The Health Care Institution, Population Health and Black Lives

Colour-blind racial attitudes in entry-level dental hygiene students in Virginia

OBJECTIVE

Subscribing to colour-blind racial attitudes may contribute to inequities in the delivery of oral care and affect treatment of diverse patients. The purpose of this study was to survey all entry-level dental hygiene students in one state to determine colour-blind racial attitudes.

METHODS

After IRB approval, a convenience sample of 220 dental hygiene students in all entry-level programmes in Virginia were invited to participate in this cross-sectional study. The Colour-Blind Racial Attitudes Scale (CoBRAS), an effective, validated measuring instrument, was used to quantify unawareness of contemporary racist ideals. Three subscales (Racial Privilege, Institutional Discrimination and Blatant Racial Issues) were also measured by the survey. Descriptive statistics, separate one-way between-subjects ANOVA and independent samples t-tests were used to analyse the data.

RESULTS

One-hundred and sixty (n = 160) dental hygiene students completed the survey. Independent samples t-tests revealed statistically significant differences when comparing year in programme and programme type. Participants in their second year of dental hygiene education had significantly lower overall CoBRAS scores compared to those in their first year of education (M = 50.76, M = 59.13, respectively; p = 0.004). Participants enrolled in a baccalaureate dental hygiene (B.S.) programme had significantly lower overall CoBRAS scores compared to those enrolled in an associate (A.S.) programme (M = 50.53, M = 59.54, respectively; p = 0.002).

CONCLUSIONS

Participants possessed moderate levels of colour-blindness, suggesting a need for more awareness and training early in dental hygiene education to increase delivery of culturally competent oral healthcare.

Opioid Misuse and Opioid Overdose Mortality Among the Black Population in the United States: An Integrative Review

Opioid misuse is a growing public health concern in the United States (U.S.). This problem continues to claim many lives and has affected the life expectancy of the U.S. population. In the past few years, the Black population has witnessed an increased rate of overdose deaths compared to their white counterparts. This review seeks to characterize recent trends in opioid prescription practices and overdose deaths among the Black population in the U.S. An integrative review was conducted with a literature search from CINHAL, MEDLINE, and PsycINFO databases. The literature search identified 11 articles for the analysis. All studies were quantitative. Six studies focused on overdose mortality and five on opioid prescription practices. The results indicate a rising trend in opioid overdose mortality among Black people due to the availability of synthetic opioids on the illegal drug market. Black people receive fewer opioid prescriptions and experience higher rates of opioid dose reduction compared to Whites. The Black population has experienced an increase in opioid overdose mortality compared to the White population within the last two decades. Opioid overdose deaths among Black people are highly associated with the proliferation of synthetic opioids, and Black men have been more affected than Black women. Black people experience lower rates of opioid prescription during E.R. visits compared to Whites. The issue of low opioid prescribing among Black people needs to be addressed since it affects their health outcomes and is a factor that contributes to the use of illicit synthetic opioids.

The Workforce Needed to Address Population Health

Policy Points Although a single definition of the population health workforce does not yet exist, this workforce needs to have the skills and competencies to address the social determinants of health, to understand intersectionality, and to coordinate and work in concert with an array of skilled providers in social and health care to address multiple health drivers. On-the-job training programs and employer support are needed for the current health workforce to gain skills and competencies to address population health. Funding and leadership combined are critical for developing the population health workforce with the goal of supporting a broad set of workers beyond health and social care to include, for example, those in urban planning, law enforcement, or transportation professions to address population health.

Failure of leadership in U.S. academic medicine after George Floyd's killing by police and amidst subsequent unrest

The horrific nature of George Floyd's killing by a Minneapolis Police Department officer on May 25, 2020 sparked an enduring stretch of nationwide protests against police brutality and in support of the Black Lives Matter movement. During periods of crisis, anchor institutions may exert leadership by issuing public statements to communicate shared institutional values, enhance morale, and signal direction in the face of crisis. In our analysis of public statements issued by 56 leading U.S. medical schools, we found that nearly all identified George Floyd by name, and a majority noted the role of racism or acknowledged the Black community specifically. Fewer referenced the act resulting in Floyd's death or made explicit reference to the police. Far fewer explicitly used terms denoting active support, like "antiracism" or "Black Lives Matter." Only a minority of institutions made reference to the killing of George Floyd by the police, and most failed to address this country's targeted, historically engrained, and sustained oppression of Black people through white supremacy. Thus, there remain significant opportunities for U.S. medical schools to exert meaningful leadership in public health.

The incidence of and risk factors for hospitalized acute kidney injury among people living with HIV on antiretroviral treatment

OBJECTIVES

The epidemiology of hospitalized acute kidney injury (AKI) among people living with HIV (PLWH) in the era of modern antiretroviral therapy (ART) for all PLWH is not well characterized. We evaluated the incidence of and risk factors for hospitalized AKI from 2005 to 2015 among PLWH on ART.

METHODS

We conducted a retrospective analysis of PLWH from the Johns Hopkins HIV Clinical Cohort. We defined hospitalized AKI as a rise of ≥ 0.3 mg/dL in serum creatinine (SCr) within any 48-h period or a 50% increase in SCr from baseline and assessed associations of risk factors with incident AKI using multivariate Cox regression models.

RESULTS

Most participants (75%) were black, 34% were female, and the mean age was 43 years. The incidence of AKI fluctuated annually, peaking at 40 per 1000 person-years (PY) [95% confidence interval (CI) 22-69 per 1000 PY] in 2007, and reached a nadir of 20 per 1000 PY (95% CI 11-34 per 1000 PY) in 2010. There was no significant temporal trend (-3.3% change per year; 95% CI -8.6 to 2.3%; P = 0.24). After multivariable adjustment, characteristics independently associated with AKI included black race [hazard ratio (HR) 2.44; 95% CI 1.42-4.20], hypertension (HR 1.62; 95% CI 1.09-2.38), dipstick proteinuria > 1 (HR 1.86; 95% CI 1.07-3.23), a history of AIDS (HR 1.82; 95% CI 1.29-2.56), CD4 count < 200 cells/µL (HR 1.46; 95% CI 1.02-2.07), and lower serum albumin (HR 1.73 per 1 g/dL decrease; 95% CI 1.02-2.07).

CONCLUSIONS

In this contemporary cohort of PLWH, the annual incidence of first AKI fluctuated during the study period. Attention to modifiable AKI risk factors and social determinants of health may further reduce AKI incidence among PLWH.

Racial disparities in provider-patient communication of incidental medical findings

Health disparities research often focuses on the social patterning of health outcomes. Increasingly, there has been an emphasis on understanding the mechanisms perpetuating disparities, even after issues of patient access to health services are addressed. The following study utilizes a novel dataset of electronic medical records (EMR), radiology records, and U.S. Census data to investigate the racial/ethnic patterning of provider-patient communication among patients diagnosed with incidental medical findings requiring follow-up. My results indicate that racial/ethnic disparities in follow-up adherence stem from initial disparities in provider-patient communication. These communication disparities persist even after accounting for multiple socioeconomic, health, and provider characteristics, indicating a bias in medicine, whereby providers are less likely to communicate information about incidental medical findings to patients of color relative to White patients. This paper has important clinical implications, as it sheds new light on why we might see low adherence to medical advice among patients of color. Findings also have social, political, and policy relevance, as they suggest an important mechanism through which health inequalities persist. To finally eliminate racial/ethnic health inequalities in the United States, racial bias and discrimination within medical and public health infrastructures must be eliminated.

Social exclusion and universal health coverage: health care rights and citizen-led accountability in Guatemala and Peru

BACKGROUND

While equity is a central concern in promoting Universal Health Coverage (UHC), the impact of social exclusion on equity in UHC remains underexplored. This paper examines challenges faced by socially excluded populations, with an emphasis on Indigenous peoples, to receive UHC in Latin America. We argue that social exclusion can have negative effects on health systems and can undermine progress towards UHC. We examine two case studies, one in Guatemala and one in Peru, involving citizen-led accountability initiatives that aim to identify and address problems with health care services for socially excluded groups. The case studies reveal how social exclusion can affect equity in UHC.

METHODS

In-depth analysis was conducted of all peer reviewed articles published between 2015 and 2019 on the two cases (11 in total), and two non-peer reviewed reports published over the same period. In addition, two of the three authors contributed their first-hand knowledge gathered through practitioner involvement with the citizen-led initiatives examined in the two cases. The analysis sought to identify and compare challenges faced by socially excluded Indigenous populations to receive UHC in the two cases.

RESULTS

Citizen-led accountability initiatives in Guatemala and Peru reveal very similar patterns of serious deficiencies that undermine efforts towards the realization of Universal Health Coverage in both countries. In each case, the socially excluded populations are served by a dysfunctional publicly provided health system marked by gaps and often invisible barriers. The cases suggest that, while funding and social rights to coverage have expanded, marginalized populations in Guatemala and Peru still do not receive either the health care services or the protection against financial hardship promised by health systems in each country. In both cases, the dysfunctional character of the system remains in place, undermining progress towards UHC.

CONCLUSIONS

We conclude that efforts to promote UHC cannot stop at increasing health systems financing. In addition, these efforts need to contend with the deeper challenges of democratizing state institutions, including health systems, involved in marginalizing and excluding certain population groups. This includes stronger accountability systems within public institutions. More inclusive accountability mechanisms are an important step in promoting equitable progress towards UHC.

Cancer Pain in Relation to Metropolitan Area Segregation and Nursing Home Racial and Ethnic Composition

OBJECTIVES

To estimate pain reporting among residents with cancer in relation to metropolitan area segregation and NH racial and ethnic composition.

DESIGN

Cross-sectional study.

SETTING AND PARTICIPANTS

383,757 newly admitted black (B), Hispanic (H), or white (W) residents with cancer in 12,096 US NHs (2011-2013).

METHODS

Using the Minimum Data Set 3.0, pain in past 5 days was determined by self-report or use of pain management. The Theil entropy index, a measure of metropolitan area segregation, was categorized [high (up to 0.20), very high (0.20-0.30), or extreme (0.30-0.53)].

RESULTS

Pain prevalence decreased across segregation level (black: high = 77%, very high = 75%, extreme = 72%; Hispanic: high = 79%, very high = 77%, extreme = 70%; white: high = 80%, very high = 77%, extreme = 74%). In extremely segregated areas, all residents were less likely to have recorded pain [adjusted prevalence ratios: blacks, 4.6% less likely, 95% confidence interval (CI) 3.1%-6.1%; Hispanics, 6.9% less likely, 95% CI 4.2%-9.6%; whites, 7.4% less likely, 95% CI 6.5%-8.2%] than in the least segregated areas. At all segregation levels, pain was recorded more frequently for residents (black or white) in predominantly white (>80%) NHs than in mostly black (>50%) NHs or residents (Hispanic or white) in predominantly white NHs than mostly Hispanic (>50%) NHs.

CONCLUSIONS AND IMPLICATIONS

We observed decreased pain recording in metropolitan areas with greater racial and ethnic segregation. This may occur through the inequitable distribution of resources between NHs, resident-provider empathy, provider implicit bias, resident trust, and other factors.

Racial Disparities in a Sample of Inpatient Youth with ASD

Although more than one in 10 youth with Autism Spectrum Disorder (ASD) is admitted to a psychiatric facility before they reach adulthood, the inpatient population is underrepresented in research. Furthermore, Black youth are more likely to be psychiatrically hospitalized, compared to their White counterparts. Yet, prior research has been inconsistent in potential racial differences in ASD symptoms and severity. This study examined differences in the symptom presentation of psychiatrically hospitalized Black and White youth with ASD. Researchers collected data as part of a larger study of youth admitted to one of six US specialized inpatient psychiatric units between 2013 and 2017. We used bivariate and multivariate models to analyze the data. The study included 654 youth diagnosed with ASD, with an average age of 13 years. While bivariate analyses found that Black youth had lower written language and daily living skills and more impaired social affect and inappropriate speech, multivariate regression models suggested that overall ability level and age may be driving these differences. Specifically, the only variables that significantly predicted adaptive functioning (written language, daily living) and behavioral profiles (social affect, inappropriate speech) were verbal ability, IQ, and age. Race was not a significant predictor in any of the models. Cultural diversity and competency are vital to the identification and treatment of ASD clinical care. Thus, understanding the role race may play in early detection and accurate diagnosis is important to improving ASD identification, diagnosis, and treatment. Autism Res 2020, 13: 532-538. © 2020 International Society for Autism Research, Wiley Periodicals, Inc. LAY SUMMARY: This study examined differences in autism symptoms between Black and White youth in psychiatric hospitals. We found that while it initially appeared that Black and White youth differed in written language and daily living skills, these racial differences were not significant once we accounted for differences in IQ, age, and verbal ability. Our findings suggest that providers should pay greater attention to other potential reasons for racial disparities in autism services.

Hospital-Community Partnerships: Facilitating Communication for Population Health on Columbus' South Side

Previous studies have focused on the role anchor institutions play in community development. However, less attention has been directed to how hospitals can effectively partner with community-organizations and residents as part of population health efforts. This article examines community views of one initiative developed by a major American children's hospital in partnership with local community organizations. The data for this study come from 35 in-depth interviews with local residents from the neighborhood adjacent to the hospital and two interviews with hospital administrators. Our findings suggest that the contexts in which hospitals and other non-profit corporations operate pose unique challenges to effective communication. In particular, hospitals and community organizations may think differently about the merits and nature of open communication. Especially when acting as anchor institutions working beyond their formal medical expertise, hospitals may struggle to communicate the scope and goals of their non-medical work in the community.

Epigenetics and Health Disparities

PURPOSE OF REVIEW

African Americans disproportionately suffer from leading causes of morbidity and mortality including cardiovascular disease (CVD), cancer, and preterm birth. Disparities can arise from multiple social and environmental exposures, but how the human body responds to these exposures to result in pathophysiologic states is incompletely understood.

RECENT FINDINGS

Epigenetic mechanisms, particularly DNA methylation, can be altered in response to exposures such as air pollution, psychosocial stress, and smoking. Each of these exposures has been linked to the above health states (CVD, cancer, and preterm birth) with striking racial disparities in exposure levels. DNA methylation patterns have also been shown to be associated with each of these health outcomes.

SUMMARY

Whether DNA methylation mediates exposure-disease relationships and can help explain racial disparities in health is not known. However, because many environmental and adverse social exposures disproportionately affect minorities, understanding the role that epigenetics plays in the human response to these exposures that often result in disease, is critical to reducing disparities in morbidity and mortality.

Improving the health of African Americans in the USA: an overdue opportunity for social justice

Using a modified social ecological model, we conducted a review of the literature and nationwide statistics on African American health. We discuss the main social determinants of health and main health disparities, risk factors, the leading causes of morbidity and mortality, and access to health services for blacks in the USA. The mechanisms through which social determinants, including racism, exert their deleterious effects on black health are discussed at the macro and individual levels. Incarceration and mental health care issues are highlighted as priorities to be addressed. African Americans remain the least healthy ethnic group in the USA, a somber legacy of years of racial and social injustice and a formidable challenge to equitable health care for all. Systemic causes of suboptimal black health require equally systemic solutions; positive trends in black health indicators seem to be driven by social development programs, economic investment in education, participation of African Americans in policy, and decision-making and expansion of access to health care.