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Patterson JG, Russomanno J, Teferra AA, Jabson Tree JM. Disparities in food insecurity at the intersection of race and sexual orientation: A population-based study of adult women in the United States. SSM Popul Health 2020; 12:100655. [PMID: 32864410 PMCID: PMC7442904 DOI: 10.1016/j.ssmph.2020.100655] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 08/16/2020] [Accepted: 08/18/2020] [Indexed: 02/07/2023] Open
Abstract
Food insecurity affects 1 in 8 American adults annually, and is more prevalent in Black and sexual minority women. We applied an intersectional approach to investigate food insecurity prevalence in women with intersecting minority race and sexual orientation. We used two United States surveillance systems-National Health Interview Survey (NHIS) 2013-2018 and National Health and Nutrition Examination Survey (NHANES) 2005-2014, to estimate how race and sexual orientation jointly influence food insecurity prevalence in women aged 18-59 years (NHIS: N = 47596; NHANES: N = 5106). All analyses were stratified for Supplemental Nutrition Assistance Program (SNAP) use. Relative measures estimated weighted prevalence ratios (PR) comparing Black and White sexual minority women (SMW) to heterosexual White women. Absolute prevalence measures estimated the excess prevalence of food insecurity due to multiple marginalization. Patterns of food insecurity prevalence were similar across NHIS and NHANES, and differed only for non-SNAP users. Relative prevalence of food insecurity was greater in Black SMW than heterosexual White women in NHIS (PR: 2.16; 95% confidence interval [CI], 1.41-3.30) and NHANES (PR: 2.79; 95% CI, 1.73-4.51). The strength of the association between multiple marginalization and food insecurity was stronger for Black SMW than White SMW. Absolute measures were significant only for NHIS and did not support our a priori hypothesis: For non-SNAP users, being Black and sexual minority reduced the joint disparity in food insecurity by approximately 50% (Synergy Index: 0.52; 95% CI, 0.11-0.93). Overall, our study illuminated population-level differences in food insecurity among women of diverse minority races and sexual orientations. Black SMW experienced high rates of food insecurity, which may contribute to chronic disease disparities. Yet, intersecting minority social positions (race and sexual orientation) reduced food insecurity; these findings are unexpected and must be further investigated. Increasing SNAP use among multiply marginalized women may attenuate food insecurity disparities.
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Affiliation(s)
- Joanne G. Patterson
- The Ohio State University Comprehensive Cancer Center, 1841 Neil Avenue, 400A Cunz Hall, Columbus, OH, 43210, United States
| | - Jennifer Russomanno
- University of Tennessee Graduate School of Medicine, Office of Continuing Education & Professional Development, 1924 Alcoa Highway, Box U94, Knoxville, TN, 37920, United States
| | - Andreas A. Teferra
- The Ohio State University College of Public Health, 1841 Neil Avenue, Cunz Hall, Columbus, OH, 43210, United States
| | - Jennifer M. Jabson Tree
- University of Tennessee Department of Public Health, 1814 Andy Holt Avenue, 360 HPER, Knoxville, TN, 37996, United States
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Zota AR, VanNoy BN. Integrating Intersectionality Into the Exposome Paradigm: A Novel Approach to Racial Inequities in Uterine Fibroids. Am J Public Health 2020; 111:104-109. [PMID: 33211578 DOI: 10.2105/ajph.2020.305979] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Intersectionality is a critical theoretical framework that emphasizes the influence of intersecting systems of oppression on the lived experiences of people marginalized by inequity. Although applications of intersectionality are increasing in public health, this framework is absent in environmental health, which has instead focused on the exposome, a paradigm that considers the totality of an individual's environmental exposures across the life course.Despite advancements in the biological complexity of exposome models, they continue to fall short in addressing health inequities. Therefore, we highlight the need for integrating intersectionality into the exposome. We introduce key concepts and tools for environmental health scientists interested in operationalizing intersectionality in exposome studies and discuss examples of this innovative approach from our work on racial inequities in uterine fibroids.Our case studies illustrate how interlocking systems of racism and sexism may affect Black women's exposure to environmental chemicals, their epigenetic regulation of uterine fibroids, and their clinical care. Because health relies on biological and social-structural determinants and varies across different intersectional positions, our proposed framework may be a promising approach for understanding environmental health inequities and furthering social justice.
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Affiliation(s)
- Ami R Zota
- Ami R. Zota and Brianna N. VanNoy are affiliated with the Department of Environmental and Occupational Health, Milken Institute School of Public Health, The George Washington University, Washington, DC
| | - Brianna N VanNoy
- Ami R. Zota and Brianna N. VanNoy are affiliated with the Department of Environmental and Occupational Health, Milken Institute School of Public Health, The George Washington University, Washington, DC
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Swords DS, Scaife CL. Decompositions of the Contribution of Treatment Disparities to Survival Disparities in Stage I-II Pancreatic Adenocarcinoma. Ann Surg Oncol 2020; 28:3157-3168. [PMID: 33145705 DOI: 10.1245/s10434-020-09267-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 10/04/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND Higher socioeconomic status (SES) and non-Hispanic White (NHW) race/ethnicity are associated with higher treatment rates and longer overall survival (OS) among US patients with stage I-II pancreatic ductal adenocarcinoma. The proportion of OS disparities mediated through treatment disparities (PM) and the proportion predicted to be eliminated (PE) if treatment disparities were eliminated are unknown. METHODS We analyzed 2007-2015 data from the Surveillance, Epidemiology, and End Results (SEER) census tract-level database and the National Cancer Database (NCDB) using causal mediation analysis methods to understand the extent to which treatment disparities mediate OS disparities. In the first set of decompositions, race/ethnicity was controlled for as a covariate proximal to SES, and lower SES strata were compared with the highest SES stratum. In the second set, an intersectional perspective was taken and each SES-race/ethnicity combination was compared with highest SES-NHW patients, who had the highest treatment rates and longest OS. RESULTS The SEER and NCDB cohorts contained 16,921 patients and 44,638 patients, respectively. When race/ethnicity was controlled for, PMs ranged from 43 to 48% and PEs ranged from 46 to 50% for various lower SES strata. When separately comparing each SES-race/ethnicity combination with the highest SES-NHW patients, results were similar for lower SES-NHW patients but differed markedly for non-Hispanic Black and Hispanic patients, for whom PMs ranged from 60 to 80% and PEs ranged from 55 to 75% for most lower SES strata. CONCLUSIONS These results suggest that efforts to reduce treatment disparities are worthwhile, particularly for NHB and Hispanic patients, and simultaneously point to the importance of non-treatment-related causal pathways.
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Affiliation(s)
- Douglas S Swords
- Department of Surgery, University of Utah, Salt Lake City, UT, USA.
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Hsueh L, Werntz A, Hobaica S, Owens SA, Lumley MA, Washburn JJ. Clinical psychology PhD students' admission experiences: Implications for recruiting racial/ethnic minority and LGBTQ students. J Clin Psychol 2020; 77:105-120. [PMID: 33058189 DOI: 10.1002/jclp.23074] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 09/28/2020] [Accepted: 10/01/2020] [Indexed: 11/09/2022]
Abstract
AIM The purpose of this study was to explore differences in the clinical psychology PhD program admissions experience (i.e., interviewing and decision-making) by race/ethnicity and lesbian, gay, bisexual, transgender, and queer (LGBTQ) identity. METHODS Participants were 803 students (24% racial/ethnic minority; 19% LGBTQ) enrolled in US clinical psychology PhD programs. Two-group comparisons tested for differences in admission experiences by race/ethnicity and LGBTQ identity. RESULTS Racial/ethnic minority and LGBTQ students considered a programmatic commitment to diversity as more important in application decisions compared to non-Hispanic White and cisgender heterosexual students, respectively. LGBTQ students were more likely to be advised to not discuss personal information (e.g., sexual orientation) than cisgender heterosexual students. Racial/ethnic minority and LGBTQ students identified financial considerations and program outcomes as more important in their decision-making compared with non-Hispanic White and cisgender heterosexual students, respectively. CONCLUSION Increasing funding and fostering authentic training environments should be prioritized in institutional conversations around recruiting racial/ethnic minority and LGBTQ trainees.
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Affiliation(s)
- Loretta Hsueh
- Department of Psychology, Indiana University-Purdue University Indianapolis (IUPUI), Indianapolis, Indiana, USA
| | - Alexandra Werntz
- Department of Psychology, University of Virginia, Charlottesville, Virginia, USA
| | - Steven Hobaica
- Department of Psychology, Washington State University, Pullman, Washington, USA
| | - Sarah A Owens
- Department of Psychology and Neuroscience, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Mark A Lumley
- Department of Psychology, Wayne State University, Detroit, Michigan, USA
| | - Jason J Washburn
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Ettman CK, Cohen GH, Abdalla SM, Galea S. Do assets explain the relation between race/ethnicity and probable depression in U.S. adults? PLoS One 2020; 15:e0239618. [PMID: 33006988 PMCID: PMC7531850 DOI: 10.1371/journal.pone.0239618] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 09/09/2020] [Indexed: 11/19/2022] Open
Abstract
Depression is a leading cause of disability in the U.S. across all race/ethnicity groups. While non-Hispanic Black and Hispanic persons have worse physical health on most indicators than non-Hispanic White persons, the literature on the association between race/ethnicity and rates of depression is mixed. Given unequal distribution of assets across racial/ethnic groups, it is possible that social and economic differences may explain differential rates of depression across race/ethnicity groups. Using National Health and Nutrition Examination Survey (NHANES) data from 2007–2016, we constructed a nationally representative sample of 26,382 adults over 18 years old (11,072 non-Hispanic White, 5,610 non-Hispanic Black, 6,981 Hispanic, and 2,719 Other race). We measured symptoms of depression using the Patient Health Questionnaire-9 (PHQ-9), with a score of 10 or more indicating probable depression. We identified three kinds of assets: financial assets (income), physical assets (home ownership), and social assets (marital status and education). We estimated the weighted prevalence of probable depression across race/ethnicity groups, odds ratios controlling for assets, and predicted probabilities of probable depression across race/ethnicity and asset groups. Three results contribute to our understanding of the differences in probable depression rates between race/ethnicity groups: 1) Non-Hispanic Black and Hispanic persons had a higher weighted prevalence of probable depression in the U.S. than non-Hispanic White persons. In models unadjusted for assets, non-Hispanic Black and Hispanic persons had 1.3 greater odds of probable depression than non-Hispanic White persons (p<0.01). 2) We found an inverse relation between assets and probable depression across all race-ethnicity groups. Also, non-Hispanic Black and Hispanic persons had fewer assets than non-Hispanic Whites. 3) When we controlled for assets, non-Hispanic Black and Hispanic persons had 0.8 times lower odds of probable depression than non-Hispanic White persons (p<0.05). Thus, when holding assets constant, minorities had better mental health than non-Hispanic White persons in the U.S. These three findings help to reconcile findings in the literature on race/ethnicity and depression. Given vastly unequal distribution of wealth in the U.S., it is not surprising that racial minorities, who hold fewer assets, would have an overall larger prevalence of mental illness, as seen in unadjusted estimates. Once assets are taken into account, Black and Hispanic persons appear to have better mental health than non-Hispanic White persons. Assets may explain much of the relation between race/ethnicity group and depression in the U.S. Future research should consider the role of assets in protecting against mental illness.
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Affiliation(s)
- Catherine K. Ettman
- Office of the Dean, Boston University School of Public Health, Boston, Massachusetts, United States of America
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, United States of America
- * E-mail:
| | - Gregory H. Cohen
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, United States of America
- Department of Epidemiology, Columbia Mailman School of Public Health, NYC, New York, United States of America
| | - Salma M. Abdalla
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, United States of America
| | - Sandro Galea
- Office of the Dean, Boston University School of Public Health, Boston, Massachusetts, United States of America
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, United States of America
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Burke NL, Schaefer LM, Hazzard VM, Rodgers RF. Where identities converge: The importance of intersectionality in eating disorders research. Int J Eat Disord 2020; 53:1605-1609. [PMID: 32856342 PMCID: PMC7722117 DOI: 10.1002/eat.23371] [Citation(s) in RCA: 73] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Revised: 07/28/2020] [Accepted: 08/10/2020] [Indexed: 11/10/2022]
Abstract
Disparities in eating disorder (ED) risk, diagnosis, and treatment for those who occupy multiple marginalized social identities (e.g., combined racial/ethnic and sexual minority statuses), underscore the need for advancing multicultural research in the ED field. In this article, we argue that intersectionality-informed approaches, which examine the ways in which one's multiple social identities interact to inform risk for ED outcomes, offer an established framework for identifying frequently underserved individuals who may be at greatest risk for EDs. We highlight preliminary intersectional research in EDs and offer suggestions for further progression. In particular, we encourage future intersectionality-informed research to incorporate a broader range of social identities (e.g., age, ability status), consider the ways in which these identities may be dimensional and fluid, and embrace strengths-based approaches to illuminate dimensions of identity that may serve as protective factors. To support such research, we describe quantitative and qualitative methods for pursuing questions of intersectionality in ED investigations. Given the success of intersectionality-informed research in other areas of psychopathology and its relevance to ED as suggested by initial research, the continued pursuit of these approaches in EDs has high potential to improve identification and treatment for patients who have too often been overlooked.
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Affiliation(s)
- Natasha L. Burke
- Department of Psychology, Fordham University, 411 East Fordham Road, Dealy Hall, Bronx, NY 10458, USA
| | - Lauren M. Schaefer
- Sanford Center for Bio-behavioral Research, 120 Eighth Street South, Fargo, ND 58103, USA
| | - Vivienne M. Hazzard
- Sanford Center for Bio-behavioral Research, 120 Eighth Street South, Fargo, ND 58103, USA
| | - Rachel F. Rodgers
- Department of Applied Psychology, Northeastern University, 360 Huntington Avenue, Boston, MA 02115, USA,Department of Psychiatric Emergency & Acute Care, Lapeyronie Hospital, CHRU Montpellier, France
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Cuevas AG, Ong AD, Carvalho K, Ho T, Chan SW(C, Allen JD, Chen R, Rodgers J, Biba U, Williams DR. Discrimination and systemic inflammation: A critical review and synthesis. Brain Behav Immun 2020; 89:465-479. [PMID: 32688027 PMCID: PMC8362502 DOI: 10.1016/j.bbi.2020.07.017] [Citation(s) in RCA: 90] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Revised: 07/01/2020] [Accepted: 07/13/2020] [Indexed: 12/21/2022] Open
Abstract
Exposure to discrimination or unfair treatment has emerged as an important risk factor for illness and disease that disproportionately affects racial and ethnic minorities. Discriminatory experiences may operate like other stressors in that they activate physiological responses that adversely affect the maintenance of homeostasis. Research suggests that inflammation plays a critical role in the pathophysiology of stress-related diseases. Recent findings on discrimination and inflammation are discussed. We highlight limitations in the current evidence and provide recommendations for future studies that seek to examine the association between discrimination and inflammation.
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Affiliation(s)
- Adolfo G. Cuevas
- Department of Community Health, Tufts University, United States,Corresponding author at: Tufts University, Department of Community Health, 574 Boston Ave, Suite 208, Medford, MA 02155, United States. (A.G. Cuevas)
| | - Anthony D. Ong
- Department of Human Development, Cornell University, United States,Department of Medicine, Weill Cornell Medical College, United States
| | - Keri Carvalho
- Department of Community Health, Tufts University, United States
| | - Thao Ho
- Department of Community Health, Tufts University, United States
| | | | | | - Ruijia Chen
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, United States
| | - Justin Rodgers
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, United States
| | - Ursula Biba
- Department of Community Health, Tufts University, United States
| | - David R. Williams
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, United States,Department of African and African American Studies, Harvard University, United States
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58
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Nyamande FN, Mosquera PA, San Sebastián M, Gustafsson PE. Intersectional equity in health care: assessing complex inequities in primary and secondary care utilization by gender and education in northern Sweden. Int J Equity Health 2020; 19:159. [PMID: 32917207 PMCID: PMC7488463 DOI: 10.1186/s12939-020-01272-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 09/01/2020] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Knowledge remains scarce about inequities in health care utilization between groups defined, not only by single, but by multiple and intersecting social categories. This study aims to estimate intersectional horizontal inequities in health care utilization by gender and educational level in Northern Sweden, applying a novel methodological approach. METHODS Data on participants (N = 22,997) aged 16-84 years from Northern Sweden came from the 2014 Health on Equal Terms cross sectional survey. Primary (general practitioner) and secondary (specialist doctor) health care utilization and health care needs indicators were self-reported, and sociodemographic information came from registers. Four intersectional categories representing high and low educated men, and high and low educated women, were created, to estimate intersectional (joint, referent, and excess) inequalities, and needs-adjusted horizontal inequities in utilization. RESULTS Joint inequalities in primary care were large; 8.20 percentage points difference (95%CI: 6.40-9.99) higher utilization among low-educated women than high-educated men. Only the gender referent inequity remained after needs adjustment, with high- (but not low-) educated women utilizing care more frequently than high-educated men (3.66 percentage points difference (95%CI: 2.67-5.25)). In contrast, inequalities in specialist visits were dominated by referent educational inequalities, (5.69 percentage points difference (95%CI: 2.56-6.19), but with no significant horizontal inequity - by gender, education, or their combination - remaining after needs adjustment. CONCLUSION This study suggests a complex interaction of gender and educational inequities in access to care in Northern Sweden, with horizontal equity observable for secondary but not primary care. The study thereby illustrates the unique knowledge gained from an intersectional perspective to equity in health care.
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Affiliation(s)
- Fortune N Nyamande
- Department of Epidemiology and Global Health, Umeå University, 901 87, Umeå, Sweden
| | - Paola A Mosquera
- Department of Epidemiology and Global Health, Umeå University, 901 87, Umeå, Sweden
| | - Miguel San Sebastián
- Department of Epidemiology and Global Health, Umeå University, 901 87, Umeå, Sweden
| | - Per E Gustafsson
- Department of Epidemiology and Global Health, Umeå University, 901 87, Umeå, Sweden.
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Jackson CL, Walker JR, Brown MK, Das R, Jones NL. A workshop report on the causes and consequences of sleep health disparities. Sleep 2020; 43:zsaa037. [PMID: 32154560 PMCID: PMC7420527 DOI: 10.1093/sleep/zsaa037] [Citation(s) in RCA: 110] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 01/16/2020] [Indexed: 01/10/2023] Open
Abstract
Sleep deficiencies, which include insufficient or long sleep duration, poor sleep quality, and irregular timing of sleep, are disproportionately distributed among populations that experience health disparities in the United States. Sleep deficiencies are associated with a wide range of suboptimal health outcomes, high-risk health behaviors, and poorer overall functioning and well-being. This report focuses on sleep health disparities (SHDs), which is a term defined as differences in one or more dimensions of sleep health on a consistent basis that adversely affect designated disadvantaged populations. SHDs appear to share many of the same determinants and causal pathways observed for health outcomes with well-known disparities. There also appears to be common behavioral and biological mechanisms that connect sleep with poorer health outcomes, suggesting a link between SHDs and other health disparities observed within these designated populations. In 2018, the National Institute on Minority Health and Health Disparities, the National Heart, Lung, and Blood Institute, and the Office of Behavioral and Social Sciences Research convened a workshop with experts in sleep, circadian rhythms, and health disparities to identify research gaps, challenges, and opportunities to better understand and advance research to address SHDs. The major strategy to address SHDs is to promote integration between health disparity causal pathways and sleep and circadian-related mechanisms in research approaches and study designs. Additional strategies include developing a comprehensive, integrative conceptual model, building transdisciplinary training and research infrastructure, and designing as well as testing multilevel, multifactorial interventions to address SHDs.
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Affiliation(s)
- Chandra L Jackson
- Epidemiology Branch, National Institute of Environmental Health Sciences, National Institutes of Health, Research Triangle Park, NC
- Intramural Program, National Institute on Minority Health and Health Disparities, National Institutes of Health, Bethesda, MD
| | - Jenelle R Walker
- Center for Translation Research and Implementation Science, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Marishka K Brown
- Division of Lung Diseases, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Rina Das
- Division of Extramural Scientific Programs, National Institute on Minority Health and Health Disparities, National Institutes of Health, Bethesda, MD
| | - Nancy L Jones
- Division of Extramural Scientific Programs, National Institute on Minority Health and Health Disparities, National Institutes of Health, Bethesda, MD
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Holman D, Salway S, Bell A. Mapping intersectional inequalities in biomarkers of healthy ageing and chronic disease in older English adults. Sci Rep 2020; 10:13522. [PMID: 32782305 PMCID: PMC7419497 DOI: 10.1038/s41598-020-69934-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Accepted: 05/05/2020] [Indexed: 11/29/2022] Open
Abstract
Chronic diseases and their inequalities amongst older adults are a significant public health challenge. Prevention and treatment of chronic diseases will benefit from insight into which population groups show greatest risk. Biomarkers are indicators of the biological mechanisms underlying health and disease. We analysed disparities in a common set of biomarkers at the population level using English national data (n = 16,437). Blood-based biomarkers were HbA1c, total cholesterol and C-reactive protein. Non-blood biomarkers were systolic blood pressure, resting heart rate and body mass index. We employed an intersectionality perspective which is concerned with how socioeconomic, gender and ethnic disparities combine to lead to varied health outcomes. We find granular intersectional disparities, which vary by biomarker, with total cholesterol and HbA1c showing the greatest intersectional variation. These disparities were additive rather than multiplicative. Each intersectional subgroup has its own profile of biomarkers. Whilst the majority of variation in biomarkers is at the individual rather than intersectional level (i.e. intersections exhibit high heterogeneity), the average differences are potentially associated with important clinical outcomes. An intersectional perspective helps to shed light on how socio-demographic factors combine to result in differential risk for disease or potential for healthy ageing.
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Affiliation(s)
- Daniel Holman
- Department of Sociological Studies, University of Sheffield, Sheffield, UK.
| | - Sarah Salway
- Department of Sociological Studies, University of Sheffield, Sheffield, UK
| | - Andrew Bell
- Sheffield Methods Institute, University of Sheffield, Sheffield, UK
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61
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Hensel DJ. Using Latent Profile Analysis and Related Approaches in Adolescent Health Research. J Adolesc Health 2020; 67:153-154. [PMID: 32739021 DOI: 10.1016/j.jadohealth.2020.05.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 05/08/2020] [Indexed: 01/17/2023]
Affiliation(s)
- Devon J Hensel
- Division of Adolescent Medicine, Department of Pediatrics, Indiana University/Purdue University Indianapolis, Indianapolis, Indiana; Department of Sociology, Indiana University/Purdue University Indianapolis, Indianapolis, Indiana
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Allen JO, Watkins DC, Chatters L, Geronimus AT, Johnson-Lawrence V. Cortisol and Racial Health Disparities Affecting Black Men in Later Life: Evidence From MIDUS II. Am J Mens Health 2020; 13:1557988319870969. [PMID: 31423887 PMCID: PMC6710693 DOI: 10.1177/1557988319870969] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
In the United States, Black men have poorer overall health and shorter life spans than most other racial/ethnic groups of men, largely attributable to chronic health conditions. Dysregulated patterns of daily cortisol, an indicator of hypothalamic–pituitary–adrenal (HPA) axis stress–response functioning, are linked to poor health outcomes. Questions remain regarding whether and how cortisol contributes to Black–White differences in men’s health. This exploratory study compared early day changes in cortisol levels (diurnal cortisol slopes from peak to pre-lunch levels) and their associations with medical morbidity (number of chronic medical conditions) and psychological distress (Negative Affect Scale) among 695 Black and White male participants in the National Survey of Midlife in the United States (MIDUS II, 2004–2009). Black men exhibited blunted cortisol slopes relative to White men (−.15 vs. −.21, t = −2.97, p = .004). Cortisol slopes were associated with medical morbidity among Black men (b = .050, t = 3.85, p < .001), but not White men, and were unrelated to psychological distress in both groups. Findings indicate cortisol may contribute to racial health disparities among men through two pathways, including the novel finding that Black men may be more vulnerable to some negative health outcomes linked to cortisol. Further, results suggest that while cortisol may be a mechanism of physical health outcomes and disparities among older men, it may be less important for their emotional health. This study increases understanding of how race and male sex intersect to affect not only men’s lived experiences but also their biological processes to contribute to racial health disparities among men in later life.
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Affiliation(s)
- Julie Ober Allen
- Population Studies Center, Institute for Social Research, University of Michigan, Ann Arbor, MI, USA
- Julie Ober Allen, Population Studies Center, Institute for Social Research, University of Michigan, 426 Thompson Street (2411 ISR), Ann Arbor, MI 48106-1248, USA.
| | | | - Linda Chatters
- School of Social Work, University of Michigan, Ann Arbor, MI, USA
- School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Arline T. Geronimus
- Population Studies Center, Institute for Social Research, University of Michigan, Ann Arbor, MI, USA
- School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Vicki Johnson-Lawrence
- Department of Family Medicine/Division of Public Health, College of Human Medicine, Michigan State University, Ann Arbor, MI, USA
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Greene N, Jackson JW, Dean LT. Examining Disparities in Excessive Alcohol Use Among Black and Hispanic Lesbian and Bisexual Women in the United States: An Intersectional Analysis. J Stud Alcohol Drugs 2020; 81:462-470. [PMID: 32800082 PMCID: PMC7437553 DOI: 10.15288/jsad.2020.81.462] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/05/2023] Open
Abstract
OBJECTIVE Sexual minority (i.e., lesbian, bisexual) women and racial-ethnic minority groups in the United States are disproportionately harmed by excessive alcohol use. This study examined disparities in excessive alcohol use at the intersection of race-ethnicity and sexual identity for non-Hispanic Black and Hispanic sexual minority women. METHOD Using data from the 2015 National Survey on Drug Use and Health, we compared the age-adjusted prevalence of binge drinking and heavy alcohol use among sexual minority women of color, sexual minority White women, and heterosexual women of color with that of White heterosexual women. The joint disparity is the difference in the prevalence of excessive alcohol use between sexual minority women of color and White heterosexual women. The excess intersectional disparity is the portion of the joint disparity that is due to being both a racial-ethnic minority and a sexual minority woman. RESULTS Black and Hispanic sexual minority women reported the highest prevalence of binge drinking (45.4% and 43.4%, respectively), followed by White sexual minority women (35.7%) and White heterosexual women (23%). Black and Hispanic heterosexual women reported the lowest prevalence of binge drinking (20.8% and 20.2%, respectively). The joint disparity in binge drinking between Black sexual minority women and White heterosexual women was 21.2%, and the excess intersectional disparity was 17.7%. The joint disparity in binge drinking between Hispanic sexual minority women and White heterosexual women was 16.8%, and the excess intersectional disparity was 10.8%. CONCLUSIONS Disparities in excessive alcohol consumption for Black and Hispanic sexual minority women, compared with White heterosexual women, were larger than what would be expected when considering differences by race or sexual identity individually.
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Affiliation(s)
- Naomi Greene
- Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - John W Jackson
- Departments of Epidemiology and Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Lorraine T Dean
- Departments of Epidemiology and Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Department of Oncology, Johns Hopkins School of Medicine, Baltimore, Maryland
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Greene N, Jackson JW, Dean LT. Examining Disparities in Excessive Alcohol Use Among Black and Hispanic Lesbian and Bisexual Women in the United States: An Intersectional Analysis. J Stud Alcohol Drugs 2020; 81:462-470. [PMID: 32800082 PMCID: PMC7437553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Accepted: 03/19/2020] [Indexed: 11/13/2023] Open
Abstract
OBJECTIVE Sexual minority (i.e., lesbian, bisexual) women and racial-ethnic minority groups in the United States are disproportionately harmed by excessive alcohol use. This study examined disparities in excessive alcohol use at the intersection of race-ethnicity and sexual identity for non-Hispanic Black and Hispanic sexual minority women. METHOD Using data from the 2015 National Survey on Drug Use and Health, we compared the age-adjusted prevalence of binge drinking and heavy alcohol use among sexual minority women of color, sexual minority White women, and heterosexual women of color with that of White heterosexual women. The joint disparity is the difference in the prevalence of excessive alcohol use between sexual minority women of color and White heterosexual women. The excess intersectional disparity is the portion of the joint disparity that is due to being both a racial-ethnic minority and a sexual minority woman. RESULTS Black and Hispanic sexual minority women reported the highest prevalence of binge drinking (45.4% and 43.4%, respectively), followed by White sexual minority women (35.7%) and White heterosexual women (23%). Black and Hispanic heterosexual women reported the lowest prevalence of binge drinking (20.8% and 20.2%, respectively). The joint disparity in binge drinking between Black sexual minority women and White heterosexual women was 21.2%, and the excess intersectional disparity was 17.7%. The joint disparity in binge drinking between Hispanic sexual minority women and White heterosexual women was 16.8%, and the excess intersectional disparity was 10.8%. CONCLUSIONS Disparities in excessive alcohol consumption for Black and Hispanic sexual minority women, compared with White heterosexual women, were larger than what would be expected when considering differences by race or sexual identity individually.
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Affiliation(s)
- Naomi Greene
- Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - John W. Jackson
- Departments of Epidemiology and Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Lorraine T. Dean
- Departments of Epidemiology and Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Department of Oncology, Johns Hopkins School of Medicine, Baltimore, Maryland
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Hunt ET, Brazendale K, Dunn C, Boutté AK, Liu J, Hardin J, Beets MW, Weaver RG. Income, Race and its Association with Obesogenic Behaviors of U.S. Children and Adolescents, NHANES 2003-2006. J Community Health 2020; 44:507-518. [PMID: 30659412 DOI: 10.1007/s10900-018-00613-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECTIVES To describe the associations of income and race with obesogenic behaviors and % body fat among a large sample of U.S. children and adolescents. DESIGN Data were obtained from the 2003-2004 and 2005-2006 National Health and Nutritional Examination Survey. Multiple linear regression models and interactions were used to examine the associations of moderate-to-vigorous physical activity (MVPA), sedentary time, diet quality, and screen-time with income-to-poverty ratio and race. Separate stratified analyses explored associations among individual obesogenic behaviors within race and income groups. RESULTS This study included children and adolescents (n = 3551, mean = 13.1 years, SD = 3.9 years) who were 37% Hispanic, 27% White, and 35% Black. Overall, Hispanic children/adolescents had significantly higher levels of adiposity (3.6, 95 CI = 0.9, 6.3) than white children and adolescents. Medium-income children and adolescents engaged in less MVPA (- 3.3 min, 95 CI = - 5.1, - 1.5), had poorer diet quality (- 1.1, 95 CI = - 1.9, - 0.2), and used screens less (- 33.9 min, 95 CI = - 45.4, - 22.4) than children and adolescents from low-income households. High-income children and adolescents also engaged in less MVPA (- 3.1 min, 95 CI = - 5.5, - 0.7) and used screens less (- 62.9 min, 95 CI = - 78.3, - 47.4) than children and adolescents from low-income households. However, there were significant race/ethnicity-by-income interactions for high-income Hispanic children and adolescents with diet quality (- 3.5 HEI-2010 score, 95 CI = - 6.6, - 0.4) and screen time (66.9 min, 95 CI = 24.7, 109.0). There was also a significant race/ethnicity-by-income interaction for the screen-time of Black children and adolescents from medium (33.8 min, 95% CI 0.2, 67.3) and high (75.8 min, 95% CI 34.7, 117.0) income households. CONCLUSIONS There appears to be a complex relationship that varies by race/ethnicity between income, obesogenic behaviors, and adiposity levels among children and adolescents. More work is needed to identify the behavioral mechanisms that are driving disparate rates of overweight and obesity among minority children and those from low-income households.
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Affiliation(s)
- Ethan T Hunt
- Department of Exercise Science Arnold School of Public Health, University of South Carolina, Public Health Research Center, 921 Assembly St, 29201, Columbia, SC, USA.
| | - Keith Brazendale
- Department of Exercise Science Arnold School of Public Health, University of South Carolina, Public Health Research Center, 921 Assembly St, 29201, Columbia, SC, USA
| | - Caroline Dunn
- Department of Exercise Science Arnold School of Public Health, University of South Carolina, Public Health Research Center, 921 Assembly St, 29201, Columbia, SC, USA
| | - Alycia K Boutté
- Department of Health Promotion Education & Behavior, University of South Carolina, Columbia, SC, USA
| | - Jihong Liu
- Department of Epidemiology and Biostatistics, University of South Carolina, Columbia, SC, USA
| | - James Hardin
- Department of Epidemiology and Biostatistics, University of South Carolina, Columbia, SC, USA
| | - Michael W Beets
- Department of Exercise Science Arnold School of Public Health, University of South Carolina, Public Health Research Center, 921 Assembly St, 29201, Columbia, SC, USA
| | - R Glenn Weaver
- Department of Exercise Science Arnold School of Public Health, University of South Carolina, Public Health Research Center, 921 Assembly St, 29201, Columbia, SC, USA
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Jackson JW, Arah OA. Invited Commentary: Making Causal Inference More Social and (Social) Epidemiology More Causal. Am J Epidemiol 2020; 189:179-182. [PMID: 31573030 PMCID: PMC7217274 DOI: 10.1093/aje/kwz199] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 07/29/2019] [Accepted: 08/01/2019] [Indexed: 01/13/2023] Open
Abstract
A society's social structure and the interactions of its members determine when key drivers of health occur, for how long they last, and how they operate. Yet, it has been unclear whether causal inference methods can help us find meaningful interventions on these fundamental social drivers of health. Galea and Hernán propose we place hypothetical interventions on a spectrum and estimate their effects by emulating trials, either through individual-level data analysis or systems science modeling (Am J Epidemiol. 2020;189(3):167-170). In this commentary, by way of example in health disparities research, we probe this "closer engagement of social epidemiology with formal causal inference approaches." The formidable, but not insurmountable, tensions call for causal reasoning and effect estimation in social epidemiology that should always be enveloped by a thorough understanding of how systems and the social exposome shape risk factor and health distributions. We argue that one way toward progress is a true partnership of social epidemiology and causal inference with bilateral feedback aimed at integrating social epidemiologic theory, causal identification and modeling methods, systems thinking, and improved study design and data. To produce consequential work, we must make social epidemiology more causal and causal inference more social.
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Affiliation(s)
- John W Jackson
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Center for Health Equity, Johns Hopkins University
- Center for Health Disparities Solutions, Johns Hopkins Bloomberg School of Public Health
| | - Onyebuchi A Arah
- Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, California
- Department of Statistics, UCLA College of Letters and Science, Los Angeles, California
- Department of Public Health, Aarhus University, Aarhus, Denmark
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Concurrently Advancing Sexual Rights and Next-Generation Sexually Transmitted Infection Prevention Through Innovative Analytical Methods. Sex Transm Dis 2020; 47:177-178. [DOI: 10.1097/olq.0000000000001131] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Gaston SA, James-Todd T, Harmon Q, Taylor KW, Baird D, Jackson CL. Chemical/straightening and other hair product usage during childhood, adolescence, and adulthood among African-American women: potential implications for health. JOURNAL OF EXPOSURE SCIENCE & ENVIRONMENTAL EPIDEMIOLOGY 2020; 30:86-96. [PMID: 31641276 PMCID: PMC6917990 DOI: 10.1038/s41370-019-0186-6] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 07/31/2019] [Accepted: 09/05/2019] [Indexed: 05/25/2023]
Abstract
Few studies have characterized life course hair product usage beyond ever/never. We investigated hair product use from childhood to adulthood, usage patterns in adulthood, and socioeconomic status (SES) correlates among African-American (AA) women. Using self-reported data from 1555 AA women enrolled in the Study of Environment, Lifestyle, and Fibroids (2010-2018), we estimated the usage frequency of chemical relaxer/straightener (≥twice/year, once/year, and rarely/never) and leave-in/leave-on conditioner (≥once/week, 1-3 times/month, and rarely/never) during childhood, adolescence, and adulthood. Latent class analysis was used to identify patterns of adulthood usage of multiple hair products. SES was compared across latent classes. With a mean age of 33 ± 3.4 years, most women reported ever using chemical relaxers/straighteners (89%), and use ≥twice/year increased from childhood (9%) to adolescence (73%) but decreased in adulthood (29%). Leave-in/leave-on conditioner use followed the same pattern. Each of three identified latent classes reported frequent styling product use and infrequent relaxer/straightener use. Class One was unlikely to use any other products, Class Two moderately used shampoo and conditioner, and Class Three frequently used multiple product types (e.g., moisturizers and conditioners). Participants in the latter two classes reported higher SES. Ever/never characterization may miss important and distinctive patterns of hair product use, which may vary by SES.
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Affiliation(s)
- Symielle A Gaston
- Epidemiology Branch, National Institute of Environmental Health Sciences, National Institutes of Health, Department of Health and Human Services, Research Triangle Park, NC, USA
| | - Tamarra James-Todd
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Quaker Harmon
- Epidemiology Branch, National Institute of Environmental Health Sciences, National Institutes of Health, Department of Health and Human Services, Research Triangle Park, NC, USA
| | - Kyla W Taylor
- National Toxicology Program, National Institute of Environmental Health Sciences, National Institutes of Health, Department of Health and Human Services, Research Triangle Park, NC, USA
| | - Donna Baird
- Epidemiology Branch, National Institute of Environmental Health Sciences, National Institutes of Health, Department of Health and Human Services, Research Triangle Park, NC, USA
| | - Chandra L Jackson
- Epidemiology Branch, National Institute of Environmental Health Sciences, National Institutes of Health, Department of Health and Human Services, Research Triangle Park, NC, USA.
- Intramural Program, National Institute on Minority Health and Health Disparities, National Institutes of Health, Department of Health and Human Services, Bethesda, MD, USA.
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Moreno FA, Chhatwal J. Diversity and Inclusion in Psychiatry: The Pursuit of Health Equity. FOCUS (AMERICAN PSYCHIATRIC PUBLISHING) 2020; 18:2-7. [PMID: 32047391 PMCID: PMC7011224 DOI: 10.1176/appi.focus.20190029] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The increasing diversity of America requires a workforce that is able to serve the mental health needs of individuals from multiple backgrounds, with a culturally proficient, inclusive, and affirming approach. To accomplish this, clinicians must be mindful of the multiple challenges presented by social determinants of mental health and access to care; the role of culture in wellness protection, mental illness expression, symptom attribution, and help seeking; the impact of provider factors, such as availability and cultural and linguistic congruence and proficiency; and the interaction of clinician and patient, who are with increasing frequency members of differing identity groups. The authors highlight the central role of clinical providers, academic institutions, and service organizations to advance health equity through training and commitment to increase high-quality services that are available, accessible, affordable, and acceptable, improving the care of all individuals.
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Affiliation(s)
- Francisco A Moreno
- Department of Psychiatry, University of Arizona College of Medicine-Tucson, Tucson
| | - Jasleen Chhatwal
- Department of Psychiatry, University of Arizona College of Medicine-Tucson, Tucson
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Do inequalities add up? Intersectional inequalities in smoking by sexual orientation and education among U.S. adults. Prev Med Rep 2019; 17:101032. [PMID: 31956472 PMCID: PMC6957789 DOI: 10.1016/j.pmedr.2019.101032] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 11/29/2019] [Accepted: 12/15/2019] [Indexed: 11/26/2022] Open
Abstract
Among men, inequalities in cigarette smoking are primarily driven by socio-economic inequalities. Among women, inequalities in cigarette smoking are primarily driven by sexual orientation inequalities.
Introduction Inequalities in smoking by socio-economic status (SES) are well-known. A growing body of literature has demonstrated additional inequalities in smoking by sexual orientation. This study used an intersectional lens to examine smoking at the intersection of sexual orientation and education. Methods Data come from 28,362 adult participants in Wave 2 (2014–2015) of the Population Assessment of Tobacco and Health (PATH) Study. We used educational level (less than high school education (HS); HS or more) and sexual orientation (heterosexual; sexual minority) to form four intersectional positions. We estimated prevalence differences in smoking corresponding to joint, referent, and excess intersectional inequalities using weighted linear binomial regression models. Results were stratified by gender and adjusted for ethnicity and age. Results The adjusted joint inequality represented 7.6% points (p.p.) (95% CI: 2.5, 12.8) difference in smoking between the doubly advantaged (heterosexual with HS or more) and doubly disadvantaged (sexual minority with less than HS) positions. Joint inequality was decomposed into referent SES inequality (12.5 p.p. (95% CI: 10.5, 14.4)); referent sexual orientation inequality (9.7 p.p. (95% CI: 6.8, 12.6)); and a substantial negative excess intersectional inequality (−14.6 p.p. (95% CI: −20.8, −8.3)), attributed to an unexpectedly low prevalence of smoking among doubly disadvantaged persons. Similar overall patterns were found in the stratified analyses. Conclusions We found that “doubly-disadvantaged” group of low-educated sexual minority adults did not have the greatest burden of smoking; whereas, low-educated heterosexual adults had the highest smoking prevalence. Our findings support tailoring cessation interventions to disadvantaged groups’ different needs.
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Mamani Ortiz Y, Gustafsson PE, San Sebastián Chasco M, Armaza Céspedes AX, Luizaga López JM, Illanes Velarde DE, Mosquera Méndez PA. Underpinnings of entangled ethnical and gender inequalities in obesity in Cochabamba-Bolivia: an intersectional approach. Int J Equity Health 2019; 18:153. [PMID: 31615512 PMCID: PMC6794886 DOI: 10.1186/s12939-019-1062-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Accepted: 09/30/2019] [Indexed: 01/20/2023] Open
Abstract
Background Social inequalities in obesity have been observed not only by gender but also between ethnic groups. Evidence on combined dimensions of inequality in health, and specifically including indigenous populations, is however scarce, and presents a particularly daunting challenge for successful prevention and control of obesity in Bolivia, as well as worldwide. Objective The aims of this study were i) to examine intersectional inequalities in obesity and ii) to identify the factors underlying the observed intersectional inequalities. Methods An intersectional approach study was employed, using the information collected in a cross-sectional community-based survey. The sample consisted of youth and adults with permanent residence in Cochabamba department (N = 5758), selected through a multistage sampling technique. An adapted version of the WHO-STEPS survey was used to collect information about Abdominal obesity and risk factors associated. Four intersectional positions were constructed from gender (woman vs. men) and ethnic group (indigenous vs. mestizo). Joint and excess intersectional disparities in obesity were estimated as absolute prevalence differences between binary groups, using binomial regression models. The Oaxaca-Blinder decomposition was applied to estimate the contributions of explanatory factors underlying the observed intersectional disparities, using Oaxaca command in Stata software v15.1. Results The prevalence of abdominal obesity had a higher prevalence in mestizos (men 35.01% and women 30.71%) as compared to indigenous (men 25.38% and women 27.75%). The joint disparity was estimated at 7.26 percentage points higher prevalence in the doubly advantaged mestizo men than in the doubly disadvantaged indigenous women. The gender referent disparity showed that mestizo-women had a higher prevalence than indigenous-women. The ethnic referent disparity showed that mestizo-men had a higher prevalence than indigenous men. The behavioural risk factors were the most important to explain the observed inequalities, while differences in socioeconomic and demographic factors played a less important role. Conclusion Our study illustrates that abdominal obesity is not distributed according to expected patterns of structural disadvantage in the intersectional space of ethnicity and gender in Bolivia. In the Cochabamba case, a high social advantage was related to higher rates of abdominal obesity, as well as the behavioural risk factors associated with them.
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Affiliation(s)
- Yercin Mamani Ortiz
- Biomedical and Social Research Institute, Faculty of Medicine, San Simon University, Cochabamba, Bolivia. .,Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden.
| | - Per E Gustafsson
- Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden
| | | | - Ada Ximena Armaza Céspedes
- Biomedical and Social Research Institute, Faculty of Medicine, San Simon University, Cochabamba, Bolivia
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Henderson ER, Jabson J, Russomanno J, Paglisotti T, Blosnich JR. Housing and food stress among transgender adults in the United States. Ann Epidemiol 2019; 38:42-47. [PMID: 31526508 PMCID: PMC6812620 DOI: 10.1016/j.annepidem.2019.08.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 05/24/2019] [Accepted: 08/10/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE The purpose of the study was to assess housing and food-related stress in transgender and cisgender adults in the United States. METHODS Data from the 2014 and 2015 Behavioral Risk Factor Surveillance System were analyzed for 53,060 adults who responded to the Sexual Orientation and Gender Identity module and the Social Context module. We used multiple logistic regression to assess the association of gender identity with housing and food-related stress. RESULTS There were no significant differences by gender identity in the odds of experiencing housing or food-related stress. A sensitivity analysis revealed that with a broader definition of food-related stress, transgender individuals had higher odds of experiencing food-related stress compared with cisgender individuals. The sample of transgender individuals who experienced food-related stress were young, single, racially diverse, sexual minorities, and the majority had a high school degree or less. Similarly, most transgender individuals who experienced housing-related stress were single, sexual minorities, and had a high school degree or less. CONCLUSIONS More precise assessments of housing and food insecurity among probability-based samples of transgender individuals are needed to fully understand housing and food-related instability and the stress associated with these experiences.
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Affiliation(s)
- Emmett R Henderson
- Department of Behavioral and Community Health Sciences, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA; Center for LGBT Health Research, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA.
| | - Jennifer Jabson
- Department of Public Health, University of Tennessee, Knoxville
| | | | - Taylor Paglisotti
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, Children's Hospital of Pittsburgh of UPMC, University of Pittsburgh, School of Medicine, Pittsburgh, PA
| | - John R Blosnich
- Center for LGBT Health Research, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA; Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, University Drive C (151C-U) Pittsburgh, PA; Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, UPMC Montefiore Hospital, Pittsburgh, PA
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Higgins Tejera C, Horner-Johnson W, Andresen EM. Application of an intersectional framework to understanding the association of disability and sexual orientation with suicidal ideation among Oregon Teens. Disabil Health J 2019; 12:557-563. [DOI: 10.1016/j.dhjo.2019.05.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Revised: 05/07/2019] [Accepted: 05/20/2019] [Indexed: 10/26/2022]
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Beccia AL, Baek J, Jesdale WM, Austin SB, Forrester S, Curtin C, Lapane KL. Risk of disordered eating at the intersection of gender and racial/ethnic identity among U.S. high school students. Eat Behav 2019; 34:101299. [PMID: 31153023 DOI: 10.1016/j.eatbeh.2019.05.002] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Revised: 03/31/2019] [Accepted: 05/03/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Gender and racial/ethnic disparities in disordered eating among youth exist, although whether having multiple marginalized identities disproportionately increases risk is unclear. Therefore, we aimed to quantify the risk of disordered eating associated with intersecting gender and racial/ethnic identities of U.S. adolescents. METHODS We analyzed data from 11,514 U.S. high school students identifying as White, Black/African American, or Hispanic/Latino who participated in the 2013 National Youth Risk Behavior Surveillance System. Age-adjusted relative risks (RR) of purging, fasting, diet pill use, and any disordered eating were estimated using log-binomial models. Relative excess risk due to interaction (RERI) was estimated to evaluate the degree to which the combined effect of marginalized gender and racial/ethnic identity was larger than the sum of their individual effects. RESULTS Disordered eating was prevalent (girls: 20.4% Black/African American, 29.2% Hispanic/Latina, 21.4% White; boys: 13.4% Black/African American, 12.4% Hispanic/Latino; 8.1% Whites). Girls of all racial/ethnic identities and racial/ethnic minority boys had elevated risks of purging, fasting, and any disordered eating compared to White boys (RR range = 1.57-7.43); Hispanic/Latina and White girls also had elevated risk of diet pill use (RR range = 1.98-3.20). Among Hispanic/Latina girls, positive interaction between gender and race/ethnicity produced excess risk of any disordered eating and purging (RERI: any = 0.42 (95% confidence interval (CI) = -0.02, 0.87); purging = 1.74 (95% CI = 0.06, 3.42). CONCLUSIONS Findings illustrate the advantages of adopting an intersectional approach to disordered eating research. Future research should investigate the mechanisms of these disparities.
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Affiliation(s)
- Ariel L Beccia
- Clinical and Population Health Research Program, Graduate School of Biomedical Sciences, University of Massachusetts Medical School, 55 Lake Ave North, Worcester, MA 01655, United States of America; Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, 55 Lake Ave North, Worcester, Massachusetts, 01655, United States of America.
| | - Jonggyu Baek
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, 55 Lake Ave North, Worcester, Massachusetts, 01655, United States of America.
| | - William M Jesdale
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, 55 Lake Ave North, Worcester, Massachusetts, 01655, United States of America.
| | - S Bryn Austin
- Division of Adolescent Adult Medicine, Boston Children's Hospital, 333 Longwood Avenue, Boston, MA 02115, United States of America; Department of Social and Behavioral Sciences, Harvard T. H. Chan School of Public Health, 677 Huntington Avenue, Boston, MA 02115, United States of America.
| | - Sarah Forrester
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, 55 Lake Ave North, Worcester, Massachusetts, 01655, United States of America.
| | - Carol Curtin
- Department of Family Medicine & Community Health, E.K. Shriver Center, University of Massachusetts Medical School, 55 Lake Ave North, Worcester, MA 01655, United States of America.
| | - Kate L Lapane
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, 55 Lake Ave North, Worcester, Massachusetts, 01655, United States of America.
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Bey G, Jesdale B, Forrester S, Person S, Kiefe C. Intersectional effects of racial and gender discrimination on cardiovascular health vary among black and white women and men in the CARDIA study. SSM Popul Health 2019; 8:100446. [PMID: 31334327 PMCID: PMC6620618 DOI: 10.1016/j.ssmph.2019.100446] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 06/30/2019] [Accepted: 07/02/2019] [Indexed: 12/21/2022] Open
Abstract
Testing hypotheses from the emerging Identity Pathology (IP) framework, we assessed race-gender differences in the effects of reporting experiences of racial and gender discrimination simultaneously compared with racial or gender discrimination alone, or no discrimination, on future cardiovascular health (CVH). Data were from a sample of 3758 black or white adults in CARDIA, a community-based cohort recruited in Birmingham, AL; Chicago, IL; Minneapolis, MN, and Oakland, CA in 1985-6 (year 0). Racial and gender discrimination were assessed using the Experiences of Discrimination scale. CVH was evaluated using a 12-point composite outcome modified from the Life's Simple 7, with higher scores indicating better health. Multivariable linear regressions were used to evaluate the associations between different perceptions of discrimination and CVH scores two decades later by race and gender simultaneously. Reporting racial and gender discrimination in ≥2 settings were 48% of black women, 42% of black men, 10% of white women, and 5% of white men. Year 30 CVH scores (mean, SD) were 7.9(1.4), 8.1(1.6), 8.8(1.6), and 8.7(1.3), respectively. Compared with those of their race-gender groups reporting no discrimination, white women reporting only gender-based discrimination saw an adjusted score difference of +0.3 (95% CI: 0.0,0.6), whereas white men reporting only racial discrimination had on average a 0.4 (95% CI: 0.1,0.8) higher score, and scores among white men reporting both racial and gender discrimination were on average 0.6 (95% CI: 1.1,-0.1) lower than those of their group reporting no discrimination. Consistent with predictions of the IP model, the associations of reported racial and gender discrimination with future CVH were different for different racially-defined gender groups. More research is needed to understand why reported racial and gender discrimination might better predict deterioration in CVH for whites than blacks, and what additional factors associated with gender and race contribute variability to CVH among these groups.
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Affiliation(s)
- G.S. Bey
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Dr. Chapel Hill, NC, 27599, USA
| | - B. Jesdale
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, 55 Lake Ave North, Worcester, MA, 01655, USA
| | - S. Forrester
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, 55 Lake Ave North, Worcester, MA, 01655, USA
| | - S.D. Person
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, 55 Lake Ave North, Worcester, MA, 01655, USA
| | - C. Kiefe
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, 55 Lake Ave North, Worcester, MA, 01655, USA
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76
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Fagrell Trygg N, Gustafsson PE, Månsdotter A. Languishing in the crossroad? A scoping review of intersectional inequalities in mental health. Int J Equity Health 2019; 18:115. [PMID: 31340832 PMCID: PMC6657170 DOI: 10.1186/s12939-019-1012-4] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 06/30/2019] [Indexed: 01/13/2023] Open
Abstract
The concept of intersectionality has gradually been introduced to health inequality research, adding depth and breadth to the way inequalities in health are approached. We conducted a scoping review with the purpose to systematically map, describe and analyze the literature about intersectional inequalities in mental health. For eligibility, the study had to analyze and report inequality defined by combinations of socioeconomic position, gender, race/ethnicity, sexual orientation or religion. The mental health outcome had to be measured as self-reported symptoms assessed through validated scales, or disorders assessed through diagnostic interviews. The search strategy was applied in two databases and the screening process yielded 20 studies. The interaction of intersectional positions showed no consistent patterns in mental health across studies, but both synergistic and antagonistic effects were observed. In most studies an absolute measure of inequality was used and few studies analyzed factors potentially explaining the intersectional inequalities. Taken together, the findings of this review highlight the value of assessing intersectional inequalities across population groups for priority setting and action on mental health inequalities.
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Affiliation(s)
| | - Per E. Gustafsson
- Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden
| | - Anna Månsdotter
- Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden
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77
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Amroussia N, Pearson JL, Gustafsson PE. What drives us apart? Decomposing intersectional inequalities in cigarette smoking by education and sexual orientation among U.S. adults. Int J Equity Health 2019; 18:109. [PMID: 31315627 PMCID: PMC6637561 DOI: 10.1186/s12939-019-1015-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Accepted: 07/07/2019] [Indexed: 11/12/2022] Open
Abstract
Background Socio-economic and sexual orientation inequalities in cigarette smoking are well-documented; however, there is a lack of research examining the social processes driving these complex inequalities. Using an intersectional framework, the current study examines key processes contributing to inequalities in smoking between four intersectional groups by education and sexual orientation. Methods The sample (28,362 adults) was obtained from Wave 2 (2014–2015) of the Population Assessment of Tobacco and Health (PATH) Study. Four intersectional positions were created by education (high- and low-education) and sexual orientation (heterosexual or lesbian, gay, bisexual, or queer/questioning (LGBQ). The joint inequality, the referent socio-economic inequality, and the referent sexual orientation inequality in smoking were decomposed by demographic, material, tobacco marketing-related, and psychosocial factors using non-linear Oaxaca decomposition. Results Material conditions made the largest contribution to the joint inequality (9.8 percentage points (p.p.), 140.9%), referent socio-economic inequality (10.01 p.p., 128.4%), and referent sexual orientation inequality (4.91 p.p., 59.8%), driven by annual household income. Psychosocial factors made the second largest contributions to the joint inequality (2.12 p.p., 30.3%), referent socio-economic inequality (2.23 p.p., 28.9%), and referent sexual orientation inequality (1.68 p.p., 20.5%). Referent sexual orientation inequality was also explained by marital status (20.3%) and targeted tobacco marketing (11.3%). Conclusion The study highlights the pervasive role of material conditions in inequalities in cigarette smoking across multiple dimensions of advantage and disadvantage. This points to the importance of addressing material disadvantage to reduce combined socioeconomic and sexual orientation inequalities in cigarette smoking.
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Affiliation(s)
- Nada Amroussia
- Division of Social and Behavioral Health, University of Nevada, Reno, USA.
| | - Jennifer L Pearson
- Division of Social and Behavioral Health/Health Administration and Policy, University of Nevada, Reno, USA.,Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Per E Gustafsson
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
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78
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Hensel DJ. Supporting Adolescent Sexual and Reproductive Health Rights Through Innovative Research Approaches. J Adolesc Health 2019; 64:288-289. [PMID: 30819329 DOI: 10.1016/j.jadohealth.2018.12.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 12/20/2018] [Indexed: 11/28/2022]
Affiliation(s)
- Devon J Hensel
- Division of Adolescent Medicine, Indiana University School of Medicine, Department of Sociology, Indiana University Purdue University-Indianapolis, Indianapolis, Indiana
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79
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Differences in pituitary-adrenal reactivity in Black and White men with and without alcohol use disorder. Psychoneuroendocrinology 2019; 100:180-189. [PMID: 30347319 PMCID: PMC6333532 DOI: 10.1016/j.psyneuen.2018.10.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Revised: 09/13/2018] [Accepted: 10/08/2018] [Indexed: 01/16/2023]
Abstract
BACKGROUND Treatment-seeking men with alcohol use disorder (AUD) classically exhibit a blunted hypothalamic-pituitary-adrenal (HPA) axis response to pharmacologic and behavioral provocations during the early phases of abstinence from alcohol. Independent of alcohol, a significant muting of HPA axis reactivity is also observed among racial minority (e.g. Black) individuals. The effect of AUD upon the altered HPA axis response of racial minority individuals has not been explored. The current work represents a secondary analysis of race and AUD status among a sample of men. METHODS Healthy male controls (17 White, 7 Black) and four-to six-week abstinent men with AUD (49 White, 13 Black) were administered a psychosocial stressor and two pharmacologic probes [ovine corticotropin releasing hormone (oCRH) and cosyntropin] to assess HPA axis reactivity. Plasma cortisol and adrenocorticotropin hormone (ACTH) were assessed at 10-20 min intervals prior to and following behavioral and pharmacological stimulation. Basal and net-integrated responses following provocations were analyzed to identify potential group differences. A measure of childhood adversity was also obtained to consider the implications of prior stressors upon HPA axis function. RESULTS A three-fold increase in oCRH-induced ACTH was seen in Black men relative to White men regardless of AUD status. Adversity exerted a dampening effect on this pituitary sensitivity within Black controls only. Adjusted for adversity, a significant blunting effect of AUD status on ACTH reactivity was identified within White participants following oCRH. No group differences were present following cosyntropin administration. In response to the psychosocial stressor, White, but not Black, men with AUD experienced the expected blunting of cortisol reactivity relative to White controls. Rather, Black men with AUD exhibited greater cortisol reactivity relative to White men with AUD. CONCLUSIONS Differences in HPA axis reactivity associated with race were present in men with and without AUD. Explanatory biological mechanisms of the relationship between alcohol use and/or stress, in both healthy and unhealthy populations, may require a reassessment in different racial populations.
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80
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Intersectional decomposition analysis with differential exposure, effects, and construct. Soc Sci Med 2019; 226:254-259. [PMID: 30770131 DOI: 10.1016/j.socscimed.2019.01.033] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Accepted: 01/19/2019] [Indexed: 12/26/2022]
Abstract
In recent years a wide array of proposals for bringing intersectional perspectives into quantitative studies of health disparities have appeared, from studies of interaction, predictive discrimination, to mediation. Bauer and Scheim, in a companion set of articles, extend these proposals by developing new attribution-blind measures of perceived discrimination and using VanderWeele's 3-way decomposition to quantify its contribution to disparities through differential exposure and differential effects (sometimes called differential vulnerability or susceptibility). In this commentary, after providing an overview of causal inference interpretations with social characteristics, we provide a broad overview of old and new decomposition methods in the social sciences literature and contrast their strengths and weaknesses for studying intersectional inequalities. We then examine how different forms of differential effects can be expressed within these decompositions and discuss their utility for the purpose of informing interventions for reducing disparities. Last, we discuss the tension in social sciences research when prominent explanatory variables represent constructs that are only defined or exist for certain marginalized populations and may not neatly fit within the decomposition methods framework. Through these discussions, we aim to provide greater conceptual clarity for applied researchers who are interested in using decomposition methods and other approaches to advance intersectional equity.
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81
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Harnois CE, Bastos JL. The promise and pitfalls of intersectional scale development. Soc Sci Med 2019; 223:73-76. [PMID: 30711781 DOI: 10.1016/j.socscimed.2019.01.039] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Revised: 01/18/2019] [Accepted: 01/23/2019] [Indexed: 11/25/2022]
Affiliation(s)
| | - João L Bastos
- Department of Public Health, Federal University of Santa Catarina, Campus Universitário Trindade, Florianópolis, SC, Brazil
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82
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Methods for analytic intercategorical intersectionality in quantitative research: Discrimination as a mediator of health inequalities. Soc Sci Med 2019; 226:236-245. [PMID: 30674435 DOI: 10.1016/j.socscimed.2018.12.015] [Citation(s) in RCA: 118] [Impact Index Per Article: 23.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Revised: 10/22/2018] [Accepted: 12/09/2018] [Indexed: 12/15/2022]
Abstract
RATIONALE Intersectionality as a theoretical framework has gained prominence in qualitative research on social inequity. Intercategorical quantitative applications have focused primarily on describing health or social inequalities across intersectional groups, coded using cross-classified categories or interaction terms. This descriptive intersectionality omits consideration of the mediating processes (e.g., discrimination) through which intersectional positions impact outcome inequalities, which offer opportunities for intervention. OBJECTIVE We argue for the importance of a quantitative analytic intersectionality. We identify methodological challenges and potential solutions in structuring studies to allow for both intersectional heterogeneity in outcomes and in the ways that processes such as discrimination may cause these outcomes for those at different intersections. METHOD To incorporate both mediation and exposure-mediator interaction, we use VanderWeele's three-way decomposition methodology, adapt the interpretation for application to analytic intersectionality studies, and present a step-by-step analytic approach. Using online panel data collected from Canada and the United States in 2016 (N = 2542), we illustrate this approach with a statistical analysis of whether and to what extent observed inequalities in psychological distress across intersections of ethnoracial group and sexual or gender minority (SGM) status may be explained by past-year experiences of day-to-day discrimination, assessed using the Intersectional Discrimination Index (InDI). RESULTS AND CONCLUSIONS We describe actual and adjusted intersectional inequalities in psychological distress and decompose them to identify three component effects for each of 11 intersectional comparison groups (e.g., Indigenous SGM), versus the reference intersectional group that experienced the lowest levels of discrimination (white non-SGM). These reflect the expected inequality in outcome: 1) due to membership in the more discriminated-against group, if its members had experienced the same lower levels of discrimination as the reference intersection; 2) due to unequal levels of discrimination; and 3), due to unequal effects of discrimination. We present considerations for use and interpretation of these methods.
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83
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Greene MZ, Hughes TL, Hanlon A, Huang L, Sommers MS, Meghani SH. Predicting cervical cancer screening among sexual minority women using Classification and Regression Tree analysis. Prev Med Rep 2018; 13:153-159. [PMID: 30591857 PMCID: PMC6305684 DOI: 10.1016/j.pmedr.2018.11.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Revised: 11/02/2018] [Accepted: 11/10/2018] [Indexed: 12/24/2022] Open
Abstract
Cervical cancer screening is a critical preventive healthcare service for all women. Sexual minority women (SMW) in the United States experience multiple health disparities including decreased access to and use of cervical cancer screening. The mechanisms driving these disparities are not clear and SMW with multiple marginalized identities may be more likely to miss recommended cervical cancer screening. This study aimed to identify subgroups of SMW that are more and less likely to be screened for cervical cancer according to American Cancer Society guidelines. We used cross-sectional data from the latest (2010-2012) wave of the Chicago Health and Life Experiences of Women (CHLEW) Study (N = 691). Informed by intersectionality theory, we performed classification and regression tree (CART) modeling to construct a data-driven, predictive model of subgroups of SMW who were more and less likely to receive guideline-recommended screening. Notably, the CART model did not include commonly tested variables such as race/ethnicity or level of income or education. The model did identify subgroups with low likelihood of receiving screening and several novel variables that may be important in understanding SMW's use of cervical cancer screening; lifetime number of sexual partners, age at drinking onset, childhood physical abuse, and internalized homonegativity. Our results point to the importance of early life experiences and identity development processes in shaping patterns of preventive healthcare use among adult SMW. Our analysis also demonstrated the potential value of CART modeling techniques for evaluating how multiple variables interact in complex ways to predict cervical cancer screening.
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Affiliation(s)
- Madelyne Z Greene
- University of Wisconsin-Madison Department of Obstetrics and Gynecology, 610 Walnut St. Suite #667, Madison 53726, WI, USA
| | - Tonda L Hughes
- Columbia University School of Nursing, 560 W 168th St, New York 10032, NY, USA
| | - Alexandra Hanlon
- University of Pennsylvania School of Nursing, 418 Curie Blvd., Philadelphia 19126, PA, USA
| | - Liming Huang
- University of Pennsylvania School of Nursing, 418 Curie Blvd., Philadelphia 19126, PA, USA
| | - Marilyn S Sommers
- University of Pennsylvania School of Nursing, 418 Curie Blvd., Philadelphia 19126, PA, USA
| | - Salimah H Meghani
- University of Pennsylvania School of Nursing, 418 Curie Blvd., Philadelphia 19126, PA, USA
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84
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Abstract
There has been considerable interest in using decomposition methods in epidemiology (mediation analysis) and economics (Oaxaca-Blinder decomposition) to understand how health disparities arise and how they might change upon intervention. It has not been clear when estimates from the Oaxaca-Blinder decomposition can be interpreted causally because its implementation does not explicitly address potential confounding of target variables. While mediation analysis does explicitly adjust for confounders of target variables, it typically does so in a way that effectively entails equalizing confounders across racial groups, which may not reflect the intended intervention. Revisiting prior analyses in the National Longitudinal Survey of Youth on disparities in wages, unemployment, incarceration, and overall health with test scores, taken as a proxy for educational attainment, as a target intervention, we propose and demonstrate a novel decomposition that controls for confounders of test scores (e.g., measures of childhood socioeconomic status [SES]) while leaving their association with race intact. We compare this decomposition with others that use standardization (to equalize childhood SES [the confounders] alone), mediation analysis (to equalize test scores within levels of childhood SES), and one that equalizes both childhood SES and test scores. We also show how these decompositions, including our novel proposals, are equivalent to implementations of the Oaxaca-Blinder decomposition but provide a more formal causal interpretation for these decompositions.
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Affiliation(s)
- John W Jackson
- From the Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Tyler J VanderWeele
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA
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85
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Ortiz K, Cuevas AG, Salloum R, Lopez N, LaVeist-Ramos T. Intra-Ethnic Racial Differences in Waterpipe Tobacco Smoking among Latinos? Subst Use Misuse 2018; 54:1-10. [PMID: 30028218 PMCID: PMC10629378 DOI: 10.1080/10826084.2018.1480040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND AND OBJECTIVES This study examined differences in waterpipe smoking (both lifetime and current) by race and ethnicity. More specifically, we evaluated intra-ethnic racial differences among Latinos using a nationally representative sample. METHODS Pooled data from the National Adult Tobacco Survey (NATS) [2012-2014] was used, in which Log-Poisson multivariable regression models were deployed to determine the prevalence of waterpipe smoking behavior. Models were stratified by gender and we further investigated acculturation, controlling for relevant sociodemographic characteristics. RESULTS In fully-adjusted models assessing lifetime WTS, Black Latinos and White Latinos exhibited an increase prevalence of lifetime WTS compared to their non-Hispanic white counterparts. Once stratifying by gender, Black Latino men (PR = 1.49; 95% CI = 1.16, 1.90) exhibited increased prevalence of lifetime WTS compared to their non-Hispanic white men counterparts; although white Latino men (PR = 0.88; 95% CI = 0.80, 0.98) exhibited decreased prevalence compared to their non-Hispanic white male counterparts. Similar trends were found for current WTS among men. In fully adjusted models assessing lifetime WTS, among women, only white Latina's (PR = 1.23; 95% CI = 1.04, 1.46) exhibited increased prevalence compared to their non-Hispanic white women counterparts. When evaluating current WTS, Black Latina's (PR = 2.19; 95% CI = 1.32, 3.65) and white Latinas (PR = 1.28; 95% CI = 1.00, 1.63) exhibited increased prevalence of WTS compared to their non-Hispanic white women counterparts. Conclusions/Importance: Among the U.S. general adult population, intra-ethnic racial differences in WTS behaviors exist among Latinos; and is shaped by gender. Future efforts to eliminate racial disparities in WTS should be attentive intra-ethnic racial differences among Latinos.
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Affiliation(s)
- Kasim Ortiz
- Department of Sociology & Criminology, University of New Mexico, Albuquerque, New Mexico, USA
| | - Adolfo G. Cuevas
- Department of Community Health, Tufts University Community Health Program, Medford, Oregon, USA
| | - Ramzi Salloum
- Department of Health Outcomes & Biomedical Informatics, University of Florida, Tallahasee, Florida, USA
| | - Nancy Lopez
- Department of Sociology & Criminology, University of New Mexico, Albuquerque, New Mexico, USA
| | - Thomas LaVeist-Ramos
- Department of Health Policy and Management, George Washington University Milken Institute of Public Health, Washington, USA
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86
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Smolen JR, de Araújo EM, de Oliveira NF, de Araújo TM. Intersectionality of Race, Gender, and Common Mental Disorders in Northeastern Brazil. Ethn Dis 2018; 28:207-214. [PMID: 30038483 DOI: 10.18865/ed.28.3.207] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
This study applies the perspective of intersectionality, defined as social identities combining with one another and with structural societal factors to produce health inequities, to assess the interaction between race, gender, and common mental disorders (CMD) in northeastern Brazil. The Self-Reporting Questionnaire was used to assess CMD among a representative sample of adults in Feira de Santana, Bahia, Brazil (N=3273). Four groups (Black men, Black women, White women, White men) represented the intersection of race and gender. We used a Chi square test to compare the four groups and Poisson regressions to determine prevalence ratios (PR). White men had the lowest prevalence of CMD (11.1%) and Black women had the highest (37.2%). After adjusting for covariates, Black women had a statistically significantly higher prevalence of CMD than White men (PR=2.43; 95% CI: 1.39-4.25), though the prevalence among White women was not statistically significantly different from White men (PR=1.74; 95% CI: .93-3.30). Interaction tests were conducted on the multiplicative and additive scale, although the results were not statistically significant. These findings indicate that the experience of being both Black and a woman in Brazil is associated with elevated prevalence of CMD. Programs and interventions are needed to address this burden and research is needed to further explore its cause.
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87
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Bellavia A, Zota AR, Valeri L, James-Todd T. Multiple mediators approach to study environmental chemicals as determinants of health disparities. Environ Epidemiol 2018; 2:e015. [PMID: 31531412 PMCID: PMC6748334 DOI: 10.1097/ee9.0000000000000015] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Accepted: 04/17/2018] [Indexed: 11/26/2022] Open
Abstract
A major goal of health disparities research is to identify and intervene upon modifiable risk factors that help explain the observed associations between social factors and adverse health outcomes. To this end, statistical methods incorporating mediation analysis have shown promise, as they quantify the contribution of an intermediate variable in an exposure-outcome association. A growing body of literature suggests that environmental chemicals can contribute to health disparities. However, evaluating environmental chemicals as an important component of health disparities introduces methodological complexities that may make standard mediation approaches inadequate. Specific to environmental health is the issue of evaluating both the source and biomarker of the environmental toxicant in order to calculate the proportion of the disparity that would remain had we intervened on the modifiable factors. Recent methodological developments on multiple mediators can improve efforts to integrate both source and biomarker of exposure into epidemiological studies of health disparities. We illustrate a conceptual framework and present how mediation techniques can be used to address environmental health disparities questions. With this, we provide a methodological tool that has the potential to advance this growing field, while simultaneously informing public health prevention and policy surrounding the impact of environmental factors on health disparities.
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Affiliation(s)
- Andrea Bellavia
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Ami R. Zota
- Department of Environmental and Occupational Health, Milken Institute School of Public Health, George Washington University, Washington, DC
| | - Linda Valeri
- Psychiatric Biostatistics Laboratory, McLean Hospital, Belmont, Massachusetts
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
| | - Tamarra James-Todd
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Division of Women’s Health, Department of Medicine, Connors Center for Women’s Health and Gender Biology, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
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88
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Nuru-Jeter AM, Michaels EK, Thomas MD, Reeves AN, Thorpe RJ, LaVeist TA. Relative Roles of Race Versus Socioeconomic Position in Studies of Health Inequalities: A Matter of Interpretation. Annu Rev Public Health 2018; 39:169-188. [PMID: 29328880 PMCID: PMC10042447 DOI: 10.1146/annurev-publhealth-040617-014230] [Citation(s) in RCA: 93] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
An abundance of research has documented health inequalities by race and socioeconomic position (SEP) in the United States. However, conceptual and methodological challenges complicate the interpretation of study findings, thereby limiting progress in understanding health inequalities and in achieving health equity. Fundamental to these challenges is a lack of clarity about what race is and the implications of that ambiguity for scientific inquiry. Additionally, there is wide variability in how SEP is conceptualized and measured, resulting in a lack of comparability across studies and significant misclassification of risk. The objectives of this review are to synthesize the literature regarding common approaches to examining race and SEP health inequalities and to discuss the conceptual and methodological challenges associated with how race and SEP have been employed in public health research. Addressing health inequalities has become increasingly important as the United States trends toward becoming a majority-minority nation. Recommendations for future research are presented.
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Affiliation(s)
- Amani M Nuru-Jeter
- Division of Community Health Sciences, School of Public Health, University of California, Berkeley, California 94720, USA; .,Division of Epidemiology, School of Public Health, University of California, Berkeley, California 94720, USA; , , ,
| | - Elizabeth K Michaels
- Division of Epidemiology, School of Public Health, University of California, Berkeley, California 94720, USA; , , ,
| | - Marilyn D Thomas
- Division of Epidemiology, School of Public Health, University of California, Berkeley, California 94720, USA; , , ,
| | - Alexis N Reeves
- Division of Epidemiology, School of Public Health, University of California, Berkeley, California 94720, USA; , , ,
| | - Roland J Thorpe
- Department of Health, Behavior, and Society, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland 21205, USA;
| | - Thomas A LaVeist
- Department of Health Policy and Management, Milken Institute School of Public Health, George Washington University, Washington, DC 20052, USA;
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89
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Patil PA, Porche MV, Shippen NA, Dallenbach NT, Fortuna LR. Which girls, which boys? The intersectional risk for depression by race and ethnicity, and gender in the U.S. Clin Psychol Rev 2017; 66:51-68. [PMID: 29310973 DOI: 10.1016/j.cpr.2017.12.003] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Revised: 12/13/2017] [Accepted: 12/19/2017] [Indexed: 11/26/2022]
Abstract
We sought to conduct the first systematic review of studies applying an intersectional lens to assessing risk and protective factors for depression in minority adolescents in the United States. Twenty-five studies were identified which investigated the role of racial and ethnic identity and gender for minority groups and how marginalization may be associated with differential outcomes in depression symptomology. The results showed substantial variability in whether studies intentionally operationalized intersectionality through theoretical frameworks, study design, sampling, and analyses. Studies were rated on a scale of 1 through 5; those with scores of 3 or higher were included in the review. A rating of 5 indicated studies had explicitly used an intersectional theoretical framework, integrating the process of racial/ethnic identity development and gender socialization during adolescence. Three studies met the criteria for 5, one study was rated 4, and 21 studies were rated 3. Attention to experiences with discrimination was common throughout. Overall, the collective findings point to the importance of using an intersectional lens for understanding differential mechanisms for how and why specific adolescent minority youth are at greater risk for reporting depression symptoms, identifying cultural and developmental protective factors, and informing how interventions can effectively target specific mechanisms for prevention and treatment.
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Affiliation(s)
- Pratima A Patil
- Boston University, School of Education, 2 Silber Way, Boston, MA 02215, USA
| | - Michelle V Porche
- Boston University, School of Education, 2 Silber Way, Boston, MA 02215, USA
| | - Nellie A Shippen
- Boston Medical Center, Department of Adolescent Psychiatry, 850 Harrison Avenue, Dowling 7, Boston, MA 02118, USA
| | - Nina T Dallenbach
- Boston Medical Center, Department of Adolescent Psychiatry, 850 Harrison Avenue, Dowling 7, Boston, MA 02118, USA
| | - Lisa R Fortuna
- Boston Medical Center, Department of Adolescent Psychiatry, 850 Harrison Avenue, Dowling 7, Boston, MA 02118, USA.
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90
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Explaining intersectionality through description, counterfactual thinking, and mediation analysis. Soc Psychiatry Psychiatr Epidemiol 2017; 52:785-793. [PMID: 28540515 DOI: 10.1007/s00127-017-1390-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Accepted: 05/01/2017] [Indexed: 10/19/2022]
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91
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Breland JY, Phibbs CS, Hoggatt KJ, Washington DL, Lee J, Haskell S, Uchendu US, Saechao FS, Zephyrin LC, Frayne SM. The Obesity Epidemic in the Veterans Health Administration: Prevalence Among Key Populations of Women and Men Veterans. J Gen Intern Med 2017; 32:11-17. [PMID: 28271422 PMCID: PMC5359156 DOI: 10.1007/s11606-016-3962-1] [Citation(s) in RCA: 133] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Most US adults are overweight or obese. Understanding differences in obesity prevalence across subpopulations could facilitate the development and dissemination of weight management services. OBJECTIVES To inform Veterans Health Administration (VHA) weight management initiatives, we describe obesity prevalence among subpopulations of VHA patients. DESIGN Cross-sectional descriptive analyses of fiscal year 2014 (FY2014) national VHA administrative and clinical data, stratified by gender. Differences ≥5% higher than the population mean were considered clinically significant. PARTICIPANTS Veteran VHA primary care patients with a valid weight within ±365 days of their first FY2014 primary care visit, and a valid height (98% of primary care patients). MAIN MEASURES We used VHA vital signs data to ascertain height and weight and calculate body mass index, and VHA outpatient, inpatient, and fee basis data to identify sociodemographic- and comorbidity-based subpopulations. KEY RESULTS Among nearly five million primary care patients (347,112 women, 4,567,096 men), obesity prevalence was 41% (women 44%, men 41%), and overweight prevalence was 37% (women 31%, men 38%). Across the VHA's 140 facilities, obesity prevalence ranged from 28% to 49%. Among gender-stratified subpopulations, obesity prevalence was high among veterans under age 65 (age 18-44: women 40%, men 46%; age 45-64: women 49%, men 48%). Obesity prevalence varied across racial/ethnic and comorbidity subpopulations, with high obesity prevalence among black women (51%), women with schizophrenia (56%), and women and men with diabetes (68%, 56%). CONCLUSIONS Overweight and obesity are common among veterans served by the VHA. VHA's weight management initiatives have the potential to avert long-term morbidity arising from obesity-related conditions. High-risk groups-such as black women veterans, women veterans with schizophrenia, younger veterans, and Native Hawaiian/Other Pacific Islander and American Indian/Alaska Native veterans-may require particular attention to ensure that systems improvement efforts at the population level do not inadvertently increase health disparities.
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Affiliation(s)
- Jessica Y Breland
- VA HSR&D Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, 795 Willow Road (MPD-152), Menlo Park, CA, 94025, USA.
- Stanford University School of Medicine, Stanford, CA, USA.
| | - Ciaran S Phibbs
- VA HSR&D Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, 795 Willow Road (MPD-152), Menlo Park, CA, 94025, USA
- Stanford University School of Medicine, Stanford, CA, USA
| | - Katherine J Hoggatt
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Sepulveda, CA, USA
- Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, CA, USA
| | - Donna L Washington
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Sepulveda, CA, USA
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Jimmy Lee
- VA HSR&D Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, 795 Willow Road (MPD-152), Menlo Park, CA, 94025, USA
| | - Sally Haskell
- United States Department of Veterans Affairs Central Office, Women's Health Services, Washington, DC, USA
- West Haven VA, West Haven, CT, USA
- Yale University School of Medicine, New Haven, CT, USA
| | - Uchenna S Uchendu
- United States Department of Veterans Affairs Central Office, Office of Health Equity, Washington, DC, USA
| | - Fay S Saechao
- VA HSR&D Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, 795 Willow Road (MPD-152), Menlo Park, CA, 94025, USA
| | - Laurie C Zephyrin
- United States Department of Veterans Affairs Central Office, Women's Health Services, Washington, DC, USA
- New York University School of Medicine, New York, NY, USA
| | - Susan M Frayne
- VA HSR&D Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, 795 Willow Road (MPD-152), Menlo Park, CA, 94025, USA
- Stanford University School of Medicine, Stanford, CA, USA
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92
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Schwartz S. Commentary: on the application of potential outcomes-based methods to questions in social psychiatry and psychiatric epidemiology. Soc Psychiatry Psychiatr Epidemiol 2017; 52:139-142. [PMID: 28180929 DOI: 10.1007/s00127-016-1334-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Accepted: 12/24/2016] [Indexed: 11/25/2022]
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93
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Gustafsson PE, Sebastián MS, Mosquera PA. Meddling with middle modalities: a decomposition approach to mental health inequalities between intersectional gender and economic middle groups in northern Sweden. Glob Health Action 2016; 9:32819. [PMID: 27887668 PMCID: PMC5124119 DOI: 10.3402/gha.v9.32819] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Revised: 10/27/2016] [Accepted: 10/31/2016] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Intersectionality has received increased interest within population health research in recent years, as a concept and framework to understand entangled dimensions of health inequalities, such as gender and socioeconomic inequalities in health. However, little attention has been paid to the intersectional middle groups, referring to those occupying positions of mixed advantage and disadvantage. OBJECTIVE This article aimed to 1) examine mental health inequalities between intersectional groups reflecting structural positions of gender and economic affluence and 2) decompose any observed health inequalities, among middle groups, into contributions from experiences and conditions representing processes of privilege and oppression. DESIGN Participants (N=25,585) came from the cross-sectional 'Health on Equal Terms' survey covering 16- to 84-year-olds in the four northernmost counties of Sweden. Six intersectional positions were constructed from gender (woman vs. men) and tertiles (low vs. medium vs. high) of disposable income. Mental health was measured through the General Health Questionnaire-12. Explanatory variables covered areas of material conditions, job relations, violence, domestic burden, and healthcare contacts. Analysis of variance (Aim 1) and Blinder-Oaxaca decomposition analysis (Aim 2) were used. RESULTS Significant mental health inequalities were found between dominant (high-income women and middle-income men) and subordinate (middle-income women and low-income men) middle groups. The health inequalities between adjacent middle groups were mostly explained by violence (mid-income women vs. men comparison); material conditions (mid- vs. low-income men comparison); and material needs, job relations, and unmet medical needs (high- vs. mid-income women comparison). CONCLUSIONS The study suggests complex processes whereby dominant middle groups in the intersectional space of economic affluence and gender can leverage strategic resources to gain mental health advantage relative to subordinate middle groups.
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Affiliation(s)
- Per E Gustafsson
- Epidemiology and Global Health, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden;
| | - Miguel San Sebastián
- Epidemiology and Global Health, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Paola A Mosquera
- Epidemiology and Global Health, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
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