Structural Racism and COVID-19 in the USA: a County-Level Empirical Analysis

Instruments for racial health equity: a scoping review of structural racism measurement, 2019-2021

Progress toward racial health equity cannot be made if we cannot measure its fundamental driver: structural racism. As in other epidemiologic studies, the first step is to measure the exposure. But how to measure structural racism is an ongoing debate. To characterize the approaches epidemiologists and other health researchers use to quantitatively measure structural racism, highlight methodological innovations, and identify gaps in the literature, we conducted a scoping review of the peer-reviewed and gray literature published during 2019-2021 to accompany the 2018 published work of Groos et al., in which they surveyed the scope of structural racism measurement up to 2017. We identified several themes from the recent literature: the current predominant focus on measuring anti-Black racism; using residential segregation as well as other segregation-driven measures as proxies of structural racism; measuring structural racism as spatial exposures; increasing calls by epidemiologists and other health researchers to measure structural racism as a multidimensional, multilevel determinant of health and related innovations; the development of policy databases; the utility of simulated counterfactual approaches in the understanding of how structural racism drives racial health inequities; and the lack of measures of antiracism and limited work on later life effects. Our findings sketch out several steps to improve the science related to structural racism measurements, which is key to advancing antiracism policies.

Disparities in Rates of Death From HIV or Tuberculosis Before Age 65 Years, by Race, Ethnicity, and Sex, United States, 2011-2020

OBJECTIVE

Death from tuberculosis or HIV among people from racial and ethnic minority groups who are aged <65 years is a public health concern. We describe age-adjusted, absolute, and relative death rates from HIV or tuberculosis from 2011 through 2020 by sex, race, and ethnicity among US residents.

METHODS

We used mortality data from the Centers for Disease Control and Prevention online data system on deaths from multiple causes from 2011 through 2020 to calculate age-adjusted death rates and absolute and relative disparities in rates of death by sex, race, and ethnicity. We calculated corresponding 95% CIs for all rates and determined significance at P < .05 by using z tests.

RESULTS

For tuberculosis, when compared with non-Hispanic White residents, non-Hispanic American Indian or Alaska Native residents had the highest level of disparity in rate of death (666.7%). Similarly, as compared with non-Hispanic White female residents, American Indian or Alaska Native female residents had a high relative disparity in death from tuberculosis (620.0%). For HIV, the age-adjusted death rate was more than 8 times higher among non-Hispanic Black residents than among non-Hispanic White residents, and the relative disparity was 735.1%. When compared with non-Hispanic White female residents, Black female residents had a high relative disparity in death from HIV (1529.2%).

CONCLUSION

Large disparities in rates of death from tuberculosis or HIV among US residents aged <65 years based on sex, race, and ethnicity indicate an ongoing unmet need for effective interventions. Intervention strategies are needed to address disparities in rates of death and infection among racial and ethnic minority populations.

Social-Economic Backgrounds to US County-Based COVID-19 Deaths: PLS-SEM Analysis

A complex interplay of social, economic, and environmental factors drove the COVID-19 epidemic. Understanding these factors is crucial in explaining the racial disparities observed in COVID-19 deaths. This research investigated various hypotheses, including ecological, racial, demographic, economic, and political party factors, to determine their impact on COVID-19 deaths. The study utilized data from the National Center for Health Statistics (NCHS), specifically focusing on COVID-19 deaths categorized by race and Hispanic origin in US counties, with over 100 recorded deaths as of July 11, 2022.

METHOD

To analyze the data, the study employed partial least squares (PLS) as the statistical approach, considering the presence of multicollinearity in the county-level socioeconomic data. SmartPLS4 software was utilized to illustrate paths depicting variance and covariance and to conduct significance tests. The analysis encompassed overall COVID-19 deaths and deaths among White, Black, and Hispanic Americans, utilizing the same latent variables and paths.

RESULTS

The results revealed that the number of residents aged 65 years or older in a county was the most influential predictor of COVID-19 deaths, irrespective of race. Economic factors emerged as the second strongest predictors. However, when considering each racial group separately, distinct factors aligned with the five hypotheses emerged as significant contributors to COVID-19 deaths. Furthermore, the diagrams illustrating the relationships between these factors (covariates) varied among racial groups, indicating that the underlying social influences differed across races.

DISCUSSION

In light of these findings, it becomes evident that a "one-size-fits-all" approach to prevention strategies is suboptimal. Instead, targeted prevention efforts tailored to specific racial and social classes at high risk of COVID-19 death could have provided more precise messaging and necessitate direct engagement.

"Now You Get to See Me": Black Women Healthcare Professionals' Experiences in Sister Circles During the Double Pandemic

In 2020, the COVID-19 pandemic impacted the world through the necessity of mask mandates and stay-at-home orders, while marginalized communities continued to grapple with disproportionate outcomes of the pandemic due to systemic racism. Hence, some had to live in a double pandemic, such as minoritized healthcare professionals on the frontlines addressing the uncertainties of the health crisis. Importantly, Black women healthcare professionals relied upon sister circles as a mental health mechanism. Sister circles are support groups for and by Black women and are often informally formed within contexts such as education, work, and recreation. This qualitative study deepens the understanding of how during the double pandemic sister circles in the United States created a space for Black women healthcare professionals to support each other in managing stress, navigating workspaces, and sustaining their personal lives. Fifteen participants across different health professions, including nursing, social work, and therapy, participated in one-time interviews and focus groups to share their experiences as members of a sister circle. Four salient themes were: (1) mental health support, (2) mutual understanding, (3) guidance on how to engage in salary negotiations, and (4) professional knowledge. Additionally, the findings indicate that sister circles provided them a space for mental health support, rooted in mutual understanding, along with offering advice on salary negotiations and advancing their overall professional knowledge.

Development and validation of mortality prediction models based on the social determinants of health

BACKGROUND

There is no standardised approach to screening adults for social risk factors. The goal of this study was to develop mortality risk prediction models based on the social determinants of health (SDoH) for clinical risk stratification.

METHODS

Data were used from REasons for Geographic And Racial Differences in Stroke (REGARDS) study, a national, population-based, longitudinal cohort of black and white Americans aged ≥45 recruited between 2003 and 2007. Analysis was limited to participants with available SDoH and mortality data (n=20 843). All-cause mortality, available through 31 December 2018, was modelled using Cox proportional hazards with baseline individual, area-level and business-level SDoH as predictors. The area-level Social Vulnerability Index (SVI) was included for comparison. All models were adjusted for age, sex and sampling region and underwent internal split-sample validation.

RESULTS

The baseline prediction model including only age, sex and REGARDS sampling region had a c-statistic of 0.699. An individual-level SDoH model (Model 1) had a higher c-statistic than the SVI (0.723 vs 0.708, p<0.001) in the testing set. Sequentially adding area-level SDoH (c-statistic 0.723) and business-level SDoH (c-statistics 0.723) to Model 1 had minimal improvement in model discrimination. Structural racism variables were associated with all-cause mortality for black participants but did not improve model discrimination compared with Model 1 (p=0.175).

CONCLUSION

In conclusion, SDoH can improve mortality prediction over 10 years relative to a baseline model and have the potential to identify high-risk patients for further evaluation or intervention if validated externally.

Continuum of Trauma: Fear and Mistrust of Institutions in Communities of Color During the COVID-19 Pandemic

Historical, cultural, and social trauma, along with social determinants of health (SDOH), shape health outcomes, attitudes toward medicine, government, and health behaviors among communities of color in the United States (U.S.). This study explores how trauma and fear influence COVID-19 testing and vaccination among Black/African American, Latinx/Indigenous Latin American, and Native American/Indigenous communities. Leveraging community-based participatory research methods, we conducted 11 virtual focus groups from January to March of 2021 with Black/African American (n = 4), Latinx/Indigenous Latin American (n = 4), and Native American/Indigenous (n = 3) identifying community members in Inland Southern California. Our team employed rapid analytic approaches (e.g., template and matrix analysis) to summarize data and identify themes across focus groups and used theories of intersectionality and trauma to meaningfully interpret study findings. Historical, cultural, and social trauma induce fear and mistrust in public health and medical institutions influencing COVID-19 testing and vaccination decisions in communities of color in Inland Southern California. This work showcases the need for culturally and structurally sensitive community-based health interventions that attend to the historical, cultural, and social traumas unique to racial/ethnic minority populations in the U.S. that underlie fear and mistrust of medical, scientific, and governmental institutions.

Healthy educators need healthy schools: Supporting educator work-related well-being through multitiered systems of support

The COVID-19 pandemic has amplified preexisting challenges for educators as manifested in high rates of work-related stress and burnout, and educators leaving the profession in higher numbers than ever before. In this article, we highlight the urgency for work-related well-being supports for educators, with a particular focus on system changes. Individual self-care is necessary, yet insufficient. To this end, we recommend the use of a multitiered system of support framework to promote a supportive and balanced work environment for all educators, tailored to local needs. We provide a rationale for the use of a tiered model and give specific recommendations for implementation and sustainability of a continuum of supports for school-wide educator well-being. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Combining artificial neural networks and a marginal structural model to predict the progression from depression to Alzheimer's disease

Introduction

Decades of research in population health have established depression as a likely precursor to Alzheimer's disease. A combination of causal estimates and machine learning methods in artificial intelligence could identify internal and external mediating mechanisms that contribute to the likelihood of progression from depression to Alzheimer's disease.

Methods

We developed an integrated predictive model, combining the marginal structural model and an artificial intelligence predictive model, distinguishing between patients likely to progress from depressive states to Alzheimer's disease better than each model alone.

Results

The integrated predictive model achieved substantial clinical relevance when using the area under the curve measure. It performed better than the traditional statistical method or a single artificial intelligence method alone.

Discussion

The integrated predictive model could form a part of a clinical screening tool that identifies patients who are likely to progress from depression to Alzheimer's disease for early behavioral health interventions. Given the high costs of treating Alzheimer's disease, our model could serve as a cost-effective intervention for the early detection of depression before it progresses to Alzheimer's disease.

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.

The American Heart Association Emergency Cardiovascular Care 2030 Impact Goals and Call to Action to Improve Cardiac Arrest Outcomes: A Scientific Statement From the American Heart Association

Every 10 years, the American Heart Association (AHA) Emergency Cardiovascular Care Committee establishes goals to improve survival from cardiac arrest. These goals align with broader AHA Impact Goals and support the AHA's advocacy efforts and strategic investments in research, education, clinical care, and quality improvement programs. This scientific statement focuses on 2030 AHA emergency cardiovascular care priorities, with a specific focus on bystander cardiopulmonary resuscitation, early defibrillation, and neurologically intact survival. This scientific statement also includes aspirational goals, such as establishing cardiac arrest as a reportable disease and mandating reporting of standardized outcomes from different sources; advancing recognition of and knowledge about cardiac arrest; improving dispatch system response, availability, and access to resuscitation training in multiple settings and at multiple time points; improving availability, access, and affordability of defibrillators; providing a focus on early defibrillation, in-hospital programs, and establishing champions for debriefing and review of cardiac arrest events; and expanding measures to track outcomes beyond survival. The ability to track and report data from these broader aspirational targets will potentially require expansion of existing data sets, development of new data sets, and enhanced integration of technology to collect process and outcome data, as well as partnerships of the AHA with national, state, and local organizations. The COVID-19 (coronavirus disease 2019) pandemic, disparities in COVID-19 outcomes for historically excluded racial and ethnic groups, and the longstanding disparities in cardiac arrest treatment and outcomes for Black and Hispanic or Latino populations also contributed to an explicit focus and target on equity for the AHA Emergency Cardiovascular Care 2030 Impact Goals.

The Psychosocial Impact of the COVID-19 Pandemic on Families of Youth of Color: A Prospective Cohort Study

OBJECTIVE

Prospectively examine racial and ethnic disparities in exposure to COVID-19-related stressors and their impact on families.

METHODS

A racially, ethnically, and socioeconomically diverse cohort of caregivers of youth (n = 1,581) representative of the population served by a pediatric healthcare system completed the COVID-19 Exposure and Family Impact Scales in Oct/Nov 2020 and March/April 2021. Linear mixed-effects models were used to examine exposure to COVID-19-related events (Exposure), impact of the pandemic on family functioning and well-being (Impact), and child and parent distress (Distress) across time and as a function of race and ethnicity, adjusting for other sociodemographic variables.

RESULTS

Exposure and Distress increased over time for all participants. After adjusting for sociodemographic factors, caregivers of Black and Hispanic youth reported greater Exposure than caregivers of White youth and caregivers of Black youth had a greater increase in Exposure over time than caregivers of White youth. Caregivers of White youth reported greater Impact than caregivers of Black and Other race youth.

CONCLUSIONS

Exposure to and impact of the COVID-19 pandemic on family psychosocial functioning varied by race and ethnicity. Although exposure to COVID-19-related events was greater among Hispanic and non-Hispanic Black families, those of marginalized races reported less family impact than non-Hispanic White families, suggesting resiliency to the pandemic. Research should examine such responses to public health crises in communities of color, with a focus on understanding protective factors. These findings suggest the importance of culturally tailored interventions and policies that support universal psychosocial screenings during times of public health crises.

Racial differences in attenuated psychotic symptoms during the COVID-19 pandemic

AIM

Rates of attenuated psychotic symptoms (APS) have increased during the COVID-19 pandemic; however, it is unclear whether this is most evident among individuals from marginalized racial groups.

METHODS

The current study evaluated APS screening data across a six-year period in the state of Georgia in the United States, spanning several years prior to and during the COVID-19 pandemic to evaluate interactions between time and race. Participants included 435 clinical help-seeking individuals.

RESULTS

The rate of individuals scoring above the APS screening cut-off was higher during the pandemic compared to pre-pandemic (41% vs 23%). This pandemic-related increase in APS was significant for Black, but not White or Asian participants.

CONCLUSIONS

Findings indicate APS are increasing during the COVID-19 pandemic among clinical help-seeking populations. Black individuals may be at greater risk for developing a psychotic disorder during the pandemic, suggesting increased need for screening, mental health monitoring, and treatment.

The importance of community-specific survey data in understanding behavioral and social drivers of COVID-19 vaccination: Lessons learned from urban neighborhoods in four United States cities

This descriptive study examined patterns and trends in coronavirus (COVID-19) vaccination rates and drivers among people living, working, or socializing in urban neighborhoods of predominantly Black and Hispanic communities and compared them with the results of two national surveys. Data for these communities came from a routine survey conducted as part of the Equity-first Vaccination Initiative (EVI) in urban neighborhoods within four United States (U.S.) cities during four phases of the pandemic between July 2021 and April 2022. Our sample included 5,970 responses, which were weighted to account for design effects and compositional differences among surveyed people across the four periods. We wanted to compare the results from the EVI survey to nationally representative surveys, therefore, we did not demographically weight the sample to look like the national surveys. As a result, the EVI survey included larger proportions of people identifying with non-white racial and ethnic groups than those groups' proportions of the national population per the last U.S. Census (African American or Black: 49.8% vs. 13.7%, Hispanic or Latino/Latinx 36.5% vs. 18.9%, respectively). More EVI respondents reported concern about vaccines and fewer reported trust in COVID-19 information key messengers than national averages. The EVI survey found variation in the proportions as well as the magnitude and directionality of increases or decreases in beliefs about vaccination safety and effectiveness, the influence of religious beliefs, and intentions to get vaccinated. These differences highlight the granular insight that community-specific data can help better tailor interventions to communities disproportionately impacted by disease.

Lessons Learned About Trauma Related to Racial Discrimination During COVID-19 in the United States

Race scholars have discussed how the pandemic has disproportionately burdened marginalized communities and exacerbated pre-existing inequities, particularly for Black Indigenous People of Color (BIPOC) in the United States (U.S.). One glaring social determinant during the time of the COVID-19 is racial discrimination. This chapter will discuss lessons learned regarding the negative impact of discrimination on BIPOC, especially as it pertains to their experiences of trauma. Some of these lessons include (1) the need for clinical psychologist to improve access to treatment through increased research on culturally adaptive interventions, (2) increased research on the effects of race-based trauma on mental health symptomatology, (3) policy and institutional changes that reduce disparities in access to care, and (4) increased education for psychologists around billing procedures for individuals with race-based stress.

Intersecting gender identity and racial/ethnic inequities in eating disorder risk factors, symptoms, and diagnosis among U.S. college students: An intersectional multilevel analysis of individual heterogeneity and discriminatory accuracy

INTRODUCTION

There are documented inequities in eating disorders (EDs) by gender and race/ethnicity, yet, little is known about population-level prevalence of ED risk factors, symptoms, and diagnosis at the intersection of diverse gender and racial/ethnic identities.

METHODS

Data from the Healthy Minds Study 2015-2019 (N = 251,310 U.S. university students) were used in a multilevel analysis of individual heterogeneity and discriminatory accuracy (MAIHDA). Participants were nested in 35 intersectional strata given by all combinations of 5 gender and 7 racial/ethnic categories. Multilevel logistic models with participants at level 1 and intersectional strata at level 2 were used to estimate stratum-specific predicted prevalence estimates for self-reported thin-ideal internalization, ED symptoms, and ED diagnosis. The variance partition coefficient (VPC) was calculated to quantify the contextual effect of the strata.

RESULTS

There was considerable heterogeneity in the predicted prevalence of our ED outcomes across the strata (e.g., .3%-18.3% for ED diagnoses). There were large disparities in all three outcomes, with transgender participants of color having a higher predicted prevalence than expected based on the additive effects of gender and race/ethnicity. Moderation by race/ethnicity was also apparent, such that racial/ethnic disparities were wider within the cisgender groups relative to the transgender groups. VPCs indicated that ~10% of the total variance in ED outcomes was due to intersectionality between gender and race/ethnicity, over and above variance due to individual-level differences.

CONCLUSION

Findings suggest that gender and racial/ethnic disparities in EDs are interrelated, underscoring the need to develop preventive interventions centering health equity.

PUBLIC SIGNIFICANCE

Despite evidence that sexism, racism, and cissexism (i.e., anti-transgender prejudice) can impact EDs risk, little research examines the social patterning of EDs at the intersection of diverse gender and racial/ethnic identities. Using data from a sample of 250,000 U.S. university students, this study found that gender and racial/ethnic disparities in eating disorder risk are interrelated, highlighting the need to develop health equity centered preventive interventions.

Faith-based organisations and their role in supporting vaccine confidence and uptake: a scoping review protocol

INTRODUCTION

Faith-based organisations (FBOs) and religious actors increase vaccine confidence and uptake among ethnoracially minoritised communities in low-income and middle-income countries. During the COVID-19 pandemic and the subsequent vaccine rollout, global organisations such as the WHO and UNICEF called for faith-based collaborations with public health agencies (PHAs). As PHA-FBO partnerships emerge to support vaccine uptake, the scoping review aims to: (1) outline intervention typologies and implementation frameworks guiding interventions; (2) describe the roles of PHAs and FBOs in the design, implementation and evaluation of strategies and (3) synthesise outcomes and evaluations of PHA-FBO vaccine uptake initiatives for ethnoracially minoritised communities.

METHODS AND ANALYSIS

We will perform six library database searches in PROQUEST-Public Health, OVID MEDLINE, Cochrane Library, CINAHL, SCOPUS- all, PROQUEST - Policy File index; three theses repositories, four website searches, five niche journals and 11 document repositories for public health. These databases will be searched for literature that describe partnerships for vaccine confidence and uptake for ethnoracially minoritised populations, involving at least one PHA and one FBO, published in English from January 2011 to October 2023. Two reviewers will pilot-test 20 articles to refine and finalise the inclusion/exclusion criteria and data extraction template. Four reviewers will independently screen and extract the included full-text articles. An implementation science process framework outlining the design, implementation and evaluation of the interventions will be used to capture the array of partnerships and effectiveness of PHA-FBO vaccine uptake initiatives.

ETHICS AND DISSEMINATION

This multiphase Canadian Institutes of Health Research (CIHR) project received ethics approval from the University of Toronto. Findings will be translated into a series of written materials for dissemination to CIHR, and collaborating knowledge users (ie, regional and provincial PHAs), and panel presentations at conferences to inform the development of a best-practices framework for increasing vaccine confidence and uptake.

The measurement of racism in health inequities research

There is limited literature on the measures and metrics used to examine racism in the health inequities literature. Health inequities research is continuously evolving, with the number of publications increasing over time. However, there is limited knowledge on the best measures and methods to examine the impact of different levels of racism (institutionalized, personally mediated, and internalized) on health inequities. Advanced statistical methods have the potential to be used in new ways to examine the relationship between racism and health inequities. In this review, we conduct a descriptive examination of the measurement of racism in the health inequities epidemiologic literature. We examine the study design, methods used for analysis, types of measures used (e.g., composite, absolute, relative), number of measures used, phase of research (detect, understand, solutions), viewpoint (oppressor, oppressed), and components of structural racism measures (historical context, geographical context, multifaceted nature). We discuss methods (e.g., Peters-Belson, latent class analysis, difference in differences) that have demonstrated potential for future work. The articles reviewed were limited to the detect (25%) and understand (75%) phases, with no studies in the solutions phase. Although the majority (56%) of studies had cross-sectional designs, many authors pointed to the need for longitudinal and multilevel data for further exploration. We examined study design features as mutually exclusive elements. However, racism is a multifaceted system and the measurement of racism in many studies does not fit into a single category. As the literature grows, the significance of methodological and measurement triangulation to assess racism should be investigated.

Church Leaders Share and Implement Solution-Focused Health Strategies During the COVID-19 Pandemic in Rural Alabama

Bridging the healthcare access gap and addressing COVID-19 vaccine hesitancy among rural-dwelling Black American adults residing in the Deep South require involvement of faith-based leaders in the community. This study explored perceived barriers and resources to meeting community needs, including vaccination, during the COVID-19 pandemic as reported by 17 Black American church leaders in the rural West Alabama Black Belt geographic region in May 2022. The main themes that emerged included (1) attending to community impact of COVID-19 illness and death; (2) maximizing health literacy and diminishing vaccine hesitancy through engaging in preventive health practices and sharing public health information; (3) addressing challenges created or exacerbated by COVID-19, including reduction in in-person attendance (particularly among adolescents and young adults), limited access to and literacy with technology, and political perceptions influencing engagement in preventive health behaviors; (4) maximizing technological solutions to increase attendance in the church; and (5) engaging in solution-focused and innovative initiatives to meet the identified needs in the congregation and community. Church leaders in West Alabama rural areas facing economic, health, and technological disparities identified "silver linings" as well as challenges created or exacerbated during the pandemic. As the need for COVID-19 vaccination and booster vaccination continues, Black American church leaders play pivotal roles in meeting rural community needs.

Neighborhood Factors Associated with COVID-19 Cases in California

BACKGROUND

There is a need to assess neighborhood-level factors driving COVID-19 disparities across racial and ethnic groups.

OBJECTIVE

To use census tract-level data to investigate neighborhood-level factors contributing to racial and ethnic group-specific COVID-19 case rates in California.

DESIGN

Quasi-Poisson generalized linear models were used to identify neighborhood-level factors associated with COVID-19 cases. In separate sequential models for Hispanic, Black, and Asian, we characterized the associations between neighborhood factors on neighborhood COVID-19 cases. Subanalyses were conducted on neighborhoods with majority Hispanic, Black, and Asian residents to identify factors that might be unique to these neighborhoods. Geographically weighted regression using a quasi-Poisson model was conducted to identify regional differences.

MAIN MEASURES

All COVID-19 cases and tests reported through January 31, 2021, to the California Department of Public Health. Neighborhood-level data from census tracts were obtained from American Community Survey 5-year estimates (2015-2019), United States Census (2010), and United States Department of Housing and Urban Development.

KEY RESULTS

The neighborhood factors associated with COVID-19 case rate were racial and ethnic composition, age, limited English proficiency (LEP), income, household size, and population density. LEP had the largest influence on the positive association between proportion of Hispanic residents and COVID-19 cases (- 2.1% change). This was also true for proportion of Asian residents (- 1.8% change), but not for the proportion of Black residents (- 0.1% change). The influence of LEP was strongest in areas of the Bay Area, Los Angeles, and San Diego.

CONCLUSION

Neighborhood-level contextual drivers of COVID-19 burden differ across racial and ethnic groups.

COVID-19 and obstetric outcomes: a single-center retrospective experience in a predominantly Black population

Objective: This retrospective, single-center case series was designed to characterize the effects of perinatal COVID-19 diagnosis on obstetric and neonatal outcomes in a predominantly high-risk, urban Black population.Study Design: Data were collected via retrospective chart review on all COVID-19-positive obstetric patients and their neonates who presented to the University of Chicago Medical Center between March 2020 and November 2020, before the availability of the COVID-19 vaccine. Patient demographics, delivery outcomes, COVID-19 symptoms, treatment, and outcomes were analyzed.Results: A total of 56 COVID-19-positive obstetric patients were included in the study, of which four were lost to follow-up before delivery. The median age of patients was 27 years (IQR 23, 32), with 73.2% publicly insured and 66.1% Black. Patients had a median body mass index (BMI) of 31.6 kg/m² (IQR 25.9, 35.5). 3.6% of patients had chronic hypertension, 12.5% had diabetes, and 16.1% had asthma. Perinatal complications were common. Twenty-six patients (50.0%) had a diagnosis of a hypertensive disorder of pregnancy (HDP). 28.8% had gestational hypertension, and 21.2% had preeclampsia (with and without severe features). The rate of maternal ICU admission was 3.6%. Furthermore, 23.5% of patients delivered preterm (<37 weeks gestation), and 50.9% of infants were admitted to the Neonatal Intensive Care Unit (NICU).Conclusion: In our study of a predominantly Black, publicly-insured, unvaccinated group of COVID-19-positive pregnant patients, we found high rates of hypertensive disorders of pregnancy, preterm delivery, and NICU admission compared to rates reported in existing literature before widespread vaccine availability. Our findings suggest that SARS-CoV-2 infection during pregnancy, irrespective of maternal disease severity, may exacerbate existing obstetric health disparities by disproportionately impacting Black, publicly insured patients. Larger comparative studies are needed to better characterize possible racial and socioeconomic disparities in obstetric outcomes in the setting of SARS-CoV-2 infection during pregnancy. These studies should examine the pathophysiology of SARS-CoV-2 infection during pregnancy, as well as potential associations between adverse perinatal outcomes and disparities in access to care, COVID-19 vaccination, and other social determinants of health amongst more vulnerable populations infected with SARS-CoV-2 during pregnancy.

Structural Racism and Well-Being Among Young People in the U.S

INTRODUCTION

Structural racism has clear and pernicious effects on population health. However, there is a limited understanding of how structural racism impacts young people's well-being. The objective of this ecologic cross-sectional study was to assess the relationship between structural racism and well-being for 2,009 U.S. counties from 2010 to 2019.

METHODS

Population-based data on demographics, health, and other variables related to young people's ability to thrive are used to construct a previously validated composite index that serves as a proxy of young people's well-being. The index is regressed on several forms of structural racism (segregation, economic, and educational) both independently and jointly while accounting for county-fixed effects, time trends, and state-specific trends as well as weighting for child population. Data were analyzed from November 2021 through March 2023.

RESULTS

Higher levels of structural racism are associated with lower well-being. A 1-SD increase in Black-White child poverty disparity is associated with a -0.034 (95% CI= -0.019, -0.050) SD change in index score. When accounting for multiple structural racism measures, associations remain statistically significant. In joint models, only estimates for economic racism measures remain significant when additionally controlling for demographic, socioeconomic, and adult health measures (β= -0.015; 95% CI= -0.001, -0.029). These negative associations are heavily concentrated in counties where Black and Latinx children are overrepresented.

CONCLUSIONS

Structural racism-particularly of the kind that produces racialized poverty outcomes-has a meaningful adverse association with child and adolescent well-being, which may produce lifelong effects. Studies of structural racism among adults should consider a lifecourse perspective.

Structural competency in pre-health and health professional learning: A scoping review

Structural competency training provides guidance to healthcare providers on recognizing and addressing structural factors leading to health inequities. To inform the evidence-based progression of structural competency curriculum development, this study was designed to map the current state of the literature on structural competency training with pre-health students, healthcare professional students, and/or healthcare professionals. We performed a scoping review and identified peer-reviewed, primary research articles assessing structural competency training interventions. The category of learners, timing of the structural competency training, types of teaching and learning activities used, instruments used to measure training outcomes, and evaluation criteria were examined. Eleven (n = 11) articles met inclusion criteria, addressing all training levels, and largely focused on medical education. Active learning strategies and researcher-developed instruments to measure training outcomes were most used. Evaluation criteria largely focused on trainees' affective reactions, utility assessments, and direct measure of the trainee learning. We suggest designing interprofessional structural competency education with an emphasis on active learning strategies and standardized training curricula. Evaluation instruments integrated at different points in the health professional learning trajectory are important for evidence-based progression in curriculum development focused on achieving structural competency.

Postpartum medication for opioid use disorder outcomes associated with prenatal treatment and neighborhood-level social determinants

BACKGROUND

Opioid use disorder is a leading cause of death through the year postpartum.

OBJECTIVE

This study aimed to identify the association of neighborhood-level social determinants of health and prenatal opioid use disorder treatment receipt with the outcomes of medication treatment for opioid use disorder through the year postpartum among a cohort of birthing people.

STUDY DESIGN

This was a population-based retrospective cohort study that used state Medicaid claims and enrollment data for the 1690 individuals who delivered a live infant between July 1, 2016 and December 31, 2020 and received medication for opioid use disorder at delivery. The primary exposure was the state Health Opportunity Index, a composite measure of social determinants of health linked at the census-tract level. Secondary exposures included comprehensiveness of opioid use disorder treatment and duration of medication treatment for opioid use disorder received prenatally. Outcomes included the duration and continuity of postpartum medication treatment for opioid use disorder, operationalized as the time from delivery to the discontinuation of medication treatment for opioid use disorder, and percentage of days covered by medication treatment for opioid use disorder within the 12 months after delivery, respectively.

RESULTS

Within the study sample, 711 deliveries were to birthing people in the lowest state Health Opportunity Index tercile (indicating high burden of negative social determinants of health), 647 in the middle state Health Opportunity Index tercile, and 332 in the highest state Health Opportunity Index tercile. Using stepwise multivariable regression (Cox proportional hazards and negative binomial models) guided by a socioecological framework, prenatal receipt of more comprehensive opioid use disorder treatment and/or longer duration of prenatal medication treatment for opioid use disorder was associated with improved 1-year postpartum opioid use disorder treatment outcomes (duration and continuity of medication treatment for opioid use disorder). When the state Health Opportunity Index was added to the models, these significant associations remained stable, with the state Health Opportunity Index not demonstrating an association with the outcomes (duration hazard ratio, 1.39; 95% confidence interval, 0.551-3.512; continuity relative risk, 1.024; 95% confidence interval, 0.323-3.247).

CONCLUSION

Targeted efforts at expanding access to and quality of evidence-based opioid use disorder treatments for reproductive-age people across the life course should be prioritized within the spectrum of work aimed at eradicating disparities in pregnancy-related mortality.

An environmental justice analysis of air pollution in India

Due to the lack of timely data on socioeconomic factors (SES), little research has evaluated if socially disadvantaged populations are disproportionately exposed to higher PM2.5 concentrations in India. We fill this gap by creating a rich dataset of SES parameters for 28,081 clusters (villages in rural India and census-blocks in urban India) from the National Family and Health Survey (NFHS-4) using a precision-weighted methodology that accounts for survey-design. We then evaluated associations between total, anthropogenic and source-specific PM2.5 exposures and SES variables using fully-adjusted multilevel models. We observed that SES factors such as caste, religion, poverty, education, and access to various household amenities are important risk factors for PM2.5 exposures. For example, we noted that a unit standard deviation increase in the cluster-prevalence of Scheduled Caste and Other Backward Class households was significantly associated with an increase in total-PM2.5 levels corresponding to 0.127 μg/m3 (95% CI 0.062 μg/m3, 0.192 μg/m3) and 0.199 μg/m3 (95% CI 0.116 μg/m3, 0.283 μg/m3, respectively. We noted substantial differences when evaluating such associations in urban/rural locations, and when considering source-specific PM2.5 exposures, pointing to the need for the conceptualization of a nuanced EJ framework for India that can account for these empirical differences. We also evaluated emerging axes of inequality in India, by reporting associations between recent changes in PM2.5 levels and different SES parameters.

Association Between Markers of Structural Racism and Mass Shooting Events in Major US Cities

Importance

The root cause of mass shooting events (MSEs) and the populations most affected by them are poorly understood.

Objective

To examine the association between structural racism and mass shootings in major metropolitan cities in the United States.

Design, Setting, and Participants

This cross-sectional study of MSEs in the 51 largest metropolitan statistical areas (MSAs) in the United States analyzes population-based data from 2015 to 2019 and the Gun Violence Archive. The data analysis was performed from February 2021 to January 2022.

Exposure

Shooting event where 4 or more people not including the shooter were injured or killed.

Main Outcome and Measures

MSE incidence and markers of structural racism from demographic data, Gini income coefficient, Black-White segregation index, and violent crime rate.

Results

There were 865 MSEs across all 51 MSAs from 2015 to 2019 with a total of 3968 injuries and 828 fatalities. Higher segregation index (ρ = 0.46, P = .003) was associated with MSE incidence (adjusted per 100 000 population) using Spearman ρ analysis. Percentage of the MSA population comprising Black individuals (ρ = 0.76, P < .001), children in a single-parent household (ρ = 0.44, P < .001), and violent crime rate (ρ = 0.34, P = .03) were other variables associated with MSEs. On linear regression, structural racism, as measured by percentage of the MSA population comprising Black individuals, was associated with MSEs (β = 0.10; 95% CI, 0.05 to 0.14; P < .001). Segregation index (β = 0.02, 95% CI, -0.03 to 0.06; P = .53), children in a single-parent household (β = -0.04, 95% CI, -0.11 to 0.04; P = .28), and Gini income coefficient (β = -1.02; 95% CI, -11.97 to 9.93; P = .93) were not associated with MSEs on linear regression.

Conclusions and Relevance

This study found that major US cities with higher populations of Black individuals are more likely to be affected by MSEs, suggesting that structural racism may have a role in their incidence. Public health initiatives aiming to prevent MSEs should target factors associated with structural racism to address gun violence.

Racism against racialized migrants in healthcare in Europe: a scoping review

BACKGROUND

Racism is frequently mentioned as a social determinant of migrants' health and a barrier to health services. However, in the European context, racism and its impact on racialized migrants' access to healthcare is remarkably under-researched. This scoping review makes a first step toward filling this void by mapping the existing literature on racial and ethnic discrimination against racialized migrants in healthcare in Europe, identifying evidence gaps, and offering recommendations for future research on this topic.

METHODS

Following PRISMA guidelines, four databases were searched for empirical studies published in English between 1992 and 2022. Studies were included if they report findings on manifestations, experiences and/or impacts of racial or ethnic discrimination against racialized migrants in a healthcare setting in a European country. They were summarized by study characteristics (geographical scope, study design, research question and measures) and research findings were synthesized.

RESULTS

Out of 2365 initial hits, 1724 records were included in the title/abstract-screening, 87 records in the full text-screening, and 38 records in the data extraction. For many country and healthcare contexts, evidence on racism in healthcare is lacking. Most studies apply an explorative qualitative research design; comparability and generalizability of research results are low. Our analysis furthermore shows a near-exclusive research focus on racism on the interpersonal level as compared to institutional and structural levels. Our synthesis of study results identifies three interrelated ways in which racism manifests in and impacts migrants' healthcare: 1) general anti-migration bias, 2) health- and healthcare-related prejudice, and 3) differential medical treatment.

CONCLUSIONS

Our review underscores how racism reinforces inequities in healthcare access and quality for racialized migrants. It also highlights the need for more research on racism in Europe across a greater scope of country contexts, healthcare settings and migrant/racialized categories in order to understand specific forms of racism and capture race as a context-contingent social construct. It is critical that future research includes the consideration of individual-level racism as embedded in racism on institutional and structural levels. Methods and insights from other disciplines may help to critically examine concepts in light of underlying historical, sociopolitical and socioeconomic processes and structures, and to improve methods for researching racialization and racism in healthcare.

The white racial frame of public health discourses about racialized health differences and "disparities": what it reveals about power and how it thwarts health equity

Although several public health scholars have advocated for more clarity about concepts such as health disparities and health equity, attention to the framing of public health discourses about racialized health differences and "disparities" in the U.S., and what it reveals about power and the potential for achieving health equity, is surprisingly rare. Sociologist Joe Feagin, in his book, The White Racial Frame: Centuries of Racial Framing and Counter-Framing coined the term white racial frame to describe the predominantly white racialized worldview of majority white and white-oriented decisionmakers in everyday and institutional operations. Informed by insights from critical race theories about the white racial frame, white epistemological ignorance, and colorblind racism; critical perspectives on social class; Black feminist perspectives; framing; and critical discourse analysis, in this perspective I discuss: (1) the power of language and discourses; (2) the white racial frame of three common public health discourses - health disparities, "race," and social determinants of health (SDOH); (3) the costs and consequences of the white racial frame for advancing health equity; and (4) the need for more counter and critical theoretical frames to inform discourses, and in turn research and political advocacy to advance health equity in the U.S.

Association Between Racial Segregation and COVID-19 Vaccination Rates

OBJECTIVE

To examine the association between county-level Black-White residential segregation and COVID-19 vaccination rates.

DESIGN

Observational cross-sectional study using multivariable generalized linear models with state fixed effects to estimate the average marginal effects of segregation on vaccination rates.

SETTING

National analysis of county-level vaccination rates.

MAIN OUTCOME MEASURE

County-level vaccination rates across the United States.

RESULTS

We found an overall positive association between county-level segregation and the proportion population fully vaccinated, with a 6.8, 11.3, and 12.8 percentage point increase in the proportion fully vaccinated by May 3, September 27, and December 6, 2021, respectively. Effects were muted after adjustment for sociodemographic variables. Furthermore, in analyses including an interaction term between the county proportion of Black residents and the county dissimilarity index, the association between segregation and vaccination is positive in counties with a lower proportion of Black residents (ie, 5%) but negative in counties with the highest proportions of Black residents (ie, 70%).

CONCLUSIONS

Findings highlight the importance of methodological decisions when modeling disparities in COVID-19 vaccinations. Researchers should consider mediating and moderating factors and examine interaction effects and stratified analyses taking racial group distributions into account. Results can inform policies around the prioritization of vaccine distribution and outreach.

The neighborhood built environment and COVID-19 hospitalizations

Research on the associations between the built environment and COVID-19 outcomes has mostly focused on incidence and mortality. Also, few studies on the built environment and COVID-19 have controlled for individual-level characteristics across large samples. In this study, we examine whether neighborhood built environment characteristics are associated with hospitalization in a cohort of 18,042 individuals who tested positive for SARS-CoV-2 between May and December 2020 in the Denver metropolitan area, USA. We use Poisson models with robust standard errors that control for spatial dependence and several individual-level demographic characteristics and comorbidity conditions. In multivariate models, we find that among individuals with SARS-CoV-2 infection, those living in multi-family housing units and/or in places with higher particulate matter (PM2.5) have a higher incident rate ratio (IRR) of hospitalization. We also find that higher walkability, higher bikeability, and lower public transit access are linked to a lower IRR of hospitalization. In multivariate models, we did not find associations between green space measures and the IRR of hospitalization. Results for non-Hispanic white and Latinx individuals highlight substantial differences: higher PM2.5 levels have stronger positive associations with the IRR of hospitalization for Latinx individuals, and density and overcrowding show stronger associations for non-Hispanic white individuals. Our results show that the neighborhood built environment might pose an independent risk for COVID-19 hospitalization. Our results may inform public health and urban planning initiatives to lower the risk of hospitalization linked to COVID-19 and other respiratory pathogens.

COVID-19 challenges, responses, and resilience among rural Black women: a study protocol

Despite the aggregated burdens and challenges experienced by rural Black women during the COVID-19 pandemic, many likely also demonstrated strength and resilience to overcome challenges. A mixed methodology and a community-based participatory approach will be used to collect multilevel data on challenges, responses, resilience, and lessons during the pandemic from Black women, community health workers, and community leaders in rural areas in South Carolina (SC). Specifically, the unique circumstances and lived experiences of rural Black women during the COVID-19 pandemic will be documented to understand their needs regarding effective management of social, physical, and mental health challenges through focus group discussions and in-depth interviews with Black women, community health workers, and local community leaders recruited from rural SC communities. Barriers, facilitators, and potential impacts of multilevel resilience development will be identified through a survey administered among rural Black women recruited from 11 rural counties (with one as site for a pilot testing of the questionnaire). A report for public health practice will be developed, including recommended strategies to optimize health systems' emergency preparedness and responses through triangulation of qualitative and quantitative data from multiple sources. Findings in the proposed study will provide valuable references in terms of addressing social determinants of health factor challenges during the pandemic, fostering resilience, and informing evidence-based decision-making for policymakers. The study will contribute to the development of public health emergency preparedness plans, which can promote the resilience of women, their families, and local communities as well as optimize effective preparedness and response of health systems for rural Black women and their families during infectious disease outbreaks and other public health emergencies.

Three dimensions of COVID-19 risk perceptions and their socioeconomic correlates in the United States: A social media analysis

Social media analysis provides an alternate approach to monitoring and understanding risk perceptions regarding COVID-19 over time. Our current understandings of risk perceptions regarding COVID-19 do not disentangle the three dimensions of risk perceptions (perceived susceptibility, perceived severity, and negative emotion) as the pandemic has evolved. Data are also limited regarding the impact of social determinants of health (SDOH) on COVID-19-related risk perceptions over time. To address these knowledge gaps, we extracted tweets regarding COVID-19-related risk perceptions and developed indicators for the three dimensions of risk perceptions based on over 502 million geotagged tweets posted by over 4.9 million Twitter users from January 2020 to December 2021 in the United States. We examined correlations between risk perception indicator scores and county-level SDOH. The three dimensions of risk perceptions demonstrate different trajectories. Perceived severity maintained a high level throughout the study period. Perceived susceptibility and negative emotion peaked on March 11, 2020 (COVID-19 declared global pandemic by WHO) and then declined and remained stable at lower levels until increasing once again with the Omicron period. Relative frequency of tweet posts on risk perceptions did not closely follow epidemic trends of COVID-19 (cases, deaths). Users from socioeconomically vulnerable counties showed lower attention to perceived severity and susceptibility of COVID-19 than those from wealthier counties. Examining trends in tweets regarding the multiple dimensions of risk perceptions throughout the COVID-19 pandemic can help policymakers frame in-time, tailored, and appropriate responses to prevent viral spread and encourage preventive behavior uptake in the United States.

Witnessing racism against racial minority individuals online and loneliness among White emerging adults: Anti-racism advocacy as a moderator

Extant literature suggests that racism is associated with difficult emotional reactions and feelings of social disconnect among White individuals. These feelings of social disconnect may be particularly salient in today's digital era in which racism against racial minority individuals is conveniently and frequently witnessed via online platforms. Thus, we examined whether witnessing racism online may be associated with feelings of loneliness among White emerging adults. We also tested whether anti-racism advocacy buffered loneliness given its potential for relationship building and community organizing to promote racial justice and equity. Using data from 227 White emerging adults (M_age  = 20.86, SD = 4.82), we conducted a latent moderated structural equation modeling to test individual and institutional anti-racism advocacy as moderators in the link between witnessing racism online (racial victimization of racial minority individuals in online interactions and online content on cultural devaluation/systemic racism against racial minority individuals) and loneliness. Greater exposure to online content on systemic racism and cultural devaluation of racial minority groups significantly predicted greater loneliness. Engagement in individual anti-racism advocacy (mean to high levels) buffered this link. White allies must engage in anti-racism practice to address racism in our society, and our findings advance our understanding of the associated psychosocial costs. Implications for research and practice are discussed.

COVID-19 Mortality by Race and Ethnicity in US Metropolitan and Nonmetropolitan Areas, March 2020 to February 2022

Importance

Prior research has established that Hispanic and non-Hispanic Black residents in the US experienced substantially higher COVID-19 mortality rates in 2020 than non-Hispanic White residents owing to structural racism. In 2021, these disparities decreased.

Objective

To assess to what extent national decreases in racial and ethnic disparities in COVID-19 mortality between the initial pandemic wave and subsequent Omicron wave reflect reductions in mortality vs other factors, such as the pandemic's changing geography.

Design, Setting, and Participants

This cross-sectional study was conducted using data from the US Centers for Disease Control and Prevention for COVID-19 deaths from March 1, 2020, through February 28, 2022, among adults aged 25 years and older residing in the US. Deaths were examined by race and ethnicity across metropolitan and nonmetropolitan areas, and the national decrease in racial and ethnic disparities between initial and Omicron waves was decomposed. Data were analyzed from June 2021 through March 2023.

Exposures

Metropolitan vs nonmetropolitan areas and race and ethnicity.

Main Outcomes and Measures

Age-standardized death rates.

Results

There were death certificates for 977 018 US adults aged 25 years and older (mean [SD] age, 73.6 [14.6] years; 435 943 female [44.6%]; 156 948 Hispanic [16.1%], 140 513 non-Hispanic Black [14.4%], and 629 578 non-Hispanic White [64.4%]) that included a mention of COVID-19. The proportion of COVID-19 deaths among adults residing in nonmetropolitan areas increased from 5944 of 110 526 deaths (5.4%) during the initial wave to a peak of 40 360 of 172 515 deaths (23.4%) during the Delta wave; the proportion was 45 183 of 210 554 deaths (21.5%) during the Omicron wave. The national disparity in age-standardized COVID-19 death rates per 100 000 person-years for non-Hispanic Black compared with non-Hispanic White adults decreased from 339 to 45 deaths from the initial to Omicron wave, or by 293 deaths. After standardizing for age and racial and ethnic differences by metropolitan vs nonmetropolitan residence, increases in death rates among non-Hispanic White adults explained 120 deaths/100 000 person-years of the decrease (40.7%); 58 deaths/100 000 person-years in the decrease (19.6%) were explained by shifts in mortality to nonmetropolitan areas, where a disproportionate share of non-Hispanic White adults reside. The remaining 116 deaths/100 000 person-years in the decrease (39.6%) were explained by decreases in death rates in non-Hispanic Black adults.

Conclusions and Relevance

This study found that most of the national decrease in racial and ethnic disparities in COVID-19 mortality between the initial and Omicron waves was explained by increased mortality among non-Hispanic White adults and changes in the geographic spread of the pandemic. These findings suggest that despite media reports of a decline in disparities, there is a continued need to prioritize racial health equity in the pandemic response.

Spatial and racial covid-19 disparities in U.S. nursing homes

In many parts of the world nursing home residents have experienced a disproportionate risk of exposure to COVID-19 and have died at much higher rates than other groups. There is a critical need to identify the factors driving COVID-19 risk in nursing homes to better understand and address the conditions contributing to their vulnerability during public health crises. This study investigates the characteristics associated with COVID-19 cases and deaths among residents in U.S. nursing homes from 2020 to 2021, with a focus on geospatial and racial inequalities. Using data from the Centers for Medicare and Medicaid Services and LTCFocus, this paper uses zero-inflated negative binomial regression models, Kruskal-Wallis tests, and Local Moran's I to generate statistical and geospatial results. Our analysis reveals that majority Hispanic facilities have alarmingly high COVID-19 cases and deaths, suggesting that these facilities have the greatest need for policy improvements in staffing and financing to reduce racial inequalities in nursing home care. At the same time we also detect COVID-19 hot spots in rural areas with predominately White residents, indicating a need to rethink public messaging strategies in these areas. The top states with COVID-19 hot spots are Kentucky, Pennsylvania, Illinois, and Oklahoma. This research provides new insights into the socio-spatial contexts and inequities that contribute to the vulnerability of nursing home residents during a pandemic.

Critical Dynamics in Black and Latino Parents' Perceptions of Childhood COVID-19 Vaccination: How the "Middle" Moves

National and state data show low adoption of childhood COVID-19 vaccinations, despite emergency use authorizations and availability. We conducted 24 in-depth, semi-structured interviews with Black and Latino parents in New York City (15 in English, 9 in Spanish), who were undecided or somewhat likely to vaccinate their 5 to 11-year-old children in early 2022. The interviews explored the evolution of parental perceptions on childhood COVID-19 vaccines, and were analyzed using a matrix-driven rapid approach to thematic analysis. We present our findings as themes oriented around trust at three levels of the social ecological model. In summary, we found that structural positionality and historical traumas of participants seeded mistrust in institutions and government. This led to parental reliance on personal observations, conversations, and norms within social groups for vaccine decision-making. Our findings also describe key features of trust-building, supportive conversations that shaped the thinking of undecided parents. This study demonstrates how relational trust becomes a key factor in parental vaccine decision-making, and suggests the potential power of community ambassador models of vaccination promotion for increasing success and rebuilding trust with members of the "movable middle."

Community-Led Response to Address Economic Vulnerability due to COVID-19 with, for, and by Transgender Women of Color: A Qualitative Pilot Evaluation

Purpose

Intersectional stigma fuels inequities among transgender women of color, which have been exacerbated by coronavirus disease 2019 (COVID-19). This study evaluated a community-led emergency assistance program for transgender women of color.

Methods

We conducted a pilot program evaluation (n=8).

Results

Retention was 87.5% over the follow-up. Funds were primarily used for bills, food, and housing. Requesting and receiving funds was described as "somewhat to extremely easy." Participants identified the need for economic empowerment components in future programming, specifically gender affirmation, skill-building for education and employment, and entrepreneurial opportunities.

Conclusion

Findings highlight the need to invest in community-led strategies to address inequities experienced by transgender women of color.

The illusion of personal health decisions for infectious disease management: disease spread in social contact networks

Close contacts between individuals provide opportunities for the transmission of diseases, including COVID-19. While individuals take part in many different types of interactions, including those with classmates, co-workers and household members, it is the conglomeration of all of these interactions that produces the complex social contact network interconnecting individuals across the population. Thus, while an individual might decide their own risk tolerance in response to a threat of infection, the consequences of such decisions are rarely so confined, propagating far beyond any one person. We assess the effect of different population-level risk-tolerance regimes, population structure in the form of age and household-size distributions, and different interaction types on epidemic spread in plausible human contact networks to gain insight into how contact network structure affects pathogen spread through a population. In particular, we find that behavioural changes by vulnerable individuals in isolation are insufficient to reduce those individuals' infection risk and that population structure can have varied and counteracting effects on epidemic outcomes. The relative impact of each interaction type was contingent on assumptions underlying contact network construction, stressing the importance of empirical validation. Taken together, these results promote a nuanced understanding of disease spread on contact networks, with implications for public health strategies.

Rural/urban differences in mental health and social well-being among older US adults in the early months of the COVID-19 pandemic

OBJECTIVES

This study seeks to identify differences in mental health and social well-being during the early months of the COVID-19 pandemic among older adults by rural/urban location.

METHODS

We use data from the COVID-19 Coping Study, a nation-wide online study of U.S. adults aged 55 and older (n = 6,873) fielded during April-May, 2020. We investigated rural/urban differences in mental health (depressive symptoms and anxiety symptoms) and social well-being (loneliness and social isolation); concern about COVID-19; and types of social participation (e.g. phone/video calls, visits). We also used multivariable logistic regression models to assess the relationship of rurality with mental health, adjusting for socio-demographic correlates, COVID-19 history, and COVID-19 concern.

RESULTS

We found similar prevalence of mental health and social well-being outcomes for rural and urban respondents. Rural respondents reported lower concern about COVID-19 and more frequent use of social media than urban respondents.

CONCLUSION

Mental health and social well-being did not differ by rural/urban location in the early months of the COVID-19 pandemic. However, rural residents reported less concern about COVID-19 and more use of social media, potentially leading to greater risk of illness from the pandemic in later months.

"Community members have more impact on their neighbors than celebrities": leveraging community partnerships to build COVID-19 vaccine confidence

BACKGROUND

Vaccines are a strong public health tool to protect against severe disease, hospitalization, and death from COVID-19. Still, inequities in COVID-19 vaccination rates and health outcomes continue to exist among Black and Latino populations. Boston Medical Center (BMC) has played a significant role in vaccinating medically underserved populations, and organized a series of community-engaged conversations to better understand community concerns regarding the COVID-19 vaccine. This paper describes the themes which resulted from these community-engaged conversations and proposes next steps for healthcare leaders.

METHODS

We accessed nine publicly available recordings of the community-engaged conversations which were held between March 2021 and September 2021 and ranged from 8 to 122 attendees. Six conversations prioritized specific groups: the Haitian-Creole community, the Cape Verdean community, the Latino community, the Black Christian Faith community, guardians who care for children living with disabilities, and individuals affected by systemic lupus erythematosus. Remaining conversations targeted the general public of the Greater Boston Area. We employed a Consolidated Framework for Implementation Research-driven codebook to code our data. Our analysis utilized a modified version of qualitative rapid analysis methods.

RESULTS

Five main themes emerged from these community-engaged conversations: (1) Structural factors are important barriers to COVID-19 vaccination; (2) Mistrust exists due to the negative impact of systemic oppression and perceived motivation of the government; (3) There is a desire to learn more about biological and clinical characteristics of the COVID-19 vaccine as well as the practical implications of being vaccinated; (4) Community leaders emphasize community engagement for delivering COVID-19 information and education and; (5) Community leaders believe that the COVID-19 vaccine is a solution to address the pandemic.

CONCLUSION

This study illustrates a need for community-engaged COVID-19 vaccine messaging which reflects the nuances of the COVID-19 vaccine and pandemic without oversimplifying information. In highlighting common concerns of the Greater Boston Area which contribute to a lack of confidence in the COVID-19 vaccine, we underscore important considerations for public health and healthcare leadership in the development of initiatives which work to advance health equity.

Modeling COVID-19 infection dynamics and mitigation strategies for in-person K-6 instruction

Background

U.S. school closures due to the coronavirus disease 2019 (COVID-19) pandemic led to extended periods of remote learning and social and economic impact on families. Uncertainty about virus dynamics made it difficult for school districts to develop mitigation plans that all stakeholders consider to be safe.

Methods

We developed an agent-based model of infection dynamics and preventive mitigation designed as a conceptual tool to give school districts basic insights into their options, and to provide optimal flexibility and computational ease as COVID-19 science rapidly evolved early in the pandemic. Elements included distancing, health behaviors, surveillance and symptomatic testing, daily symptom and exposure screening, quarantine policies, and vaccination. Model elements were designed to be updated as the pandemic and scientific knowledge evolve. An online interface enables school districts and their implementation partners to explore the effects of interventions on outcomes of interest to states and localities, under a variety of plausible epidemiological and policy assumptions.

Results

The model shows infection dynamics that school districts should consider. For example, under default assumptions, secondary infection rates and school attendance are substantially affected by surveillance testing protocols, vaccination rates, class sizes, and effectiveness of safety education.

Conclusions

Our model helps policymakers consider how mitigation options and the dynamics of school infection risks affect outcomes of interest. The model was designed in a period of considerable uncertainty and rapidly evolving science. It had practical use early in the pandemic to surface dynamics for school districts and to enable manipulation of parameters as well as rapid update in response to changes in epidemiological conditions and scientific information about COVID-19 transmission dynamics, testing and vaccination resources, and reliability of mitigation strategies.

Health Justice: A Framework for Mitigating the Impacts of HIV and COVID-19 on Disproportionately Affected Communities

Health crises have a disproportionate impact on communities that are marginalized by systems of oppression such as racism and capitalism. Benefits of advances such as in the prevention and treatment of HIV disease are unequally distributed. Intersecting factors including poverty, homophobia, homelessness, racism, and mass incarceration expose marginalized populations to greater risks while limiting access to resources that buffer these risks. Similar patterns have emerged with COVID-19. We identify comparable pitfalls in our responses to HIV and COVID-19. We introduce health justice as a framework for mitigating the long-term impact of the HIV epidemic and COVID-19 pandemic. The health justice framework considers the central role of power in the health and liberation of communities hit hardest by legacies of marginalization. We provide 5 recommendations grounded in health justice: (1) redistribute resources, (2) enforce mandates that redistribute power, (3) enact legislation that guarantees support for people with long-haul COVID-19, (4) center experiences of the most impacted communities in policy development, and (5) evaluate multidimensional effects of policies across systems. Successful implementation of these recommendations requires community organizing and collective action. (Am J Public Health. 2023;113(2): 194-201. https://doi.org/10.2105/AJPH.2022.307139).

Political Economy of the COVID-19 Pandemic: How State Policies Shape County-Level Disparities in COVID-19 Deaths

The authors examine how two state-level coronavirus disease 2019 (COVID-19) policy indices (one capturing economic support and one capturing stringency measures such as stay-at-home orders) were associated with county-level COVID-19 mortality from April through December 2020 and whether the policies were more beneficial for certain counties. Using multilevel negative binominal regression models, the authors found that high scores on both policy indices were associated with lower county-level COVID-19 mortality. However, the policies appeared to be most beneficial for counties with fewer physicians and larger shares of older adults, low-educated residents, and Trump voters. They appeared to be less effective in counties with larger shares of non-Hispanic Black and Hispanic residents. These findings underscore the importance of examining how state and local factors jointly shape COVID-19 mortality and indicate that the unequal benefits of pandemic policies may have contributed to county-level disparities in COVID-19 mortality.

An exploration of structural determinants driving racial disparities in COVID-19 deaths in Michigan

Aim

Racial disparities in COVID-19 death rates have largely been driven by structural racism in health, housing, and labor systems that place Black, Brown, and Indigenous populations at greater risk for COVID-19 exposure, transmission, and severe illness, compared to non-Hispanic White populations. Here we examine the association between taxable property values per capita, an indicator influenced by historical and contemporary housing policies that have disproportionately impacted people of color, and COVID-19 deaths.

Methods

Taxable values serve as a proxy for fiscal health providing insight on the county's ability to address imminent needs, including COVID-19 responses. Therefore, higher taxable values indicate local governments that are better equipped to deliver these public services. We used county-level data from the American Community Survey, the Michigan Community Financial Dashboard, The Atlantic's COVID Tracking Project, and the Community Health Rankings and Roadmap for this cross-sectional study. Maps were created to examine the geographic distribution of cumulative death rates and taxable values per capita, and regression models were used to examine the association between the two while controlling for population density, age, education, race, income, obesity, diabetes, and smoking rates.

Results

Seventy-five counties were included. The mean taxable value per capita was $43,764.50 and the mean cumulative death rate was 171.86. Findings from the regression analysis showed that counties with higher taxable values were associated with lower COVID-19 death rates (B = -2.45, P < 0.001).

Conclusion

Our findings reveal a need to reevaluate current policies surrounding taxable property values in the state of Michigan, not solely for their inequitable impact on local governments' financial solvency and service quality, but also for their negative consequences for population health and racial health equity.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10389-022-01817-w.

An Equity-Based Scoring System for Evaluating Surveillance-Related Harm in Public Health Crises

Background

Although surveillance systems used to mitigate disasters serve essential public health functions, communities of color have experienced disproportionate harms (eg, criminalization) as a result of historic and enhanced surveillance.

Methods

To address this, we developed and piloted a novel, equity-based scoring system to evaluate surveillance systems regarding their potential and actual risk of adverse effects on communities made vulnerable through increased exposure to policing, detention/incarceration, deportation, and disruption of access to social services or public resources. To develop the scoring system, we reviewed the literature and surveyed an expert panel on surveillance to identify specific harms (eg, increased policing) that occur through surveillance approaches.

Results

Scores were based on type of information collected (individual and/or neighborhood level) and evidence of sharing information with law enforcement. Scores were 0 (no risk of harm identified), 1 (potential for risk), 2 (evidence of risk), and U (data not publicly accessible). To pilot the scoring system, 44 surveillance systems were identified between June 2020 and October 2020 through an environmental scan of systems directly related to COVID-19 (n=21), behavioral and health-related services (n=11), and racism and racism-related factors (n=12). A score of 0-2 was assigned to 91% (n=40) of the systems; 9% were scored U; 30% (n=13) scored a 0. Half scored a 1 (n=22), indicating a "potential for the types of harm of concern in this analysis." "Evidence of harm," a score of 2, was found for 12% (n=5).

Conclusions

The potential for surveillance systems to compromise the health and well-being of racialized and/or vulnerable populations has been understudied. This project developed and piloted a scoring system to accomplish this equity-based imperative. The nobler pursuits of public health to improve the health for all must be reconciled with these potential harms.

Empirical evidence on structural racism as a driver of racial inequities in COVID-19 mortality

Objective

This study contributes to the literature by empirically testing the extent to which place-based structural racism is a driver of state-level racial inequalities in COVID-19 mortality using theoretically-informed, innovative approaches.

Methods

CDC data are used to measure cumulative COVID-19 death rates between January 2020 and August 2022. The outcome measure is a state-level Black-White (B/W) ratio of age-adjusted death rates. We use state-level 2019 administrative data on previously validated indicators of structural racism spanning educational, economic, political, criminal-legal and housing to identify a novel, multi-sectoral latent measure of structural racism (CFI = 0.982, TLI = 0.968, and RMSEA = 0.044). We map B/W inequalities in COVID-19 mortality as well as the latent measure of structural racism in order to understand their geographic distribution across U.S. states. Finally, we use regression analyses to estimate the extent to which structural racism contributes to Black-White inequalities in COVID-19 mortality, net of potential confounders.

Results

Results reveal substantial state-level variation in the B/W ratio of COVID-19 death rates and structural racism. Notably, regression estimates indicate that the relationship between the structural racism and B/W inequality in COVID-19 mortality is positive and statistically significant (p < 0.001), both in the bivariate model (adjusted R2 = 0.37) and net of the covariates (adjusted R2 = 0.54). For example, whereas states with a structural racism value 2 standard deviation below the mean have a B/W ratio of approximately 1.12, states with a structural racism value 2 standard deviation above the mean have a ratio of just above 2.0.

Discussion

Findings suggest that efficacious health equity solutions will require bold policies that dismantle structural racism across numerous societal domains.

Predicting COVID-19 community infection relative risk with a Dynamic Bayesian Network

As COVID-19 continues to impact the United States and the world at large it is becoming increasingly necessary to develop methods which predict local scale spread of the disease. This is especially important as newer variants of the virus are likely to emerge and threaten community spread. We develop a Dynamic Bayesian Network (DBN) to predict community-level relative risk of COVID-19 infection at the census tract scale in the U.S. state of Indiana. The model incorporates measures of social and environmental vulnerability-including environmental determinants of COVID-19 infection-into a spatial temporal prediction of infection relative risk 1-month into the future. The DBN significantly outperforms five other modeling techniques used for comparison and which are typically applied in spatial epidemiological applications. The logic behind the DBN also makes it very well-suited for spatial-temporal prediction and for "what-if" analysis. The research results also highlight the need for further research using DBN-type approaches that incorporate methods of artificial intelligence into modeling dynamic processes, especially prominent within spatial epidemiologic applications.

Municipal Ethnic Composition and Disparities in COVID-19 Infections in New Jersey: A Blinder-Oaxaca Decomposition Analysis

COVID-19 has disproportionally impacted Latinx and Black communities in the US. Our study aimed to extend the understanding of ethnic disparities in COVID-19 case rates by using a unique dataset of municipal case rates across New Jersey (NJ) during the first 17 months of the pandemic. We examined the extent to which there were municipal-level ethnic disparities in COVID-19 infection rates during three distinct spikes in case rates over this period. Furthermore, we used the Blinder-Oaxaca decomposition analysis to identify municipal-level exposure and vulnerability factors that contributed to ethnic disparities and how the contributions of these factors changed across the three initial waves of infection. Two clear results emerged. First, in NJ, the COVID-19 infection risk disproportionally affected Latinx communities across all three waves during the first 17 months of the pandemic. Second, the exposure and vulnerability factors that most strongly contributed to higher rates of infection in Latinx and Black communities changed over time as the virus, alongside medical and societal responses to it, also changed. These findings suggest that understanding and addressing ethnicity-based COVID-19 disparities will require sustained attention to the systemic and structural factors that disproportionately place historically marginalized ethnic communities at greater risk of contracting COVID-19.