Use of race and ethnicity in epidemiologic research: concepts, methodological issues, and suggestions for research

Evaluation of Reliability Between Race and Ethnicity Data Obtained from Self-report Versus Electronic Health Record

INTRODUCTION

Disparities based on perceived race and ethnicity exist in all fields of medicine. Accurate data collection is crucial to addressing these disparities, yet few studies have evaluated the validity of data gathered. This study compares self-reported race and ethnicity data, considered the gold standard, with data documented in the electronic health record (EHR), to assess the validity of that data.

METHODS

Data from self-reported questionnaires was collected from adolescents admitted to a psychiatric inpatient unit from February 2019 to July 2022. Demographic questionnaires were self-administered as part of a larger battery completed during the admission process. Data was compared to demographic information collected from the hospital's EHR for the same patients and time.

RESULTS

In a sample of 1191 patients (ages 11-18, 61.9% female, 89% response rate), substantial agreement was observed for Hispanic ethnicity (κ = 0.64), while agreement for specific racial groups ranged from slight to substantial (κ = 0.10-0.63). In addition, it was noted that there was discrepancy between multiracial identification, with 17.1% of patients identifying as more than one race in self-reported data compared to 3.1% in EHR data.

CONCLUSIONS

The findings from this data set highlight the need for caution when using EHR data to draw conclusions about health disparities. It also suggests that the method of data collection meaningfully influences the responses patients provide. Addressing these challenges is essential for advancing equitable healthcare and mitigating disparities among patients.

Race and Ethnicity in Cardiac Surgery: A Missed Opportunity?

BACKGROUND

Patients' race and/or ethnicity are increasingly being associated with differential surgical access and outcomes in cardiac surgery. However, deriving evidence-based conclusions that can inform surgical care has been difficult because of poor diversity in study populations and conflicting research methodology and findings. Using a fictional patient example, this review identifies areas of concern in research engagement, methodology, and analyses, as well as potential steps to improve race and ethnicity considerations in cardiac surgical research.

METHODS

A narrative literature review was performed using the PubMed/MEDLINE and Google Scholar databases, with a combination of cardiac surgery, race, ethnicity, and disparities keywords.

RESULTS

Less than half of the published cardiac surgery randomized control trials report the race and/or ethnicity of research participants. Racial and/or ethnic minorities make up <20% of most study populations and are significantly underrepresented relative to their proportions of the general population. Further, race and/or ethnicity of research participants is variably categorized based on ancestry, geographic regions, cultural similarities, or minority status. There is growing consideration of analyzing interrelated and confounding variables, such as socioeconomic status, geographic location, or hospital quality, to better elucidate racial and/or ethnic disparities; however, intersectionality considerations remain limited in cardiac surgery research.

CONCLUSIONS

Racial and/or ethnic disparities are increasingly being reported in research engagement, cardiac pathologies, and surgical outcomes. To promote equitable surgical care, tangible efforts are needed to recruit racially and/or ethnically minoritized patients to research studies, be transparent and consistent in their groupings, and elucidate the impact of their intersectional social identities.

Accuracy of patient race and ethnicity data in a central cancer registry

PURPOSE

Race and Hispanic ethnicity data can be challenging for central cancer registries to collect. We evaluated the accuracy of the race and Hispanic ethnicity variables collected by the Utah Cancer Registry compared to self-report.

METHODS

Participants were 3,162 cancer survivors who completed questionnaires administered in 2015-2022 by the Utah Cancer Registry. Each survey included separate questions collecting race and Hispanic ethnicity, respectively. Registry-collected race and Hispanic ethnicity were compared to self-reported values for the same individuals. We calculated sensitivity and specificity for each race category and Hispanic ethnicity separately.

RESULTS

Survey participants included 323 (10.2%) survivors identifying as Hispanic, a lower proportion Hispanic than the 12.1% in the registry Hispanic variable (sensitivity 88.2%, specificity 96.5%). For race, 43 participants (1.4%) self-identified as American Indian or Alaska Native (AIAN), 32 (1.0%) as Asian, 23 (0.7%) as Black or African American, 16 (0.5%) Pacific Islander (PI), and 2994 (94.7%) as White. The registry race variable classified a smaller proportion of survivors as members of each of these race groups except White. Sensitivity for classification of race as AIAN was 9.3%, Asian 40.6%, Black 60.9%, PI 25.0%, and specificity for each of these groups was > 99%. Sensitivity and specificity for White were 98.8% and 47.4%.

CONCLUSION

Cancer registry race and Hispanic ethnicity data often did not match the individual's self-identification. Of particular concern is the high proportion of AIAN individuals whose race is misclassified. Continued attention should be directed to the accurate capture of race and ethnicity data by hospitals.

Impact of migration on diabetes burden: audit in the metropolitan area of Bologna, Italy

PURPOSE

To investigate the impact of diabetes in immigrants on the Italian healthcare system, as well as their compliance with standard protocols of control and treatment.

METHODS

The prevalence of immigrants with diabetes living in the metropolitan area of Bologna (about 1 million inhabitants) in 2019 was investigated using a database containing all subjects in active follow-up for diabetes, based on antidiabetic drug use, disease-specific copayment exemption, ICD-9 codes, continuous care in diabetes units. Country of origin was derived from fiscal code.

RESULTS

The overall prevalence of diabetes (n = 53,941; 51.8% males, median age 64) was 6.1% in both Italy-born and immigrant cohorts. Immigrant prevalence was 12.4%, moderately higher than that observed in the total population (12.2%). Diabetes risk was increased in the whole immigrant cohort (odds ratio (OR) 1.74; 95% Confidence Interval (CI) 1.69-1.79). Among cases with incident diabetes, the proportion of immigrants (median age, 49 vs. 65 in Italy-born individuals) increased progressively from 11.7% to 26.5% from 2011 to 2019 (males, 8.9-21.0%; females, 14.9-32.8%) in all age groups, particularly in young adults, but also in older subjects. Metabolic control was lower in immigrants, as was adherence to shared diagnostic and therapeutic protocols, without systematic differences in antidiabetic drug use, but much lower use of drugs for comorbid conditions.

CONCLUSIONS

The population with diabetes in the metropolitan area of Bologna is rapidly changing. Quality improvement initiatives are needed to reduce the burden for the universalistic Italian health care system generated by the rapidly-growing high-risk immigrant population.

Reporting of Participant Demographics in Clinical Trials Published in General Radiology Journals

OBJECTIVES

The reporting of research participant demographics provides insights into study generalizability. Our study aimed to determine the frequency at which participant age, sex/gender, race/ethnicity, and socioeconomic status (SES) are reported and used for subgroup analyses in radiology randomized controlled trials (RCTs) and their secondary analyses; as well as the study characteristics associated with, and the classification systems used for demographics reporting.

METHODS

RCTs and their secondary analyses published in 8 leading radiology journals between 2013 and 2021 were included. Associations between study characteristics and demographic reporting were tested with the chi-square goodness of fit test for categorical variables, Wilcoxon-Mann-Whitney test for impact factor, and logistic regression for publication year.

RESULTS

Among 432 included articles, 89.4% (386) reported age, 90.3% (390) sex/gender, 5.6% (24) race/ethnicity, and 3.0% (13) SES. Among articles that reported these demographics and were not specific to a subgroup, results were analyzed by age in 14.2% (55/386), sex/gender in 19.4% (66/340), race/ethnicity in 13.6% (3/22), and SES in 46.2% (6/13). Journal, impact factor, and last author continent were predictors of race/ethnicity and SES reporting. Funding was associated with race/ethnicity reporting. No study reported sex and gender separately, or documented transgender, nonbinary gender spectrum or intersex participants. A single category for race/ethnicity was used in 37.5% (9/24) of studies, consisting of either "White" or "Caucasian."

CONCLUSION

The reporting of participant demographics in radiology trials is variable and not always representative of the population diversity. Editorial guidelines on the reporting and analysis of participant demographics could help standardize practices.

Systematic review of how racialized health inequities are addressed in Epidemiologic Reviews articles (1979-2021): a critical conceptual and empirical content analysis and recommendations for best practices

Critical analysis of the determinants of current and changing racialized health inequities, including the central role of racism, is an urgent priority for epidemiology, for both original research studies and epidemiologic review articles. Motivating our systematic overview review of Epidemiologic Reviews articles is the critical role of epidemiologic reviews in shaping discourse, research priorities, and policy relevant to the social patterning of population health. Our approach was first to document the number of articles published in Epidemiologic Reviews (1979-2021; n = 685) that either: (1) focused the review on racism and health, racial discrimination and health, or racialized health inequities (n = 27; 4%); (2) mentioned racialized groups but did not focus on racism or racialized health inequities (n = 399; 59%); or (3) included no mention of racialized groups or racialized health inequities (n = 250; 37%). We then conducted a critical content analysis of the 27 review articles that focused on racialized health inequities and assessed key characteristics, including (1) concepts, terms, and metrics used regarding racism and racialized groups (notably only 26% addressed the use or nonuse of measures explicitly linked to racism; 15% provided explicit definitions of racialized groups); (2) theories of disease distribution guiding (explicitly or implicitly) the review's approach; (3) interpretation of findings; and (4) recommendations offered. Guided by our results, we offer recommendations for best practices for epidemiologic review articles for addressing how epidemiologic research does or does not address ubiquitous racialized health inequities.

The Association Between Black vs. White Race and 30-Day Hospitalization Among People Diagnosed with COVID-19 Within an Integrated Care Setting: a Cohort Study

BACKGROUND

Black Americans are more likely to experience hospitalization from COVID-19 compared with White Americans. Whether this excess risk differs by age, sex, obesity, or diabetes, key risk factors for COVID hospitalization, among an integrated population with uniform healthcare access, are less clear.

METHODS

We identified all adult members (≥ 18 years) of Kaiser Permanente Georgia (KPGA) diagnosed with COVID-19 between January 1, 2020, and September 30, 2021 (N = 24,564). We restricted the analysis to members of Black or White race identified from electronic medical records. Our primary outcome was first hospitalization within 30 days of COVID-19 diagnosis. To assess the association between race and 30-day hospitalization, we performed multivariable logistic regression adjusting for several member and neighborhood-level characteristics, and tested for interactions of race with age, sex, diabetes, and obesity. A regression-based decomposition method was then used to estimate how much of the observed race disparity in 30-day hospitalization could be explained by member and neighborhood-level factors.

RESULTS

Overall, 11.27% of Black KPGA members were hospitalized within 30 days of a COVID diagnosis, as compared with 9.44% of White KPGA members. Black (vs. White) KPGA members had a 34% (aOR: 1.32 [95% CI: 1.19-1.47]) higher odds of 30-day hospitalization following COVID-19 after accounting for clinical differences. The odds of 30-day hospitalization in Black vs. White KPGA members did not differ significantly by sex (men: 1.46 [1.25-1.70]; women: 1.24 [1.07-1.43]), by age (18-29 years: 1.33 [0. 841-2.10]; 30-49 years: 1.26 [1.02-1.56]; ≥ 50 years: 1.24 [1.10-1.41]); by diabetes status (with diabetes: 1.38 [1.16-1.66]; without diabetes: 1.26 [1.11-1.44]), or by obesity (with obesity: 1.31 [1.15-1.50]; without obesity: 1.28 [1.06-1.53]). Factors that, if Black and White KPGA members had the same level of exposure, would be most likely to reduce the Black-White disparity in 30-day hospitalization from COVID-19 were obesity, history of flu vaccine, and neighborhood-level income and social vulnerability.

CONCLUSIONS

Early in the pandemic, Black (vs. White) members of an integrated health system had higher odds of being hospitalized within 30 days of COVID-19 diagnosis and this excess risk was similar by sex, age, and comorbidities. Factors that explained the largest proportions of race-based disparities were obesity, receipt of flu vaccine, and neighborhood-level social determinants of health. These findings suggest that social determinants of health, or other unmeasured factors, may be drivers of racial disparities in COVID-19 outcomes.

Racial and Ethnic Inequities in Health: Examining the Contributions of the American Journal of Epidemiology to Advancing the Science

The perverseness of racial and ethnic inequities in the United States continues to implore the investigation of their causes. While there have been improvements in the health of the US population, these improvements have not been equally distributed. To commemorate the 100th anniversary of the American Journal of Epidemiology, in this commentary, we aim to highlight the Journal's contributions to: 1) the definition and use of race and ethnicity in research, and 2) understanding racial and ethnic inequities, both empirically and methodologically, over the past decade. We commend the Journal for its contributions and for spearheading many of the challenges related to measuring and interpreting racial and ethnic data for the past 20 years. We identify 3 additional areas in which the Journal could make further impact to address racial and ethnic inequities: 1) devote a section in every issue of the Journal to scientific papers that make substantive epidemiologic or methodological contributions to racial and ethnic inequities in health; 2) update the Journal's guidelines for authors to include justifying the use of race and ethnicity; and 3) diversify the field of epidemiology by bringing a new cadre of scholars from minoritized racial and ethnic groups who represent the most affected communities into the research process.

Measuring Food Security among American Indian and Alaska Native Adults: Validity Evidence Supports the Use of the US Department of Agriculture Module

BACKGROUND

Inequities in access, availability, and affordability of nutritious foods produced by settler colonialism contribute to high rates of food insecurity among American Indian and Alaska Native (AI/AN) households. Efforts to understand the influences of food security programming among AI/AN individuals in the United States are constrained by the absence of validity evidence for food security assessments for this population.

OBJECTIVE

This study assessed whether AI/AN adult responses on the Food Security Survey Module provide an accurate assessment of food security prevalence, especially when compared with other racial and ethnic groups.

DESIGN

A correlational design with the cross-sectional 2019 National Health Interview Survey was used to address the research objective.

PARTICIPANTS AND SETTING

The 2019 National Health Interview Survey contains a sample (N = 30,052) representative of the resident civilian noninstitutionalized population.

MAIN OUTCOME MEASURES

The primary outcome was food security, as characterized by the 10-item US Department of Agriculture Adult Food Security Survey Module. The module evaluates whether insufficient finances result in perceived food shortages and a reduction in the quantity and/or quality of food intake during the prior 30 days.

STATISTICAL ANALYSES PERFORMED

Data were analyzed by racial and ethnic subsamples to assess scale dimensionality (confirmatory factor analysis), Item Response Theory item analysis, differential item functioning, and external validity (χ2 tests).

RESULTS

Results supported the use of the 10-item module for racial and ethnic groups. However, differential item functioning effect sizes exceeded criteria for the Asian, AI/AN, and Hispanic respondents when compared with White respondents. Food security was not significantly related to all expected correlates in the AI/AN subsample.

CONCLUSIONS

Compelling evidence is presented for validity of the FSSM scores in determining food security status of AI/AN adults. Qualitative inquiry that explores how culture influences the way food security is conceptualized and experienced is warranted.

Race as a Component of Cardiovascular Disease Risk Prediction Algorithms

PURPOSE OF REVIEW

Several prediction algorithms include race as a component to account for race-associated variations in disease frequencies. This practice has been questioned recently because of the risk of perpetuating race as a biological construct and diverting attention away from the social determinants of health (SDoH) for which race might be a proxy. We evaluated the appropriateness of including race in cardiovascular disease (CVD) prediction algorithms, notably the pooled cohort equations (PCE).

RECENT FINDINGS

In a recent investigation, we reported substantial and biologically implausible differences in absolute CVD risk estimates upon using PCE for predicting CVD risk in Black and White persons with identical risk factor profiles, which might result in differential treatment decisions based solely on their race. We recommend the development of raceless CVD risk prediction algorithms that obviate race-associated risk misestimation and racializing treatment practices, and instead incorporate measures of SDoH that mediate race-associated risk differences.

Characteristics of Cancer Epidemiology Studies That Employ Metabolomics: A Scoping Review

An increasing number of cancer epidemiology studies use metabolomics assays. This scoping review characterizes trends in the literature in terms of study design, population characteristics, and metabolomics approaches and identifies opportunities for future growth and improvement. We searched PubMed/MEDLINE, Embase, Scopus, and Web of Science: Core Collection databases and included research articles that used metabolomics to primarily study cancer, contained a minimum of 100 cases in each main analysis stratum, used an epidemiologic study design, and were published in English from 1998 to June 2021. A total of 2,048 articles were screened, of which 314 full texts were further assessed resulting in 77 included articles. The most well-studied cancers were colorectal (19.5%), prostate (19.5%), and breast (19.5%). Most studies used a nested case-control design to estimate associations between individual metabolites and cancer risk and a liquid chromatography-tandem mass spectrometry untargeted or semi-targeted approach to measure metabolites in blood. Studies were geographically diverse, including countries in Asia, Europe, and North America; 27.3% of studies reported on participant race, the majority reporting White participants. Most studies (70.2%) included fewer than 300 cancer cases in their main analysis. This scoping review identified key areas for improvement, including needs for standardized race and ethnicity reporting, more diverse study populations, and larger studies.

Disparities in Toxic Chemical Exposures and Associated Neurodevelopmental Outcomes: A Scoping Review and Systematic Evidence Map of the Epidemiological Literature

BACKGROUND

Children are routinely exposed to chemicals known or suspected of harming brain development. Targeting Environmental Neuro-Development Risks (Project TENDR), an alliance of > 50 leading scientists, health professionals, and advocates, is working to protect children from these toxic chemicals and pollutants, especially the disproportionate exposures experienced by children from families with low incomes and families of color.

OBJECTIVE

This scoping review was initiated to map existing literature on disparities in neurodevelopmental outcomes for U.S. children from population groups who have been historically economically/socially marginalized and exposed to seven exemplar neurotoxicants: combustion-related air pollution (AP), lead (Pb), mercury (Hg), organophosphate pesticides (OPs), phthalates (Phth), polybrominated diphenyl ethers (PBDEs), and polychlorinated biphenyls (PCBs).

METHODS

Systematic literature searches for the seven exemplar chemicals, informed by the Population, Exposure, Comparator, Outcome (PECO) framework, were conducted through 18 November 2022, using PubMed, CINAHL Plus (EBSCO), GreenFILE (EBSCO), and Web of Science sources. We examined these studies regarding authors' conceptualization and operationalization of race, ethnicity, and other indicators of sociodemographic and socioeconomic disadvantage; whether studies presented data on exposure and outcome disparities and the patterns of those disparities; and the evidence of effect modification by or interaction with race and ethnicity.

RESULTS

Two hundred twelve individual studies met the search criteria and were reviewed, resulting in 218 studies or investigations being included in this review. AP and Pb were the most commonly studied exposures. The most frequently identified neurodevelopmental outcomes were cognitive and behavioral/psychological. Approximately a third (74 studies) reported investigations of interactions or effect modification with 69% (51 of 74 studies) reporting the presence of interactions or effect modification. However, less than half of the studies presented data on disparities in the outcome or the exposure, and fewer conducted formal tests of heterogeneity. Ninety-two percent of the 165 articles that examined race and ethnicity did not provide an explanation of their constructs for these variables, creating an incomplete picture.

DISCUSSION

As a whole, the studies we reviewed indicated a complex story about how racial and ethnic minority and low-income children may be disproportionately harmed by exposures to neurotoxicants, and this has implications for targeting interventions, policy change, and other necessary investments to eliminate these health disparities. We provide recommendations on improving environmental epidemiological studies on environmental health disparities. To achieve environmental justice and health equity, we recommend concomitant strategies to eradicate both neurotoxic chemical exposures and systems that perpetuate social inequities. https://doi.org/10.1289/EHP11750.

Examining the association between prenatal maternal stress and infant non-nutritive suck

BACKGROUND

This study examined the relationship between prenatal maternal stress (PREMS) and non-nutritive suck (NNS) and tested its robustness across 2 demographically diverse populations.

METHODS

The study involved 2 prospective birth cohorts participating in the national Environmental influences on Child Health Outcomes (ECHO) Program: Illinois Kids Development Study (IKIDS) and ECHO Puerto Rico (ECHO-PROTECT). PREMS was measured during late pregnancy via the 10-item Perceived Stress Scale (PSS-10). NNS was sampled from 1- to 8-week-olds using a custom pacifier for ~5 min.

RESULTS

Overall, 237 mother-infant dyads completed this study. Despite several significant differences, including race/ethnicity, income, education, and PREMS levels, significant PREMS-NNS associations were found in the 2 cohorts. In adjusted linear regression models, higher PREMS, measured through PSS-10 total scores, related to fewer but longer NNS bursts per minute.

CONCLUSIONS

A significant association was observed between PREMS and NNS across two diverse cohorts. This finding is important as it may enable the earlier detection of exposure-related deficits and, as a result, earlier intervention, which potentially can optimize outcomes. More research is needed to understand how NNS affects children's neurofunction and development.

IMPACT

In this double-cohort study, we found that higher maternal perceived stress assessed in late pregnancy was significantly associated with fewer but longer sucking bursts in 1- to 8-week-old infants. This is the first study investigating the association between prenatal maternal stress (PREMS) and infant non-nutritive suck (NNS), an early indicator of central nervous system integrity. Non-nutritive suck is a potential marker of increased prenatal stress in diverse populations. Non-nutritive suck can potentially serve as an early indicator of exposure-related neuropsychological deficits allowing for earlier interventions and thus better prognoses.

Decolonizing nursing education and research to address racial disparities in maternal health

PURPOSE

In this paper, we discuss the need to move beyond theoretical explorations of social determinants of health (SDoH) to addressing systemic racism and its effect on Black maternal health outcomes. We also address the importance of connecting nursing research, education and practice and offer suggestions on how to transform the teaching, research and clinical practice specific to Black maternal health.

KNOWLEDGE DEVELOPMENT

A critical analysis of current Black maternal health teaching and research practices in nursing informed by the authors' experience in Black/African diasporic maternal health and reproductive justice.

DISCUSSION

There is a need for nursing to be more intentional in addressing the effects of systemic racism on Black maternal health outcomes. In particular, there is still a substantial focus on race rather than racism as a risk factor. The focus on racial and cultural differences rather than systems of oppression continues to pathologize racialized groups while failing to address the impact of systemic racism on the health outcomes of Black women.

CONCLUSION

Using a social determinant of health framework to examine maternal health disparities is useful; however, focusing on SDoH without challenging systems of oppression producing these disparities does not produce substantial changes. We suggest adding frameworks grounded in intersectionality, reproductive and racial justice and moving beyond biological assumptions about race that pathologize Black women. We also recommend a deliberate commitment to reshaping nursing research and education to centre anti-racist and anti-colonial practices that value community knowledge and practices.

NO PATIENT OR PUBLIC CONTRIBUTION

The discussion in this paper is based on the author's expertise.

Reductionist methodology and the ambiguity of the categories of race and ethnicity in biomedical research: an exploratory study of recent evidence

In this article, we analyse how researchers use the categories of race and ethnicity with reference to genetics and genomics. We show that there is still considerable conceptual "messiness" (despite the wide-ranging and popular debate on the subject) when it comes to the use of ethnoracial categories in genetics and genomics that among other things makes it difficult to properly compare and interpret research using ethnoracial categories, as well as draw conclusions from them. Finally, we briefly reconstruct some of the biases of reductionism to which geneticists (as well as other researchers referring to genetic methods and explanations) are particularly exposed to, and we analyse the problem in the context of the biologization of ethnoracial categories. Our work constitutes a novel, in-depth contribution to the debate about reporting race and ethnicity in biomedical and health research. First, we reconstruct the theoretical background assumptions about racial ontology which researchers implicitly presume in their studies with the aid of a sample of recent papers published in medical journals about COVID-19. Secondly, we use the typology of the biases of reductionism to the problem of biologization of ethnoracial categories with reference to genetics and genomics.

Decolonizing nursing through the lens of Black maternal health

In the United States, there is a long history of racial disparities in maternal health, with Black women disproportionately representing poor maternal health outcomes. Black women are three to four times more likely to die from a pregnancy-related complication and twice as likely to experience severe maternal morbidity when compared to white women. Where are nurses in the development of knowledge to improve maternal health outcomes among Black birthing people? This dialogue discusses how decolonizing nursing can occur by examining the history of Black maternal health in the United States and using the works of nursing scholars of color to inform nursing education, research, and clinical practice.

A scoping review of guidelines for the use of race, ethnicity, and ancestry reveals widespread consensus but also points of ongoing disagreement

The use of population descriptors such as race, ethnicity, and ancestry in science, medicine, and public health has a long, complicated, and at times dark history, particularly for genetics, given the field's perceived importance for understanding between-group differences. The historical and potential harms that come with irresponsible use of these categories suggests a clear need for definitive guidance about when and how they can be used appropriately. However, while many prior authors have provided such guidance, no established consensus exists, and the extant literature has not been examined for implied consensus and sources of disagreement. Here, we present the results of a scoping review of published normative recommendations regarding the use of population categories, particularly in genetics research. Following PRISMA guidelines, we extracted recommendations from n = 121 articles matching inclusion criteria. Articles were published consistently throughout the time period examined and in a broad range of journals, demonstrating an ongoing and interdisciplinary perceived need for guidance. Examined recommendations fall under one of eight themes identified during analysis. Seven are characterized by broad agreement across articles; one, "appropriate definitions of population categories and contexts for use," revealed substantial fundamental disagreement among articles. Additionally, while many articles focus on the inappropriate use of race, none fundamentally problematize ancestry. This work can be a resource to researchers looking for normative guidance on the use of population descriptors and can orient authors of future guidelines to this complex field, thereby contributing to the development of more effective future guidelines for genetics research.

Race and Ethnicity in Non-Alcoholic Fatty Liver Disease (NAFLD): A Narrative Review

Non-alcoholic fatty liver disease (NAFLD) is a significant public health concern worldwide with a complex etiology attributed to behavioural, environmental, and genetic causes. The worldwide prevalence of NAFLD is estimated to be 32.4% and constantly rising. Global data, however, indicate considerable heterogeneity among studies for both NAFLD prevalence and incidence. Identifying variables that affect the estimated epidemiological measures is essential to all stakeholders, including patients, researchers, healthcare providers, and policymakers. Besides helping with the research on disease etiology, it helps to identify individuals at risk of the disease, which in turn will outline the focus of the preventive measures and help to fittingly tailor individualized treatments, targeted prevention, screening, or treatment programs. Several studies suggest differences in the prevalence and severity of NAFLD by race or ethnicity, which may be linked to differences in lifestyle, diet, metabolic comorbidity profile, and genetic background, among others. Race/ethnicity research is essential as it can provide valuable information regarding biological and genetic differences among people with similar cultural, dietary, and geographical backgrounds. In this review, we examined the existing literature on race/ethnicity differences in susceptibility to NAFLD and discussed the contributing variables to such differences, including diet and physical activity, the comorbidity profile, and genetic susceptibility. We also reviewed the limitations of race/ethnicity studies in NAFLD.

Study Protocol: A Mixed-Methods Study for Understanding Racial Disparities in COVID-19-Related Complications

Background

In the United States, the COVID-19 pandemic has magnified the disproportionate and long-standing health disparities experienced by Black communities. Although it is acknowledged that social determinants of health (SDOH) rather than biological factors likely contribute to this disparity, few studies using rigorous analytic approaches in large, information-rich community-based data sets are dedicated to understanding the underlying drivers of these racial disparities.

Objective

The overall aim of our study is to elucidate the mechanisms by which racial disparities in severe COVID-19 outcomes arise, using both quantitative and qualitative methods.

Methods

In this protocol, we outline a convergent parallel mixed methods approach to identifying, quantifying, and contextualizing factors that contribute to the dramatic disparity in COVID-19 severity (ie, hospitalization, mortality) in Black versus white COVID-19 patients within the integrated health care system of Kaiser Permanente Georgia (KPGA). Toward this end, we will generate two quantitative cohorts of KPGA members with a confirmed COVID-19 diagnosis between January 1, 2020, and September 30, 2021: (1) an electronic medical record (EMR) cohort including routinely captured data on diagnoses, medications, and laboratory values, and a subset of patients hospitalized at Emory Healthcare to capture additional in-hospital data; and (2) a survey cohort, where participants will answer a range of questions related to demographics (eg, race, education), usual health behaviors (eg, physical activity, smoking), impact of COVID-19 (eg, job loss, caregiving responsibilities), and medical mistrust. Key outcomes of interest for these two cohorts include hospitalization, mortality, intensive care unit admission, hospital readmission, and long COVID-19. Finally, we will conduct qualitative semistructured interviews to capture perceptions of and experiences of being hospitalized with COVID-19 as well as related interactions with KPGA health care providers. We will analyze and interpret the quantitative and qualitative data separately, and then integrate the qualitative and quantitative findings using a triangulation design approach.

Results

This study has been funded by a Woodruff Health Sciences grant from December 2020 to December 2022. As of August 31, 2022, 31,500 KPGA members diagnosed with COVID-19 have been included in the EMR cohort, including 3028 who were hospitalized at Emory Healthcare, and 482 KPGA members completed the survey. In addition, 20 KPGA members (10 Black and 10 white) have been interviewed about their experiences navigating care with COVID-19. Quantitative and qualitative data cleaning and coding have been completed. Data analysis is underway with results anticipated to be published in December 2022.

Conclusions

Results from this mixed methods pilot study in a diverse integrated care setting in the southeastern United States will provide insights into the mechanisms underpinning racial disparities in COVID-19 complications. The quantitative and qualitative data will provide important context to generate hypotheses around the mechanisms for racial disparities in COVID-19, and may help to inform the development of multilevel strategies to reduce the burden of racial disparities in COVID-19 and its ongoing sequelae. Incorporating contextual information, elucidated from qualitative interviews, will increase the efficacy, adoption, and sustainability of such strategies.

International Registered Report Identifier (IRRID)

RR1-10.2196/38914

The Challenge of Recruiting Diverse Populations into Health Research: An embedded social science perspective

Addressing health disparities has become a central remit for conducting health research. In the following paper, we explore the conceptual and methodological challenges posed by the call to recruit medically underserved populations. This exploration of challenges is undertaken from the perspective of social science researchers embedded in a large within a clinical genomics research study. We suggest that these challenges are found in respect to the development of recruiting strategies, analysis of the data in respect to understanding and interpreting the experiences of being medically underserved, and in comparing the experiences of being medically underserved compared to not being underserved. By way of conclusion, it is argued that there is important role for social scientists with large health research studies which, if achieved successfully, can benefit study teams and society as a whole.

Risk of Food Insecurity in Young Adulthood and Longitudinal Changes in Cardiometabolic Health: Evidence from the National Longitudinal Study of Adolescent to Adult Health

BACKGROUND

Studies have demonstrated relations between food insecurity, the lack of access to enough nutritious food, and greater risk of diet-sensitive chronic diseases. However, most prior evidence relies on cross-sectional studies and self-reported disease.

OBJECTIVES

The objective was to assess the longitudinal relation between risk of food insecurity in young adulthood and changes in diet-sensitive cardiometabolic health outcomes across 10 y among non-Hispanic white, non-Hispanic black, American Indian or Alaska Native, and Hispanic adults.

METHODS

Data from the fourth and fifth waves (n = 3992) of the National Longitudinal Study of Adolescent to Adult Health were used. Measures included risk of food insecurity, body weight, diabetes, and sociodemographic characteristics. Body weight and diabetes were assessed with direct measures. Mixed-effects models assessed the association of risk of food insecurity with BMI, obesity, and diabetes while accounting for sociodemographic characteristics and the complex survey design.

RESULTS

Risk of food insecurity was associated with increases in BMI as well as incidence of obesity and diabetes from young to middle adulthood in unadjusted and adjusted models (all P < 0.01). In models stratified by race and ethnicity, the relations of risk of food insecurity with body weight outcomes and diabetes varied.

CONCLUSIONS

Risk of food insecurity in young adulthood was related to BMI and obesity during young and middle adulthood but not in changes over time. Risk of food insecurity in young adulthood related to an increased incidence of diabetes in middle adulthood. However, the relations among specific racial and ethnic groups were unclear. Estimates of the relation between food insecurity and cardiometabolic health outcomes within racial and ethnic groups experiencing the highest prevalence of these conditions should be refined.

Pandemics, past and present: The role of biological anthropology in interdisciplinary pandemic studies

Biological anthropologists are ideally suited for the study of pandemics given their strengths in human biology, health, culture, and behavior, yet pandemics have historically not been a major focus of research. The COVID‐19 pandemic has reinforced the need to understand pandemic causes and unequal consequences at multiple levels. Insights from past pandemics can strengthen the knowledge base and inform the study of current and future pandemics through an anthropological lens. In this paper, we discuss the distinctive social and epidemiological features of pandemics, as well as the ways in which biological anthropologists have previously studied infectious diseases, epidemics, and pandemics. We then review interdisciplinary research on three pandemics–1918 influenza, 2009 influenza, and COVID‐19–focusing on persistent social inequalities in morbidity and mortality related to sex and gender; race, ethnicity, and Indigeneity; and pre‐existing health and disability. Following this review of the current state of pandemic research on these topics, we conclude with a discussion of ways biological anthropologists can contribute to this field moving forward. Biological anthropologists can add rich historical and cross‐cultural depth to the study of pandemics, provide insights into the biosocial complexities of pandemics using the theory of syndemics, investigate the social and health impacts of stress and stigma, and address important methodological and ethical issues. As COVID‐19 is unlikely to be the last global pandemic, stronger involvement of biological anthropology in pandemic studies and public health policy and research is vital.

The Assessment of Social Determinants of Health in Postsepsis Mortality and Readmission: A Scoping Review

To summarize knowledge and identify gaps in evidence about the relationship between social determinants of health (SDH) and postsepsis outcomes.

DATA SOURCES

We conducted a comprehensive search of PubMed/Medical Literature Analysis and Retrieval System Online, Excerpta Medica database, and the Cochrane Library.

STUDY SELECTION

We identified articles that evaluated SDH as risk factors for mortality or readmission after sepsis hospitalization. Two authors independently screened and selected articles for inclusion.

DATA EXTRACTION

We dual-extracted study characteristics with specific focus on measurement, reporting, and interpretation of SDH variables.

DATA SYNTHESIS

Of 2,077 articles screened, 103 articles assessed risk factors for postsepsis mortality or readmission. Of these, 28 (27%) included at least one SDH variable. Inclusion of SDH in studies assessing postsepsis adverse outcomes increased over time. The most common SDH evaluated was race/ethnicity (n = 21, 75%), followed by payer type (n = 10, 36%), and income/wealth (n = 9, 32%). Of the studies including race/ethnicity, nine (32%) evaluated no other SDH. Only one study including race/ethnicity discussed the use of this variable as a surrogate for social disadvantage, and none specifically discussed structural racism. None of the studies specifically addressed methods to validate the accuracy of SDH or handling of missing data. Eight (29%) studies included a general statement that missing data were infrequent. Several studies reported independent associations between SDH and outcomes after sepsis discharge; however, these findings were mixed across studies.

CONCLUSIONS

Our review suggests that SDH data are underutilized and of uncertain quality in studies evaluating postsepsis adverse events. Transparent and explicit ontogenesis and data models for SDH data are urgently needed to support research and clinical applications with specific attention to advancing our understanding of the role racism and racial health inequities in postsepsis outcomes.

Association of food security with cardiometabolic health during young adulthood: cross-sectional comparison of American Indian adults with other racial/ethnic groups

OBJECTIVES

Our aim was to assess the cross-sectional associations between food insecurity and cardiometabolic health indicators in American Indian young adults compared with non-Hispanic white, black, Asian or Pacific Islander and Hispanic young adults.

DESIGN

Data from the fourth wave of the National Longitudinal Study of Adolescent to Adult Health (Add Health) were used. Variables included a self-assessed measure of risk of food insecurity, indicators of cardiometabolic health (body mass index, haemoglobin A1c, blood pressure) and sociodemographic characteristics. Multivariable regression models were used to assess the association of risk of food insecurity with cardiometabolic health, while controlling for sociodemographic variables. All analyses were weighted and accounted for the complex survey design.

PARTICIPANTS

The analytical sample of n=12 799 included mostly non-Hispanic white respondents (n=7900), followed by n=2666 black, n=442 American Indian, n=848 Asian or Pacific Islander and n=943 Hispanic.

RESULTS

Risk of food insecurity was more common among respondents who were female, Black, American Indian, had lower educational attainment, and were classified as having obesity or diabetes. In unadjusted models, risk of food insecurity was significantly associated with greater odds of obesity (OR=1.39; 95% CI 1.20 to 1.60) and diabetes (OR=1.61; 95% CI 1.23 to 2.11). After adjusting for sociodemographic factors (age, sex, education, income, household size, tobacco smoking, alcohol intake and race/ethnicity), only the association between risk of food insecurity and obesity remained (OR=1.19; 95% CI 1.03 to 1.38). Relationships among risk of food insecurity, sociodemographic characteristics and diabetes varied across models stratified by race and ethnicity.

CONCLUSIONS

Results suggest that elevated risk of food insecurity is present in young American Indian adults, but its relationship with cardiometabolic health is unclear. Future work should capitalise on longitudinal data and the US Department of Agriculture's Food Security Survey Modules.

Examining educational attainment and allostatic load in non-Hispanic Black women

Background

Research suggests that non-Hispanic Black (henceforth, Black) women and people with lower educational attainment have higher levels of allostatic load (AL). This study sought to determine the association between educational attainment and AL among a large sample of Black women.

Methods

We analyzed data among 4177 Black women from the National Health and Nutrition Examination Survey years 1999–2018. AL score was defined as the total for abnormal measures of eight biomarkers. We further categorized participants with AL score greater than or equal to 4 as having high AL. We calculated mean estimates of total allostatic load scores using generalized linear models. We performed modified Poisson Regression models with robust variance estimation to estimate prevalence ratios (PRs) of high allostatic load and their associated 95% confidence intervals (CIs) by educational attainment.

Results

Black women with a college degree or higher had the lowest prevalence of high allostatic load (31.8% vs. 42.7%, 36.3%, 36.6%), and age adjusted mean allostatic load scores (mean = 1.90 vs. mean = 2.34, mean = 1.99, mean = 2.05) when compared to Black women with less than a high school diploma, high school diploma or GED, and some college or associates degree respectively. Even after accounting for age, poverty-to-income ratio, smoking, congestive heart failure, and heart attack, Black college graduates had an 14.3% lower prevalence of high allostatic load (PR = 0.857, 95% CI 0.839–0.876) when compared to Black women with lower educational attainment.

Conclusions

Black women with a baccalaureate degree or higher educational attainment had lower allostatic load compared to Black women with less than a high school education. This finding further confirms higher education is a social determinant of health. Future research should explore differences in AL by more granular degree types.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12905-022-01641-0.

Hurricane flooding and acute gastrointestinal illness in North Carolina

Hurricanes often flood homes and industries, spreading pathogens. Contact with pathogen-contaminated water can result in diarrhea, vomiting, and/or nausea, known collectively as acute gastrointestinal illness (AGI). Hurricanes Matthew and Florence caused record-breaking flooding in North Carolina (NC) in October 2016 and September 2018, respectively. To examine the relationship between hurricane flooding and AGI in NC, we first calculated the percent of each ZIP code flooded after Hurricanes Matthew and Florence. Rates of all-cause AGI emergency department (ED) visits were calculated from NC's ED surveillance system data. Using controlled interrupted time series, we compared AGI ED visit rates during the three weeks after each hurricane in ZIP codes with a third or more of their area flooded to the predicted rates had these hurricanes not occurred, based on AGI 2016-2019 ED trends, and controlling for AGI ED visit rates in unflooded areas. We examined alternative case definitions (bacterial AGI) and effect measure modification by race and age. We observed an 11% increase (rate ratio (RR): 1.11, 95% CI: 1.00, 1.23) in AGI ED visit rates after Hurricanes Matthew and Florence. This effect was particularly strong among American Indian patients and patients aged 65 years and older after Florence and elevated among Black patients for both hurricanes. Florence's effect was more consistent than Matthew's effect, possibly because little rain preceded Florence and heavy rain preceded Matthew. When restricted to bacterial AGI, we found an 85% (RR: 1.85, 95% CI: 1.37, 2.34) increase in AGI ED visit rate after Florence, but no increase after Matthew. Hurricane flooding is associated with an increase in AGI ED visit rate, although the strength of effect may depend on total storm rainfall or antecedent rainfall. American Indians and Black people-historically pushed to less desirable, flood-prone land-may be at higher risk for AGI after storms.

Use of Race, Ethnicity, and National Origin in Studies Assessing Cardiovascular Risk in Women With a History of Hypertensive Disorders of Pregnancy

Women with a history of hyperBtensive disorders of pregnancy (HDP) are at particularly high risk for cardiovascular disease (CVD) and CVD-related death, and certain racial and ethnic subpopulations are disproportionately affected by these conditions. We examined the use of race, ethnicity, and national origin in observational studies assessing CVD morbidity and mortality in women with a history of HDP. A total of 124 studies, published between 1976 and 2021, were reviewed. We found that white women were heavily overrepresented, encompassing 53% of all participants with HDP. There was limited and heterogeneous reporting of race and ethnicity information across studies and only 27 studies reported including race and/or ethnicity variables in at least 1 statistical analysis. Only 2 studies mentioned the use of these variables as a strength; several others (k = 18) reported a lack of diversity among participants as a study limitation. Just over half of included articles (k = 68) reported at least 1 sociodemographic variable other than race and ethnicity (eg, marital status and income); however, none investigated how they might have worked synergistically or antagonistically with race and/or ethnicity to influence participants' risk of CVD. These findings highlight significant areas for improvement in cardiovascular obstetrics research, including the need for more robust and standardized methods for collecting, reporting, and using sociodemographic information. Future studies of CVD risk in women with a history of HDP should explicitly examine racial and ethnic differences and use an intersectional approach.

The lived experience of severe maternal morbidity among Black women

Black women are 3-4 times more likely to die from a pregnancy-related complication and twice as likely to experience severe maternal morbidity when compared to white women in the United States. The risks for pregnancy-related maternal mortality are well documented, yet Black women's experiences of life-threatening morbidity are essentially absent in the nursing literature. The purpose of this interpretive phenomenological study was to understand the experiences of Black women who developed severe maternal morbidity. Face-to-face, one-to-one, in-depth conversational interviews were conducted with nine Black women who experienced life-threatening complications during childbirth or postpartum. Five essential themes emerged (1) I Only Know What I Know; (2) How You Cared for Me; (3) Race Matters; (4) Faced with Uncertainty; and (5) Still Healing. These themes illuminate the complexity of Black women's subjective interpretations of severe maternal morbidity, and reveal ways in which racism, not race, places Black women at risk for poor maternal health outcomes. The author envisions greater equity for Black mothers entrusted to nursing care, guided by nursing theories informed by these study findings.

Tubal Factor Infertility, In Vitro Fertilization, and Racial Disparities: A Retrospective Cohort in Two US Clinics

BACKGROUND

Nearly 14% of US women report any lifetime infertility which is associated with health care costs and psychosocial consequences. Tubal factor infertility (TFI) often occurs as a result of sexually transmitted diseases and subsequent pelvic inflammatory disease. We sought to evaluate for and describe potential racial disparities in TFI and in vitro fertilization (IVF) prevalence.

METHODS

Records of women aged 19 to 42 years in our retrospective cohort from 2 US infertility clinics were reviewed. We calculated TFI prevalence, IVF initiation prevalence, and prevalence ratios (PRs), with 95% confidence intervals (CIs) for each estimate, overall and by race.

RESULTS

Among 660 infertile women, 110 (16.7%; 95% CI, 13.8-19.5%) had TFI which was higher in Black compared with White women (30.3% [33/109] vs 13.9% [68/489]; PR, 2.2 [95% CI, 1.5-3.1]). For women with TFI, IVF was offered to similar proportions of women by race (51.5% [17/33] vs 52.9% [36/68] for Black vs White women); however, fewer Black than White women with TFI started IVF (6.7% [1/15] vs 31.0% [9/29]; PR, 0.2 [95% CI, 0-1.0]), although the difference was not statistically different.

CONCLUSIONS

Tubal factor infertility prevalence was 2-fold higher among Black than White women seeking care for infertility. Among women with TFI, data suggested a lower likelihood of Black women starting IVF than White women. Improved sexually transmitted disease prevention and treatment might ameliorate disparities in TFI.

Risk Factors in Adolescence for the Development of Elevated Blood Pressure and Hypertension in American Indian and Alaskan Native Adults

To examine risk factors for elevated blood pressure and hypertension in American Indians and Alaska Natives (AI/ANs), compared to three other ethnic groups in the US. Weighted relative risk regression models, stratified by race/ethnicity, were used to measure the associations between risk factors and elevated blood pressure and hypertension in AI/ANs, compared to non-Hispanic Whites, non-Hispanic Blacks and Hispanics, with data from the National Longitudinal Study of Adolescent to Adult Health. In all groups, females had a lower risk of both elevated blood pressure and hypertension than males. Increasing body mass index raised hypertension risk in all groups. In AI/ANs, financial instability increased the risk of hypertension by 88% (95% CI: 1.27-2.77), but not in other groups. No other statistically significant associations were found. Future interventions should include socio-economic factors in efforts to prevent hypertension in AI/ANs.

An Innovative Individual-Level Socioeconomic Measure Predicts Critical Care Outcomes in Older Adults: A Population-Based Study

BACKGROUND

Little is known about the impact of socioeconomic status (SES) as a key element of social determinants of health on intensive care unit (ICU) outcomes for adults.

OBJECTIVE

We assessed whether a validated individual SES index termed HOUSES (HOUsing-based SocioEconomic status index) derived from housing features was associated with short-term outcomes of critical illness including ICU mortality, ICU-free days, hospital-free days, and ICU readmission.

METHODS

We performed a population-based cohort study of adult patients living in Olmsted County, Minnesota, admitted to 7 intensive care units at Mayo Clinic from 2011 to 2014. We compared outcomes between the lowest SES group (HOUSES quartile 1 [Q1]) and the higher SES group (HOUSES Q2-4). We stratified the cohort based on age (<50 years old and ≥50 years old).

RESULTS

Among 4134 eligible patients, 3378 (82%) patients had SES successfully measured by the HOUSES index. Baseline characteristics, severity of illness, and reason for ICU admission were similar among the different SES groups as measured by HOUSES except for larger number of intoxications and overdoses in younger patients from the lowest SES. In all adult patients, there were no overall differences in mortality, ICU-free days, hospital-free days, or ICU readmissions in patients with higher SES compared to lower SES. Among older patients (>50 years), those with higher SES (HOUSES Q2-4) compared to those with lower SES (HOUSES Q1) had lower mortality rates (hazard ratio = 0.72; 95% CI: 0.56-0.93; adjusted P = .01), increased ICU-free days (mean 1.08 days; 95% CI: 0.34-1.84; adjusted P = .004), and increased hospital-free days (mean 1.20 days; 95% CI: 0.45-1.96; adjusted P = .002). There were no differences in ICU readmission rates (OR = 0.74; 95% CI: 0.55-1.00; P = .051).

CONCLUSION

Individual-level SES may be an important determinant or predictor of critical care outcomes in older adults. Housing-based socioeconomic status may be a useful tool for enhancing critical care research and practice.

Examination of Racial and Ethnic Differences in Deceased Organ Donation Ratio Over Time in the US

Importance

Historically, deceased organ donation was lower among Black compared with White populations, motivating efforts to reduce racial disparities. The overarching effect of these efforts in Black and other racial/ethnic groups remains unclear.

Objective

To examine changes in deceased organ donation over time.

Design, Setting, and Participants

This population-based cohort study used data from January 1, 1999, through December 31, 2017, from the Scientific Registry of Transplant Recipients to quantify the number of actual deceased organ donors, and from the Centers for Disease Control and Prevention Wide-ranging Online Data for Epidemiologic Research Detailed Mortality File to quantify the number of potential donors (individuals who died under conditions consistent with organ donation). Data were analyzed from December 2, 2019, to May 14, 2020.

Exposures

Race and ethnicity of deceased and potential donors.

Main Outcomes and Measures

For each racial/ethnic group and year, a donation ratio was calculated as the number of actual deceased donors divided by the number of potential donors. Direct age and sex standardization was used to allow for group comparisons, and Poisson regression was used to quantify changes in donation ratio over time.

Results

A total of 141 534 deceased donors and 5 268 200 potential donors were included in the analysis. Among Black individuals, the donation ratio increased 2.58-fold from 1999 to 2017 (yearly change in adjusted incidence rate ratio [aIRR], 1.05; 95% CI, 1.05-1.05; P < .001). This increase was significantly greater than the 1.60-fold increase seen in White individuals. Nevertheless, substantial racial differences remained, with Black individuals still donating at only 69% the rate of White individuals in 2017 (P < .001). Among other racial minority populations, changes were less drastic. Deceased organ donation increased 1.80-fold among American Indian/Alaska Native and 1.40-fold among Asian or Pacific Islander populations, with substantial racial differences remaining in 2017 (American Indian/Alaska Native population donation at 28% and Asian/Pacific Islander population donation at 85% the rate of the White population). Deceased organ donation differences between Hispanic/Latino and non-Hispanic/Latino populations increased over time (4% lower in 2017).

Conclusions and Relevance

The findings of this cohort study suggest that differences in deceased organ donation between White and some racial minority populations have attenuated over time. The greatest gains were observed among Black individuals, who have been the primary targets of study and intervention. Despite improvements, substantial differences remain, suggesting that novel approaches are needed to understand and address relatively lower rates of deceased organ donation among all racial minorities.

Adopting a "Compound" Exposome Approach in Environmental Aging Biomarker Research: A Call to Action for Advancing Racial Health Equity

BACKGROUND

In June 2020, the National Academies of Sciences, Engineering, and Medicine hosted a virtual workshop focused on integrating the science of aging and environmental health research. The concurrent COVID-19 pandemic and national attention on racism exposed shortcomings in the environmental research field's conceptualization and methodological use of race, which have subsequently hindered the ability of research to address racial health disparities. By the workshop's conclusion, the authors deduced that the utility of environmental aging biomarkers-aging biomarkers shown to be specifically influenced by environmental exposures-would be greatly diminished if these biomarkers are developed absent of considerations of broader societal factors-like structural racism-that impinge on racial health equity.

OBJECTIVES

The authors reached a post-workshop consensus recommendation: To advance racial health equity, a "compound" exposome approach should be widely adopted in environmental aging biomarker research. We present this recommendation here.

DISCUSSION

The authors believe that without explicit considerations of racial health equity, people in most need of the benefits afforded by a better understanding of the relationships between exposures and aging will be the least likely to receive them because biomarkers may not encompass cumulative impacts from their unique social and environmental stressors. Employing an exposome approach that allows for more comprehensive exposure-disease pathway characterization across broad domains, including the social exposome and neighborhood factors, is the first step. Exposome-centered study designs must then be supported with efforts aimed at increasing the recruitment and retention of racially diverse study populations and researchers and further "compounded" with strategies directed at improving the use and interpretation of race throughout the publication and dissemination process. This compound exposome approach maximizes the ability of our science to identify environmental aging biomarkers that explicate racial disparities in health and best positions the environmental research community to contribute to the elimination of racial health disparities. https://doi.org/10.1289/EHP8392.

An analysis of the academic capacity of anaesthesia in the UK by publication trends and academic units

Over a decade ago, bibliometric analysis predicted the disappearance of UK publishing in anaesthesia by 2020. We repeated this analysis to assess if this had turned out to be the case, searching PubMed for papers associated with UK consultant anaesthetists for 2017-2019 across 15 journals. Although the rate of decline has flattened using the same search filter, including a wider range of publication types shows that outputs still remain at half 1990s levels (381 papers for all 3 years combined), authored by 769 anaesthetists, 274 of whom are associated with an academic centre. There are now 11 identifiable academic units, and a further 15 places where anaesthetists have affiliations with academic centres as individuals. The majority of papers (71%) are in secondary analysis (observational, database and association studies, surveys and meta-analyses), rather than in primary research (clinical trials or laboratory studies). These data reflect the current academic capacity in terms of publications, academic units and staffing. We discuss how this information can be used to inform a new strategy for UK academic anaesthesia.

Race Differences in the Effect of Subjective Social Status on Hostility and Depressive Symptoms Among 9- to 11-Year-Old Children

PURPOSE

Research shows that subjective social status (SSS) is a salient determinant of health. However, there is little research on SSS-related group differences on psychosocial outcomes among children. The purpose of the current study was to determine if associations between psychosocial functioning and SSS in children varied as a function of racial groups.

METHODS

We used a series of regression models to examine associations between SSS and measures of hostility and depressive symptom severity in groups of Black and White children. All analyses controlled for objective markers of family- and neighborhood-level socioeconomic status. Participants included 291 school-age children in Syracuse, NY.

RESULTS

Among Black children, SSS was negatively associated with hostility scores, R² = 0.10, F(6, 160) = 3.34, p = 0.006, but not depressive symptom severity. Conversely, among White children, SSS was negatively associated with depressive symptom severity, R² = 0.18, F(6, 117) = 4.37, p = 0.001, but not hostility.

CONCLUSION

These racial differences in SSS-associated psychosocial functioning could be explained by race-based differences in attributions of social mobility and socioeconomic inequalities. Findings provide support for investigating possible tailoring of behavioral interventions to assist children in developing high SSS or coping with low SSS.

Validation of Self-Reported Race in a Canadian Provincial Renal Administrative Database

Background:

Administrative data are commonly used to study clinical outcomes in renal disease. Race is an important determinant of renal health delivery and outcomes in Canada but is not validated in most administrative data, and the correlation with census-based definitions of race is unknown.

Objectives:

Validation of self-reported race (SRR) in a Canadian provincial renal administrative database (Patient Records and Outcome Management Information System [PROMIS]) and comparison with the Canadian census categories of race.

Design:

Prospective patient survey study to validate SRR in PROMIS.

Setting:

British Columbia, Canada.

Patients:

Adult patients registered in PROMIS.

Measurements:

Survey SRR was used as gold standard to validate SRR in PROMIS. Self-reported race in PROMIS was compared with census race categories.

Methods:

This is a cross-sectional telephone survey of a random sample of all adults in PROMIS conducted between February 2016 and November 2016. Responders selected a race category from PROMIS and from the Canadian census. Sensitivity (Sn) and specificity (Sp) were calculated with 95% confidence intervals (CIs).

Results:

A total of 21 039 patients met inclusion criteria, 1677 were selected for the survey and 637 participated (38% response rate). There were no differences between the PROMIS, sampled, and responder populations. PROMIS SRR had an accuracy of 95.3% (95% CI: 94.2%-97.0%) when validated against the survey SRR with Sn and Sp ≥90% in all race groups except in Aboriginals (Sn 87.5%). The positive and negative predictive values were ≥95%, except in very low and high–prevalence groups, respectively. The Canadian census had an accuracy of 95.7% (95% CI: 94.4%-97.6%) when validated against PROMIS SRR with Sn and Sp ≥90%. The results did not differ in subgroups based on age, sex, birth outside Canada, or renal group (glomerulonephritis, chronic kidney disease, hemodialysis, peritoneal dialysis, transplant recipients, or live donors).

Limitations:

Analysis of minority groups and lower prevalence groups is limited by sample size. Results may not be generalizable to other administrative databases.

Conclusions:

We have shown high accuracy of PROMIS SRR that validates its use in the secondary analysis of administrative data for research. There is high correlation between PROMIS and census race categories which allows linkage with other data sources that use census-based definitions of race.

Psychopathology, cognition and outcome in Dutch and immigrant first-episode psychosis patients

AIM

The primary aim was to examine differences in baseline symptom expression, neurocognition, social cognition and psychosocial functioning between Dutch, first-generation immigrants and second-generation immigrants with a first-episode psychosis (FEP). The secondary aim was to examine functional and symptomatic change and between-group differences at 12-months follow-up. Associations between migration, baseline characteristics and outcome were explored.

METHODS

Forty-six Dutch, 56 second-generation- and 60 first-generation immigrant patients completed baseline measures for 6 symptom dimensions (positive symptoms, negative symptoms, neurocognitive functioning, social cognitive functioning, excitement and emotional distress) and 5 domains of psychosocial functioning (general functioning, work and study, relationships, self-care and disturbing behaviour). Functioning and psychotic symptoms were assessed at baseline and 12-months follow-up. ANCOVA and t tests were used to assess between-group differences. General linear models were used to explore within-group differences. Backward-regression was used to explore predictors of outcome.

RESULTS

Levels of positive symptoms, excitement and emotional distress did not differ between groups at baseline or follow-up. Dutch patients had lower levels of negative symptoms than both immigrant groups at follow-up. On neurocognition and social cognition, Dutch performed better than second-generation immigrants, who in turn performed better than first-generation immigrants. Psychosocial functioning across all domains at baseline and at 12-months follow-up was similar across groups. Baseline levels of general psychosocial functioning and income were the strongest predictors of outcome at follow-up.

CONCLUSIONS

Psychosocial functioning and symptom profiles are comparable between Dutch, first-generation immigrant and second-generation immigrant FEP patients, excluding neurocognitive and social cognitive deficits. A range of baseline characteristics predicted outcome.

ACL injury incidence, severity and patterns in professional male soccer players in a Middle Eastern league

Aim

To ascertain ACL injury incidence, severity (injury burden) and patterns (contact/non-contact and reinjuries) in a professional male football league in the Middle East over five consecutive seasons.

Methods

Prospective epidemiological study reporting ACL injuries in professional male soccer players in the Qatar Stars League, with complete matches/training exposure over five seasons (2013–2014 to 2017–2018), corresponding to 2243 player seasons and 729 team months.

Results

37 complete ACL ruptures occurred in 37 players during 486 951  hours of player exposure. The overall ACL injury rate was 0.076 injuries/1000  hours of exposure (season range 0.045–0.098). Injury incidence during matches and training was 0.41 and 0.04 injuries/1000  hours of exposure, respectively. Match injury incidence was greater than that of training (OR 11.8, 95%  CI 6.21 to 23.23, p<0.001). Average injury-related time-loss following ACL injury was 225 days±65 (range 116–360). Overall injury burden was 16.3 days lost/1000  hours of exposure.

Conclusion

The overall ACL injury rate in professional male soccer players competing in the Middle East was 0.076 injuries/1000  hours of exposure, match injury incidence was greater than training, while the average ACL time-loss was 225 days.

Relationship of socioeconomic status to olfactory function

Socioeconomic status can significantly impact health. To what degree education and other socioeconomic factors influence the chemical sense of olfaction is not clear. Most studies that have assessed such influences come from countries lacking large disparities in education and income and generally view such measures as nuisance variables to be controlled for statistically. In this study, we evaluated the influences of education and income on odor identification in a diverse sample of subjects from Brazil, a society where large disparities in both income and education are present. The 40-item University of Pennsylvania Smell Identification Test (UPSIT) was administered to 1572 healthy Brazilian citizens with no self-reported olfactory or gustatory deficits and for whom detailed socioeconomic and educational status data were obtained. Univariate and multivariate models were employed to examine the influence of socioeconomic status on the test scores. After controlling for age, sex, ethnicity, and smoking behavior, income and educational level were positively and independently related to the olfactory test scores (respective ps < 0.001 & 0.01). Both linear and quadratic functions described the relationship between the UPSIT scores and the levels of education and socioeconomic status. Individuals of lower socioeconomic status performed significantly worse than those of higher socioeconomic status on 20 of the 40 odorant items. This study demonstrates socioeconomic status is significantly associated with influence the ability to identify odors. The degree to which this reflects differential exposures to xenobiotic agents, cultural differences, familiarity with odors or their names, cognitive development, or other factors requires further investigation.

Risk factors for pre-diabetes and diabetes in adolescence and their variability by race and ethnicity

Adolescent risk factors for pre-diabetes and diabetes in young adulthood were examined in three minority groups and compared to those in non-Hispanic Whites. Retrospective cohort study with data on 8337 adolescent respondents from Add Health (1994-2008). Participants included 5131 non-Hispanic Whites, 1651 non-Hispanic Blacks, 1223 Hispanics, and 332 American Indians/Alaska Natives. Diabetes was defined as: hemoglobin A1C ≥ 6.5%, glucose > 125 mg/dl, self-reported diabetes, or self-reported diabetes medication use, in Wave 4 data. Pre-diabetes was defined as hemoglobin A1C ≥ 5.7%. Relative risk regression models were used to evaluate the association between risk factors and risk of diabetes and pre-diabetes, controlling for body mass index, sedentary and physical activity habits, fast food consumption, and parental education, parental diabetes status, and financial stability. 484 participants developed diabetes; 2878 developed pre-diabetes between 1994 and 2008. Pre-diabetes and diabetes were more prevalent in non-Hispanic Blacks (55% and 12%, respectively) than in American Indians/Alaska Natives (43% and 11%), Hispanics (37% and 6%), and non-Hispanic Whites (27% and 3%). In all races, higher body mass index and parental diabetes were associated with higher risk of pre-diabetes and diabetes, while female sex was associated with lower risk of pre-diabetes. Efforts to reduce the risk of pre-diabetes and diabetes in adolescents should emphasize parental diabetes and BMI in all races, independent of physical activity, sedentary behaviors, or fast food consumption. Future interventions might be interested in targeting households, rather than individuals, to prevent pre-diabetes and diabetes in adolescents and young adults.

Parenting Practices in Diverse Family Structures: Examination of Adolescents' Development and Adjustment

This article explored the implications of diverse family structures on adolescents' adjustment, with an emphasis on whether and, if so, how diverse family structures influence and predict developmental outcomes. Family relationships within the family unit are a stronger predictor of adolescents' development than the particular family structure. Transitions in families that result in notable reductions in effective parenting practices and economic well-being will negatively affect youth, regardless of family structure. Family processes that promote optimal growth and development among youth in traditional two-parent, heterosexual households work similarly for those growing up in nontraditional family structures. A conceptual model to advance this field of research is offered, and implications for research and policy are discussed.

Healthcare Utilization and All-Cause Premature Mortality in Hungarian Segregated Roma Settlements: Evaluation of Specific Indicators in a Cross-Sectional Study

Roma is the largest ethnic minority of Europe with deprived health status, which is poorly explored due to legal constrains of ethnicity assessment. We aimed to elaborate health indicators for adults living in segregated Roma settlements (SRS), representing the most vulnerable Roma subpopulation. SRSs were mapped in a study area populated by 54,682 adults. Records of all adults living in the study area were processed in the National Institute of Health Insurance Fund Management. Aggregated, age-sex standardized SRS-specific and non-SRS-specific indicators on healthcare utilization and all-cause premature death along with the ratio of them (RR) were computed with 95% confidence intervals. The rate of GP appointments was significantly higher among SRS inhabitants (RR = 1.152, 95% CI: 1.136–1.167). The proportion of subjects hospitalized (RR = 1.286, 95% CI: 1.177–1.405) and the reimbursement for inpatient care (RR = 1.060, 95% CI: 1.057–1.064) were elevated for SRS. All-cause premature mortality was significantly higher in SRSs (RR = 1.711, 1.085–2.696). Our study demonstrated that it is possible to compute the SRS-specific version of routine healthcare indicators without violating the protection of personal data by converting a sensitive ethical issue into a non-sensitive small-area geographical analysis; there is an SRS-specific healthcare utilization pattern, which is associated with elevated costs and increased risk of all-cause premature death.

Immigration, region of origin, and the epidemiology of venous thromboembolism: A population-based study

BACKGROUND

Venous thromboembolism (VTE) epidemiology has been mainly studied in populations largely of European ancestry.

OBJECTIVES

To assess the epidemiology of VTE in immigrants to Ontario, Canada.

PATIENTS/METHODS

We conducted a population-based retrospective cohort study using linked health-care and administrative databases. We included 1 195 791 immigrants to Ontario and 1 195 791 nonimmigrants, matched on age, sex, and place of residence. The main exposure was ethnicity according to world region of origin, using a previously validated algorithm. The main outcome was incident onset of VTE during the period of observation. Risk ratios (RR) were calculated using Poisson regression models.

RESULTS

The incidence rate (IR) of VTE was lower among immigrants (0.87 per 1000 PY; 95% confidence interval [CI] 0.85-0.89) than nonimmigrants (1.59 per 1000 PY; 95% CI 1.56-1.61). Age- and sex-standardized IR were lower among East and South Asian immigrants. Compared to immigrants for predominantly White regions, age- and sex-specific RRs were consistently lower for East Asian (0.18-0.30) and South Asian (0.29-0.75) immigrants. In contrast, the RRs of VTE among Black (0.38-1.50), Latin American (0.29-1.25), Arab/Middle Eastern (0.44-1.08) and West Asian (0.31-1.16) immigrants were not significantly different from White immigrants.

CONCLUSIONS

In Ontario, the incidence of VTE is lower among immigrants compared to nonimmigrants. East and South Asian immigrants have a lower risk of VTE compared to White immigrants.

Racial disparities in surgical outcomes of patients with Inflammatory Bowel Disease

BACKGROUND

Inflammatory Bowel Disease (IBD) has not historically been a focus of racial health disparities research. IBD has been increasing in the black community. We hypothesized that outcomes following surgery would be worse for black patients.

METHODS

A retrospective cohort study of death and serious morbidity (DSM) of patients undergoing surgery for IBD was performed using data from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP 2011-2014). Multivariable logistic regression modeling was performed to evaluate associations between race and outcomes.

RESULTS

Among 14,679 IBD patients, the overall rate of DSM was 20.3% (white: 19.3%, black 27.0%, other 23.8%, p < 0.001). After adjustment, black patients remained at increased risk of DSM compared white patients (OR: 1.37; 95% CI 1.14-1.64).

CONCLUSIONS

Black patients are at increased risk of post-operative DSM following surgery for IBD. The elevated rates of DSM are not explained by traditional risk factors like obesity, ASA class, emergent surgery, or stoma creation.

Relative Roles of Race Versus Socioeconomic Position in Studies of Health Inequalities: A Matter of Interpretation

An abundance of research has documented health inequalities by race and socioeconomic position (SEP) in the United States. However, conceptual and methodological challenges complicate the interpretation of study findings, thereby limiting progress in understanding health inequalities and in achieving health equity. Fundamental to these challenges is a lack of clarity about what race is and the implications of that ambiguity for scientific inquiry. Additionally, there is wide variability in how SEP is conceptualized and measured, resulting in a lack of comparability across studies and significant misclassification of risk. The objectives of this review are to synthesize the literature regarding common approaches to examining race and SEP health inequalities and to discuss the conceptual and methodological challenges associated with how race and SEP have been employed in public health research. Addressing health inequalities has become increasingly important as the United States trends toward becoming a majority-minority nation. Recommendations for future research are presented.

Epidemiology of Parkinson's Disease-East Versus West

Background

The cause of PD at present remains unknown. A number of epidemiological studies have been conducted across the globe to ascertain the disease burden and the possible risk factors. In this review, we analyze the various studies from East and West with an aim to observe the important similarities and differences in the disease occurrence and risk factor profile.

Methods

A comprehensive search of descriptive and analytical epidemiological studies was undertaken. The descriptive studies and meta-analysis providing the standardised population rates were selected. The demographics, ethnicity and geographical differences between East and West were analysed. In analytical epidemiology, more established and well-studied non-genetic risk factors for PD were reviewed utilising the prospective cohort studies, case control studies and meta-analysis where available.

Results and Conclusion

PD is more common with increasing age and shows male predominance, which is more obvious in Western studies. The PD prevalence and incidence rates are slightly lower in the East compared to the West. Incidence studies on different ethnic populations in the same country have also found a lower occurrence of PD amongst Easterners compared to Westerners. Setting methodological differences aside, studies from East and West suggest a role for both environmental and genetic risk factors in PD causation. Smoking, caffeine intake and pesticide exposure are well-established risk factors across regions. There is a robust data for dairy product consumption, urate levels and physical activity in the West while studies on certain risk factors like head injury and alcohol show conflicting and mixed results.