Racism and hypertension: a review of the empirical evidence and implications for clinical practice

Effects of residential socioeconomic polarization on high blood pressure among nursing home residents

OBJECTIVE

Neighborhood concentration of racial, income, education, and housing deprivation is known to be associated with higher rates of hypertension. The objective of this study is to examine the association between tract-level spatial social polarization and hypertension in a cohort with relatively equal access to health care, a Veterans Affairs nursing home.

METHODS

41,973 long-term care residents aged ≥65 years were matched with tract-level Indices of Concentration at the Extremes across four socioeconomic domains. We modeled high blood pressure against these indices controlling for individual-level cardiovascular confounders.

RESULTS

We found participants who had resided in the most disadvantaged quintile had a 1.10 (95% 1.01, 1.19) relative risk of high blood pressure compared to those in the other quintiles for the joint measuring race/ethnicity and income domain.

CONCLUSIONS

We achieved our objective by demonstrating that concentrated deprivation is associated with worse cardiovascular outcomes even in a population with equal access to care. Measures that jointly consider economic and racial/ethnic polarization elucidate larger disparities than single domain measures.

Disparities in Cardiovascular Disease-Related Outcomes Among Cancer Survivors in the United States: A Systematic Review of the Literature

BACKGROUND

Cancer and cardiovascular disease (CVD) are major causes of morbidity and mortality in the United States (US). Cancer survivors have increased risks for CVD and CVD-related mortality due to multiple factors including cancer treatment-related cardiotoxicity. Disparities are rooted in differential exposure to risk factors and social determinants of health (SDOH), including systemic racism. This review aimed to assess SDOH's role in disparities, document CVD-related disparities among US cancer survivors, and identify literature gaps for future research.

METHODS

Following the Peer Review of Electronic Search Strategies (PRESS) guidelines, MEDLINE, PsycINFO, and Scopus were searched on March 15, 2021, with an update conducted on September 26, 2023. Articles screening was performed using the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) 2020, a pre-defined Population, Exposure, Comparison, Outcomes, and Settings (PECOS) framework, and the Rayyan platform. A modified version of the Newcastle-Ottawa Scale was used to assess the risk of bias, and RAW Graphs for alluvial charts. This review is registered with PROSPERO under ID #CRD42021236460.

RESULTS

Out of 7,719 retrieved articles, 24 were included, and discussed diverse SDOH that contribute to CVD-related disparities among cancer survivors. The 24 included studies had a large combined total sample size (n=7,704,645; median=19,707). While various disparities have been investigated, including rural-urban, sex, socioeconomic status, and age, a notable observation is that non-Hispanic Black cancer survivors experience disproportionately adverse CVD outcomes when compared to non-Hispanic White survivors. This underscores historical racism and discrimination against non-Hispanic Black individuals as fundamental drivers of CVD-related disparities.

CONCLUSIONS

Stakeholders should work to eliminate the root causes of disparities. Clinicians should increase screening for risk factors that exacerbate CVD-related disparities among cancer survivors. Researchers should prioritise the investigation of systemic factors driving disparities in cancer and CVD and develop innovative interventions to mitigate risk in cancer survivors.

Race Disparities in Hypertension Prevalence Among Older Men

This study aimed to examine whether hypertension prevalence varies by race/ethnicity and within age groups in a nationally representative sample of men in the United States. Hypertension was defined as blood pressure (BP) readings of 140 mm Hg and higher for systolic BP, 90 mm Hg and higher for diastolic BP, or self-reports of taking medication for hypertension. Modified Poisson models estimated prevalence ratios (PRs) and 95% confidence intervals (CI) for race and age group associations with hypertension. The prevalence of hypertension was 38% overall and 46% of the men were aged 50 and older. Analyses that focused on older men (50 years of age or older) found that non-Hispanic Black men had a higher prevalence of hypertension (PR  =  1.28, 95% CI: 1.19 - 1.37) compared to non-Hispanic White men. We suggest future research utilize life course perspectives to better identify which cumulative experiences impact hypertension disparities.

Socioeconomic disparities in the management and outcomes of acute myocardial infarction

BACKGROUND

Patients from lower socioeconomic status areas have poorer outcomes following acute myocardial infarction (AMI); however, how ethnicity modifies such socioeconomic disparities is unclear.

METHODS

Using the UK Myocardial Ischaemia National Audit Project (MINAP) registry, we divided 370 064 patients with AMI into quintiles based on Index of Multiple Deprivation (IMD) score, comprising seven domains including income, health, employment and education. We compared white and 'ethnic-minority' patients, comprising Black, Asian and mixed ethnicity patients (as recorded in MINAP); further analyses compared the constituents of the ethnic-minority group. Logistic regression models examined the role of the IMD, ethnicity and their interaction on the odds of in-hospital mortality.

RESULTS

More patients from the most deprived quintile (Q5) were from ethnic-minority backgrounds (Q5; 15% vs Q1; 4%). In-hospital mortality (OR 1.10, 95% CI 1.01 to 1.19, p=0.025) and major adverse cardiovascular event (MACE) (OR 1.07, 95% CI 1.00 to 1.15, p=0.048) were more likely in Q5, and MACE was more likely in ethnic-minority patients (OR 1.40, 95% CI 1.00 to 1.95, p=0.048) versus white (OR 1.05, 95% CI 0.98 to 1.13, p=0.027) in Q5. In subgroup analyses, Black patients had the highest in-hospital mortality within the most affluent quintile (Q1) (Black: 0.079, 95% CI 0.046 to 0.112, p<0.001; White: 0.062, 95% CI 0.059 to 0.066, p<0.001), but not in Q5 (Black: 0.065, 95% CI 0.054 to 0.077, p<0.001; White: 0.065, 95% CI 0.061 to 0.069, p<0.001).

CONCLUSION

Patients with a higher deprivation score were more often from an ethnic-minority background, more likely to suffer in-hospital mortality or MACE when compared with the most affluent quintile, and this relationship was stronger in ethnic minorities compared with White patients.

Investigating the Associations of Sexual Minority Stressors and Incident Hypertension in a Community Sample of Sexual Minority Adults

BACKGROUND

Sexual minority adults are at higher risk of hypertension than their heterosexual counterparts. Sexual minority stressors (i.e., unique stressors attributed to sexual minority identity) are associated with a variety of poor mental and physical health outcomes. Previous research has not tested associations between sexual minority stressors and incident hypertension among sexual minority adults.

PURPOSE

To examine the associations between sexual minority stressors and incident hypertension among sexual minority adults assigned female sex at birth.

METHODS

Using data from a longitudinal study, we examined associations between three sexual minority stressors and self-reported hypertension. We ran multiple logistic regression models to estimate the associations between sexual minority stressors and hypertension. We conducted exploratory analyses to determine whether these associations differed by race/ethnicity and sexual identity (e.g., lesbian/gay vs. bisexual).

RESULTS

The sample included 380 adults, mean age 38.4 (± 12.81) years. Approximately 54.5% were people of color and 93.9% were female-identified. Mean follow-up was 7.0 (± 0.6) years; during which 12.4% were diagnosed with hypertension. We found that a 1-standard deviation increase in internalized homophobia was associated with higher odds of developing hypertension (AOR 1.48, 95% Cl: 1.06-2.07). Stigma consciousness (AOR 0.85, 95% CI: 0.56-1.26) and experiences of discrimination (AOR 1.07, 95% CI: 0.72-1.52) were not associated with hypertension. The associations of sexual minority stressors with hypertension did not differ by race/ethnicity or sexual identity.

CONCLUSIONS

This is the first study to examine the associations between sexual minority stressors and incident hypertension in sexual minority adults. Implications for future studies are highlighted.

Implementation Strategies to Improve Blood Pressure Control in the United States: A Scientific Statement From the American Heart Association and American Medical Association

Hypertension is one of the most important risk factors that contribute to incident cardiovascular events. A multitude of US and international hypertension guidelines, scientific statements, and policy statements have recommended evidence-based approaches for hypertension management and improved blood pressure (BP) control. These recommendations are based largely on high-quality observational and randomized controlled trial data. However, recent published data demonstrate troubling temporal trends with declining BP control in the United States after decades of steady improvements. Therefore, there is a widening disconnect between what hypertension experts recommend and actual BP control in practice. This scientific statement provides information on the implementation strategies to optimize hypertension management and to improve BP control among adults in the United States. Key approaches include antiracism efforts, accurate BP measurement and increased use of self-measured BP monitoring, team-based care, implementation of policies and programs to facilitate lifestyle change, standardized treatment protocols using team-based care, improvement of medication acceptance and adherence, continuous quality improvement, financial strategies, and large-scale dissemination and implementation. Closing the gap between scientific evidence, expert recommendations, and achieving BP control, particularly among disproportionately affected populations, is urgently needed to improve cardiovascular health.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Migrant status disparities in blood pressure: a multiple mediation analysis of modifiable factors

BACKGROUND

We examined differences in blood pressure (BP) levels between first-generation immigrants and natives in adult residents in Northeast Italy, and investigated the role of lifestyle behaviors, body mass index (BMI), and education as potentially modifiable mediating factors.

METHODS

We included 20-69-year-old participants from the Health Surveillance Program of the Veneto Region (n = 37,710). Immigrants born in a high migratory pressure country (HMPC) were further grouped into geographical macro-areas. The outcomes were systolic BP (SBP) and hypertension. Multiple mediation analyses were performed to determine the contribution of each mediator of the SBP/migrant status association.

RESULTS

Of the 37,380 subjects included, 8.7% were born in an HMPC. BMI, education, alcohol, sweets and meat consumption were included as potential mediators. A small advantage in SBP was seen for immigrants compared to natives (β =  - 0.71,95%CI  - 1.30;  - 0.10). The direct effect (net of the covariates) of immigrant status on SBP was a reduction of 1.62 mmHg (95%CI  - 2.25;  - 0.98). BMI played the highest suppressive role (β = 1.14,95%CI 0.99; 1.35), followed by education. Alcohol consumption amplified the health advantage of immigrants. The suppressing effect of BMI was particularly evident among women and North Africans compared to natives. Similar results were seen for hypertension rates.

CONCLUSIONS

Although causation cannot be proven given the cross-sectional design, our findings identify BMI as the most effective target to preserve the health advantage of immigrants with respect to BP levels.

Role of Dysfunctional Attitudes in the Association Between Discrimination and Adolescents' Mental and Physical Health

Our study is based on Beck's cognitive stress-vulnerability theory of depression and research on (a) disparities in elevated blood pressure between adolescents from minority and majority backgrounds, (b) the effects of perceived everyday discrimination (PED) on depression and elevated blood pressure, and (c) the associations between depression and cardiovascular diseases. The purpose of our study is to integrate Beck's model and the different research lines by examining the associations of the stressor PED and depressive symptoms with blood pressure through the cognitive vulnerability of dysfunctional attitudes in adolescents. In our cross-sectional study, 97 adolescents (40% female) aged 13 to 15 (M = 14.15, SD = .53) who identified as Black (47.5%), white (47.5%), and mixed race (5%) completed self-reports of PED, dysfunctional attitudes, and depressive symptoms and had their blood pressure measured. We used the PROCESS command tool for SPSS to compute OLS regressions and direct, indirect, and total effects of PED, dysfunctional attitudes, and depressive symptoms on blood pressure. As predicted, our analyses revealed that PED predicts dysfunctional attitudes and depressive symptoms, dysfunctional attitudes predict marginally significant depressive symptoms and significantly systolic blood pressure. Our findings highlight the relevance of PED and dysfunctional attitudes for adolescents mental (i.e., depressive symptoms) and physical health (i.e., blood pressure). If this pattern is replicated, systemic interventions to reduce PED and individual interventions to address dysfunctional attitudes in adolescents could be promising to improve both mental (i.e., depressive symptoms) and physical health (i.e., BP).

Evaluating the use of blood pressure polygenic risk scores across race/ethnic background groups

We assess performance and limitations of polygenic risk scores (PRSs) for multiple blood pressure (BP) phenotypes in diverse population groups. We compare "clumping-and-thresholding" (PRSice2) and LD-based (LDPred2) methods to construct PRSs from each of multiple GWAS, as well as multi-PRS approaches that sum PRSs with and without weights, including PRS-CSx. We use datasets from the MGB Biobank, TOPMed study, UK biobank, and from All of Us to train, assess, and validate PRSs in groups defined by self-reported race/ethnic background (Asian, Black, Hispanic/Latino, and White). For both SBP and DBP, the PRS-CSx based PRS, constructed as a weighted sum of PRSs developed from multiple independent GWAS, perform best across all race/ethnic backgrounds. Stratified analysis in All of Us shows that PRSs are better predictive of BP in females compared to males, individuals without obesity, and middle-aged (40-60 years) compared to older and younger individuals.

Opportunities and challenges in discussing racism during primary care visits

OBJECTIVE

To understand how patients and primary care practitioners (PCPs) discuss racism and their perspectives on having these conversations during primary care visits.

DATA SOURCES/STUDY SETTING

We conducted semi-structured interviews from September 2020-March 2021 at a Federally Qualified Health Center in the San Francisco Bay Area.

STUDY DESIGN

We conducted an inductive qualitative descriptive pilot study using one-on-one, semi-structured interviews with 5 members of a Patient Advisory Council and 10 internal medicine PCPs.

DATA COLLECTION/EXTRACTION METHODS

Interviews were conducted via video conferencing, recorded, and transcribed. An iterative analytic process was used to thematically assess participants' experiences and perspectives and identify key themes.

PRINCIPAL FINDINGS

Patients and PCPs identified benefits from engaging in conversations about racism during primary care visits and noted challenges and concerns. Patients and PCPs highlighted strategies to advance communication about racism in primary care.

CONCLUSIONS

Initiating conversations about racism with patients in primary care can be meaningful, but also has risks. More research is needed for deeper exploration of patients' perspectives and development of trainings. Improving how PCPs communicate with patients about racism represents an opportunity to advance antiracism in medicine and improve health outcomes for individuals who have historically been poorly served by our health care system.

Experience of Ethnic Discrimination, Anxiety, Perceived Risk of COVID-19, and Social Support among Polish and International Students during the Pandemic

BACKGROUND

Our research aimed to assess the experiences of ethnic discrimination among students in Poland (Polish and international) during the COVID-19 pandemic. We also tested the prevalence of anxiety symptoms and their relationship with perceived COVID-19 risk, the severity of discrimination, and social support.

METHODS

The data from Polish (n = 481) and international university students (n = 105) were collected online (November-January 2020). Participants completed measures of ethnic discrimination (GEDS), anxiety scale (GAD-7), COVID-19 risk perception index, and perceived social support scale (MSPSS) questionnaires.

RESULTS

The results showed that international students reported being much more discriminated than Polish students during the first year of the COVID-19 pandemic. Contrary to our expectation, a higher risk of anxiety disorders (GAD) was observed in 42% of Polish students compared to 31% of international students. The predictors of higher anxiety symptoms among both groups were the perceived risk of COVID-19 and the greater severity of ethnic discrimination. In both groups, the perceived social support had a protective role in anxiety symptomatology.

CONCLUSIONS

The high prevalence of discrimination, especially among international students, simultaneously with high symptoms of anxiety, requires vigorous action involving preventive measures and psychological support.

Physician experiences of workplace racial and gender microaggressions

OBJECTIVES

To investigate racial and gender-specific microaggressions that are experienced by pediatric otolaryngologists at work.

METHODS

An anonymous web-based survey consisting of 18 questions was sent to American Society of Pediatric Otolaryngology (ASPO) members via an email link. The survey included questions from the Workplace and School Microaggressions component of the Racial and Ethnic Microaggressions (REM) Scale.

RESULTS

125 out of 610 ASPO members completed the survey for a response rate of 20.5%. 28% of respondents reported experiencing a racial/ethnic microaggression in the last six months. Respondents who identified as Asian American Pacific Islander had significantly higher REM scores when compared with Caucasian respondents (p < 0.05). There was no significant difference in scores when comparing the other Race categories. Female respondents reported significantly higher gendered-microaggression scores compared to those identifying as male (p < 0.001). 66% of female respondents experienced some form of gender-based microaggression in the last six months.

CONCLUSION

By providing evidence that pediatric otolaryngologists continue to report experiences of discrimination in the form of microaggressions, this study aims to increase awareness and inspire a more inclusive work environment.

A Systematic Review of Black People Coping With Racism: Approaches, Analysis, and Empowerment

This article reviews the current research literature concerning Black people in Western societies to better understand how they regulate their emotions when coping with racism, which coping strategies they use, and which strategies are functional for well-being. A systematic review of the literature was conducted, and 26 studies were identified on the basis of a comprehensive search of multiple databases and reference sections of relevant articles. Studies were quantitative and qualitative, and all articles located were from the United States or Canada. Findings demonstrate that Black people tend to cope with racism through social support (friends, family, support groups), religion (prayer, church, spirituality), avoidance (attempting to avoid stressors), and problem-focused coping (confronting the situation directly). Findings suggest gender differences in coping strategies. We also explore the relationship between coping with physical versus emotional pain and contrast functional versus dysfunctional coping approaches, underscoring the importance of encouraging personal empowerment to promote psychological well-being. Findings may help inform mental-health interventions. Limitations include the high number of American-based samples and exclusion of other Black ethnic and national groups, which is an important area for further exploration.

Racial Disparities in Avoidant Coping and Hypertension Among Midlife Adults

While associations between stress and hypertension have been documented, little research has examined the association between coping and hypertension, especially in the context of understanding racial disparities. Utilizing data from the CHDS-DISPAR study, we examine the association between avoidant coping and hypertension among adults age 50 while assessing for potential differences across (1) coping in response to the general stress and discrimination and (2) African American and White racial groups. Coping was measured using a 9-item scale with an avoidant coping subscale (e.g., drinking alcohol). Mean avoidance coping scores were calculated for both general stress and discrimination. No racial differences in avoidant coping were found. Within our sample (n = 414), there was a high burden of hypertension among African American respondents compared to White respondents (50.3% vs. 22.6%). Models assessed associations between avoidant coping and hypertension adjusted for sociodemographic factors, obesity, and either experience of stress or discrimination depending on the coping domain examined. Avoidant coping in response to the general stress and discrimination was associated with increased hypertension among White respondents (PR: 1.63 [95%CI 1.01, 2.24]; PR: 1.69 [95%CI 1.12, 2.26], respectively) and no associations among African American respondents (PR: 0.83 [95%CI 0.57, 1.09]; PR: 0.82 [95%CI 0.52, 1.12], respectively). This research suggests that racial disparities in hypertension may not be attributable to individual-level coping behaviors.

Neighborhood social organization exposures and racial/ethnic disparities in hypertension risk in Los Angeles

Despite a growing evidence base documenting associations between neighborhood characteristics and the risk of developing high blood pressure, little work has established the role played by neighborhood social organization exposures in racial/ethnic disparities in hypertension risk. There is also ambiguity around prior estimates of neighborhood effects on hypertension prevalence, given the lack of attention paid to individuals' exposures to both residential and nonresidential spaces. This study contributes to the neighborhoods and hypertension literature by using novel longitudinal data from the Los Angeles Family and Neighborhood Survey to construct exposure-weighted measures of neighborhood social organization characteristics-organizational participation and collective efficacy-and examine their associations with hypertension risk, as well as their relative contributions to racial/ethnic differences in hypertension. We also assess whether the hypertension effects of neighborhood social organization vary across our sample of Black, Latino, and White adults. Results from random effects logistic regression models indicate that adults living in neighborhoods where people are highly active in informal and formal organizations have a lower probability of being hypertensive. This protective effect of exposure to neighborhood organizational participation is also significantly stronger for Black adults than Latino and White adults, such that, at high levels of neighborhood organizational participation, the observed Black-White and Black-Latino hypertension differences are substantially reduced to nonsignificance. Nonlinear decomposition results also indicate that almost one-fifth of the Black-White hypertension gap can be explained by differential exposures to neighborhood social organization.

Racial/Ethnic Differences in Psychiatric and Medical Diagnoses Among Autistic Adults

Background

Racial/ethnic disparities in access to diagnostic services are pervasive for autistic children. However, a few studies have examined racial/ethnic health disparities among autistic adults, who commonly experience higher rates of health conditions than non-autistic adults. We aimed at examining the intersection of autism and race/ethnicity in association with psychiatric and medical diagnoses.

Methods

The study population included adult members of Kaiser Permanente Northern California enrolled from 2008 to 2012. We ascertained 1507 adults who had an autism diagnosis documented in their electronic medical records. We sampled a matched control group of adults without an autism diagnosis (N = 15,070) at a 10:1 ratio. Our sample was 46% White, 17% Hispanic, 16% Asian, 7% Black, and 14% other race/ethnicity. We compared health diagnoses (a) between autistic and non-autistic adults within strata of race/ethnicity and (b) across race/ethnicity within strata of autistic and non-autistic adults. Lastly, we examined the interaction between autism and race/ethnicity on both multiplicative and additive scales.

Results

Autistic adults were more likely to be diagnosed with most medical and psychiatric conditions compared with their non-autistic counterparts of the same race/ethnicity. Among autistic adults, Black, Hispanic, and Asian adults were less likely to be diagnosed with psychiatric conditions and Black and Hispanic autistic adults were more likely to be diagnosed with obesity than their White counterparts. In interaction models, we found that adults who were Black and autistic were disproportionately less likely to be diagnosed with psychiatric conditions and autoimmune disease and more likely to be diagnosed with hypertension than expected.

Conclusion

Health vulnerabilities may be compounded at the intersection of autism and race/ethnicity. Future research should continue to apply an intersectional lens toward understanding and addressing these disparities. Our findings likely underestimate the health disparities that exist in uninsured autistic adults and those living in other parts of the United States.

Self-employment, educational attainment, and hypertension among Black women and men

Background

Self-employment is generally associated with better health outcomes and educational attainment can shape self-employment. Yet, Black Americans are less likely to be self-employed and analyses of self-employment and health among Black Americans are few. The aim of this study was to determine how educational attainment moderates the associations between self-employment and hypertension among Black adults.

Methods

Using data from the 2007-2018 National Health and Nutrition Examination Survey, participants who self-identified as non-Hispanic Black (n = 2,855) were categorized as (1) employees with no self-employment income, (2) employees with self-employment income, or (3) having full-time self-employment. Modified Poisson regressions and multiplicative interaction terms were used to determine whether educational attainment moderated the associations between self-employment and measured hypertension (i.e., 140/90 mm Hg or anti-hypertensive medication).

Results

Most participants were employees with no self-employment income (81.9%), but 11.8% were employees reporting some self-employment income and 6.3% were self-employed full-time. About two in five (40.9%) had hypertension. Having full-time self-employment was associated with lower risk of hypertension compared to those who were employees (risk ratio = 0.82, 95% confidence interval = 0.67-0.98), and educational attainment moderated the associations among Black men such that part-time self-employment was associated with high rates of hypertension among Black men who had not completed high school.

Conclusions

These results suggest that full-time self-employment is associated with lower risk of hypertension among Black adults, but that being an employee with some self-employment income may elevate rates of hypertension among Black men depending on educational attainment. Future studies should assess pathways between self-employment and hypertension by educational attainment among Black women and men.

Experiences of ethnic discrimination and COMT rs4680 polymorphism are associated with depressive symptoms in Latinx adults at risk for cardiovascular disease

BACKGROUND

Ethnic discrimination is frequently experienced among U.S. Latinx communities, and is linked to CVD risk factors, such as depression. Genetic variants may influence this relationship.

OBJECTIVES

The objectives of this study were to examine associations between experiences of discrimination, rs4680 genotype, and depressive symptoms in Latinx adults.

METHODS

We analyzed data from 124 Latinx adults with two or more CVD risk factors, and conducted hierarchical linear regression, adjusting for sex, age, income, education, and acculturation.

RESULTS

Participants were predominately female (74.2%) and aged 40.2 ± 9.3 years. More experiences of discrimination were associated with higher depressive symptoms (p = 0.041). Those with Met-Met-and Val-Met-genotypes had increased depressive symptoms than those with Val-Val-genotype (p = 0.049). Rs4680 was not a moderator.

CONCLUSION

Findings suggest discrimination and rs4680 genotype are associated with depressive symptoms in Latinx adults, which may increase CVD risk. Further research is needed to better understand biological mechanisms of these relationships.

Prevalence, Treatment, and Control of Hypertension Among US Women of Reproductive Age by Race/Hispanic Origin

BACKGROUND

To explore the prevalence, pharmacologic treatment, and control of hypertension among US nonpregnant women of reproductive age by race/Hispanic origin to identify potential gaps in care.

METHODS

We pooled data from the 2011 to March 2020 (prepandemic) National Health and Nutrition Examination Survey cycles. Our analytic sample included 4,590 nonpregnant women aged 20-44 years who had at least 1 examiner-measured blood pressure (BP) value. We estimated prevalences and 95% confidence intervals (CIs) of hypertension, pharmacologic treatment, and control based on the 2003 Joint Committee on High Blood Pressure (JNC 7) and the 2017 American College of Cardiology and the American Heart Association (ACC/AHA) guidelines. We evaluated differences by race/Hispanic origin using Rao-Scott chi-square tests.

RESULTS

Applying ACC/AHA guidelines, hypertension prevalence ranged from 14.0% (95% CI: 12.0, 15.9) among Hispanic women to 30.9% (95% CI: 27.8, 34.0) among non-Hispanic Black women. Among women with hypertension, non-Hispanic Black women had the highest eligibility for pharmacological treatment (65.5%, 95% CI: 60.4, 70.5); current use was highest among White women (61.8%, 95% CI: 53.8, 69.9). BP control ranged from 5.2% (95% CI: 1.1, 9.3) among women of another or multiple non-Hispanic races to 18.6% (95% CI: 12.1, 25.0) among Hispanic women.

CONCLUSIONS

These findings highlight the importance of monitoring hypertension, pharmacologic treatment, and control by race/Hispanic origin and addressing barriers to equitable hypertension care among women of reproductive age.

The neurobiology of social stress resulting from Racism: Implications for pain disparities among racialized minorities

Extant literature posits that humans experience two types of threat: physical threat and social threat. While describing pain as "physical" or "social" can be helpful for understanding pain origins (i.e., broken bone versus lost relationship), this dichotomy is largely artificial and not particularly helpful for understanding how the human brain experiences pain. One real world example of social exclusion and rejection that is threatening and likely to bring about significant stress is racism. Racism is a system of beliefs, practices, and policies that operates to disadvantage racialized minorities while providing advantage to those with historical power, particularly White people in the United States and most other Western nations. The objective of this Mini-Review is to present evidence in support of the argument that racism promotes physical pain in racialized minorities, which in turn promotes chronic pain disparities. First, we provide a theoretical framework describing how racism is a potent stressor that affects the health and well-being of racialized minorities. We will then address the neurobiological underpinnings linking racism to social threat, as well as that linking social threats and physical pain. Finally, we will discuss how the perception of social threat brought about by racism may undermine pain management efforts.

Lethal Police Encounters and Cardiovascular Health among Black Americans

This study uses insights from social stress theory to examine associations between exposure to police killings of Black Americans and cardiovascular health among Black women and men. Data on lethal police encounters come from the Mapping Police Violence (MPV) database, which allows for examination of total exposures to police killings of Black people and exposures to events when decedents were unarmed. MPV data are merged with the Behavioral Risk Factor Surveillance System (n = 26,086) and state-level information from multiple federal databases. Four cardiovascular health outcomes are examined-hypertension, diabetes, heart attack, and stroke. After adjusting for important risk factors, results from gender-stratified multilevel logistic regressions reveal a positive association between exposures to police killings of unarmed Black people and odds of hypertension among Black women and stroke among Black men. Total exposures to police killings of Black people are also associated with greater likelihood of stroke for Black men. Findings from this study demonstrate that stress exposures generated by the quantity and injustice of police killings have important implications for cardiovascular health among Black Americans. Furthermore, adverse cardiovascular health associated with exposure to police violence tends to manifest differently for Black men and women.

Toward a Theory of the Underpinnings and Vulnerabilities of Structural Racism: Looking Upstream from Disease Inequities among People Who Use Drugs

Structural racism is increasingly recognized as a key driver of health inequities and other adverse outcomes. This paper focuses on structural racism as an "upstream" institutionalized process, how it creates health inequities and how structural racism persists in spite of generations of efforts to end it. So far, "downstream" efforts to reduce these health inequities have had little success in eliminating them. Here, we attempt to increase public health awareness of structural racism and its institutionalization and sociopolitical supports so that research and action can address them. This paper presents both a theoretic and an analytic approach to how structural racism contributes to disproportionate rates of HIV/AIDS and related diseases among oppressed populations. We first discuss differences in disease and health outcomes among people who use drugs (PWUD) and other groups at risk for HIV from different racial and ethnic populations. The paper then briefly analyzes the history of racism; how racial oppression, class, gender and other intersectional divisions interact to create health inequities; and how structural racism is institutionalized in ways that contribute to disease disparities among people who use drugs and other people. It examines the processes, institutions and other structures that reinforce structural racism, and how these, combined with processes that normalize racism, serve as barriers to efforts to counter and dismantle the structural racism that Black, indigenous and Latinx people have confronted for centuries. Finally, we discuss the implications of this analysis for public health research and action to undo racism and to enhance the health of populations who have suffered lifetimes of racial/ethnic oppression, with a focus on HIV/AIDS outcomes.

Diferenças Raciais no Controle da Pressão Arterial em Usuários de Anti-Hipertensivos em Monoterapia: Resultados do Estudo ELSA-Brasil

Fundamento

Aparentemente, a pior resposta a algumas classes de anti-hipertensivos, especialmente inibidores da enzima conversora da angiotensina e bloqueadores de receptor de angiotensina, pela população negra, explicaria, pelo menos parcialmente, o pior controle da hipertensão entre esses indivíduos. Entretanto, a maioria das evidências vêm de estudos norte-americanos.

Objetivos

Este estudo tem o objetivo de investigar a associação entre raça/cor da pele autorrelatadas e controle de PA em participantes do Estudo Longitudinal de Saúde do Adulto (ELSA-Brasil) utilizando várias classes de anti-hipertensivos em monoterapia.

Métodos

O estudo envolveu uma análise transversal, realizada com participantes da linha de base do ELSA-Brasil. O controle de pressão arterial foi a variável de resposta, participantes com valores de PA ≥140/90 mmHg foram considerados descontrolados em relação aos níveis de pressão arterial. A raça/cor da pele foi autorrelatada (branco, pardo, negro). Todos os participantes tiveram que responder perguntas sobre uso contínuo de medicamentos. A associação entre o controle de PA e raça/cor da pele foi estimada por regressão logística. O nível de significância adotado nesse estudo foi de 5%.

Resultados

Do total de 1.795 usuários de anti-hipertensivos em monoterapia na linha de base, 55,5% se declararam brancos, 27,9%, pardos e 16,7%, negros. Mesmo depois de padronizar em relação a variáveis de confusão, negros em uso de inibidores da enzima conversora de angiotensina (IECA), bloqueadores de receptor de angiotensina (BRA), diuréticos tiazídicos (DIU tiazídicos) e betabloqueadores (BB) in monoterapia tinham controle de pressão arterial pior em comparação a brancos.

Conclusões

Os resultados deste estudo sugerem que, nesta amostra de brasileiros adultos utilizando anti-hipertensivos em monoterapia, as diferenças de controle de pressão arterial entre os vários grupos raciais não são explicadas pela possível eficácia mais baixa dos IECA e BRA em indivíduos negros.

The relationship between Social Determinants of Health (SDoH) and death from cardiovascular disease or opioid use in counties across the United States (2009-2018)

BACKGROUND

Death from cardiovascular disease (CVD) has been a longstanding public health challenge in the US, whereas death from opioid use is a recent, growing public health crisis. While population-level approaches to reducing CVD risk are known to be effective in preventing CVD deaths, more targeted approaches in high-risk communities are known to work better for reducing risk of opioid overdose. For communities to plan effectively in addressing both public health challenges, they need information on significant community-level (vs individual-level) predictors of death from CVD or opioid use. This study addresses this need by examining the relationship between 1) county-level social determinants of health (SDoH) and CVD deaths and 2) county-level SDoH and opioid-use deaths in the US, over a ten-year period (2009-2018).

METHODS

A single national county-level ten-year 'SDoH Database' is analyzed, to address study objectives. Fixed-effects panel-data regression analysis, including county, year, and state-by-year fixed effects, is used to examine the relationship between 1) SDoH and CVD death-rate and 2) SDoH and opioid-use death-rate. Eighteen independent (SDoH) variables are included, spanning three contexts: socio-economic (e.g., race/ethnicity, income); healthcare (e.g., system-characteristics); and physical-infrastructure (e.g., housing).

RESULTS

After adjusting for county, year, and state-by-year fixed effects, the significant county-level positive SDoH predictors for CVD death rate were, median age and percentage of civilian population in armed forces. The only significant negative predictor was percentage of population reporting White race. On the other hand, the four significant negative predictors of opioid use death rate were median age, median household income, percent of population reporting Hispanic ethnicity and percentage of civilian population consisting of veterans. Notably, a dollar increase in median household income, was estimated to decrease sample mean opioid death rate by 0.0015% based on coefficient value, and by 20.05% based on effect size.

CONCLUSIONS

The study provides several practice and policy implications for addressing SDoH barriers at the county level, including population-based approaches to reduce CVD mortality risk among people in military service, and policy-based interventions to increase household income (e.g., by raising county minimum wage), to reduce mortality risk from opioid overdoses.

Race, geographical location and other risk factors for hypertension: South African National Health and Nutrition Examination Survey 2011/12

BACKGROUND

Hypertension is the leading cardiovascular disease in Africa. It is increasing in prevalence due partly to the epidemiological transition that African countries, including South Africa, are undergoing. This epidemiological transition is characterised by a nutrition transition andurbanisation; resulting in behavioural, environmental and stress changes that are subject to racial and geographic divides. The South African National Health and Nutrition Examination Survey (SANHANES) examined the association of traditional risk factors; and less traditional risk factors such as race, geographical location, social stressors and psychological distress with hypertension in a national population-based sample of South Africans.

METHODS

Data were analysed on individuals ≥15 years who underwent a physical examination in the SANHANES (n = 7443). Hypertension was defined by blood pressure ≥140/90 mmHg or self-reported hypertension medication usage. Stepwise regression examined the association of demographic, socioeconomic, life stressors, and health risk factors with systolic blood pressure, diastolic blood pressure, and hypertension. Secondly, the risk factor associations and geographical location effects were investigated separately for the African race group.

RESULTS

Increasing age (AOR = 1.069, p < 0.001); male gender (AOR = 1.413, p = 0.037); diabetes (AOR = 1.66, p = 0.002); family history of high blood pressure (AOR = 1.721, p < 0.001); and normal weight, overweight and obesity (relative to underweight: AOR = 1.782, p = 0.008; AOR = 2.232, p < 0.001; AOR = 3.874, p < 0.001 respectively) were associated with hypertension. Amongst African participants (n = 5315) age (AOR = 1.068, p < 0.001); male gender (AOR = 1.556, p = 0.001); diabetes (AOR = 1.717, p = 0.002); normal weight, overweight and obesity (relative to underweight: AOR = 1.958, p = 0.006; AOR = 2.118, p = 0.002; AOR = 3.931, p < 0.001); family history of high blood pressure (AOR = 1.485, p = 0.005); and household crowding (AOR = 0.745, p = 0.037) were associated with hypertension. There was a significantly lower prevalence of hypertension in rural informal compared to urban formal settings amongst African participants (AOR = 0.611, p = 0.005). Other social stressors and psychological distress were not significantly associated with hypertension.

CONCLUSION

There was no significant association between social stressors or psychological distress and hypertension. However, the study provides evidence of high-risk groups for whom hypertension screening and management should be prioritised, including older ages, males, people with diabetes or with family history of hypertension, and Africans who live in urban formal localities.

Social Determinants of Health in Neurology

Neurologic health disparities are created and perpetuated by structural and social determinants of health. These factors include, but are not limited to, interpersonal bias, institutional factors that lead to disparate access to care, and neighborhood-level factors, such as socioeconomic status, segregation, and access to healthy food. Effects of these determinants of health can be seen throughout neurology, including in stroke, epilepsy, headache, amyotrophic lateral sclerosis, multiple sclerosis, and dementia. Interventions to improve neurologic health equity require multilayered approaches to address these interdependent factors that create and perpetuate disparate neurologic health access and outcomes.

Effects of chronic ethnic discrimination in the daily life of Turkish immigrants living in Austria: study protocol of a 30-day ambulatory assessment study

INTRODUCTION

Chronic ethnic discrimination is associated with negative mental and physical health outcomes in ethnic minority groups. It is assumed that suffering from repeated discriminatory events leads, over time, to psychological consequences such as higher perceived stress, higher negative affect and lower positive affect. Higher stress reactivity to non-discriminatory stressors, such as daily hassles, as well as anticipation and avoidance behaviour regarding discriminatory events, may further contribute to the overall burden for affected individuals. Studies investigating chronic ethnic discrimination and its psychological consequences in the daily lives of affected persons are lacking. Here, we present a study protocol to investigate the impact of chronic ethnic discrimination and acute discriminatory events in the daily lives of Turkish immigrants living in Austria, using an ambulatory assessment design. The feasibility of our study design was tested and confirmed in a pilot study (n=10).

METHODS AND ANALYSIS

Ninety male Turkish immigrants will complete daily questionnaires for 30 days. Participants will indicate stress, perceived discrimination, negative and positive affect, daily hassles, anticipation and avoidance behaviour, as well as rumination with regard to discriminatory events on a daily basis. Furthermore, they will use preprogrammed iPods to assess acute discriminatory events in real time. Our hypotheses will be tested using multilevel analyses.

ETHICS AND DISSEMINATION

This study has been approved by the institutional review board of the University of Vienna (reference number 00358). Results will be presented at conferences and submitted for publication in a peer-reviewed journal.

What Are the Relationships between Psychosocial Community Characteristics and Dietary Behaviors in a Racially/Ethnically Diverse Urban Population in Los Angeles County?

To address existing gaps in public health practice, we used data from a 2014 internet panel survey of 954 Los Angeles County adults to investigate the relationships between psychosocial community characteristics (PCCs) and two key chronic disease-related dietary behaviors: fruit and vegetable (F+V) and soda consumption. Negative binomial regression models estimated the associations between 'neighborhood risks and resources' and 'sense of community' factors for each dietary outcome of interest. While high perceived neighborhood violence (p < 0.001) and perceived community-level collective efficacy (p < 0.001) were associated with higher F+V consumption, no PCCs were directly associated with soda consumption overall. However, moderation analyses by race/ethnicity showed a more varied pattern. High perceived violence was associated with lower F+V consumption among White and Asian/Native Hawaiian/Other Pacific Islander (ANHOPI) groups (p < 0.01). Inadequate park access and walking as the primary mode of transportation to the grocery store were associated with higher soda consumption among the ANHOPI group only (p < 0.05). Study findings suggest that current and future chronic disease prevention efforts should consider how social and psychological dynamics of communities influence dietary behaviors, especially among racially/ethnically diverse groups in urban settings. Intervention design and implementation planning could benefit from and be optimized based on these considerations.

A randomized trial of race-related stress among African Americans with chronic kidney disease

OBJECTIVE

African Americans progress from early to late-stage chronic kidney disease (CKD) at a rate that is three times that of Whites. Given research that implicates social stress in poor kidney outcomes, there is a need to examine whether race-related stress contributes to these disparities. Through experimental manipulation, this study sought to determine whether acute race-related stress was associated with autonomic arousal and an inflammatory marker, which are well-established pathways to poor kidney outcomes. Further we tested the hypothesis that expectations of racism may moderate this relationship.

METHOD

Fifty-two African American patients along the CKD continuum were randomized to recall a general or race-related stressful experience. Before, during, and after the recall, patients' blood pressure and Interleukin-6 (IL-6) were monitored. Prior to the experimental manipulation, participants completed self-reported measures of expectations of racism.

RESULTS

Across both study conditions, change in self-reported distress from baseline to stress was associated with both systolic and diastolic reactivity (both ps <.01), but not change in IL-6 responses (all ps > 0.05). A significant interaction revealed that those who were randomized to recall a race-related stressor demonstrated less diastolic blood pressure reactivity (F=4.80, p<.05) if they scored lower in expectations of racism as compared to those who scored high. Moreover, those who were randomized to the race-related stressor demonstrated greater increase in IL-6 from 45 to 90 min post-recall than those who recalled a general stressor (F=6.35, p<.05).

CONCLUSIONS

Acute race-related stress may be associated with autonomic arousal and inflammatory response among African American patients along the CKD continuum, suggesting the need to further understand its role in racial disparities in CKD progression.

The perspectives of health professionals and patients on racism in healthcare: A qualitative systematic review

OBJECTIVE

To understand racial bias in clinical settings from the perspectives of minority patients and healthcare providers to inspire changes in the way healthcare providers interact with their patients.

METHODS

Articles on racial bias were searched on Medline, CINAHL, PsycINFO, Web of Science. Full text review and quality appraisal was conducted, before data was synthesized and analytically themed using the Thomas and Harden methodology.

RESULTS

23 articles were included, involving 1,006 participants. From minority patients' perspectives, two themes were generated: 1) alienation of minorities due to racial supremacism and lack of empathy, resulting in inadequate medical treatment; 2) labelling of minority patients who were stereotyped as belonging to a lower socio-economic class and having negative behaviors. From providers' perspectives, one theme recurred: the perpetuation of racial fault lines by providers. However, some patients and providers denied racism in the healthcare setting.

CONCLUSION

Implicit racial bias is pervasive and manifests in patient-provider interactions, exacerbating health disparities in minorities. Beyond targeted anti-racism measures in healthcare settings, wider national measures to reduce housing, education and income inequality may mitigate racism in healthcare and improve minority patient care.

Lifecourse Educational Trajectories and Hypertension in Midlife: An Application of Sequence Analysis

BACKGROUND

Higher educational attainment predicts lower hypertension. Yet, associations between non-traditional educational trajectories (e.g., interrupted degree programs) and hypertension are less well understood, particularly among structurally marginalized groups who are more likely to experience these non-traditional trajectories.

METHODS

In National Longitudinal Survey of Youth 1979 cohort data (N=6,317), we used sequence and cluster analyses to identify groups of similar educational sequences - characterized by timing and type of terminal credential - that participants followed from age 14-48. Using logistic regression, we estimated associations between the resulting 10 educational sequences and hypertension at age 50. We evaluated effect modification by individual-level indicators of structural marginalization (race, gender, race and gender, and childhood socioeconomic status (cSES)).

RESULTS

Compared to terminal high school (HS) diploma completed at traditional age, terminal GED (OR:1.32;95%CI:1.04,1.66; RR:1.21;95%CI:1.03,1.43) or Associate Degree after <HS (OR:1.93;95%CI: 1.11,3.35; RR:1.55;95%CI:1.10,2.17) was associated with higher hypertension. There was some evidence of effect modification. Hypertension associated with delayed HS diploma versus HS diploma at a traditional age (the reference) was lower for Black men than White men (interaction term:0.44;95%CI:0.21,0.91); similarly, hypertension associated with <HS versus completing HS at a traditional age was lower for people with low cSES than people with high cSES (interaction term:0.52;95%CI:0.30,0.90).

CONCLUSIONS

Both type and timing to terminal credential matter for hypertension but effects may vary by experiences of structural marginalization. Documenting the nuanced ways in which complex educational trajectories are associated with health could elucidate underlying mechanisms and inform systems-level interventions for health equity.

Intersectional Discrimination and Change in Blood Pressure Control among Older Adults: The Health and Retirement Study

BACKGROUND

Associations between multiple forms of discrimination and blood pressure control in older populations remain unestablished.

METHODS

Participants were 14582 non-institutionalized individuals (59% women) in the Health and Retirement Study aged at least 51 years (76% Non-Hispanic White, 15% Non-Hispanic Black, 9% Hispanic/Latino). Primary exposures included the mean frequency of discrimination in everyday life, intersectional discrimination (defined as marginalization ascribed to more than one reason), and the sum of discrimination over the lifespan. We assessed whether discrimination was associated with change in measured hypertension status (N=14582) and concurrent medication use among reported hypertensives (N=9086) over four years (2008-2014).

RESULTS

There was no association between the frequency of everyday discrimination and change in measured hypertension. Lifetime discrimination was associated with higher odds of hypertension four years later among men (OR: 1.21, 95% CI: 1.08, 1.36) but not women (OR: 0.98, 95% CI: 0.86, 1.13). Only among men, everyday discrimination due at least two reasons was associated with a 1.44 (95% CI: 1.03, 2.01)-fold odds of hypertension than reporting no everyday discrimination; reporting intersectional discrimination was not associated with developing hypertension among women (OR: 0.91, 95% CI: 0.70, 1.20). All three discriminatory measures were inversely related to time-averaged antihypertensive medication use, without apparent gender differences (e.g., OR for everyday discrimination-antihypertensive use associations: 0.85, 95% CI: 0.77, 0.94)).

CONCLUSIONS

Gender differences in marginalization may more acutely elevate hypertensive risk among older men than similarly aged women. Experiences of discrimination appear to decrease the likelihood of antihypertensive medication use among older adults overall.

Social Determinants of Health and Cardiovascular Disease: Current State and Future Directions Towards Healthcare Equity

PURPOSE OF REVIEW

We sought to examine the role of social and environmental conditions that determine an individual's behaviors and risk of disease-collectively known as social determinants of health (SDOH)-in shaping cardiovascular (CV) health of the population and giving rise to disparities in risk factors, outcomes, and clinical care for cardiovascular disease (CVD), the leading cause of death in the United States (US).

RECENT FINDINGS

Traditional CV risk factors have been extensively targeted in existing CVD prevention and management paradigms, often with little attention to SDOH. Limited evidence suggests an association between individual SDOH (e.g., income, education) and CVD. However, inequities in CVD care, risk factors, and outcomes have not been studied using a broad SDOH framework. We examined existing evidence of the association between SDOH-organized into 6 domains, including economic stability, education, food, neighborhood and physical environment, healthcare system, and community and social context-and CVD. Greater social adversity, defined by adverse SDOH, was linked to higher burden of CVD risk factors and poor outcomes, such as stroke, myocardial infarction (MI), coronary heart disease, heart failure, and mortality. Conversely, favorable social conditions had protective effects on CVD. Upstream SDOH interact across domains to produce cumulative downstream effects on CV health, via multiple physiologic and behavioral pathways. SDOH are major drivers of sociodemographic disparities in CVD, with a disproportionate impact on socially disadvantaged populations. Efforts to achieve health equity should take into account the structural, institutional, and environmental barriers to optimum CV health in marginalized populations. In this review, we highlight major knowledge gaps for each SDOH domain and propose a set of actionable recommendations to inform CVD care, ensure equitable distribution of healthcare resources, and reduce observed disparities.

Uprooting race-based assumptions in biomedical journal articles

Coronavirus disease 2019 (COVID-19) has exacerbated the structural inequities in healthcare and the challenges of translating research into public discourse. This article highlights key antiracist considerations, presents previously noted core challenges, and provides recommendations for writing and reporting. Importantly, this article contributes to combating racialized science in the biomedical community.

The Impact of Health Narratives on Persuasion in African American Women: A Systematic Review and Meta-Analysis

African American women (AAW) experience higher burdens of disease and have the highest rate of heart disease, cancer, stroke, and diabetes when compared to females of other ethnic groups. Health narratives are a communication strategy that has been used to improve population health outcomes. Narrative storytelling is considered to be effective for improving health outcomes in African Americans because of the strong cultural storytelling background. The purpose of this study was to determine if health narratives have a significant effect on persuasion among AAW, as measured by changes in attitudes, beliefs, intentions, and behaviors. Meta-analysis of health narrative experiments (k = 13) for AAW (N = 2,746) revealed that health narratives have a significant overall effect on persuasion (d = .243; p < .01). Sub-group analyses revealed no significant difference between audio-visual and written-based narratives, and no significant difference between general health topics and cancer topics. Narrative communication was effective for promoting health in AAW. These findings imply that narratives can effectively be used as an audio-visual or written-based communication for AAW, and that health topic may not impact outcomes of narrative communication.

The complexities of race and health

It is widely accepted that race and related social factors largely underpin patients' access to healthcare, and even have a direct impact on patients' care. The reality that racism is the source of these health inequalities, and that racism within health organisations compounds the issue, undeniably means that racism is a public health issue. The ongoing pandemic has not only shone a light on underlying issues that have silently plagued the Black, Asian and minority ethnic community but has helped us understand the devastating impact of racism. Closing the gap in these populations is required to ensuring equitable access. This article aims to highlight how racism impacts people of colour within the healthcare system and beyond and calls for dismantling of the structural racism that exists within the NHS and other UK organisations.

Perceived Discrimination and Hypertension Risk Among Participants in the Multi-Ethnic Study of Atherosclerosis

Background

Black Americans have a higher risk of hypertension compared with White Americans. Perceived discrimination is a plausible explanation for these health disparities. Few studies have examined the impact of perceived discrimination on the incidence of hypertension among a racially diverse sample. Our study examined associations of everyday and lifetime discrimination with incidence of hypertension and whether these associations varied by sex, discrimination attribution, and racial residential segregation.

Methods and Results

The study included 3297 Black, Hispanic, Chinese, and White participants aged 45 to 84 years from the Multi‐Ethnic Study of Atherosclerosis who were without hypertension at exam 1 (2000–2002) and who completed at least 1 of 5 follow‐up exams (2002–2018). Cox proportional hazards regression was used to estimate associations of perceived discrimination with incident hypertension. Over the follow‐up period, 49% (n=1625) of participants developed hypertension. After adjustment for age, sex, socioeconomic status, hypertension risk factors, and study site, Black participants reporting any lifetime discrimination (compared with none) were more likely to develop hypertension (hazard ratio [HR], 1.35; 95% CI, 1.07–1.69). In fully adjusted models, everyday discrimination (high versus low) was associated with a lower risk for hypertension among Hispanic participants (HR, 0.73; 95% CI, 0.55–0.98). Statistically significant interactions of perceived discrimination (everyday and lifetime) with sex, discrimination attribution, and racial residential segregation were not observed.

Conclusions

This study suggests that lifetime, but not everyday discrimination is associated with incident hypertension in Black Americans.

Social determinants and cardiovascular care: A focus on vulnerable populations and the Jamaica experience

The concept of social determinants of health (SDOH) describes the complex interplay of social, economic, cultural, and environmental forces that influence health and illness and result in health inequities in society. In cardiovascular disease (CVD), SDOH play a significant role in contributing to the severe morbidity and mortality that various cardiovascular diseases inflict on our societies. The components of SDOH include wealth/income, employment status, education, social interactions/support, access to medical care (including mental health services), housing, transportation, physical environment (including availability of green space, water/sanitation, air pollution, noise pollution), work environment, access to good nutrition, social and community networks, access to technology and data, exposure to crime/social disorder/violence, exposure to adverse law enforcement/bad governance, and cultural norms. Leveraging reliable SDOH data is critical to addressing healthcare needs of the community. At‐risk populations must be connected to the appropriate resources needed to overcome these barriers to access to achieve better health outcomes. This review explores this theme with a focus on several vulnerable populations and offers possible strategies to reduce these inequalities. The Heart Institute of the Caribbean (HIC) was founded in 2005 to improve access to quality medical and cardiovascular services, made available to everyone regardless of their socioeconomic status. HIC has encountered and learned to navigate a myriad structural, institutional, socio‐economic, cultural, and behavioral barriers to appropriate CVD care for vulnerable populations in Jamaica and the wider Caribbean. The successes attained and the lessons learned by HIC can be replicated in other nations to address social determinants that impede cardiovascular and medical care in vulnerable populations and may alleviate the access gap in high‐quality care in developing countries and in underserved and marginalized communities in developed countries.

Racism, stress and health in Asian Americans: A structural equation analysis of mediation and social support group differences

The buffering effect of social support on the negative effects of racism exposure on health outcomes has been mixed in prior studies regarding Asian Americans. Based on the stress-coping framework and using structural equation modelling (SEM) methods, we tested a theoretical model portraying simultaneous mediational paths from racism exposure to general physical and mental health through racism-related stress. Bootstrap analysis was used to test the indirect effects present in the model. Additionally, multi-group SEM analysis was conducted to investigate the moderation effect of social support from family and friends on the paths in the model. The sample consisted of 310 Asian American adults who completed an online survey. The results from the two-step SEM analysis and bootstrap analysis supported the theoretical model-racism exposure can simultaneously have a negative indirect effect on Asian Americans' physical and mental health via racism-related stress. Multi-group SEM analysis showed that there were no differences in model path coefficients based on having varying levels of social support from friends or family.

The Relationship Between Social Determinants of Health and Racial Disparities in COVID-19 Mortality

BACKGROUND

The COVID-19 pandemic has magnified existing health disparities for marginalized populations in the United States (U.S.), particularly among Black Americans. Social determinants of health are powerful drivers of health outcomes that could influence COVID-19 racial disparities.

METHODS

We collected data from publicly available databases on COVID-19 death rates through October 28, 2020, clinical covariates, and social determinants of health indicators at the U.S. county level. We utilized negative binomial regression to assess the association between social determinants of health and COVID-19 mortality focusing on racial disparities in mortality.

RESULTS

Counties with higher death rates had a higher proportion of Black residents and greater levels of adverse social determinants of health. A one percentage point increase in percent Black residents, percent uninsured adults, percent low birthweight, percent adults without high school diploma, incarceration rate, and percent households without internet in a county increased COVID-19 death rates by 0.9% (95% CI 0.5%-1.3%), 1.9% (95% CI 1.1%-2.7%), 7.6% (95% CI 4.4%-11.0%), 3.5% (95% CI 2.5%-4.5%), 5.4% (95% CI 1.3%-9.7%), and 3.4% (95% CI 2.5%-4.2%), respectively. Counties in the lowest quintile of a measure of economic privilege had an increased COVID-19 death rates of 67.5% (95% CI 35.9%-106.6%). Multivariate regression and subgroup analyses suggested that adverse social determinants of health may partially explain racial disparities in COVID-19 mortality.

CONCLUSIONS

This study demonstrates that social determinants of health contribute to COVID-19 mortality for Black Americans at the county level, highlighting the need for public health policies that address racial disparities in health outcomes.

Race, ethnicity, and racism in the nutrition literature: an update for 2020

Social disparities in the US and elsewhere have been terribly highlighted by the current COVID-19 pandemic but also an outbreak of state-sponsored violence. The field of nutrition, like other areas of science, has commonly used 'race' to describe research participants and populations, without the recognition that race is a social, not a biologic, construct. We review the limitations of classifying participants by race, and recommend a series of steps for authors, researchers and policymakers to consider when producing and reading the nutrition literature. We recommend that biomedical researchers, especially those in the field of nutrition, abandon the use of racial categories to explain biologic phenomena but instead rely on a more comprehensive framework of ethnicity; that authors consider not just race and ethnicity but many social determinants of health, including experienced racism; that race and ethnicity not be conflated; that dietary pattern descriptions inform ethnicity descriptions; and that depersonalizating language be avoided.

Prejudice, Does It Exist or Not? Consumer Price Discrimination in Minority Entrepreneurship

Many prior studies on minority entrepreneurship have found that some consumers display a strong bias against products from minority ventures. Not surprisingly, discrimination against products sold by minority-owned businesses increases the failure rate for such ventures. This paper seeks to verify the extent of consumer discrimination for minority products, and investigates whether it varies among different products. Building on insights from the theory of consumer discrimination, we conducted a comparative behavior experiment on 155 subjects for the expected pricing of two new products (common products and products with ethnic characteristics). Consistent with prior literature, we found that potential consumers held a bias against common products from minority ventures and offered a lower price. However, the theory of consumer discrimination could not be applied to the products with ethnic characteristics. Instead, potential consumers viewed ethnic characteristics products from minority ventures as being high quality and offered higher prices. This finding complements the theory of consumer discrimination and provides useful knowledge for minority entrepreneurs: minority entrepreneurs can employ price discrimination to strengthen the ethnic brand’s impression by integrating ethnic cultural features into new products.

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

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

Insights to potential antihypertensive activity of berry fruits

Hypertension is one of the main risk factors for cardiovascular disease and causes widespread morbidity and mortality worldwide. Although several antihypertensive drugs have been proposed for management of high blood pressure, changing lifestyle, including diet, has attracted interest recently. In this sense, consumption of fruits and vegetables, which are rich in vitamins, minerals, and phytochemicals, has been assigned as an efficient therapeutics. Berry fruits contain various bioactive compounds with potential health implications such as antioxidant, antimicrobial, anticancer, and anti-inflammatory properties. The main mechanisms responsible for antihypertensive activity mainly arise from the activity of flavonoids, minerals, and vitamins, as well as fibers. The objective of this review is to provide a summary of studies regarding the effect of berry fruits on the hypertensive animals and humans. The mechanisms involved in reducing blood pressure by each group of compounds have been highlighted. It can be concluded that berries' bioactive compounds are efficient in mitigation of hypertension through improvement of vascular function, angiotensin-converting enzyme's (ACE) inhibitory activity, increasing endothelial nitric oxide synthase (eNOS) activity, and nitric oxide (NO) production, besides anti-oxidative and anti-inflammatory activities. These fruits can be considered as potential sources of invaluable compounds for development of antihypertensive foods and pharmaceuticals.

Community-engaged and community-based participatory research to promote American Heart Association Life's Simple 7 among African American adults: A systematic review

BACKGROUND

Cardiovascular disease (CVD) is the leading cause of death in the United States and African Americans (AA) have a disproportionately greater burden of CVD as compared to Whites. The American Heart Association (AHA) Life's Simple 7 (LS7) framework outlines goals for attaining ideal cardiovascular health. Yet, there is a lack of evidence summarizing best practices to maximize LS7 attainment. The objective of the present study was to systematically review the extant peer-reviewed literature on community-engaged and community-based participatory research (CBPR) aimed at improving one or more LS7 metrics among AA.

METHODS

PubMed, CINAHL, and Embase databases were searched. We included articles that reported quantitative results for one or more of the following LS7 metrics: physical activity, diet, cholesterol, blood pressure, body mass index, smoking, and glycemia. We included analyses with a greater than 50% AA study population focused on adults (≥18 years of age).

RESULTS

Of the 1008 unique studies identified, 54 met inclusion criteria; 27 of which were randomized controlled trials. 50% of studies assessed more than one LS7 metric but only two studies evaluated all seven of the LS7 metrics. No studies had a high proportion of AA males. 40 studies improved at least one LS7 metric at the study end-point. Formative research was used in many studies to guide intervention design. Studies were of varying quality, but overall rated "fair" using a modified approach to the National Institute of Health quality assessment tool.

CONCLUSION

There is insufficient data to recommend a specific community-engaged or CBPR intervention to improve attainment of LS7 metrics among AA. Future studies using rigorous methodology with increased gender diversity and utilizing the AHA LS7 framework are required to establish a validated program to improve LS7 in AAs.

Discrimination and Hypertension Risk Among African Americans in the Jackson Heart Study

African Americans have a higher risk of hypertension compared with other racial or ethnic groups in the United States. One possible explanation for this disparity is discrimination. Few studies have examined the association between discrimination and incidence of hypertension. We examined whether everyday discrimination, lifetime discrimination, and stress from discrimination were associated with incident hypertension and whether these associations differed by gender, age, discrimination attribution, and coping responses to discrimination among African Americans in the Jackson Heart Study. Discrimination was self-reported by 1845 African Americans aged 21 to 85 years without hypertension at baseline (2000-2004). Participants completed 2 follow-up study visits from 2005 to 2008 and 2009 to 2013. We used Cox proportional hazards regression to estimate associations of discrimination with incident hypertension. Overall, 52% (n=954) of the participants developed hypertension over the follow-up period. After adjustment for age, gender, socioeconomic status and hypertension risk factors, medium versus low levels of lifetime discrimination (hazard ratio, 1.49 [95% CI, 1.18-1.89]), and high versus low levels of lifetime discrimination (hazard ratio, 1.34 [95% CI, 1.07-1.68]) were associated with a higher incidence of hypertension. No statistically significant interactions with gender, age, attribution, or coping were present. Higher stress from lifetime discrimination was associated with higher hypertension risk after adjustment for demographics (hazard ratio for high versus low, 1.19 [95% CI, 1.01-1.40]), but the association was attenuated after adjustment for hypertension risk factors (hazard ratio, 1.14 [95% CI, 0.97-1.35]). Lifetime discrimination may increase the risk of hypertension in African Americans.

The RICH LIFE Project: A cluster randomized pragmatic trial comparing the effectiveness of health system only vs. health system Plus a collaborative/stepped care intervention to reduce hypertension disparities

Disparities in the control of hypertension and other cardiovascular disease risk factors are well-documented in the United States, even among patients seen regularly in the healthcare system. Few existing approaches explicitly address disparities in hypertension care and control. This paper describes the RICH LIFE Project (Reducing Inequities in Care of Hypertension: Lifestyle Improvement for Everyone) design.

METHODS

RICH LIFE is a two-arm, cluster-randomized trial, comparing the effectiveness of enhanced standard of care, "Standard of Care Plus" (SCP), to a multi-level intervention, "Collaborative Care/Stepped Care" (CC/SC), for improving blood pressure (BP) control and patient activation and reducing disparities in BP control among 1890 adults with uncontrolled hypertension and at least one other cardiovascular disease risk factor treated at 30 primary care practices in Maryland and Pennsylvania. Fifteen practices randomized to the SCP arm receive standardized BP measurement training; race/ethnicity-specific audit and feedback of BP control rates; and quarterly webinars in management practices, quality improvement and disparities reduction. Fifteen practices in the CC/SC arm receive the SCP interventions plus implementation of the collaborative care model with stepped-care components (community health worker referrals and virtual specialist-panel consults). The primary clinical outcome is BP control (<140/90 mm Hg) at 12 months. The primary patient-reported outcome is change from baseline in self-reported patient activation at 12 months.

DISCUSSION

This study will provide knowledge about the feasibility of leveraging existing resources in routine primary care and potential benefits of adding supportive community-facing roles to improve hypertension care and reduce disparities.

TRIAL REGISTRATION

Clinicaltrials.govNCT02674464.

Associations between Perceived Racial Discrimination and Tobacco Cessation among Diverse Treatment Seekers

Objectives

This study investigated a) racial/ethnic differences in past-year discrimination experiences and b) associations between discrimination and smoking abstinence.

Design

Prospective, longitudinal analysis of smoking status. Perceived past-year discrimination was assessed at baseline. ANCOVAs and intent-to-treat hierarchical logistic regressions were conducted.

Setting

Dual-site (Tampa, FL and Miami, FL) randomized controlled trial testing the effects of a group cessation intervention plus pharmacotherapy.

Participants

Treatment-seeking adult smokers (N=347; non-Hispanic White, non-Hispanic African American/Black, or Hispanic).

Main Outcome Measures

Biochemically verified 7-day point prevalence abstinence (7-day ppa) was assessed immediately post-intervention and at 6-month follow-up.

Results

After controlling for covariates, African Americans/Blacks reported greater perceived discrimination compared with non-Hispanic Whites (P=.02), and Hispanics (P=.06). Non-Hispanic Whites and Hispanics did not differ in perceived racial/ethnic discrimination experiences over the past year. Irrespective of race/ethnicity, past-year perceived discrimination was inversely associated with 7-day ppa, both post-intervention (AOR=.97, CI: .95-.99) and at 6-months (AOR=.98, CI: .96-.99). Among African Americans/Blacks, past-year perceived discrimination was inversely associated with 7-day ppa, both post-intervention (AOR=.95, CI: .92-.97) and at 6-months (AOR=.97, CI: .94-.99). Perceived discrimination was unrelated to 7-day ppa among Hispanics. Among non-Hispanic Whites, past-year perceived discrimination was inversely associated with post-intervention 7-day ppa (AOR=.95, CI: .91-.99), but not 6-months.

Conclusions

Perceived racial/ethnic discrimination was greater among African American/Black smokers compared with non-Hispanic Whites. Perceived discrimination was negatively associated with tobacco cessation in the full sample, and for African Americans at 6-months post-intervention. These data have implications for intervention delivery and health disparities.