Housing Discrimination, Residential Racial Segregation, and Colorectal Cancer Survival in Southeastern Wisconsin

Neighborhood economic vulnerability as a predictor for patterns of care and outcomes for patients with uterine cancer

OBJECTIVE

To quantify the effect of neighborhood socioeconomic vulnerability as it relates to racial disparity in uterine cancer treatment and survival.

METHODS

Patients with a diagnosis of uterine cancer who underwent hysterectomy in New York State from 2004 to 2017 were included in this retrospective cohort study. Neighborhood socioeconomic vulnerability as quantified by the Area Deprivation Index was calculated. Primary outcome was guideline adherent treatment; secondary outcome was 5 year overall survival.

RESULTS

A total of 34,356 patients were included in the final cohort. Residence within a vulnerable neighborhood was associated with a lower likelihood of receiving appropriate adjuvant chemotherapy (59.7% vs 75.7% with aRR = 0.81; 95% CI, 0.77-0.86) and timely surgery (63.7% vs. 74.5% with aRR = 0.85; 95% CI, 0.82-0.87). All-cause mortality was 24% higher for those who resided in vulnerable neighborhoods compared to affluent neighborhoods (aHR = 1.24; 95% CI, 1.16-1.32). The greatest Black/White racial disparity in 5 year overall survival was seen in the most affluent neighborhoods at 18.6%, with survival being 79.8% for White patients and 61.2% for Black patients (aHR 1.31; 95% CI 1.14-1.51). For patients with advanced stage disease, this disparity was driven by improved survival for White patients with increasing neighborhood affluence but no change in survival for Black patients. On adjusted analysis controlling for age, comorbidities, insurance, tumor histology, stage, and grade, the disparity remained widest in the most affluent neighborhoods in NYC (aHR = 1.59; 95%CI 1.26-1.2.01).

CONCLUSIONS

Neighborhood socioeconomic vulnerability is associated with poor outcomes for patients with uterine cancer. The greatest Black/White survival disparities are in the wealthiest neighborhoods. Neighborhood affluence may not affect survival of Black patients with advanced stage endometrial cancer.

Associations of Historical Redlining With BMI and Waist Circumference in Coronary Artery Risk Development in Young Adults

Introduction

Historical maps of racialized evaluation of mortgage lending risk (i.e., redlined neighborhoods) have been linked to adverse health outcomes. Little research has examined whether living in historically redlined neighborhoods is associated with obesity, differentially by race or gender.

Methods

This is a cross-sectional study to examine whether living in historically redlined neighborhoods is associated with BMI and waist circumference among Black and White adults in 1985-1986. Participants' addresses were linked to the 1930s Home Owners' Loan Corporation maps that evaluated mortgage lending risk across neighborhoods. The authors used multilevel linear regression models clustered on Census tract, adjusted for confounders to estimate main effects, and stratified, and interaction models by (1) race, (2) gender, and (3) race by gender with redlining differentially for Black versus White adults and men versus women. To better understand strata differences, they compared Census tract-level median household income across race and gender groups within Home Owners' Loan Corporation grade.

Results

Black adults (n=2,103) were more likely than White adults (n=1,767) to live in historically rated hazardous areas and to have higher BMI and waist circumference. Redlining and race and redlining and gender interactions for BMI and waist circumference were statistically significant (p<0.10). However, in stratified analyses, the only statistically significant associations were among White participants. White participants living in historically rated hazardous areas had lower BMI (β = - 0.63 [95% CI= -1.11, -0.15]) and lower waist circumference (β = - 1.50 [95% CI= -2.62, -0.38]) than those living in declining areas. Within each Home Owners' Loan Corporation grade, residents in White participants' neighborhoods had higher incomes than those living in Black participants' neighborhoods (p<0.0001). The difference was largest within historically redlined areas. Covariate associations differed for men, women, Black, and White adults, explaining the difference between the interaction and the stratified models. Race by redlining interaction did not vary by gender.

Conclusions

White adults may have benefitted from historical redlining, which may have reinforced neighborhood processes that generated racial inequality in BMI and waist circumference 50 years later.

The Association between State-Level Structural Racism and Alcohol and Tobacco Use Behaviors among a National Probability Sample of Black Americans

BACKGROUND

Structural racism is how society maintains and promotes racial hierarchy and discrimination through established and interconnected systems. Structural racism is theorized to promote alcohol and tobacco use, which are risk factors for adverse health and cancer-health outcomes. The current study assesses the association between measures of state-level structural racism and alcohol and tobacco use among a national sample of 1,946 Black Americans.

METHODS

An existing composite index of state-level structural racism including five dimensions (subscales; i.e., residential segregation and employment, economic, incarceration, and educational inequities) was merged with individual-level data from a national sample dataset. Hierarchical linear and logistic regression models, accounting for participant clustering at the state level, assessed associations between structural racism and frequency of alcohol use, frequency of binge drinking, smoking status, and smoking frequency. Two models were estimated for each behavioral outcome, one using the composite structural racism index and one modeling dimensions of structural racism in lieu of the composite measure, each controlling for individual-level covariates.

RESULTS

Results indicated positive associations between the incarceration dimension of the structural racism index and binge drinking frequency, smoking status, and smoking frequency. An inverse association was detected between the education dimension and smoking status.

CONCLUSIONS

Results suggest that state-level structural racism expressed in incarceration disparities, is positively associated with alcohol and tobacco use among Black Americans.

IMPACT

Addressing structural racism, particularly in incarceration practices, through multilevel policy and intervention may help to reduce population-wide alcohol and tobacco use behaviors and improve the health outcomes of Black populations.

Association of area-level mortgage denial and guideline-concordant non-small-cell lung cancer care and outcomes in the United States

BACKGROUND

Racial and socioeconomic disparities in receipt of care for non-small-cell lung cancer (NSCLC) are well described. However, no previous studies have evaluated the association between mortgage denial rates and receipt of timely and guideline-concordant care for NSCLC and patient outcomes.

METHODS

We identified individuals ≥18 years diagnosed with NSCLC between 2014 and 2019 from the National Cancer Database. Using the Home Mortgage Disclosure Act database, we calculated the proportion of denied home loans to total loans at the zip-code level and categorized them into quintiles. Our outcomes included receipt of guideline-concordant care based on clinical and pathologic stage at diagnosis and the National Comprehensive Cancer Network guidelines, time from surgery to chemotherapy initiation, and overall survival.

RESULTS

Of the 629,288 individuals diagnosed with NSCLC (median age 69; IQR 61-76 years, 49.1% female), 47.8% did not receive guideline-concordant care. Residing in areas with higher mortgage denial rates and lower income was associated with worse guideline-concordant care overall (aRR = 1.28; 95% CI = 1.25-1.32) and for each cancer treatment modality, worse receipt of timely chemotherapy (aHR = 1.14; 95% CI = 1.11-1.17) and worse overall survival (aHR = 1.21; 95% CI = 1.19-1.22), compared with residing in areas with the lowest mortgage denial rate and highest income.

CONCLUSIONS

Area-level mortgage denial rate was associated with worse receipt of timely and guideline-concordant NSCLC care and survival. This highlights the critical need to understand and address systemic practices, such as mortgage denial, that limit access to resources and are associated with worse access to quality cancer care and outcomes.

The measurement of racism in health inequities research

There is limited literature on the measures and metrics used to examine racism in the health inequities literature. Health inequities research is continuously evolving, with the number of publications increasing over time. However, there is limited knowledge on the best measures and methods to examine the impact of different levels of racism (institutionalized, personally mediated, and internalized) on health inequities. Advanced statistical methods have the potential to be used in new ways to examine the relationship between racism and health inequities. In this review, we conduct a descriptive examination of the measurement of racism in the health inequities epidemiologic literature. We examine the study design, methods used for analysis, types of measures used (e.g., composite, absolute, relative), number of measures used, phase of research (detect, understand, solutions), viewpoint (oppressor, oppressed), and components of structural racism measures (historical context, geographical context, multifaceted nature). We discuss methods (e.g., Peters-Belson, latent class analysis, difference in differences) that have demonstrated potential for future work. The articles reviewed were limited to the detect (25%) and understand (75%) phases, with no studies in the solutions phase. Although the majority (56%) of studies had cross-sectional designs, many authors pointed to the need for longitudinal and multilevel data for further exploration. We examined study design features as mutually exclusive elements. However, racism is a multifaceted system and the measurement of racism in many studies does not fit into a single category. As the literature grows, the significance of methodological and measurement triangulation to assess racism should be investigated.

Tools to Measure the Impact of Structural Racism and Discrimination on Gastrointestinal and Hepatology Disease Outcomes: A Scoping Review

BACKGROUND & AIMS

Structural racism and discrimination (SRD) are important upstream determinants of health perpetuated by discriminatory laws and policies. Therefore, measuring SRD and its impact on health is critical to developing interventions that address resultant health disparities. We aimed to identify gastrointestinal (GI) or liver studies that report measures of SRD or interventions to achieve health equity in these domains by addressing upstream determinants of health.

METHODS

We conducted a scoping review according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses scoping reviews guidelines. Studies that used an SRD measure or examined an upstream intervention in GI or liver disease were included. Studies that described health disparities in GI or liver conditions without mentioning SRD were excluded. Study characteristics, findings, and limitations were extracted.

RESULTS

Forty-six articles (19 studies using SRD measures and 27 studies of upstream interventions) were identified. Measures of residential racial segregation were reported most frequently. SRD was associated with poorer health outcomes for racial and ethnic minority populations. Although upstream intervention studies focused primarily on policies related to colon cancer screening and organ graft allocation, racial and ethnic disparities often persisted post-intervention.

CONCLUSIONS

To achieve health equity in GI and liver conditions, there is an urgent need for research that goes beyond describing health disparities to incorporating measures of SRD and implementing interventions that address this understudied determinant of health.

Neighborhood-level Residential Isolation and Neighborhood Composition: Similar but Different

Residential segregation has been considered as a potential cause of racial and/or ethnic disparities in health. Among the five dimensions of residential segregation, the isolation dimension has been conceived to play an essential role in disproportionately shaping the health of racial and ethnic minorities, particularly in urban or metropolitan areas. However, a noticeable amount of research studies has been using informal measures of neighborhood composition (i.e., proportions or percentages), which do not capture any of the five dimensions of residential segregation. Since the inappropriateness of measurement may obstruct a meaningful interpretation and an effective dissemination of research findings, a combination of graphical and non-graphical techniques was used to demonstrate the similarities and differences between formal measures of neighborhood-level residential isolation and informal measures of neighborhood composition. These were intended to provide intuitive and mutual understandings across academic disciples (e.g., city or urban planning, geography, public health, and sociology) and practitioners or professionals in multiple fields (e.g., community development workers, health service providers, policymakers, and social workers). Conceptual and methodological explanations with analytical discussions are also provided to differentiate and/or distinguish the two types of measures. While the concepts, methodologies, and research implications discussed herein are most relevant for research studies in urban or metropolitan areas of the United States, the general framework is also applicable to those of other industrialized counties.

Advancing health equity through implementation science: Identifying and examining measures of the outer setting

BACKGROUND

Implementation science (IS) could accelerate progress toward achieving health equity goals. However, the lack of attention to the outer setting where interventions are implemented limits applicability and generalizability of findings to different populations, settings, and time periods. We developed a data resource to assess outer setting across seven centers funded by the National Cancer Institute's IS Centers in Cancer Control (ISC3) Network Program.

OBJECTIVE

To describe the development of the Outer Setting Data Resource and characterize the county-level outer context across Centers.

METHODS

Our Data Resource captures seven key environments, including: (1) food; (2) physical; (3) economic; (4) social; (5) health care; (6) cancer behavioral and screening; and (7) cancer-related policy. Data were obtained from public sources including the US Census and American Community Survey. We present medians and interquartile ranges based on the distribution of all counties in the US, all ISC3 centers, and within each Center for twelve selected measures. Distributions of each factor are compared with the national estimate using single sample sign tests.

RESULTS

ISC3 centers' catchment areas include 458 counties and over 126 million people across 28 states. The median percentage of population living within ½ mile of a park is higher in ISC3 counties (38.0%, interquartile range (IQR): 16.0%-59.0%) compared to nationally (18.0%, IQR: 7.0%-38.0%; p < 0.0001). The median percentage of households with no broadband access is significantly lower in ISC3 counties (28.4%, IQR: 21.4%-35.6%) compared the nation overall (32.8%, IQR: 25.8%-41.2%; p < 0.0001). The median unemployment rate was significantly higher in ISC3 counties (5.2%, IQR: 4.1%-6.4%) compared to nationally (4.9%, 3.6%-6.3%, p = 0.0006).

CONCLUSIONS

Our results indicate that the outer setting varies across Centers and often differs from the national level. These findings demonstrate the importance of assessing the contextual environment in which interventions are implemented and suggest potential implications for intervention generalizability and scalability.

Ethnic enclaves and colon cancer stage at diagnosis among New Jersey Hispanics

Ethnic enclaves are neighborhoods with high concentrations of individuals of the same ethnic origin. Researchers have hypothesized that residence in ethnic enclaves may contribute to cancer outcomes through detrimental or protective pathways. A limitation of previous work, however, is their cross-sectional approach whereby an individual's residence at the time of diagnosis was used to capture residence in an ethnic enclave at a single point in time. This study addresses this limitation by adopting a longitudinal approach to investigating the association between the duration of residence in an ethnic enclave and the colon cancer (CC) stage at diagnosis. Colon cancer incidence cases diagnosed between 2006 and 2014, for Hispanics aged 18 years and older from the New Jersey State Cancer Registry (NJSCR) were linked to residential histories obtained from a commercial database LexisNexis, Inc. We examined associations between residence in an enclave and stage at diagnosis using binary and multinomial logistic regression, adjusted for age, sex, primary payer, and marital status. Among the 1076 Hispanics diagnosed with invasive colon cancer in New Jersey from 2006 to 2014, 48.4% lived in a Hispanic enclave at the time of diagnosis. Over the ten years preceding CC diagnosis, 32.6% lived in an enclave for the entire period. We found that Hispanics living in an ethnic enclave at diagnosis had significantly lower odds of distant-stage CC than Hispanics not living in an enclave at the time of diagnosis. Additionally, we found a significant association between living in an enclave for an extended period (e.g., over ten years) and lower odds of being diagnosed with distant stage CC. Integrating residential histories opens research possibilities to examine how minorities' residential mobility and residence in enclaves affect cancer diagnosis over time.

Area-level Socioeconomic Disadvantage and Cancer Survival in Metropolitan Detroit

BACKGROUND

Racial segregation is linked to poorer neighborhood quality and adverse health conditions among minorities, including worse cancer outcomes. We evaluated relationships between race, neighborhood social disadvantage, and cancer survival.

METHODS

We calculated overall and cancer-specific survival for 11,367 non-Hispanic Black (NHB) and 29,481 non-Hispanic White (NHW) individuals with breast, colorectal, lung, or prostate cancer using data from the Metropolitan Detroit Cancer Surveillance System. The area deprivation index (ADI) was used to measure social disadvantage at the census block group level, where higher ADI is associated with poorer neighborhood factors. Associations between ADI and survival were estimated using Cox proportional hazards mixed-effects models accounting for geographic grouping and adjusting for demographic and clinical factors.

RESULTS

Increasing ADI quintile was associated with increased overall mortality for all four cancer sites in multivariable-adjusted models. Stratified by race, these associations remained among breast (NHW: HR = 1.16, P < 0.0001; NHB: HR = 1.20, P < 0.0001), colorectal (NHW: HR = 1.11, P < 0.0001; NHB: HR = 1.09, P = 0.00378), prostate (NHW: HR = 1.18, P < 0.0001; NHB: HR = 1.18, P < 0.0001), and lung cancers (NHW: HR = 1.06, P < 0.0001; NHB: HR = 1.07, P = 0.00177). Cancer-specific mortality estimates were similar to overall mortality. Adjustment for ADI substantially attenuated the effects of race on mortality for breast [overall proportion attenuated (OPA) = 47%, P < 0.0001; cancer-specific proportion attenuated (CSPA) = 37%, P < 0.0001] prostate cancer (OPA = 51%, P < 0.0001; CSPA = 56%, P < 0.0001), and colorectal cancer (OPA = 69%, P = 0.032; CSPA = 36%, P = 0.018).

CONCLUSIONS

Area-level socioeconomic disadvantage is related to cancer mortality in a racially diverse population, impacting racial differences in cancer mortality.

IMPACT

Understanding the role of neighborhood quality in cancer survivorship could improve community-based intervention practices.

The impact of social and environmental factors on cancer biology in Black Americans

Low socioeconomic status (SES) is associated with early onset of chronic diseases and reduced life expectancy. The involvement of neighborhood-level factors in defining cancer risk and outcomes for marginalized communities has been an active area of research for decades. Yet, the biological processes that underlie the impact of SES on chronic health conditions, such as cancer, remain poorly understood. To date, limited studies have shown that chronic life stress is more prevalent in low SES communities and can affect important molecular processes implicated in tumor biology such as DNA methylation, inflammation, and immune response. Further efforts to elucidate how neighborhood-level factors function physiologically to worsen cancer outcomes for disadvantaged communities are underway. This review provides an overview of the current literature on how socioenvironmental factors within neighborhoods contribute to more aggressive tumor biology, specifically in Black U.S. women and men, including the impact of environmental pollutants, neighborhood deprivation, social isolation, structural racism, and discrimination. We also summarize commonly used methods to measure deprivation, discrimination, and structural racism at the neighborhood-level in cancer health disparities research. Finally, we offer recommendations to adopt a multi-faceted intersectional approach to reduce cancer health disparities and develop effective interventions to promote health equity.

Housing and Cancer Care and Outcomes: A Systematic Review

BACKGROUND

Access to stable and affordable housing is an important social determinant of health in the United States. However, research addressing housing and cancer care, diagnosis, and outcomes has not been synthesized.

METHODS

We conducted a systematic review of studies examining associations of housing and cancer care and outcomes using PubMed, Embase, Scopus, and CINAHL. Included studies were conducted in the United States and published in English between 1980 and 2021. Study characteristics and key findings were abstracted and qualitatively synthesized.

RESULTS

A total of 31 studies were identified. Housing-related measures were reported at the individual level in 20 studies (65%) and area level in 11 studies (35%). Study populations and housing measures were heterogeneous. The most common housing measures were area-level housing discrimination (8 studies, 26%), individual-level housing status (8 studies, 26%), and individual-level housing concerns (7 studies, 23%). The most common cancer outcomes were screening (12 studies, 39%) and mortality (9 studies, 29%). Few studies assessed multiple dimensions of housing. Most studies found that exposure to housing insecurity was statistically significantly associated with worse cancer care (11 studies) or outcomes (10 studies).

CONCLUSIONS

Housing insecurity is adversely associated with cancer care and outcomes, underscoring the importance of screening for housing needs and supporting systemic changes to advance equitable access to care. Additional research is needed to develop and test provider- and policy-level housing interventions that can effectively address the needs of individuals throughout the cancer care continuum.

Housing Insecurity Among Patients With Cancer

Social determinants of health are the economic and environmental conditions under which people are born, live, work, and age that affect health. These structural factors underlie many of the long-standing inequities in cancer care and outcomes that vary by geography, socioeconomic status, and race and ethnicity in the United States. Housing insecurity, including lack of safe, affordable, and stable housing, is a key social determinant of health that can influence-and be influenced by-cancer care across the continuum, from prevention to screening, diagnosis, treatment, and survivorship. During 2021, the National Cancer Policy Forum of the National Academies of Science, Engineering, and Medicine sponsored a series of webinars addressing social determinants of health, including food, housing, and transportation insecurity, and their associations with cancer care and patient outcomes. This dissemination commentary summarizes the formal presentations and panel discussions from the webinar devoted to housing insecurity. It provides an overview of housing insecurity and health care across the cancer control continuum, describes health system interventions to minimize the impact of housing insecurity on patients with cancer, and identifies challenges and opportunities for addressing housing insecurity and improving health equity. Systematically identifying and addressing housing insecurity to ensure equitable access to cancer care and reduce health disparities will require ongoing investment at the practice, systems, and broader policy levels.

A comprehensive framework for operationalizing structural racism in health research: The association between mass incarceration of Black people in the U.S. and adverse birth outcomes

Structural racism represents a key determinant of the racial health disparities that has characterized the U.S. population throughout its existence. While this reality has recently begun to gain increasing acknowledgment and acceptance within the health sciences, there are still considerable challenges related to defining the concept of structural racism and operationalizing it in empirical study. In this paper, building on the existing evidence base, we propose a comprehensive framework that centers structural racism in terms of its historical roots and continued manifestation in most domains of society, and offer solutions for the study of this phenomenon and the pathways that connect it to population-level health disparities. We showcase our framework by applying it to the known link between spatial and racialized clustering of incarceration - a previously cited representation of structural racism - and disparities in adverse birth outcomes. Through this process we hypothesize pathways that focus on social cohesion and community-level chronic stress, community crime and police victimization, as well as infrastructural community disinvestment. First, we contextualize these mechanisms within the relevant extant literature. Then, we make recommendations for future empirical pathway analyses. Finally, we identify key areas for policy, community, and individual-level interventions that target the impact of concentrated incarceration on birth outcomes among Black people in the U.S.

Institutional Racism and Health: a Framework for Conceptualization, Measurement, and Analysis

Despite growing interest in the health-related consequences of racially discriminatory institutional policies and practices, public health scholars have yet to reach a consensus on how to measure and analyze exposure to institutional racism. The purpose of this paper is to provide an overview of the conceptualization, measurement, and analysis of institutional racism in the context of quantitative research on minority health and health disparities in the United States. We begin by providing definitions of key concepts (e.g., racialization, racism, racial inequity) and describing linkages between these ideas. Next, we discuss the hypothesized mechanisms that link exposure to institutional racism with health. We then provide a framework to advance empirical research on institutional racism and health, informed by a literature review that summarizes measures and analytic approaches used in previous studies. The framework addresses six considerations: (1) policy identification, (2) population of interest, (3) exposure measurement, (4) outcome measurement, (5) study design, and (6) analytic approach. Research utilizing the proposed framework will help inform structural interventions to promote minority health and reduce racial and ethnic health disparities.

Social Determinants of Health in Oncology: Towards a More Personalized and Equitable Delivery of Cancer Care

Social determinants of health (SDOH) are defined as the set of modifiable social and physical risk factors that affect health. It is known that SDOH directly influence the population's overall health, but their effects on patients with cancer are considerably less elucidated. Here, we review the literature describing the effects of SDOH outlined by the Healthy People 2020 framework on patients diagnosed with cancer. We have found that while some SDOH are well-defined in cancer patients, evidence surrounding several variables is scarce. In addition, we have found that many SDOH are associated with disparities at the screening stage, indicating that upstream interventions are necessary before addressing the clinical outcomes themselves. Further investigation is warranted to understand how SDOH affect screenings and outcomes in multiple disciplines of oncology and types of cancers as well as explore how SDOH affect the treatments sought by these vulnerable patients.

Historical redlining and food environments: A study of 102 urban areas in the United States

OBJECTIVE

Unhealthy food environments are disproportionally concentrated in neighborhoods with clustering of racial/ethnic minorities and poverty. This disparity has been blamed, in part, on market self-regulation. This explanation risks overlooking past and current practices of racial segregation that have created and reinforced the obstacles blocking investments from food retailers in marginalized neighborhoods. We fill this gap by investigating how the long-term ramifications of redlining, discriminatory housing practices enacted by federal Home Owner Lending Corporation (HOLC) in the 1930s, has evolved generations later to disproportionally exposing neighborhoods to unhealthy food environments.

METHODS

We overlaid historical redlining maps over 2010 food environment observations at the census tract level to identify areas with less healthy food environments and to assess the historical context of those areas. For 11,651 census tracts within 102 U.S. urban areas, we described the healthiness of food environments as measured by the modified retail food environment index (mRFEI). Using hurdle models with random effects, we further examined the association between redlining housing practice and food environments.

RESULTS

The results indicate that historically redlined neighborhoods show a higher likelihood for unhealthy retail food environments even for census tracts with present-day economic and racial privilege.

CONCLUSION

The current evidence shows how structural discrimination manifested by unjust housing practices and racial residential segregation fueled an uneven food environment where minority neighborhoods disproportionally bore the brunt of restrictive food access. It highlights an urgent need to ameliorate patterns of housing inequality as a fix to unequal food environments.

Home mortgage discrimination and incidence of triple-negative and Luminal A breast cancer among non-Hispanic Black and non-Hispanic White females in California, 2006-2015

Purpose

In the United States, Black females are burdened by more aggressive subtypes and increased mortality from breast cancer compared to non-Hispanic (NH) White females. Institutional racism may contribute to these inequities. We aimed to characterize the association between home mortgage discrimination, a novel measure of institutional racism, and incidence of Luminal A and triple-negative breast cancer (TNBC) subtypes among NH Black and NH White females in California metropolitan areas.

Methods

We merged data from the California Cancer Registry on females aged 20 + diagnosed with primary invasive breast cancer between 2006 and 2015 with a census tract-level index of home mortgage lending bias measuring the odds of mortgage loan denial for Black versus White applicants, generated from the 2007–2013 Home Mortgage Disclosure Act database. Poisson regression estimated cross-sectional associations of census tract-level racial bias in mortgage lending with race/ethnicity- and Luminal A and TNBC-specific incidence rate ratios, adjusting for neighborhood confounders.

Results

We identified n = 102,853 cases of Luminal A and n = 15,528 cases of TNBC over the study period. Compared to NH Whites, NH Black females had higher rates of TNBC, lower rates of Luminal A breast cancer, and lived in census tracts with less racial bias in home mortgage lending. There was no evidence of association between neighborhood racial bias in mortgage lending at the time of diagnosis and either subtype among either racial/ethnic group.

Conclusion

Future research should incorporate residential history data with measures of institutional racism to improve estimation and inform policy interventions.

Improving The Measurement Of Structural Racism To Achieve Antiracist Health Policy

Antiracist health policy research requires methodological innovation that creates equity-centered and antiracist solutions to health inequities by centering the complexities and insidiousness of structural racism. The development of effective health policy and health equity interventions requires sound empirical characterization of the nature of structural racism and its impact on public health. However, there is a disconnect between the conceptualization and measurement of structural racism in the public health literature. Given that structural racism is a system of interconnected institutions that operates with a set of racialized rules that maintain White supremacy, how can anyone accurately measure its insidiousness? This article highlights methodological approaches that will move the field forward in its ability to validly measure structural racism for the purposes of achieving health equity. We identify three key areas that require scholarly attention to advance antiracist health policy research: historical context, geographical context, and theory-based novel quantitative and qualitative methods that capture the multifaceted and systemic properties of structural racism as well as other systems of oppression.

Historical Redlining and Resident Exposure to COVID-19: A Study of New York City

The Coronavirus Disease 2019 (COVID-19) has been reported to disproportionately impact racial/ethnic minorities in the USA, both in terms of infections and deaths. This racial disparity in the COVID-19 outcomes may result from the segregation of minorities in neighborhoods with health-compromising conditions. We, thus, anticipate that neighborhoods would be especially vulnerable to COVID-19 if they are of present-day economic and racial disadvantage and were redlined historically. To test this expectation, we examined the change of both confirmed COVID-19 cases and deaths from April to July, 2020, in zip code tabulation areas (ZCTAs) in the New York City using multilevel regression analysis. The results indicate that ZCTAs with a higher proportion of black and Hispanic populations are associated with a higher percentage of COVID-19 infection. Historically low-graded neighborhoods show a higher risk for COVID-19 infection, even for ZCTAs with present-day economic and racial privilege. These associations change over time as the pandemic unfolds. Racial/ethnic minorities are bearing the brunt of the COVID-19 pandemic's health impact. The current evidence shows that the pre-existing social structure in the form of racial residential segregation could be partially responsible for the disparities observed, highlighting an urgent need to stress historical segregation and to build a less segregated and more equal society.

Healthcare Inequities Experienced by Patients with Cancer: A Qualitative Study in Medellín, Colombia

PURPOSE

This study aimed to understand the lived experiences of patients with cancer that facing inequities in oncological care in the city of Medellín.

PATIENTS AND METHODS

A qualitative study was conducted based on the theoretical and methodological elements of the grounded theory, specifically the description and conceptual ordering of Corbin and Strauss. Sixteen patients with cancer, who belonged to low (n=5), middle (n=4) and high (n=7) social classes, were included by theoretical sampling with category saturation. Data were collected using semi-structured interviews and analyzed in a category system based on the three social classes.

RESULTS

The patients were aged between 23 and 71 years old, and they were diagnosed with different types of cancer such as breast, cervical, prostate, stomach, leukemia and lymphoma. Patients' experiences showed that diagnosis, specialized care, treatment and hospital discharge were different based on their social class.

CONCLUSION

Patients' lived experiences associated with cancer reflect complex social situations, in which social determinants affect the level of citizens' empowerment and self-management against the risks of get disease and die. Being part of low and middle social classes meant being subjected to a dehumanized, cold, impersonal and discontinuous treatment, in which healthcare was focused on the disease instead of individuals' preferences and values. In contrast, patients belonging to the high class had the resources necessary to face risks, which ensured access to more humanized and individualized healthcare.

Tip of the iceberg: Measuring racial discrimination in studies of health

There is compelling evidence that racial discrimination is a risk factor for illness and disease. But what are health scientists measuring-and what do they think they are measuring-when they include measures of racial discrimination in health research? We synthesize theoretical conceptualizations of racial discrimination in health research and critically assess whether and how these concepts correspond (or not) to widely used measures of racial discrimination. In doing so, we show that while researchers often use terms such as 'self-reported discrimination', 'perceptions of discrimination', and 'exposure to discrimination' interchangeably, these concepts are indeed unique, with each holding a distinct epistemological position and theoretical and methodological capacity to uncover the impact of racial discrimination on health and health disparities. Importantly, we argue that commonly used measures of self-reported or perceived racial discrimination are just the 'tip of the iceberg' in terms of revealing the ways in which discrimination shapes health inequities. Scientists and practitioners must be cognizant of and intentional in their measurement choices and language, as the framing of these processes will inform policy and intervention efforts aimed at eliminating discrimination.

Mortgage Lending Bias and Breast Cancer Survival Among Older Women in the United States

PURPOSE

The objective was to examine the relationship between contemporary redlining (mortgage lending bias on the basis of property location) and survival among older women with breast cancer in the United States.

METHODS

A redlining index using Home Mortgage Disclosure Act data (2007-2013) was linked by census tract with a SEER-Medicare cohort of 27,516 women age 66-90 years with an initial diagnosis of stage I-IV breast cancer in 2007-2009 and follow-up through 2015. Cox proportional hazards models were used to examine the relationship between redlining and both all-cause and breast cancer-specific mortality, accounting for covariates.

RESULTS

Overall, 34% of non-Hispanic White, 57% of Hispanic, and 79% of non-Hispanic Black individuals lived in redlined tracts. As the redlining index increased, women experienced poorer survival. This effect was strongest for women with no comorbid conditions, who comprised 54% of the sample. For redlining index values of 1 (low), 2 (moderate), and 3 (high), as compared with 0.5 (least), hazard ratios (HRs) (and 95% CIs) for all-cause mortality were HR = 1.10 (1.06 to 1.14), HR = 1.27 (1.17 to 1.38), and HR = 1.39 (1.25 to 1.55), respectively, among women with no comorbidities. A similar pattern was found for breast cancer-specific mortality.

CONCLUSION

Contemporary redlining is associated with poorer breast cancer survival. The impact of this bias is emphasized by the pronounced effect even among women with health insurance (Medicare) and no comorbid conditions. The magnitude of this neighborhood level effect demands an increased focus on upstream determinants of health to support comprehensive patient care. The housing sector actively reveals structural racism and economic disinvestment and is an actionable policy target to mitigate adverse upstream health determinants for the benefit of patients with cancer.

The Impact of Racial Residential Segregation on Colorectal Cancer Outcomes and Treatment

OBJECTIVE

We sought to examine the impact of racial residential segregation on Black-White disparities in colorectal cancer diagnosis, surgical resection, and cancer-specific survival.

SUMMARY BACKGROUND DATA

There are clear Black-White disparities in colorectal cancer diagnosis and treatment with equally disparate explanations for these findings, including genetics, socioeconomic factors, and health behaviors.

METHODS

Data on Black and White patients with colorectal cancer were obtained from SEER between 2005 and 2015. The exposure of interest was the index of dissimilarity (IoD), a validated measure of segregation derived from 2010 Census data. Outcomes included advanced stage at diagnosis (AJCC stage IV), resection of localized disease (AJCC stage I-II), and cancer-specific survival. We used Poisson regression with robust error variance for the outcomes of interest and Cox proportional hazards were used to assess cancer-specific 5-year survival.

RESULTS

Black patients had a 41% increased risk of presenting at advanced stage per IoD [risk ratio (RR) 1.41, 95% confidence intervals (CI) 1.18, 1.69] and White patients saw a 17% increase (RR 1.17, 95%CI 1.04, 1.31). Black patients were 5% less likely to undergo surgical resection (RR 0.95, 95%CI 0.90, 0.99), whereas Whites were 5% more likely (RR 1.05, 95%CI 1.03, 1.07). Black patients had 43% increased hazards of cancer-specific mortality with increasing IoD (hazard ratio (HR) 1.43, 95%CI 1.17, 1.74).

CONCLUSIONS

Black patients with colorectal cancer living in more segregated counties are significantly more likely to present at advanced stage and have worse cancer-specific survival. Enduring structural racism in the form of residential segregation has strong impacts on the colorectal cancer outcomes.

Association between disparities in intergenerational economic mobility and cause-specific mortality among Black and White persons in the United States

BACKGROUND

Evidence about the association between structural racism and mortality in the United States is limited. We examined the association between ongoing structural racism, measured as inequalities in adulthood income between White and Black children with similar parental household income (economic mobility gap) in a recent birth cohort, and Black-White disparities in death rates (mortality gap) overall and for major causes.

METHODS

Sex-, race/ethnicity-, and county-specific data were used to examine sex-specific associations between economic mobility and mortality gaps for all causes combined, heart diseases, cerebrovascular diseases, chronic obstructive pulmonary disease (COPD), injury/violence, all malignant cancers, and 14 cancer types. Economic mobility data for 1978-1983 birth cohorts and death rates during 2011-2018 were obtained from the Opportunity Atlas and National Center for Health Statistics, respectively. Data from 471 counties were included in analyses of all-cause mortality at ages 30-39 years during 2011-2018 (corresponding to partially overlapping 1978-1983 birth cohorts); and from 1,572 and 1,248 counties in analyses of all-cause and cause-specific mortality in all ages combined, respectively.

RESULTS

In ages 30-39 years, a one percentile increase in the economic mobility gap was associated with a 6.8 % (95 % confidence interval 1.8 %-11.8 %) increase in the Black-White mortality gap among males and a 13.5 % (8.9 %-18.1 %) increase among females, based on data from 471 counties. In all ages combined, the corresponding percentages based on data from 1,572 counties were 10.2 % (7.2 %-13.2 %) among males and 14.8 % (11.4 %-18.2 %) among females, equivalent to an increase of 18.4 and 14.0 deaths per 100,000 in the mortality gap, respectively. Similarly, strong associations between economic mobility gap and mortality gap in all ages were found for major causes of death, notably for potentially preventable conditions, including COPD, injury/violence, and cancers of the lung, liver, and cervix.

CONCLUSIONS

Economic mobility gap conditional on parental income in a recent birth cohort as a marker of ongoing structural racism is strongly associated with Black-White disparities in all-cause mortality and mortality from several causes.

Disparities in Prostate Cancer Survival According to Neighborhood Archetypes, A Population-Based Study

OBJECTIVES

To examine survival among men with prostate cancer according to neighborhood archetypes. As an advancement beyond measures of neighborhood socioeconomic status (nSES) or specific measures of the neighborhood environment, archetypes consider interactions among many social and built environment attributes.

METHODS

Neighborhood archetypes for California census tracts in the year 2000 were previously developed through latent class analysis of 39 measures of social and built environment attributes. We assessed associations between archetypes and overall and prostate cancer-specific survival in this population-based study using geocoded cancer registry data for prostate cancer patients diagnosed 1996-2005 in California, followed through 2017 (n = 185,613). We used Cox proportional hazard models stratified by race/ethnicity and adjusted for age at diagnosis, year of diagnosis, tumor factors, treatment, marital status and cluster effect by census tract. Additional analyses examined associations between race/ethnicity and survival, while accounting for neighborhood archetypes.

RESULTS

We observed disparities in overall and prostate cancer-specific risk of death by neighborhood archetypes. Classes with the highest risk of death were defined by lower nSES, but also other domains such as rural/urban status, racial/ethnic composition or age of residents, commuting and traffic patterns, residential mobility, and food environment. Associations between archetypes and survival varied by race/ethnicity.

CONCLUSION

We observe interactions among several domains of neighborhood social and built environment attributes as demonstrated by the associations between neighborhood archetypes and prostate cancer survival. These results highlight opportunities for multilevel neighborhood interventions to reduce neighborhood disparities in prostate cancer survival.

The legacy of structural racism: Associations between historic redlining, current mortgage lending, and health

Structural racism, which is embedded in past and present operations of the U.S. housing market, is a fundamental cause of racial health inequities. We conducted an ecologic study to 1) examine historic redlining in relation to current neighborhood lending discrimination and three key indicators of societal health (mental health, physical health, and infant mortality rate (IMR)) and 2) investigate sustained lending disinvestment as a determinant of current neighborhood health in one of the most hypersegregated metropolitan areas in the United States, Milwaukee, Wisconsin. We calculated weighted historic redlining scores from the proportion of 1930s Home Owners' Loan Corporation residential security grades contained within 2010 census tract boundaries. We combined two lending indicators from 2018 Home Mortgage Disclosure Act data to capture current neighborhood lending discrimination: low lending occurrence and high cost loans (measured via loan rate spread). Using historic redlining score and current lending discrimination, we created a 4-level hierarchical measure of lending trajectory. In Milwaukee neighborhoods, greater historic redlining was associated with current lending discrimination (OR = 1.73, 95%CI: 1.16, 2.58) and increased prevalence of poor physical health (β = 1.34, 95%CI: 0.40, 2.28) and poor mental health (β = 1.26, 95%CI: 0.51, 2.01). Historic redlining was not associated with neighborhood IMR (β = -0.48, 95%CI: -2.12, 1.15). A graded association was observed between lending trajectory and health: neighborhoods with high sustained disinvestment had worse physical and mental health than neighborhoods with high investment (poor physical health: β = 5.33, 95%CI: 3.05, 7.61; poor mental health: β = 4.32, 95%CI: 2.44, 6.20). IMR was highest in 'disinvested' neighborhoods (β = 5.87, 95%CI: 0.52, 11.22). Our findings illustrate ongoing legacies of government sponsored historic redlining. Structural racism, as manifested in historic and current forms of lending disinvestment, predicts poor health in Milwaukee's hypersegregated neighborhoods. We endorse equity focused policies that dismantle and repair the ways racism is entrenched in America's social fabric.

The legacy of redlining: Associations between historical neighborhood mapping and contemporary tobacco retailer density in Ohio

In the 1930s United States, urban neighborhoods were graded on their desirability for investment (often based on race), a process known as "redlining." This study examined how historical redlining relates to current disparities in an important health determinant: tobacco retailer density. Analyses were conducted for thirteen Ohio cities using negative binomial models that accounted for retailer spatial dependence and controlled for present-day sociodemographic characteristics. Findings indicated that as grades increased from "Best" to "Still Desirable" to "Definitely Declining" and "Hazardous," retailer density increased monotonically. These results highlight the persisting impacts of redlining and how disparities, once intentionally created, can be perpetuated over time.

Incorporating Measures of Structural Racism into Population Studies of Reproductive Health in the United States: A Narrative Review

Purpose: Black women in the United States face poor outcomes across reproductive health measures-from pregnancy outcomes to gynecologic cancers. Racial health inequities are attributable to systemic racism, but few population studies of reproductive health outcomes integrate upstream measures of systemic racism, and those who do are limited to maternal and infant health outcomes. Advances in understanding and intervening on the pathway from racism to reproductive health outcomes are limited by a paucity of methodological guidance toward this end. We aim to fill this gap by identifying quantitative measures of systemic racism that are salient across reproductive health outcomes. Methods: We conducted a review of literature from 2000 to 2019 to identify studies that use quantitative measures of exposure to systemic racism in population reproductive health studies. We analyzed the catalog of literature to identify cohesive domains and measures that integrate data across domains. For each domain, we contextualize its use within population health research, describe metrics currently in use, and present opportunities for their application to reproductive health research. Results: We identified four domains of systemic racism that may affect reproductive health outcomes: (1) civil rights laws and legal racial discrimination, (2) residential segregation and housing discrimination, (3) police violence, and (4) mass incarceration. Multiple quantitative measures are available for each domain. In addition, a multidimensional measure exists and additional domains of systemic racism are salient for future development into distinct measures. Conclusion: There are quantitative measures of systemic racism available for incorporation into population studies of reproductive health that investigate hypotheses, including and beyond those related to maternal and infant health. There are also promising areas for future measure development, such as the child welfare system and intersectionality. Incorporating such measures is critical for appropriate assessment of and intervention in racial inequities in reproductive health outcomes.

All-cause mortality and three aspects of social relationships: an eight-year follow-up of older adults from one entire Korean village

Various aspects of social relationships have been examined as risk factors for mortality. In particular, most research has focused on either loneliness or social disengagement. We aimed to extend the current research by adding a group-level segregation measure utilizing the whole social network of one entire village in South Korea. The analyses were based on the Korean Social Life, Health and Aging Project data collected over eight years across five waves. Of the 679 old adults who participated throughout the entire project (to wave 5), 63 were confirmed as deceased. All three aspects of social relationships examined, loneliness, social disengagement, and group-level segregation, were associated with mortality in the traditional Cox proportional hazard model without considering health-related time-varying covariates. However, a Cox marginal structural model, a counterfactual statistical measure that is designed to control for censoring bias due to sample attrition over the eight years and time-varying confounding variables, revealed that only group-level segregation was associated with mortality. Our results strongly suggest that more attention is needed on group-level segregation for mortality studies, as well as on well-known individual-level risk factors, including social disengagement and loneliness. All methods were carried out in accordance with relevant guidelines and regulations.

Structural violence: A concept analysis to inform nursing science and practice

This analysis is meant to elucidate the concept of structural violence and its implications for nursing science and practice. The concept of structural violence, also known as indirect violence, was first identified in the literature by peace researcher Johan Galtung. According to Galtung, structural violence broadly represents harm done to persons and groups through inequitable social, political, or economic structures. Such inequitable structures, such as systemic discrimination based on race, ethnicity, religion, gender, sexual orientation, etc. create conditions within society that directly disadvantage and oppress members of certain groups. This oppression can inflict profound physical, psychological, and socioeconomic harm on individuals, leading to disparate health outcomes. Using techniques for developing conceptual meaning as outlined in Chinn and Kramer (2018), our analysis seeks to specify meanings and applications of structural violence for application to nursing. This analysis draws on literature from clinical, historical, and other social sciences. Databases including CINAHL, PubMed, JSTOR, and PsychInfo were explored for references to structural violence. Structural violence is readily identified in specific contexts where individuals or groups are disadvantaged by socially constructed systems, such as those of race, gender, and economic privilege. Structural violence can result in health disparities and the development of conditions that predispose individuals to health risks. Nurses must be familiar with the concept to address these issues with patients.

The impact of racial residential segregation on prostate cancer diagnosis and treatment

OBJECTIVES

To examine the effects of racial residential segregation and structural racism on the diagnosis, treatment, and outcomes of patients with prostate cancer.

PATIENTS AND METHODS

This retrospective cohort study examined men diagnosed with prostate cancer between 2005 and 2015. We collected data from Black and White men, aged ≥30 years, living within the 100 most populous counties participating in the Surveillance, Epidemiology, and End Results programme, a nationally representative dataset. The racial Index of Dissimilarity, a validated measure of segregation, was the primary exposure of interest. Outcomes of interest included advanced stage at diagnosis (Stage IV), surgery for localised disease (Stage I-II), and 10-year overall and cancer-specific survival. Multivariable Poisson regression analyses with robust error variance estimated the relative risk (RR) of advanced stage at diagnosis and surgery for localised disease at differing levels of segregation. Survival analysis was performed using competing hazards analysis.

RESULTS

Multivariable models estimating stage at diagnosis showed that the disparities between Black and White men disappeared at low levels of segregation. Disparities in receiving surgery for localised disease persisted across all levels of segregation. In racially stratified analyses, segregation had no effect on stage at diagnosis or surgical resection for Black patients. White patients saw a 56% (RR 0.42, P < 0.001) reduced risk of presenting at advanced stage and 20% increased likelihood (RR 1.20, P < 0.001) of surgery for localised disease. Black patients in the lowest segregation areas had the lowest overall mortality, but the highest cancer-specific mortality.

CONCLUSIONS

Our study provides evidence that residential segregation has a significant impact on Black-White disparities in prostate cancer, likely through improved outcomes for White patients and worse outcomes for Black patients in more segregated areas. These findings suggest that mitigating segregation and the downstream effects of socioeconomic factors could alleviate these disparities.

The Impact of Residential Segregation on Pancreatic Cancer Diagnosis, Treatment, and Mortality

BACKGROUND

Disparities in pancreatic cancer outcomes between black and white patients are well documented. This study aimed to use a more novel index to examine the impact of racial segregation on the diagnosis, management, and outcomes of pancreatic cancer in black patients compared with white patients.

METHODS

Black and white adults with pancreatic cancer in urban counties were identified using data from the 2018 submission of the Surveillance, Epidemiology and End Results (SEER) Program and the 2010 Census. The racial index of dissimilarity (IoD), a validated proxy of racial segregation, was used to assess the evenness with which whites and blacks are distributed across census tracts in each county. Multivariate Poisson regression was performed, and stepwise models were constructed for each of the outcomes. Overall survival was studied using the Kaplan-Meier method.

RESULTS

The study enrolled 60,172 adults with a diagnosis of pancreatic cancer between 2005 and 2015. Overall, the black patients (13.8% of the cohort) lived in more segregated areas (IoD, 0.67 vs 0.61; p < 0.05). They were less likely to undergo surgery for localized disease (relative risk [RR], 0.80; 95% confidence interval [CI], 0.76-0.83) and more frequently had a diagnosis of advanced-stage disease (RR, 1.09; 95% CI, 1.01-1.19) with increasing segregation. They also had shorter survival times (9.8 vs 11.4 months; p < 0.05).

CONCLUSIONS

Disparities in advanced-stage disease at diagnosis, surgery for localized disease, and overall survival are directly related to the degree of residential segregation, a proxy for structural racism. In searching for solutions to this problem, it is important to account for the historical marginalization of black Americans.

Air Pollution across the Cancer Continuum: Extending Our Understanding of the Relationship between Environmental Exposures and Cancer

Previous studies of the environment and cancer have focused on etiology, showing that extrinsic factors in the environment contribute to 70% to 90% of cancers. Cancer patients and survivors often continue to live in the same neighborhoods they resided in before their cancer diagnosis. Thus, patients and survivors are exposed to the same environmental contexts that likely contributed to their original cancer, but little is known about the health effects of continued exposure to carcinogens after a cancer diagnosis. This commentary provides a summary of studies of the association between PM_2.5 and cancer mortality among patients and PM_2.5 and posttreatment morbidity among cancer survivors, and proposes new directions and opportunities for future research on such topics.See all articles in this CEBP Focus section, "Environmental Carcinogenesis: Pathways to Prevention."

Social determinants of colorectal cancer risk, stage, and survival: a systematic review

BACKGROUND

Several social determinants of health have been examined in relation to colorectal cancer incidence, stage at diagnosis, and survival including income, education, neighborhood disadvantage, immigration status, social support, and social network. Colorectal cancer incidence rates are positively associated with income and other measures of socioeconomic status. In contrast, low socioeconomic status tends to be associated with poorer survival.

METHODS

The present review is based upon bibliographic searches in PubMed and CINAHL and relevant search terms. Articles published in English from 1970 through April 1, 2019 were identified using the following MeSH search terms and Boolean algebra commands: colorectal cancer AND (incidence OR stage OR mortality) AND (social determinants OR neighborhood disadvantage OR racial discrimination OR immigration OR social support).

RESULTS

This review indicates that poverty, lack of education, immigration status, lack of social support, and social isolation play important roles in colorectal cancer stage at diagnosis and survival.

CONCLUSIONS

To address social determinants of colorectal cancer, effective interventions are needed that account for the social contexts in which patients live.

Use of empiric methods to inform prostate cancer health disparities: Comparison of neighborhood-wide association study "hits" in black and white men

BACKGROUND

Black men are more likely to die of prostate cancer (PCa) compared with white men. Factors ranging from genetics to neighborhood environment contribute to these disparities. However, unlike genetics, agnostic investigations that identify candidate variables from large-scale data, and that allow for empiric investigations into differential associations between neighborhood and PCa by race/ethnicity, to the authors' knowledge have not been well explored. Thus, herein, the authors built on their previously developed, empiric neighborhood-wide association study (NWAS) in white men and conducted a NWAS in black men to determine whether findings differed by race.

METHODS

Pennsylvania Cancer Registry data were linked to US Census data. For the NWAS in non-Hispanic black men, the authors evaluated the association between 14,663 neighborhood census variables and advanced PCa (11 high-stage and/or high-grade cases and 8632 low-stage and/or low-grade cases), adjusting for age, diagnosis year, spatial correlation, and multiple testing. Odds ratios and 95% credible intervals were reported. Replication of NWAS findings across black and white races was assessed using Bayesian mixed effects models.

RESULTS

Five variables related to housing (3 variables), education (1 variable), and employment and/or transportation (1 variable) were found to be significantly associated with advanced PCa in black men compared with 17 socioeconomic variables (mostly related to poverty and/or income) in white men. The top hit in black men was related to crowding in renter-occupied housing (odds ratio, 1.10; 95% credible interval, 1.001-1.12). Nine of 22 NWAS hits (4 of 5 hits in black men) were replicated across racial/ethnic groups.

CONCLUSIONS

Different neighborhood variables, or "candidates," were identified across race-specific NWASs. These findings and empiric approaches warrant additional study and may inform PCa racial disparities, particularly future gene-environment studies aimed at identifying patients and/or communities at risk of advanced PCa.

Do neighborhood characteristics contribute beyond individual demographics to cancer control behaviors among African American adults?

BACKGROUND

Recent years have seen increased interest in the role of neighborhood factors in chronic diseases such as cancers. Less is known about the role of neighborhood factors beyond individual demographics such as age or education. It is particularly important to examine neighborhood effects on health among African American men and women, considering the disproportionate impact of cancer on this group. This study evaluated the unique contribution of neighborhood characteristics (e.g., racial/ethnic diversity, income) beyond individual demographics, to cancer control behaviors in African American men and women.

METHODS

Individual-level data were drawn from a national survey (N = 2,222). Participants' home addresses were geocoded and merged with neighborhood data from the American Community Survey. Multi-level regressions examined the unique contribution of neighborhood characteristics beyond individual demographics, to a variety of cancer risk, prevention, and screening behaviors.

RESULTS

Neighborhood racial/ethnic diversity, median income, and percentage of home ownership made modest significant contributions beyond individual factors, in particular to smoking status where these factors were associated with lower likelihood of smoking (ps < .05). Men living in neighborhoods with older residents, and greater income and home ownership were significantly more likely to report prostate specific antigen testing (ps < .05). Regional analyses suggested different neighborhood factors were associated with smoking status depending on the region.

CONCLUSION

Findings provide a more nuanced understanding of the interplay of social determinants of health and neighborhood social environment among African American men and women, with implications for cancer control interventions to eliminate cancer disparities.

Racial disparities of liver cancer mortality in Wisconsin

PURPOSE

To calculate tract-level estimates of liver cancer mortality in Wisconsin and identify relationships with racial and socioeconomic variables.

METHODS

County-level standardized mortality ratios (SMRs) of liver cancer in Wisconsin were calculated using traditional indirect adjustment methods for cases from 2003 to 2012. Tract-level SMRs were calculated using adaptive spatial filtering (ASF). The tract-level SMRs were checked for correlations to a socioeconomic advantage index (SEA) and percent racial composition. Non-spatial and spatial regression analyses with tract-level SMR as the outcome were conducted.

RESULTS

County-level SMR estimates were shown to mask much of the variance within counties across their tracts. Liver cancer mortality was strongly correlated with the percent of Black residents in a census tract and moderately associated with SEA. In the multivariate spatially-adjusted regression analysis, only Percent Black composition remained significantly associated with an increased liver cancer SMR.

CONCLUSIONS

Using ASF, we developed a high-resolution map of liver cancer mortality in Wisconsin. This map provided details on the distribution of liver cancer that were inaccessible in the county-level map. These tract-level estimates were associated with several racial and socioeconomic variables.

Housing discrimination and racial cancer disparities among the 100 largest US metropolitan areas

BACKGROUND

Cancer contributes substantially to the life expectancy gap between US blacks and whites, and racial cancer disparities remain stubborn to eradicate. Disparities vary geographically, suggesting that they are not inevitable.

METHODS

The authors examined the relationship between housing discrimination and the size of cancer disparities across large US metropolitan statistical areas (MSAs). MSA-level cancer disparities were measured using data from the US Centers for Disease Control and Prevention. Mortgage discrimination for each MSA was estimated using the Home Mortgage Disclosure Act database, and MSA racial segregation was determined using US Census data. Patterns of housing discrimination and cancer disparities were mapped, and the associations between these place-based factors and cancer disparities across MSAs were measured.

RESULTS

Black-to-white cancer mortality disparities (rate ratios) varied geographically, ranging from 1.50 to 0.86; 88% of mortality ratios were >1, indicating higher mortality for blacks. In areas with greater mortgage discrimination, the gap between black and white cancer mortality rates was larger (correlation coefficient [r] = 0.32; P = .001). This relationship persisted in sex-specific analyses (males, r = 0.37; P < .001; females, r = 0.23; P = .02) and in models controlling for confounders. In contrast, segregation was inconsistently associated with disparities. Adjusting for incidence disparities attenuated, but did not eliminate, the correlation between mortgage discrimination and mortality disparities (r = 0.22-0.24), suggesting that cancer incidence and survival each account for part of the mortality disparity.

CONCLUSIONS

Mortgage discrimination is associated with larger black-to-white cancer mortality disparities. Some areas are exceptions to this trend. Examination of these exceptions and of policies related to housing discrimination may offer novel strategies for explaining and eliminating cancer disparities.

Racially-motivated housing discrimination experienced by Indigenous postsecondary students in Canada: impacts on PTSD symptomology and perceptions of university stress

OBJECTIVES

To examine the impacts of housing discrimination experienced by Indigenous postsecondary students on post-traumatic stress disorder (PTSD) symptomology and perceptions of university stress.

STUDY DESIGN

Cross-sectional study.

METHODS

Data were gathered via in-person surveys completed by 142 Indigenous students between 2015 and 2017. Associations were analyzed using phi coefficients and linear regression models adjusted for confounders. Qualitative data were examined using thematic analyses.

RESULTS

Indigenous students who had children (almost 50% of the sample), were living with a romantic partner, and/or were between the ages of 25-44 years experienced significantly more racially-motivated housing discrimination than other Indigenous students in the sample. The frequency of housing discrimination in the past 12 months was significantly associated with increased PTSD symptoms; particularly, intrusive recollection and more perceived stress at university in linear regression models adjusted for confounders. Every 1-point increase in the frequency of housing discrimination on a 4-point scale resulted in a 5.4-point increase in PTSD score. Although living with a romantic partner resulted in more housing discrimination, it also served as a resilience factor, buffering the impact of housing discrimination on PTSD symptomology. Qualitative data indicated students faced Racially-motivated housing discrimination that was blunt and deliberate and highlighted the resourceful ways students sought to resist it.

CONCLUSIONS

Racially-motivated housing discrimination exacerbated PTSD symptomology among Indigenous students and adversely impacted perceptions of their university experience. Efforts are needed to address housing discrimination directly, as well as provide greater family-focused housing and mental wellness supports to Indigenous students to reduce potential impacts of this public health problem on postsecondary success and degree completion.

The legacy of redlining in the effect of foreclosures on Detroit residents' self-rated health

Historical practices, such as housing discrimination in Detroit, have been shown to have lasting impacts on communities. Perhaps the most explicit example is the practice of redlining in the 1930s, whereby lenders outlined financially undesirable neighborhoods, populated by minority families, on maps and prevented residents from moving to better resourced neighborhoods. Awareness of historical housing discrimination may improve research assessing the impacts of current neighborhood characteristics on health. Using the Detroit Neighborhood Health Study (DNHS), we assessed the association between two-year changes in home foreclosure rates following the 2007-2008 Great Recession, and residents' five-year self-rated health trajectories (2008-2013); and estimated the confounding bias introduced by ignoring historical redlining practices in the city. We used both ecological and multilevel models to make inference about person- and community-level processes. In a neighborhood-level linear regression adjusted for confounders (including percent redlined); a 10%-point slower foreclosure rate recovery was associated with an increase in prevalence of poor self-rated health of 0.31 (95% CI:-0.02 to 0.64). At the individual level, it was associated with a within-person increase in probability of poor health of 0.45 (95% CI:0.15-0.72). Removing redlining from the model biased the estimated effect upward to 0.38 (95% CI:0.07-0.69) and 0.56 (95% CI:0.21-0.84) in the neighborhood and individual-level models, respectively. Stratum-specific foreclosure recovery effects indicate stronger influence in neighborhoods with a greater proportion of residents identifying as white and a greater degree of historic redlining. These findings support earlier theory suggesting a historical influence of structural discrimination on the association between current neighborhood characteristics and health, and suggests that historical redlining specifically may increase vulnerability to contemporary neighborhood foreclosures. Community interventions should consider historical discrimination in conjunction with current place-based indicators to more equitably improve population health.

Housing Discrimination and Health: Understanding Potential Linking Pathways Using a Mixed-Methods Approach

Few studies have examined the impact of housing discrimination on health. This study explores potential pathways linking housing discrimination and health using concept mapping, a mixed-method approach. Participants included employees from twenty Fair Housing Organizations nationwide who participated in two online sessions, brainstorming, and structuring. Responses were generated representing biological, social, economic, and physical connections between housing discrimination and health. Using hierarchical cluster analysis, five clusters were identified: (1) Access and barriers; (2) Opportunities for growth; (3) Neighborhood and communities; (4) Physical effects of housing discrimination; and (5) Mental health. Clusters 1 (4.09) and 2 (4.08) were rated as most important for health, while clusters 2 (3.93) and 3 (3.90) were rated as most frequently occurring. These findings add to the limited evidence connecting housing discrimination to health and highlight the need for studies focusing on the long-term health effects of housing discrimination on individuals and neighborhoods.

Ethnic density and cancer: A review of the evidence

Accumulating data suggest that factors in the social environment may be associated with cancer-related outcomes. Ethnic density, defined as the proportion of racial/ethnic minority individuals residing in a given geographic area, is 1 of the most frequently studied social environment factors, but studies on ethnic density and cancer have yielded inconsistent findings. Thus, the objective of the current review was to summarize the extant data on ethnic density and cancer-related outcomes (cancer risk, stage at diagnosis, and mortality) with the aim of identifying pathways by which ethnic density may contribute to outcomes across populations. In general, the findings indicated an association between ethnic density and increased risk for cancers of infectious origin (eg, liver, cervical) but lower risk for breast and colorectal cancers, particularly among Hispanic and Asian Americans. Hispanic ethnic density was associated with greater odds of late-stage cancer diagnosis, whereas black ethnic density was associated with greater mortality. In addition, this review highlights several methodological and conceptual issues surrounding the measurement of ethnic neighborhoods and their available resources. Clarifying the role of neighborhood ethnic density is critical to developing a greater understanding of the health risks and benefits accompanying these environments and how they may affect racial and ethnic disparities in cancer-related outcomes. Cancer 2018;124:1877-903. © 2018 American Cancer Society.

Geospatial approaches to cancer control and population sciences at the United States cancer centers

PURPOSE

Geospatial, contextual, and multilevel research is integral to cancer prevention and control. NCI-designated Cancer Centers are at the forefront of cancer research; therefore, this paper sought to review the geospatial, contextual, and multilevel research at these cancer centers.

METHODS

Investigators used PubMed and Web of Science to compile geospatial publications from 1971 to February 2016 with cancer center-affiliated authors. Relevant abstracts were pulled and classified by six geospatial approaches, eight geospatial scales, and eight cancer sites.

RESULTS

The searches identified 802 geospatial, contextual, and multilevel publications with authors affiliated at 60 of the 68 NCI-designated Cancer Centers. Over 90% were published after 2000. Five cancer centers accounted for approximately 50% of total publications, and 30 cancer centers accounted for over 85% of total publications. Publications covered all geospatial approaches and scales to varying degrees, and 90% dealt with cancer.

CONCLUSIONS

The NCI-designated Cancer Center network is increasingly pursuing geospatial, contextual, and multilevel cancer research, although many cancer centers still conduct limited to no research in this area. Expanding geospatial efforts to research programs across all cancer centers will further enrich cancer prevention and control. Similar reviews may benefit other domestic and international cancer research institutions.