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Evans E, Jacobs M. Diabetes and Financial Well-Being: Differential Hardship Among Vulnerable Populations. Sci Diabetes Self Manag Care 2024:26350106241256324. [PMID: 38853573 DOI: 10.1177/26350106241256324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/11/2024]
Abstract
PURPOSE The purpose of the study was to examine financial well-being among a diverse population of individuals with and without diabetes. METHODS Data from the Understanding America Survey, a nationally representative, longitudinal panel, were utilized to identify adults with self-reported diabetes diagnoses between 2014 and 2020. We used longitudinal mixed effects regression models to assess the association between diabetes and financial well-being score (FWBS) among racial and ethnic population subgroups. Models included sex, age, marital status, household size, income, education, race/ethnicity, insurance, body mass index, employment, and health insurance, incorporating individual- and household-level fixed effects. Racial and ethnic differentials were captured using group-condition interactions. RESULTS Black participants (17.06%) had the highest prevalence of diabetes, followed by White participants (12.2%), "other" racial groups (10.7%), and Hispanic participants (10.0%). In contrast, White participants (M = 67.66, SD = 22.63) and other racial groups (M = 67.99, SD = 18.45) had the highest FWBSs, followed by Hispanic participants (M = 59.31, SD = 22.78) and Black participants (M = 55.86, SD = 25.67). Compared to White participants, Black participants (β = -5.49, SE = 0.71) and Hispanic participants (β = -2.06, SE = 0.63) have significantly lower FWBSs. Compared to males, females (β = -3.25, SE = 0.41) had lower FWBSs among individuals with diabetes. FWBSs of individuals with diabetes was 2.71 points lower (SE = 0.52), on average, than those without diabetes. Education, household size, age, marital status, and income were also significantly associated with FWBSs. CONCLUSIONS Findings suggest potential disparities in the financial ramifications of diabetes among socially marginalized populations.
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Affiliation(s)
- Elizabeth Evans
- Communication Equity and Outcomes Laboratory, Department of Speech, Language and Hearing Sciences, College of Public Health and Health Professions, University of Florida, Gainesville, Florida
| | - Molly Jacobs
- Department of Health Services Research, Management and Policy, College of Public Health and Health Professions, University of Florida, Gainesville, Florida
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2
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Eliason EL, Agostino J, MacDougall H. Social Determinants and Perinatal Hardships During the COVID-19 Pandemic. J Womens Health (Larchmt) 2024; 33:371-378. [PMID: 38011003 PMCID: PMC10924118 DOI: 10.1089/jwh.2023.0290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2023] Open
Abstract
Background: This study examined perinatal experiences of pandemic-related hardships and disparities by race/ethnicity, income, insurance type at childbirth, and urban/rural residency. Materials and Methods: We used cross-sectional survey data from the 2020 Pregnancy Risk Assessment Monitoring System COVID-19 supplement in 26 states, the District of Columbia, and New York City to explore: (1) job loss or cut work hours/pay, (2) having to move/relocate or becoming homeless, (3) problems paying the rent, mortgage, or bills, or (4) worries that food would run out. We estimated the prevalence of outcomes overall and by race/ethnicity, income, insurance, and urban/rural residency. We used weighted multivariable logistic regression models to calculate adjusted predicted probabilities. Results: Due to the COVID-19 pandemic, 31.9% of respondents reported losing their job or having a cut in work hours or pay, 11.2% of respondents had to move/relocate or became homeless, 21.8% had problems paying the rent, mortgage, or bills, and 16.86% reported worries that food would run out. Compared to overall, rates of all hardships were higher among respondents who were non-Hispanic Black, Hispanic, uninsured, or Medicaid insured. The adjusted predicted probability of employment instability, financial hardships, and food insecurity was significantly higher among non-Hispanic Black respondents and respondents who were uninsured. The adjusted predicted probability of all hardships was significantly higher among respondents with Medicaid. Conclusions: Black, Medicaid-insured, and uninsured respondents were particularly vulnerable to perinatal hardships during COVID-19. Our results suggest a need to alleviate the overall and disparate consequences of hardships for individuals who gave birth during the COVID-19 pandemic.
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Affiliation(s)
- Erica L. Eliason
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Jasmine Agostino
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Hannah MacDougall
- School of Social Work, University of Minnesota, Minneapolis, Minnesota, USA
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3
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Scott KA, Elliott KC, Lincoln J, Flynn MA, Hill R, Hall DM. Rural health and rural industries: Opportunities for partnership and action. J Rural Health 2024; 40:401-405. [PMID: 37669228 PMCID: PMC10912364 DOI: 10.1111/jrh.12791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 08/18/2023] [Accepted: 08/20/2023] [Indexed: 09/07/2023]
Affiliation(s)
- Kenneth A. Scott
- National Institute for Occupational Safety and Health, Denver, Colorado, USA
| | - K. C. Elliott
- National Institute for Occupational Safety and Health, Anchorage, Alaska, USA
| | - Jennifer Lincoln
- National Institute for Occupational Safety and Health, Cincinnati, Ohio, USA
| | - Michael A. Flynn
- National Institute for Occupational Safety and Health, Cincinnati, Ohio, USA
| | - Ryan Hill
- National Institute for Occupational Safety and Health, Spokane, Washington, USA
| | - Diane M. Hall
- Office of Rural Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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Silver SR, Sweeney MH, Sanderson WT, Pana-Cryan R, Steege AL, Quay B, Carreón T, Flynn MA. Assessing the role of social determinants of health in health disparities: The need for data on work. Am J Ind Med 2024; 67:129-142. [PMID: 38103002 PMCID: PMC10842318 DOI: 10.1002/ajim.23557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 11/15/2023] [Accepted: 11/30/2023] [Indexed: 12/17/2023]
Abstract
BACKGROUND Work is a key social determinant of health. Without the collection of work-related information in public health data systems, the role of social determinants in creating and reinforcing health disparities cannot be fully assessed. METHODS The Centers for Disease Control and Prevention (CDC) maintains or supports a number of public health surveillance and health monitoring systems, including surveys, case-based disease and exposure systems, vital status records, and administrative data systems. We evaluated a convenience sample of these systems for inclusion of information in three work-related domains: employment status, industry and occupation, and working conditions. RESULTS While 12 of 39 data systems were identified as collecting work-related data, this information was often minimal (e.g., only employment status), restricted to a subset of respondents, or only gathered periodically. Information on working conditions was particularly sparse. CONCLUSION Historically, the limited and inconsistent collection of work-related information in public health data systems has hindered understanding of the role work plays in health disparities. Current CDC data modernization efforts present opportunities to enhance the identification and mitigation of health disparities by prioritizing inclusion of an expanded set of work-related data elements.
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Affiliation(s)
- Sharon R Silver
- Division of Field Studies and Engineering, National Institute for Occupational Safety and Health, Health Informatics Branch, Cincinnati, Ohio, USA
| | - Marie H Sweeney
- Division of Field Studies and Engineering, National Institute for Occupational Safety and Health, Health Informatics Branch, Cincinnati, Ohio, USA
| | - Wayne T Sanderson
- Department of Biosystems and Agricultural Engineering, Southeast Center for Agricultural Health and Injury Prevention, Central Appalachian Regional Education Research Center, College of Agriculture Food and Environment, University of Kentucky, Lexington, Kentucky, USA
| | - Regina Pana-Cryan
- National Institute for Occupational Safety and Health, Economic Research and Support Office, Washington, District of Columbia, USA
| | - Andrea L Steege
- Division of Field Studies and Engineering, National Institute for Occupational Safety and Health, Health Informatics Branch, Cincinnati, Ohio, USA
| | - Brian Quay
- National Institutes of Health (work performed at NIOSH), Bethesda, MD, USA
| | - Tania Carreón
- World Trade Center Health Program, National Institute for Occupational Safety and Health, Cincinnati, Ohio, USA
| | - Michael A Flynn
- Division of Science Integration, National Institute for Occupational Safety and Health, Cincinnati, Ohio, USA
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Seidu AA, Malau-Aduli BS, McBain-Rigg K, Malau-Aduli AEO, Emeto TI. A mixed-methods study of the awareness and functionality of sexual and reproductive health services among persons with disability in Ghana. Reprod Health 2023; 20:162. [PMID: 37907933 PMCID: PMC10619320 DOI: 10.1186/s12978-023-01700-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 10/13/2023] [Indexed: 11/02/2023] Open
Abstract
BACKGROUND Persons with disabilities (PwDs) face barriers in accessing sexual and reproductive health (SRH) services due to lack of knowledge and awareness, stigma and discrimination, and inadequate service provision. This study aimed to examine the determinants of SRH knowledge and awareness among PwDs in Ghana, and to explore their perceptions of the functionality of SRH services. METHODS A sequential explanatory mixed-methods study design was used to collect and analyse quantitative (n = 402) and qualitative (n = 37) data from PwDs in two districts in Ghana. Quantitative data were analysed using descriptive and inferential statistics, while qualitative data was analysed thematically. RESULTS Most of the participants had high awareness of SRH (94.3%), sexually transmitted infections (STIs) (92.5%) and HIV/AIDS (97.0%). Employment status was positively associated with SRH awareness [aOR = 1.62; 95% CI = 1.02, 2.59]. Disability type was a significant predictor of STI [aOR = 2.02; 95% CI = 1.39, 2.94] and HIV/AIDS [aOR = 2.32; 95% CI = 1.21, 4.44] awareness, with the visually impaired having higher odds than the physically disabled. Age group was also a significant predictor of STI awareness, with older respondents having higher odds than younger ones [aOR = 1.76; CI = 1.01,3.05 for 30-39 years; aOR = 2.48; CI = 1.22, 5.05 for 40-49 years]. The qualitative findings revealed four main themes: conceptualisation of SRH, active engagement in SRH information seeking, tensions between knowledge and religious beliefs and perceived utility of SRH services. CONCLUSION Despite the high levels of SRH knowledge and awareness among PwDs, there are significant gaps and challenges related to disability type, age group, misconceptions, beliefs, and service non-functionality that limit the utility of SRH services. The findings call for tailored education to reduce misconceptions and put in pragmatic steps to deliver quality SRH services and information to PwDs. Further research is needed to assess the sexual lives of PwDs and explore the perspectives of all relevant stakeholders, including service providers and policymakers on how to enhance SRH outcomes for PwDs in Ghana.
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Affiliation(s)
- Abdul-Aziz Seidu
- Public Health and Tropical Medicine, College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, QLD, 4811, Australia.
- Department of Population and Health, University of Cape Coast, P.O. Box UC 182, Cape Coast, Ghana.
| | - Bunmi S Malau-Aduli
- College of Medicine and Dentistry, James Cook University, Townsville, QLD, 4811, Australia
- School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, 2308, Australia
| | - Kristin McBain-Rigg
- Public Health and Tropical Medicine, College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, QLD, 4811, Australia
| | - Aduli E O Malau-Aduli
- School of Environmental and Life Sciences, The University of Newcastle, Newcastle, NSW, 2308, Australia
| | - Theophilus I Emeto
- Public Health and Tropical Medicine, College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, QLD, 4811, Australia.
- World Health Organization Collaborating Center for Vector-Borne and Neglected Tropical Diseases, James Cook University, Townsville, QLD, 4811, Australia.
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Rinne H, Blomgren J. Use of outpatient healthcare services before and after the onset of unemployment: A register-based propensity score matched study from Finland. PLoS One 2023; 18:e0288423. [PMID: 37556479 PMCID: PMC10411812 DOI: 10.1371/journal.pone.0288423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 06/27/2023] [Indexed: 08/11/2023] Open
Abstract
AIMS The aim was to examine the use of outpatient healthcare services in different sectors of healthcare before and after the onset of unemployment and to study whether job loss affected the use of these services. METHODS Longitudinal individual-level register-based data was utilized on all individuals living in the City of Oulu, Finland, who became unemployed in 2017 (N = 1,999), their propensity matched controls (N = 1,999), and unmatched controls (N = 58,459) in a quasi-experimental design. Use of outpatient healthcare services was examined in one-month periods from 12 months before to 12 months after the onset of unemployment. Several socio-demographic factors, along with sickness and employment histories, were used for matching. Difference-in-differences analysis was used to measure the differences in the use of outpatient healthcare services between the unemployed and their matched controls. RESULTS The use of health services decreased significantly after the onset of unemployment. This was due to a decrease in the use of occupational health services. No change related to job loss was observed in the use of public or private healthcare services. The number of healthcare visits increased again after the unemployment ended. Difference-in-differences analyses showed that compared to propensity score matched controls, becoming unemployed reduced the use of health services. CONCLUSIONS When access to occupational healthcare services ceases, other health services do not appear to fill the gap among those who become unemployed. Adequate healthcare services should be guaranteed to all population groups equally based on need, irrespective of the labour market status.
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Affiliation(s)
- Hanna Rinne
- The Social Insurance Institution of Finland, Helsinki, Finland
| | - Jenni Blomgren
- The Social Insurance Institution of Finland, Helsinki, Finland
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Dean CA, Liu E, Enard KR, Qian Z, Elder KT. Factors associated with food insecurity among the chronically ill population during the COVID-19 pandemic in the United States. Front Public Health 2023; 11:1142603. [PMID: 37483922 PMCID: PMC10360174 DOI: 10.3389/fpubh.2023.1142603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 06/16/2023] [Indexed: 07/25/2023] Open
Abstract
Introduction Little is known about food insecurity among Americans with chronic diseases, one of the vulnerable groups in health care. Factors influencing food insecurity among this population group are especially poorly understood. Methods Using data from the COVID Impact Survey, this cross-sectional study sought to examine food insecurity among adults with chronic diseases in the United States and to identify factors associated with their risks for food insecurity during the COVID-19 pandemic. Results Nearly 28% of the national and 32% of the regional samples from the COVID Impact Survey were at risk for food insecurity. The logistic regressions show that chronically ill US adults with one of the following characteristics have higher odds of being at risk for food insecurity: younger than 60 years, having financial stress, unemployed, having received food from a food pantry, without health insurance, having a household income lower than $100,000, and without a college degree. Discussion Targeted policies and programs are warranted to address underlying determinants of food insecurity that adults with chronic illnesses experience.
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Affiliation(s)
- Caress A. Dean
- School of Health Sciences, Oakland University, Rochester, MI, United States
| | - Echu Liu
- Department of Health Management and Policy, College for Public Health and Social Justice, Saint Louis University, Saint Louis, MO, United States
| | - Kimberly R. Enard
- Department of Health Management and Policy, College for Public Health and Social Justice, Saint Louis University, Saint Louis, MO, United States
| | - Zhengmin Qian
- Department of Epidemiology and Biostatistics, College for Public Health and Social Justice, Saint Louis University, Saint Louis, MO, United States
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Asfaw A. Association between reasons for not working and reporting of major depression and anxiety symptoms among U.S. adult population during the COVID-19 pandemic. JOURNAL OF WORKPLACE BEHAVIORAL HEALTH 2023; 38:293-320. [PMID: 37608841 PMCID: PMC10440807 DOI: 10.1080/15555240.2023.2181178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 02/05/2023] [Indexed: 02/27/2023]
Abstract
COVID-19 continues to take a large toll on the mental health of the not working population, particularly of those who were unable to work. This study, using the Household Pulse Survey, estimated the association between reasons for not working and major depression and anxiety symptoms (MDAS). The lowest MDAS was reported by retirees. Individuals who were unable to work because of transportation problems, layoffs, COVID-19 concerns, and sickness or disability reported the highest MDAS. Mediation analysis showed that the direct and indirect effects of reasons for not working were much higher for those individuals who were unable to work than for individuals who were working or decided not to work.
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Affiliation(s)
- Abay Asfaw
- Centers for Disease Control and Prevention (CDC), National Institute for Occupational Safety and Health (NIOSH), Washington, DC, USA
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Schulte PA, Delclos GL, Felknor SA, Streit JMK, McDaniel M, Chosewood LC, Newman LS, Bhojani FA, Pana-Cryan R, Swanson NG. Expanding the Focus of Occupational Safety and Health: Lessons from a Series of Linked Scientific Meetings. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:15381. [PMID: 36430096 PMCID: PMC9690540 DOI: 10.3390/ijerph192215381] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 11/14/2022] [Accepted: 11/16/2022] [Indexed: 06/16/2023]
Abstract
There is widespread recognition that the world of work is changing, and agreement is growing that the occupational safety and health (OSH) field must change to contribute to the protection of workers now and in the future. Discourse on the evolution of OSH has been active for many decades, but formalized support of an expanded focus for OSH has greatly increased over the past 20 years. Development of approaches such as the National Institute for Occupational Safety and Health (NIOSH)'s Total Worker Health® concept and the World Health Organization (WHO)'s Healthy Workplace Framework are concrete examples of how OSH can incorporate a new focus with a wider view. In 2019, NIOSH initiated a multi-year effort to explore an expanded focus for OSH. This paper is a report on the outputs of a three-year cooperative agreement between NIOSH and The University of Texas School of Public Health, which led to subject matter expert workshops in 2020 and an international conference of global interest groups in 2021. This article traces the background of these meetings and identifies and assesses the lessons learned. It also reviews ten thematic topics that emerged from the meetings: worker health inequalities; training new OSH professionals; future OSH research and practice; tools to measure well-being of workers; psychosocial hazards and adverse mental health effects; skilling, upskilling and improving job quality; socioeconomic influences; climate change; COVID-19 pandemic influences; and strategic foresight. Cross-cutting these themes is the need for systems and transdisciplinary thinking and operationalization of the concept of well-being to prepare the OSH field for the work of the future.
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Affiliation(s)
- Paul A. Schulte
- Advanced Technologies and Laboratories International, Inc., Gaithersburg, MD 20878, USA
| | - George L. Delclos
- Southwest Center for Occupational and Environmental Health, The University of Texas Health Science Center at Houston School of Public Health, Houston, TX 77030, USA
| | - Sarah A. Felknor
- National Institute for Occupational Safety and Health, Atlanta, GA 30333, USA
| | - Jessica M. K. Streit
- National Institute for Occupational Safety and Health, Cincinnati, OH 45226, USA
| | - Michelle McDaniel
- Southwest Center for Occupational and Environmental Health, The University of Texas Health Science Center at Houston School of Public Health, Houston, TX 77030, USA
| | - L. Casey Chosewood
- National Institute for Occupational Safety and Health, Atlanta, GA 30333, USA
| | - Lee S. Newman
- Center for Health, Work & Environment and Department of Environmental and Occupational Health, Colorado School of Public Health, CU Anschutz, University of Colorado, Aurora, CO 80045, USA
| | | | - Rene Pana-Cryan
- National Institute for Occupational Safety and Health, Washington, DC 20024, USA
| | - Naomi G. Swanson
- National Institute for Occupational Safety and Health, Cincinnati, OH 45226, USA
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Qiu Y, Liao K, Zou Y, Huang G. A Bibliometric Analysis on Research Regarding Residential Segregation and Health Based on CiteSpace. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:10069. [PMID: 36011701 PMCID: PMC9408714 DOI: 10.3390/ijerph191610069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 08/10/2022] [Accepted: 08/12/2022] [Indexed: 06/15/2023]
Abstract
Considerable scholarly attention has been directed to the adverse health effects caused by residential segregation. We aimed to visualize the state-of-the-art residential segregation and health research to provide a reference for follow-up studies. Employing the CiteSpace software, we uncovered popular themes, research hotspots, and frontiers based on an analysis of 1211 English-language publications, including articles and reviews retrieved from the Web of Science Core Collection database from 1998 to 2022. The results revealed: (1) The Social Science & Medicine journal has published the most studies. Roland J. Thorpe, Thomas A. LaVeist, Darrell J. Gaskin, David R. Williams, and others are the leading scholars in residential segregation and health research. The University of Michigan, Columbia University, Harvard University, the Johns Hopkins School of Public Health, and the University of North Carolina play the most important role in current research. The U.S. is the main publishing country with significant academic influence. (2) Structural racism, COVID-19, mortality, multilevel modelling, and environmental justice are the top five topic clusters. (3) The research frontier of residential segregation and health has significantly shifted from focusing on community, poverty, infant mortality, and social class to residential environmental exposure, structural racism, and health care. We recommend strengthening comparative research on the health-related effects of residential segregation on minority groups in different socio-economic and cultural contexts.
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Affiliation(s)
- Yanrong Qiu
- School of Architecture and Urban Planning, Guangdong University of Technology, Guangzhou 510060, China
| | - Kaihuai Liao
- School of Architecture and Urban Planning, Guangdong University of Technology, Guangzhou 510060, China
| | - Yanting Zou
- School of Architecture and Urban Planning, Guangdong University of Technology, Guangzhou 510060, China
| | - Gengzhi Huang
- School of Geography and Planning, Sun Yat-sen University, Guangzhou 510275, China
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Silver SR, Li J, Quay B. Visual representation of work as a social determinant of health: Augmenting Silver et al., Employment status, unemployment duration, and health-related metrics among US adults of prime working age. Am J Ind Med 2022; 65:697-698. [PMID: 35612358 PMCID: PMC9283259 DOI: 10.1002/ajim.23398] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 05/10/2022] [Accepted: 05/11/2022] [Indexed: 11/08/2022]
Affiliation(s)
- Sharon R. Silver
- Division of Field Studies and Engineering National Institute for Occupational Safety and Health Cincinnati Ohio USA
| | - Jia Li
- Division of Field Studies and Engineering National Institute for Occupational Safety and Health Cincinnati Ohio USA
| | - Brian Quay
- Economic Research and Support Office National Institute for Occupational Safety and Health Cincinnati Ohio USA
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