanic youth. Experiencing IBB based on multiple stigmatized identities was associated with all outcomes, including delayed well care (aOR, 1.41; 95% CI, 1.20-1.65), forgone medical care (aOR, 1.64; 95% CI, 1.44-1.87), nonsuicidal self-injury (aOR, 2.86; 95% CI, 2.53-3.24), suicidal ideation (aOR, 2.49; 95% CI, 2.20-2.83), and greater violence involvement (experiencing violence: aOR, 2.90; 95% CI, 2.45-3.43; homicide survivorship: aOR, 1.19; 95% CI, 1.06-1.33).

CONCLUSIONS AND RELEVANCE

These results further encourage the development of youth health, mental health, and violence prevention programs that address experiences of bullying based on multiple marginalized identities.

Conducting a Community "Street Survey" to Inform an Obesity Intervention: The WE Project

Using a community-based participatory research approach, a citywide survey was conducted to explore perceptions of obesity and interventions to reduce obesity within an African American urban community. More than 1300 surveys were collected within 3 months; 92.9% of respondents agreed or strongly agreed that obesity was an important health issue in the community and the majority indicated that family-based interventions were the preferred pathway for improving physical activity (86.0%) and nutrition (85.2%). Engaging community members in survey development and implementation was an effective approach to build local research capacity and establish a shared agenda of reaching a diverse sample of community residents.

Effect of the FDA Safety and Innovation Act on racial and gender diversity in neurosurgical device trials

OBJECTIVE

The US FDA uses evidence from clinical trials in its determination of safety and utility. However, these trials have often suffered from limited external validity and generalizability due to unrepresentative study populations with respect to clinical patient demographics. Section 907 of the FDA Safety and Innovation Act (FDASIA) of 2012 attempted to address this issue by mandating the reporting of certain study demographics in new device applications. However, no study has been performed on its effectiveness in the participant diversity of neurosurgical device trials.

METHODS

The FDA premarket approval (PMA) online database was queried for all original neurosurgical device submissions from January 1, 2006, to December 31, 2019. Endpoints of the study included racial and gender demographics of reported effectiveness trials, which were summated for each submission. Chi-square tests were performed on both endpoints for before and after years of FDASIA passage and implementation.

RESULTS

A total of 33 device approvals were analyzed, with 14 occurring before SIA implementation and 19 after. Most trials (96.97%) reported gender to the FDA, while 66.67% reported race and 63.64% reported ethnicity. Gender breakdown did not change significantly post-SIA (53.30% female, p = 0.884). Racial breakdown was significantly different from the 2010 US Census for all races (p < 0.001) both pre- and post-SIA. Only Native American race was significantly different in terms of representation post-SIA, increasing from 0% to 0.63% (p = 0.0187). There was no significant change in ethnicity.

CONCLUSIONS

The FDASIA, as currently written, does not appear to have had a significant impact on the racial or gender diversity of neurosurgical device clinical trial populations. This may be due to the noncompulsory nature of its guidance, or a lack of more stringent regulation on the composition of clinical trials themselves.

TechQuity is an imperative for health and technology business: Let's work together to achieve it

Open discussions of social justice and health inequities may be an uncommon focus within information technology science, business, and health care delivery partnerships. However, the COVID-19 pandemic—which disproportionately affected Black, indigenous, and people of color—has reinforced the need to examine and define roles that technology partners should play to lead anti-racism efforts through our work. In our perspective piece, we describe the imperative to prioritize TechQuity—equity and social justice as a technology business strategy—through collaborating in partnerships that focus on eliminating racial and social inequities.

Perceived protectiveness of research safeguards and influences on willingness to participate in research: A novel MTurk pilot study

Little is known about how individuals with mood disorders view the protectiveness of research safeguards, and whether their views affect their willingness to participate in psychiatric research. We conducted an online survey with 80 individuals (self-reported mood disorder [n = 25], self-reported good health [n = 55]) recruited via MTurk. We assessed respondents' perceptions of the protectiveness of five common research safeguards, as well as their willingness to participate in research that incorporates each safeguard. Perceived protectiveness was strongly related to willingness to participate in research for four of the safeguards. Our findings add to a limited literature on the motivations and perspectives of key stakeholders in psychiatric research.

A pilot study of a culturally-appropriate, educational intervention to increase participation in cancer clinical trials among African Americans and Latinos

AIM

Culturally-appropriate, educational programs are recommended to improve cancer clinical trial participation among African Americans and Latinos. This study investigated the effect of a culturally-appropriate, educational program on knowledge, trust in medical researchers, and intent for clinical trial participation among African Americans and Latinos in Middle Tennessee.

METHOD

Trained community health educators delivered a 30-min presentation with video testimonials to 198 participants in 13 town halls. A pre-post survey design was used to evaluate the intervention among 102 participants who completed both pre- and post-surveys one to two weeks after the session.

RESULTS

Paired-sample t-test showed significant increases in unadjusted mean scores for knowledge (p < 0.001), trust in medical researchers (p < 0.001), and willingness to participate in clinical trials (p = 0.003) after the town halls in the overall sample. After adjusting for gender and education, all three outcomes remained significant for the overall sample (knowledge: p < 0.001; trust in medical researchers: p < 0.001; willingness: p = 0.001) and for African Americans (knowledge: p < 0.001; trust in medical researchers: p = 0.007; willingness: p = 0.005). However, willingness to participate was no longer significant for Latinos (knowledge: p < 0.001; trust in medical researchers: p = 0.034; willingness: p = 0.084).

CONCLUSIONS

The culturally-appropriate, educational program showed promising results for short-term, clinical trial outcomes. Further studies should examine efficacy to improve research participation outcomes.

Inequities in Hypertension Control in the United States Exposed and Exacerbated by COVID-19 and the Role of Home Blood Pressure and Virtual Health Care During and After the COVID-19 Pandemic

The COVID‐19 pandemic is a public health crisis, having killed more than 514 000 US adults as of March 2, 2021. COVID‐19 mitigation strategies have unintended consequences on managing chronic conditions such as hypertension, a leading cause of cardiovascular disease and health disparities in the United States. During the first wave of the pandemic in the United States, the combination of observed racial/ethnic inequities in COVID‐19 deaths and social unrest reinvigorated a national conversation about systemic racism in health care and society. The 4th Annual University of Utah Translational Hypertension Symposium gathered frontline clinicians, researchers, and leaders from diverse backgrounds to discuss the intersection of these 2 critical social and public health phenomena and to highlight preexisting disparities in hypertension treatment and control exacerbated by COVID‐19. The discussion underscored environmental and socioeconomic factors that are deeply embedded in US health care and research that impact inequities in hypertension. Structural racism plays a central role at both the health system and individual levels. At the same time, virtual healthcare platforms are being accelerated into widespread use by COVID‐19, which may widen the divide in healthcare access across levels of wealth, geography, and education. Blood pressure control rates are declining, especially among communities of color and those without health insurance or access to health care. Hypertension awareness, therapeutic lifestyle changes, and evidence‐based pharmacotherapy are essential. There is a need to improve the implementation of community‐based interventions and blood pressure self‐monitoring, which can help build patient trust and increase healthcare engagement.

Using Critical Race Theory to Understand Trial Participation Among Black Individuals with Systemic Lupus Erythematosus: A Qualitative Study of Patients and Caregivers

OBJECTIVE

Black patients with systemic lupus erythematous (SLE) experience greater disease incidence and severity than White patients yet are underrepresented in SLE clinical trials. We applied Critical Race Theory to qualitatively explore the influence of racism on the underrepresentation of Black patients in SLE clinical trials and to develop a framework for future intervention.

METHODS

We conducted groups in Chicago and Boston with Black adults (age ≥18 years) with SLE and their caregivers. We queried participants' knowledge about clinical trials, factors that might motivate or hinder trial participation, and how race and experiences of racism might impact clinical trial participation. Focus group responses were transcribed verbatim and analyzed thematically.

RESULTS

We held four focus groups (N=31); 20 participants had SLE, 11 were caregivers. All participants were Black, 90% were female and the mean age was 54 years. Qualitative analyses revealed several themes that negatively impact trial participation including mistrust related to racism, concerns about assignment to placebo groups, strict study exclusion criteria, and SLE-related concerns. Factors that motivated trial participation included recommendations from physicians and reputable institutions, a desire to help the greater good, and culturally-sensitive marketing of trials.

CONCLUSION

Actions to improve clinical trial participation among Black individuals should focus on reframing how trial information is presented and disseminated and on reevaluating barriers that may restrict trial participation. Additionally, researchers must acknowledge and respond to the presence of racial bias in healthcare. Community-Academic Partnerships may help build trust and reduce fears of mistreatment among Black individuals with SLE.

Need for Ethnic and Population Diversity in Psychosis Research

This article aims to evaluate "racial", ethnic, and population diversity-or lack thereof-in psychosis research, with a particular focus on socio-environmental studies. Samples of psychosis research remain heavily biased toward Western, Educated, Industrialized, Rich, and Democratic (WEIRD) societies. Furthermore, we often fail to acknowledge the lack of diversity, thereby implying that our findings can be generalized to all populations regardless of their social, ethnic, and cultural background. This has major consequences. Clinical trials generate findings that are not generalizable across ethnicity. The genomic-based prediction models are far from being applicable to the "Majority World." Socio-environmental theories of psychosis are solely based on findings of the empirical studies conducted in WEIRD populations. If and how these socio-environmental factors affect individuals in entirely different geographic locations, gene pools, social structures and norms, cultures, and potentially protective counter-factors remain unclear. How socio-environmental factors are assessed and studied is another major shortcoming. By embracing the complexity of environment, the exposome paradigm may facilitate the evaluation of interdependent exposures, which could explain how variations in socio-environmental factors across different social and geographical settings could contribute to divergent paths to psychosis. Testing these divergent paths to psychosis will however require increasing the diversity of study populations that could be achieved by establishing true partnerships between WEIRD societies and the Majority World with the support of funding agencies aspired to foster replicable research across diverse populations. The time has come to make diversity in psychosis research more than a buzzword.

Stigma as a Barrier to Participant Recruitment of Minority Populations in Diabetes Research: Development of a Community-Centered Recruitment Approach

BACKGROUND

The development of evidence-based care geared towards Black and Latina women living with uncontrolled type 2 diabetes is contingent upon their active recruitment into clinical interventions. Well-documented impediments to recruitment include a historical mistrust of the research community and socioeconomic factors that limit awareness and access to research studies. Although sociocultural and socioeconomic factors deter minorities from participating in clinical research, it is equally important to consider the role of stigma in chronic disease intervention studies.

OBJECTIVE

We aim to share our discovery of diabetes-related stigma as an underrecognized impediment to recruitment for the Women in Control 2.0 virtual diabetes self-management education study.

METHODS

Our initial recruitment plan used traditional strategies to recruit minority women with uncontrolled type 2 diabetes, which included letters and phone calls to targeted patients, referrals from clinicians, and posted flyers. After engaging a patient advisory group and consulting with experts in community advocacy, diabetes-related stigma emerged as a prominent barrier to recruitment. The study team reviewed and revised recruitment scripts and outreach material in order to better align with the lived experience and needs of potential enrollees.

RESULTS

Using a more nuanced, community-centered recruitment approach, we achieved our target recruitment goal, enrolling 309 participants into the study, exceeding our target of 212.

CONCLUSIONS

There is a need for updated recruitment methods that can increase research participation of patients who experience internalized diabetes stigma. To address disparities in minority health, further research is needed to better understand diabetes-related stigma and devise strategies to avert or address it.

Determinants of kidney transplant candidates' decision to accept organ donor intervention transplants and participate in post-transplant research: A conjoint analysis

Deceased organ donor intervention research aims to increase organ quality and quantity for transplantation. We assessed the proportion of kidney transplant candidates who would accept "intervention organs," participate in organ intervention research, and factors influencing acceptance. Kidney transplant candidates were presented 12 hypothetical scenarios, which varied three attributes, donor age, predicted waiting time to receive another organ offer, and research risk to the organ. Candidates were also randomly assigned to one of two conditions varying recipient risk. For each scenario, candidates agreed to accept the intervention organ or remain waitlisted. We fit a multivariable logit model to determine the association between scenario attributes and the acceptance decision. Of 249 participants, most (96%) accepted intervention organs under some or all conditions. Factors independently associated with candidates' greater likelihood of accepting an intervention organ included: low risk to the kidney from the intervention (OR 20.53 [95% Confidence Interval (CI), 13.91-30.29]); younger donor age (OR 3.72 [95% CI, 2.83-4.89]), longer time until the next organ offer (OR 3.48 [95% CI, 2.65-4.57]), and greater trust in their transplant physician (OR 1.03 [95% CI, 1.00-1.06]). Candidates with a lower likelihood of acceptance had been waitlisted longer (OR 0.97 per month [95% CI, 0.96-0.99]) and were Black (OR 0.21 [95% CI, 0.08-0.55]). Most candidates would accept an intervention organ, which should encourage transplant leaders to conduct deceased donor organ intervention trials.

Black and Latino Persons Living with HIV Evidence Risk and Resilience in the Context of COVID-19: A Mixed-Methods Study of the Early Phase of the Pandemic

The COVID-19 pandemic has great potential to disrupt the lives of persons living with HIV (PLWH). The present convergent parallel design mixed-methods study explored the early effects of COVID-19 on African American/Black or Latino (AABL) long-term survivors of HIV in a pandemic epicenter, New York City. A total of 96 AABL PLWH were recruited from a larger study of PLWH with non-suppressed HIV viral load. They engaged in structured assessments focused on knowledge, testing, trust in information sources, and potential emotional, social, and behavioral impacts. Twenty-six of these participants were randomly selected for in-depth semi-structured interviews. Participants were mostly men (64%), African American/Black (75%), and had lived with HIV for 17 years, on average (SD=9 years). Quantitative results revealed high levels of concern about and the adoption of recommended COVID-19 prevention recommendations. HIV care visits were commonly canceled but, overall, engagement in HIV care and antiretroviral therapy use were not seriously disrupted. Trust in local sources of information was higher than trust in various federal sources. Qualitative findings complemented and enriched quantitative results and provided a multifaceted description of both risk factors (e.g., phones/internet access were inadequate for some forms of telehealth) and resilience (e.g., “hustling” for food supplies). Participants drew a direct line between structural racism and the disproportional adverse effects of COVID-19 on communities of color, and their knowledge gleaned from the HIV pandemic was applied to COVID-19. Implications for future crisis preparedness are provided, including how the National HIV/AIDS Strategy can serve as a model to prevent COVID-19 from becoming another pandemic of the poor.

Understanding racial disparities in the care of patients with irritable bowel syndrome: The need for a unified approach

Irritable bowel syndrome (IBS) is a highly prevalent disorder of gut-brain interaction, which significantly erodes the quality of life of those it affects. Recent studies have confirmed that its prevalence varies quite markedly between countries, implying that it is affected by cultural and socioeconomic factors. In an important study, Silvernale at al. have recently reported racial disparities including potential referral biases, with reduced opportunities to access specialist care and differing patterns of healthcare utilization affecting ethnic minority populations with IBS. Similar disparities have also been reported for other gastrointestinal disorders. In this paper, we, therefore, discuss the potential implications of such disparities and how they can impact clinical outcomes, and discuss ways in which this problem could be addressed, and highlighting areas for future research.

Pre-procedural barriers to accessing novel treatments for aortic stenosis among racial/ethnic minorities in the veterans affairs healthcare system

Background

Novel structural heart procedures offer life-saving treatment advantages, yet little is known about pre-procedural barriers to care by race/ethnicity.

Methods

All echocardiograms performed at a Veterans Affairs hospital from 2015 to 2019 were reviewed to identify patients with severe aortic stenosis and their access to transcatheter aortic valve replacement (TAVR) by race/ethnicity.

Results

From 19,403 echocardiograms, 355 individuals were identified to have severe aortic stenosis (72.6% White, 9.8% Hispanic, 3.9% Black). There was a non-significant trend towards increased TAVR treatment among White compared to non-White patients (OR 2.02, CI 0.96-4.24, p = 0.063), which attenuated after adjustment for age and comorbidities. Reasons for not undergoing replacement included poor procedural candidacy (25.3%), loss of follow-up (17.8%), and patient refusal (16.4%).

Conclusions

Racial/ethnic inequities were not detected in novel structural heart treatment within the VA. However, a high proportion of eligible patients did not receive procedural treatment due to patient refusal or loss of follow-up, highlighting barriers that require further study.

Use of a Qualitative Story Deck to Create Scenarios and Uncover Factors Associated with African American Participation in Genomics Research

To gain a complex understanding of willingness to participate in genomics research among African Americans, we developed a technique specifically suited to studying decision making in a relaxed social setting. The "Qualitative Story Deck," (QSD) is a gamified, structured elicitation technique that allows for the spontaneous creation of scenarios with variable attributes. We used the QSD to create research scenarios that varied on four details (race/ethnicity of the researcher; research goal; biospecimen requested; and institutional affiliation). Participants created scenarios by randomly choosing cards from these categories and provided: (1) a judgement about their willingness to participate in the research project represented; and (2) their thought process in reaching a decision. The QSD has applicability to topics involving decision making or in cases where it would be beneficial to provide vignettes with alternate attributes. Additional benefits include: rapid establishment of rapport and engagement and the facilitation of discussion of little known or sensitive topics.

Individual and social determinants of COVID-19 vaccine uptake

Background

COVID-19 has had a devastating impact and efforts are being made to speed up vaccinations. The growing problem of vaccine hesitancy may affect the uptake of COVID-19 vaccine. We examined the individual, communication and social determinants associated with vaccines uptake.

Methods

Data come from a nationwide online probability-based panel of 1012 representative adults in the United States and the survey was conducted before the vaccines were available. People under the federal poverty level and racial and ethnic minorities were oversampled. Our outcome variables of interest were likelihood of vaccinating self and likelihood of vaccinating people under one’s care (such as children) measuring behavioral intentions. Independent variables included perceptions of risk, exposure to different media for COVID-19 news, political party identification, confidence in scientists and social determinants of health. Logistic regression analysis was used to ascertain the effects of independent variables on the two outcome variables.

Results

The results indicated that 68 and 65% agreed to get the vaccine for themselves and people under their care, respectively. Risk perceptions (severity of and susceptibility to COVID-19) were significantly associated with vaccine uptake. People who relied on “conservative” news outlets, Republicans, and who had low confidence in scientists are least likely to vaccinate self or children. Non-Hispanic Blacks and those with least schooling were also less likely to receive vaccine for themselves or people in their care.

Conclusions

Our study identified race/ethnicity, risk perceptions, exposure to different media for COVID-19 news, party identification and confidence in scientists as factors that would be affecting COVID-19 vaccine uptake. The good news is that these are addressable through strategic public health communications, but a lot of work remains to be done with some urgency.

Burn model system national longitudinal database representativeness by race, ethnicity, gender, and age

INTRODUCTION

Representativeness of research populations impacts the ability to extrapolate findings. The Burn Model System (BMS) National Database is one of the largest prospective, longitudinal, multi-center research repositories collecting patient-reported outcomes after burn injury.

OBJECTIVE

To assess if the BMS Database is representative of the population that is eligible to participate.

DESIGN

Data on adult burn survivors who were eligible for the BMS Database from 2015 to 2019 were analyzed.

SETTING

Not applicable.

PARTICIPANTS

Burn survivors treated at BMS centers meeting eligibility criteria for the BMS Database. Eligibility for the database is based on burn size and receipt of autografting surgery.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE(S)

Race, ethnicity, gender, and age were compared between individuals who did and did not enroll. Regression analysis examined the correlation between demographic characteristics and study enrollment. Additional regression analysis examined the association between enrollment and the intersection of race, ethnicity, and gender.

RESULTS

A total of 982 adult burn survivors were eligible for the BMS database during the study period. Of those who were eligible, 72.1% Enrolled and 27.9% were Not Enrolled. The Enrolled group included more female and more younger survivors compared to the Not Enrolled group. In regression analyses, Black/African American burn survivors were less likely and individuals identifying as female were more likely to enroll in the BMS Database. Furthermore, White men and women were more likely to enroll compared to Black/African American men and women, and non-Hispanic/Latino men were more likely to enroll compared to Hispanic/Latino men.

CONCLUSIONS

This study found differences in BMS Database enrollment by race, ethnicity, and gender. Further research is warranted to investigate causes for the disparities found in this study. In addition, strategies are needed to improve enrollment to ensure future representativeness.

Fostering the trustworthiness of researchers: SPECS and the role of ethical reflexivity in novel neurotechnology research

The development of novel neurotechnologies, such as brain-computer interface (BCI) and deep-brain stimulation (DBS), are very promising in improving the welfare and life prospects many people. These include life-changing therapies for medical conditions and enhancements of cognitive, emotional, and moral capacities. Yet there are also numerous moral risks and uncertainties involved in developing novel neurotechnologies. For this reason, the progress of novel neurotechnology research requires that diverse publics place trust in researchers to develop neural interfaces in ways that are overall beneficial to society and responsive to ethical values and concerns. In this article, we argue that researchers and research institutions have a moral responsibility to foster and demonstrate trustworthiness with respect to broader publics whose lives will be affected by their research. Using Annette Baier’s conceptual analysis of trust, which takes competence and good will to be its central components, we propose that practices of ethical reflexivity could play a valuable role in fostering the trustworthiness of individual researchers and research institutions through building and exhibiting their moral competence and good will. By ethical reflexivity, we mean the reflective and discursive activity of articulating, analyzing, and assessing the assumptions and values that might be underlying their ethical actions and projects. Here, we share an ethics dialog tool—called the Scientific Perspectives and Ethics Commitments Survey (or SPECS)—developed by the University of Washington’s Center of Neurotechnology (CNT) Neuroethics Thrust. Ultimately, the aim is to show the promise of ethical reflexivity practices, like SPECS, as a method of enhancing trustworthiness in researchers and their institutions that seek to develop novel neurotechnologies for the overall benefit of society.

Social inequalities in accelerated aging among southern U.S. women: an analysis of the biosocial and behavioral pathways linking social determinants to telomere length

Few studies have examined the biosocial pathways linking socioeconomic status (SES) to accelerated aging in a population-based sample of southern US women. Even fewer have examined the importance of chronic compared to perceived stress in linking SES to women's salivary telomere length (STL). Using data from a probability-based sample of 156 US women and structural equation modeling, we examined three pathways - chronic stress exposure, stress appraisal, and coping behavior - linking SES to STL. SES was positively associated with STL (β_TE = 0.16, p < .05). Everyday discrimination was negatively associated with STL (β_DE = -0.21, p < .05), but perceived stress was positively associated with STL (β_DE = 0.20, p < .05). Current smoking decreased STL (β_DE = -0.19, p < .01). Perceived stress acted to suppress the negative relationship of chronic stress exposure on STL. Given the dearth of STL studies that include measures of both perceived and chronic stress, our study supports the importance of disentangling stress measures and a biosocial approach to the study of accelerated aging.

Adopting a "Compound" Exposome Approach in Environmental Aging Biomarker Research: A Call to Action for Advancing Racial Health Equity

BACKGROUND

In June 2020, the National Academies of Sciences, Engineering, and Medicine hosted a virtual workshop focused on integrating the science of aging and environmental health research. The concurrent COVID-19 pandemic and national attention on racism exposed shortcomings in the environmental research field's conceptualization and methodological use of race, which have subsequently hindered the ability of research to address racial health disparities. By the workshop's conclusion, the authors deduced that the utility of environmental aging biomarkers-aging biomarkers shown to be specifically influenced by environmental exposures-would be greatly diminished if these biomarkers are developed absent of considerations of broader societal factors-like structural racism-that impinge on racial health equity.

OBJECTIVES

The authors reached a post-workshop consensus recommendation: To advance racial health equity, a "compound" exposome approach should be widely adopted in environmental aging biomarker research. We present this recommendation here.

DISCUSSION

The authors believe that without explicit considerations of racial health equity, people in most need of the benefits afforded by a better understanding of the relationships between exposures and aging will be the least likely to receive them because biomarkers may not encompass cumulative impacts from their unique social and environmental stressors. Employing an exposome approach that allows for more comprehensive exposure-disease pathway characterization across broad domains, including the social exposome and neighborhood factors, is the first step. Exposome-centered study designs must then be supported with efforts aimed at increasing the recruitment and retention of racially diverse study populations and researchers and further "compounded" with strategies directed at improving the use and interpretation of race throughout the publication and dissemination process. This compound exposome approach maximizes the ability of our science to identify environmental aging biomarkers that explicate racial disparities in health and best positions the environmental research community to contribute to the elimination of racial health disparities. https://doi.org/10.1289/EHP8392.

Reporting of Study Participant Demographic Characteristics and Demographic Representation in Premarketing and Postmarketing Studies of Novel Cancer Therapeutics

Importance

Adequate representation of demographic subgroups in premarketing and postmarketing clinical studies is necessary for understanding the safety and efficacy associated with novel cancer therapeutics.

Objective

To characterize and compare the reporting of demographic data and the representation of individuals by sex, age, and race in premarketing and postmarketing studies used by the Food and Drug Administration (FDA) to evaluate novel cancer therapeutics.

Design, Setting, and Participants

In this cross-sectional study, premarketing and postmarketing studies for novel cancer therapeutics approved by the FDA from 2012 through 2016 were identified. Study demographic information was abstracted from publicly available sources, and US cancer population demographic data was abstracted from US Cancer Statistics. Analyses were conducted from February 25 through September 21, 2020.

Main Outcomes and Measures

The percentages of trials reporting sex, age, and race/ethnicity were calculated, and participation to prevalence ratios (PPRs) were calculated by dividing the percentage of study participants in each demographic group by the percentage of the US cancer population in each group. PPRs were constructed for premarketing and postmarketing studies and by cancer type. Underrepresentation was defined as PPR less than 0.8.

Results

From 2012 through 2016, the FDA approved 45 cancer therapeutics. The study sample included 77 premarketing studies and 56 postmarketing studies. Postmarketing studies, compared with premarketing studies, were less likely to report patient sex (42 studies reporting [75.0%] vs 77 studies reporting [100%]; P < .001) and race (27 studies reporting [48.2%] vs 62 studies reporting [80.5%]; P < .001). Women were adequately represented in premarketing studies (mean [SD] PPR, 0.91; 95% CI, 0.90-0.91) and postmarketing studies (mean PPR, 1.00; 95% CI, 1.00-1.01). Although older adults and Black patients were underrepresented in premarketing studies (older adults: mean PPR, 0.73; 95% CI, 0.72-0.74; Black patients: mean PPR, 0.32; 95% CI, 0.31-0.32), these groups continued to be underrepresented in postmarketing studies (older adults: mean PPR, 0.75; 95% CI, 0.75-0.76; Black patients: mean PPR, 0.21; 95% CI, 0.21-0.21).

Conclusions and Relevance

This study found that older adults and Black patients were underrepresented in postmarketing studies of novel cancer therapeutics to a similar degree that they were underrepresented in premarketing studies. These findings suggest that postmarketing studies are not associated with improvements to gaps in demographic representation present at the time of FDA approval.

A free mailed naloxone program in Philadelphia amidst the COVID-19 pandemic

BACKGROUND

Access to naloxone is essential as the overdose crisis persists. We described barriers to accessing naloxone among individuals who requested and received the medication from a free mailed program and explored the relationship between how individuals with and without personal proximity to overdose learned about the program.

METHODS

Secondary analysis of data from a web-based form collected 1st March 2020 to 31st January 2021. Access barriers, personal proximity to overdose (broadly defined as personally overdosing or witnessing/worrying about others overdosing), and method of learning about the program were categorized and described.

RESULTS

Among 422 respondents, the most frequently reported barriers to accessing naloxone were: COVID quarantine (25.1%), lack of knowledge about access (13.2%), and cost (11.2%). Compared to those without personal proximity to overdose (38.2%), individuals with personal proximity (61.8%) heard about the program more often through an active online search (21.4% vs. 8.8%; p-value = 0.001) and less often through word of mouth (19.8% vs. 40.9%; p-value = <0.001).

CONCLUSIONS

Longstanding barriers to naloxone access are compounded by the COVID-19 pandemic, making mailing programs especially salient. Differences in ways that individuals with and without personal proximity to substance use and overdose learned about this program can inform how such programs can effectively reach their target audience.

Challenges in Diversity, Equity, and Inclusion in Research and Clinical Oncology

Disparities are common and well-known in the field of clinical oncology and cancer research. In patient care, poor access and a number of other factors disadvantage patients and this can lead to inadequate screening, prevention or treatment of cancer and poor patient outcomes. World-wide, socioeconomic status, health care expenditures and a number of other challenges contribute to disparities in cancer care and patient outcomes. Access to cancer clinical trials remains inadequate for underrepresented minorities as well as non-white racial and ethnic groups. There are also disparities and many challenges in the biomedical research enterprise that can limit innovation and that must be addressed as part of active interventions.

Responding to the COVID-19 pandemic: University rankings or co-operatives as a strategy for developing an equitable and resilient post-secondary education sector?

University leaders, governments, industries and donors use university rankings to assess the success or failure of higher education institutions; however, these rankings tell us nothing about how universities are challenging or amplifying oppression in response to the COVID-19 pandemic. This article first examines the implications of the incompatible aims of universities: performing well based on rankings while espousing commitments to equity and anti-oppressive practices. Second, this article proposes co-operatives as a strategy for developing a more equitable and resilient post-secondary education sector. The assumption underpinning this proposal is that without structural changes to higher education, COVID-19 will amplify an already inequitable distribution of resources and lessen the ability of universities to play a responsible role in expanding public debate and increasing understanding of critical issues facing the planet. Co-operatives could be an effective way for the sector to engage with the need to radically alter how we interact with each other and the natural world, both now and beyond the pandemic.

Aging and COVID-19 in Minority Populations: a Perfect Storm

PURPOSE OF REVIEW

COVID-19 is a major concern for the health and wellbeing of individuals worldwide. As COVID-19 cases and deaths continue to increase in the USA, aging Black and Hispanic populations have emerged as especially at-risk for increased exposure to COVID-19 and susceptibility to severe health outcomes. The current review discusses the weathering hypothesis and the influence of social inequality on the identified health disparities.

RECENT FINDINGS

Aging minoritized populations have endured structural and social inequality over the lifecourse. Consequently, these populations experience weathering, a process that results in physiological dysregulation due to stress associated with persistent disadvantage. Through weathering and continued inequity, aging minoritized populations have an increased risk of exposure and poor health outcomes from COVID-19.

SUMMARY

Current literature and available data suggests that aging minoritized persons experience high rates of COVID-19 morbidity and mortality. The current review hypothesizes and supports that observed disparities are the result of inequalities that especially affect Black and Hispanic populations over the lifecourse. Future efforts to address these disparities should emphasize research that supports governments in identifying at-risk groups, providing accessible COVID-19-related information to those groups, and implementing policy that addresses the structural and social inequities that perpetuate current COVID-19 disparities.

Peer coach delivered storytelling program improved diabetes medication adherence: A cluster randomized trial

BACKGROUND

Because medication adherence is linked to better diabetes outcomes, numerous interventions have aimed to improve adherence. However, suboptimal adherence persists and necessitate continued research into intervention strategies. This study evaluated the effectiveness of an intervention that combined storytelling and peer support to improve medication adherence and health outcomes in adults with diabetes.

METHODS

Living Well with Diabetes was a cluster randomized controlled trial. Intervention participants received a six-month, 11-session peer-delivered behavioral diabetes self-care program over the phone. Control participants received a self-paced general health program. Outcomes were changes in medication adherence and physiologic measures (hemoglobin A1c, systolic blood pressure, low-density lipoprotein cholesterol, body mass index).

RESULTS

Of the 403 participants with follow-up data, mean age was 57 (±SD 11), 78% were female, 91% were African American, 56.4% had high school education or less, and 70% had an annual income of < $20,000. At follow-up, compared to controls, intervention participants had greater improvement in medication adherence (β = -0.25 [95% CI -0.35, -0.15]). Physiologic measures did not change significantly in either group. Intervention participants had significant improvements in beliefs about the necessity of medications (β = 0.87 [95% CI 0.27, 1.47]) concerns about the negative effects of medication (β = -0.91 [95% CI -1.35, -0.47]), and beliefs that medications are harmful (β = -0.50 [95% CI -0.89, -0.10]). In addition, medication use self-efficacy significantly improved in intervention participants (β = 1.0 [95% CI 0.23, 1.76]). 473 individuals were enrolled in the study and randomized.

DISCUSSION

Living Well intervention resulted in improved medication adherence, medication beliefs, and medication use self-efficacy but not improved risk factor levels.

It Starts with a Conversation: The Importance of Values as Building Blocks of Engagement Strategies in Community-Centered Public Health Research

This study examined the life-motivating values of residents in underserved minority communities to inform the development of community engagement strategies. Semi-structured interviews were conducted to explore the main research questions: (1) what were the values of research participants, and (2) what did they consider important in their lives? The participants included twenty-seven ethnically diverse individuals living in low-income neighborhoods in New York City (NYC). Thematic analysis was performed to identify common themes and patterns related to the values that participants considered important in their lives. Three broad themes were identified: (1) benevolence; (2) universalism, and (3) self-direction. Benevolence implies a sense of belonging as the central meaning in life; community engagement strategies focused on this value emphasize concern for the welfare of loved ones. Community engagement strategies focused on universalism emphasize social justice and concern for the environment and the world. Finally, community engagement strategies focused on self-direction seek to satisfy participants' needs for control, autonomy, and mastery. This study introduces the Value-Based Framework for Community-Centered Research. It illustrates how value exploration is central to a community-centered approach to public health research and can be an important first step for designing studies that are better aligned with community needs and contexts. Such an approach can also help to co-create a "research identity" with community members and integrate their values into a project's purpose, thereby increasing community ownership and engagement in the study.

Messaging on Slow Impacts: Applying Lessons Learned from Climate Change Communication to Catalyze and Improve Marine Nutrient Communication

Building publics' understanding about human-environmental causes and impacts of nutrient pollution is difficult due to the diverse sources and, at times, extended timescales of increasing inputs, consequences to ecosystems, and recovery after remediation. Communicating environmental problems with "slow impacts" has long been a challenge for scientists, public health officials, and science communicators, as the time delay for subsequent consequences to become evident dilutes the sense of urgency to act. Fortunately, scientific research and practice in the field of climate change communication has begun to identify best practices to address these challenges. Climate change demonstrates a delay between environmental stressor and impact, and recommended practices for climate change communication illustrate how to explain and motivate action around this complex environmental problem. Climate change communication research provides scientific understanding of how people evaluate risk and scientific information about climate change. We used a qualitative coding approach to review the science communication and climate change communication literature to identify approaches that could be used for nutrients and how they could be applied. Recognizing the differences between climate change and impacts of nutrient pollution, we also explore how environmental problems with delayed impacts demand nuanced strategies for effective communication and public engagement. Applying generalizable approaches to successfully communicate the slow impacts related to nutrient pollution across geographic contexts will help build publics' understanding and urgency to act on comprehensive management of nutrient pollution, thereby increasing protection of coastal and marine environments.

Perceptions of clinical care and research among African-American patients with lymphoma

Across lymphoma subtypes, African Americans experience disparities in clinical trial enrollment and outcomes. Understanding the needs of this population can aid addressing these disparities. Semi-structured interviews were conducted with 14 self-identified Black/African-American lymphoma patients to determine their perceptions and attitudes about aspects of treatment and research. Constant-comparative methods identified themes including trust in medical staff, lack of diagnosis information, interest in research, research priorities, and potentially unaddressed emotional needs. Patients trusted their doctors and desired more diagnosis information. Participants often did not consider the emotions surrounding their diagnoses and concentrated on positive attitudes during treatment. Most participants were interested in clinical trials to help future lymphoma patients. Participants suggested a range of future research topics emphasizing lymphoma etiology. Building on trusting doctor-patient relationships, expanding clinical trials information, addressing emotional needs, and aligning research objectives with patient concerns are potential strategies for increasing clinical trial enrollment among Black lymphoma patients.

What YouTube narratives reveal about online support, counseling entrance, and how Black Americans manage depression symptomatology

This manuscript explores the depression disease management of Black Americans (N = 50) who post their experiences on YouTube. The narratives garnered five themes: (1) personal and national histories as a barrier to treatment and contributor to depression, (2) utilizing the social network as informal counseling and as the catalyst for formal counseling, (3) long-term undiagnosed depression management and mismanagement, (4) advocating to destigmatize and treat depression, and (5) positive experiences initiating and engaging in treatment. Novel findings include how participants discuss narratives in third person, the importance of the Youtube community, and advocacy to destigmatize and treat depression.

Community-Engaged Approaches for Minority Recruitment Into Clinical Research: A Scoping Review of the Literature

Underrepresentation of racial and ethnic minority populations in clinical research persists in the United States, highlighting the unmet ideals of generalizability and equity of research findings and products. Previous systematic reviews exploring various facets of this phenomenon concluded that community engagement with minority groups may effectively promote recruitment and retention, but the ways in which community-engaged approaches have been used for recruitment have not been examined. We performed a scoping review of the literature to identify studies of community-engaged recruitment processes. The search resulted in 2842 articles, of which 66 met inclusion criteria. These articles demonstrated a relatively large literature base of descriptive studies conveying details of community engagement approaches to enhance recruitment of minority research participants. We summarize key aspects of current practices across the spectrum of community engagement. A gap in the literature is the relative lack of the comparative studies among different engagement strategies.

Talking About Public Health With African American Men: Perceptions of Environmental Health and Infertility

While the past two decades have seen rapid advances in research demonstrating links between environmental health and reproductive capacity, African American men have largely been overlooked as study participants. To give voice to the perceptions of urban African American men, the present qualitative study conducted focus groups of men recruited from street- and internet-based advertisements in Washington, DC. Participants were asked for their perspectives on their environment, reproductive health and fertility, and factors that would influence their participation in public health research. Participants expressed concern about ubiquitous environmental exposures characteristic of their living environments, which they attributed in part to gentrification and urban development. Infertility was seen as a threat to masculinity and a taboo subject in the African American community and several participants shared personal stories describing a general code of silence about the subject. Each group offered multiple suggestions for recruiting African American men into research studies; facilitators for study participation included cultural relevance, incentives, transparent communication, internet- and community-based recruitment, and use of African Americans and/or recruiters of color as part of the research team. When asked whether participants would participate in a hypothetical study on fertility that involved providing a sperm sample, there was a mixed reaction, with some expressing concern about how such a sample would be used and others describing a few facilitators for participation in such a study. These are unique perspectives that are largely missing from current-day evidence on the inclusion of African American men in environmental health and reproductive health research.

Development of a web tool to increase research literacy in underserved populations through public library partnerships

OBJECTIVE

Inadequate diversity in clinical trials is widely recognized as a significant contributing factor to health disparities experienced by racial/ethnic minorities and other diverse populations in the US. To address this in a scalable way, we sought to develop a web tool that could help enhance underserved minority participation in clinical research.

METHODS

We used our research literacy support flashcard tool as the initial prototype for human-centered design and usability testing of the web tool Health for All in public library settings. After forming partnerships with leadership from Chicago Public Libraries (CPL), local medical libraries, and the Chicago Department of Public Health, we conducted seven iterative design sessions with focus groups of library patrons and library staff from six CPL branches serving underserved communities followed by two rounds of usability testing and website modification.

RESULTS

Based on the qualitative research findings from Design Sessions 1-7, we enacted the design decision of a website that was a hybrid of fact-filled and vignette (personal stories) paper prototypes divided into 4 modules (trust, diversity, healthy volunteers, pros/cons), each with their own outcome metrics. The website was thus constructed, and navigation issues identified in two rounds of usability testing by library patrons were addressed through further website modification, followed by the launch of a beta version of a hybridized single-scrolling and guided module prototype to allow further development with website analytics.

CONCLUSIONS

We report the development of Health for All, a website designed to enhance racial/ethnic minority participation in clinical trials by imparting research literacy, mitigating distrust engendered by longstanding racism and discrimination, and providing connections to clinical trials recruiting participants.

Disparities in Research Participation by Level of Health Literacy

OBJECTIVE

To determine at which phase in the recruitment process for participation in clinical research studies do health literacy and other patient characteristics influence recruitment outcomes.

PATIENTS AND METHODS

Using a sample of 5872 patients hospitalized with cardiovascular disease approached for participation in the Vanderbilt Inpatient Cohort Study from October 2011 through December 2015, we examined the independent association of patients' health literacy with two steps in their research participation decision-making process: (1) research interest - willingness to hear more about a research study; and (2) research participation - the decision to enroll after an informed consent discussion. Best practices for effective health communication were implemented in recruitment approaches and informed consent processes. Using logistic regression models, we determined patient characteristics independently associated with patients' willingness to hear about and participate in the study.

RESULTS

In unadjusted analyses, participants with higher health literacy, and those who were younger, female, or had more education had higher levels of both research interest and research participation. Health literacy remained independently associated with both outcomes in multivariable models, after adjustment for sociodemographic factors.

CONCLUSION

Because identical variables predicted both research interest and eventual consent, efforts to recruit broad populations must include acceptable methods of approaching potential participants as well as explaining study materials.

Sex Differences in Willingness to Participate in Research Based on Study Risk Level Among a Community Sample of African Americans in North Central Florida

This study examined the association between sex, study risks and willingness to participate in research among a community sample of African Americans. We hypothesized that African American males would be more willing to participate in studies involving both minimal and greater-than-minimal risk. The study sample was recruited through a community engagement program (HealthStreet). Interviewers obtained information on socio-demographic variables and willingness to participate in various research types. We categorized research types into minimal risk and greater- than- minimal risk based on the IRB classification. The study sample comprised 6544 African-Americans; 58.4% were females. About 92.6% of the participants were willing to participate in surveys and 58.1% in research requiring medication use. More males would participate in minimal risk studies requiring review of medical records (males 87.0% vs. females 84.2%, p = 0.0021) and studies involving giving a blood sample (males 84.2% vs. females 81.7%, p = 0.0083). Also, more males would participate in greater than minimal risk studies involving the use of medication (60.5% v. 56.3% p = 0.0007). More males were willing to participate in minimal risk studies (studies involving the review of medical records and giving blood samples) and greater-than-minimal risk study involving the use of medication.

Sensing everyday activity: Parent perceptions and feasibility

Mobile and wearable sensors provide a unique opportunity to capture the daily activities and interactions that shape developmental trajectories, with potential to revolutionize the study of development (de Barbaro, 2019). However, developmental research employing sensors is still in its infancy, and parents' comfort using these devices is uncertain. This exploratory report assesses parent willingness to participate in sensor studies via a nationally representative survey (N = 210) and live recruitment of a low-income, minority population for an ongoing study (N = 359). The survey allowed us to assess how protocol design influences acceptability, including various options for devices and datastream resolution, conditions of data sharing, and feedback. By contrast, our recruitment data provided insight into parents' true willingness to participate in a sensor study, with a protocol including 72 h of continuous audio, motion, and physiological data. Our results indicate that parents are relatively conservative when considering participation in sensing studies. However, nearly 41 % of surveyed parents reported that they would be at least somewhat willing to participate in studies with audio or video recordings, 26 % were willing or extremely willing, and 14 % reported being extremely willing. These results roughly paralleled our recruitment results, where 58 % of parents indicated interest, 29 % of parents scheduled to participate, and 10 % ultimately participated. Additionally, 70 % of caregivers stated their reason for not participating in the study was due to barriers unrelated to sensing while about 25 % noted barriers due to either privacy concerns or the physical sensors themselves. Parents' willingness to collect sensitive datastreams increased if data stayed within the household for individual use only, are shared anonymously with researchers, or if parents receive feedback from devices. Overall, our findings suggest that given the correct circumstances, mobile sensors are a feasible and promising tool for characterizing children's daily interactions and their role in development.

Racial/Ethnic Disparities in Maternal Vaccine Knowledge, Attitudes, and Intentions

OBJECTIVES

Although disparities in maternal vaccine acceptance among racial/ethnic groups are well documented, the reasons for these disparities are unclear. The objective of this study was to describe differences in pregnant women's knowledge, attitudes, beliefs, intentions, and trust regarding maternal and infant vaccines by race/ethnicity.

METHODS

We collected survey data from 1862 pregnant women from diverse prenatal care practices in Georgia and Colorado from June 2017 through July 2018. We performed multiple logistic regressions to determine differences in intentions, knowledge, attitudes, beliefs, and trust by race/ethnicity and calculated odds ratios (ORs) and 95% CIs.

RESULTS

Compared with White women, Black and Hispanic women were less confident in vaccine safety and efficacy and less likely to perceive risk of acquiring vaccine-preventable diseases, report provaccine social norms, indicate having enough vaccine knowledge, and trust vaccine information from health care providers and public health authorities. Black women were the least confident in the safety of the maternal influenza vaccine (OR = 0.37; 95% CI, 0.27-0.49); maternal tetanus, diphtheria, and acellular pertussis vaccine (OR = 0.37; 95% CI, 0.27-0.52); and infant vaccines overall (OR = 0.40; 95% CI, 0.28-0.58), and were least likely to intend to receive both maternal vaccines (OR = 0.35; 95% CI, 0.27-0.47) or all infant vaccines on time (OR = 0.45; 95% CI, 0.34-0.61) as compared with White women.

CONCLUSIONS

Understanding differences in behavioral constructs integral to vaccine decision making among women of different races/ethnicities can lead to tailored interventions to improve vaccine acceptance.