Perceived Discrimination and Cardiovascular Outcomes in Older African Americans: Insights From the Jackson Heart Study

Nursing's Role in Psychosocial Health Management After a Stroke Event: A Scientific Statement From the American Heart Association

INTRODUCTION

Stroke can have profound psychosocial health implications. These constructs are often overlooked and undertreated yet can be as devastating as the physical, functional, and cognitive consequences after stroke.

AIM

This scientific statement aims to evaluate 5 important aspects of psychosocial health (depression, stress, anxiety, fatigue, and quality of life) after a stroke to provide a framework for related nursing care across the poststroke continuum.

METHODS

A narrative review of the literature published from 2018 to 2023 was conducted with databases such as PubMed/MEDLINE, ClinicalTrials.gov, PsychInfo/EBSCOHost, PsychArticles, CINHAL, and the Cochrane Library.

RESULTS

Findings reveal a gap in evidence-based nursing interventions for addressing poststroke psychosocial needs. Critical strategies for shaping therapeutic nursing care include enhanced screening with validated tools; educating stroke survivors, families, and staff on symptom recognition, prevention, and treatment; and ensuring appropriate pharmacological management and access to psychological and psychosocial interventions, including referrals to social services and other essential support systems. Care should be comprehensive and interdisciplinary. Nurse-led research can benefit from more inclusive inclusion, including individuals with recurrent strokes and preexisting psychosocial conditions, focusing on the impact of structural racism and care disparities and expanding evidence-based nursing interventions.

CONCLUSIONS

Although there is limited high-level evidence on the nursing care for patients with suboptimal psychosocial health after stroke, nurses have a crucial role in addressing these needs. Enhanced screening, assessment, supportive services, and education are vital to ensure that patients receive the necessary treatment and care.

Subjective social status and socio-demographic correlates of perceived discrimination among older adults in India

BACKGROUND

Considering India's diversity, marked by differences in caste, class, ethnicity, religion, region, and language, discrimination can take on varying forms across social-structural locations. We examined the association between subjective social status (SSS) and perceived discrimination, and assessed the sociodemographic correlates of perceived discrimination among older persons in India.

METHODS

Data come from the 2017-18 wave 1 of the Longitudinal Aging Study in India (LASI) with a sample of 30,253 adults 60 years or older. SSS was examined using the Macarthur scale with a ladder technique. Perceived discrimination was evaluated with the Everyday Discrimination Scale. Multivariable logistic regression models examined the odds of reporting discrimination by its types and attributions.

RESULTS

39% of older adults reported low SSS, whereas 7.3% reported high SSS. Older adults with low SSS had significantly higher odds of experiencing some discrimination than those with high SSS. Compared to high-SSS peers, low-SSS individuals attributed age, gender, caste, financial, and health status as reasons for discrimination. Older women attributed gender as a reason for discrimination. Caste was reported as a reason for discrimination by rural but not urban dwellers. Relative to northerners, those from southern India reported age, financial, and health statuses as reasons for discrimination.

CONCLUSIONS

That low-SSS older adults reported age, gender, caste, financial status, and health status as reasons for discrimination and that this association persisted after considering objective indicators of socioeconomic status (SES) is suggestive of SSS as independently consequential for perceived discrimination. These findings are useful for care providers and practitioners as they encourage older patients -- especially those with low SSS who may feel stigmatized -- to seek care, comply with care regimen, and engage in behaviors that protect and promote health.

Factors Associated With Healthcare and Financial Decision Making Among Older Black Adults Without Dementia

OBJECTIVES

The study aims to identify factors associated with health care and financial decision-making among older Black adults without dementia.

METHODS

Participants (N = 326) underwent assessments of decision-making and completed measurements of factors from four categories: cognitive, contextual, psychosocial, and personality. We performed separate linear regression models to examine the association between each factor and decision-making and created a fully adjusted model.

RESULTS

Higher global cognition (estimate = 1.92, SE = 0.21, p < .0001) was associated with better decision-making. Contextual factors including higher current annual income (estimate = 0.23, SE = 0.05, p < .0001), higher childhood socioeconomic status (estimate = 0.48, SE = 0.18, p = .006), higher health and financial literacy (estimate = 0.08, SE = 0.01, p < .0001), and lower financial stress (estimate = -0.19, SE = 0.07, p = .01) were associated with better decision-making. More psychological well-being (estimate = 0.07, SE = 0.22, p = .001), a psychosocial factor, and less neuroticism (estimate = -0.06, SE = 0.02, p = .002), a personality factor, were associated with better decision-making. In the fully adjusted model, two factors, higher global cognition and higher literacy (health and financial), remained associated with better decision-making.

CONCLUSIONS

Cognitive and contextual factors serve as drivers of decision-making among older Black adults.

CLINICAL IMPLICATIONS

Clinicians may implement strategies to bolster cognition and improve health and financial literacy to facilitate optimal decision-making among older Black adults.

Everyday Discrimination Is Associated With Higher Odds of Hospitalizations Among Older African Americans

BACKGROUND

Everyday discrimination-experiences of being treated unfairly based on background characteristics like race-is linked to poor physical and mental health throughout the lifespan. Whether more experiences of discrimination are associated with higher odds of being hospitalized in older African Americans has not been explored.

METHODS

Community-dwelling participants from 3 longitudinal cohort studies (N = 446, age 65+ years) with discrimination scores and ≥12 months of linked Medicare claims were included. Hospitalizations were identified using Medicare fee-for-service claims, available for an average of 6.2 (SD: 3.7) years of follow-up after baseline.

RESULTS

In mixed-effects ordinal logistic regression models (outcomes of 0, 1, or 2+ hospitalizations per year) adjusted for age, sex, education, and income, higher discrimination was associated with higher odds of total annual hospitalizations (odds ratio [OR] per point higher = 1.09, 95% confidence intervals [95% CI]: 1.02-1.17). Results were similar when accounting for depressive symptoms.

CONCLUSIONS

Higher exposure to everyday discrimination is associated with higher odds of hospitalization among older African Americans. Mechanisms underlying associations should be explored further to understand how hospitalizations may be reduced in older African Americans.

Racial/Ethnic Discrimination and Cardiometabolic Diseases: A Systematic Review

INTRODUCTION

Racial discrimination has been identified as a risk factor for cardiometabolic diseases, the leading cause of morbidity and mortality among racial/ethnic minority groups; however, there is no synthesis of current knowledge on the association between discrimination and cardiometabolic diseases. The objective of this systematic review was to summarize evidence linking racial/ethnic discrimination and cardiometabolic diseases.

METHODS

The review was conducted based on studies identified via electronic searches of 5 databases (PubMed, Google Scholar, WorldWideScience.org, ResearchGate and Microsoft Academic) using terms related to discrimination and cardiometabolic disease.

RESULTS

Of the 123 eligible studies included in the review, 87 were cross-sectional, 25 longitudinal, 8 quasi-experimental, 2 randomized controlled trials and 1 case-control. Cardiometabolic disease outcomes discussed were hypertension (n = 46), cardiovascular disease (n = 40), obesity (n = 12), diabetes (n = 11), metabolic syndrome (n = 9), and chronic kidney disease (n = 5). Although a variety of discrimination measures was employed across the studies, the Everyday Discrimination Scale was used most often (32.5%). African Americans/Blacks were the most frequently studied racial/ethnic group (53.1%), and American Indians the least (0.02%). Significant associations between racial/ethnic discrimination and cardiometabolic disease were found in 73.2% of the studies.

DISCUSSION

Racial/ethnic discrimination is positively associated with increased risk of cardiometabolic disease and higher levels of cardiometabolic biomarkers. Identifying racial/ethnic discrimination as a potential key contributor to the health inequities associated with cardiometabolic diseases is important for addressing the significant burden borne by racial/ethnic minorities.

Discrimination and Cardiovascular Health in Black Americans: Exploring Inflammation as a Mechanism and Perceived Control as a Protective Factor

OBJECTIVE

Inflammation may be an integral physiological mechanism through which discrimination impacts cardiovascular health and contributes to racial health disparities. Limited research has examined psychosocial factors that protect against the negative effects of discrimination on inflammation. Perceived control is a promising possible protective factor, given that it has been shown to moderate the relationship between other psychosocial stressors and physiological outcomes. This study thus tested whether systemic inflammation mediated the link between discrimination and cardiovascular health and whether perceived control moderated this relationship.

METHODS

Data for this project included 347 non-Hispanic/Latinx Black adults (mean [standard deviation] age = 51.64 [11.24] years; 33% female) taken from the Midlife in the United States study. Perceived control and daily discrimination were assessed via self-report, and inflammation was measured via circulating levels of C-reactive protein (CRP), interleukin-6 (IL-6), fibrinogen, and tumor necrosis factor α. Cardiovascular health was measured by morbidity of cardiovascular conditions: heart disease, hypertension, and/or stroke.

RESULTS

CRP (indirect effect: b = 0.004, 95% confidence interval [CI] = 0.001-0.007) and fibrinogen (indirect effect: b = 0.002, 95% CI = 0.0003-0.005) mediated the link between discrimination and cardiovascular conditions. Perceived control moderated the relationship between discrimination and CRP ( F (1, 293) = 4.58, Δ R2 = 0.013, b = -0.02, SE = 0.01, p = .033). CRP mediated the link between discrimination and cardiovascular conditions only for those who reported low levels of perceived control (Index = -0.003, 95% CI = -0.007 to -0.0001).

CONCLUSION

Findings provide empirical evidence of inflammation as a mechanism linking discrimination to cardiovascular conditions among Black Americans. Additionally, perceived control may be protective. Findings could suggest beliefs about control as a potential intervention target to help reduce the negative effects of discrimination on cardiovascular health among Black Americans.

Race, everyday discrimination, and cognitive function in later life

Discrimination is pernicious in many ways, but there are inconsistent findings regarding whether it is harmful to cognitive function in later life. To address the inconsistency, we use two closely related concepts of everyday discrimination to predict cognitive trajectories in a diverse sample. Using data from the Health and Retirement Study (HRS), we examine whether the frequency of discrimination, measured at baseline with six questions, is related to poorer cognitive function and change in function over time (2008-2016). Age at baseline ranged from 53 to 100. Growth curve models of initial cognitive function and change in function were estimated. Everyday global discrimination was associated with poorer initial cognition and slower declines over time, and these relationships were not moderated by race and ethnicity. By contrast, the relationship between everyday racial discrimination and cognition was moderated by race: more frequent everyday racial discrimination was associated with better initial cognitive function among Black adults but not among Hispanic and White adults. Discrimination is a multifaceted concept, and specific types of discrimination manifest lower or higher cognitive function during later life for White, Black, and Hispanic adults.

The association of perceived discrimination with dementia risk in Black older adults

INTRODUCTION

Non-Hispanic Black, compared to non-Hispanic White, older adults are at increased risk for dementia. This may be due partly to greater exposure to psychosocial stressors, such as discrimination; however, few studies have examined this association.

METHODS

We examined the association of perceived discrimination (e.g., everyday, lifetime, and discrimination burden) with dementia risk in 1583 Black adults co-enrolled in the Atherosclerosis Risk in Communities (ARIC) Study and the Jackson Heart Study (JHS). Perceived discrimination (defined continuously and using tertiles) was assessed at JHS Exam 1 (2000-2004; mean age ± SD:66.2 ± 5.5) and related to dementia risk through ARIC visit 6 (2017) using covariate-adjusted Cox proportional hazards models.

RESULTS

Associations of perceived everyday, lifetime, and burden of discrimination with dementia risk were not supported in age-adjusted models or demographic- and cardiovascular health-adjusted models. Results were similar across sex, income, and education.

DISCUSSION

In this sample, associations between perceived discrimination and dementia risk were not supported.

HIGHLIGHTS

In Black older adults perceived discrimination not associated with dementia risk. Younger age and greater education linked to greater perceived discrimination. Older age and less education among factors associated with dementia risk. Factors increasing exposure to discrimination (education) are also neuroprotective.

Attributions for Everyday Discrimination and All-Cause Mortality Risk Among Older Black Women: A Latent Class Analysis Approach

BACKGROUND AND OBJECTIVES

This study examined the relationship between number of attributed reasons for everyday discrimination and all-cause mortality risk, developed latent classes of discrimination attribution, and assessed whether these latent classes were related to all-cause mortality risk among U.S. older Black women.

RESEARCH DESIGN AND METHOD

Participants were from the 2006 and 2008 waves of the Health and Retirement Study (N = 1,133; 335 deaths). Vital status was collected through the National Death Index through 2013 and key informant reports through 2019. Latent class analyses were conducted on discrimination attributions. Weighted Cox proportional hazards model was used to predict all-cause mortality. Analyses controlled for demographic characteristics, socioeconomic status, and health.

RESULTS

Reporting greater attributions for everyday discrimination was associated with higher mortality risk (hazard ratio [HR] = 1.117; 95% confidence interval [CI]: 1.038-1.202; p < .01), controlling for demographic characteristics, socioeconomic status, and health as well as health behaviors. A 4-class solution of the latent class analysis specified the following attribution classes: No/Low Attribution; Ancestry/Gender/Race/Age; Age/Physical Disability; High on All Attributions. When compared to the No/Low Attribution class, membership in the High on All Attributions class was associated with greater mortality risk (HR = 2.809; CI: 1.458-5.412; p < .01).

DISCUSSION AND IMPLICATIONS

Findings underscore the importance of everyday discrimination experiences from multiple sources in shaping all-cause mortality risk among older Black women. Accordingly, this study problematizes the homogenization of Black women in aging research and suggests the need for health interventions that consider Black women's multiplicity of social statuses.

Understanding the relationship between perceived discrimination and mortality in United States adults

OBJECTIVE

To understand the relationship between mortality and three types of perceived discrimination (lifetime, daily, chronic job) using a nationally representative sample of U.S. adults.

METHODS

Data from 4562 adults in the Midlife in the United States (MIDUS) between 2004 and 2006 (MIDUS II and MIDUS African American sample) were analyzed. Unadjusted associations between primary independent discrimination variables (lifetime, chronic job, daily) and mortality were analyzed using univariate Cox's proportional hazards regression models. Covariates were added to the models by group: predisposing (sex, age, race/ethnicity, education, marital status); enabling (household income, employment status, insurance status); and need factors (body mass index, diabetes, hypertension, stroke, cancer) to estimate hazard ratios.

RESULTS

After adjusting for all covariates, hazard ratios for lifetime discrimination (HR: 1.09, p = 0.034) and daily discrimination (HR: 1.03, p = 0.030) were statistically significant. There was no relationship between mortality and chronic job discrimination (HR:1.03, p = 0.15).

CONCLUSIONS

Adults experiencing lifetime and daily discrimination had significantly increased risk of mortality after adjusting for predisposing, enabling, and need factors. The findings highlight the importance of screening patients during clinical encounters for experiences of discrimination and providing appropriate resources to mitigate the negative impact of discriminatory events on mortality. Future research should work to fully understand the mechanism by which discrimination increases risk of mortality. These future findings should be used to develop targets for interventions designed to decrease mortality among adults who have experienced discrimination.

Associations between perceived discrimination and immune cell composition in the Jackson Heart Study

African American adults suffer disproportionately from several non-communicable and infectious diseases. Among numerous contributing factors, perceived discrimination is considered a stressor for members of historically marginalized groups that contributes to health risk, although biological pathways are incompletely understood. Previous studies have reported associations between stress and both an up-regulation of non-specific (innate) inflammation and down-regulation of specific (adaptive) immunity. While associations between perceived discrimination and markers of inflammation have been explored, it is unclear if this is part of an overall shift that also includes down-regulated adaptive immunity. Relying on a large cross-section of African American adults (n = 3,319) from the Jackson Heart Study (JHS) in Jackson, Mississippi, we tested whether perceived everyday and lifetime discrimination as well as perceived burden from lifetime discrimination were associated with counts of neutrophils (innate), monocytes (innate), lymphocytes (adaptive), and the neutrophil-to-lymphocyte ratio (NLR), derived from complete white blood cell counts with differential. In addition, DNA methylation (DNAm) was measured on the EPIC array in a sub-sample (n = 1,023) of participants, allowing estimation of CD4T, CD8T and B lymphocyte proportions. Unexpectedly, high lifetime discrimination compared to low was significantly associated with lower neutrophils (b : -0.14, [95% CI: -0.24, -0.04]) and a lower NLR (b : -0.15, [95% CI: -0.25, -0.05]) after controlling for confounders. However, high perceived burden from lifetime discrimination was significantly associated with higher neutrophils (b : 0.17, [95% CI: 0.05, 0.30]) and a higher NLR (b : 0.16, [95% CI: 0.03, 0.29]). High perceived burden was also associated with lower lymphocytes among older men, which our analysis suggested might have been attributable to differences in CD4T cells. These findings highlight immune function as a potentially important pathway linking perceived discrimination to health outcomes.

Multiple Reasons for Perceived Everyday Discrimination and All-Cause Mortality Risk Among Older Black Adults

BACKGROUND

This study assessed whether reporting multiple reasons for perceived everyday discrimination was associated with an increased risk for all-cause mortality risk among older Black adults.

METHODS

This study utilized data from a subsample of older Black adults from the Health and Retirement Study (HRS), a nationally representative panel study of older adults in the United States. Our measure of multiple reasons for perceived everyday discrimination was based on self-reports from the 2006/2008 HRS waves. Respondents' vital status was obtained from the National Death Index and reports from key household informants (spanning 2006-2019). Cox proportional hazard models, which accounted for covariates linked to mortality, were used to estimate the risk of all-cause mortality.

RESULTS

During the observation period, 563 deaths occurred. Twenty percent of Black adults attributed perceived everyday discrimination to 3 or more sources. In demographic adjusted models, attributing perceived everyday discrimination to 3 or more sources was a statistically significant predictor of all-cause mortality risk (hazard ratio = 1.45; 95% confidence interval = 1.12-1.87). The association remained significant (hazard ratio = 1.49; 95% confidence interval = 1.15-1.93) after further adjustments for health, behavioral, and economic characteristics.

CONCLUSIONS

Examining how multiple reasons for perceived everyday discrimination relate to all-cause mortality risk has considerable utility in clarifying the unique contributions of perceived discrimination to mortality risk among older Black adults. Our findings suggest that multiple reasons for perceived everyday discrimination are a particularly salient risk factor for mortality among older Black adults.

The accelerated aging phenotype: The role of race and social determinants of health on aging

The pursuit to discover the fundamental biology and mechanisms of aging within the context of the physical and social environment is critical to designing interventions to prevent and treat its complex phenotypes. Aging research is critically linked to understanding health disparities because these inequities shape minority aging, which may proceed on a different trajectory than the overall population. Health disparities are characteristically seen in commonly occurring age-associated diseases such as cardiovascular and cerebrovascular disease as well as diabetes mellitus and cancer. The early appearance and increased severity of age-associated disease among African American and low socioeconomic status (SES) individuals suggests that the factors contributing to the emergence of health disparities may also induce a phenotype of 'premature aging' or 'accelerated aging' or 'weathering'. In marginalized and low SES populations with high rates of early onset age-associated disease the interaction of biologic, psychosocial, socioeconomic and environmental factors may result in a phenotype of accelerated aging biologically similar to premature aging syndromes with increased susceptibility to oxidative stress, premature accumulation of oxidative DNA damage, defects in DNA repair and higher levels of biomarkers of oxidative stress and inflammation. Health disparities, therefore, may be the end product of this complex interaction in populations at high risk. This review will examine the factors that drive both health disparities and the accelerated aging phenotype that ultimately contributes to premature mortality.

Psychosocial determinants of cardiovascular events among black Americans with chronic kidney disease or associated risk factors in the Jackson heart study

Background

Individuals with chronic kidney disease (CKD), hypertension (HTN), or diabetes mellitus (DM) are at increased risk for cardiovascular disease (CVD). The extent to which psychosocial factors are associated with increased CVD risk within these individuals is unclear. Black individuals experience a high degree of psychosocial stressors due to socioeconomic factors, environment, racism, and discrimination. We examined the association between psychosocial factors and risk of CVD events among Black men and women with CKD and CKD risk factors in the Jackson Heart Study.

Methods and Results

We identified 1919 participants with prevalent CKD or CKD risk factors at baseline. We used rotated principal component analysis - a form of unsupervised machine learning that may identify constructs not intuitively identified by a person - to describe five groups of psychosocial components (including negative moods, religiosity, discrimination, negative outlooks, and negative coping resources) based on a battery of questionnaires. Multiple imputation by chained equation (MICE) was used to impute missing covariate data. Cox models were used to quantify the association between psychosocial components and incident CVD, defined as a fatal coronary heart disease event, myocardial infarction, cardiac procedure (angiography or revascularization procedure), or stroke. Of the 929 participants in the analysis, 67% were female, 28% were current/former smokers with mean age of 56 years and mean BMI of 33 kg/m². Over a median follow-up of 8 years, 6% had an incident CVD event. In multivariable models, each standard deviation (SD) increase in the religiosity component was associated with an increased hazard for CVD event (hazard ratio [HR] = 1.52, 95% CI: 1.09–2.13).

Conclusions

Religiosity was associated with CVD among participants with prevalent CKD or CKD risk factors. Studies to better understand the mechanisms of this relationship are needed.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12882-021-02594-6.

What the Jackson Heart Study Has Taught Us About Diabetes and Cardiovascular Disease in the African American Community: a 20-year Appreciation

PURPOSE OF REVIEW

The burden of cardiometabolic diseases such as cardiovascular disease (CVD) and type 2 diabetes (T2D) is pronounced among African Americans. Research has shown that behavioral, social, metabolic, psychosocial, and genetic risk factors of CVD and T2D are closely interwoven. Approximately 20 years ago, the Jackson Heart Study (JHS) was established to investigate this constellation of risk factors.

RECENT FINDINGS

Findings from neighborhood studies emphasize the importance of social cohesion and physical environment in the context CVD and T2D risk. Socioeconomic status factors such as income and education were significant predictors for CVD and T2D. Behavioral studies indicate that modifiable risk factors such as smoking, physical inactivity, lack of sleep, and poor nutrition are associated with CVD risk and all-cause mortality. Mental health also was found to be associated with CVD and T2D. Genetic influences are associated with disease etiology. This review summarizes the joint contributions of CVD and cardiometabolic risk factors in an African American population.

Assessing Perceived Discrimination as Reported by Black and White Women Diagnosed with Breast Cancer

OBJECTIVE

Although a number of factors contribute to racial disparities in breast cancer outcomes, perceived discrimination in healthcare may be a key factor that hinders positive interactions and negatively impacts patient outcomes. The goals of our study were to (1) assess the prevalence of perceived discrimination as reported by breast cancer patients and (2) identify factors related to discrimination in women overall as well as by race.

DESIGN

This study is a secondary analysis of a larger study, "Narrowing the Gaps in Adjuvant Therapy," where a convenience sample of 359 women completed one telephone survey assessing sociodemographics, and attitudes and beliefs concerning breast cancer treatments and care. Chi-square analysis was used to assess the relationship of categorical variables with perceived discrimination, while the F-test was employed for continuous variables. Logistic regression determined predictors of perceived discrimination, a dichotomous variable (none vs. any).

RESULTS

A majority of women were Black (58%), privately insured (85%), and had at least a Bachelor's degree (48%). Discrimination was reported by 32.4% of women, with significantly more Black women reporting discrimination than White women. Insurance status, attitudes toward treatment, and distress factors were significantly related to perceived discrimination. In the logistic model, women who were less trusting of their providers (OR = 0.863 [0.751, 0.993], p = .021) and Black women (OR = 7.241 [0.751, 0.993], p = .039) were more likely to report incidences of discrimination.

CONCLUSIONS

Our findings suggest a need to understand Black survivor's experiences with healthcare. Similarly, future work must focus on identifying ways to improve provider trust amongst breast cancer survivors.

The Mediating role of perceived discrimination and stress in the associations between neighborhood social environment and TV Viewing among Jackson Heart Study participants

Objectives

The aim of this study was to test the mediating role of perceived discrimination and stress on associations between perceived neighborhood social environment (PNSE) and TV viewing.

Methods

Baseline data were used for 4716 participants (mean age = 55.1 y; 63.4% female) in the Jackson Heart Study (JHS), a large prospective cohort study of African Americans in Jackson, Mississippi. One binary TV viewing outcome was created: ≥4 h/day versus <4 h/day. PNSE variables included neighborhood violence, problems (higher value = more violence/problems), and social cohesion (higher value = more cohesion). Mediators included perceived lifetime discrimination, daily discrimination, and chronic stress (higher value = greater discrimination/stress). Multivariable regression was used with bootstrap-generated 95% bias-corrected confidence intervals (BC CIs) to test for mediation adjusting for demographics, health-related and psychosocial factors, and population density.

Results

Neighborhood violence, problems, and social cohesion were indirectly associated with TV viewing through lifetime discrimination (OR = 1.03, 95%BC CI = 1.00, 1.07; OR = 1.03, 95%BC CI = 0.99, 1.06 [marginal]; OR = 0.98, 95%BC CI = 0.94, 0.99, respectively) and chronic stress (OR = 0.95, 95%BC CI = 0.90, 0.99; OR = 0.96, 95%BC CI = 0.92, 0.99; OR = 1.05, 95%BC CI = 1.01, 1.10, respectively). Daily discrimination was neither directly nor indirectly associated with TV viewing.

Conclusions

Each PNSE variable was indirectly associated with TV viewing via lifetime discrimination and perceived stress, but not with daily discrimination among JHS participants. Unexpected directionality of mediating effects of lifetime discrimination and chronic stress should be replicated in future studies. Further research is also needed to pinpoint effective community efforts and physical environmental policies (e.g., installing bright street lights, community policing) to reduce adverse neighborhood conditions and psychosocial factors, and decrease TV viewing and subsequent cardiovascular disease risk.

Twitter-Characterized Sentiment Towards Racial/Ethnic Minorities and Cardiovascular Disease (CVD) Outcomes

Sentiments towards racial/ethnic minorities may impact cardiovascular disease (CVD) through direct and indirect pathways. In this study, we assessed the association between Twitter-derived sentiments towards racial/ethnic minorities at state-level and individual-level CVD-related outcomes from the 2017 Behavioral Risk Factor Surveillance System (BRFSS). Outcomes included hypertension, diabetes, obesity, stroke, myocardial infarction (MI), coronary heart disease (CHD), and any CVD from BRFSS 2017 (N = 433,434 to 433,680 across outcomes). A total of 30 million race-related tweets were collected using Twitter Streaming Application Programming Interface (API) from 2015 to 2018. Prevalence of negative and positive sentiment towards racial/ethnic minorities were constructed at the state level and merged with CVD outcomes. Poisson regression was used, and all the models adjusted for individual-level demographics as well as state-level demographics. Individuals living in states with the highest level of negative sentiment towards racial/ethnic minorities had 11% higher prevalence of hypertension (PR 1.11, 95% CI 1.08, 1.14), 15% higher prevalence of diabetes (PR 1.15, 95% CI 1.08, 1.22), 14% higher prevalence of obesity (PR 1.14, 95% CI 1.10, 1.18), 30% higher prevalence of stroke (PR 1.30, 95% CI 1.16, 1.46), 14% higher prevalence of MI (PR 1.14, 95% CI 1.03, 1.25), 9% higher prevalence of CHD (PR 1.09, 95% CI 1.00, 1.19), and 16% higher prevalence of any CVD outcomes (PR 1.16, 95% CI 1.09, 1.24). Conversely, Twitter-derived positive sentiment towards racial/ethnic minorities was associated with a lower prevalence of CVD outcomes. Programs and policies that promote racially inclusive environments may improve population health.

Experiences of Discrimination Are Associated With Worse Metabolic Syndrome Severity Among African Americans in the Jackson Heart Study

BACKGROUND

Metabolic syndrome (MetS) is a risk factor for the development of cardiovascular disease and type 2 diabetes. Although the development of MetS is attributed to known lifestyle factors, perceived discrimination may also contribute to MetS development and severity.

PURPOSE

We examined the associations of perceived discrimination with MetS severity among African American adults at baseline and 8-year follow-up.

METHODS

Three thousand eight hundred and seventy participants (mean age 53.8 ± 13.0; 63.1% female) without diabetes and no missing MetS severity scores at baseline were included. Each self-reported measure of discrimination at baseline (everyday, lifetime, and burden of lifetime) was classified into tertiles (low, medium, high). After adjustment for demographics and MetS risk factors, associations of discrimination were examined with a sex- and race/ethnicity-specific MetS severity Z-score. We employed a mixed model approach that allowed for the assessment of an overall association between reported discrimination at baseline and MetS severity, and for the possible change over time.

RESULTS

Sex and age differences were observed in experiences with discrimination, such that men reported higher levels of all aspects of discrimination relative to women. Everyday discrimination decreased with age, whereas lifetime discrimination increased with age (p < .05). Independent of lifestyle and demographic factors, everyday and lifetime discrimination were significantly associated with MetS severity (p = .003 and p = .017, respectively) and the associations remained constant over the 8 years (i.e., no interaction with time).

CONCLUSIONS

Our results suggest that, in a large community-based sample of African Americans, discrimination is a salient psychosocial risk factor for severity of MetS.

Back to the Future: Achieving Health Equity Through Health Informatics and Digital Health

The rapid proliferation of health informatics and digital health innovations has revolutionized clinical and research practices. There is no doubt that these fields will continue to have accelerated growth and a substantial impact on population health. However, there are legitimate concerns about how these promising technological advances can lead to unintended consequences such as perpetuating health and health care disparities for underresourced populations. To mitigate this potential pitfall, it is imperative for the health informatics and digital health scientific communities to understand the challenges faced by disadvantaged groups, including racial and ethnic minorities, which hinder their achievement of ideal health. This paper presents illustrative exemplars as case studies of contextually tailored, sociotechnical mobile health interventions designed with community members to address health inequities using community-engaged research approaches. We strongly encourage researchers and innovators to integrate community engagement into the development of data-driven, modernized solutions for every sector of society to truly achieve health equity for all.

Gendered Race and Setting Matter: Sources of Complexity in the Relationships Between Reported Interpersonal Discrimination and Cardiovascular Health in the CARDIA Study

OBJECTIVES

Using data from black and white adults enrolled in a community-based, multi-city cohort assembled in the mid-1980s, we examined whether reported experiences of interpersonal racial and gender discrimination differentially impacted on future cardiovascular health (CVH) depending on gendered race and the setting in which the interactions were reported to have occurred.

METHODS

Discrimination in eight possible settings was assessed using the Experiences of Discrimination scale at year 7; CVH two decades later was examined using a modified Life's Simple 7 score, with higher scores indicating better health. Separate multivariable linear regressions evaluated the associations between reports of racial and gender discrimination and CVH score in each possible setting stratified by gendered race.

RESULTS

Mean (SD) CVH scores at year 30 were 7.8(1.9), 8.1(1.8), 8.9(2. 0), and 8.8(1.8) among black women, black men, white women, and white men, respectively. For black women, reporting both racial and gender discrimination while receiving medical care was associated with lower CVH score. Among black men, reporting both forms of discrimination while getting a job, at work, at school, and receiving medical care was associated with lower CVH score. Among whites, reported discrimination while obtaining housing and by the police or courts (women), and in public and at work (men), was associated with a lower CVH score.

CONCLUSIONS

The setting in which discrimination is reported may be an important indicator of whether discriminatory experiences are negatively associated with CVH, providing insight on distinct effect pathways among black and white women and men.

Intersectional effects of racial and gender discrimination on cardiovascular health vary among black and white women and men in the CARDIA study

Testing hypotheses from the emerging Identity Pathology (IP) framework, we assessed race-gender differences in the effects of reporting experiences of racial and gender discrimination simultaneously compared with racial or gender discrimination alone, or no discrimination, on future cardiovascular health (CVH). Data were from a sample of 3758 black or white adults in CARDIA, a community-based cohort recruited in Birmingham, AL; Chicago, IL; Minneapolis, MN, and Oakland, CA in 1985-6 (year 0). Racial and gender discrimination were assessed using the Experiences of Discrimination scale. CVH was evaluated using a 12-point composite outcome modified from the Life's Simple 7, with higher scores indicating better health. Multivariable linear regressions were used to evaluate the associations between different perceptions of discrimination and CVH scores two decades later by race and gender simultaneously. Reporting racial and gender discrimination in ≥2 settings were 48% of black women, 42% of black men, 10% of white women, and 5% of white men. Year 30 CVH scores (mean, SD) were 7.9(1.4), 8.1(1.6), 8.8(1.6), and 8.7(1.3), respectively. Compared with those of their race-gender groups reporting no discrimination, white women reporting only gender-based discrimination saw an adjusted score difference of +0.3 (95% CI: 0.0,0.6), whereas white men reporting only racial discrimination had on average a 0.4 (95% CI: 0.1,0.8) higher score, and scores among white men reporting both racial and gender discrimination were on average 0.6 (95% CI: 1.1,-0.1) lower than those of their group reporting no discrimination. Consistent with predictions of the IP model, the associations of reported racial and gender discrimination with future CVH were different for different racially-defined gender groups. More research is needed to understand why reported racial and gender discrimination might better predict deterioration in CVH for whites than blacks, and what additional factors associated with gender and race contribute variability to CVH among these groups.

The association of self-reported discrimination to all-cause mortality: A population-based prospective cohort study

Discrimination has is an important social determinant of health and though some research has been carried out on this it is mostly from the United States, which may not be generalisable to Europe and Sweden. This study investigated the association between self-reported experiences of repeated discrimination and all-cause mortality in Scania, Sweden. The Scania Public Health survey was sent out in 2008 with a follow-up in 2013 through the Swedish national cause of death register (N=28,062). The exposure variable under investigation was self-reported discrimination and the outcome variable was all-cause mortality. Additional variables included demographics (age, sex, marital status, immigrant status), health behaviours (smoking, alcohol consumption, physical exercise), BMI, social participation, economic stress, and mental health. Time was measured as total number of days. Statistical analysis included association of the different variables to discrimination (ORs) and to all-cause mortality (HRs) adjusting for different covariates. Effect modification was tested for social participation, economic stress and mental health. The odds of discrimination was higher among the most vulnerable groups in society. All-cause mortality was strongly associated to age and sex, with a much higher risk among men than women. The association of repeated discrimination to all-cause mortality remained significant after adjusting for demographic variables, health behaviours and either social participation or economic stress, but not both. The association was non-significant after adjusting for demographic variables and mental health. Social participation was found to be an effect modifier with low participation strengthening the effect of the association of repeated discrimination to all-cause mortality. Repeated discrimination clearly has a strong impact on mental health but also on economic stress and social participation which in turn have a strong impact on mortality.

Racism and Health: Evidence and Needed Research

In recent decades, there has been remarkable growth in scientific research examining the multiple ways in which racism can adversely affect health. This interest has been driven in part by the striking persistence of racial/ethnic inequities in health and the empirical evidence that indicates that socioeconomic factors alone do not account for racial/ethnic inequities in health. Racism is considered a fundamental cause of adverse health outcomes for racial/ethnic minorities and racial/ethnic inequities in health. This article provides an overview of the evidence linking the primary domains of racism-structural racism, cultural racism, and individual-level discrimination-to mental and physical health outcomes. For each mechanism, we describe key findings and identify priorities for future research. We also discuss evidence for interventions to reduce racism and describe research needed to advance knowledge in this area.

Racism and Health: Evidence and Needed Research

In recent decades, there has been remarkable growth in scientific research examining the multiple ways in which racism can adversely affect health. This interest has been driven in part by the striking persistence of racial/ethnic inequities in health and the empirical evidence that indicates that socioeconomic factors alone do not account for racial/ethnic inequities in health. Racism is considered a fundamental cause of adverse health outcomes for racial/ethnic minorities and racial/ethnic inequities in health. This article provides an overview of the evidence linking the primary domains of racism-structural racism, cultural racism, and individual-level discrimination-to mental and physical health outcomes. For each mechanism, we describe key findings and identify priorities for future research. We also discuss evidence for interventions to reduce racism and describe research needed to advance knowledge in this area.

Women's heart health at mid-life: what is the role of psychosocial stress?

BACKGROUND

Women in mid-life experience unique stressors, including transitions within their family roles, informal caregiving, job stress, and perceived discrimination. The impact of these stressors on cardiovascular health in women during mid-life is of growing interest in both the popular and scientific literature. The objective of this review is to summarize the recent literature on stress and cardiovascular health in mid-life women. We focus on stressors that are relevant to mid-life women, including social stress and discrimination, and long-term risk of CVD events and subclinical CVD measures.

METHODS

We systematically reviewed the literature published between January 2012 and April 2018 for studies examining stress in mid-life and either CVD endpoints or subclinical CVD outcomes. Eligible studies included at least one psychosocial stress exposure, a CVD or subclinical CVD outcome, and either included only female participants, reported sex-stratified analyses or tested for a sex*stress interaction.

RESULTS

We identified 37 studies published since 2012 that met our criteria and included women between the ages of 40 and 65, including 3 case-control studies, 15 cross-sectional studies, and 19 prospective cohort studies. Because clinical CVD events typically occur after age 65 in women, only 22 studies were available that evaluated stress and hard CVD events in samples with mid-life women. Results from these studies suggested an increased and significant risk of CVD due to stress. Of the 15 studies that included subclinical CVD outcomes, the majority showed that mid-life women experiencing greater levels of stress had more subclinical CVD, as indicated by carotid intima-media thickness, flow-mediated dilation and arterial stiffness; however, several studies reported null associations.

CONCLUSIONS

General life stress, including perceived stress and life events, in mid-life was significantly related to later-life CVD risk and mid-life subclinical CVD in the majority of studies published in the past six years. Job stress was inconsistently related to CVD risk in women, and fewer studies examined characteristics of other social roles, such as marriage, motherhood or caregiving. Perceived discrimination also was associated with CVD events and subclinical CVD in some samples of mid-life women. Further investigation into specific stressors relevant to women in mid-life, including caregiving and marital stress, are needed to understand the full extent to which life stress impacts CVD risk in mid-life women.

Stress and Achievement of Cardiovascular Health Metrics: The American Heart Association Life's Simple 7 in Blacks of the Jackson Heart Study

BACKGROUND

Ideal cardiovascular health metrics (defined by the American Heart Association Life's Simple 7 [LS7]) are suboptimal among blacks, which results in high risk of cardiovascular disease. We examined the association of multiple stressors with LS7 components among blacks.

METHODS AND RESULTS

Using a community-based cohort of blacks (N=4383), we examined associations of chronic stress, minor stressors, major life events, and a cumulative stress score with LS7 components (smoking, diet, physical activity, body mass index, blood pressure, total cholesterol, and fasting plasma glucose) and an LS7 composite score. Multivariable logistic regression assessed the odds of achieving intermediate/ideal levels of cardiovascular health adjusted for demographic, socioeconomic, behavioral, and biomedical factors. The LS7 components with the lowest percentages of intermediate/ideal cardiovascular health levels were diet (39%), body mass index (47%), and physical activity (51%). Higher chronic, minor, and cumulative stress scores were associated with decreased odds (odds ratio [OR]) of achieving intermediate/ideal levels for smoking (OR [95% confidence interval], 0.80 [0.73-0.88], 0.84 [0.75-0.94], and 0.81 [0.74-0.90], respectively). Participants with more major life events had decreased odds of achieving intermediate/ideal levels for smoking (OR, 0.84; 95% confidence interval, 0.76-0.92) and fasting plasma glucose (OR, 0.90; 95% confidence interval, 0.82-0.98). Those with higher scores for minor stressors and major life events were less likely to achieve intermediate or ideal LS7 composite scores (OR [95% confidence interval], 0.89 [0.81-0.97] and 0.91 [0.84-0.98], respectively).

CONCLUSIONS

Blacks with higher levels of multiple stress measures are less likely to achieve intermediate or ideal levels of overall cardiovascular health (LS7 composite score), specific behaviors (smoking), and biological factors (fasting plasma glucose).

Dimensions of and Responses to Perceived Discrimination and Subclinical Disease Among African-Americans in the Jackson Heart Study

BACKGROUND

Although discrimination among African Americans (AAs) has been linked to various health outcomes, few studies have examined associations of multiple measures of discrimination with prevalent subclinical disease in a large sample of AAs.

OBJECTIVES

To examine the associations of measures of discrimination and coping responses to discrimination with prevalent subclinical disease among AAs in the Jackson Heart Study (JHS); and whether this association is modified by sex.

METHODS

We examined the associations of everyday, lifetime, and burden of lifetime discrimination with carotid intima-media thickness (cIMT), and left ventricular hypertrophy (LVH) among 3029 AAs in the JHS. Prevalence ratios (PR 95% confidence interval-CI) and odds ratios (OR 95% CI) were estimated for above-median cIMT and LVH, respectfully, adjusting for demographic, behavioral, and clinical risk factors.

RESULTS

No significant associations were found between everyday and lifetime discrimination and median cIMT and LVH. Participants who reported high (vs. no) burden of lifetime discrimination had a 48% reduced odds of LVH (OR, 0.52; 95% CI, 0.29, 0.94) after full adjustment. There was evidence of effect modification by sex in the association of coping with everyday discrimination and LVH after full adjustment (p value for interaction < 0.01). Women who actively (vs. passively) coped with everyday discrimination had a greater odds of prevalent LVH (OR, 2.49; 95% CI, 1.39, 4.46).

CONCLUSIONS

This study suggests that the manner by which AA women cope with discriminatory events is associated with subclinical disease.