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Lewis TL, Tupas KD. Enhancing hypertension pharmacotherapeutics education by integrating social determinants of health. AMERICAN JOURNAL OF PHARMACEUTICAL EDUCATION 2024; 88:100727. [PMID: 38844067 DOI: 10.1016/j.ajpe.2024.100727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 05/07/2024] [Accepted: 05/29/2024] [Indexed: 06/16/2024]
Abstract
OBJECTIVE Social determinants of health (SDOHs) play a significant role in hypertension management. Pharmacy program accreditation standards include that students should understand SDOHs. However, there are limited data regarding approaches to incorporating SDOHs within pharmacotherapeutics courses. This study evaluated the changes in student knowledge, understanding, perceptions, beliefs, and confidence by integrating SDOH topics in hypertension pharmacotherapeutics lectures. METHODS The study invited students enrolled in cardiovascular pharmacotherapeutics courses at 2 institutions to participate. Participation involved a preintervention questionnaire, a lecture on clinical management of hypertension incorporating SDOH concepts, an assignment involving reading a journal article and answering related questions, and a postintervention questionnaire. Data analysis was conducted using SPSS, with a predetermined α level of 0.05 for statistical significance. Mean composite questionnaire scores were calculated and compared with Wilcoxon signed rank test. RESULTS Of 109 students, the response rate was 85.3 % (93 participants). The combined questionnaire results demonstrated a statistically significant improvement in all questionnaire item composites. The open-ended knowledge assessment yielded a mean score of 5.75 (range 3-6). CONCLUSION The study intervention enhanced student knowledge, understanding, perceptions, beliefs, and confidence regarding the impact of SDOHs on hypertension. This practical and reproducible approach offers a valuable method for incorporating SDOH concepts into pharmacotherapeutics courses.
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Affiliation(s)
- Troy Lynn Lewis
- Wilkes University Nesbitt School of Pharmacy, Wilkes-Barre, PA, USA.
| | - Kris Denzel Tupas
- Roosevelt University College of Science, Health, and Pharmacy, Schaumburg, IL, USA
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2
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Ponukumati AS, Krafcik BM, Newton L, Baribeau V, Mao J, Zhou W, Goodney EJ, Fowler XP, Eid MA, Moore KO, Armstrong DG, Feinberg MW, Bonaca MP, Creager MA, Goodney PP. Association between tissue loss type and amputation risk among Medicare patients with concomitant diabetes and peripheral arterial disease. J Vasc Surg 2024:S0741-5214(24)01279-5. [PMID: 38880181 DOI: 10.1016/j.jvs.2024.06.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 06/05/2024] [Accepted: 06/09/2024] [Indexed: 06/18/2024]
Abstract
OBJECTIVE Prior studies have described risk factors associated with amputation in patients with concomitant diabetes and peripheral arterial disease(DM/PAD). However, the association between the severity and extent of tissue loss type and amputation risk remains less well-described. We aimed to quantify the role of different tissue loss types in amputation risk among patients with DM/PAD, in the context of demographic, preventive, and socioeconomic factors. METHODS Applying ICD-9 and ICD-10 codes to Medicare claims data(2007-2019), we identified all patients with continuous fee-for-service Medicare coverage diagnosed with DM/PAD. Eight tissue loss categories were established using ICD-9 and ICD-10 diagnosis codes, ranging from lymphadenitis(least severe) to gangrene(most severe). We created a Cox proportional hazards model to quantify associations between tissue loss type and one- and five-year amputation risk, adjusting for age, race/ethnicity, sex, rurality, income, comorbidities, and preventive factors. Regional variation in DM/PAD rates and risk-adjusted amputation rates was examined at the hospital referral region(HRR) level. RESULTS We identified 12,257,174 patients with DM/PAD(48% male, 76% White, 10% prior myocardial infarction, 30% chronic kidney disease). While 2.2 million patients(18%) had some form of tissue loss, 10.0 million patients(82%) did not. The one-year crude amputation rate(major and minor) was 6.4% in patients with tissue loss, and 0.4% in patients without tissue loss. Among patients with tissue loss, one-year any amputation rate varied from 0.89% for patients with lymphadenitis to 26% for patients with gangrene. One-year amputation risk varied from two-fold for patients with lymphadenitis(aHR 1.96, 95%CI 1.43-2.69) to 29-fold for patients with gangrene(aHR 28.7, 95%CI 28.1-29.3), compared to patients without tissue loss. No other demographic variable including age, sex, race, or region incurred a hazard ratio for one- or five-year amputation risk higher than the least severe tissue loss category. Results were similar across minor and major amputation, and one- and five-year amputation outcomes. At a regional level, higher DM/PAD rates were inversely correlated with risk-adjusted five-year amputation rates(R2=0.43). CONCLUSION Among 12 million patients with DM/PAD, the most significant predictor of amputation was presence and extent of tissue loss, with an association greater in effect size than any other factor studied. Tissue loss could be used in awareness campaigns as a simple marker of high-risk patients. Patients with any type of tissue loss require expedited wound care, revascularization as appropriate, and infection management to avoid amputation. Establishing systems of care to provide these interventions in regions with high amputation rates may prove beneficial for these populations.
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Affiliation(s)
- Aravind S Ponukumati
- Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA; VA Medical Center, White River Junction, VT, USA.
| | - Brianna M Krafcik
- Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Laura Newton
- VA Medical Center, White River Junction, VT, USA; Department of General Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | | | - Jialin Mao
- Weill Cornell Medical Center, New York, NY, USA
| | - Weiping Zhou
- The Dartmouth Institute, Dartmouth College, Hanover, NH, USA
| | - Eric J Goodney
- Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Xavier P Fowler
- Department of General Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Mark A Eid
- Department of General Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Kayla O Moore
- Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - David G Armstrong
- Southwestern Academic Limb Salvage Alliance (SALSA), Department of Surgery, Keck School of Medicine of University of Southern California, Los Angeles, CA, USA
| | | | - Marc P Bonaca
- Colorado Prevention Center, University of Colorado, Denver, CO, USA
| | - Mark A Creager
- Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Philip P Goodney
- Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA; VA Medical Center, White River Junction, VT, USA; The Dartmouth Institute, Dartmouth College, Hanover, NH, USA
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Ali MR, Nacer H, Lawson CA, Khunti K. Racial and Ethnic Disparities in Primary Prevention of Cardiovascular Disease. Can J Cardiol 2024; 40:1016-1030. [PMID: 38309463 DOI: 10.1016/j.cjca.2024.01.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Revised: 12/19/2023] [Accepted: 01/02/2024] [Indexed: 02/05/2024] Open
Abstract
Cardiovascular disease (CVD) disproportionately affects ethnic-minority groups globally. Ethnic-minority groups face particularly high CVD burden and mortality, exacerbated by disparities across modifiable risk factors, wider determinants of health, and limited access to preventative interventions. This narrative review summarizes evidence on modifiable risk factors, such as physical activity, hypertension, diet, smoking, alcohol consumption, diabetes, and the polypill for the primary prevention of CVD in ethnic minorities. Across these factors, we find inequities in risk factor prevalence. The evidence underscores that inequalities in accessibility to interventions and treatments impede progress in reducing CVD risk using primary prevention interventions for ethnic-minority people. Although culturally tailored interventions show promise, further research is required across the different risk factors. Social determinants of health and structural inequities also exacerbate CVD risk for ethnic-minority people and warrant greater attention. Additionally, we find that only limited ethnicity-specific data and guidelines are available on CVD primary prevention interventions for most risk factors. To address these gaps in research, we provide recommendations that include the following: investigating the sustainability and real-world effectiveness of culturally sensitive interventions; ensuring that ethnic-minority peoples' perspectives are considered in research; longitudinal tracking of risk factors; interventions and outcomes in ethnic-minority people; and ensuring that data collection and reporting of ethnicity data are standardized.
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Affiliation(s)
- Mohammad R Ali
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom; National Institute for Health Research (NIHR) Leicester Cardiovascular Biomedical Research Unit, Glenfield Hospital, Leicester, United Kingdom; Diabetes Research Centre, University of Leicester, Leicester, United Kingdom.
| | | | - Claire A Lawson
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom; National Institute for Health Research (NIHR) Leicester Cardiovascular Biomedical Research Unit, Glenfield Hospital, Leicester, United Kingdom
| | - Kamlesh Khunti
- Diabetes Research Centre, University of Leicester, Leicester, United Kingdom; National Institute for Health Research (NIHR) Applied Research Collaboration East Midlands, University of Leicester, Leicester, United Kingdom
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Jain S, Bey GS, Forrester SN, Rahman-Filipiak A, Thompson Gonzalez N, Petrovsky DV, Kritchevsky SB, Brinkley TE. Aging, Race, and Health Disparities: Recommendations From the Research Centers Collaborative Network. J Gerontol B Psychol Sci Soc Sci 2024; 79:gbae028. [PMID: 38442186 PMCID: PMC11101762 DOI: 10.1093/geronb/gbae028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Indexed: 03/07/2024] Open
Abstract
Racial disparities in adverse health outcomes with aging have been well described. Yet, much of the research focuses on racial comparisons, with relatively less attention to the identification of underlying mechanisms. To address these gaps, the Research Centers Collaborative Network held a workshop on aging, race, and health disparities to identify research priorities and inform the investigation, implementation, and dissemination of strategies to mitigate disparities in healthy aging. This article provides a summary of the key recommendations and highlights the need for research that builds a strong evidence base with both clinical and policy implications. Successful execution of these recommendations will require a concerted effort to increase participation of underrepresented groups in research through community engagement and partnerships. In addition, resources to support and promote the training and development of health disparities researchers will be critical in making health equity a shared responsibility for all major stakeholders.
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Affiliation(s)
- Snigdha Jain
- Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Ganga S Bey
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Sarah N Forrester
- Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Annalise Rahman-Filipiak
- Department of Psychiatry—Neuropsychology Section, University of Michigan, Ann Arbor, Michigan, USA
| | - Nicole Thompson Gonzalez
- Department of Integrative Anthropological Sciences, University of California Santa Barbara, Santa Barbara, California, USA
| | - Darina V Petrovsky
- School of Nursing, Institute for Health, Health Care Policy, and Aging Research, Rutgers University, New Brunswick, New Jersey, USA
| | - Stephen B Kritchevsky
- Department of Internal Medicine, Section on Gerontology and Geriatric Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Tina E Brinkley
- Department of Internal Medicine, Section on Gerontology and Geriatric Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
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Gonzalez CJ, Krishnamurthy S, Rollin FG, Siddiqui S, Henry TL, Kiefer M, Wan S, Weerahandi H. Incorporating Anti-racist Principles Throughout the Research Lifecycle: A Position Statement from the Society of General Internal Medicine (SGIM). J Gen Intern Med 2024:10.1007/s11606-024-08770-2. [PMID: 38743167 DOI: 10.1007/s11606-024-08770-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 04/12/2024] [Indexed: 05/16/2024]
Abstract
Biomedical research has advanced medicine but also contributed to widening racial and ethnic health inequities. Despite a growing acknowledgment of the need to incorporate anti-racist objectives into research, there remains a need for practical guidance for recognizing and addressing the influence of ingrained practices perpetuating racial harms, particularly for general internists. Through a review of the literature, and informed by the Research Lifecycle Framework, this position statement from the Society of General Internal Medicine presents a conceptual framework suggesting multi-level systemic changes and strategies for researchers to incorporate an anti-racist perspective throughout the research lifecycle. It begins with a clear assertion that race and ethnicity are socio-political constructs that have important consequences on health and health disparities through various forms of racism. Recommendations include leveraging a comprehensive approach to integrate anti-racist principles and acknowledging that racism, not race, drives health inequities. Individual researchers must acknowledge systemic racism's impact on health, engage in self-education to mitigate biases, hire diverse teams, and include historically excluded communities in research. Institutions must provide clear guidelines on the use of race and ethnicity in research, reject stigmatizing language, and invest in systemic commitments to diversity, equity, and anti-racism. National organizations must call for race-conscious research standards and training, and create measures to ensure accountability, establishing standards for race-conscious research for research funding. This position statement emphasizes our collective responsibility to combat systemic racism in research, and urges a transformative shift toward anti-racist practices throughout the research cycle.
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Affiliation(s)
- Christopher J Gonzalez
- Division of General Internal Medicine, Department of Medicine, Weill Cornell Medicine, New York, NY, USA.
| | - Sudarshan Krishnamurthy
- Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Francois G Rollin
- Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Sarah Siddiqui
- Division of General Medicine, Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Tracey L Henry
- Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Meghan Kiefer
- Division of General Internal Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Shaowei Wan
- Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Himali Weerahandi
- Division of Hospital Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
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Fahoum K, Ringel JB, Hirsch JA, Rundle A, Levitan EB, Reshetnyak E, Sterling MR, Ezeoma C, Goyal P, Safford MM. Development and validation of mortality prediction models based on the social determinants of health. J Epidemiol Community Health 2024:jech-2023-221287. [PMID: 38729661 DOI: 10.1136/jech-2023-221287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Accepted: 05/01/2024] [Indexed: 05/12/2024]
Abstract
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.
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Affiliation(s)
- Khalid Fahoum
- Weill Cornell Medicine, New York, New York, USA
- Department of Medicine, NYU Grossman School of Medicine, New York, New York, USA
| | | | - Jana A Hirsch
- Urban Health Collaborative, Drexel University School of Public Health, Philadelphia, Pennsylvania, USA
| | | | - Emily B Levitan
- University of Alabama at Birmingham, Birmingham, Alabama, USA
| | | | | | - Chiomah Ezeoma
- Department of Population Health Sciences, Weill Cornell Medicine, New York, New York, USA
| | - Parag Goyal
- Department of Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Monika M Safford
- Department of Medicine, Weill Cornell Medicine, New York, New York, USA
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Riley T, Enquobahrie DA, Callegari LS, Hajat A. Structural gendered racism and preterm birth inequities in the United States. Soc Sci Med 2024; 348:116793. [PMID: 38547809 DOI: 10.1016/j.socscimed.2024.116793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Revised: 03/12/2024] [Accepted: 03/13/2024] [Indexed: 04/29/2024]
Abstract
Structural gendered racism - the "totality of interconnectedness between structural racism and sexism" - is conceptualized as a fundamental cause of the persistent preterm birth inequities experienced by Black and Indigenous people in the United States. Our objective was to develop a state-level latent class measure of structural gendered racism and examine its association with preterm birth among all singleton live births in the US in 2019. Using previously-validated inequity indicators between White men and Black women across 9 domains (education, employment, poverty, homeownership, health insurance, segregation, voting, political representation, incarceration), we conducted a latent profile analysis to identify a latent categorical variable with k number of classes that have similar values on the observed continuous input variables. Racialized group-stratified multilevel modified Poisson regression models with robust variance and random effects for state assessed the association between state-level classes and preterm birth. We found four distinct latent classes that were all characterized by higher levels of disadvantage for Black women and advantages for White men, but the magnitude of that difference varied by latent class. We found preterm birth risk among Black birthing people was higher across all state-level latent classes compared to White birthing people, and there was some variation of preterm birth risk across classes among Black but not White birthing people. These findings further emphasize the importance of understanding and interrogating the whole system and the need for multifaceted policy solutions.
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Affiliation(s)
- Taylor Riley
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, WA, USA.
| | - Daniel A Enquobahrie
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, WA, USA; Department of Health Systems and Population Health, School of Public Health, University of Washington, Seattle, WA, USA
| | - Lisa S Callegari
- Department of Obstetrics and Gynecology, School of Medicine, University of Washington, Seattle, WA, USA; Department of Health Systems and Population Health, School of Public Health, University of Washington, Seattle, WA, USA; Health Systems Research, Department of Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA
| | - Anjum Hajat
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, WA, USA
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Brown TH, Homan P. Structural Racism and Health Stratification: Connecting Theory to Measurement. JOURNAL OF HEALTH AND SOCIAL BEHAVIOR 2024; 65:141-160. [PMID: 38308499 PMCID: PMC11110275 DOI: 10.1177/00221465231222924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2024]
Abstract
Less than 1% of studies on racialized health inequities have empirically examined their root cause: structural racism. Moreover, there has been a disconnect between the conceptualization and measurement of structural racism. This study advances the field by (1) distilling central tenets of theories of structural racism to inform measurement approaches, (2) conceptualizing U.S. states as racializing institutional actors shaping health, (3) developing a novel latent measure of structural racism in states, (4) using multilevel models to quantify the association between structural racism and five individual-level health outcomes among respondents from the Health and Retirement Study (N = 9,020) and the Behavioral Risk Factor Surveillance System (N = 308,029), and (5) making our measure of structural racism publicly available to catalyze research. Results show that structural racism is consistently associated with worse health for Black people but not White people. We conclude by highlighting this study's contributions (theoretical, methodological, and substantive) and important avenues for future research on the topic.
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Askew AJ, Randall A, Alvarez JC, Elbe CI, Caravelli N, Gonzales M, van der Star A, Blashill AJ. Examining the association of structural stigmas with body image-related outcomes among sexual minority individuals. Body Image 2024; 48:101652. [PMID: 38141492 DOI: 10.1016/j.bodyim.2023.101652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 11/13/2023] [Accepted: 11/20/2023] [Indexed: 12/25/2023]
Abstract
Sexual minority individuals display heightened body image disturbance, which is associated with negative health outcomes. Structural stigmas are associated with negative health outcomes among sexual minority individuals, but the association between structural stigmas and body image is not understood. Using a linear regression approach, we examined how U.S. state-level structural racism and structural sexual minority stigma were associated with body image-related outcomes including eating pathology, appearance and/or performance-enhancing drug (APED) misuse, and dysmorphic concern. Participants were 942 cisgender sexual minority individuals ages 18-30, with approximately equal representation among non-Hispanic/Latinx White, Black, Asian, and Hispanic/Latinx individuals. There was not a significant main effect of state-level structural sexual minority stigma on body image-related outcomes. In states with higher structural racism, Hispanic/Latinx participants endorsed higher APED misuse, and this interaction was not significant among non-Hispanic/Latinx White individuals. This pattern was not found among Black or Asian participants, nor was it replicated for dysmorphic concern or eating pathology. Findings suggest that reducing exposure to structural racism could reduce APED misuse among Hispanic/Latinx individuals.
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Affiliation(s)
- Autumn J Askew
- San Diego State University/University of California San Diego Joint Doctoral Program in Clinical Psychology, 6363 Alvarado Court, Suite 103, San Diego, CA 92120, United States
| | - Alyson Randall
- Department of Psychology, San Diego State University, 5500 Campanile Drive, San Diego, CA 92182, United States
| | - Jordan C Alvarez
- Department of Psychology, Auburn University, Auburn AL, United States
| | - Connor I Elbe
- Department of Psychology, San Diego State University, 5500 Campanile Drive, San Diego, CA 92182, United States
| | - Nicolas Caravelli
- Department of Psychology, San Diego State University, 5500 Campanile Drive, San Diego, CA 92182, United States
| | - Manuel Gonzales
- San Diego State University/University of California San Diego Joint Doctoral Program in Clinical Psychology, 6363 Alvarado Court, Suite 103, San Diego, CA 92120, United States
| | - Arjan van der Star
- Department of Psychology, San Diego State University, 5500 Campanile Drive, San Diego, CA 92182, United States
| | - Aaron J Blashill
- San Diego State University/University of California San Diego Joint Doctoral Program in Clinical Psychology, 6363 Alvarado Court, Suite 103, San Diego, CA 92120, United States; Department of Psychology, San Diego State University, 5500 Campanile Drive, San Diego, CA 92182, United States.
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10
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Sheehy S, Brock M, Palmer JR, Albert MA, Cozier Y, Rosenberg L. Perceived Interpersonal Racism in Relation to Incident Coronary Heart Disease Among Black Women. Circulation 2024; 149:521-528. [PMID: 38235551 PMCID: PMC10926238 DOI: 10.1161/circulationaha.123.066471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 01/06/2024] [Indexed: 01/19/2024]
Abstract
BACKGROUND Racism is highly prevalent in the United States. Few data exist about whether perceived interpersonal racism is associated with risk of coronary heart disease (CHD). METHODS We followed 48 305 participants in the Black Women's Health Study through biennial mailed and Internet-based health questionnaires from 1997, when they provided information on perceived interpersonal racism and were free of cardiovascular disease and cancer, until the end of 2019. We averaged participant responses to 5 validated questions about perceived interpersonal racism in everyday activities, such as "people act as if they think you are dishonest." We summed the positive responses to 3 questions about perceived racism in interactions that involved jobs, housing, and police; scores ranged from 0 (no to all) to 3 (yes to all). CHD cases were defined as nonfatal myocardial infarctions confirmed through medical records, fatal cases identified through the National Death Index, and self-reported revascularization events. We used Cox proportional hazard models adjusting for major confounders to estimate hazard ratios (HRs). RESULTS During 22 years of follow-up, we identified 1947 incident CHD cases. For women who reported experiences of racism in employment, housing, or involving the police relative to women who reported no such experiences, the age-adjusted HR for CHD was 1.35 (95% CI, 1.13-1.61; Ptrend=0.006), and the multivariable HR for CHD was 1.26 (95% CI, 1.05-1.51; Ptrend=0.05). For women in the highest quartile of perceived interpersonal racism in daily life relative to women in the lowest quartile, the age-adjusted HR for CHD was 1.25 (95% CI, 1.07-1.46; Ptrend=0.006). After multivariable adjustment, the HR was attenuated and no longer statistically significant. CONCLUSIONS Perceived experiences of interpersonal racism in employment, in housing, and with the police were associated with higher incidence of CHD among Black women, whereas perceived racism in everyday life was not associated with higher risk.
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Affiliation(s)
| | | | | | | | - Yvette Cozier
- Slone Epidemiology Center at Boston University, Boston,
MA
- Boston University School of Public Health
| | - Lynn Rosenberg
- Slone Epidemiology Center at Boston University, Boston,
MA
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11
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Woodard N, Butler J, Ghosh D, Green KM, Knott CL. The Association between State-Level Structural Racism and Alcohol and Tobacco Use Behaviors among a National Probability Sample of Black Americans. Cancer Epidemiol Biomarkers Prev 2024; 33:261-269. [PMID: 38032218 PMCID: PMC10872984 DOI: 10.1158/1055-9965.epi-23-0873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 10/24/2023] [Accepted: 11/28/2023] [Indexed: 12/01/2023] Open
Abstract
BACKGROUND Structural racism is how society maintains and promotes racial hierarchy and discrimination through established and interconnected systems. Structural racism is theorized to promote alcohol and tobacco use, which are risk factors for adverse health and cancer-health outcomes. The current study assesses the association between measures of state-level structural racism and alcohol and tobacco use among a national sample of 1,946 Black Americans. METHODS An existing composite index of state-level structural racism including five dimensions (subscales; i.e., residential segregation and employment, economic, incarceration, and educational inequities) was merged with individual-level data from a national sample dataset. Hierarchical linear and logistic regression models, accounting for participant clustering at the state level, assessed associations between structural racism and frequency of alcohol use, frequency of binge drinking, smoking status, and smoking frequency. Two models were estimated for each behavioral outcome, one using the composite structural racism index and one modeling dimensions of structural racism in lieu of the composite measure, each controlling for individual-level covariates. RESULTS Results indicated positive associations between the incarceration dimension of the structural racism index and binge drinking frequency, smoking status, and smoking frequency. An inverse association was detected between the education dimension and smoking status. CONCLUSIONS Results suggest that state-level structural racism expressed in incarceration disparities, is positively associated with alcohol and tobacco use among Black Americans. IMPACT Addressing structural racism, particularly in incarceration practices, through multilevel policy and intervention may help to reduce population-wide alcohol and tobacco use behaviors and improve the health outcomes of Black populations.
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Affiliation(s)
- Nathaniel Woodard
- Cancer Care Quality Training Program, Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - James Butler
- Department of Behavioral and Community Health, School of Public Health, University of Maryland, College Park, College Park, MD, USA
| | - Debarchana Ghosh
- Department of Geography, University of Connecticut, University of Connecticut, Storrs, CT, USA
| | - Kerry M. Green
- Department of Behavioral and Community Health, School of Public Health, University of Maryland, College Park, College Park, MD, USA
| | - Cheryl L. Knott
- Department of Behavioral and Community Health, School of Public Health, University of Maryland, College Park, College Park, MD, USA
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Riley T, Schleimer JP, Jahn JL. Organized abandonment under racial capitalism: Measuring accountable actors of structural racism for public health research and action. Soc Sci Med 2024; 343:116576. [PMID: 38237286 DOI: 10.1016/j.socscimed.2024.116576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 12/14/2023] [Accepted: 01/05/2024] [Indexed: 02/10/2024]
Abstract
Understanding the shifting nature of structural racism historically and across institutions is vital for effective action towards racial health equity. While public health research on structural racism is rapidly increasing, most studies are missing the interdependence of policies and institutional practices over time that shape power imbalances and lead to entrenched health inequities. Here, we discuss Ruth Wilson Gilmore's concept of organized abandonment - the intentional disinvestment in communities which, in turn, creates opportunities for extraction, revenue generation, and carceral enforcement to fill the cracks of a compromised social infrastructure - to encourage action-oriented public health research that is grounded in history and an understanding of racial capitalism. We present a case example using publicly-available data on redlining, gentrification and policing in Seattle, Washington. We mapped the intersections of redlining and gentrification and estimated their neighborhood-level association with police activity using Bayesian spatial Poisson regression models. We found that histories of racist housing policies like redlining and processes of gentrification are interdependent and shape contemporary neighborhood racial and economic segregation and police activity. Compared to structurally advantaged neighborhoods, police stops were higher in neighborhoods that were 1) historically disinvested (i.e. redlined) and remain low-income and structurally disadvantaged and 2) formerly industrial and business districts that were not redlined and are now gentrified. Notably, we found that policing practices were significantly more intensive in neighborhoods that were both high redlined and gentrified. Together, these findings illustrate how the place-based racialized processes of dispossession, displacement and policing are deeply intertwined to maintain racial capitalism. Our findings also highlight the importance of examining multiple racialized processes simultaneously to fill critical gaps in the existing literature that are necessary for sustainable solutions to address structural racism.
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Affiliation(s)
- Taylor Riley
- Department of Epidemiology, University of Washington School of Public Health, Seattle, WA, USA.
| | - Julia P Schleimer
- Department of Epidemiology, University of Washington School of Public Health, Seattle, WA, USA
| | - Jaquelyn L Jahn
- Ubuntu Center on Racism, Global Movements, and Population Health Equity, Department of Epidemiology & Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, PA, USA
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Allgood KL, Fleischer NL, Morenoff J, Assari S, Needham BL. Do Police Encounters Increase the Risk for Cardiovascular Disease? Police Encounters and Framingham 30-Year Cardiovascular Risk Score. J Racial Ethn Health Disparities 2024; 11:348-363. [PMID: 36719543 DOI: 10.1007/s40615-023-01523-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 12/23/2022] [Accepted: 01/16/2023] [Indexed: 02/01/2023]
Abstract
INTRODUCTION Despite increased attention to the societal consequences of aggressive policing, the focus on rarer instances of deaths/severe injuries fails to fully capture the day-to-day experiences that racially minoritized groups face during police encounters (PEs). We explored differential vulnerability by race/ethnicity in the relationship between PEs and cardiovascular disease (CVD) risk. METHODS Using data from the National Longitudinal Study of Adolescent to Adult Health, we regressed the Framingham 30-Year CVD risk score on a high number of lifetime PEs (6 + among men and 2 + among women). To explore differential vulnerability by race, we added an interaction between PEs and race/ethnicity. We also examined sex- and race and sex-stratified models. RESULTS We observed no association between PEs and CVD risk in the sample overall, but the interaction between PEs and race/ethnicity was statistically significant. In race stratified models, we found that higher PEs were associated with a lower CVD risk among Black respondents, whereas among White respondents there was no relationship. In the sex-stratified analysis, reporting higher PEs was associated with lower CVD risk among men, while among women there was no relationship. In sex- and race-stratified models, higher PEs was associated with lower CVD risk among Black men and higher CVD risk among White women, while there was no association among Black women and White men. CONCLUSION The association between PEs and CVD risk depends on race/ethnicity and sex. More work is needed to understand the counterintuitive finding that high PEs are associated with lower CVD risk among Black men.
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Affiliation(s)
- Kristi L Allgood
- Department of Epidemiology, Center for Social Epidemiology and Population Health, School of Public Health, University of Michigan, 1415 Washington Heights, 2649A, SPH Tower, Ann Arbor, MI, 48109, USA.
| | - Nancy L Fleischer
- Department of Epidemiology, Center for Social Epidemiology and Population Health, School of Public Health, University of Michigan, 1415 Washington Heights, 2649A, SPH Tower, Ann Arbor, MI, 48109, USA
| | - Jeffrey Morenoff
- Institute for Social Research, Population Health Studies, University of Michigan, Ann Arbor, MI, USA
- Department of Sociology, University of Michigan, Ann Arbor, MI, USA
| | - Shervin Assari
- Charles R. Drew University of Medicine and Science, Los Angeles, CA, USA
| | - Belinda L Needham
- Department of Epidemiology, Center for Social Epidemiology and Population Health, School of Public Health, University of Michigan, 1415 Washington Heights, 2649A, SPH Tower, Ann Arbor, MI, 48109, USA
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14
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Kotit S. Rurality and race in heart failure risk: Insights from the Southern Community Cohort Study. Glob Cardiol Sci Pract 2024; 2024:e202404. [PMID: 38404655 PMCID: PMC10886951 DOI: 10.21542/gcsp.2024.4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Accepted: 11/11/2023] [Indexed: 02/27/2024] Open
Abstract
INTRODUCTION Rural-urban health disparities are apparent in the burden of disease and health outcomes, including cardiovascular disease (CVD), specifically heart failure (HF). However, the factors influencing these disparities are not fully understood. Study and results: Among 27,115 participants in the Southern Community Cohort Study (SCCS) (mean age: 54 years (47-65)), 18,647 (68.8%) were black, 8,468 (32.3%) were white, and 20% resided in rural areas. Over a median 13-year follow-up period, 7,542 HF events occurred (rural = 1,865 vs. urban = 5,677). The age-adjusted HF incidence was 29.6 (95% CI, 28.9-30.5) and 36.5 (95% CI, 34.9-38.3) per 1,000 person-years for urban and rural participants, respectively (P < .001). The risk of HF associated with rurality varied by race and sex. Rural black men had the highest risk across all groups (HR, 1.34; 95% CI, 1.19-1.51) (age-adjusted incidence rate: 40.4/1000 person-years (95% CI, 36.8-44.3)) followed by black women (HR, 1.18; 95% CI, 1.08-1.28) and white women (HR, 1.22; 95% CI, 1.07-1.39). Rurality was not associated with HF risk among white men (HR, 0.97; 95% CI, 0.81-1.16). LESSONS LEARNED This large study shows that rural populations have an increased incidence of HF, which is particularly striking among women and black men, independent of individual-level biological, behavioral, and sociocultural risk factors. It also shows the need for further investigation into the rurality-associated risk of HF, the impact of preventive care utilization on the risk of HF and interpersonal, community, or societal factors that could contribute to rural-urban disparities. This will help to guide public health efforts aimed at HF prevention among rural populations.
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15
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Guglielminotti J, Samari G, Friedman AM, Landau R, Li G. State-Level Indicators of Structural Racism and Severe Adverse Maternal Outcomes During Childbirth. Matern Child Health J 2024; 28:165-176. [PMID: 37938439 DOI: 10.1007/s10995-023-03828-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/24/2023] [Indexed: 11/09/2023]
Abstract
OBJECTIVES Structural racism (SR) is viewed as a root cause of racial and ethnic disparities in maternal health outcomes. However, evidence linking SR to increased odds of severe adverse maternal outcomes (SAMO) is scant. This study assessed the association between state-level indicators of SR and SAMO during childbirth. METHODS Data for non-Hispanic Black and non-Hispanic white women came from the US Natality file, 2017-2018. The exposures were state-level Black-to-white inequity ratios for lower education level, unemployment, and prison incarceration. The outcome was patient-level SAMO, including eclampsia, blood transfusion, hysterectomy, or intensive care unit admission. Adjusted odds ratios (aORs) of SAMO associated with each ratio were estimated using multilevel models adjusting for patient, hospital, and state characteristics. RESULTS A total of 4,804,488 birth certificates were analyzed, with 22.5% for Black women. SAMO incidence was 106.4 per 10,000 (95% CI 104.5, 108.4) for Black women, and 72.7 per 10,000 (95% CI 71.8, 73.6) for white women. Odds of SAMO increased 35% per 1-unit increase in the unemployment ratio for Black women (aOR 1.35; 95% CI 1.04, 1.73), and 16% for white women (aOR 1.16; 95% CI 1.01, 1.33). Odds of SAMO increased 6% per 1-unit increase in the incarceration ratio for Black women (aOR 1.06; 95% CI 1.03, 1.10), and 4% for white women (aOR 1.04; 95% CI 1.02, 1.06). No significant association was observed between SAMO and the lower education level ratio. CONCLUSIONS FOR PRACTICE State-level Black-to-white inequity ratios for unemployment and incarceration are associated with significantly increased odds of SAMO.
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Affiliation(s)
- Jean Guglielminotti
- Department of Anesthesiology, Columbia University Vagelos College of Physicians and Surgeons, 622 West 168th Street, PH5-505, New York, NY, 10032, USA.
| | - Goleen Samari
- Heilbrunn Department of Population and Family Health, Columbia University Mailman School of Public Health, 722 West 168th Street, New York, NY, 10032, USA
| | - Alexander M Friedman
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Columbia University Vagelos College of Physicians and Surgeons, 622 West 168th Street, New York, NY, 10032, USA
| | - Ruth Landau
- Department of Anesthesiology, Columbia University Vagelos College of Physicians and Surgeons, 622 West 168th Street, PH5-505, New York, NY, 10032, USA
| | - Guohua Li
- Department of Anesthesiology, Columbia University Vagelos College of Physicians and Surgeons, 622 West 168th Street, PH5-505, New York, NY, 10032, USA
- Department of Epidemiology, Columbia University Mailman School of Public Health, 722 West 168th Street, New York, NY, 10032, USA
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Hatzenbuehler ML, McLaughlin KA, Weissman DG, Cikara M. A research agenda for understanding how social inequality is linked to brain structure and function. Nat Hum Behav 2024; 8:20-31. [PMID: 38172629 PMCID: PMC11112523 DOI: 10.1038/s41562-023-01774-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 11/01/2023] [Indexed: 01/05/2024]
Abstract
Consistent evidence documents powerful effects of social inequality on health, well-being and academic achievement. Yet research on whether social inequality may also be linked to brain structure and function has, until recently, been rare. Here we describe three methodological approaches that can be used to study this question-single site, single study; multi-site, single study; and spatial meta-analysis. We review empirical work that, using these approaches, has observed associations between neural outcomes and structural measures of social inequality-including structural stigma, community-level prejudice, gender inequality, neighbourhood disadvantage and the generosity of the social safety net for low-income families. We evaluate the relative strengths and limitations of these approaches, discuss ethical considerations and outline directions for future research. In doing so, we advocate for a paradigm shift in cognitive neuroscience that explicitly incorporates upstream structural and contextual factors, which we argue holds promise for uncovering the neural correlates of social inequality.
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Affiliation(s)
| | | | - David G Weissman
- Department of Psychology, Harvard University, Cambridge, MA, USA
| | - Mina Cikara
- Department of Psychology, Harvard University, Cambridge, MA, USA
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17
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Wizentier MM, Stephenson BJK, Goodman MS. The measurement of racism in health inequities research. Epidemiol Rev 2023; 45:32-43. [PMID: 37147182 DOI: 10.1093/epirev/mxad004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Revised: 04/30/2023] [Accepted: 05/02/2023] [Indexed: 05/07/2023] Open
Abstract
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.
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Affiliation(s)
- Marina Mautner Wizentier
- Department of Biostatistics, School of Global Public Health, New York University, New York, New York 10003, United States
| | - Briana Joy K Stephenson
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States
| | - Melody S Goodman
- Department of Biostatistics, School of Global Public Health, New York University, New York, New York 10003, United States
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Watkins SH, Testa C, Simpkin AJ, Smith GD, Coull B, De Vivo I, Tilling K, Waterman PD, Chen JT, Diez-Roux AV, Krieger N, Suderman M, Relton C. An epigenome-wide analysis of DNA methylation, racialized and economic inequities, and air pollution. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.12.07.570610. [PMID: 38105971 PMCID: PMC10723401 DOI: 10.1101/2023.12.07.570610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2023]
Abstract
Importance DNA methylation (DNAm) provides a plausible mechanism by which adverse exposures become embodied and contribute to health inequities, due to its role in genome regulation and responsiveness to social and biophysical exposures tied to societal context. However, scant epigenome-wide association studies (EWAS) have included structural and lifecourse measures of exposure, especially in relation to structural discrimination. Objective Our study tests the hypothesis that DNAm is a mechanism by which racial discrimination, economic adversity, and air pollution become biologically embodied. Design A series of cross-sectional EWAS, conducted in My Body My Story (MBMS, biological specimens collected 2008-2010, DNAm assayed in 2021); and the Multi Ethnic Study of Atherosclerosis (MESA; biological specimens collected 2010-2012, DNAm assayed in 2012-2013); using new georeferenced social exposure data for both studies (generated in 2022). Setting MBMS was recruited from four community health centers in Boston; MESA was recruited from four field sites in: Baltimore, MD; Forsyth County, NC; New York City, NY; and St. Paul, MN. Participants Two population-based samples of US-born Black non-Hispanic (Black NH), white non-Hispanic (white NH), and Hispanic individuals (MBMS; n=224 Black NH and 69 white NH) and (MESA; n=229 Black NH, n=555 white NH and n=191 Hispanic). Exposures Eight social exposures encompassing racial discrimination, economic adversity, and air pollution. Main outcome Genome-wide changes in DNAm, as measured using the Illumina EPIC BeadChip (MBMS; using frozen blood spots) and Illumina 450k BeadChip (MESA; using purified monocytes). Our hypothesis was formulated after data collection. Results We observed the strongest associations with traffic-related air pollution (measured via black carbon and nitrogen oxides exposure), with evidence from both studies suggesting that air pollution exposure may induce epigenetic changes related to inflammatory processes. We also found suggestive associations of DNAm variation with measures of structural racial discrimination (e.g., for Black NH participants, born in a Jim Crow state; adult exposure to racialized economic residential segregation) situated in genes with plausible links to effects on health. Conclusions and Relevance Overall, this work suggests that DNAm is a biological mechanism through which structural racism and air pollution become embodied and may lead to health inequities.
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Affiliation(s)
- Sarah Holmes Watkins
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Integrative Epidemiology Unit, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Christian Testa
- Department of Social and Behavioral Sciences, Harvard T H Chan School of Public Health, Harvard University, Boston, MA 02115, USA
- Department of Biostatistics, Harvard School of Public Health, Boston, MA 02115, USA
| | - Andrew J. Simpkin
- School of Mathematical and Statistical Sciences, University of Galway, Galway, Ireland
| | - George Davey Smith
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Integrative Epidemiology Unit, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Brent Coull
- Department of Biostatistics, Harvard School of Public Health, Boston, MA 02115, USA
| | - Immaculata De Vivo
- Program in Genetic Epidemiology and Statistical Genetics, Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Kate Tilling
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Integrative Epidemiology Unit, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Pamela D. Waterman
- Department of Social and Behavioral Sciences, Harvard T H Chan School of Public Health, Harvard University, Boston, MA 02115, USA
| | - Jarvis T. Chen
- Department of Social and Behavioral Sciences, Harvard T H Chan School of Public Health, Harvard University, Boston, MA 02115, USA
| | - Ana V. Diez-Roux
- Department of Epidemiology and Biostatistics and Urban Health Collaborative, Dornsife School of Public Health, Drexel University, Philadelphia, USA
| | - Nancy Krieger
- Department of Social and Behavioral Sciences, Harvard T H Chan School of Public Health, Harvard University, Boston, MA 02115, USA
| | - Matthew Suderman
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Integrative Epidemiology Unit, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Caroline Relton
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Integrative Epidemiology Unit, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
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Siegel M, Rieders M, Rieders H, Moumneh J, Asfour J, Oh J, Oh S. Measuring Structural Racism and Its Association with Racial Disparities in Firearm Homicide. J Racial Ethn Health Disparities 2023; 10:3115-3130. [PMID: 36508134 PMCID: PMC9744051 DOI: 10.1007/s40615-022-01485-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 11/07/2022] [Accepted: 11/29/2022] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Structural racism is strongly related to racial health disparities. However, surprisingly few studies have developed empirical tools to measure structural racism. In addition, the few measures that have been employed have only considered structural racism at the neighborhood level. To expand upon previous studies, this paper uses a novel measure to measure structural racism at the county level for the non-Hispanic Black population. METHODS We used confirmatory factor analysis to create a model to measure the latent construct of structural racism for 1181 US counties. The model included five indicators across five dimensions: racial segregation, incarceration, educational attainment, employment, and economic status/wealth. Structural equation modeling and factor analysis were used to generate factor scores that weighted the indicators in order to produce the best model fit. The resulting factor scores represented the level of structural racism in each county. We demonstrated the utility of this measure by demonstrating its strong correlation with Black-White disparities in firearm homicide rates. RESULTS Our calculations revealed striking geographic differences across counties in the magnitude of structural racism, with the highest values generally being observed in the Midwest and Northeast. Structural racism was significantly associated with higher Black firearm homicide rates, lower White homicide rates, and a higher Black-White racial disparity in firearm homicide. CONCLUSIONS These new measures can be utilized by researchers to relate structural racism to racial health disparities at the county level.
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Affiliation(s)
- Michael Siegel
- Department of Public Health and Community Medicine, Tufts University School of Medicine, 636 Harrison Avenue, Boston, MA, 02111, USA.
| | - Madeline Rieders
- Department of Public Health and Community Medicine, Tufts University School of Medicine, 636 Harrison Avenue, Boston, MA, 02111, USA
| | - Hannah Rieders
- Department of Public Health and Community Medicine, Tufts University School of Medicine, 636 Harrison Avenue, Boston, MA, 02111, USA
| | - Jinan Moumneh
- Department of Public Health and Community Medicine, Tufts University School of Medicine, 636 Harrison Avenue, Boston, MA, 02111, USA
| | - Julia Asfour
- Department of Public Health and Community Medicine, Tufts University School of Medicine, 636 Harrison Avenue, Boston, MA, 02111, USA
| | - Jinseo Oh
- Department of Public Health and Community Medicine, Tufts University School of Medicine, 636 Harrison Avenue, Boston, MA, 02111, USA
| | - Seungjin Oh
- Department of Public Health and Community Medicine, Tufts University School of Medicine, 636 Harrison Avenue, Boston, MA, 02111, USA
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Mohottige D, Davenport CA, Bhavsar N, Schappe T, Lyn MJ, Maxson P, Johnson F, Planey AM, McElroy LM, Wang V, Cabacungan AN, Ephraim P, Lantos P, Peskoe S, Lunyera J, Bentley-Edwards K, Diamantidis CJ, Reich B, Boulware LE. Residential Structural Racism and Prevalence of Chronic Health Conditions. JAMA Netw Open 2023; 6:e2348914. [PMID: 38127347 PMCID: PMC10739116 DOI: 10.1001/jamanetworkopen.2023.48914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 11/01/2023] [Indexed: 12/23/2023] Open
Abstract
Importance Studies elucidating determinants of residential neighborhood-level health inequities are needed. Objective To quantify associations of structural racism indicators with neighborhood prevalence of chronic kidney disease (CKD), diabetes, and hypertension. Design, Setting, and Participants This cross-sectional study used public data (2012-2018) and deidentified electronic health records (2017-2018) to describe the burden of structural racism and the prevalence of CKD, diabetes, and hypertension in 150 residential neighborhoods in Durham County, North Carolina, from US census block groups and quantified their associations using bayesian models accounting for spatial correlations and residents' age. Data were analyzed from January 2021 to May 2023. Exposures Global (neighborhood percentage of White residents, economic-racial segregation, and area deprivation) and discrete (neighborhood child care centers, bus stops, tree cover, reported violent crime, impervious areas, evictions, election participation, income, poverty, education, unemployment, health insurance coverage, and police shootings) indicators of structural racism. Main Outcomes and Measures Outcomes of interest were neighborhood prevalence of CKD, diabetes, and hypertension. Results A total of 150 neighborhoods with a median (IQR) of 1708 (1109-2489) residents; median (IQR) of 2% (0%-6%) Asian residents, 30% (16%-56%) Black residents, 10% (4%-20%) Hispanic or Latino residents, 0% (0%-1%) Indigenous residents, and 44% (18%-70%) White residents; and median (IQR) residential income of $54 531 ($37 729.25-$78 895.25) were included in analyses. In models evaluating global indicators, greater burden of structural racism was associated with greater prevalence of CKD, diabetes, and hypertension (eg, per 1-SD decrease in neighborhood White population percentage: CKD prevalence ratio [PR], 1.27; 95% highest density interval [HDI], 1.18-1.35; diabetes PR, 1.43; 95% HDI, 1.37-1.52; hypertension PR, 1.19; 95% HDI, 1.14-1.25). Similarly in models evaluating discrete indicators, greater burden of structural racism was associated with greater neighborhood prevalence of CKD, diabetes, and hypertension (eg, per 1-SD increase in reported violent crime: CKD PR, 1.15; 95% HDI, 1.07-1.23; diabetes PR, 1.20; 95% HDI, 1.13-1.28; hypertension PR, 1.08; 95% HDI, 1.02-1.14). Conclusions and Relevance This cross-sectional study found several global and discrete structural racism indicators associated with increased prevalence of health conditions in residential neighborhoods. Although inferences from this cross-sectional and ecological study warrant caution, they may help guide the development of future community health interventions.
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Affiliation(s)
- Dinushika Mohottige
- Institute for Health Equity Research, Department of Population Health, Icahn School of Medicine at Mount Sinai, New York, New York
- Barbara T. Murphy Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - Nrupen Bhavsar
- Center for Community and Population Health Improvement, Duke Clinical and Translational Science Institute, Duke University, Durham, North Carolina
- Division of General Internal Medicine, Department of Medicine, Duke University, Durham, North Carolina
| | - Tyler Schappe
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina
| | - Michelle J. Lyn
- Center for Community and Population Health Improvement, Duke Clinical and Translational Science Institute, Duke University, Durham, North Carolina
- Department of Family Medicine and Community Health, Duke University, Durham, North Carolina
| | - Pamela Maxson
- Center for Community and Population Health Improvement, Duke Clinical and Translational Science Institute, Duke University, Durham, North Carolina
| | - Fred Johnson
- Center for Community and Population Health Improvement, Duke Clinical and Translational Science Institute, Duke University, Durham, North Carolina
- Department of Family Medicine and Community Health, Duke University, Durham, North Carolina
| | - Arrianna M. Planey
- Department of Health Policy and Management, Gillings School of Global Public Health, Chapel Hill, North Carolina
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill
| | - Lisa M. McElroy
- Division of Abdominal Transplant Surgery, Department of Surgery, Duke University, Durham, North Carolina
- Department of Population Health, Duke University, Durham, North Carolina
| | - Virginia Wang
- Division of General Internal Medicine, Department of Medicine, Duke University, Durham, North Carolina
- Department of Population Health, Duke University, Durham, North Carolina
| | - Ashley N. Cabacungan
- Division of General Internal Medicine, Department of Medicine, Duke University, Durham, North Carolina
| | - Patti Ephraim
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York
| | - Paul Lantos
- Duke Global Health Institute, Duke University, Durham, North Carolina
- Department of Pediatrics, Duke University, Durham, North Carolina
- Division of General Internal Medicine, Department of Medicine, Duke University, Durham, North Carolina
| | - Sarah Peskoe
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina
| | - Joseph Lunyera
- Division of General Internal Medicine, Department of Medicine, Duke University, Durham, North Carolina
| | - Keisha Bentley-Edwards
- Duke Global Health Institute, Duke University, Durham, North Carolina
- Duke Cancer Institute, Duke University, Durham, North Carolina
- Samuel DuBois Cook Center on Social Equity, Duke University, Durham, North Carolina
| | - Clarissa J. Diamantidis
- Division of General Internal Medicine, Department of Medicine, Duke University, Durham, North Carolina
- Division of Nephrology, Department of Medicine, Duke University, Durham, North Carolina
| | - Brian Reich
- Department of Statistics, North Carolina State University, Raleigh
| | - L. Ebony Boulware
- Wake Forest University School of Medicine, Winston Salem, North Carolina
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21
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Anderson NW, Eisenberg D, Zimmerman FJ. Structural Racism and Well-Being Among Young People in the U.S. Am J Prev Med 2023; 65:1078-1091. [PMID: 37385571 DOI: 10.1016/j.amepre.2023.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 06/23/2023] [Accepted: 06/23/2023] [Indexed: 07/01/2023]
Abstract
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.
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Affiliation(s)
- Nathaniel W Anderson
- Department of Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, California.
| | - Daniel Eisenberg
- Department of Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, California
| | - Frederick J Zimmerman
- Department of Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, California; Department of Urban Planning, Luskin School of Public Affairs, University of California, Los Angeles, Los Angeles, California
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22
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Jayasekera J, El Kefi S, Fernandez JR, Wojcik KM, Woo JMP, Ezeani A, Ish JL, Bhattacharya M, Ogunsina K, Chang CJ, Cohen CM, Ponce S, Kamil D, Zhang J, Le R, Ramanathan AL, Butera G, Chapman C, Grant SJ, Lewis-Thames MW, Dash C, Bethea TN, Forde AT. Opportunities, challenges, and future directions for simulation modeling the effects of structural racism on cancer mortality in the United States: a scoping review. J Natl Cancer Inst Monogr 2023; 2023:231-245. [PMID: 37947336 PMCID: PMC10637025 DOI: 10.1093/jncimonographs/lgad020] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 05/23/2023] [Accepted: 07/03/2023] [Indexed: 11/12/2023] Open
Abstract
PURPOSE Structural racism could contribute to racial and ethnic disparities in cancer mortality via its broad effects on housing, economic opportunities, and health care. However, there has been limited focus on incorporating structural racism into simulation models designed to identify practice and policy strategies to support health equity. We reviewed studies evaluating structural racism and cancer mortality disparities to highlight opportunities, challenges, and future directions to capture this broad concept in simulation modeling research. METHODS We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses-Scoping Review Extension guidelines. Articles published between 2018 and 2023 were searched including terms related to race, ethnicity, cancer-specific and all-cause mortality, and structural racism. We included studies evaluating the effects of structural racism on racial and ethnic disparities in cancer mortality in the United States. RESULTS A total of 8345 articles were identified, and 183 articles were included. Studies used different measures, data sources, and methods. For example, in 20 studies, racial residential segregation, one component of structural racism, was measured by indices of dissimilarity, concentration at the extremes, redlining, or isolation. Data sources included cancer registries, claims, or institutional data linked to area-level metrics from the US census or historical mortgage data. Segregation was associated with worse survival. Nine studies were location specific, and the segregation measures were developed for Black, Hispanic, and White residents. CONCLUSIONS A range of measures and data sources are available to capture the effects of structural racism. We provide a set of recommendations for best practices for modelers to consider when incorporating the effects of structural racism into simulation models.
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Affiliation(s)
- Jinani Jayasekera
- Division of Intramural Research at the National Institute on Minority Health and Health Disparities, National Institutes of Health, Bethesda, MD, USA
| | - Safa El Kefi
- NYU Langone Health, New York University, New York, NY, USA
| | - Jessica R Fernandez
- Division of Intramural Research at the National Institute on Minority Health and Health Disparities, National Institutes of Health, Bethesda, MD, USA
| | - Kaitlyn M Wojcik
- Division of Intramural Research at the National Institute on Minority Health and Health Disparities, National Institutes of Health, Bethesda, MD, USA
| | - Jennifer M P Woo
- Epidemiology Branch at the National Institute of Environmental Health Sciences at the National Institutes of Health, Bethesda, MD, USA
| | - Adaora Ezeani
- Health Behaviors Research Branch of the Behavioral Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, MD, USA
| | - Jennifer L Ish
- Epidemiology Branch at the National Institute of Environmental Health Sciences at the National Institutes of Health, Bethesda, MD, USA
| | - Manami Bhattacharya
- Cancer Prevention Fellowship Program, Division of Cancer Prevention, and the Surveillance Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, MD, USA
| | - Kemi Ogunsina
- Epidemiology Branch at the National Institute of Environmental Health Sciences at the National Institutes of Health, Bethesda, MD, USA
| | - Che-Jung Chang
- Epidemiology Branch at the National Institute of Environmental Health Sciences at the National Institutes of Health, Bethesda, MD, USA
| | - Camryn M Cohen
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, MD, USA
| | - Stephanie Ponce
- Division of Intramural Research at the National Institute on Minority Health and Health Disparities, National Institutes of Health, Bethesda, MD, USA
| | - Dalya Kamil
- Division of Intramural Research at the National Institute on Minority Health and Health Disparities, National Institutes of Health, Bethesda, MD, USA
| | - Julia Zhang
- Division of Intramural Research at the National Institute on Minority Health and Health Disparities, National Institutes of Health, Bethesda, MD, USA
- Sophomore at Williams College, Williamstown, MA, USA
| | - Randy Le
- Division of Intramural Research at the National Institute on Minority Health and Health Disparities, National Institutes of Health, Bethesda, MD, USA
| | - Amrita L Ramanathan
- Diabetes, Endocrinology, & Obesity Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Gisela Butera
- Office of Research Services, National Institutes of Health Library, Bethesda, MD, USA
| | - Christina Chapman
- Department of Radiation Oncology, Baylor College of Medicine, and the Center for Innovations in Quality, Effectiveness, and Safety in the Department of Medicine, Baylor College of Medicine and the Houston Veterans Affairs, Houston, TX, USA
| | - Shakira J Grant
- Department of Medicine, Division of Hematology, University of North Carolina, Chapel Hill, NC, USA
| | - Marquita W Lewis-Thames
- Department of Medical Social Science, Center for Community Health at Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Chiranjeev Dash
- Office of Minority Health and Health Disparities Research at the Georgetown-Lombardi Comprehensive Cancer Center, Washington, DC, USA
| | - Traci N Bethea
- Office of Minority Health and Health Disparities Research at the Georgetown-Lombardi Comprehensive Cancer Center, Washington, DC, USA
| | - Allana T Forde
- Division of Intramural Research at the National Institute on Minority Health and Health Disparities, National Institutes of Health, Bethesda, MD, USA
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Stanhope KK, Kapila P, Umerani A, Hossain A, Abu-Salah M, Singisetti V, Carter S, Boulet SL. Political representation and perinatal outcomes to Black, White, and Hispanic people in Georgia: a cross-sectional study. Ann Epidemiol 2023; 87:S1047-2797(23)00167-9. [PMID: 37689094 PMCID: PMC10842944 DOI: 10.1016/j.annepidem.2023.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 07/24/2023] [Accepted: 09/05/2023] [Indexed: 09/11/2023]
Abstract
PURPOSE Our goal was to estimate differences in perinatal outcomes by racial differences in political representation, a measure of structural racism. METHODS We gathered data on the racial composition of county-level elected officials for all counties in Georgia (n = 159) in 2022. We subtracted the percent of non-White elected officials from the percent of non-White residents to calculate the "representation difference," with greater positive values indicating a larger disparity. We linked this to data from 2020-2021 birth certificates (n = 238,795) on outcomes (preterm birth, <37 weeks, low birthweight birth <2500 g, birthweight, hypertensive disorders of pregnancy, cesarean delivery). We fit log binomial and linear models with generalized estimating equations, stratified by individual race/ethnicity and including individual and county covariates. RESULTS Median representation difference was 17.5% points (interquartile range: 17.2). A 25-percentile point increase in representation difference was associated with a greater risk of hypertensive disorders of pregnancy [White: adjusted risk ratio (RR): 1.12, 95% confidence interval (CI): (1.05, 1.2), Black: 1.06, 95% CI: (0.95, 1.17), other: 1.14, 95% CI: (1.0, 1.3), Hispanic: 1.19, 95% CI: (1.07, 1.32)] and lower mean birthweight for Black birthing people [adjusted beta -15.3, 95% CI: (-25.5, -7.4)]. CONCLUSIONS Parity in political representation may be associated with healthier environments.
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Affiliation(s)
- Kaitlyn K Stanhope
- Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, GA.
| | - Pari Kapila
- Emory College of Arts and Sciences, Atlanta, GA
| | | | | | | | | | - Sierra Carter
- Department of Psychology, Georgia State University, Atlanta
| | - Sheree L Boulet
- Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, GA
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Ghio M, Simpson JT, Ali A, Fleckman JM, Theall KP, Constans JI, Tatum D, McGrew PR, Duchesne J, Taghavi S. Association Between Markers of Structural Racism and Mass Shooting Events in Major US Cities. JAMA Surg 2023; 158:1032-1039. [PMID: 37466952 PMCID: PMC10357360 DOI: 10.1001/jamasurg.2023.2846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 04/22/2023] [Indexed: 07/20/2023]
Abstract
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.
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Affiliation(s)
- Michael Ghio
- Department of Surgery, Tulane University School of Medicine, New Orleans, Louisiana
| | - John Tyler Simpson
- Department of Surgery, Tulane University School of Medicine, New Orleans, Louisiana
| | - Ayman Ali
- Department of Surgery, Tulane University School of Medicine, New Orleans, Louisiana
| | - Julia M. Fleckman
- Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana
| | - Katherine P. Theall
- Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana
| | - Joseph I. Constans
- Tulane University School of Science & Engineering, New Orleans, Louisiana
| | - Danielle Tatum
- Department of Surgery, Tulane University School of Medicine, New Orleans, Louisiana
| | - Patrick R. McGrew
- Department of Surgery, Tulane University School of Medicine, New Orleans, Louisiana
| | - Juan Duchesne
- Department of Surgery, Tulane University School of Medicine, New Orleans, Louisiana
- University Medical Center, New Orleans, Louisiana
| | - Sharven Taghavi
- Department of Surgery, Tulane University School of Medicine, New Orleans, Louisiana
- University Medical Center, New Orleans, Louisiana
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25
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Liu JJ, DeCuir N, Kia L, Peterson J, Miller C, Issaka RB. Tools to Measure the Impact of Structural Racism and Discrimination on Gastrointestinal and Hepatology Disease Outcomes: A Scoping Review. Clin Gastroenterol Hepatol 2023; 21:2759-2788.e6. [PMID: 36549469 PMCID: PMC10279803 DOI: 10.1016/j.cgh.2022.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 11/23/2022] [Accepted: 12/02/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND & AIMS Structural racism and discrimination (SRD) are important upstream determinants of health perpetuated by discriminatory laws and policies. Therefore, measuring SRD and its impact on health is critical to developing interventions that address resultant health disparities. We aimed to identify gastrointestinal (GI) or liver studies that report measures of SRD or interventions to achieve health equity in these domains by addressing upstream determinants of health. METHODS We conducted a scoping review according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses scoping reviews guidelines. Studies that used an SRD measure or examined an upstream intervention in GI or liver disease were included. Studies that described health disparities in GI or liver conditions without mentioning SRD were excluded. Study characteristics, findings, and limitations were extracted. RESULTS Forty-six articles (19 studies using SRD measures and 27 studies of upstream interventions) were identified. Measures of residential racial segregation were reported most frequently. SRD was associated with poorer health outcomes for racial and ethnic minority populations. Although upstream intervention studies focused primarily on policies related to colon cancer screening and organ graft allocation, racial and ethnic disparities often persisted post-intervention. CONCLUSIONS To achieve health equity in GI and liver conditions, there is an urgent need for research that goes beyond describing health disparities to incorporating measures of SRD and implementing interventions that address this understudied determinant of health.
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Affiliation(s)
- Joy J Liu
- Division of Gastroenterology, Department of Medicine, Feinberg School of Medicine at Northwestern University, Chicago, Illinois
| | - Nicole DeCuir
- Division of Gastroenterology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Leila Kia
- Division of Gastroenterology, Department of Medicine, Feinberg School of Medicine at Northwestern University, Chicago, Illinois
| | - Jonna Peterson
- Galter Health Sciences Library & Learning Center, Feinberg School of Medicine at Northwestern University, Chicago, Illinois
| | - Corinne Miller
- Galter Health Sciences Library & Learning Center, Feinberg School of Medicine at Northwestern University, Chicago, Illinois
| | - Rachel B Issaka
- Division of Gastroenterology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington; Clinical Research and Public Health Sciences Divisions, Fred Hutchinson Cancer Center, Seattle, Washington; Hutchinson Institute for Cancer Outcomes Research, Fred Hutchinson Cancer Center, Seattle, Washington.
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26
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Slopen N, Umaña-Taylor AJ, Shonkoff JP, Carle AC, Hatzenbuehler ML. State-Level Anti-Immigrant Sentiment and Policies and Health Risks in US Latino Children. Pediatrics 2023; 152:e2022057581. [PMID: 37581234 PMCID: PMC10565791 DOI: 10.1542/peds.2022-057581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/27/2023] [Indexed: 08/16/2023] Open
Abstract
BACKGROUND Although systemic inequities, broadly defined, are associated with health disparities in adults, there is a dearth of research linking contextual measures of exclusionary policies or prejudicial attitudes to health impairments in children, particularly among Latino populations. In this study, we examined a composite measure of systemic inequities in relation to the cooccurrence of multiple health problems in Latino children in the United States. METHODS Participants included 17 855 Latino children aged 3 to 17 years from the National Survey of Children's Health (2016-2020). We measured state-level systemic inequities using a factor score that combined an index of exclusionary state policies toward immigrants and aggregated survey data on prejudicial attitudes toward immigrants and Latino individuals. Caregivers reported on 3 categories of child health problems: common health difficulties in the past year, current chronic physical health conditions, and current mental health conditions. For each category, we constructed a variable reflecting 0, 1, or 2 or more conditions. RESULTS In models adjusted for sociodemographic covariates, interpersonal discrimination, and state-level income inequality, systemic inequities were associated with 1.13 times the odds of a chronic physical health condition (95% confidence interval: 1.02-1.25) and 1.24 times the odds of 2 or more mental health conditions (95% confidence interval: 1.06-1.45). CONCLUSIONS Latino children residing in states with higher levels of systemic inequity are more likely to experience mental health or chronic physical health conditions relative to those in states with lower levels of systemic inequity.
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Affiliation(s)
- Natalie Slopen
- Department of Social & Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Center on the Developing Child
| | | | - Jack P. Shonkoff
- Department of Social & Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Center on the Developing Child
- Harvard Graduate School of Education, Harvard University, Cambridge, Massachusetts
- Harvard Medical School and Boston Children’s Hospital, Boston, Massachusetts
- Department of Pediatrics, Massachusetts General Hospital, Boston, Massachusetts
| | - Adam C. Carle
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, Ohio
- Department of Psychology University of Cincinnati College of Arts and Sciences
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Siegel M, Rieders M, Rieders H, Moumneh J, Asfour J, Oh J, Oh S. Structural racism and racial health disparities at the state level: A latent variable approach. J Natl Med Assoc 2023; 115:338-352. [PMID: 37500328 DOI: 10.1016/j.jnma.2023.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 06/22/2023] [Accepted: 07/17/2023] [Indexed: 07/29/2023]
Abstract
Introduction Structural racism is increasingly being recognized as a fundamental cause of racial health disparities. We used a novel measure of structural racism at the state level to examine the relationship between structural racism and disparities in death rates from firearm homicide, infant mortality, HIV, diabetes, stroke, hypertension, asthma, and kidney disease between non-Hispanic Black and non-Hispanic White people in the United States. Methods We used confirmatory factor analysis to measure the latent construct of structural racism for all 50 states. The model included seven indicators across the structural racism domains of residential segregation, economic status/employment, education, incarceration, political participation and representation, environmental racism, and racial equity inclusion. Weights for each of the indicators were determined by examining alternative models and selecting the model with the best fit statistics. The resulting factor scores, representing the level of structural racism in each state across the seven domains, were then used as predictor variables in a series of linear regressions with the ratio of Black to White death rates for each health outcome as the dependent variables. Results We found significant relationships between higher levels of the latent structural racism measure and greater disparities between non-Hispanic Black and non-Hispanic White people in age-adjusted death rates for firearm homicide, infant mortality, HIV, asthma, and obesity. The magnitude of this relationship was greatest for firearm homicide, with each one standard deviation increase in a state's structural racism factor score being associated with an increase of 4.54 (95% CI, 2.91-6.17) in that state's Black-White firearm homicide rate ratio. Conclusions This research provides further evidence that structural racism is a fundamental cause of racial health disparities and that to repair these inequities, macro-level changes in societal structures, institutions, resource allocation, representation, and power will be necessary.
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Affiliation(s)
- Michael Siegel
- Department of Public Health and Community Medicine, Tufts University School of Medicine, 636 Harrison Avenue, Boston, MA 02111, USA.
| | - Madeline Rieders
- Department of Public Health and Community Medicine, Tufts University School of Medicine, 636 Harrison Avenue, Boston, MA 02111, USA
| | - Hannah Rieders
- Department of Public Health and Community Medicine, Tufts University School of Medicine, 636 Harrison Avenue, Boston, MA 02111, USA
| | - Jinan Moumneh
- Department of Public Health and Community Medicine, Tufts University School of Medicine, 636 Harrison Avenue, Boston, MA 02111, USA
| | - Julia Asfour
- Department of Public Health and Community Medicine, Tufts University School of Medicine, 636 Harrison Avenue, Boston, MA 02111, USA
| | - Jinseo Oh
- Department of Public Health and Community Medicine, Tufts University School of Medicine, 636 Harrison Avenue, Boston, MA 02111, USA
| | - Seungjin Oh
- Department of Public Health and Community Medicine, Tufts University School of Medicine, 636 Harrison Avenue, Boston, MA 02111, USA
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Spatz ES, Roy B, Riley C, Witters D, Herrin J. Association of Population Well-Being With Cardiovascular Outcomes. JAMA Netw Open 2023; 6:e2321740. [PMID: 37405774 PMCID: PMC10323707 DOI: 10.1001/jamanetworkopen.2023.21740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/06/2023] Open
Abstract
Importance Mortality from cardiovascular disease (CVD) varies across communities and is associated with known structural and population health factors. Still, a population's well-being, including sense of purpose, social relationships, financial security, and relationship to community, may be an important target to improve cardiovascular health. Objective To examine the association of population level measures of well-being with rates of CVD mortality in the US. Design, Setting, and Participants This cross-sectional study linked data from the Gallup National Health and Well-Being Index (WBI) survey to county-level rates of CVD mortality from the Centers for Disease Control and Prevention Atlas of Heart Disease and Stroke. Participants were respondents of the WBI survey, which was conducted by Gallup with randomly selected adults aged 18 years or older from 2015 to 2017. Data were analyzed from August 2022 to May 2023. Main Outcomes and Measures The primary outcome was the county-level rate of total CVD mortality; secondary outcomes were mortality rates for stroke, heart failure, coronary heart disease, acute myocardial infarction, and total heart disease. The association of population well-being (measured using a modified version of the WBI) with CVD mortality was assessed, and an analysis of whether the association was modified by county structural factors (Area Deprivation Index [ADI], income inequality, and urbanicity) and population health factors (percentages of the adult population who had hypertension, diabetes, or obesity; were currently smoking; and were physically inactive) was conducted. Population WBI and its ability to mediate the association of structural factors associated with CVD using structural equation models was also assessed. Results Well-being surveys were completed by 514 971 individuals (mean [SD] age 54.0 [19.2] years; 251 691 [48.9%] women; 379 521 [76.0%] White respondents) living in 3228 counties. Mortality rates for CVD decreased from a mean of 499.7 (range, 174.2-974.7) deaths per 100 000 persons in counties with the lowest quintile of population well-being to 438.6 (range, 110.1-850.4) deaths per 100 000 persons in counties with the highest quintile of population well-being. Secondary outcomes showed similar patterns. In the unadjusted model, the effect size (SE) of WBI on CVD mortality was -15.5 (1.5; P < .001), or a decrease of 15 deaths per 100 000 persons for each 1-point increase of population well-being. After adjusting for structural factors and structural plus population health factors, the association was attenuated but still significant, with an effect size (SE) of -7.3 (1.6; P < .001); for each 1-point increase in well-being, the total cardiovascular death rate decreased by 7.3 deaths per 100 000 persons. Secondary outcomes showed similar patterns, with mortality due to coronary heart disease and heart failure being significant in fully adjusted models. In mediation analyses, associations of income inequality and ADI with CVD mortality were all partly mediated by the modified population WBI. Conclusions and Relevance In this cross-sectional study assessing the association of well-being and cardiovascular outcomes, higher well-being, a measurable, modifiable, and meaningful outcome, was associated with lower CVD mortality, even after controlling for structural and cardiovascular-related population health factors, indicating that well-being may be a focus for advancing cardiovascular health.
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Affiliation(s)
- Erica S Spatz
- Section of Cardiovascular Medicine, Department of Medicine, Yale School of Medicine, New Haven, Connecticut
- Yale University/Yale New Haven Health Center for Outcomes Research and Evaluation, New Haven, Connecticut
| | - Brita Roy
- Section of General Internal Medicine, Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Carley Riley
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
- Division of Critical Care, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Dan Witters
- Gallup National Health and Well-Being Index, Omaha, Nebraska
| | - Jeph Herrin
- Section of Cardiovascular Medicine, Department of Medicine, Yale School of Medicine, New Haven, Connecticut
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Stelkia K. Structural Racism as an Ecosystem: An Exploratory Study on How Structural Racism Influences Chronic Disease and Health and Wellbeing of First Nations in Canada. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:ijerph20105851. [PMID: 37239577 DOI: 10.3390/ijerph20105851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 05/05/2023] [Accepted: 05/10/2023] [Indexed: 05/28/2023]
Abstract
Indigenous peoples in Canada experience disproportionately higher rates of chronic disease than their non-Indigenous counterparts. Previous research has identified structural racism as a powerful determinant of health and wellbeing. Mounting evidence demonstrates that First Nations are disproportionately over-represented, compared to other Canadians, in several domains that have been used to measure structural racism in other countries. Despite growing concern of the impact of structural racism on health, there remains little empirical evidence on the impact structural racism has on chronic disease health outcomes of First Nations. This qualitative study examines the complex and intersecting ways in which structural racism can influence chronic disease health outcomes and the overall health and wellbeing of First Nations in Canada. In-depth semi-structured interviews were conducted with twenty-five participants, including subject matter experts in health, justice, education, child welfare, politics, and researchers in racism scholarship and First Nations who have lived experience with a chronic condition(s). Thematic analysis was used to analyze the data collected. Six themes on how structural racism influences chronic disease and the health of First Nations were identified: (1) multiple and intersecting pathways; (2) systems of failure, harm, and indifference; (3) impacts on access to healthcare; (4) colonial policies of structural deprivation; (5) increased risk factors for chronic disease and poor health; and (6) structural burden leading to individual-level outcomes. Structural racism creates an ecosystem that negatively impacts chronic diseases and the health of First Nations. The findings illuminate how structural racism can have micro-level influences at an individual level and can influence one's chronic disease journey and progression. Recognizing how structural racism shapes our environments may help to catalyze a shift in our collective understanding of the impact of structural racism on health.
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Affiliation(s)
- Krista Stelkia
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC V5A 1S6, Canada
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Dantas-Silva A, Santiago SM, Surita FG. Racism as a Social Determinant of Health in Brazil in the COVID-19 Pandemic and Beyond. REVISTA BRASILEIRA DE GINECOLOGIA E OBSTETRÍCIA 2023; 45:221-224. [PMID: 37339640 PMCID: PMC10281767 DOI: 10.1055/s-0043-1770135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/22/2023] Open
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Philbin MM, Menza TW, Legrand SH, Muessig KE, Hightow-Weidman L. Structural-Level Racial-, Sexual Orientation-, and HIV-Related Discrimination and Subsequent Criminal Justice Involvement Among Young, Black, Men Who Have Sex With Men in North Carolina. STIGMA AND HEALTH 2023; 8:170-178. [PMID: 37456791 PMCID: PMC10348694 DOI: 10.1037/sah0000290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Abstract
Multiple aspects of Black young men who have sex with men's (YMSM) identities cause them to be differentially targeted for arrest and incarceration. However, limited research has explored structural drivers of Black YMSM' criminal justice involvement, particularly co-occurring forms of discrimination. This article examines the temporal relationship between perceived racial discrimination, perceived sexual orientation discrimination, and community-level HIV discrimination and criminal justice involvement among Black YMSM in North Carolina. The study followed 465 Black YMSM from November 2013 to October 2016 who were recruited for a randomized controlled trial to test an internet-based intervention for Black YMSM living with, and at risk for HIV; participants completed online surveys at baseline, 3, 6, and 12 months. Logistic regression was used to explore the relationship between the three predictors at baseline (i.e., perceived racism and sexual orientation discrimination and community-level HIV discrimination) and criminal justice involvement at follow-up. All three predictor variables were significantly associated with subsequent criminal justice involvement in separate regression models that adjusted for other covariates: HIV discrimination (aOR = 1.06 [1.01-1.11]), perceived sexual orientation discrimination (aOR = 1.12 [1.00-1.27]), and perceived racism (aOR = 1.26 [1.12-1.42]). Perceived racism remained significant in the model with all three predictors (aOR = 1.29 [1.07-1.55]). Racism did not modify the relationship between HIV discrimination and perceived sexual orientation discrimination and criminal justice involvement. This study expands existing research by exploring racism as a structural driver of criminal justice involvement; we subsequently examined whether racism modified the effect of the two other predictors. It also contributes to research on co-occurring discrimination by examining their impact on an underrepresented population.
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Affiliation(s)
- Morgan M Philbin
- Department of Sociomedical Sciences, Columbia University Mailman School of Public Health
| | | | | | - Kathryn E Muessig
- Department of Health Behavior, Gillings School of Public Health, University of North Carolina at Chapel Hill
| | - Lisa Hightow-Weidman
- Division of Global Health and Infectious Diseases, University of North Carolina at Chapel Hill
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Chesley CF, Chowdhury M, Small DS, Schaubel D, Liu VX, Lane-Fall MB, Halpern SD, Anesi GL. Racial Disparities in Length of Stay Among Severely Ill Patients Presenting With Sepsis and Acute Respiratory Failure. JAMA Netw Open 2023; 6:e239739. [PMID: 37155170 PMCID: PMC10167564 DOI: 10.1001/jamanetworkopen.2023.9739] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 03/07/2023] [Indexed: 05/10/2023] Open
Abstract
Importance Although racial and ethnic minority patients with sepsis and acute respiratory failure (ARF) experience worse outcomes, how patient presentation characteristics, processes of care, and hospital resource delivery are associated with outcomes is not well understood. Objective To measure disparities in hospital length of stay (LOS) among patients at high risk of adverse outcomes who present with sepsis and/or ARF and do not immediately require life support and to quantify associations with patient- and hospital-level factors. Design, Setting, and Participants This matched retrospective cohort study used electronic health record data from 27 acute care teaching and community hospitals across the Philadelphia metropolitan and northern California areas between January 1, 2013, and December 31, 2018. Matching analyses were performed between June 1 and July 31, 2022. The study included 102 362 adult patients who met clinical criteria for sepsis (n = 84 685) or ARF (n = 42 008) with a high risk of death at the time of presentation to the emergency department but without an immediate requirement for invasive life support. Exposures Racial or ethnic minority self-identification. Main Outcomes and Measures Hospital LOS, defined as the time from hospital admission to the time of discharge or inpatient death. Matches were stratified by racial and ethnic minority patient identity, comparing Asian and Pacific Islander patients, Black patients, Hispanic patients, and multiracial patients with White patients in stratified analyses. Results Among 102 362 patients, the median (IQR) age was 76 (65-85) years; 51.5% were male. A total of 10.2% of patients self-identified as Asian American or Pacific Islander, 13.7% as Black, 9.7% as Hispanic, 60.7% as White, and 5.7% as multiracial. After matching racial and ethnic minority patients to White patients on clinical presentation characteristics, hospital capacity strain, initial intensive care unit admission, and the occurrence of inpatient death, Black patients experienced longer LOS relative to White patients in fully adjusted matches (sepsis: 1.26 [95% CI, 0.68-1.84] days; ARF: 0.97 [95% CI, 0.05-1.89] days). Length of stay was shorter among Asian American and Pacific Islander patients with ARF (-0.61 [95% CI, -0.88 to -0.34] days) and Hispanic patients with sepsis (-0.22 [95% CI, -0.39 to -0.05] days) or ARF (-0.47 [-0.73 to -0.20] days). Conclusions and Relevance In this cohort study, Black patients with severe illness who presented with sepsis and/or ARF experienced longer LOS than White patients. Hispanic patients with sepsis and Asian American and Pacific Islander and Hispanic patients with ARF both experienced shorter LOS. Because matched differences were independent of commonly implicated clinical presentation-related factors associated with disparities, identification of additional mechanisms that underlie these disparities is warranted.
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Affiliation(s)
- Christopher F. Chesley
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia
- Palliative and Advanced Illness Research Center, University of Pennsylvania Perelman School of Medicine, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Marzana Chowdhury
- Palliative and Advanced Illness Research Center, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Dylan S. Small
- Palliative and Advanced Illness Research Center, University of Pennsylvania Perelman School of Medicine, Philadelphia
- Wharton Department of Statistics and Data Science, University of Pennsylvania, Philadelphia
| | - Douglas Schaubel
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Vincent X. Liu
- Division of Research, Kaiser Permanente, Oakland, California
| | - Meghan B. Lane-Fall
- Palliative and Advanced Illness Research Center, University of Pennsylvania Perelman School of Medicine, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia
- Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Scott D. Halpern
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia
- Palliative and Advanced Illness Research Center, University of Pennsylvania Perelman School of Medicine, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia
- Department of Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - George L. Anesi
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia
- Palliative and Advanced Illness Research Center, University of Pennsylvania Perelman School of Medicine, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
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Emani S, Rodriguez JA, Bates DW. Racism and Electronic Health Records (EHRs): Perspectives for research and practice. J Am Med Inform Assoc 2023; 30:995-999. [PMID: 36869772 PMCID: PMC10114075 DOI: 10.1093/jamia/ocad023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 01/17/2023] [Accepted: 02/19/2023] [Indexed: 03/05/2023] Open
Abstract
Informatics researchers and practitioners have started exploring racism related to the implementation and use of electronic health records (EHRs). While this work has begun to expose structural racism which is a fundamental driver of racial and ethnic disparities, there is a lack of inclusion of concepts of racism in this work. This perspective provides a classification of racism at 3 levels-individual, organizational, and structural-and offers recommendations for future research, practice, and policy. Our recommendations include the need to capture and use structural measures of social determinants of health to address structural racism, intersectionality as a theoretical framework for research, structural competency training, research on the role of prejudice and stereotyping in stigmatizing documentation in EHRs, and actions to increase the diversity of private sector informatics workforce and participation of minority scholars in specialty groups. Informaticians have an ethical and moral obligation to address racism, and private and public sector organizations have a transformative role in addressing equity and racism associated with EHR implementation and use.
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Affiliation(s)
- Srinivas Emani
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham & Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Department of Behavioral, Social, and Health Education Sciences, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Jorge A Rodriguez
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham & Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - David W Bates
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham & Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
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BROWN TYSONH, HOMAN PATRICIA. The Future of Social Determinants of Health: Looking Upstream to Structural Drivers. Milbank Q 2023; 101:36-60. [PMID: 37096627 PMCID: PMC10126983 DOI: 10.1111/1468-0009.12641] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 10/15/2022] [Accepted: 01/06/2023] [Indexed: 04/26/2023] Open
Abstract
Policy Points Policies that redress oppressive social, economic, and political conditions are essential for improving population health and achieving health equity. Efforts to remedy structural oppression and its deleterious effects should account for its multilevel, multifaceted, interconnected, systemic, and intersectional nature. The U.S. Department of Health and Human Services should facilitate the creation and maintenance of a national publicly available, user-friendly data infrastructure on contextual measures of structural oppression. Publicly funded research on social determinants of health should be mandated to (a) analyze health inequities in relation to relevant data on structural conditions and (b) deposit the data in the publicly available data repository.
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Shour AR, Anguzu R, Zhou Y, Muehlbauer A, Joseph A, Oladebo T, Puthoff D, Onitilo AA. Your neighborhood matters: an ecological social determinant study of the relationship between residential racial segregation and the risk of firearm fatalities. Inj Epidemiol 2023; 10:14. [PMID: 36915201 PMCID: PMC10012477 DOI: 10.1186/s40621-023-00425-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 02/27/2023] [Indexed: 03/14/2023] Open
Abstract
BACKGROUND Firearm fatalities are a major public health concern, claiming the lives of 40,000 Americans each year. While firearm fatalities have pervasive effects, it is unclear how social determinants of health (SDOH) such as residential racial segregation, income inequality, and community resilience impact firearm fatalities. This study investigates the relationships between these SDOH and the likelihood of firearm fatalities. METHODS County-level SDOH data from the Agency for Health Care Research and Quality for 2019 were analyzed, covering 72 Wisconsin counties. The dependent variable was the number of firearm fatalities in each county, used as a continuous variable. The independent variable was residential racial segregation (Dissimilarity Index), defined as the degree to which non-White and White residents were distributed across counties, ranging from 0 (complete integration) to 100 (complete segregation), and higher values indicate greater residential segregation (categorized as low, moderate, and high). Covariates were income inequality ranging from zero (perfect equality) to one (perfect inequality) categorized as low, moderate, and high, community resilience risk factors (low, moderate, and high risks), and rural-urban classifications. Descriptive/summary statistics, unadjusted and adjusted negative binomial regression adjusting for population weight, were performed using STATA/MPv.17.0; P-values ≤ 0.05 were considered statistically significant. ArcMap was used for Geographic Information System analysis. RESULTS In 2019, there were 802 firearm fatalities. The adjusted model demonstrates that the risk of firearm fatalities was higher in areas with high residential racial segregation compared to low-segregated areas (IRR.:1.26, 95% CI:1.04-1.52) and higher in areas with high-income inequality compared to areas with low-income inequality (IRR.:1.18, 95% CI:1.00-1.40). Compared to areas with low-risk community resilience, the risk of firearm fatalities was higher in areas with moderate (IRR.:0.61, 95% CI:0.48-0.78), and in areas with high risk (IRR.:0.53, 95% CI:0.41-0.68). GIS analysis demonstrated that areas with high racial segregation also have high rates of firearm fatalities. CONCLUSION Areas with high residential racial segregation have a high rate of firearm fatalities. With high income inequality and low community resilience, the likelihood of firearm fatalities increases.
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Affiliation(s)
- Abdul R Shour
- Marshfield Clinic Cancer Care and Research Center, Clinical Research Institute, Marshfield, WI, USA. .,Department of Oncology, Marshfield Clinic Health System, 1000 N Oak Ave, Marshfield, WI, 54449, USA. .,Marshfield Clinic Research Institute, Marshfield Clinic Health System, 1000 N Oak Ave, Marshfield, WI, 54449, USA.
| | - Ronald Anguzu
- Division of Epidemiology and Social Sciences, Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Yuhong Zhou
- Division of Epidemiology and Social Sciences, Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Alice Muehlbauer
- Logistics, and Guest Relations, Froedtert Hospital, Milwaukee, WI, USA
| | - Adedayo Joseph
- NSIA-LUTH Cancer Center, Lagos University Teaching Hospital, Lagos, Nigeria
| | - Tinuola Oladebo
- Masters of Sustainable Peacebuilding Program, University of Wisconsin Milwaukee, Milwaukee, WI, USA
| | - David Puthoff
- Marshfield Clinic Research Institute, Marshfield Clinic Health System, 1000 N Oak Ave, Marshfield, WI, 54449, USA
| | - Adedayo A Onitilo
- Marshfield Clinic Cancer Care and Research Center, Clinical Research Institute, Marshfield, WI, USA.,Department of Oncology, Marshfield Clinic Health System, 1000 N Oak Ave, Marshfield, WI, 54449, USA.,Marshfield Clinic Research Institute, Marshfield Clinic Health System, 1000 N Oak Ave, Marshfield, WI, 54449, USA
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Wen A, Gubner NR, Garrison MM, Walker SC. Racial disparities in youth pretrial detention: a retrospective cohort study grounded in critical race theory. HEALTH & JUSTICE 2023; 11:14. [PMID: 36882535 PMCID: PMC9993616 DOI: 10.1186/s40352-022-00203-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 12/22/2022] [Indexed: 06/18/2023]
Abstract
BACKGROUND AND METHOD Pretrial detention makes up 75% of juvenile detention admissions and contributes to the disproportionate contact of minoritized youth in the juvenile carceral system. Given that prior evidence largely examines differences between Black and white youth, this study expands research on disproportionate contact in the pretrial detention setting to Hispanic/Latinx, Indigenous, and Asian youth. With a sample of over 44,000 juvenile cases in a northwest state, we used a generalized linear mixed model to estimate the effect of individual level characteristics while accounting for the random effect of differences at the county level. Additionally, we utilized Critical Race Theory (CRT) in formulating our theoretical model and predictions and apply CRT in our analysis and discussion of our results. In doing so we hope to build upon its application in public health discourse for naming and deconstructing processes that lead to unjust social and health stratification. RESULTS After factoring in gender, age, crime severity, previous offenses, and variation between counties, our analyses show that Black, Hispanic/Latinx, and American Indian/Alaskan Native youth are more likely to experience pretrial detention than white youth. The likelihood of pretrial detention for Asian youth and for youth identified as "Other" or "Unknown" was not significantly different from white youth. CONCLUSIONS As the iatrogenic effects of detention are disproportionately imposed upon youth of color-particularly Black, Indigenous, and Hispanic/Latinx youth-the disparities present in our study reveal further evidence of institutional racism. In this way, we can see how this carceral process operates as a mechanism of racialized social stratification as put forth by CRT. Considering implications for policy or further research, persistent disparity highlights an enduring need for building or strengthening diversion programs and alternatives to the carceral system, with emphasis on those that are culturally responsive.
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Affiliation(s)
- Andy Wen
- University of Washington School of Medicine, Seattle, USA.
- Department of Psychiatry, Yale School of Medicine, New Haven, USA.
- University of Washington School of Public Health, Seattle, USA.
| | - Noah R Gubner
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, USA
| | | | - Sarah Cusworth Walker
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, USA
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Kellogg AJ, Hancock DW, Cho GY, Reid AE. Reprint of: Community-level age bias and older adult mortality. Soc Sci Med 2023; 320:115699. [PMID: 36739253 DOI: 10.1016/j.socscimed.2023.115699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 08/30/2022] [Accepted: 10/08/2022] [Indexed: 01/31/2023]
Abstract
RATIONALE As the older adult population increases, understanding the health effects of bias against older adults is increasingly important. Whether structural forms of age bias predict worse health has received limited attention. OBJECTIVE We hypothesized that communities with greater age bias would have higher mortality among residents aged 65 and older. We expected the association to be unique to age bias, rather than general bias (i.e., sexual minority and racial bias), and that the age bias-mortality association would be strongest in predominantly White and younger communities. METHODS Explicit and implicit attitudes toward older adults (N = 1,001,735), sexual minorities (N = 791,966), and Black Americans (N = 2,255,808) were drawn from Project Implicit. Post-stratification relative to U.S. Census demographics was executed to improve the representativeness of county-level explicit and implicit bias estimates. County older adult mortality, estimated cross-sectionally with and longitudinally relative to bias scores, served as outcomes. Models controlled for relevant county-level covariates (e.g., median age) and included all U.S. counties (N = 3142). RESULTS Contrary to hypotheses but consistent with prior work, explicit age bias was cross-sectionally and longitudinally associated with lower mortality, over and above covariates and generalized community bias. The explicit age bias-lower mortality association only emerged in younger counties but did not depend on county ethnic composition. Implicit age bias was unassociated with outcomes. Post-hoc analyses supported that ageist communities may be associated with better health across the lifespan. Explicit age bias predicted lower mortality in young and middle adulthood; better mental health in middle adulthood, but not exercise or self-rated health, mediated the explicit age bias-older adult mortality association. CONCLUSIONS Results highlight the uniqueness of older age relative to other stigmatized identities. Further examination of the association of community-level age bias with better health may improve longevity for all communities.
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Affiliation(s)
- Alexander J Kellogg
- University of Massachusetts, Amherst; Department of Psychological and Brain Sciences; 135 Hicks Way, Tobin Hall, Amherst, MA, 01003, USA
| | - David W Hancock
- University of Massachusetts, Amherst; Department of Psychological and Brain Sciences; 135 Hicks Way, Tobin Hall, Amherst, MA, 01003, USA
| | - Grace Y Cho
- University of Massachusetts, Amherst; Department of Psychological and Brain Sciences; 135 Hicks Way, Tobin Hall, Amherst, MA, 01003, USA
| | - Allecia E Reid
- University of Massachusetts, Amherst; Department of Psychological and Brain Sciences; 135 Hicks Way, Tobin Hall, Amherst, MA, 01003, USA.
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Turecamo SE, Xu M, Dixon D, Powell-Wiley TM, Mumma MT, Joo J, Gupta DK, Lipworth L, Roger VL. Association of Rurality With Risk of Heart Failure. JAMA Cardiol 2023; 8:231-239. [PMID: 36696094 PMCID: PMC9878434 DOI: 10.1001/jamacardio.2022.5211] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 11/23/2022] [Indexed: 01/26/2023]
Abstract
Importance Rural populations experience an increased burden of heart failure (HF) mortality compared with urban populations. Whether HF incidence is greater among rural individuals is less known. Additionally, the intersection between racial and rural health inequities is understudied. Objective To determine whether rurality is associated with increased risk of HF, independent of cardiovascular (CV) disease and socioeconomic status (SES), and whether rurality-associated HF risk varies by race and sex. Design, Setting, and Participants This prospective cohort study analyzed data for Black and White participants of the Southern Community Cohort Study (SCCS) without HF at enrollment who receive care via Centers for Medicare & Medicaid Services (CMS). The SCCS is a population-based cohort of low-income, underserved participants from 12 states across the southeastern United States. Participants were enrolled between 2002 and 2009 and followed up until December 31, 2016. Data were analyzed from October 2021 to November 2022. Exposures Rurality as defined by Rural-Urban Commuting Area codes at the census-tract level. Main Outcomes and Measures Heart failure was defined using diagnosis codes via CMS linkage through 2016. Incidence of HF was calculated by person-years of follow-up and age-standardized. Sequentially adjusted Cox proportional hazards regression models tested the association between rurality and incident HF. Results Among 27 115 participants, the median (IQR) age was 54 years (47-65), 18 647 (68.8%) were Black, and 8468 (32.3%) were White; 5556 participants (20%) resided in rural areas. Over a median 13-year follow-up, age-adjusted HF incidence was 29.6 (95% CI, 28.9-30.5) per 1000 person-years for urban participants and 36.5 (95% CI, 34.9-38.3) per 1000 person-years for rural participants (P < .001). After adjustment for demographic information, CV risk factors, health behaviors, and SES, rural participants had a 19% greater risk of incident HF (hazard ratio [HR], 1.19; 95% CI, 1.13-1.26) compared with their urban counterparts. The rurality-associated risk of HF varied across race and sex and was greatest among Black men (HR, 1.34; 95% CI, 1.19-1.51), followed by White women (HR, 1.22; 95% CI, 1.07-1.39) and Black women (HR, 1.18; 95% CI, 1.08-1.28). Among White men, rurality was not associated with greater risk of incident HF (HR, 0.97; 95% CI, 0.81-1.16). Conclusions and Relevance Among predominantly low-income individuals in the southeastern United States, rurality was associated with an increased risk of HF among women and Black men, which persisted after adjustment for CV risk factors and SES. This inequity points to a need for additional emphasis on primary prevention of HF among rural populations.
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Affiliation(s)
- Sarah E. Turecamo
- Division of Intramural Research, Epidemiology and Community Health Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Meng Xu
- Vanderbilt Translational and Clinical Cardiovascular Research Center, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Debra Dixon
- Vanderbilt Translational and Clinical Cardiovascular Research Center, Vanderbilt University Medical Center, Nashville, Tennessee
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Tiffany M. Powell-Wiley
- Division of Intramural Research, Cardiovascular Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
- Intramural Research Program, National Institute on Minority Health and Health Disparities, National Institutes of Health, Bethesda, Maryland
| | - Michael T. Mumma
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jungnam Joo
- Office of Biostatistics Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Deepak K. Gupta
- Vanderbilt Translational and Clinical Cardiovascular Research Center, Vanderbilt University Medical Center, Nashville, Tennessee
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Loren Lipworth
- Vanderbilt Translational and Clinical Cardiovascular Research Center, Vanderbilt University Medical Center, Nashville, Tennessee
- Vanderbilt O’Brien Center for Kidney Disease, Nashville, Tennessee
- Division of Epidemiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Véronique L. Roger
- Division of Intramural Research, Epidemiology and Community Health Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
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Perng W, Conway R, Mayer-Davis E, Dabelea D. Youth-Onset Type 2 Diabetes: The Epidemiology of an Awakening Epidemic. Diabetes Care 2023; 46:490-499. [PMID: 36812420 PMCID: PMC10090267 DOI: 10.2337/dci22-0046] [Citation(s) in RCA: 25] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 11/26/2022] [Indexed: 02/24/2023]
Abstract
In this narrative review, we describe the epidemiology (prevalence, incidence, temporal trends, and projections) of type 2 diabetes among children and adolescents (<20 years), focusing on data from the U.S. and reporting global estimates where available. Secondarily, we discuss the clinical course of youth-onset type 2 diabetes, from prediabetes to complications and comorbidities, drawing comparisons with youth type 1 diabetes to highlight the aggressive course of this condition, which, only recently, has become recognized as a pediatric disease by health care providers. Finally, we end with an overview of emerging topics in type 2 diabetes research that have potential to inform strategies for effective preventive action at the community and individual levels.
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Affiliation(s)
- Wei Perng
- Lifecourse Epidemiology of Adiposity and Diabetes (LEAD) Center, University of Colorado Anschutz Medical Campus, Aurora, CO
- Department of Epidemiology, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Rebecca Conway
- Lifecourse Epidemiology of Adiposity and Diabetes (LEAD) Center, University of Colorado Anschutz Medical Campus, Aurora, CO
- Department of Epidemiology, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO
| | | | - Dana Dabelea
- Lifecourse Epidemiology of Adiposity and Diabetes (LEAD) Center, University of Colorado Anschutz Medical Campus, Aurora, CO
- Department of Epidemiology, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO
- Department of Pediatrics, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
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Carr D. Ageism and late-life mortality: How community matters. Soc Sci Med 2023; 320:115501. [PMID: 36424283 PMCID: PMC9678335 DOI: 10.1016/j.socscimed.2022.115501] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 10/30/2022] [Indexed: 11/23/2022]
Abstract
AGEISM: the deeply entrenched biases that people hold about old age-is a persistent social problem that intensified during the COVID-19 pandemic. The harmful physical, emotional, and cognitive health consequences of individual-level age bias are well-documented, with most studies operationalizing ageism as an older adult's personal encounters with age discrimination, self-perceptions of their own aging, and internalized negative beliefs about old age. However, the impacts of community-level age bias on older adults' well-being have received less attention. This commentary reviews recent evidence (Kellogg et al.,) showing that county-level explicit age bias is associated with lower mortality rates among older adults, with effects limited to older adults residing in counties with relatively younger populations. Effects were not detected in counties with relatively older populations, or for implicit age bias. These counterintuitive findings require further exploration, including the use of more fine-grained measures of community-level ageism, attention to the role of gentrification in communities, and the development of new measures of structural ageism, drawing on approaches used to study the impacts of structural racism. Data science approaches, including the use of social media data in tandem with mortality data, may reveal how age bias affects older adults. Communities are especially important to older adults, who spend much of their time in areas immediately proximate to their homes. As more individuals age in place, and as federal funding for home-based and community services (HCBS) increases, researchers should identify which community-level characteristics, including age bias, undermine or enhance late-life well-being.
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Affiliation(s)
- Deborah Carr
- Department of Sociology and Center for Innovation in Social Science, Boston University, 704 Commonwealth Ave, Boston, MA, 02215, USA.
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Wien S, Miller AL, Kramer MR. Structural racism theory, measurement, and methods: A scoping review. Front Public Health 2023; 11:1069476. [PMID: 36875414 PMCID: PMC9978828 DOI: 10.3389/fpubh.2023.1069476] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 01/30/2023] [Indexed: 02/18/2023] Open
Abstract
Introduction Epidemiologic and public health interest in structural racism has grown dramatically, producing both increasingly sophisticated questions, methods, and findings, coupled with concerns of atheoretical and ahistorical approaches that often leave the actual production of health or disease ambiguous. This trajectory raises concerns as investigators adopt the term "structural racism" without engaging with theories and scholars with a long history in this area. This scoping review aims to build upon recent work by identifying current themes about the incorporation of structural racism into (social) epidemiologic research and practice with respect to theory, measurement, and practices and methods for trainees and public health researchers who are not already deeply grounded in this work. Methods This review uses methodological framework and includes peer-review articles written in English published between January 2000-August 2022. Results A search of Google Scholar, manual collection, and referenced lists identified a total of 235 articles; 138 met the inclusion criteria after duplicates were removed. Results were extracted by, and organized into, three broad sections: theory, construct measurement, and study practice and methods, with several themes summarized in each section. Discussion This review concludes with a summary of recommendations derived from our scoping review and a call to action echoing previous literature to resist an uncritical and superficial adoption of "structural racism" without attention to already existing scholarship and recommendations put forth by experts in the field.
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Affiliation(s)
- Simone Wien
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States
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Siegel M, Wiklund E. The relationship between state-level structural racism and disparities between the non-hispanic black and non-hispanic white populations in multiple health outcomes. J Natl Med Assoc 2023; 115:207-222. [PMID: 36801076 DOI: 10.1016/j.jnma.2023.01.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 01/16/2023] [Accepted: 01/25/2023] [Indexed: 02/17/2023]
Abstract
AIMS While several studies have examined the impact of individual indicators of structural racism on single health outcomes, few have explicitly modeled racial disparities in a wide range of health outcomes using a multidimensional, composite structural racism index. This paper builds on the previous research by examining the relationship between state-level structural racism and a wider array of health outcomes, focusing on racial disparities in mortality from firearm homicide, infant mortality, stroke, diabetes, hypertension, asthma, HIV, obesity, and kidney disease. METHODS We used a previously developed state structural racism index that consists of a composite score derived by averaging eight indicators across five domains: (1) residential segregation; (2) incarceration; (3) employment; (4) economic status/wealth; and (5) education. Indicators were obtained for each of the 50 states using Census data from 2020. We estimated the Black-White disparity in each health outcome in each state by dividing the age-adjusted mortality rate for the non-Hispanic Black population by the age-adjusted mortality rate for the non-Hispanic White population. These rates were obtained from the CDC WONDER Multiple Cause of Death database for the combined years 1999-2020. We conducted linear regression analyses to examine the relationship between the state structural racism index and the Black-White disparity in each health outcome across the states. In multiple regression analyses, we controlled for a wide range of potential confounding variables. RESULTS Our calculations revealed striking geographic differences in the magnitude of structural racism, with the highest values generally being observed in the Midwest and Northeast. Higher levels of structural racism were significantly associated with greater racial disparities in mortality for all but two of the health outcomes. CONCLUSIONS There is a robust relationship between structural racism and Black-White disparities in multiple health outcomes across states. Programs and policies to reduce racial heath disparities must include strategies to help dismantle structural racism and its consequences.
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Affiliation(s)
- Michael Siegel
- Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, MA, USA.
| | - Emma Wiklund
- Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, MA, USA
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Chen E, Lam PH, Yu T, Brody GH. Racial Disparities in School Belonging and Prospective Associations With Diabetes and Metabolic Syndrome. JAMA Pediatr 2023; 177:141-148. [PMID: 36574239 PMCID: PMC9856891 DOI: 10.1001/jamapediatrics.2022.3856] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 05/18/2022] [Indexed: 12/29/2022]
Abstract
Importance School belonging has important implications for academic, psychological, and health outcomes, but the associations between racial disparities in school belonging and health have not been explored to date. Objective To examine associations between school-level racial disparities in belonging and cardiometabolic health into adulthood in a national sample of Black and White children, adolescents, and young adults. Design, Setting, and Participants Prospective cohort study of a US national sample of 4830 Black and White students (National Longitudinal Study of Adolescent Health) followed up for 13 years. The study was conducted from 1994 to 1995 for wave 1 and in 2008 for wave 4. Data were analyzed from June 14 to August 13, 2021. Main Outcomes and Measures School-level racial disparities in belonging at baseline were calculated as the mean level of school belonging for Black students minus the mean level of school belonging for White students at the school that they attended when they were aged 12 to 20 years. Diabetes and metabolic syndrome were measured as outcomes for these same participants at 24 to 32 years of age. Results The study included 4830 students. For wave 1, mean (SD) age was 16.1 (1.7) years, and for wave 4, 29.0 (1.7) years. A total of 2614 (54.1%) were female, 2219 were non-Hispanic Black (45.9%), and 2611 were non-Hispanic White (54.1%). Among Black students, attending a school with a greater Black-White disparity in school belonging (more negative scores) was associated with an increased risk for diabetes (odds ratio, 0.66 [95% CI, 0.46-0.95]) and more risk factors for metabolic syndrome (rate ratio, 0.95 [95% CI, 0.90-1.00]) in adulthood 13 years later. These associations persisted above individual-level controls (age, sex, and body mass index) and school-level controls (school size, percentage of Black students, and percentage of Black teachers) and were not explained by either an individual's own perception of school belonging or the mean level of belonging across the whole school. Conclusions and Relevance In this prospective cohort study of US students, racial disparities in school belonging were associated with risks for diabetes and metabolic syndrome in Black students. Among students, fostering a more equal sense of school belonging across racial groups may have implications for health disparities in the cardiometabolic domain into adulthood.
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Affiliation(s)
- Edith Chen
- Institute for Policy Research and Department of Psychology, Northwestern University, Evanston, Illinois
| | - Phoebe H. Lam
- Institute for Policy Research and Department of Psychology, Northwestern University, Evanston, Illinois
| | - Tianyi Yu
- Center for Family Research, University of Georgia, Athens
| | - Gene H. Brody
- Center for Family Research, University of Georgia, Athens
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Child Health Advocacy: The Journey to Antiracism. Pediatr Clin North Am 2023; 70:91-101. [PMID: 36402474 DOI: 10.1016/j.pcl.2022.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The last several years have seen accelerated activity and discourse directed at antiracism. Specifically following the 2020 murder of George Floyd, institutions across the country engaged in a range of introspective exercises and transparent reckonings examining their practices, policies, and history insofar as equity and racism is concerned. The authors of this article, both active protagonists in this domain, have been, and continue to be, part of ongoing national efforts and have learned much about the strategies and tactics necessary to initiate, engage, and sustain traction on the path to antiracism.
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Ahmed MK, Scretching D, Lane SD. Study designs, measures and indexes used in studying the structural racism as a social determinant of health in high income countries from 2000-2022: evidence from a scoping review. Int J Equity Health 2023; 22:4. [PMID: 36609274 PMCID: PMC9817325 DOI: 10.1186/s12939-022-01796-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 11/22/2022] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Globally, structural racism has been well documented as an important social determinant of health (SODH) resulting in racial inequality related to health. Although studies on structural racism have increased over the years, the selection of appropriate designs, measures, and indexes of measurement that respond to SODH has not been comprehensively documented. Therefore, the lack of evidence seems to exist. This scoping review was conducted to map and summarize global evidence on the use of various designs, measures, and indexes of measurement when studying structural racism as a social determinant of health. METHODS We performed a scoping review of global evidence from 2000 to 2022 published in 5 databases: PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycInfo, Web of Science, ProQuest, and relevant grey literature on structural racism. We conducted a systematic search using keywords and subject headings around 3 concepts. We included peer reviewed original research/review articles which conceived the framework of social determinants of health (SODH) and studied structural racism. RESULTS Our review identified 1793 bibliographic citations for screening and 54 articles for final review. Articles reported 19 types of study design, 87 measures of exposure and 58 measures of health outcomes related to structural racism. 73 indexes or scales of measurement were used to assess health impacts of structural racism. Majority of articles were primary research (n = 43/54 articles; 79.6%), used quantitative research method (n = 32/54 articles; 59.3%) and predominantly conducted in the United States (n = 46/54 articles; 85.2.6%). Cross-sectional study design was the most used design (n = 17/54 articles; 31.5%) followed by systematic review (n = 7/54 articles; 13.0%) and narrative review (n = 6/54 articles; 11.1%). Housing and residential segregation was the largest cluster of exposure with the highest impact in infant health outcome. CONCLUSIONS Our review found several key gaps and research priorities on structural racism such as lack of longitudinal studies and availability of structural or ecological data, lack of consensus on the use of consolidated appropriate measures, indexes of measurement and appropriate study designs that can capture complex interactions of exposure and outcomes related to structural racism holistically.
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Affiliation(s)
- Md Koushik Ahmed
- grid.264484.80000 0001 2189 1568Department of Public Health, Falk College of Sports and Human Dynamics, Syracuse University, 150 Crouse Dr, 430 White Hall, Syracuse, NY 13244 USA
| | - Desiree Scretching
- grid.264484.80000 0001 2189 1568School of Information Studies, Syracuse University, 343 Hinds Hall, Syracuse, NY 13244 USA
| | - Sandra D. Lane
- grid.264484.80000 0001 2189 1568Department of Public Health, Falk College of Sports and Human Dynamics, 439 White Hall, Syracuse University, Syracuse, NY 13244 USA
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Alvarez CH. Structural Racism as an Environmental Justice Issue: A Multilevel Analysis of the State Racism Index and Environmental Health Risk from Air Toxics. J Racial Ethn Health Disparities 2023; 10:244-258. [PMID: 34993918 PMCID: PMC9810559 DOI: 10.1007/s40615-021-01215-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 12/16/2021] [Accepted: 12/17/2021] [Indexed: 02/03/2023]
Abstract
Communities of color and poor neighborhoods are disproportionately exposed to more air pollution-a pattern known as environmental injustices. Environmental injustices increase susceptibility to negative health outcomes among residents in affected communities. The structural mechanisms distributing environmental injustices in the USA are understudied. Bridging the literatures on the social determinants of health and environmental justice highlights the importance of the environmental conditions for health inequalities and sheds light on the institutional mechanisms driving environmental health inequalities. Employing a critical quantitative methods approach, we use data from an innovative state racism index to argue that systematic racialized inequalities in areas from housing to employment increase outdoor airborne environmental health risks in neighborhoods. Results of a multilevel analysis in over 65,000 census tracts demonstrate that tracts in states with higher levels of state-level Black-white gaps report greater environmental health risk exposure to outdoor air pollution. The state racism index explains four-to-ten percent of county- and state-level variation in carcinogenic risk and noncarcinogenic respiratory system risks from outdoor air toxics. The findings suggest that the disproportional exposure across communities is tied to systematic inequalities in environmental regulation and other structural elements such as housing and incarceration. Structural racism is an environmental justice issue.
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Affiliation(s)
- Camila H. Alvarez
- grid.266096.d0000 0001 0049 1282Department of Sociology, University of California–Merced, 5200 N. Lake Rd., CA 95343 Merced, USA
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Racism measurement and influences, variations on scientific racism, and a vision. Soc Sci Med 2023; 316:115247. [PMID: 36180279 DOI: 10.1016/j.socscimed.2022.115247] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 07/09/2022] [Accepted: 07/26/2022] [Indexed: 01/11/2023]
Abstract
The knowledge base regarding the impact of racism and discrimination on African American health and well-being has grown significantly since the first models of racism and health, but many questions remain. In this commentary, I discuss three challenges requiring attention in future research. The first is measurement. The second is consideration of individual and contextual influences that shape vulnerability to racism. The third challenge is racism in science itself (e.g., racial disparities in funding, absence, and erasure of African American voices in scientific discourse on health disparities). I discuss the benefits of addressing these challenges and offer a vision of what research on racism and African American health and well-being might look like as we move toward the eradication of racism and promotion of health equity.
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Kellogg AJ, Hancock DW, Cho GY, Reid AE. Community-level age bias and older adult mortality. Soc Sci Med 2023; 317:115449. [PMID: 36494219 DOI: 10.1016/j.socscimed.2022.115449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 08/30/2022] [Accepted: 10/08/2022] [Indexed: 11/22/2022]
Abstract
RATIONALE As the older adult population increases, understanding the health effects of bias against older adults is increasingly important. Whether structural forms of age bias predict worse health has received limited attention. OBJECTIVE We hypothesized that communities with greater age bias would have higher mortality among residents aged 65 and older. We expected the association to be unique to age bias, rather than general bias (i.e., sexual minority and racial bias), and that the age bias-mortality association would be strongest in predominantly White and younger communities. METHODS Explicit and implicit attitudes toward older adults (N = 1,001,735), sexual minorities (N = 791,966), and Black Americans (N = 2,255,808) were drawn from Project Implicit. Post-stratification relative to U.S. Census demographics was executed to improve the representativeness of county-level explicit and implicit bias estimates. County older adult mortality, estimated cross-sectionally with and longitudinally relative to bias scores, served as outcomes. Models controlled for relevant county-level covariates (e.g., median age) and included all U.S. counties (N = 3142). RESULTS Contrary to hypotheses but consistent with prior work, explicit age bias was cross-sectionally and longitudinally associated with lower mortality, over and above covariates and generalized community bias. The explicit age bias-lower mortality association only emerged in younger counties but did not depend on county ethnic composition. Implicit age bias was unassociated with outcomes. Post-hoc analyses supported that ageist communities may be associated with better health across the lifespan. Explicit age bias predicted lower mortality in young and middle adulthood; better mental health in middle adulthood, but not exercise or self-rated health, mediated the explicit age bias-older adult mortality association. CONCLUSIONS Results highlight the uniqueness of older age relative to other stigmatized identities. Further examination of the association of community-level age bias with better health may improve longevity for all communities.
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Affiliation(s)
- Alexander J Kellogg
- University of Massachusetts, Amherst; Department of Psychological and Brain Sciences; 135 Hicks Way, Tobin Hall, Amherst, MA, 01003, USA
| | - David W Hancock
- University of Massachusetts, Amherst; Department of Psychological and Brain Sciences; 135 Hicks Way, Tobin Hall, Amherst, MA, 01003, USA
| | - Grace Y Cho
- University of Massachusetts, Amherst; Department of Psychological and Brain Sciences; 135 Hicks Way, Tobin Hall, Amherst, MA, 01003, USA
| | - Allecia E Reid
- University of Massachusetts, Amherst; Department of Psychological and Brain Sciences; 135 Hicks Way, Tobin Hall, Amherst, MA, 01003, USA.
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Structural racism is associated with adverse postnatal outcomes among Black preterm infants. Pediatr Res 2022:10.1038/s41390-022-02445-6. [PMID: 36577795 PMCID: PMC9795138 DOI: 10.1038/s41390-022-02445-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 11/03/2022] [Accepted: 11/28/2022] [Indexed: 12/29/2022]
Abstract
BACKGROUND Structural racism contributes to racial disparities in adverse perinatal outcomes. We sought to determine if structural racism is associated with adverse outcomes among Black preterm infants postnatally. METHODS Observational cohort study of 13,321 Black birthing people who delivered preterm (gestational age 22-36 weeks) in California in 2011-2017 using a statewide birth cohort database and the American Community Survey. Racial and income segregation was quantified by the Index of Concentration at the Extremes (ICE) scores. Multivariable generalized estimating equations regression models were fit to test the association between ICE scores and adverse postnatal outcomes: frequent acute care visits, readmissions, and pre- and post-discharge death, adjusting for infant and birthing person characteristics and social factors. RESULTS Black birthing people who delivered preterm in the least privileged ICE tertiles were more likely to have infants who experienced frequent acute care visits (crude risk ratio [cRR] 1.3 95% CI 1.2-1.4), readmissions (cRR 1.1 95% CI 1.0-1.2), and post-discharge death (cRR 1.9 95% CI 1.2-3.1) in their first year compared to those in the privileged tertile. Results did not differ significantly after adjusting for infant or birthing person characteristics. CONCLUSION Structural racism contributes to adverse outcomes for Black preterm infants after hospital discharge. IMPACT STATEMENT Structural racism, measured by racial and income segregation, was associated with adverse postnatal outcomes among Black preterm infants including frequent acute care visits, rehospitalizations, and death after hospital discharge. This study extends our understanding of the impact of structural racism on the health of Black preterm infants beyond the perinatal period and provides reinforcement to the concept of structural racism contributing to racial disparities in poor postnatal outcomes for preterm infants. Identifying structural racism as a primary cause of racial disparities in the postnatal period is necessary to prioritize and implement appropriate structural interventions to improve outcomes.
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Cerdeña JP, Grubbs V, Non AL. Racialising genetic risk: assumptions, realities, and recommendations. Lancet 2022; 400:2147-2154. [PMID: 36502852 DOI: 10.1016/s0140-6736(22)02040-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 09/07/2022] [Accepted: 10/14/2022] [Indexed: 12/13/2022]
Affiliation(s)
- Jessica P Cerdeña
- Yale School of Medicine, Yale University, New Haven, CT, USA; Department of Anthropology, University of Connecticut, Storrs, CT, USA
| | - Vanessa Grubbs
- Department of Ambulatory and Preventive Medicine, Alameda Health System, Oakland, CA, USA
| | - Amy L Non
- Department of Anthropology, University of California, San Diego, CA, USA.
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