How Structural Racism Works - Racist Policies as a Root Cause of U.S. Racial Health Inequities

Rates of Recent Adverse Childhood Experiences Among Indigenous Children

The current paper describes rates of recent (past six months) adverse childhood experiences (ACEs) and examines the association of ACEs with cultural connection and depressive symptoms among Indigenous children aged 10 to 14 (N = 177; mean age = 11.8; 48.3% boys; 44.3% girls; 7.4% another gender identity). Children completed baseline surveys as part of a larger evaluation of a culturally grounded, strengths-focused, family-based program to prevent ACEs. Surveys included an inclusive measure of ACEs developed for the current study, an adapted measure of connection to culture, and the Children's Depression Screener. Results for ACEs indicated that 18.6% of Indigenous children reported none, 37.2% reported one to three, and 44.2% reported four or more in the past six months. Importantly, children who reported no ACEs reported greater cultural connection than children who reported one to three ACEs. Depressive symptoms were higher among children who reported one to three and four or more ACEs compared to children who reported no ACEs.

Forty years of struggle in North Carolina: Workplace segregation and fatal occupational injury rates

OBJECTIVE

To assess workplace segregation in fatal occupational injury from 1992 to 2017 in North Carolina.

METHODS

We calculated occupational fatal injury rates within categories of occupation, industry, race, age, and sex; and estimated expected numbers of fatalities among Black and Hispanic male workers had they experienced the rates of White male workers. We also estimated the contribution of workforce segregation to disparities by estimating the expected number of fatalities among Black and Hispanic male workers had they experienced the industry and occupation patterns of White male workers. We assessed person-years of life-lost, using North Carolina life expectancy estimates.

RESULTS

Hispanic workers contributed 32% of their worker-years and experienced 58% of their fatalities in construction. Black workers were most overrepresented in the food manufacturing industry. Hispanic males experienced 2.11 (95% CI: 1.86-2.40) times the mortality rate of White males. The Black-White and Hispanic-White disparities were widest among workers aged 45 and older, and segregation into more dangerous industries and occupations played a substantial role in driving disparities. Hispanic workers who suffered occupational fatalities lost a median 47 life-years, compared to 37 among Black workers and 36 among White workers.

CONCLUSIONS

If Hispanic and Black workers experienced the workplace safety of their White counterparts, fatal injury rates would be substantially reduced. Workforce segregation reflects structural racism, which also contributes to mortality disparities. Root causes must be addressed to eliminate disparities.

Geographic Variation in Racial Disparities in Receipt of High-Dose Influenza Vaccine Among US Older Adults

BACKGROUND

Racial disparities in receipt of high-dose influenza vaccine (HDV) have been documented nationally, but whether small-area geographic variation in such disparities exists remains unknown. We assessed the distribution of disparities in HDV receipt between Black and White traditional Medicare beneficiaries vaccinated against influenza within states and hospital referral regions (HRRs).

METHODS

We conducted a nationally representative retrospective cohort study of 11,768,724 community-dwelling traditional Medicare beneficiaries vaccinated against influenza during the 2015-2016 influenza season (94.3% White and 5.7% Black). Our comparison was marginalized versus privileged racial group measured as Black versus White race. Vaccination and type of vaccine were obtained from Medicare Carrier and Outpatient files. Differences in the proportions of individuals who received HDV between Black and White beneficiaries within states and HRRs were used to measure age- and sex-standardized disparities in HDV receipt. We restricted to states and HRRs with ≥ 100 beneficiaries per age-sex strata per racial group.

RESULTS

We detected a national disparity in HDV receipt of 12.8 percentage points (pps). At the state level, the median standardized HDV receipt disparity was 10.7 pps (minimum, maximum: 2.9, 25.6; n = 30 states). The median standardized HDV receipt disparity among HRRs was 11.6 pps (minimum, maximum: 0.4, 24.7; n = 54 HRRs).

CONCLUSION

Black beneficiaries were less likely to receive HDV compared to White beneficiaries in almost every state and HRR in our analysis. The magnitudes of disparities varied substantially across states and HRRs. Local interventions and policies are needed to target geographic areas with the largest disparities to address these inequities.

Development of Neighborhood Trajectories Employing Historic Redlining and the Area Deprivation Index

The role of historic residential redlining on health inequities is intertwined with policy changes made before and after the 1930s that influence current neighborhood characteristics and shape ongoing structural racism in the United States (U.S.). We developed Neighborhood Trajectories which combine historic redlining data and the current neighborhood socioeconomic characteristics as a novel approach to studying structural racism. Home Owners' Loan Corporation (HOLC) neighborhoods for the entire U.S. were used to map the HOLC grades to the 2020 U.S. Census block group polygons based on the percentage of HOLC areas in each block group. Each block group was also assigned an Area Deprivation Index (ADI) from the Neighborhood Atlas®. To evaluate changes in neighborhoods from historic HOLC grades to present degree of deprivation, we aggregated block groups into "Neighborhood Trajectories" using historic HOLC grades and current ADI. The Neighborhood Trajectories are "Advantage Stable"; "Advantage Reduced"; "Disadvantage Reduced"; and "Disadvantage Stable." Neighborhood Trajectories were established for 13.3% (32,152) of the block groups in the U.S., encompassing 38,005,799 people. Overall, the Disadvantage-Reduced trajectory had the largest population (16,307,217 people). However, the largest percentage of non-Hispanic/Latino Black residents (34%) fell in the Advantage-Reduced trajectory, while the largest percentage of Non-Hispanic/Latino White residents (60%) fell in the Advantage-Stable trajectory. The development of the Neighborhood Trajectories affords a more nuanced mechanism to investigate dynamic processes from historic policy, socioeconomic development, and ongoing marginalization. This adaptable methodology may enable investigation of ongoing sociopolitical processes including gentrification of neighborhoods (Disadvantage-Reduced trajectory) and "White flight" (Advantage Reduced trajectory).

Disparities in pediatric hospital use during transition to adult healthcare for young adults with childhood-onset chronic conditions

BACKGROUND

Young adults (YA) with childhood-onset chronic conditions-particularly YA with cystic fibrosis (CF), congenital heart disease (CHD), and sickle cell disease (SCD)-continue to have pediatric hospital admissions. Factors associated with this continued pediatric hospital use remain underexplored.

OBJECTIVE

To determine if pediatric hospital use by YA differed (1) across condition and (2) within each condition by sociodemographic factors.

METHODS

Conducted a cross-sectional analysis of admissions for YA 22-35 years with CF, CHD, and SCD from 2016 to 2020 in the National Inpatient Sample. Admissions for YA with CF, CHD, and SCD were identified by international classification of diseases, 10th revision-clinical modification diagnosis codes. To determine if conditions or sociodemographic factors were associated with YA pediatric hospital use, we used multivariable logistic regression with separate models for the different objectives.

RESULTS

YA with SCD had lower odds of pediatric hospital use compared to YA with CF. Relationships between sociodemographic factors and pediatric hospital use varied. Black YA with both CF and CHD had lower odds of pediatric hospital use than white YA with CF and CHD. For YA with SCD, despite 17,810 (6.5%) having rural residence, zero (0) had pediatric hospital use; whereas YA with CF living in a rural area had greater odds of pediatric hospital use compared to urban residents.

CONCLUSION

YA with SCD used pediatric hospitals less than YA with either CF or CHD. Coupled with our findings that Black YA with CF and CHD had less pediatric hospital use, these data may reflect systematic racial differences within pediatric to adult healthcare transition programs.

Disparities by Social Determinants of Health: Links Between Long COVID and Cardiovascular Disease

Long COVID has been defined by the World Health Organisation as "continuation or development of new symptoms 3 months after the initial SARS-CoV-2 infection, with these symptoms lasting for at least 2 months with no other explanation." Cardiovascular disease is implicated as a risk factor, concomitant condition, and consequence of long COVID. As well as heterogeneity in definition, presentation, and likely underlying pathophysiology of long COVID, disparities by social determinants of health, extensively studied and described in cardiovascular disease, have been observed in 3 ways. First, underlying long-term conditions, such as cardiovascular disease and its risk factors, are associated with incidence and severity of long COVID, and previously described socioeconomic disparities in these factors are important in exacerbating disparities in long COVID. Second, socioeconomic disparities in management of COVID-19 may themselves lead to distal disparities in long COVID. Third, there are socioeconomic disparities in the way that long COVID is diagnosed, managed, and prevented. Together, factors such as age, sex, deprivation, and ethnicity have far-reaching implications in this new postviral syndrome across its management spectrum. There are similarities and differences compared with disparities for cardiovascular disease. Some of these disparities are in fact, inequalities, that is, rather than simply observed variations, they represent injustices with costs to individuals, communities, and economies. This review of current literature considers opportunities to prevent or at least attenuate these socioeconomic disparities in long COVID and cardiovascular disease, with special challenges for research, clinical practice, public health, and policy in a new disease which is evolving.

Cohort Study of Downgraded Misdemeanor Convictions and Subsequent Violent Crime: Differences by Defendant Race and Ethnicity

Introduction

Criminal convictions may be imperfect markers of criminalized behavior, in part because of criminal legal system processes (e.g., plea bargaining). In this retrospective cohort study of individuals convicted of misdemeanors, authors compared the risk of subsequent criminal charges for a violent crime among those initially charged with a felony with that among those initially charged with only misdemeanors, overall and by defendant race and ethnicity.

Methods

The study population included individuals aged ≥18 years who were convicted of a misdemeanor in Washington Superior Courts from January 1, 2015 to December 31, 2019. Those with and without initial felony charges were age/gender matched in a 4:1 ratio. The primary outcome was the first subsequent violent crime charge in Washington Superior Courts through December 31, 2020. Data were analyzed with Fine-Gray hazard models from June 2022 to November 2023.

Results

There were 3,841 individuals with initial felony charges and 956 with initial misdemeanor charges only. Median follow-up was 2.4 years for both groups. During follow-up, there were 166 new violent crime charges. In multivariable models, White defendants with initial felony charges had a greater risk of subsequent violent crime charges (subdistribution hazard ratio=2.58; 95% CI=1.24, 5.36) than White defendants with initial misdemeanor charges only. Among Black and Hispanic/Latinx defendants, initial felony versus misdemeanor charges were not associated with subsequent violent crime charges (subdistribution hazard ratio=0.93; 95% CI=0.44, 1.97 among Black defendants; subdistribution hazard ratio=0.49; 95% CI=0.15, 1.57 among Hispanic/Latinx defendants).

Conclusions

Findings suggest differential associations between downgrading of felony charges to misdemeanor convictions and future violent crime charges by defendant race and ethnicity, with implications for inequitable collateral consequences of criminal convictions.

Choosing to End African American Health Disparities in Patients With Systemic Lupus Erythematosus

Systemic lupus erythematosus (SLE) is three times more common and its manifestations are more severe in African American women compared to women of other races. It is not clear whether this is due to genetic differences or factors related to the physical or social environments, differences in health care, or a combination of these factors. Health disparities in patients with SLE between African American patients and persons of other races have been reported since the 1960s and are correlated with measures of lower socioeconomic status. Risk factors for these disparities have been demonstrated, but whether their mitigation improves outcomes for African American patients has not been tested except in self-efficacy. In 2002, the first true US population-based study of patients with SLE with death certificate records was conducted, which demonstrated a wide disparity between the number of African American women and White women dying from SLE. Five years ago, another study showed that SLE mortality rates in the United States had improved but that the African American patient mortality disparity persisted. Between 2014 and 2021, one study demonstrated racism's deleterious effects in patients with SLE. Racism may have been the unmeasured confounder, the proverbial "elephant in the room"-unnamed and unstudied. The etymology of "risk factor" has evolved from environmental risk factors to social determinants to now include structural injustice/structural racism. Racism in the United States has a centuries-long existence and is deeply ingrained in US society, making its detection and resolution difficult. However, racism being man made means Man can choose to change the it. Health disparities in patients with SLE should be addressed by viewing health care as a basic human right. We offer a conceptual framework and goals for both individual and national actions.

Geospatial Distribution of Racial Disparities in Influenza Vaccination in Nursing Homes

OBJECTIVES

This study aimed to assess the distribution of racial disparities in influenza vaccination between White and Black short-stay and long-stay nursing home residents among states and hospital referral regions (HRRs).

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

We included short-stay and long-stay older adults residing in US nursing homes during influenza seasons between 2011 and 2018. Included residents were aged ≥65 years and enrolled in Traditional Medicare. Analyses were conducted using resident-seasons, whereby residents could contribute to one or more influenza seasons if they resided in a nursing home across multiple seasons.

METHODS

Our comparison of interest was marginalized vs privileged racial group membership measured as Black vs White race. We obtained influenza vaccination documentation from resident Minimum Data Set assessments from October 1 through June 30 of a particular influenza season. Nonparametric g-formula was used to estimate age- and sex-standardized disparities in vaccination, measured as the percentage point (pp) difference in the proportions of individuals vaccinated between Black and White nursing home residents within states and HRRs.

RESULTS

The study included 7,807,187 short-stay resident-seasons (89.7% White and 10.3% Black) in 14,889 nursing homes and 7,308,111 long-stay resident-seasons (86.7% White and 13.3% Black) in 14,885 nursing homes. Among states, the median age- and sex-standardized disparity between Black and White residents was 10.1 percentage points (pps) among short-stay residents and 5.3 pps among long-stay residents across seasons. Among HRRs, the median disparity was 8.6 pps among short-stay residents and 5.0 pps among long-stay residents across seasons.

CONCLUSIONS AND IMPLICATIONS

Our analysis revealed that the magnitudes of vaccination disparities varied substantially across states and HRRs, from no disparity in vaccination to disparities in excess of 25 pps. Local interventions and policies should be targeted to high-disparity geographic areas to increase vaccine uptake and promote health equity.

Polarized Perspectives on Health Equity: Results from a Nationally Representative Survey on US Public Perceptions of COVID-19 Disparities in 2023

Republicans and Democrats responded to the COVID-19 pandemic in starkly different ways, from their attitudes in 2020 about whether the virus posed a threat to whether the pandemic ended in 2023. The consequences of COVID-19 for health equity have been a central concern in public health, and the concept of health equity has also been beset by partisan polarization. In this article, the authors present and discuss nationally representative survey data from 2023 on US public perceptions of disparities in COVID-19 mortality (building on a previous multiwave survey effort) as well as causal attributions for racial disparities, the contribution of structural racism, and broader attitudes about public health authority. The authors find anticipated gulfs in perspectives between Democrats on the one hand and independents and Republicans on the other. The results offer a somewhat pessimistic view of the likelihood of finding common ground in how the general public understands health inequities or the role of structural racism in perpetuating them. However, the authors show that those who acknowledge racial disparities in COVID-19 are more likely to support state public health authority to act in response to other infectious disease threats. The authors explore the implications of these public opinion data for advocacy, communication, and future needed research.

Social Determinants of Health Mediate Racial Disparities in Cardiovascular Disease in Men With Prostate Cancer

Background

Cardiovascular disease (CVD) is a significant cause of morbidity and mortality in men with prostate cancer; however, data on racial disparities in CVD outcomes are limited.

Objectives

We quantified the disparities in CVD according to self-identified race and the role of the structural social determinants of health in mediating disparities in prostate cancer patients.

Methods

A retrospective cohort study of 3,543 prostate cancer patients treated with systemic androgen deprivation therapy (ADT) between 2008 and 2021 at a quaternary, multisite health care system was performed. The multivariable adjusted association between self-reported race (Black vs White) and incident major adverse cardiovascular events (MACE) after ADT initiation was evaluated using cause-specific proportional hazards. Mediation analysis determined the role of theme-specific and overall social vulnerability index (SVI) in explaining the racial disparities in CVD outcomes.

Results

Black race was associated with an increased hazard of MACE (HR: 1.38; 95% CI: 1.16-1.65; P < 0.001). The association with Black race was strongest for incident heart failure (HR: 1.79; 95% CI: 1.32-2.43), cerebrovascular disease (HR: 1.98; 95% CI: 1.37-2.87), and peripheral artery disease (HR: 1.76; 95% CI: 1.26-2.45) (P < 0.001). SVI, specifically the socioeconomic status theme, mediated 98% of the disparity in MACE risk between Black and White patients.

Conclusions

Black patients are significantly more likely to experience adverse CVD outcomes after systemic ADT compared with their White counterparts. These disparities are mediated by socioeconomic status and other structural determinants of health as captured by census tract SVI. Our findings motivate multilevel interventions focused on addressing socioeconomic vulnerability.

The health equity implications of the Health Resources and Services Administration's Ryan White HIV/AIDS Program

OBJECTIVE

Investigate the role of the Ryan White HIV/AIDS Program (RWHAP) - which funds services for vulnerable and historically disadvantaged populations with HIV - in reducing health inequities among people with HIV over a 10-year horizon.

DESIGN

We use an agent-based microsimulation model to incorporate the complexity of the program and long-time horizon.

METHODS

We use a composite measure (the Theil index) to evaluate the health equity implications of the RWHAP for each of four subgroups (based on race and ethnicity, age, gender, and HIV transmission category) and two outcomes (probability of being in care and treatment and probability of being virally suppressed). We compare results with the RWHAP fully funded versus a counterfactual scenario, in which the medical and support services funded by the RWHAP are not available.

RESULTS

The model indicates the RWHAP will improve health equity across all demographic subgroups and outcomes over a 10-year horizon. In Year 10, the Theil index for race and ethnicity is 99% lower for both outcomes under the RWHAP compared to the non-RWHAP scenario; 71-93% lower across HIV transmission categories; 31-44% lower for age; and 73-75% lower for gender.

CONCLUSION

Given the large number of people served by the RWHAP and our findings on its impact on equity, the RWHAP represents an important vehicle for achieving the health equity goals of the National HIV/AIDS Strategy (2022-2025) and the Ending the HIV Epidemic Initiative goal of reducing new infections by 90% by 2030.

The EMPOWER program: a history and guide for increasing diversity using integrated research and education

The prevalence and pervasive nature of emerging chemicals of concern have created widespread environmental injustice apprehensions in vulnerable communities. To alleviate and address these concerns, identifying, engaging, and training a diverse environmental health research workforce will be critical and necessary steps to combat and prevent the consequences of environmental injustice. While there is an obvious need to enhance diversity in environmental health research, this process is hampered by facets of systemic racism that reduce access to educational resources needed to build interest and knowledge in students and teachers. We present here a historical perspective to offer a guide for building programs and relationships with underserved schools to help overcome limiting factors that have plagued certain public school systems. With the proper training and mentorship, the untapped workforce present within these schools will be empowered to understand and address current and emerging environmental health and safety threats. Through this transformative 8-week high school research program, we will develop well-prepared, ethical researchers committed to scientific inquiry, intensive fieldwork, and collaborative problem solving to address environmental health challenges. Following the four-step risk assessment process, students, teachers, and faculty mentors will work collaboratively to identify toxicants, potential hazards and risks, and environmental disparities in urban neighborhoods, which provides the necessary training to formulate critical thinking skills for use in academic or nonacademic careers.NEW & NOTEWORTHY The Engaging Multidisciplinary Professional Opportunities for Women in Environmental Research (EMPOWER) program is a one-of-a-kind research summer experience for minority female high school students in the state of Georgia. In addition, this program provides high school teachers with hands-on experiences that can be adapted to use in the classrooms. This combination of lab and field research immerses participants in understanding urban environmental exposures and their health effects. The EMPOWER program was established to meet the critical need for increasing diversity in science, technology, engineering, and mathematics.

Social Determinants of Health are Associated with Coping of Informal Caregivers of Adults with Heart Failure

We explored the influence of social determinants of health (SDH) risk on stress and coping style in heart failure (HF) caregivers. In this cross-sectional study, data from 250 caregivers were analyzed. Multivariable linear regression analyses were performed to determine the extent to which SDH risk (measured using a modified PRAPARE tool (National Association of Community Health Centers), range 0-22) predicted stress (Perceived Stress Scale, 0-56) and coping style (active (0-45), avoidance (0-30), and minimization (0-30)) while accounting for caregiver burden (HF Caregiver Questionnaire (HF-CQ) 0-100). Multivariable regression analysis with backwards elimination variable selection approach was used to identify which SDH risk factors best predicted coping styles. SDH risk was significantly associated with avoidance and minimization coping styles. Each unit increase in SDH risk was associated with an increase of 0.6 ± 0.2 units (p = .0008) in avoidance and 0.7 ± 0.2 units (p < .0001) in minimization coping style. Race and "supporting others" significantly predicted avoidance coping style; scores were 3.3 ± 0.8 units greater for caregivers who were not White (p < .0001) and 1.4 ± 0.5 units greater (p < .01) for each additional person whom they supported. Race significantly predicted minimization coping style; scores were 4.4 ± 0.7 units greater for caregivers who were not White (p < .0001). Caregivers with higher SDH risk may avoid and minimize to cope with caregiving challenges.

Modifications of the readiness assessment for pragmatic trials tool for appropriate use with Indigenous populations

BACKGROUND

Inequities in health access and outcomes exist between Indigenous and non-Indigenous populations. Embedded pragmatic randomized, controlled trials (ePCTs) can test the real-world effectiveness of health care interventions. Assessing readiness for ePCT, with tools such as the Readiness Assessment for Pragmatic Trials (RAPT) model, is an important component. Although equity must be explicitly incorporated in the design, testing, and widespread implementation of any health care intervention to achieve equity, RAPT does not explicitly consider equity. This study aimed to identify adaptions necessary for the application of the 'Readiness Assessment for Pragmatic Trials' (RAPT) tool in embedded pragmatic randomized, controlled trials (ePCTs) with Indigenous communities.

METHODS

We surveyed and interviewed participants (researchers with experience in research involving Indigenous communities) over three phases (July-December 2022) in this mixed-methods study to explore the appropriateness and recommended adaptions of current RAPT domains and to identify new domains that would be appropriate to include. We thematically analyzed responses and used an iterative process to modify RAPT.

RESULTS

The 21 participants identified that RAPT needed to be modified to strengthen readiness assessment in Indigenous research. In addition, five new domains were proposed to support Indigenous communities' power within the research processes: Indigenous Data Sovereignty; Acceptability - Indigenous Communities; Risk of Research; Research Team Experience; Established Partnership). We propose a modified tool, RAPT-Indigenous (RAPT-I) for use in research with Indigenous communities to increase the robustness and cultural appropriateness of readiness assessment for ePCT. In addition to producing a tool for use, it outlines a methodological approach to adopting research tools for use in and with Indigenous communities by drawing on the experience of researchers who are part of, and/or working with, Indigenous communities to undertake interventional research, as well as those with expertise in health equity, implementation science, and public health.

CONCLUSION

RAPT-I has the potential to provide a useful framework for readiness assessment prior to ePCT in Indigenous communities. RAPT-I also has potential use by bodies charged with critically reviewing proposed pragmatic research including funding and ethics review boards.

Community Voices: A Qualitative Study Exploring Perceptions of Menthol Cigarette Sales Restrictions in Los Angeles County Among Black Adults Who Smoke Menthol Cigarettes

INTRODUCTION

The commercial tobacco industry has long targeted Black communities by making menthol cigarettes not only appealing but affordable through marketing, advertising, and pricing strategies, particularly in the retail environment. Policies that focus on restricting the sale of menthol cigarettes have the potential to significantly reduce the death toll from smoking while also mitigating health inequities and advancing racial equity. However, limited qualitative research exists on the perceptions of menthol cigarette sales restrictions, including local policies, among Black adults who smoke menthol cigarettes.

AIMS AND METHODS

In-depth semi-structured interviews were conducted between January and September 2021 with self-identified non-Hispanic Black adults who reported current menthol cigarette use (n = 26). Participants were asked open-ended questions about awareness and perceptions of the Los Angeles County law banning the retail sale of menthol cigarettes in unincorporated communities, including how it influences their smoking and purchasing behaviors.

RESULTS

We used three thematic categories to structure the results: (1) Are People Aware of Local Menthol Cigarette Sales Restrictions? Levels of Awareness and Strategies to Increase Awareness, (2) Why Ban Menthol? Concerns About Equity and Fairness, and (3) Will Menthol Cigarette Bans Decrease Smoking? Mixed Perceptions About Potential Impact. Most participants (88.5%) had heard about the menthol ban in their communities. Participants described ambivalence towards the ban and identified several factors that hinder support, participation, and well-being, including uncertainty regarding the rationale for banning menthol cigarettes; perceptions that the ban specifically targets Black communities; and concerns regarding government overreach and constraining individual choice. Participants had differing views on whether the ban would likely help them and others who smoke menthol cigarettes reduce or quit smoking. Participants also described situations in which they would purchase menthol cigarettes in another state, country, online, or in the illicit market. Furthermore, participants often viewed the ban as perpetuating criminalization and over-policing of Black communities-arguments used by the commercial tobacco industry to oppose menthol bans.

CONCLUSIONS

Our community-based sample of Black adults who smoke menthol cigarettes face challenges and concerns about local menthol bans. Community-centered interventions, messages, and materials about racial equity in menthol bans, access to free cessation services, and countering commercial tobacco industry interference, in addition to measurable steps toward rectifying injustice from the commercial tobacco industry and repeated exemptions of menthol cigarettes from federal legislation through tangible reparations, would be helpful to this community.

IMPLICATIONS

We sought to add to the literature on flavored nicotine and commercial tobacco policies in the United States by centering the voices of Black adults who smoke menthol cigarettes regarding their awareness, perceptions, and opinions of local laws restricting menthol cigarette retail sales and how such polices influence their smoking and purchasing behaviors. Our findings suggest that Black adults who smoke menthol cigarettes are aware of local laws restricting menthol cigarette retail sales and are ambivalent about the rationale. Our findings have implications for the development and delivery of equity-focused strategies and resources to increase awareness of and rationale for the ban; counter commercial tobacco industry interference; and facilitate smoking cessation among Black adults who experience more combustible tobacco-related morbidity and mortality than their racial/ethnic counterparts. By understanding this relevance, we can also recognize how individual awareness and perceptions are moored within and contextualized by broader social structures and systemic inequities that warrant policy considerations.

Everyday discrimination and satisfaction with nature experiences

Introduction

There is growing interest in creating public green spaces to promote health. Yet, discussions about these efforts often overlook how experiences of chronic discrimination-which may manifest as racism, sexism, or homophobia, and more-could undermine satisfaction with nature experiences.

Methods

Using data from the 2018 wave of the National Opinion Research Center (NORC) General Social Survey (GSS), we quantified associations of frequency of everyday discrimination, operationalized using the Everyday Discrimination Scale (EDS, the primary independent variable), with respondents' perceptions of nature experiences and with their reported time spent in nature. Specifically, we quantified associations with the following three variables: (1) dissatisfaction with day-to-day experiences of nature, (2) not spending as much time as they would like in natural environments, and (3) usually spending at least one day per week in nature. We used survey-weighted robust Poisson models to estimate overall associations, and also stratified analyses by racial/ethnic and gender identity categories.

Results

Of 768 GSS respondents, 14% reported dissatisfaction with nature experiences, 36% reported not spending as much time as they would like in nature, and 33% reported that they did not spend at least one day per week in nature. The median non-standardized EDS, coded such that a higher value indicates greater frequency of discrimination, was 11 (interquartile range: 8, 15). Prevalence of reporting dissatisfaction with day-to-day experiences in nature was 7% higher in association with every one unit increase in EDS score above the median (PR: 1.07, 95% CI: 1.02-1.11). The prevalence of reporting not spending as much time as one would like in nature was 2% higher for every unit increase in higher than median everyday discrimination frequency (PR: 1.02, 95% CI: 1.00-1.05). Higher than median frequency in everyday discrimination was not associated with spending less than one day per week in nature. Race/ethnicity and gender identity did not modify associations.

Conclusion

Greater frequency of everyday discrimination is associated with less satisfaction with experiences in nature. This relationship could undermine efforts to promote health equity through green interventions.

The American Society for Bone and Mineral Research Task Force on clinical algorithms for fracture risk report

Using race and ethnicity in clinical algorithms potentially contributes to health inequities. The American Society for Bone and Mineral Research (ASBMR) Professional Practice Committee convened the ASBMR Task Force on Clinical Algorithms for Fracture Risk to determine the impact of race and ethnicity adjustment in the US Fracture Risk Assessment Tool (US-FRAX). The Task Force engaged the University of Minnesota Evidence-based Practice Core to conduct a systematic review investigating the performance of US-FRAX for predicting incident fractures over 10 years in Asian, Black, Hispanic, and White individuals. Six studies from the Women's Health Initiative (WHI) and Study of Osteoporotic Fractures (SOF) were eligible; cohorts only included women and were predominantly White (WHI > 80% and SOF > 99%), data were not consistently stratified by race and ethnicity, and when stratified there were far fewer fractures in Black and Hispanic women vs White women rendering area under the curve (AUC) estimates less stable. In the younger WHI cohort (n = 64 739), US-FRAX without bone mineral density (BMD) had limited discrimination for major osteoporotic fracture (MOF) (AUC 0.53 (Black), 0.57 (Hispanic), and 0.57 (White)); somewhat better discrimination for hip fracture in White women only (AUC 0.54 (Black), 0.53 (Hispanic), and 0.66 (White)). In a subset of the older WHI cohort (n = 23 918), US-FRAX without BMD overestimated MOF. The Task Force concluded that there is little justification for estimating fracture risk while incorporating race and ethnicity adjustments and recommends that fracture prediction models not include race or ethnicity adjustment but instead be population-based and reflective of US demographics, and inclusive of key clinical, behavioral, and social determinants (where applicable). Research cohorts should be representative vis-à-vis race, ethnicity, gender, and age. There should be standardized collection of race and ethnicity; collection of social determinants of health to investigate impact on fracture risk; and measurement of fracture rates and BMD in cohorts inclusive of those historically underrepresented in osteoporosis research.

Racial and Socioeconomic Disparities in Laminoplasty Versus Laminectomy With Fusion in Patients With Cervical Spondylosis

STUDY DESIGN

A retrospective cohort study using prospectively collected data.

OBJECTIVE

The aim of this study was to investigate preoperative differences in racial and socioeconomic factors in patients undergoing laminoplasty (LP) versus laminectomy and fusion (LF) for degenerative cervical myelopathy (DCM).

SUMMARY OF BACKGROUND DATA

DCM is prevalent in the United States, requiring surgical intervention to prevent neurological degeneration. While LF is utilized more frequently, LP is an emerging alternative. Previous studies have demonstrated similar neurological outcomes for both procedures. However, treatment selection is primarily at the discretion of the surgeon and may be influenced by social determinants of health that impact surgical outcomes.

MATERIALS AND METHODS

The Quality Outcome Database (QOD), a national spine registry, was queried for adult patients who underwent either LP or LF for the management of DCM. Covariates associated with socioeconomic status, pain and disability, and demographic and medical history were collected. Multivariate logistic regression was performed to assess patient factors associated with undergoing LP versus LF.

RESULTS

Of 1673 DCM patients, 157 (9.4%) underwent LP and 1516 (90.6%) underwent LF. A significantly greater proportion of LP patients had private insurance (P<0.001), a greater than high school level education (P<0.001), were employed (P<0.001), and underwent primary surgery (P<0.001). LP patients reported significantly lower baseline neck/arm pain and Neck Disability Index (P<0.001). In the multivariate regression model, lower baseline neck pain [odds ratio (OR)=0.915, P=0.001], identifying as non-Caucasian (OR=2.082, P<0.032), being employed (OR=1.592, P=0.023), and having a greater than high school level education (OR=1.845, P<0.001) were associated with undergoing LP rather than LF.

CONCLUSIONS

In DCM patients undergoing surgery, factors associated with patients undergoing LP versus LF included lower baseline neck pain, non-Caucasian race, higher education, and employment. While symptomatology may influence the decision to choose LP over LF, there may also be socioeconomic factors at play. The trend of more educated and employed patients undergoing LP warrants further investigation.

Core Competencies of an Anti-racist Physician: Elective Course for Undergraduate Medical Students

Introduction

Medical schools seeking to correct and reform curricula towards anti-racist perspectives need to address anti-Black forms of racism specifically and teach students critical upstander skills to interrupt manifestations of racism. We developed a course to teach preclinical medical students basic anti-racism competencies including recognition and awareness of anti-Black racism in medicine and upstander skills to advocate for patients and colleagues.

Methods

In 2021 and 2022, we designed, implemented, and evaluated an elective course for second-year medical students (N = 149) to introduce competencies of anti-racism focusing on upstander skills for addressing anti-Blackness. We designed three patient cases and one student-centered case to illustrate manifestations of anti-Black racism in medicine and used these cases to stimulate small-group discussions and guide students toward recognizing and understanding ways of responding to racism. We designed pre- and postassessments to evaluate the effectiveness of the course and utilized anonymous feedback surveys.

Results

Participants showed significant improvement in pre- to postassessment scores in both years of the course. The anonymous feedback survey showed that 97% of students rated the course at least somewhat effective, and the qualitative responses revealed five core themes: course timing, case complexity, learner differentiation, direct instruction, and access to resources.

Discussion

This course reinforces upstander competencies necessary for advancing anti-racism in medicine. It addresses a gap in medical education by reckoning with the entrenched nature of anti-Black racism in the culture of medicine and seeks to empower undergraduate medical students to advocate for Black-identifying patients and colleagues.

2024 Alzheimer's disease facts and figures

This article describes the public health impact of Alzheimer's disease (AD), including prevalence and incidence, mortality and morbidity, use and costs of care and the ramifications of AD for family caregivers, the dementia workforce and society. The Special Report discusses the larger health care system for older adults with cognitive issues, focusing on the role of caregivers and non-physician health care professionals. An estimated 6.9 million Americans age 65 and older are living with Alzheimer's dementia today. This number could grow to 13.8 million by 2060, barring the development of medical breakthroughs to prevent or cure AD. Official AD death certificates recorded 119,399 deaths from AD in 2021. In 2020 and 2021, when COVID-19 entered the ranks of the top ten causes of death, Alzheimer's was the seventh-leading cause of death in the United States. Official counts for more recent years are still being compiled. Alzheimer's remains the fifth-leading cause of death among Americans age 65 and older. Between 2000 and 2021, deaths from stroke, heart disease and HIV decreased, whereas reported deaths from AD increased more than 140%. More than 11 million family members and other unpaid caregivers provided an estimated 18.4 billion hours of care to people with Alzheimer's or other dementias in 2023. These figures reflect a decline in the number of caregivers compared with a decade earlier, as well as an increase in the amount of care provided by each remaining caregiver. Unpaid dementia caregiving was valued at $346.6 billion in 2023. Its costs, however, extend to unpaid caregivers' increased risk for emotional distress and negative mental and physical health outcomes. Members of the paid health care and broader community-based workforce are involved in diagnosing, treating and caring for people with dementia. However, the United States faces growing shortages across different segments of the dementia care workforce due to a combination of factors, including the absolute increase in the number of people living with dementia. Therefore, targeted programs and care delivery models will be needed to attract, better train and effectively deploy health care and community-based workers to provide dementia care. Average per-person Medicare payments for services to beneficiaries age 65 and older with AD or other dementias are almost three times as great as payments for beneficiaries without these conditions, and Medicaid payments are more than 22 times as great. Total payments in 2024 for health care, long-term care and hospice services for people age 65 and older with dementia are estimated to be $360 billion. The Special Report investigates how caregivers of older adults with cognitive issues interact with the health care system and examines the role non-physician health care professionals play in facilitating clinical care and access to community-based services and supports. It includes surveys of caregivers and health care workers, focusing on their experiences, challenges, awareness and perceptions of dementia care navigation.

Charting the Advocacy Landscape: A Qualitative Content Analysis of Syllabi in Public Health Graduate Education

CONTEXT

Addressing public health challenges necessitates policy approaches, but concerns persist about public health graduates' preparedness to advocate.

OBJECTIVE

This qualitative study sought to assess advocacy content and skills taught to Master of Public Health students enrolled in US accredited schools and programs of public health (SPPHs) by analyzing 98 course syllabi submitted to the Council on Education for Public Health (CEPH) between 2019 and 2021. Syllabi were submitted by SPPHs during their (re)accreditation process to demonstrate compliance with CEPH's advocacy competency requirement.

DESIGN

Qualitative content analysis study. Syllabi were analyzed using MAXQDA Qualitative Data Analysis Software using a 2-coder approach.

SETTING

SPPHs accredited by CEPH.

PARTICIPANTS

Ninety-eight syllabi submitted to CEPH by 22 schools of public health and 54 programs of public health.

MAIN OUTCOME MEASURES

Exemplary language from advocacy courses and assignments and aggregate frequency of syllabi advocacy content and skills.

RESULTS

Most advocacy courses (61%) were survey, health policy, or health care delivery courses, covering policy (66%), policy communication (46%), coalition-building (45%), lobbying (36%), community organizing (33%), and media advocacy (24%) skills. Only 7% prioritized advocacy skill instruction, and 10% addressed how to advocate in an equitable way.

CONCLUSIONS

Defining public health advocacy and essential skills is crucial. Issuing competency guidelines, supporting advocacy faculty, offering standardized training, and expanding experiential learning are important first steps. More research is needed on how academic institutions are incorporating equity skill training into courses, whether separate from or combined with advocacy skills.

Association of Historical Housing Discrimination and Colon Cancer Treatment and Outcomes in the United States

PURPOSE

In the 1930s, the federally sponsored Home Owners' Loan Corporation (HOLC) used racial composition in its assessment of areas worthy of receiving loans. Neighborhoods with large proportions of Black residents were mapped in red (ie, redlining) and flagged as hazardous for mortgage financing. Redlining created a platform for systemic disinvestment in these neighborhoods, leading to barriers in access to resources that persist today. We investigated the association between residing in areas with different HOLC ratings and receipt of quality cancer care and outcomes among individuals diagnosed with colon cancer-a leading cause of cancer deaths amenable to early detection and treatment.

METHODS

Individuals who resided in zip code tabulation areas in 196 cities with HOLC rating and were diagnosed with colon cancer from 2007 to 2017 were identified from the National Cancer Database and assigned a HOLC grade (A, best; B, still desirable; C, definitely declining; and D, hazardous and mapped in red). Multivariable logistic regression models investigated association of area-level HOLC grade and late stage at diagnosis and receipt of guideline-concordant care. The product-limit method evaluated differences in time to adjuvant chemotherapy. Multivariable Cox proportional hazard models investigated differences in overall survival (OS).

RESULTS

There were 149,917 patients newly diagnosed with colon cancer with a median age of 68 years. Compared with people living in HOLC A areas, people living in HOLC D areas were more likely to be diagnosed with late-stage disease (adjusted odds ratio, 1.06 [95% CI, 1.00 to 1.12]). In addition, people living in HOLC B, C, and D areas had 8%, 16%, and 24% higher odds of not receiving guideline-concordant care, including lower receipt of surgery, evaluation of ≥12 lymph nodes, and chemotherapy. People residing in HOLC B, C, or D areas also experienced delays in initiation of adjuvant chemotherapy after surgery. People residing in HOLC C (adjusted hazard ratio [aHR], 1.09 [95% CI, 1.05 to 1.13]) and D (aHR, 1.13 [95% CI, 1.09 to 1.18]) areas had worse OS, including 13% and 20% excess risk of death for individuals diagnosed with early- and 6% and 8% for late-stage disease for HOLC C and D, respectively.

CONCLUSION

Historical housing discrimination is associated with worse contemporary access to colon cancer care and outcomes.

Hospice Readmission, Hospitalization, and Hospital Death Among Patients Discharged Alive from Hospice

Importance

Transitions in care settings following live discharge from hospice care are burdensome for patients and families. Factors contributing to risk of burdensome transitions following hospice discharge are understudied.

Objective

To identify factors associated with 2 burdensome transitions following hospice live discharge, as defined by the Centers for Medicare & Medicaid Services.

Design, Setting, and Participants

This population-based retrospective cohort study included a 20% random sample of Medicare fee-for-service beneficiaries using 2014 to 2019 Medicare claims data. Data were analyzed from April 22, 2023, to March 4, 2024.

Exposure

Live hospice discharge.

Main Outcomes and Measures

Multivariable logistic regression examined associations among patient, health care provision, and organizational characteristics with 2 burdensome transitions after live hospice discharge (outcomes): type 1, hospice discharge, hospitalization within 2 days, and hospice readmission within 2 days; and type 2, hospice discharge, hospitalization within 2 days, and hospital death.

Results

This study included 115 072 Medicare beneficiaries discharged alive from hospice (mean [SD] age, 84.4 [6.6] years; 71892 [62.5%] female; 5462 [4.8%] Hispanic, 9822 [8.5%] non-Hispanic Black, and 96 115 [83.5%] non-Hispanic White). Overall, 10 381 individuals (9.0%) experienced a type 1 burdensome transition and 3144 individuals (2.7%) experienced a type 2 burdensome transition. In adjusted models, factors associated with higher odds of burdensome transitions included identifying as non-Hispanic Black (type 1: adjusted odds ratio [aOR], 1.47; 95% CI, 1.36-1.58; type 2: aOR, 1.70; 95% CI, 1.51-1.90), hospice stays of 7 days or fewer (type 1: aOR, 1.13; 95% CI, 1.06-1.21; type 2: aOR, 1.71; 95% CI, 1.53-1.90), and care from a for-profit hospice (type 1: aOR, 1.78; 95% CI, 1.62-1.96; type 2: aOR, 1.32; 95% CI, 1.15-1.52). Nursing home residence (type 1: aOR, 0.66; 95% CI, 0.61-0.72; type 2: aOR, 0.47; 95% CI, 0.40-0.54) and hospice stays of 180 days or longer (type 1: aOR, 0.63; 95% CI, 0.59-0.68; type 2: aOR, 0.60; 95% CI, 0.52-0.69) were associated with lower odds of burdensome transitions.

Conclusion and Relevance

This retrospective cohort study of burdensome transitions following live hospice discharge found that non-Hispanic Black race, short hospice stays, and care from for-profit hospices were associated with higher odds of experiencing a burdensome transition. These findings suggest that changes to clinical practice and policy may reduce the risk of burdensome transitions, such as hospice discharge planning that is incentivized, systematically applied, and tailored to needs of patients at greater risk for burdensome transitions.

Cumulative Systolic Blood Pressure and Incident Stroke Type Variation by Race and Ethnicity

Importance

Stroke risk varies by systolic blood pressure (SBP), race, and ethnicity. The association between cumulative mean SBP and incident stroke type is unclear, and whether this association differs by race and ethnicity remains unknown.

Objective

To examine the association between cumulative mean SBP and first incident stroke among 3 major stroke types-ischemic stroke (IS), intracerebral hemorrhage (ICH), and subarachnoid hemorrhage (SAH)-and explore how these associations vary by race and ethnicity.

Design, Setting, and Participants

Individual participant data from 6 US longitudinal cohorts (January 1, 1971, to December 31, 2019) were pooled. The analysis was performed from January 1, 2022, to January 2, 2024. The median follow-up was 21.6 (IQR, 13.6-31.8) years.

Exposure

Time-dependent cumulative mean SBP.

Main Outcomes and Measures

The primary outcome was time from baseline visit to first incident stroke. Secondary outcomes consisted of time to first incident IS, ICH, and SAH.

Results

Among 40 016 participants, 38 167 who were 18 years or older at baseline with no history of stroke and at least 1 SBP measurement before the first incident stroke were included in the analysis. Of these, 54.0% were women; 25.0% were Black, 8.9% were Hispanic of any race, and 66.2% were White. The mean (SD) age at baseline was 53.4 (17.0) years and the mean (SD) SBP at baseline was 136.9 (20.4) mm Hg. A 10-mm Hg higher cumulative mean SBP was associated with a higher risk of overall stroke (hazard ratio [HR], 1.20 [95% CI, 1.18-1.23]), IS (HR, 1.20 [95% CI, 1.17-1.22]), and ICH (HR, 1.31 [95% CI, 1.25-1.38]) but not SAH (HR, 1.13 [95% CI, 0.99-1.29]; P = .06). Compared with White participants, Black participants had a higher risk of IS (HR, 1.20 [95% CI, 1.09-1.33]) and ICH (HR, 1.67 [95% CI, 1.30-2.13]) and Hispanic participants of any race had a higher risk of SAH (HR, 3.81 [95% CI, 1.29-11.22]). There was no consistent evidence that race and ethnicity modified the association of cumulative mean SBP with first incident stroke and stroke type.

Conclusions and Relevance

The findings of this cohort study suggest that cumulative mean SBP was associated with incident stroke type, but the associations did not differ by race and ethnicity. Culturally informed stroke prevention programs should address modifiable risk factors such as SBP along with social determinants of health and structural inequities in society.

Lessons Learned from Immigrant Health Cohorts: A Review of the Evidence and Implications for Policy and Practice in Addressing Health Inequities among Asian Americans, Native Hawaiians, and Pacific Islanders

The health of Asian Americans, Native Hawaiians, and Pacific Islanders (AANHPI) is uniquely impacted by structural and social determinants of health (SSDH) shaped by immigration policies and colonization practices, patterns of settlement, and racism. These SSDH also create vast heterogeneity in disease risks across the AANHPI population, with some ethnic groups having high disease burden, often masked with aggregated data. Longitudinal cohort studies are an invaluable tool to identify risk factors of disease, and epidemiologic cohort studies among AANHPI populations have led to seminal discoveries of disease risk factors. This review summarizes the limited but growing literature, with a focus on SSDH factors, from seven longitudinal cohort studies with substantial AANHPI samples. We also discuss key information gaps and recommendations for the next generation of AANHPI cohorts, including oversampling AANHPI ethnic groups; measuring and innovating on measurements of SSDH; emphasizing the involvement of scholars from diverse disciplines; and, most critically, engaging community members to ensure relevancy for public health, policy, and clinical impact.

Incidence, risk factors, and a prognostic nomogram for distant metastasis in endometrial cancer: A SEER-based study

OBJECTIVE

To evaluate the metastatic pattern, identify the risk factors, and establish a nomogram for predicting prognosis of endometrial cancer (EC) with distant metastasis.

METHODS

A retrospective cohort study of women diagnosed with EC was conducted according to the Surveillance, Epidemiology, and End Results (SEER) database during 2010-2017. Multivariate logistic analysis and Cox analysis were performed to identify the risk factors in promoting distant metastasis and predictors associated with overall survival (OS) in this particular subpopulation. A nomogram was then constructed and validated by the concordance index (C-index), the area under the receiver operating characteristic curve (AUC), calibration plots, and decision curve analysis.

RESULTS

A total of 2799 cases of distant metastasis in EC patients were identified, with an overall incidence rate of 3.74% from 2010 to 2017. Black race, unmarried status, non-endometrioid histologic types, and grade IV were significant risk factors for distant metastasis in EC patients. Meanwhile, race, histology, grade, metastasis status, surgery, lymphadenectomy, and chemotherapy were identified as independent prognostic factors for OS. A nomogram to predict 1-, 3-, and 5-year OS was established, and presented favorable accuracy and clinical applicability. Patients were further divided into high- and low-risk groups according to the model.

CONCLUSION

The nomogram was developed as a highly accurate, individualized tool to better predict the prognosis of EC patients with distant metastasis, which would help clinicians to identify high-risk patients, and adjust and tailor their treatment strategies.

Ramifications of Precarious Employment for Health and Health Inequity: Emerging Trends from the Americas

Precarious employment (PE), which encompasses the power relations between workers and employers, is a well-established social determinant of health that has strong ramifications for health and health inequity. In this review, we discuss advances in the measurement of this multidimensional construct and provide recommendations for overcoming continued measurement challenges. We then evaluate recent evidence of the negative health impacts of PE, with a focus on the burgeoning studies from North America and South America. We also establish the role of PE in maintaining and perpetuating health inequities and review potential policy solutions to help alleviate its health burden. Last, we discuss future research directions with a call for a better understanding of the heterogeneity within PE and for research that focuses both on upstream drivers that shape PE and its impacts on health, as well as on the mechanisms by which PE causes poor health.

Challenges in Palliative Care in Latin America: A Narrative Review

In "graying" populations with extended lifespans and survivable forms of cancer, palliative services become increasingly important but may be difficult to introduce into public discourse, public policy, and healthcare systems. Latin America (LATAM) faces many challenges as it introduces and, in some cases, develops its palliative care programs; though the challenges faced here are in many ways universal ones, LATAM approaches may be unique and based on the region's specific culture, politics, and economics. This narrative review based on a literature search identified 10 main themes that can be interpreted as challenges and opportunities for palliative care in LATAM. These challenges are integrating palliation into healthcare systems; public policy and funding; therapeutic obstinacy; changing demographics; access to services; analgesia; the role of religion, spirituality, and folk medicine; social determinants of palliative care; low health literacy; and limited clinician training. Some of the LATAM nations have palliative programs and palliative care training in place while others are developing these systems. Integrating this care into existing healthcare and reimbursement systems has been a challenge. A notable challenge in LATAM is also access to care since palliative programs tend to cluster in metropolitan areas and create hardships for rural citizens to access them. The better-defined role of familial caregivers and telehealth may be important factors in the expansion of palliative care in LATAM and beyond.

All in the Family? A Systematic Review and Meta-analysis of Parenting and Family Environment as Risk Factors for Attention-Deficit/Hyperactivity Disorder (ADHD) in Children

Parenting and family environment have significant impact on child development, including development of executive function, attention, and self-regulation, and may affect the risk of developmental disorders including attention-deficit/hyperactivity disorder (ADHD). This paper examines the relationship of parenting and family environment factors with ADHD. A systematic review of the literature was conducted in 2014 and identified 52 longitudinal studies. A follow-up search in 2021 identified 7 additional articles, for a total of 59 studies that examined the association of parenting factors with ADHD outcomes: ADHD overall (diagnosis or symptoms), ADHD diagnosis specifically, or presence of the specific ADHD symptoms of inattention and hyperactivity/impulsivity. For parenting factors that were present in three or more studies, pooled effect sizes were calculated separately for dichotomous or continuous ADHD outcomes, accounting for each study's conditional variance. Factors with sufficient information for analysis were parenting interaction quality (sensitivity/warmth, intrusiveness/reactivity, and negativity/harsh discipline), maltreatment (general maltreatment and physical abuse), parental relationship status (divorce, single parenting), parental incarceration, and child media exposure. All factors showed a significant direct association with ADHD outcomes, except sensitivity/warmth which had an inverse association. Parenting factors predicted diagnosis and overall symptoms as well as inattentive and hyperactive symptoms when measured, but multiple factors showed significant heterogeneity across studies. These findings support the possibility that parenting and family environment influences ADHD symptoms and may affect a child's likelihood of being diagnosed with ADHD. Prevention strategies that support parents, such as decreasing parenting challenges and increasing access to parent training in behavior management, may improve children's long-term developmental health.

Scoping Review of Barriers and Facilitators to Recruitment of Black People With Cancer in Biospecimen-Based Research

The increasing focus on precision medicine to optimize cancer treatments and improve cancer outcomes is an opportunity to consider equitable engagement of people racialized as Black or African American (B/AA) in biospecimen-based cancer research. B/AA people have the highest cancer incidence and mortality rates compared with all other racial and ethnic groups in the United States, yet are under-represented in biospecimen-based research. A narrative scoping review was conducted to understand the current literature on barriers, facilitators, and evidence-based strategies associated with the engagement of B/AA people with cancer in biospecimen research. Three comprehensive searches of MEDLINE, CINAHL, Embase, and Scopus were conducted. Of 770 studies generated by the search, 10 met all inclusion criteria for this review. The most frequently reported barriers to engagement of B/AA people in biospecimen research were lack of biospecimen research awareness, fear of medical harm, and violation of personal health information privacy, resource constraints, and medical mistrust. Key facilitators included previous exposure to research, knowledge about underlying genetic causes of cancer, and altruism. Recommended strategies to increase participation of B/AA people in biospecimen-based research included community engagement, transparent communication, workforce diversity, education and training, and research participant incentives. Inclusion of B/AA people in biospecimen-based research has the potential to advance the promise of precision oncology for all patients and reduce racial disparities in cancer outcomes.

Racial and Ethnic Inequities in Cancer Care Continuity During the COVID-19 Pandemic Among Those With SARS-CoV-2

Importance

Racially and ethnically minoritized US adults were disproportionately impacted by the COVID-19 pandemic and experience poorer cancer outcomes, including inequities in cancer treatment delivery.

Objective

To evaluate racial and ethnic disparities in cancer treatment delays and discontinuations (TDDs) among patients with cancer and SARS-CoV-2 during different waves of the COVID-19 pandemic in the United States.

Design, Setting, and Participants

This cross-sectional study used data from the American Society of Clinical Oncology Survey on COVID-19 in Oncology Registry (data collected from April 2020 to September 2022), including patients with cancer also diagnosed with SARS-CoV-2 during their care at 69 US practices. Racial and ethnic differences were examined during 5 different waves of the COVID-19 pandemic in the United States based on case surge (before July 2020, July to November 2020, December 2020 to March 2021, April 2021 to February 2022, and March to September 2022).

Exposures

Race and ethnicity.

Main Outcomes and Measures

TDD was defined as any cancer treatment postponed more than 2 weeks or cancelled with no plans to reschedule. To evaluate TDD associations with race and ethnicity, adjusted prevalence ratios (aPRs) were estimated using multivariable Poisson regression, accounting for nonindependence of patients within clinics, adjusting for age, sex, body mass index, comorbidities, cancer type, cancer extent, and SARS-CoV-2 severity (severe defined as death, hospitalization, intensive care unit admission, or mechanical ventilation).

Results

A total of 4054 patients with cancer and SARS-CoV-2 were included (143 [3.5%] American Indian or Alaska Native, 176 [4.3%] Asian, 517 [12.8%] Black or African American, 469 [11.6%] Hispanic or Latinx, and 2747 [67.8%] White; 2403 [59.3%] female; 1419 [35.1%] aged 50-64 years; 1928 [47.7%] aged ≥65 years). The analysis focused on patients scheduled (at SARS-CoV-2 diagnosis) to receive drug-based therapy (3682 [90.8%]), radiation therapy (382 [9.4%]), surgery (218 [5.4%]), or transplant (30 [0.7%]), of whom 1853 (45.7%) experienced TDD. Throughout the pandemic, differences in racial and ethnic inequities based on case surge with overall TDD decreased over time. In multivariable analyses, non-Hispanic Black (third wave: aPR, 1.56; 95% CI, 1.31-1.85) and Hispanic or Latinx (third wave: aPR, 1.35; 95% CI, 1.13-1.62) patients with cancer were more likely to experience TDD compared with non-Hispanic White patients during the first year of the pandemic. By 2022, non-Hispanic Asian patients (aPR, 1.51; 95% CI, 1.08-2.12) were more likely to experience TDD compared with non-Hispanic White patients, and non-Hispanic American Indian or Alaska Native patients were less likely (aPR, 0.37; 95% CI, 0.16-0.89).

Conclusions and Relevance

In this cross-sectional study of patients with cancer and SARS-CoV-2, racial and ethnic inequities existed in TDD throughout the pandemic; however, the disproportionate burden among racially and ethnically minoritized patients with cancer varied across SARS-CoV-2 waves. These inequities may lead to downstream adverse impacts on cancer mortality among minoritized adults in the United States.

Lack of racial and ethnic disparities in mortality in minority patients hospitalised with COVID-19 in a mid-Atlantic healthcare system

INTRODUCTION

In the USA, minoritised communities (racial and ethnic) have suffered disproportionately from COVID-19 compared with non-Hispanic white communities. In a large cohort of patients hospitalised for COVID-19 in a healthcare system spanning five adult hospitals, we analysed outcomes of patients based on race and ethnicity.

METHODS

This was a retrospective cohort analysis of patients 18 years or older admitted to five hospitals in the mid-Atlantic area between 4 March 2020 and 27 May 2022 with confirmed COVID-19. Participants were divided into four groups based on their race/ethnicity: non-Hispanic black, non-Hispanic white, Latinx and other. Propensity score weighted generalised linear models were used to assess the association between race/ethnicity and the primary outcome of in-hospital mortality.

RESULTS

Of the 9651 participants in the cohort, more than half were aged 18-64 years old (56%) and 51% of the cohort were females. Non-Hispanic white patients had higher mortality (p<0.001) and longer hospital length-of-stay (p<0.001) than Latinx and non-Hispanic black patients.

DISCUSSION

In this large multihospital cohort of patients admitted with COVID-19, non-Hispanic black and Hispanic patients did not have worse outcomes than white patients. Such findings likely reflect how the complex range of factors that resulted in a life-threatening and disproportionate impact of incidence on certain vulnerable populations by COVID-19 in the community was offset through admission at well-resourced hospitals and healthcare systems. However, there continues to remain a need for efforts to address the significant pre-existing race and ethnicity inequities highlighted by the COVID-19 pandemic to be better prepared for future public health emergencies.

Prompt access to outpatient care post-incarceration among adults with a history of substance use: Predisposing, enabling, and need-based factors

INTRODUCTION

As expanded Medicaid coverage reduces financial barriers to receiving health care among formerly incarcerated adults, more information is needed to understand the factors that predict prompt use of health care after release among insured adults with a history of substance use. This study's aim was to estimate the associations between characteristics suggested by the Andersen behavioral model of health service use and measures of health care use during the immediate reentry period and in the presence of Medicaid coverage.

METHODS

In this retrospective cohort study, we linked individual-level data from multiple Wisconsin agencies. The sample included individuals aged 18-64 released from a Wisconsin State Correctional Facility between April 2014 and June 2017 to a community in the state who enrolled in Medicaid within one month of release and had a history of substance use. We grouped predictors of outpatient care into variable domains within the Andersen model: predisposing- individual socio-demographic characteristics; enabling characteristics including area-level socio-economic resources, area-level health care supply, and characteristics of the incarceration and release; and need-based- pre-release health conditions. We used a model selection algorithm to select a subset of variable domains and estimated the association between the variables in these domains and two outcomes: any outpatient visit within 30 days of release from a state correctional facility, and receipt of medication for opioid use disorder within 30 days of release.

RESULTS

The size and sign of many of the estimated associations differed for our two outcomes. Race was associated with both outcomes, Black individuals being 12.1 p.p. (95 % CI, 8.7-15.4, P < .001) less likely than White individuals to have an outpatient visit within 30 days of release and 1.3 p.p. (95 % CI, 0.48-2.1, P = .002) less likely to receive MOUD within 30 days of release. Chronic pre-release health conditions were positively associated with the likelihood of post-release health care use.

CONCLUSIONS

Conditional on health insurance coverage, meaningful differences in post-incarceration outpatient care use still exist across adults leaving prison with a history of substance use. These findings can help guide the development of care transition interventions including the prioritization of subgroups that may warrant particular attention.

Effects of communicating health disparities using social comparison framing: A comprehensive review

Communicating health disparities in mass and social media has typically taken the form of comparing disease risks and outcomes between two or more social groups, a strategy known as social comparison framing. This comprehensive review examined the design and results of 17 studies from 15 peer-reviewed journal articles about the effects of social comparison framing of health disparities. Most studies focus on race-based disparities across a variety of health topics. For individual-level outcomes, social comparison tends to reduce perceived disease risks for the lower disease prevalence group while prompting negative emotions and yielding inconsistent impact on health behavioral intentions among members of the higher prevalence group. For societal-level outcomes, social comparison often has either null or polarizing effects on support for policies to address these disparities that vary by racial identity/attitudes of the respondents. Studies also find that racial comparisons trigger lower levels of support for policy remedies relative to economic, educational, or geographic comparisons. We conclude that social comparison framing of health disparities, in the absence of broader discussion of the social and structural causes of these disparities, is more likely to incur negative consequences. We propose several possible strategies to communicate health disparity information more effectively.

Why location matters: associations between county-level characteristics and availability of National Cancer Oncology Research Program and National Cancer Institute sites

BACKGROUND

The majority of patients with cancer seek care at community oncology sites; however, most clinical trials are available at National Cancer Institute (NCI)-designated sites. Although the NCI National Cancer Oncology Research Program (NCORP) was designed to address this problem, little is known about the county-level characteristics of NCORP site locations.

METHODS

This cross-sectional analysis determined the association between availability of NCORP or NCI sites and county-level characteristic theme percentile scores from the Center for Disease Control and Prevention's Social Vulnerability Index themes. Health Resources and Services Administration's Area Health Resource Files were used to determine contiguous counties. We estimated risk ratios and 95% confidence intervals (CIs) using modified Poisson regression models to evaluate the association between county-level characteristics and site availability within singular and singular and contiguous counties.

RESULTS

Of 3141 included counties, 14% had an NCORP, 2% had an NCI, and 1% had both sites. Among singular counties, for a standard deviation increase in the racial and ethnic theme score, there was a 22% higher likelihood of NCORP site availability (95% CI = 1.10 to 1.36); for a standard deviation increase in the socioeconomic status theme score, there was a 24% lower likelihood of NCORP site availability (95% CI = 0.67 to 0.87). Associations were of smaller magnitude when including contiguous counties. NCI sites were located in more vulnerable counties.

CONCLUSIONS

NCORP sites were more often in racially diverse counties and less often in socioeconomically vulnerable counties. Research is needed to understand how clinical trial representation will increase if NCORP sites strategically increase their locations in more vulnerable counties.

Structural adverse childhood experiences associated with suicidal ideation, suicide attempts, and repetitive nonsuicidal self-injury among racially and ethnically minoritized youth

INTRODUCTION

High rates of suicidal ideation (SI), suicide attempts (SA), and repetitive nonsuicidal self-injury (NSSI) among some ethnoracially minoritized United States youth populations may be related to adverse childhood experiences (ACEs) with structural roots.

METHODS

Using the 2013-2019 Minnesota Student Surveys, we assessed associations of student-reported structural ACEs (parental incarceration, housing instability, food insecurity, and foster care involvement) with SI, SA, and repetitive NSSI within the past 12 months using multilevel logistic regression stratified by ethnoracial group (American Indian/Alaskan Native [AIAN], Hmong, other Asian, Black Latino, other Latino, Somali, other Black/African American [AA], Native Hawaiian/Pacific Islander [NHPI], and multiracial), and adjusted for sex, grade, ACEs experienced within one's household, mental health treatment, and perceived safety.

RESULTS

Structural ACEs were strongly associated with increasing SI, SA, and NSSI. At ≥2 structural ACEs, repetitive NSSI rates ranged from 7% to 29% (female), 8% to 20% (male); SA rates ranged from 13% to 35% (female), 10% to 22% (male); and SI rates ranged from 31% to 50% (female), 20% to 32% (male). Black Latino, NHPI, AIAN, and Black/AA students most often reported structural ACE exposures.

CONCLUSION

Reducing structural ACEs may reduce SI, SA, and repetitive NSSI among ethnoracially minoritized youth populations. Disaggregating diverse youth groups revealed variations in these outcomes that remain hidden when subpopulations are aggregated.

Racial/Ethnic Disparities: Discrimination's Impact on Health-Related Quality of Life-An All of Us Cancer Survivors' Cross-sectional Study

BACKGROUND

Discrimination is associated with worse mental and physical health outcomes. However, the associations among cancer survivors are limited.

OBJECTIVE

We examined whether discrimination is associated with HRQoL and whether adjusting for it reduces racial/ethnic disparities in HRQoL among cancer survivors.

METHODS

Cross-sectional data from adult cancer survivors who completed surveys on discrimination in the medical settings (DMS), everyday perceived discrimination (PD), and HRQoL in the "All of Us" Program from 2018 to 2022 were assessed. We created a binary indicator for fair-to-poor vs. good-to-excellent physical health and mental health. PD and DMS scores were a continuous measure with higher scores reflecting more discrimination. Multivariable logistic regression models tested whether DMS and PD are associated with HRQoL and whether they differently affect the association between race/ethnicity and HRQoL.

RESULTS

The sample (N = 16,664) of cancer survivors was predominantly White (86%) and female (59%), with a median age of 69. Every 5-unit increase in DMS and PD scores was associated with greater odds of fair-to-poor physical health (DMS: OR [95%CI] = 1.66 [1.55, 1.77], PD: 1.33 [1.27, 1.40]) and mental health (DMS: 1.57 [1.47, 1.69], PD: 1.33 [1.27, 1.39]). After adjusting for DMS or PD, Black and Hispanic survivors had a decreased likelihood of fair-to-poor physical health and mental health (decrease estimate range: - 6 to - 30%) compared to White survivors. This effect was greater for Black survivors when adjusting for PD, as the odds of fair-to-poor mental health compared to White survivors were no longer statistically significant (1.78 [1.32, 2.34] vs 1.22 [0.90, 1.64]).

CONCLUSION

Experiences of discrimination are associated with lower HRQoL and reducing it may mitigate racial/ethnic disparities in HRQoL.

The Maternal and Infant Environmental Health Riskscape study of perinatal disparities in greater Houston: rationale, study design and participant profiles

Introduction

The Maternal and Infant Environmental Health Riskscape (MIEHR) Center was established to address the interplay among chemical and non-chemical stressors in the biological, physical, social, and built environments that disproportionately impact perinatal health among Black pregnant people in a large and diverse urban area with documented disparities in the U.S.

Methods

The MIEHR cohort is recruiting non-Hispanic Black and non-Hispanic white pregnant people who deliver their infants at major obstetric hospitals in Houston, Texas. At enrollment, all participants are asked to provide urine samples for chemical [metals, cotinine, and polycyclic aromatic hydrocarbons (PAHs)] analyses and blood samples. A subset of the cohort is asked to provide oral and vaginal swabs, and fecal samples. Questionnaire and electronic health record data gather information about residential address history during pregnancy, pregnancy history and prenatal care, sociodemographic and lifestyle factors, experiences of discrimination and stress, and sources of social support. Using information on where a participant lived during their pregnancy, features of their neighborhood environment are characterized. We provide summaries of key individual- and neighborhood-level features of the entire cohort, as well as for Black and white participants separately.

Results

Between April 2021 and February 2023, 1,244 pregnant people were recruited. Nearly all participants provided urine samples and slightly less than half provided blood samples. PAH exposure patterns as assessed on 47% of participants thus far showed varying levels depending on metabolite as compared to previous studies. Additionally, analyses suggest differences between Black and white pregnant people in experiences of discrimination, stress, and levels of social support, as well as in neighborhood characteristics.

Discussion

Our findings to date highlight racial differences in experiences of discrimination, stress, and levels of support, as well as neighborhood characteristics. Recruitment of the cohort is ongoing and additional neighborhood metrics are being constructed. Biospecimens will be analyzed for metals and PAH metabolites (urine samples), miRNAs (plasma samples) and the microbiome (oral swabs). Once enrollment ends, formal assessments are planned to elucidate individual- and neighborhood-level features in the environmental riskscape that contribute to Black-White disparities in perinatal health.

The C2DREAM framework: Investigating the structural mechanisms undergirding racial health inequities

Racism shapes the distribution of the social determinants of health (SDoH) along racial lines. Racism determines the environments in which people live, the quality of housing, and access to healthcare. Extensive research shows racism in its various forms negatively impacts health status, yet few studies and interventions seriously interrogate the role of racism in impacting health. The C2DREAM framework illuminates how exposure to racism, in multiple forms, connects to cardiovascular disease, hypertension, and obesity. The goal of the C2DREAM framework is to guide researchers to critically think about and measure the role of racism across its many levels of influence to better elucidate the ways it contributes to persistent health inequities. The conceptual framework highlights the interconnectedness between forms of racism, SDoH, and the lifecourse to provide a greater context to individual health outcomes. Utilizing this framework and critically contending with the effects of racism in its multiple and cumulative forms will lead to better research and interventions.

Locked in and left out: the "prison penalty" for implementation of evidence-based interventions

BACKGROUND

While the broader medical community grapples with the widely accepted notion that it takes an average of 17 years for research evidence to be incorporated into clinical practice, the implementation of evidence-based interventions in carceral settings (i.e., jails and prisons) faces longer delays, exacerbating health disparities.

MAIN BODY

The "prison implementation penalty" describes the significant delay in and limited adoption of evidence-based healthcare practices in carceral settings. We explore the complex challenges of implementing evidence-based interventions in jails and prisons, environments where healthcare often plays a secondary role under security and discipline. We use specific frameworks to highlight the unique barriers within these settings and propose potential implementation strategies. These challenges have broad implications for health equity due to the disproportionate impact on the marginalized groups affected by mass incarceration. Implementation science has potential to mitigate these disparities.

CONCLUSION

Bridging the gap between healthcare evidence and practice in carceral settings offers a public health opportunity. Implementation science offers a unique role in improving healthcare standards and reducing health inequities in this environment.

Equity M&M - Adaptation of the Morbidity and Mortality Conference to Analyze and Confront Structural Inequity in Internal Medicine

BACKGROUND

At morbidity and mortality (M&M) conferences, medical teams review cases for medical education and system improvement. Adverse outcomes are often driven by social inequity, but processes to analyze such outcomes are lacking.

AIM

Adapt quality improvement and patient safety (QIPS) tools in the M&M format to systematically analyze adverse patient outcomes rooted in social and structural determinants of health (SSDH).

SETTING

One-hour conferences conducted in health systems in Seattle, WA, and Dallas, TX.

PARTICIPANTS

Equity M&M conferences were held 11 times, each with approximately 45 participants comprised of internal medicine trainees, faculty, and non-medical staff.

PROGRAM DESCRIPTION

Conferences included a case narrative and counternarrative highlighting SSDH, an equity-framed root cause analysis, and potential interventions.

PROGRAM EVALUATION

Conferences were received well across both institutions. Following conferences, most respondents reported increased identification of opportunities for action towards equity (88.5%) and confidence in discussing equity issues with colleagues (92.3%).

DISCUSSION

Equity M&M conferences are a structured tool for deconstructing and confronting structural inequity that leads to adverse patient outcomes. Evaluations demonstrate educational impact on participants. Anecdotal examples suggest institutional impact. Other health systems could adopt this model for similar advocacy and system improvement.

A systematic review of barriers to pursuing careers in medicine among Black premedical students

Among the various etiologies of the exclusion of Black male physicians from the healthcare workforce, it is critical to identify and examine the barriers in their trajectory. Given that most medical school matriculants graduate and pursue residency training, medical school admission has been identified as the primary impediment to a career in medicine. Thus, this work aims to identify barriers in the journey of primarily Black, and secondarily underrepresented minority, premedical students. A systematic review of the medical literature was conducted for articles pertaining to the undergraduate/premedical period, Black experiences, and the medical school application process. The search yielded 5336 results, and 13 articles were included. Most papers corroborated common barriers, such as financial/socioeconomic burdens, lack of access to preparatory materials and academic enrichment programs, lack of exposure to the medical field, poor mentorship/advising experiences, systemic and interpersonal racism, and limited support systems. Common facilitators of interest and interventions included increasing academic enrichment programs, improving mentorship and career guidance quality and availability, and improving access to and availability of resources as well as exposure opportunities. No article explicitly discussed addressing racism. There is a dearth of studies exploring the premedical stage-the penultimate point of entry into medicine. Though interest in becoming a physician may be present, multiple and disparate impediments restrict Black men's participation in medicine. Addressing the barriers Black and underrepresented minority premedical students face requires an awareness of how multiple systems work together to discriminate and restrict access to careers in medicine beyond the traditional pipeline understanding.

Neighborhood Segregation and Access to Live Donor Kidney Transplantation

Importance

Identifying the mechanisms of structural racism, such as racial and ethnic segregation, is a crucial first step in addressing the persistent disparities in access to live donor kidney transplantation (LDKT).

Objective

To assess whether segregation at the candidate's residential neighborhood and transplant center neighborhood is associated with access to LDKT.

Design, Setting, and Participants

In this cohort study spanning January 1995 to December 2021, participants included non-Hispanic Black or White adult candidates for first-time LDKT reported in the US national transplant registry. The median (IQR) follow-up time for each participant was 1.9 (0.6-3.0) years.

Main Outcome and Measures

Segregation, measured using the Theil H method to calculate segregation tertiles in zip code tabulation areas based on the American Community Survey 5-year estimates, reflects the heterogeneity in neighborhood racial and ethnic composition. To quantify the likelihood of LDKT by neighborhood segregation, cause-specific hazard models were adjusted for individual-level and neighborhood-level factors and included an interaction between segregation tertiles and race.

Results

Among 162 587 candidates for kidney transplant, the mean (SD) age was 51.6 (13.2) years, 65 141 (40.1%) were female, 80 023 (49.2%) were Black, and 82 564 (50.8%) were White. Among Black candidates, living in a high-segregation neighborhood was associated with 10% (adjusted hazard ratio [AHR], 0.90 [95% CI, 0.84-0.97]) lower access to LDKT relative to residence in low-segregation neighborhoods; no such association was observed among White candidates (P for interaction = .01). Both Black candidates (AHR, 0.94 [95% CI, 0.89-1.00]) and White candidates (AHR, 0.92 [95% CI, 0.88-0.97]) listed at transplant centers in high-segregation neighborhoods had lower access to LDKT relative to their counterparts listed at centers in low-segregation neighborhoods (P for interaction = .64). Within high-segregation transplant center neighborhoods, candidates listed at predominantly minority neighborhoods had 17% lower access to LDKT relative to candidates listed at predominantly White neighborhoods (AHR, 0.83 [95% CI, 0.75-0.92]). Black candidates residing in or listed at transplant centers in predominantly minority neighborhoods had significantly lower likelihood of LDKT relative to White candidates residing in or listed at transplant centers located in predominantly White neighborhoods (65% and 64%, respectively).

Conclusions

Segregated residential and transplant center neighborhoods likely serve as a mechanism of structural racism, contributing to persistent racial disparities in access to LDKT. To promote equitable access, studies should assess targeted interventions (eg, community outreach clinics) to improve support for potential candidates and donors and ultimately mitigate the effects of segregation.

Individual and Neighborhood Level Predictors of Children's Exposure to Residential Greenspace

Inequities in urban greenspace have been identified, though patterns by race and socioeconomic status vary across US settings. We estimated the magnitude of the relationship between a broad mixture of neighborhood-level factors and residential greenspace using weighted quantile sum (WQS) regression, and compared predictive models of greenspace using only neighborhood-level, only individual-level, or multi-level predictors. Greenspace measures included the Normalized Difference Vegetation Index (NDVI), tree canopy, and proximity of the nearest park, for residential locations in Shelby County, Tennessee of children in the CANDLE cohort. Neighborhood measures include socioeconomic and education resources, as well as racial composition and racial residential segregation. In this sample of 1012 mother-child dyads, neighborhood factors were associated with higher NDVI and tree canopy (0.021 unit higher NDVI [95% CI: 0.014, 0.028] per quintile increase in WQS index); homeownership rate, proximity of and enrollment at early childhood education centers, and racial composition, were highly weighted in the WQS index. In models constrained in the opposite direction (0.028 unit lower NDVI [95% CI: - 0.036, - 0.020]), high school graduation rate and teacher experience were highly weighted. In prediction models, adding individual-level predictors to the suite of neighborhood characteristics did not meaningfully improve prediction accuracy for greenspace measures. Our findings highlight disparities in greenspace for families by neighborhood socioeconomic and early education factors, and by race, suggesting several neighborhood indicators for consideration both as potential confounders in studies of greenspace and pediatric health as well as in the development of policies and programs to improve equity in greenspace access.

Structural Racism and Use of Labor Neuraxial Analgesia Among Non-Hispanic Black Birthing People

OBJECTIVE

To assess the association between structural racism and labor neuraxial analgesia use.

METHODS

This cross-sectional study analyzed 2017 U.S. natality data for non-Hispanic Black and White birthing people. The exposure was a multidimensional structural racism index measured in the county of the delivery hospital. It was calculated as the mean of three Black-White inequity ratios (ratios for lower education, unemployment, and incarceration in jails) and categorized into terciles, with the third tercile corresponding to high structural racism. The outcome was the labor neuraxial analgesia rate. Adjusted odds ratios and 95% CIs of neuraxial analgesia associated with terciles of the index were estimated with multivariate logistic regression models. Black and White people were compared with the use of an interaction term between race and ethnicity and the racism index.

RESULTS

Of the 1,740,716 birth certificates analyzed, 396,303 (22.8%) were for Black people. The labor neuraxial analgesia rate was 77.2% for Black people in the first tercile of the racism index, 74.7% in the second tercile, and 72.4% in the third tercile. For White people, the rates were 80.4%, 78.2%, and 78.2%, respectively. For Black people, compared with the first tercile of the racism index, the second tercile was associated with 18.4% (95% CI, 16.9-19.9%) decreased adjusted odds of receiving neuraxial analgesia and the third tercile with 28.3% (95% CI, 26.9-29.6%) decreased adjusted odds. For White people, the decreases were 13.4% (95% CI, 12.5-14.4%) in the second tercile and 15.6% (95% CI, 14.7-16.5%) in the third tercile. A significant difference in the odds of neuraxial analgesia was observed between Black and White people for the second and third terciles.

CONCLUSION

A multidimensional index of structural racism is associated with significantly reduced odds of receiving labor neuraxial analgesia among Black people and, to a lesser extent, White people.

Continuity of Trust: Health Systems' Role in Advancing Health Equity Beyond the COVID-19 Pandemic

Given COVID-19's disproportionate impact on populations that identify as Black, Indigenous, and People of Color (BIPOC) in the United States, researchers and advocates have recommended that health systems and institutions deepen their engagement with community-based organizations (CBOs) with longstanding relationships with these communities. However, even as CBOs leverage their earned trust to promote COVID-19 vaccination, health systems and institutions must also address underlying causes of health inequities more broadly. In this commentary, we discuss key lessons learned about trust from our participation in the U.S. Equity-First Vaccination Initiative, an effort funded by The Rockefeller Foundation to promote COVID-19 vaccination equity. The first lesson is that trust cannot be "surged" to meet the needs of the moment until it is no longer deemed important; rather, it must predate and outlast the crisis. Second, to generate long-term change, health systems cannot simply rely on CBOs to bridge the trust gap; instead, they must directly address the root causes of this gap among BIPOC populations.

Social Determinants Among Pregnant Clients With Perinatal Depression, Anxiety, Or Serious Mental Illness

To characterize co-occurring social determinants of health for clients experiencing perinatal anxiety and depression (perinatal mood and anxiety disorders) or serious mental illness (SMI) in a diverse population receiving prenatal care in a safety-net health system, we conducted a latent class analysis, using data from a social determinants screener in pregnancy for the health system's clients during 2017-20. The sample included clients with positive screens for depression or anxiety or SMI diagnoses. Prenatal clients with a positive screen for perinatal mood and anxiety disorders or SMI comprised 13-30 percent of classes, characterized by more than two co-occurring social determinants (for example, co-occurring socioeconomic and interpersonal factors). The study findings highlight the salience of social determinants among prenatal patients experiencing perinatal mood and anxiety disorder and SMI and suggest the necessity of consistent screening for both social determinants and perinatal mental health. Policies to address social determinants within and beyond health care settings are critical.