Structural racism and myocardial infarction in the United States

Disparities in Reproductive Aging and Midlife Health between Black and White women: The Study of Women's Health Across the Nation (SWAN)

This paper reviews differences in the experience of the menopause transition and midlife health outcomes between Black and White women who participated in the Study of Women's Health Across the Nation (SWAN), a 25-year, longitudinal, multi-racial/ethnic cohort study. We identify health disparities, i.e., instances in which Black women's outcomes are less favorable than those of White women, and consider whether structural racism may underlie these disparities. Although SWAN did not explicitly assess structural racism, Black women in SWAN grew up during the Jim Crow era in the United States, during which time racism was legally sanctioned. We consider how we might gain insight into structural racism by examining proxy exposures such as socioeconomic characteristics, reports of everyday discrimination, and a range of life stressors, which likely reflect the longstanding, pervasive and persistent inequities that have roots in systemic racism in the US. Thus, this paper reviews the presence, magnitude, and longitudinal patterns of racial disparities observed in SWAN in six areas of women's health - menopause symptoms, sleep, mental health, health related quality of life, cardio-metabolic health, and physical function -and elucidates the contextual factors that are likely influencing these disparities. We review the strengths and weaknesses of SWAN's design and approach to analysis of racial disparities and use this as a springboard to offer recommendations for future cohort studies.

Sick And Tired Of Being Excluded: Structural Racism In Disenfranchisement As A Threat To Population Health Equity

Theoretical research suggests that racialized felony disenfranchisement-a form of structural racism-is likely to undermine the health of Black people, yet empirical studies on the topic are scant. We used administrative data on disproportionate felony disenfranchisement of Black residents across US states, linked to geocoded individual-level health data from the 2016 Health and Retirement Study, to estimate race-specific regression models describing the relationship between racialized disenfranchisement and health among middle-aged and older adults, adjusting for other individual- and state-level factors. Results show that living in states with higher levels of racialized disenfranchisement is associated with more depressive symptoms, more functional limitations, more difficulty performing instrumental activities of daily living, and more difficulty performing activities of daily living among Black people. However, there are no statistically significant relationships between racialized disenfranchisement and health among White people. These findings suggest that policies aiming to mitigate disproportionate Black felony disenfranchisement not only are essential for political inclusion but also may be valuable tools for improving population health equity.

Improving The Measurement Of Structural Racism To Achieve Antiracist Health Policy

Antiracist health policy research requires methodological innovation that creates equity-centered and antiracist solutions to health inequities by centering the complexities and insidiousness of structural racism. The development of effective health policy and health equity interventions requires sound empirical characterization of the nature of structural racism and its impact on public health. However, there is a disconnect between the conceptualization and measurement of structural racism in the public health literature. Given that structural racism is a system of interconnected institutions that operates with a set of racialized rules that maintain White supremacy, how can anyone accurately measure its insidiousness? This article highlights methodological approaches that will move the field forward in its ability to validly measure structural racism for the purposes of achieving health equity. We identify three key areas that require scholarly attention to advance antiracist health policy research: historical context, geographical context, and theory-based novel quantitative and qualitative methods that capture the multifaceted and systemic properties of structural racism as well as other systems of oppression.

Disparities in Timing of Alveolar Bone Grafting and Dental Reconstruction in Patients With Clefts

This study sought to identify disparities in the timing of alveolar bone grafting (ABG) surgery and the replacement strategy for missing maxillary lateral incisors for patients with clefts.

A retrospective record review identified patients who underwent ABG. Multivariable regression analyzed the independent contribution of each variable.

This institutional study was performed at the University of California, San Francisco.

Patients who presented under age 12 and underwent secondary ABG between 2012 and 2020 (n = 160).

The age at secondary ABG and the recommended dental replacement treatment for each patient, either dental implantation or canine substitution.

The average age at ABG was 10.8 ± 2.1 years, 106 (66.3%) patients were not White, and 80 (50.0%) had private insurance. Independent predictors of older age at ABG included an income below $ 50 000 as estimated from ZIP code (β = 15.0 months, 95% CI, 5.7-24.3, P = .002) and identifying as a race other than White (β = 10.1 months, 95% CI, 2.1-18.0, P = .01). After ABG, patients were more likely to undergo dental implantation over canine substitution if they were female (odds ratio [OR] = 4.3, 95% CI, 1.3-17.1, P = .02) or had private insurance (OR = 12.5, 95% CI, 2.2-143.2, P = .01).

Patients who were low-income or not White experienced delays in ABG, whereas dental implantation was more likely to be recommended for patients with private insurance. Understanding the sources of disparities in dental reconstruction of cleft deformities may reveal opportunities to improve equity.

Association of historic redlining and present-day health in Baltimore

BACKGROUND

In the 1930s, the Home Owners' Loan Corporation categorized neighborhoods by investment grade along racially discriminatory lines, a process known as redlining. Although other authors have found associations between Home Owners' Loan Corporation categories and current impacts on racial segregation, analysis of current health impacts rarely use these maps.

OBJECTIVE

To study whether historical redlining in Baltimore is associated with health impacts today.

APPROACH

Fifty-four present-day planning board-defined community statistical areas are assigned historical Home Owners' Loan Corporation categories by area predominance. Categories are red ("hazardous"), yellow ("definitely declining") with blue/green ("still desirable"/"best") as the reference category. Community statistical area life expectancy is regressed against Home Owners' Loan Corporation category, controlling for median household income and proportion of African American residents.

CONCLUSION

Red categorization is associated with 4.01 year reduction (95% CI: 1.47, 6.55) and yellow categorization is associated with 5.36 year reduction (95% CI: 3.02, 7.69) in community statistical area life expectancy at baseline. When controlling for median household income and proportion of African American residents, red is associated with 5.23 year reduction (95% CI: 3.49, 6.98) and yellow with 4.93 year reduction (95% CI: 3.22, 6.23). Results add support that historical redlining is associated with health today.

New Preemption as a Tool of Structural Racism: Implications for Racial Health Inequities

Preemption is a substantial threat to achieving racial equity. Since 2011, states have increasingly preempted local governments from enacting policies that can improve health and reduce racial inequities such as increasing minimum wage and requiring paid leave.

Psychosocial stress and neuroendocrine biomarker concentrations among women living with or without HIV

OBJECTIVE

Women living with HIV (WLWH) experience psychosocial stress related to social-structural vulnerabilities. To investigate neuroendocrine pathways linking stress and increased cardiovascular disease risk among WLWH, we evaluated associations between psychosocial stress (i.e., perceived stress, posttraumatic stress, and experiences of race- and gender-based harassment) and a composite neuroendocrine biomarker index among WLWH and women without HIV.

METHODS

In 2019-2020, Women's Interagency HIV Study participants in Washington, DC completed a questionnaire and provided blood and 12-hour overnight urine samples for testing of serum dehydroepiandrosterone sulfate (DHEA-S) and urinary free cortisol, epinephrine, and norepinephrine. Psychosocial stress was measured using the Perceived Stress Scale, PTSD Checklist-Civilian Version, and Racialized Sexual Harassment Scale. Latent profile analysis was used to classify participants into low (38%), moderate (44%), and high (18%) stress groups. Composite biomarker index scores between 0-4 were assigned based on participants' number of neuroendocrine biomarkers in high-risk quartiles (≥75th percentile for cortisol, epinephrine, and norepinephrine and ≤25th percentile for DHEA-S). We evaluated associations between latent profile and composite biomarker index values using multivariable linear regression, adjusting for socio-demographic, behavioral, metabolic, and HIV-related factors.

RESULTS

Among 90 women, 62% were WLWH, 53% were non-Hispanic Black, and median age was 55 years. In full multivariable models, there was no statistically significant association between psychosocial stress and composite biomarker index values among all women independent of HIV status. High (vs. low) psychosocial stress was positively associated with higher mean composite biomarker index values among all monoracial Black women (adjusted β = 1.32; 95% CI: 0.20-2.43), Black WLWH (adjusted β = 1.93; 95% CI: 0.02-3.83) and Black HIV-negative women (adjusted β = 2.54; 95% CI: 0.41-4.67).

CONCLUSIONS

Despite a null association in the overall sample, greater psychosocial stress was positively associated with higher neuroendocrine biomarker concentrations among Black women, highlighting a plausible mechanism by which psychosocial stress could contribute to cardiovascular disease risk.

Race and Ethnicity Considerations in Patients With Coronary Artery Disease and Stroke: JACC Focus Seminar 3/9

Notable racial and ethnic differences and disparities exist in coronary artery disease (CAD) and stroke epidemiology and outcomes despite substantial advances in these fields. Racial and ethnic minority subgroups remain underrepresented in population data and clinical trials contributing to incomplete understanding of these disparities. Differences in traditional cardiovascular risk factors such as hypertension and diabetes play a role; however, disparities in care provision and process, social determinants of health including socioeconomic position, neighborhood environment, sociocultural factors, and racial discrimination within and outside of the health care system also drive racial and ethnic CAD and stroke disparities. Improved culturally congruent and competent communication about risk factors and symptoms is also needed. Opportunities to achieve improved and equitable outcomes in CAD and stroke must be identified and pursued.

Essentialism and Exclusion: Racism in Cancer Risk Prediction Models

Cancer risk prediction models have the potential to revolutionize the science and practice of cancer prevention and control by identifying the likelihood that a patient will develop cancer at some point in the future, likely experience more benefit than harm from a given intervention, and survive their cancer for a certain number of years. The ability of risk prediction models to produce estimates that are valid and reliable for people from diverse socio-demographic backgrounds-and consequently their utility for broadening the reach of precision medicine to marginalized populations-depends on ensuring that the risk factors included in the model are represented as thoroughly and as accurately as possible. However, cancer risk prediction models created in the United States have a critical limitation, the origins of which stem from the country's earliest days: they either erroneously treat the social construct of race as an immutable biological factor (ie, they "essentialize" race), or they exclude from the model those socio-contextual factors that are associated with both race and health outcomes. Models that essentialize race and/or exclude socio-contextual factors sometimes incorporate "race corrections" that adjust a patient's risk estimate up or down based on their race. This commentary discusses the origins of race corrections, potential flaws with such corrections, and strategies for developing cohorts for developing risk prediction models that do not essentialize race or exclude key socio-contextual factors. Such models will help move the science of cancer prevention and control towards its goal of eliminating cancer disparities and achieving health equity.

Uses of Theory in Racial Health Disparities Research: A Scoping Review and Application of Public Health Critical Race Praxis

Given the persistence of racial health disparities, scholars have called for investigations into structural origins of health inequity and deeper engagement with theory. We systematically assessed uses of theory-including theory-informed conceptualizations of race and ethnicity, social structure, and racial hierarchy-in epidemiology and other quantitative population health literature on racial health disparities. We conducted a scoping review of systematically identified original research articles (n=650) that sought to explain racial health disparities; articles were published in 17 high-impact epidemiology, public health, and social science journals. Trained coders abstracted data from each article. We applied Public Health Critical Race Praxis and an iterative data-charting method to identify key themes. Only 63 (9.7%) of 650 racial health disparities articles explicitly used theory. Among studies that engaged theory, one third (n=21/63) clearly conceptualized race and/or ethnicity, and a minority theorized social structure (n=19/63; 30%) and/or racial hierarchy as a structural relation (n=4/63; 6%). There is a pressing need for racial health disparities researchers to unambiguously use theory to conceptualize race and ethnicity in social and historical contexts and explain relational aspects of racial hierarchy. These approaches can better elucidate and inform action on structural determinants of both racial inequity and racial health inequity.

Social and Structural Determinants of Health: Exploring Occupational Therapy's Structural (In)competence

Background: In high-income countries, such as Canada, 50% of health outcomes are attributable to social determinants. Occupational opportunities are also structurally determined, yet these inequities are obscured by the White, Western assumptions and ableist neoliberal ideology in which the profession is deeply rooted. Purpose. To highlight the impact of structural injustices and other social determinants of health and occupation; explore the occupational therapy profession's structural competence; and build on existing knowledge to advance an agenda for action on injustice and inequity for the occupational therapy profession. Key issues. Occupational therapy's failure to prioritize education, research and action on systemic injustices and other social determinants of health and occupation reflects a lack of commitment to achieving the World Federation of Occupational Therapists' Minimal Standards. Implications. If occupational therapy is to advance knowledge and practices that address inequities in the social and structural determinants of health and occupation, we must strive towards structural competence.

The intricacy of structural racism measurement: A pilot development of a latent-class multidimensional measure

BACKGROUND

Structural racism is a complex system of inequities working in tandem to cause poor health for communities of color, especially for Black people. However, the multidimensional nature of structural racism is not captured by existing measures used by population health scholars to study health inequities. Multidimensional measures can be made using complex analytical techniques. Whether or not the multidimensional measure of structural racism provides more insight than the existing unidimensional measures is unknown.

METHODS

We derived measures of Black-White residential segregation, inequities in education, employment, income, and homeownership, evaluated for 2,338 Public Use Microdata Areas (PUMAs) in the United States (US), and consolidated them into a multidimensional measure of structural racism using a latent class model. We compared the median COVID-19 vaccination rates observed across 54 New York City (NYC) PUMAs by levels (high/low) of structural racism and the multidimensional class using the Kruskal-Wallis test. This study was conducted in March 2021.

FINDINGS

Our latent class model identified three structural racism classes in the US, all of which can be found in NYC. We observed intricate interactions between the five dimensions of structural racism of interest that cannot be simply classified as "high" (i.e., high on all dimensions of structural racism), "medium," or "low." Compared to Class A PUMAs with the median rate of two-dose completion of 6·9%, significantly lower rates were observed for Class B PUMAs (5·5%, p = 0·04) and Class C PUMAs (5·2%, p = 0·01). When the vaccination rates were evaluated based on each dimension of structural racism, significant differences were observed between PUMAs with high and low Black-White income inequity only (7·2% vs. 5·3%, p = 0·001).

INTERPRETATION

Our analysis suggests that measuring structural racism as a multidimensional determinant of health provides additional insight into the mechanisms underlying population health inequity vis-à-vis using multiple unidimensional measures without capturing their joint effects.

FUNDING

This project is funded by the Robert J. Jones Urban Research and Outreach-Engagement Center, University of Minnesota. Additional support is provided by the Minnesota Population Center, which is funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development (Grant P2C HD041023).

Structural Intersectionality as a New Direction for Health Disparities Research

This article advances the field by integrating insights from intersectionality perspectives with the emerging literatures on structural racism and structural sexism-which point to promising new ways to measure systems of inequality at a macro level-to introduce a structural intersectionality approach to population health. We demonstrate an application of structural intersectionality using administrative data representing macrolevel structural racism, structural sexism, and income inequality in U.S. states linked to individual data from the Behavioral Risk Factor Surveillance System to estimate multilevel models (N = 420,644 individuals nested in 76 state-years) investigating how intersecting dimensions of structural oppression shape health. Analyses show that these structural inequalities: (1) vary considerably across U.S. states, (2) intersect in numerous ways but do not strongly or positively covary, (3) individually and jointly shape health, and (4) are most consistently associated with poor health for black women. We conclude by outlining an agenda for future research on structural intersectionality and health.

Trends in U.S. Population Health: The Central Role of Policies, Politics, and Profits

Recent trends in U.S. health have been mixed, with improvements among some groups and geographic areas alongside declines among others. Medical sociologists have contributed to the understanding of those disparate trends, although important questions remain. In this article, we review trends since the 1980s in key indicators of U.S. health and weigh evidence from the last decade on their causes. To better understand contemporary trends in health, we propose that commonly used conceptual frameworks, such as social determinants of health, should be strengthened by prominently incorporating commercial, political-economic, and legal determinants. We illustrate how these structural determinants can provide new insights into health trends, using disparate health trajectories across U.S. states as an example. We conclude with suggestions for future research: focusing on structural causes of health trends and inequalities, expanding interdisciplinary perspectives, and integrating methods better equipped to handle the complexity of causal processes driving health trends and inequalities.

State- and Provider-Level Racism and Health Care in the U.S

INTRODUCTION

This study examines the associations between state-level and provider sources of racism and healthcare access and quality for non-Hispanic Black and White individuals.

METHODS

Data from 2 sources were integrated: (1) data from the Association of American Medical Colleges' Consumer Survey of Health Care Access (2014-2019), which included measures of self-reported healthcare access, healthcare quality, and provider racial discrimination and (2) administrative data compiled to index state-level racism. State-level racism composite scores were calculated from federal sources (U.S. Census, Department of Labor, Department of Justice). The data set comprised 21,030 adults (n=2,110 Black, n=18,920 White) who needed care within the past year. Participants were recruited from a national panel, and the survey employed age-insurance quotas. Logistic and linear regressions were conducted in 2020, adjusting for demographic, geographic, and health-related covariates.

RESULTS

Among White individuals, more state-level racism was associated with 5% higher odds of being able to get care and 6% higher odds of sufficient time with provider. Among Black individuals, more state-level racism was associated with 8% lower odds of being able to get care. Provider racial discrimination was also associated with 80% lower odds of provider explaining care, 77% lower odds of provider answering questions, and 68% lower odds of sufficient time with provider.

CONCLUSIONS

State-level racism may engender benefits to healthcare access and quality for White individuals and may decrease access for Black individuals. Disparities may be driven by both White advantage and Black disadvantage. State-level policies may be the actionable levers of healthcare inequities with implications for preventive medicine.

Racism as Public Health Crisis: Assessment and Review of Municipal Declarations and Resolutions Across the United States

Racism in the United States has been cited as a key driver of racial health inequities. Racism as a public health crisis has been in the forefront, particularly with respect to state and municipal governments that have developed legislation, resolutions, and declarations. This policy brief includes a review of resolutions and declarations across the US related to Racism as a Public Health Crisis through the end of September 2020. There were 125 resolutions reviewed for content related to the history of racism, reference to racial health equity data, content related to action steps or implementation, and any accompanying funding or resources. We found that the majority of policies name racism as critical in addressing racial inequities in health with limited details about specific actions, funding, or resources.

Differences in U.S. Rural-Urban Trends in Diabetes ABCS, 1999-2018

OBJECTIVE

To examine changes in and the relationships between diabetes management and rural and urban residence.

RESEARCH DESIGN AND METHODS

Using National Health and Nutrition Examination Survey (1999-2018) data from 6,372 adults aged ≥18 years with self-reported diagnosed diabetes, we examined poor ABCS: A1C >9% (>75 mmol/mol), Blood pressure (BP) ≥140/90 mmHg, Cholesterol (non-HDL) ≥160 mg/dL (≥4.1 mmol/L), and current Smoking. We compared odds of urban versus rural residents (census tract population size ≥2,500 considered urban, otherwise rural) having poor ABCS across time (1999-2006, 2007-2012, and 2013-2018), overall and by sociodemographic and clinical characteristics.

RESULTS

During 1999-2018, the proportion of U.S. adults with diabetes residing in rural areas ranged between 15% and 19.5%. In 1999-2006, there were no statistically significant rural-urban differences in poor ABCS. However, from 1999-2006 to 2013-2018, there were greater improvements for urban adults with diabetes than for rural for BP ≥140/90 mmHg (relative odds ratio [OR] 0.8, 95% CI 0.6-0.9) and non-HDL ≥160 mg/dL (≥4.1 mmol/L) (relative OR 0.45, 0.4-0.5). These differences remained statistically significant after adjustment for race/ethnicity, education, poverty levels, and clinical characteristics. Yet, over the 1999-2018 time period, minority race/ethnicity, lower education attainment, poverty, and lack of health insurance coverage were factors associated with poorer A, B, C, or S in urban adults compared with their rural counterparts.

CONCLUSIONS

Over two decades, rural U.S. adults with diabetes have had less improvement in BP and cholesterol control. In addition, rural-urban differences exist across sociodemographic groups, suggesting that efforts to narrow this divide may need to address both socioeconomic and clinical aspects of care.

Fighting for America's Paradise: The Struggle against Structural Racism

Structural racism is a fundamental cause of racial inequities in health in the United States. Structural racism is manifested in inequality in the criminal justice system; de facto segregation in education, health care, and housing; and ineffective and disproportionately violent policing and economic disenfranchisement in communities of color. The inequality that Black people and communities of color face is the direct result of centuries of public policy that made Black and Brown skin a liability. The United States is now in an unprecedented moment in its history with a new administration that explicitly states, "The moment has come for our nation to deal with systemic racism . . . and to deal with the denial of the promise of this nation-to so many." The opportunities for creating innovative and bold policy must reflect the urgency of the moment and seek to dismantle the systems of oppression that have for far too long left the American promise unfulfilled. The policy suggestions made by the authors of this article speak to the structural targets needed for dismantling some of the many manifestations of structural racism so as to achieve health equity.

Formation and Evaluation of an Academic Elective for Residents in a Combined Internal Medicine-Pediatrics Residency Program

Background

Recently, there has been increasing focus on skills that are crucial for success in residency that is not explicitly taught. Specifically, the four domains of teaching skills, evidence appraisal, wellness, and education on structural racism have been identified as topics that are important and underrepresented in current resident education curriculums, largely due to time constraints.

Methods

A task force consisting of one post-graduate year 2 (PGY-2) resident, one PGY-4 resident, the Associate Program Director, and the Program Director of the Internal Medicine-Pediatrics residency program was formed to explore current deficiencies in resident curriculum and to research possible solutions. As an intervention, we created and executed a four-week academic elective with dedicated time for upper-level residents to learn and explore the four domains of resident teaching, evidence-based clinical practice, wellness, and anti-racism work. The elective included several clinical sessions dedicated to implementing the skills taught in the elective. The month-long elective completed in January 2021. All residents evaluated each lecture or experience based on how valuable it was to their education on a Likert scale from 1 to 7, with 1 defined as “not valuable at all” and 7 defined as “extremely valuable.”

Results

Residents rated the overall value of teaching in each domain highly. Education and activities in wellness lectures were found to have the highest value-added material (6.20 ± 0.41, n = 18), followed by residents-as-teachers lectures (5.93 ± 0.25, n = 48), anti-racism (5.57 ± 1.11, n = 9), and evidence-based clinical practice (5.18 ± 0.50, n = 43). In addition, each domain was found to have at least one high-yield topic.

Conclusions

We were able to create and execute an academic elective with dedicated time for upper-level residents to develop and utilize valuable skills in teaching, evidence appraisal, wellness, and anti-racism. Future work will focus on refining the curriculum based on resident evaluations and expanding this elective to the Internal Medicine and Pediatrics categorical programs at our institution.

Gender contexts, dowry and women's health in India: a national multilevel longitudinal analysis

Gender-biased contexts may impact women's lives across a variety of domains. This study examined whether changes in district prevalence of a salient gendered practice - dowry - are associated with changes in poor health for women in India. Two waves of national multilevel panel data were used to assess the relationship between changes in district-level dowry prevalence and changes in self-rated health for 23,785 ever-married women aged 15-50 years. Increased dowry prevalence was found to be associated with increased poor self-rated health for women. This relationship remained when controlling for potentially confounding factors including household socioeconomic status, caste, infrastructure, mobility and state fixed-effects.

A retrospective on fundamental cause theory: State of the literature, and goals for the future

Fundamental Cause Theory (FCT) was originally proposed to explain how socioeconomic inequalities in health emerged and persisted over time. The concept was that higher socioeconomic status helped some people to avoid risks and adopt protective strategies using flexible resources - knowledge, money, power, prestige and beneficial social connections. As a sociological theory, FCT addressed this issue by calling on social stratification, stigma, and racism as they affected medical treatments and health outcomes. The last comprehensive review was completed a decade ago. Since then, FCT has been tested, and new applications have extended central features. The current review consolidates key foci in the literature in order to guide future research in the field. Notable themes emerged around types of resources and their usage, approaches used to test the theory, and novel extensions. We conclude that after 25 years of use, there remain crucial questions to be addressed.

Intersecting Structural Oppression and Black Sexual Minority Men's Health

INTRODUCTION

Although evidence indicates that Black gay, bisexual, and other sexual minority men experience vast psychological and behavioral health inequities, most research has focused on individual rather than structural drivers of these inequities. This study examines the associations between structural racism and anti-lesbian, gay, bisexual, transgender, and queer policies and the psychological and behavioral health of Black and White sexual minority men.

METHODS

Participants were an Internet-based U.S. national sample of 1,379 Black and 5,537 White sexual minority men during 2017-2018. Analysis occurred in 2019-2020. Structural equation modeling tested the associations from indicators of structural racism, anti‒lesbian, gay, bisexual, transgender, and queer policies, and their interaction to anxiety symptoms, depressive symptoms, perceived burdensomeness, heavy drinking, and HIV testing frequency. Separate models for Black and White sexual minority men adjusted for contextual and individual covariates.

RESULTS

For Black participants, structural racism was positively associated with anxiety symptoms (β=0.20, SE=0.10, p=0.04), perceived burdensomeness (β=0.42, SE=0.09, p<0.001), and heavy drinking (β=0.23, SE=0.10, p=0.01). Anti‒lesbian, gay, bisexual, transgender, and queer policies were positively associated with anxiety symptoms (β=0.08, SE=0.04, p=0.03), perceived burdensomeness (β=0.20, SE=0.04, p<0.001), and heavy drinking (β=0.10, SE=0.04, p=0.01) and were negatively associated with HIV testing frequency (β= -0.14, SE=0.07, p=0.04). Results showed significant interaction effects, such that the positive associations between structural racism and both perceived burdensomeness (β=0.38, SE=0.08, p≤0.001) and heavy drinking (β=0.22, SE=0.07, p=0.003) were stronger for individuals living in states with high levels of anti‒lesbian, gay, bisexual, transgender, and queer policies. Neither of the oppression variables nor their interaction was significantly associated with outcomes for White sexual minority men.

CONCLUSIONS

Results highlight the intersectional nature of structural oppression and suggest that racist and anti-lesbian, gay, bisexual, transgender, and queer policies must be repealed to rectify health inequities facing Black sexual minority men.

Political Economies of Acute Childhood Illnesses: Measuring Structural Racism as Mesolevel Mortgage Market Risks

Objectives

Health studies of structural racism/discrimination have been animated through the deployment of neighborhood effects frameworks that engage institutionalist concerns about sociopolitical resources and mobility structures. This study highlights the acute illness risks of place-based inequalities and neighborhood-varying race-based inequalities by focusing on access to and the regulation of mortgage markets.

Design

By merging neighborhood data on lending processes from the Home Mortgage Disclosure Act with individual health from the Project on Human Development in Chicago Neighborhoods, this article evaluates the acute childhood illness risks of four mutually inclusive, political economies using multilevel generalized linear models.

Setting

Chicago, IL, USA.

Participants

Youth aged 0 to 17 years.

Main Outcome Measures

The prevalence of 11 acute illnesses (cold/flu, sinus trouble, sore throat/tonsils, headache, upset stomach, bronchitis, skin infection, pneumonia, urinary tract infections, fungal disease, mononucleosis) and the past-year frequencies of 6 acute illnesses (cold/flu, sinus trouble, sore throat/tonsils, headache, upset stomach, bronchitis) are evaluated.

Methods

Multilevel logistic regression.

Results

The most theoretically consistent predictor of illness is a measure identifying neighborhoods with above-city-median levels of racial disparities in the regulation of loans - a mesolevel measure of structural racism. In areas with high levels of minority-White differences in less-regulated credit, youth are more likely to have a range of acute illnesses and experience them at more frequent intervals in the past year.

Conclusions

This article highlights the substantive and methodological importance of focusing on multidimensional representations of institutionalized political economic inequalities circumscribed and traversed by the power relations established by institutions and the state.

Association Between Social Determinants of Health and Postoperative Outcomes in Patients Undergoing Single-Level Lumbar Fusions: A Matched Analysis

STUDY DESIGN

Retrospective cohort.

OBJECTIVE

The aim of this study was to analyze association between social determinants of health (SDH) disparity on postoperative complication rates, and 30-day and 90-day all-cause readmission in patients undergoing single-level lumbar fusions.

SUMMARY OF BACKGROUND DATA

Decreasing postoperative complication rates is of great interest to surgeons and healthcare systems. Postoperative complications are associated with poor convalescence, inferior patient reported outcomes measures, and increased health care resource utilization. Better understanding of the association between Social Determinants of Health (SDH) on postoperative outcomes maybe helpful to decrease postoperative complication rates.

METHODS

MARINER 2020, an all-payer claims database, was utilized to identify patients undergoing single-level lumbar fusions between 2010 and 2018. The primary outcomes were the rates of any postoperative complication, symptomatic pseudarthrosis, need for revision surgery, or 30-day and 90-day all-cause readmission.

RESULTS

The exact matched population analyzed in this study contained 16,560 patients (8280 [50.0%] patients undergoing single-level lumbar fusion with an SDH disparity; 8280 [50.0%] patients undergoing single-level lumbar fusion without a disparity). Both patient groups were balanced at baseline. The rate of symptomatic pseudarthrosis (1.0% vs. 0.6%, P < 0.05) or any postoperative complication (16.3% vs. 10.4%, P < 0.05) in the matched analysis was higher in the disparity group. The presence of a disparity was associated with 70% increased odds of developing any complication (OR 1.7, 95% CI 1.53-1.84) or symptomatic pseudarthrosis (OR 1.7, 95% CI 1.17-2.37). Unadjusted and adjusted sensitivity analyses yielded similar results as the primary analysis.

CONCLUSION

Social Determinants of Health affect outcomes in spine surgery patients and are associated with an increased risk of developing postoperative complications following lumbar spine fusion.Level of Evidence: 3.

Actual Racial/Ethnic Disparities in COVID-19 Mortality for the Non-Hispanic Black Compared to Non-Hispanic White Population in 35 US States and Their Association with Structural Racism

Introduction

While the increased burden of COVID-19 among the Black population has been recognized, most attempts to quantify the extent of this racial disparity have not taken the age distribution of the population into account. In this paper, we determine the Black–White disparity in COVID-19 mortality rates across 35 states using direct age standardization. We then explore the relationship between structural racism and differences in the magnitude of this disparity across states.

Methods

Using data from the Centers for Disease Control and Prevention, we calculated both crude and age-adjusted COVID-19 mortality rates for the non-Hispanic White and non-Hispanic Black populations in each state. We explored the relationship between a state-level structural racism index and the observed differences in the racial disparities in COVID-19 mortality across states. We explored the potential mediating effects of disparities in exposure based on occupation, underlying medical conditions, and health care access.

Results

Relying upon crude death rate ratios resulted in a substantial underestimation of the true magnitude of the Black–White disparity in COVID-19 mortality rates. The structural racism index was a robust predictor of the observed racial disparities. Each standard deviation increase in the racism index was associated with an increase of 0.26 in the ratio of COVID-19 mortality rates among the Black compared to the White population.

Conclusions

Structural racism should be considered a root cause of the Black–White disparity in COVID-19 mortality. Dismantling the long-standing systems of racial oppression is critical to adequately address both the downstream and upstream causes of racial inequities in the disease burden of COVID-19.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40615-021-01028-1.

The legacy of structural racism: Associations between historic redlining, current mortgage lending, and health

Structural racism, which is embedded in past and present operations of the U.S. housing market, is a fundamental cause of racial health inequities. We conducted an ecologic study to 1) examine historic redlining in relation to current neighborhood lending discrimination and three key indicators of societal health (mental health, physical health, and infant mortality rate (IMR)) and 2) investigate sustained lending disinvestment as a determinant of current neighborhood health in one of the most hypersegregated metropolitan areas in the United States, Milwaukee, Wisconsin. We calculated weighted historic redlining scores from the proportion of 1930s Home Owners' Loan Corporation residential security grades contained within 2010 census tract boundaries. We combined two lending indicators from 2018 Home Mortgage Disclosure Act data to capture current neighborhood lending discrimination: low lending occurrence and high cost loans (measured via loan rate spread). Using historic redlining score and current lending discrimination, we created a 4-level hierarchical measure of lending trajectory. In Milwaukee neighborhoods, greater historic redlining was associated with current lending discrimination (OR = 1.73, 95%CI: 1.16, 2.58) and increased prevalence of poor physical health (β = 1.34, 95%CI: 0.40, 2.28) and poor mental health (β = 1.26, 95%CI: 0.51, 2.01). Historic redlining was not associated with neighborhood IMR (β = -0.48, 95%CI: -2.12, 1.15). A graded association was observed between lending trajectory and health: neighborhoods with high sustained disinvestment had worse physical and mental health than neighborhoods with high investment (poor physical health: β = 5.33, 95%CI: 3.05, 7.61; poor mental health: β = 4.32, 95%CI: 2.44, 6.20). IMR was highest in 'disinvested' neighborhoods (β = 5.87, 95%CI: 0.52, 11.22). Our findings illustrate ongoing legacies of government sponsored historic redlining. Structural racism, as manifested in historic and current forms of lending disinvestment, predicts poor health in Milwaukee's hypersegregated neighborhoods. We endorse equity focused policies that dismantle and repair the ways racism is entrenched in America's social fabric.

Patient race and racial composition of delivery unit associated with disparities in severe maternal morbidity: a multistate analysis 2007-2014

BACKGROUND

High Black-serving delivery units and high hospital safety-net burden have been associated with poorer patient outcomes. We examine these hospital-level factors and their association with severe maternal morbidity (SMM), independently and as effect modifiers of patient-level factors.

METHODS

Using the 2007-2014 State Inpatient Databases (Florida, New York, California, Maryland, Kentucky), we analyzed delivery hospitalizations. We constructed generalized linear mixed models with patient- and hospital-level variables (Black-serving delivery units: high: top 5th percentile; medium: 5th-25th percentile; low: bottom 75th percentile; hospital safety-net burden status defined by insurance status) and report adjusted odds ratios (aOR) and 99% confidence intervals (CI). We repeated our mixed models with stratification and interaction analysis.

RESULTS

6 879 332 delivery hospitalizations were included in the analysis. Deliveries at high (aOR 1.83; 99% CI 1.34 to2.50) or medium (aOR 1.27; 99% CI 1.10 to 1.46) Black-serving delivery units were more likely to have SMM than deliveries at low Black-serving delivery units. Hospital safety-net burden was not significantly associated with SMM. In stratified models by hospital category, deliveries of Black women were associated with an increase in SMM compared with deliveries of White women in all hospital categories. In interaction models, Black women giving birth in high Black-serving delivery units had more than twice the odds of White women in low Black-serving delivery units of experiencing SMM (aOR 2.42; 99% CI 1.90 to 3.08).

CONCLUSION

The patient racial/ethnic composition of the delivery unit is associated with adjusted-odds of SMM, both independently and interactively with individual patient race.

An Eye on Disparities, Health Equity, and Racism-The Case of Firearm Injuries in Urban Youth in the United States and Globally

Firearm violence is a significant public health problem, particularly among youth in the United States. Regardless of the data source or setting, young Black men have consistently been found to be disproportionately affected by firearm injuries and deaths. Public health research indicates that racial segregation likely increases racial disparities in firearm violence. To minimize deaths and injuries due to firearms and their cascading health consequences and to ultimately achieve health equity, preventive efforts will need to address the social determinants of health, including racism.

Incorporating Measures of Structural Racism into Population Studies of Reproductive Health in the United States: A Narrative Review

Purpose: Black women in the United States face poor outcomes across reproductive health measures-from pregnancy outcomes to gynecologic cancers. Racial health inequities are attributable to systemic racism, but few population studies of reproductive health outcomes integrate upstream measures of systemic racism, and those who do are limited to maternal and infant health outcomes. Advances in understanding and intervening on the pathway from racism to reproductive health outcomes are limited by a paucity of methodological guidance toward this end. We aim to fill this gap by identifying quantitative measures of systemic racism that are salient across reproductive health outcomes. Methods: We conducted a review of literature from 2000 to 2019 to identify studies that use quantitative measures of exposure to systemic racism in population reproductive health studies. We analyzed the catalog of literature to identify cohesive domains and measures that integrate data across domains. For each domain, we contextualize its use within population health research, describe metrics currently in use, and present opportunities for their application to reproductive health research. Results: We identified four domains of systemic racism that may affect reproductive health outcomes: (1) civil rights laws and legal racial discrimination, (2) residential segregation and housing discrimination, (3) police violence, and (4) mass incarceration. Multiple quantitative measures are available for each domain. In addition, a multidimensional measure exists and additional domains of systemic racism are salient for future development into distinct measures. Conclusion: There are quantitative measures of systemic racism available for incorporation into population studies of reproductive health that investigate hypotheses, including and beyond those related to maternal and infant health. There are also promising areas for future measure development, such as the child welfare system and intersectionality. Incorporating such measures is critical for appropriate assessment of and intervention in racial inequities in reproductive health outcomes.

Developing a Database of Structural Racism-Related State Laws for Health Equity Research and Practice in the United States

OBJECTIVES

Although US state laws shape population health and health equity, few studies have examined how state laws affect the health of marginalized racial/ethnic groups (eg, Black, Indigenous, and Latinx populations) and racial/ethnic health inequities. A team of public health researchers and legal scholars with expertise in racial equity used systematic policy surveillance methods to develop a comprehensive database of state laws that are explicitly or implicitly related to structural racism, with the goal of evaluating their effect on health outcomes among marginalized racial/ethnic groups.

METHODS

Legal scholars used primary and secondary sources to identify state laws related to structural racism pertaining to 10 legal domains and developed a coding scheme that assigned a numeric code representing a mutually exclusive category for each salient feature of each law using a subset of randomly selected states. Legal scholars systematically applied this coding scheme to laws in all 50 US states and the District of Columbia from 2010 through 2013.

RESULTS

We identified 843 state laws linked to structural racism. Most states had in place laws that disproportionately discriminate against marginalized racial/ethnic groups and had not enacted laws that prevent the unjust treatment of individuals from marginalized racial/ethnic populations from 2010 to 2013.

CONCLUSIONS

By providing comprehensive, detailed data on structural racism-related state laws in all 50 states and the District of Columbia over time, our database will provide public health researchers, social scientists, policy makers, and advocates with rigorous evidence to assess states' racial equity climates and evaluate and address their effect on racial/ethnic health inequities in the United States.

Changing Spatiotemporal Trends in County-Level Heart Failure Death Rates in the United States, 1999 to 2018

Background

Amid recently rising heart failure (HF) death rates in the United States, we describe county‐level trends in HF mortality from 1999 to 2018 by racial/ethnic group and sex for ages 35 to 64 years and 65 years and older.

Methods and Results

Applying a hierarchical Bayesian model to National Vital Statistics data representing all US deaths, ages 35 years and older, we estimated annual age‐standardized county‐level HF death rates and percent change by age group, racial/ethnic group, and sex from 1999 through 2018. During 1999 to 2011, ~30% of counties experienced increasing HF death rates among adults ages 35 to 64 years. However, during 2011 to 2018, 86.9% (95% CI, 85.2–88.2) of counties experienced increasing mortality. Likewise, for ages 65 years and older, during 1999 to 2005 and 2005 to 2011, 27.8% (95% CI, 25.8–29.8) and 12.6% (95% CI, 11.2–13.9) of counties, respectively, experienced increasing mortality. However, during 2011 to 2018, most counties (67.4% [95% CI, 65.4–69.5]) experienced increasing mortality. These temporal patterns by age group held across racial/ethnic group and sex.

Conclusions

These results provide local context to previously documented recent national increases in HF death rates. Although county‐level declines were most common before 2011, some counties and demographic groups experienced increasing HF death rates during this period of national declines. However, recent county‐level increases were pervasive, occurring across counties, racial/ethnic group, and sex, particularly among ages 35 to 64 years. These spatiotemporal patterns highlight the need to identify and address underlying clinical risk factors and social determinants of health contributing to these increasing trends.

Structural racism, racial inequities and urban-rural differences in infant mortality in the US

Background

While evidence shows considerable geographic variations in county-level racial inequities in infant mortality, the role of structural racism across urban–rural lines remains unexplored. The objective of this study was to examine the associations between county-level structural racism (racial inequity in educational attainment, median household income and jail incarceration) and infant mortality and heterogeneity between urban and rural areas.

Methods

Using linked live birth/infant death data provided by the National Center for Health Statistics, we calculated overall and race-specific 2013–2017 5-year infant mortality rates (IMRs) per 1000 live births in every county. Racially stratified and area-stratified negative binomial regression models estimated IMR ratios and 95% CIs associated with structural racism indicators, adjusting for county-level confounders. Adjusted linear regression models estimated associations between structural racism indicators and the absolute and relative racial inequity in IMR.

Results

In urban counties, structural racism indicators were associated with 7%–8% higher black IMR, and an overall structural racism score was associated with 9% greater black IMR; however, these findings became insignificant when adjusting for the region. In white population, structural racism indicators and the overall structural racism score were associated with a 6% decrease in urban white IMR. Both absolute and relative racial inequity in IMR were exacerbated in urban counties with greater levels of structural racism.

Conclusions

Our findings highlight the complex relationship between structural racism and population health across urban–rural lines and suggest its contribution to the maintenance of health inequities in urban settings.

Black Women's Perspectives on Structural Racism across the Reproductive Lifespan: A Conceptual Framework for Measurement Development

BACKGROUND

Exposures to structural racism has been identified as one of the leading risk factors for adverse maternal and infant health outcomes among Black women; yet current measures of structural racism do not fully account for inequities seen in adverse maternal and infant health outcomes between Black and white women and infants. In response, the purpose of this study was to conceptualize structural racism from the perspectives of Black women across the reproductive lifespan and its potential impact on adverse maternal and infant health outcomes.

METHODS

We conducted a series of focus groups with 32 Black women across the reproductive lifespan (5 preconception, 13 pregnant, and 14 postpartum). Study criteria including self-identifying as Black, residing in Oakland or Fresno, California and representing one of three reproductive life tracks (preconception, pregnant, postpartum). We consulted with study participants and an expert advisory board to validate emergent domains of structural racism.

RESULTS

Nine domains of structural racism emerged from a ground theory constant comparative analysis: Negative Societal Views; Housing; Medical Care; Law Enforcement; Hidden Resources; Employment; Education, Community Infrastructure; and Policing Black Families.

CONCLUSIONS FOR PRACTICE

Findings from this study suggest that there is an interplay among structural racism, and social and structural determinants of health which has negative impacts on Black women's sexual and reproductive health. Furthermore, findings from this study can be used to develop more comprehensive medical assessments and policies to address structural racism experienced by Black women across the reproductive lifespan.

Stigma of persons with disabilities in South Africa: Uncovering pathways from discrimination to depression and low self-esteem

Despite the fact that universal inclusion is a basic principle of the Sustainable Development Goals, the inclusion of persons with disabilities in humanitarian interventions and development policies remains elusive. Persons with disabilities face high risks of poverty, poor nutrition, limited inclusion in labor markets and poor mental health as a result. Stigma is likely to play a negative role in this regard and yet, no study has investigated the impact of stigma on depression and self-esteem of persons with disabilities. To address this gap in the literature, we conducted in June 2017 a random sample disability case control household study in Soweto, a township in Johannesburg, South Africa. Using propensity score analysis and structural equation modeling, we investigated the relationship between disability, stigma, depression and self-esteem controlling for socioeconomic covariates. Our main empirical results showed that stigma significantly mediates the association between disability and higher depression on the one hand and between disability and lower self-esteem on the other. This mediating effect exists even after controlling for age, gender, marital status, education, employment and wealth. We also found strong direct associations between disability and depressive mood, somatic indicators and negative feelings such as unhappiness and low self-esteem. Unemployment aggravates depression and low self-esteem while low education worsens self-esteem only. In addition, depression exacerbates low self-esteem. Both unemployment and low education are more common among persons with disabilities aggravating the disability, depression, poor self-esteem nexus. Similarly, persons with disabilities who are more likely to be depressed are also at higher risk of low self-esteem. These results point to a vicious reinforcing circle of exclusion from society, despair and self-deprecation, which could prove difficult to break. Substantial psycho-social support and anti-stigma policies anchored in local cultural values, engaging persons with disabilities and their communities, are required to break this vicious circle.

Diversity and Political Leaning: Considerations for Epidemiology

The positive effects of increased diversity and inclusion in scientific research and practice are well documented. In this issue, DeVilbiss et al. (Am J Epidemiol. 2020;189(10):998-1010) present findings from a survey used to collect information to characterize diversity among epidemiologists and perceptions of inclusion in the epidemiologic profession. They capture identity across a range of personal characteristics, including race, gender, socioeconomic background, sexual orientation, religion, and political leaning. In this commentary, we assert that the inclusion of political leaning as an axis of identity alongside the others undermines the larger project of promoting diversity and inclusion in the profession and is symptomatic of the movement for "ideological diversity" in higher education. We identify why political leaning is not an appropriate metric of diversity and detail why prioritizing ideological diversity counterintuitively can work against equity building initiatives. As an alternative to ideological diversity, we propose that epidemiologists take up an existing framework for research and practice that centers the voices and perspectives of historically marginalized populations in epidemiologic work.

Racial Segregation and Intraventricular Hemorrhage in Preterm Infants

BACKGROUND

Intraventricular hemorrhage (IVH) disproportionately affects black neonates. Other conditions that are more common in black neonates, including low birth weight and preterm delivery, have been linked with residential racial segregation (RRS). In this study, we investigated the association between RRS and IVH.

METHODS

A retrospective cohort of neonates born between 24 and 32 weeks' gestation was constructed by using birth certificates linked to medical records from California, Missouri, and Pennsylvania between 1995 and 2009. Dissimilarity, a measure of RRS indicating the proportion of minorities in the census tract of the mother in comparison to the larger metropolitan area, was linked to patient data, yielding a cohort of 70 775 infants. Propensity score analysis matched infants born to mothers living in high segregation to those living in less segregated areas on the basis of race, sociodemographic factors, and medical comorbidities to compare the risk of developing IVH.

RESULTS

Infants born to mothers in the most segregated quartile had a greater risk of developing IVH compared with those in the lowest quartile (12.9% vs 10.4%; P < .001). In 17 918 pairs matched on propensity scores, the risk of developing IVH was greater in the group exposed to a segregated environment (risk ratio = 1.08, 95% confidence interval: 1.01-1.15). This effect was stronger for black infants alone (risk ratio = 1.16; 95% confidence interval: 1.03-1.30).

CONCLUSIONS

RRS is associated with an increased risk of IVH in preterm neonates, but the effect size varies by race. This association persists after balancing for community factors and birth weight, representing a novel risk factor for IVH.

Social Determinants of Health Improve Predictive Accuracy of Clinical Risk Models for Cardiovascular Hospitalization, Annual Cost, and Death

BACKGROUND

Risk models in the private insurance setting may systematically underpredict in the socially disadvantaged. In this study, we sought to determine whether US minority Medicare beneficiaries had disproportionately low costs compared with their clinical outcomes and whether adding social determinants of health (SDOH) into risk prediction models improves prediction accuracy.

METHODS AND RESULTS

Retrospective observational cohort study of 2016 to 2017 Medicare Current Beneficiary Survey data (n=3614) linked to Medicare fee-for-service claims. Logistic and linear regressions were used to determine the relationship between race/ethnicity and annual costs of care, all-cause hospitalization, cardiovascular hospitalization, and death. We calculated the observed-to-expected (O:E) ratios for all outcomes under 4 risk models: (1) age+sex, (2) model 1+clinical comorbidity adjustment, (3) model 2+SDOH, and (4) SDOH alone. Our sample was 44% male and 11% black or Hispanic. Among minorities, adverse clinical outcomes were inversely related to cost. After multivariable adjustment, blacks/Hispanics had higher rates of cardiovascular hospitalization (incidence rate ratio, 1.78; P=0.012) but similar annual costs ($-336, P=0.77) compared with whites. Among whites, models 1 to 4 all showed similar O:E ratios, suggesting high accuracy in risk prediction using current models. Among minorities, adjustment for age, sex, and comorbidities underpredicted all-cause hospitalization by 20% (O:E, 1.20) and cardiovascular hospitalization by 70% (O:E, 1.70) and overpredicted death by 21% (O:E, 0.79); adding SDOH brought O:E near 1 for all outcomes. Among both groups, the SDOH risk model alone performed with equal or superior accuracy to the model based on clinical comorbidities.

CONCLUSIONS

A paradoxical relationship was observed between clinical outcomes and costs among racial and ethnic minorities. Because of systematic differences in access to care, cost may not be an appropriate surrogate for predicting clinical risk among vulnerable populations. Adjustment for SDOH improves the accuracy of risk models among racial and ethnic minorities and could guide use of prevention strategies.

Structural racism, economic opportunity and racial health disparities: Evidence from U.S. counties

In this study, we introduce the 'racial opportunity gap' as a place-based measure of structural racism for use in population health research. We first detail constructing the opportunity gap using race-sex specific estimates of intergenerational economic mobility outcomes for a recent cohort. We then illustrate its utility in examining spatial variation in the racial mortality gap. First we demonstrate a correlation between the racial opportunity gap and the racial mortality gap across U.S. counties; where the gap in the adult earnings of black and white children born to families at the same income level is greater so, too, is the gap in mortality. Second, we show in a multivariable framework that the racial opportunity gap is associated with the racial mortality gap net of differences in the socioeconomic composition of the two groups. In so doing, we aim to provide population health researchers with a new empirical tool and analytic framework for examining the role of structural racism in generating racial health disparities.

Structural racism, economic opportunity and racial health disparities: Evidence from U.S. counties

In this study, we introduce the ‘racial opportunity gap’ as a place-based measure of structural racism for use in population health research. We first detail constructing the opportunity gap using race-sex specific estimates of intergenerational economic mobility outcomes for a recent cohort. We then illustrate its utility in examining spatial variation in the racial mortality gap. First we demonstrate a correlation between the racial opportunity gap and the racial mortality gap across U.S. counties; where the gap in the adult earnings of black and white children born to families at the same income level is greater so, too, is the gap in mortality. Second, we show in a multivariable framework that the racial opportunity gap is associated with the racial mortality gap net of differences in the socioeconomic composition of the two groups. In so doing, we aim to provide population health researchers with a new empirical tool and analytic framework for examining the role of structural racism in generating racial health disparities.

Pulmonary arterial capacitance predicts outcomes in patients with pulmonary hypertension independent of race/ethnicity, sex, and etiology

BACKGROUND

Pulmonary arterial capacitance (PAC) is a strong hemodynamic predictor of outcomes in patients with pulmonary hypertension (PH). Its value across subgroups of race/ethnicity, sex, and PH etiologies is unclear. We hypothesized that the association of PAC with outcomes would not vary across World Health Organization (WHO) PH group, race/ethnicity, or sex.

METHODS

We performed a retrospective study in patients with PH diagnosed and managed at the Pulmonary Hypertension Comprehensive Care Center of a tertiary care hospital (n = 270). Demographic, diagnostic, treatment, and outcome data were extracted from the electronic medical record. Cox proportional hazards models were used to model time from right heart catheterization to event in univariate and multivariable models. Our primary outcome was all-cause mortality and our secondary outcome was PH hospitalization.

RESULTS

The median age of the cohort was 56 years (±14.6), and 67% were female. In multivariable Cox models adjusted for significant covariates, decreased PAC remained independently and significantly associated with both all-cause mortality (p = 0.029) and hospitalization for PH (p = 0.010). No significant interactions were observed between PAC and race, sex, or WHO group. Hispanic patients exhibited a significant independent association with increased hospitalizations (p = 0.030), and there was a trend toward increased all-cause mortality in African Americans. WHO group 2 PH was associated with more frequent hospitalization (p = 0.004).

CONCLUSIONS

Decreased PAC is significantly associated with mortality and hospitalization in PH patients independent of race, sex, and PH subgroups. Further investigation is required to characterize the effects and determinants of racial disparities in PH.

Self-Rated Health and Structural Racism Indicated by County-Level Racial Inequalities in Socioeconomic Status: The Role of Urban-Rural Classification

Recent attention to the interrelationship between racism, socioeconomic status (SES) and health has led to a small, but growing literature of empirical work on the role of structural racism in population health. Area-level racial inequities in SES are an indicator of structural racism, and the associations between structural racism indicators and self-rated health are unknown. Further, because urban-rural differences have been observed in population health and are associated with different manifestations of structural racism, explicating the role of urban-rural classification is warranted. This study examined the associations between racial inequities in SES and self-rated health by county urban-rural classification. Using data from County Health Rankings and American Communities Surveys, black-white ratios of SES were regressed on rates of fair/poor health in U.S. counties. Racial inequities in homeownership were negatively associated with fair/poor health (β = -0.87, s.e. = 0.18), but racial inequities in unemployment were positively associated with fair/poor health (β = 0.03, s.e. = 0.01). The associations between structural racism and fair/poor health varied by county urban-rural classification. Potential mechanisms include the concentration of resources in racially segregated counties with high racial inequities that lead to better health outcomes, but are associated with extreme black SES disadvantage. Racial inequities in SES are a social justice imperative with implications for population health that can be targeted by urban-rural classification and other social contextual characteristics.

Toward an Anti-Racist Curriculum: Incorporating Art into Medical Education to Improve Empathy and Structural Competency

BACKGROUND

There is an urgent need for medical school curricula that address the effects of structural influences, particularly racism, on health, healthcare access, and the quality of care for people of color. Underrepresented racial minorities in the United States receive worse health care relative to their White counterparts. Structural competency, a framework for recognizing and understanding social influences on health, provides a means for understanding the structural violence that results from and perpetuates racism in classroom and clinical education. Some medical schools have incorporated art into their curricula to increase empathy generally, yet few programs use art to address racial disparities in medicine specifically.

OBJECTIVE

"Can We Talk About Race?" (CWTAR) aims to increase medical students' empathy for racial minorities and increase the ease and ability of students to address racial issues. CWTAR also provides a unique context for ongoing conversations about racism and structural inequality within the health care system.

METHODS

Sixty-four first-year medical students were randomly selected to participate in CWTAR. The on-campus Ackland Art Museum staff and trained student facilitators lead small group discussions on selected artworks. A course evaluation was sent to all participants consisting of 4 questions: (1) Likert scale rating the quality of the program, (2) the most important thing learned from the program, (3) any differences between discussion at this program versus other conversations around race, and (4) suggestions for changes to the program. Free text responses were content coded and analyzed to reveal common themes.

RESULTS

Out of 64 students, 63 (98%) responded to at least one course evaluation question. The majority (89%) of participants rated the program quality as either "Very Good" or "Excellent." Of the 37 students who responded to the free text question regarding the most important thing they learned from the program, 16 (44%) responses revealed students felt that they were exposed to perspectives that differed from their own, and 19% of respondents reported actively viewing a subject through another's perspective. Of the 33 students who responded to the free text question regarding any differences between discussion at this program versus other conversations around race, 48% noted an increased comfort level discussing race during the program. A common theme in responses to the question regarding suggested changes to the program was a more explicit connection to medicine in the discussion around race.

CONCLUSIONS

Student responses to CWTAR suggest that the program is effective in engaging students in discussions of racial issues. More investigation is needed to determine whether this methodology increases empathy among medical students for racial minorities specifically.

Interactive Relations Across Dimensions of Interpersonal-Level Discrimination and Depressive Symptoms to Carotid Intimal-Medial Thickening in African Americans

OBJECTIVE

This study aimed to examine within-race interactions of multiple dimensions of self-reported discrimination with depressive symptoms in relation to carotid intimal-medial thickness (IMT), a subclinical marker of atherosclerosis prospectively implicated in stroke incidence, in middle-aged to older African American and white adults.

METHODS

Participants were a socioeconomically diverse group of 1941 African Americans (56.5%) and whites from the Healthy Aging in Neighborhoods of Diversity across the Life Span study (30-64 years old, 47% men, 45.2% with household income <125% federal poverty threshold) who underwent carotid IMT measurement. Discrimination was assessed across four dimensions (everyday, frequency across various social statuses, racial, and lifetime burden). The Center for Epidemiologic Studies Depression scale was used to assess depressive symptoms.

RESULTS

In cross-sectional hierarchical regression analyses, two interactions were observed in African Americans: more frequent discrimination across various social statuses (b < 0.001, p = .006) and a higher lifetime discrimination burden (b < 0.001, p = .02) were each related to thicker carotid IMT in those with greater depressive symptoms. No significant findings were observed within whites.

CONCLUSIONS

Among African Americans, those reporting high levels of discrimination and depressive symptoms have increased carotid atherosclerosis and may be at greater risk for clinical end points compared with those reporting one or neither of these risk factors. Findings suggest that assessment of interactive relationships among social and psychological factors may elucidate novel pathways for cardiovascular disease, including stroke, among African Americans.

Structural Racism and Odds for Infant Mortality Among Infants Born in the United States 2010

OBJECTIVES

While ecological studies indicate that high levels of structural racism within US states are associated with elevated infant mortality rates, studies using individual-level data are needed. To determine whether indicators of structural racism are associated with the individual odds for infant mortality among white and black infants in the US.

METHODS

We used data on 2,163,096 white and 590,081 black infants from the 2010 US Cohort Linked Birth/Infant Death Data Files. Structural racism indicators were ratios of relative proportions of blacks to whites for these domains: electoral (registered to vote and voted; state legislature representation), employment (civilian labor force; employed; in management; with a bachelor's degree), and justice system (sentenced to death; incarcerated). Multilevel logistic regression was used to determine whether structural racism indicators were risk factors of infant mortality.

RESULTS

Compared to the lowest tertile ratio of relative proportions of blacks to whites with a bachelor's degree or higher-indicative of low structural racism-black infants, but not whites, in states with moderate (OR = 1.12, 95% CI = 0.94, 1.32) and high tertiles (OR = 1.25, 95% CI = 1.03, 1.51) had higher odds of infant mortality.

CONCLUSIONS

Educational and judicial indicators of structural racism were associated with infant mortality among blacks. Decreasing structural racism could prevent black infant deaths.