Triple jeopardy: the joint impact of racial segregation and neighborhood poverty on the mental health of black Americans

Structural Stigma, Racism, and Sexism Studies on Substance Use and Mental Health: A Review of Measures and Designs

PURPOSE

Most research on the structural determinants of substance use and mental health has centered around widely studied factors such as alcohol taxes, tobacco control policies, essential/precursor chemical regulations, neighborhood/city characteristics, and immigration policies. Other structural determinants exist, however, many of which are being identified in the emerging fields of structural stigma, structural racism, and structural sexism. This narrative review surveys the measures and designs used in substance use and mental health studies from these three fields.

SEARCH METHODS

The PubMed, PsycINFO, and Scopus databases were searched on May 11, 2023. A focused search approach used terminology for structural racism, stigma, or sexism combined with terminology for substance use or mental health. Peer-reviewed studies were included if they were written in English and assessed associations between objective structural measures and substance use and mental health outcomes.

SEARCH RESULTS

Of 2,536 studies identified, 2,487 were excluded. Forty-nine studies (30 related to stigma, 16 related to racism, and three related to sexism) met the inclusion criteria. Information was abstracted about the structural measures, outcome measures, research design, sample, and findings of each study.

DISCUSSION AND CONCLUSIONS

The structural determinant measures used in the studies reviewed were diverse. They addressed, for example, community opinions, the gender of legislators, economic vulnerability, financial loan discrimination, college policies, law enforcement, historical trauma, and legislative protections for sexual and gender minorities and for reproductive rights. Most of the structural determinant measures were constructed by combining multiple indicators into indexes or by merging indexes into composite indexes, although some studies relied on single indicators alone. The substance use and mental health outcome measures most frequently examined were related to alcohol and depression, respectively. The studies were conducted in numerous nations and drew samples from an array of groups, including, for example, patients who experienced overdoses from substance use, sexual and gender minorities, racial and ethnic minority groups, women, youth, migrants, and patients subject to involuntary psychiatric hospitalization. Most of the studies used passive-observational (correlational) research designs and, as a result, did not assess whether their structural determinant variables were causally related to substance use and mental health. Nevertheless, the studies reviewed can be used by public health proponents to foster awareness that a wide range of structural determinants correlate with the substance use and mental health of many groups within and across nations.

Cohort profile update: the Johns Hopkins HIV clinical cohort, 1989-2023

The Johns Hopkins HIV Clinical Cohort, established in 1989, links comprehensive, longitudinal clinical data for adults with HIV receiving care in the Johns Hopkins John G. Bartlett Specialty Practice in Baltimore, Maryland, USA, to aid in understanding HIV care and treatment outcomes. Data include demographics, laboratory results, inpatient and outpatient visit information and clinical diagnoses, and prescribed and dispensed medications abstracted from medical records. A subset of patients separately consents to self-report patient-centric outcomes on standardized instruments approximately every 6 months, and another subset separately consents to contribute plasma and peripheral blood mononuclear cells to a linked specimen repository approximately annually. The cohort has cumulatively enrolled over 8000 people, with just under 2000 on average attending ≥ 1 HIV primary care visit in any given year. The cohort reflects the HIV epidemic in Baltimore: in 2021, median age was 57, 64% of participants were male, 77% were non-Hispanic Black, and 37% acquired HIV through injection drug use. This update to the cohort profile of the Johns Hopkins HIV Clinical Cohort illustrates both how the population of people with HIV in Baltimore, Maryland, USA has changed over three decades, and we have adapted data collection procedures over three decades to ensure this long-running cohort remains responsive to patient characteristics and research gaps in the provision of care to people with HIV and substance use.

Human mobility networks reveal increased segregation in large cities

A long-standing expectation is that large, dense and cosmopolitan areas support socioeconomic mixing and exposure among diverse individuals1-6. Assessing this hypothesis has been difficult because previous measures of socioeconomic mixing have relied on static residential housing data rather than real-life exposures among people at work, in places of leisure and in home neighbourhoods7,8. Here we develop a measure of exposure segregation that captures the socioeconomic diversity of these everyday encounters. Using mobile phone mobility data to represent 1.6 billion real-world exposures among 9.6 million people in the United States, we measure exposure segregation across 382 metropolitan statistical areas (MSAs) and 2,829 counties. We find that exposure segregation is 67% higher in the ten largest MSAs than in small MSAs with fewer than 100,000 residents. This means that, contrary to expectations, residents of large cosmopolitan areas have less exposure to a socioeconomically diverse range of individuals. Second, we find that the increased socioeconomic segregation in large cities arises because they offer a greater choice of differentiated spaces targeted to specific socioeconomic groups. Third, we find that this segregation-increasing effect is countered when a city's hubs (such as shopping centres) are positioned to bridge diverse neighbourhoods and therefore attract people of all socioeconomic statuses. Our findings challenge a long-standing conjecture in human geography and highlight how urban design can both prevent and facilitate encounters among diverse individuals.

Empirical evidence supporting the inclusion of multi-axes segregation in assessing US county health

To facilitate community action toward health equity, the County Health Rankings & Roadmaps program (CHR&R) assigns health rankings to US counties. The CHR&R conceptual model considers White-Black and White-non-White dissimilarity values to represent residential segregation as part of the family and social support subcomponent. As the US is greying and becoming more multi-racial-ethnic, the two-group White-centered segregation measures are inadequate to capture segregation among population subgroups in the US. Thus, we evaluate the relevancy of segregation measures that consider multiple racial, ethnic, and age groups in assessing US county health. Besides using the two-group dissimilarity index to measure White-centered racial segregation as conceptualized by CHR&R, the study also uses the multi-group generalized dissimilarity index to measure racial-ethnic-age segregation by counties, employing both aspatial and spatial versions of these measures. These indices are computed for counties using the 2015-2019 American Community Survey data at the census tract level. Descriptive statistics and regressions controlling for sociodemographic factors and healthcare access are used to assess the contributions of individual segregation measures to mortality (life expectancy, years of potential life lost and premature mortality) and morbidity (frequent mental distress, frequent physical distress, and low birth weight) indicators representing county health. Overall, correlations between these indicators and most segregation measures are significant but weak. Regression results show that many segregation measures are not significantly related to mortality indicators, but most are significantly associated with morbidity indicators, with the magnitudes of these associations higher for the multi-group racial-ethnic-age segregation index and its spatial version. Results provide evidence that racial-ethnic-age segregation is associated with county-level morbidity and that spatial measures capturing segregation of multiple population axes should be considered for ranking county health.

Perceived Neighborhood Racial Composition and Depressive Symptoms Among Black Americans Across Adulthood: Evaluating the Role of Psychosocial Risks and Resources

Objectives: To evaluate the relationships between perceived neighborhood racial composition (PNRC), psychosocial risks and resources, and depressive symptoms among young (ages 22-35), middle-aged (ages 36-49), and older (ages 50+) Black Americans. Methods: Full sample and age-stratified linear regression models estimated the PNRC-depressive symptoms association and the extent to which it persisted after accounting for psychosocial risks (i.e., neighborhood disorder, other social stressors) and resources (i.e., mastery, social support, racial identity) among 627 Black Americans in the Nashville Stress and Health Study. Results: Living in racially integrated and predominately White neighborhoods was associated with elevated depressive symptoms. While psychosocial risks and resources explained a substantial portion of these associations, patterns varied across age groups. Discussion: PNRC impacts depressive symptoms among Black Americans by shaping psychosocial risks and resources. Findings underscore interconnections between contextual and psychosocial factors, as well as the distinct mental health significance of these processes across stages of adulthood.

Institutional Racism and Health: a Framework for Conceptualization, Measurement, and Analysis

Despite growing interest in the health-related consequences of racially discriminatory institutional policies and practices, public health scholars have yet to reach a consensus on how to measure and analyze exposure to institutional racism. The purpose of this paper is to provide an overview of the conceptualization, measurement, and analysis of institutional racism in the context of quantitative research on minority health and health disparities in the United States. We begin by providing definitions of key concepts (e.g., racialization, racism, racial inequity) and describing linkages between these ideas. Next, we discuss the hypothesized mechanisms that link exposure to institutional racism with health. We then provide a framework to advance empirical research on institutional racism and health, informed by a literature review that summarizes measures and analytic approaches used in previous studies. The framework addresses six considerations: (1) policy identification, (2) population of interest, (3) exposure measurement, (4) outcome measurement, (5) study design, and (6) analytic approach. Research utilizing the proposed framework will help inform structural interventions to promote minority health and reduce racial and ethnic health disparities.

Environmental equity and COVID-19 experiences in the United States: Results from three survey waves of a nationally representative study conducted between 2020-2022

Certain environmental exposures, such as air pollution, are associated with COVID-19 incidence and mortality. To determine whether environmental context is associated with other COVID-19 experiences, we used data from the nationally representative Tufts Equity in Health, Wealth, and Civic Engagement Study data (n=1785; three survey waves 2020-2022). Environmental context was assessed using self-reported climate stress and county-level air pollution, greenness, toxic release inventory site, and heatwave data. Self-reported COVID-19 experiences included willingness to vaccinate against COVID-19, health impacts from COVID-19, receiving assistance for COVID-19, and provisioning assistance for COVID-19. Self-reported climate stress in 2020 or 2021 was associated with increased COVID-19 vaccination willingness by 2022 (odds ratio [OR] = 2.35; 95% confidence interval [CI] = 1.47, 3.76), even after adjusting for political affiliation (OR = 1.79; 95% CI = 1.09, 2.93). Self-reported climate stress in 2020 was also associated with increased likelihood of receiving COVID-19 assistance by 2021 (OR = 1.89; 95% CI = 1.29, 2.78). County-level exposures (i.e., less greenness, more toxic release inventory sites, more heatwaves) were associated with increased vaccination willingness. Air pollution exposure in 2020 was positively associated with likelihood of provisioning COVID-19 assistance in 2020 (OR = 1.16 per μg/m3; 95% CI = 1.02, 1.32). Associations between certain environmental exposures and certain COVID-19 outcomes were stronger among those who identify as a race/ethnicity other than non-Hispanic White and among those who reported experiencing discrimination; however, these trends were not consistent. A latent variable representing a summary construct for environmental context was associated with COVID-19 vaccination willingness. Our results add to the growing body of literature suggesting that intersectional equity issues affecting likelihood of exposure to adverse environmental conditions are also associated with health-related outcomes.

Mental health of ethnic minorities: the role of racism

Racism and racial discrimination heavily impact on health and mental health of ethnic minorities. In this conceptual paper and narrative review, we aim to report on relevant evidence from the international literature describing the prevalence and the qualitative aspects of mental illness due to racism and ethnic- discrimination in different settings and populations. Some variables related to racism, such as cultural, institutional, interpersonal factors, as well as the concepts of perceived and internalised racism will be described and discussed. These are relevant characteristics in the explanatory model of the relationship between racism and mental health. Epidemiological data on the prevalence of depressive and psychotic symptoms as well as substance abuse/misuse among ethnic minorities in large catchment areas, such as United States and United Kingdom, will be represented. We conclude that anti-racism policies are essential in order to address racism and racial discrimination around the world. Pluralistic societies should be promoted in order to understand mental illnesses among ethnic and cultural minorities. Also, anti-racism programs should be delivered in the educational and health-care settings and their impact evaluated.

Gender Disparities Between Neighborhood Social Vulnerability and Psychological Distress Among Patients with Heart Disease

Background: Psychological stress disorders are twice as prevalent in women with ischemic heart disease compared to men. The disproportionate psychological health experience of these women is not well understood. The objective of this study was to examine whether neighborhood social factors are associated with disparities in psychological health by gender. Materials and Methods: We studied 286 patients with heart disease recruited from Emory-based hospitals in the Myocardial Infarction and Mental Stress 2 Study (n = 286). A global measure of psychological distress was calculated by taking an average of ranks across symptom scales for depression, post-traumatic stress disorder, anxiety, anger, and perceived stress. The social vulnerability index (SVI) was developed by the Centers for Disease Control and Prevention and was used to rank patients' census tracks on 14 social factors. Beta coefficients for mean ranks in psychological distress scores were estimated per 10-unit increase in SVI percentile ranking using multilevel regression models. Results: The mean age of the sample was 51 years, 49% were women, and 66% African American. After adjusting for demographics, cardiovascular risk factors, and antidepressant use, each 10-unit increase in SVI percentile ranking was associated with 4.65 (95% CI: 0.61-8.69; p = 0.02) unit increase in mean scores for psychological distress among women only (SVI-by-gender-interaction = 0.01). These associations were driven by the SVI themes of lower socioeconomic status and poorer access to housing and transportation. Conclusion: Neighborhood social vulnerability may be a psychosocial stressor that potentiates women's susceptibility to adverse psychological and cardiovascular health.

Neighborhood social cohesion and serious psychological distress among Asian, Black, Hispanic/Latinx, and White adults in the United States: a cross-sectional study

BACKGROUND

Serious psychological distress (SPD) is common and more prevalent in women, older adults, and individuals with a low-income. Prior studies have highlighted the role of low neighborhood social cohesion (nSC) in potentially contributing to SPD; however, few have investigated this association in a large, nationally representative sample of the United States. Therefore, our objective was to investigate the overall and racial/ethnic-, sex/gender-, self-rated health status-, age-, and household income-specific relationships between nSC and SPD.

METHODS

We used data from survey years 2013 to 2018 of the National Health Interview Survey to investigate nSC and SPD among Asian, Non-Hispanic (NH)-Black, Hispanic/Latinx, and NH-White men as well as women in the United States (N = 168,573) and to determine modification by race/ethnicity, sex/gender, self-rated health status, age, and annual household income. nSC was measured by asking participants four questions related to the trustworthiness and dependability of their neighbors. nSC scores were trichotomized into low (< 12), medium (12-14), and high (15-16). SPD was measured using the Kessler 6 psychological distress scale with scores ≥ 13 indicating SPD. After adjusting for sociodemographic, health behavior, and clinical confounders, we used Poisson regression with robust variance to estimate prevalence ratios (PRs) and 95% confidence intervals (CIs).

RESULTS

Among 168,573 participants, most were Non-Hispanic (NH)-White (69%), and mean age was 47 ± 0.01 years. After adjustment, low vs. high nSC was associated with a 75% higher prevalence of SPD overall (PR = 1.75 [1.59-1.92]), 4 times the prevalence of SPD among Asian men (PR = 4.06 [1.57-10.50]), 2 times the prevalence of SPD among participants in at least good health (PR = 2.02 [95% CI: 1.74-2.35]), 92% higher prevalence of SPD among participants ≥ 50 years old (PR = 1.92 [1.70-2.18]), and approximately 3 times the prevalence of SPD among Hispanic/Latinx participants with household incomes ≥ $75,000 (PR = 2.97 [1.45-6.08]).

CONCLUSIONS

Low nSC was associated with higher SPD in the overall population and the magnitude of the association was higher in Asian men, participants who reported good health, older participants, and Hispanic/Latinx adults with higher household incomes. Future research should continue to examine how neighborhood contexts can affect health across various sociodemographic groups, especially among groups with multiple marginalized social identities.

Structural Racism and Inequities in Incidence, Course of Illness, and Treatment of Psychotic Disorders Among Black Americans

Psychotic disorders (e.g., schizophrenia, schizoaffective disorder) are a leading cause of morbidity and premature mortality and an overlooked health inequity in the United States. European data indicate inequities in incidence, severity, and treatment of psychotic disorders, particularly for Black communities, that appear to be primarily attributable to social adversities. The dominant US narrative is that any observed differences are primarily a result of clinician bias and misdiagnosis. We propose that employing the framework of structural racism will prompt European and US research to converge and consider the multifaceted drivers of inequities in psychotic disorders among Black Americans. In particular, we describe how historical and contemporary practices of (1) racialized policing and incarceration, and (2) economic exploitation and disinvestment, which are already linked to other psychiatric disorders, likely contribute to risks and experiences of psychotic disorders among Black Americans. This framework can inform new strategies to (1) document the role of racism in the incidence, severity, and treatment of psychotic disorders; and (2) dismantle how racism operates in the United States, including defunding the police, abolishing carceral systems, and redirecting funds to invest in neighborhoods, housing, and community-based crisis response and mental health care. (Am J Public Health. 2022;112(4):624-632. https://doi.org/10.2105/AJPH.2021.306631).

Complicating Narratives of Sexual Minority Mental Health: An Intersectional Analysis of Frequent Mental Distress at the Intersection of Sexual Orientation, Gender Identity, and Race/Ethnicity

Purpose: Research indicates that sexual minority populations experience mental health inequities. However, few studies have examined mental health outcomes in sexual minority populations while including intersecting dimensions of social identity. This study had two objectives: (1) to quantify the prevalence of frequent mental distress among U.S. adults across intersecting social identity categories and (2) to evaluate the contribution of intersectional interactions to observed inequities. Methods: Using data from the Behavioral Risk Factor Surveillance System 2014-2019 (N = 1,024,261), we performed an intersectional multilevel analysis of individual heterogeneity and discriminatory accuracy (I-MAIHDA). Participants were nested in 45 intersectional groups defined by combining 3 sexual orientation (gay/lesbian, bisexual, and heterosexual), 5 gender identity (transgender women, transgender men, gender nonconforming, cisgender women, and cisgender men), and 3 racial/ethnic (non-Hispanic Black, Hispanic/Latinx, and non-Hispanic White) categories. We estimated the predicted probability of frequent mental distress for each stratum. We then calculated the variance partition coefficient (VPC) and proportional change in variance (PCV). Results: We found that multiply marginalized groups tended to have the highest prevalence of frequent mental distress. Groups with racial/ethnic minority individuals were equally represented among low- and high-prevalence groups. The VPC indicated that slightly over 10% of observed variance in prevalence was attributable to group-level differences, while the PCV revealed that a small but meaningful amount of observed heterogeneity in prevalence was due to intersectional interactions between the dimensions of social identity. Conclusion: I-MAIHDA is a promising method for examining the patterning of sexual orientation-based mental health inequities at the population level.

Community ethnic density, ethnic segregation, and ethnic minorities' common mental disorders in the UK

Studies in the UK demonstrate evidence that ethnic minorities living in communities with a higher proportion of co-ethnics report better mental health: co-ethnic density effects. This paper aims to address three gaps in this literature. Firstly, most UK research has focused on acute mental disorders (e.g., psychosis), with little work examining co-ethnic density effects for more common mental disorders. Secondly, there is a paucity of research exploring the role that residential segregation may play alongside co-ethnic density in minority mental health. Thirdly, little systematic testing has examined at what geographic-scale co-ethnic density effects are most salient for minority-group mental health. To address these potential gaps, we apply multi-level linear regression modelling to a large-scale, nationally-representative UK panel dataset, containing an ethnic minority booster-sample, to study the community-level drivers of mental health-related quality-of-life (SF-12 Mental Component Summary Score). The results demonstrate mixed support for the protective-effects of co-ethnic density on mental well-being. However, they demonstrate broadly consistent support for the impact of residential segregation on mental well-being. In particular, that segregation exerts a non-linear effect: mental well-being is at its most positive at medium-levels of segregation, somewhat more negative at low-levels of segregation, and much more negative at higher-levels of segregation. These patterns are present for the 'all ethnic minority' sample, and stronger for Black sub-groups compared to Asian sub-groups. These relationships appear most consistent at meso-local geographic scales (Middle Super Output Areas). These findings have important implications for theorising our understanding of the nexus between the community and mental health among minority-groups.

Pathways linking census tract typologies with subjective neighborhood disorder and depressive symptoms in the Black Women's Experiences Living with Lupus (BeWELL) Study

Depression is a common comorbidity among Black women with systemic lupus erythematosus (SLE), an understudied autoimmune disease characterized by major racial and gender inequities. Research is needed that examines how area-level factors influence risk of depression in this population. Latent profile analysis revealed four neighborhood typologies among metropolitan Atlanta, Georgia census tracts that participants (n=438) in the Black Women's Experiences Living with Lupus (BeWELL) Study were living in: Integrated/High-SES, Moderately Segregated/Mid-SES, Highly Segregated/Mid-SES, and Highly Segregated/Low-SES. Structural equation models indicated that highly segregated census tracts were associated with the greatest levels of depression via increased subjective assessments of neighborhood disorder. Policies that invest in segregated areas and address physical and social aspects of the environment that contribute to neighborhood disorder may promote mental health among Black women with SLE.

Race/ethnicity, neighborhood socioeconomic status and cardio-metabolic risk

Objective

To determine the association between neighborhood socioeconomic status (NSES) and cardio-metabolic risk and whether this relationship differs by race/ethnicity.

Methods

Participants in the Multi-Ethnic Study of Atherosclerosis (n = 5750), ages 45–84 years, from 6 US counties, including 5 examinations from 2000 to 2012. We calculated a modified allostatic load (AL) index, indicating cardio-metabolic risk. NSES score included census-derived measures at census tract of residence. Mixed effects growth curve models were used to assess linear and non-linear associations between NSES and AL at baseline and over time.

Results

Higher NSES was associated with lower AL across race/ethnic groups; considering NSES quintiles, significant associations were found only for the highest NSES quintiles (difference of -0.86 and -1.15 for white and Hispanic participants) vs. the lowest. We found no significant association between NSES and change in AL over time.

Discussion

Our findings suggest that the relationship between NSES and AL reflects the health benefits of living in the most advantaged neighborhoods.

Public health implications

Understanding the impact of higher NSES on health effects may help identify interventions to effectively target high risk neighborhoods.

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These findings confirm the association between high NSES and low AL; pattern is similar across race/ethnic groups.

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The relationship between NSES and AL reflects the health benefits of living in the most advantaged neighborhoods.

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Identifying neighborhood factors that impact health is crucial to effectively target high risk neighborhoods.