Systemic And Structural Racism: Definitions, Examples, Health Damages, And Approaches To Dismantling

Influence of structural racism on cancer health disparities: Tailoring measures relevant to multiple myeloma

This commentary highlights a need for comprehensive measures of structural racism tailored to cancer health disparities, in particular Black-White disparities in multiple myeloma (MM). Recent political and social calls and advances in the ability to quantitate structural racism have led to rapidly growing research on the health consequences of structural racism. However, to date, most studies have used unidimensional measures of structural racism that do not capture cumulative influences or enable the identification of factors most responsible for driving disparities. Furthermore, measures may not reflect aspects of structural racism most relevant to underlying disease processes and risks. This study proposes a multifaceted approach to measuring structural racism relevant to MM that includes comprehensive, disease- and at-risk population-tailored social and environmental data and biomarkers of susceptibility and progression related to underlying biological changes associated with structural racism. Such novel measures of structural racism may improve the ability to assess the influence of structural racism on cancer health disparities, which may advance understanding of disease etiology and differences observed by racialized groups.

Association Between Changes in Racial Residential Segregation and Trends in Racial Disparities in Early Mortality in 220 Metropolitan Areas, 2001-2018

INTRODUCTION

Racial residential segregation has been shown to affect the absolute levels of racial disparities in a wide variety of health outcomes in the USA but it is not known whether changes in segregation also influence these racial health disparities. This study examines the relationship between changes in racial residential segregation over four decades (1980-2020) and trends in racial disparities in early mortality (under age 65) rates among non-Hispanic Black and non-Hispanic White persons across a wide range of health outcomes in 220 metropolitan statistical areas (MSAs) during the period 2001-2018.

METHODS

Using the CDC WONDER Underlying Cause of Death database, we derived annual estimates of race-specific death rates and rate ratios for each MSA. We used latent trajectory analysis to examine the relationship between the level of segregation and changes in segregation over time in an MSA and trends in death rate disparities in that MSA.

RESULTS

The trajectory analysis resulted in a linear, three group model in which trajectory Groups 1 and 2 had decreasing trends in the ratios of Black to White death rates over time while in Group 3, the disparity remained almost constant over time. Increases in the level of segregation in an MSA from 1980 to 2000 were significantly associated with the likelihood that the MSA was in Group 3 and experienced no improvement in racial health disparities in mortality over time.

CONCLUSION

This paper provides new evidence that changes in segregation are related to trends in racial health disparities in mortality rates over time.

How do Students' Science, Social, and Personal Identities Influence their Experiences in Undergraduate Field Biology Courses?

Field biology courses can be formative learning experiences that develop students' science identities. Yet, they can also pose challenges to students that may disaffirm their science identities-especially to those who identify with underrepresented, excluded, and minoritized groups. It is largely unknown how students' social (e.g., gender) and personal (e.g., where they grew up) identities intersect with their science identities in field biology courses. Therefore, we used the Expanded Model of Science Identity to determine: 1) the factors that influence students' science, social, and personal identities; and 2) whether and how these identities intersect in field biology courses. Using a card sorting task during semistructured interviews, we found variation in science identities with which students identified, mediated by social factors (e.g., social comparison). These social factors influenced how students' social and personal identities intersected with their science identities. Intersections between students' social and science identities were also facilitated by structural factors (e.g., privilege, lack of representation) that perpetuate inequities in field biology. Based on our findings, we offer suggestions to support welcoming, equitable, and inclusive field biology education that nurtures the science identities of all students.

The need for critical and intersectional approaches to equity efforts in postgraduate medical education: A critical narrative review

BACKGROUND

Racialised trainees in Canada and the USA continue to disproportionately experience discrimination and harassment in learning environments despite equity, diversity, and inclusion (EDI) reform efforts. Using critical approaches to understand what problems have been conceptualised and operationalised as EDI issues within postgraduate medical education (PGME) is important to inform ongoing learning environment reform in resident training.

METHODS

We conducted a critical narrative review of EDI literature from 2009-2022 using critical race theory (CRT) and the concept of intersectionality to analyse how issues of discrimination in PGME have been studied. Our search yielded 2244 articles that were narrowed down to 349 articles for relevance to Canadian and American PGME contexts. We attended to reflexivity and our positionality in analysing the database and identifying themes related to EDI reform.

RESULTS

Interest convergence was noted in how EDI reform was rationalised primarily by increased productivity. Problems of learner representation, gender inequities and curricular problems were conceptualised as EDI issues. The role that racism played in EDI-related problems was largely invisible, as were explicit conceptualisations of race and gender as social constructs. Overall, there was a lack of critical or intersectional approaches in the literature reviewed. Misalignment was noted where studies would frame a problem through a critical lens, but then study the problem without attention to power.

DISCUSSION

Interest convergence and epistemic injustice can account for the absence of critical approaches due to the alignment of existing EDI work with institutional interests and priorities. Interest convergence conceptually limits existing EDI reform efforts in PGME. CRT and intersectionality connect racialised learner experiences to systemic phenomena like racism and other forms of discrimination to challenge dominant assumptions. Because they attend to power, critical approaches are key to understanding why inequities have persisted to advance equity in learning environments for racialised and intersectionally marginalised learners.

Addressing Mental Health and Social Needs in Tandem to Promote Health Equity

Compelling evidence shows that social risks and mental health are intertwined. Pediatric clinicians can maximize the effectiveness of interventions that address mental health concerns by incorporating social risks and social needs screening and interventions. Approaches that elevate the interconnectedness of social risks and mental health require (a) an understanding of the multi-level contextual factors that contribute to patient and family functioning; and (b) a culturally responsive and multidisciplinary clinical practice that targets contextual factors. Supporting families to see the value of concurrently addressing social and mental health needs may be an important step to amplify clinical practice changes.

Indigenous Cultural Identity Protects Against Intergenerational Transmission of ACEs Among Indigenous Caregivers and Their Children

A large body of empirical research has demonstrated that caregiver adverse childhood experiences (ACEs) predict ACEs in one's child, a phenomenon known as the intergenerational transmission of ACEs. Little of this empirical research, however, has focused specifically on Indigenous peoples despite a growing body of theoretical literature and the wisdom of Elders and Traditional Knowledge Keepers that speaks to the presence of this phenomenon within Indigenous communities as well as the protective role of Indigenous cultural identity in preventing the intergenerational transmission of ACEs. The purpose of the current study was to conduct an empirical evaluation of this hypothesis, specifically that Indigenous cultural identity and social support protects against the intergenerational transmission of ACEs among Indigenous peoples and their children in the USA. Participants were 106 Indigenous women caregivers of children ages 10 to 14 in South Dakota who completed surveys. Results showed that Indigenous cultural identity moderated the association between caregiver ACEs and child ACEs. At high levels of cultural identity, there was no association between caregiver ACEs and child ACEs. At low levels of Indigenous cultural identity, however, there was a strong and positive relationship between caregiver ACEs and child ACEs. Social support did not moderate the association between caregiver ACEs and child ACEs. These findings underscore the need for initiatives that enhance Indigenous cultural identity and social support among Indigenous caregivers to prevent the intergenerational transmission of ACEs.

Call to Action: Integrating Anti-racist Philosophies in Dismantling Racism and Anti-Black Racism in Nursing Education in Canada

Despite nursing's stated mandate of health equity and social justice, concrete steps to address racism and anti-Black racism in the profession and nursing education remain mainly non-significant and are often seen as performative. It is crucial to implement tangible measures to dismantle racism and anti-Black racism in nursing education to address racial health disparities. Throughout history, nursing education has been shaped by colonial and Eurocentric ideologies, leading to the silencing and erasure of the knowledge, culture, perspectives, and ways of knowing of Black and other racialized communities. Consequently, urgent action is required to dismantle embedded racism and anti-Black racism in the nursing profession. Drawing on anti-racist philosophies, we argue that dismantling racism in nursing education goes beyond superficial discussions of equity, diversity, and inclusion. Instead, it demands a proactive approach to tackle the underlying causes of racial inequities. In this article, we propose several recommendations and implications for nursing educators, researchers, policymakers, and educational institutions to eliminate racism and anti-Black racism in both nursing education and practice. These recommendations include acknowledging the historical and contemporary impacts of racism and anti-Black racism on the health and well-being of Black individuals, engaging in critical self-reflexivity, integrating and prioritizing Black knowledge and perspectives in nursing education, practice, and research, and intentionally adopting anti-racist pedagogy.

Race, Neighborhood Disadvantage, and Prehospital Law Enforcement Handcuffing in Children With Behavioral Health Emergencies

Importance

Minoritized youth and children in resource-limited neighborhoods rely on emergency medical services (EMS) for accessing care, including during behavioral health emergencies (BHEs). Law enforcement (LE) officers sometimes use forceful tactics in such settings. Assessing LE actions is needed to ensure safe and equitable care for vulnerable populations.

Objective

To examine whether race and ethnicity, neighborhood disadvantage, sex, and age are associated with LE handcuffing during pediatric BHEs.

Design, Setting, and Participants

This cross-sectional study analyzed LE handcuffing, demographic factors, and neighborhood disadvantage in Alameda County, California. The study population included children younger than 18 years who were evaluated by EMS for BHEs between January 1, 2012, and June 30, 2019. Data analysis was completed between January 1, 2022, and August 30, 2023.

Exposures

Primary exposures included race and ethnicity and Area Deprivation Index (ADI) rank as ADI I (1-3 [lowest]), ADI II (4-6 [moderate]), and ADI III (7-10 [highest]).

Main Outcome and Measure

The primary outcome was LE handcuffing during BHEs. The study calculated handcuffing proportions stratified by race and ethnicity, ADI, and sex.

Results

The final dataset consisted of 6759 pediatric BHE encounters with complete data. Among these, 3864 encounters (57.2%) were with females. The median age was 14.9 (IQR, 13.4-16.2) years. Overall, LE handcuffing occurred in 517 encounters (7.6%); Black children had higher odds than their White peers (adjusted odds ratio [AOR], 1.80; 95% CI, 1.39-2.33). Compared with low neighborhood disadvantage, moderate neighborhood disadvantage was independently associated with increased odds of handcuffing (ADI II: AOR, 1.51; 95% CI, 1.21-1.88), as was highest neighborhood disadvantage (ADI III: AOR, 1.54; 95% CI, 1.19-1.99). Male sex (AOR, 2.31; 95% CI, 1.91-2.79) and age (AOR per 1-year increase, 1.15; 95% CI, 1.10-1.21) were also associated with increased odds of handcuffing. In moderately disadvantaged neighborhoods, the odds were higher for Black children (AOR, 2.52; 95% CI, 1.65-3.86). When stratified by sex, the odds of handcuffing were significantly higher for Black females compared with White females (AOR, 2.59; 95% CI, 1.69-3.98).

Conclusions and Relevance

The findings of this cross-sectional study suggest that accessing EMS for BHEs may expose Black children and youth in disadvantaged neighborhoods to LE use of handcuffing. Emergency medical services should reconsider the role of LE officers in these settings.

Racism and health and wellbeing among children and youth-An updated systematic review and meta-analysis

BACKGROUND

Evidence of racism's health harms among children and youth is rapidly increasing, though attention to impacts on physical health and biomarker outcomes is more emergent. We performed a systematic review of recent publications to examine the association between racism and health among children and youth, with a meta-analysis of the specific relationships between racism and physical health and biomarkers.

METHODS

We conducted a systematic literature search using four databases: Medline, PsycINFO, PubMed, and ERIC. Four inclusion criteria were used to identify eligible studies: (1) exposure was experiences of racism, (2) outcome was health and wellbeing, (3) quantitative methods were used to estimate the association between racism and health outcomes, and (4) the effect size of associations between racism and health and wellbeing was reported for participants aged 0-24 years. Correlation coefficients were used to report the pooled effect size for each outcome indicator.

RESULTS

There were 463 eligible studies included in the screening process, with 42 studies focusing on physical health or biomarker outcomes. Random-effects meta-analysis found minimal to moderate positive associations between racism and C-reactive protein, Interleukin 6, body mass index (BMI), obesity, systolic blood pressure, salivary cortisol, asthma, and somatic symptoms. There were marginal positive associations between racism and Tumour Necrosis Factor-α, cortisol collected via saliva, urine and hair, BMI-z score, and diastolic blood pressure, with imprecise estimates and wide confidence intervals.

CONCLUSIONS

Racism is associated with negative physical health and biomarker outcomes that relate to multiple physiological systems and biological processes in childhood and adolescence. This has implications for health and wellbeing during childhood and adolescence and future chronic disease risk. Collective and structural changes to eliminate racism and create a healthy and equitable future for all children and youth are urgently required.

Asking difficult questions about fetal alcohol spectrum disorder in the context of the child, the mother, and the systems in which they live

Alcohol is a known teratogen and prenatal alcohol exposure remains a major ongoing public health concern. Fetal alcohol spectrum disorder has become the diagnosis for describing individuals who have been affected by prenatal alcohol exposure. In this Viewpoint, we raise major concerns about its continued use as a diagnostic term in how it perpetuates a misleading and outdated narrative about child development and maternal health. We argue that the term fetal alcohol spectrum disorder has contributed to a culture of racism and discrimination for many who are diagnosed with it. The term fetal alcohol spectrum disorder fails to capture the progress made in our collective understanding of neurodevelopment through advancements in the field of genetics and in understanding the effects of trauma and adversity. We call for urgent international collaborative action to review the use of it as a diagnostic term and, more broadly, to reconsider the practice of diagnosing disabilities as medical illnesses. We suggest that this practice fails to recognise that outcomes of functioning and participation in individuals are not only the results of health conditions, but are also the products of complex interactions and experiences of individuals within the families and societies in which they live.

Multidimensional structural racism and estimated cancer risk from traffic-related air pollution

BACKGROUND

Traffic-related air pollutants have been associated with a variety of adverse human health impacts, including cancers. In the United States, numerous studies have documented racial inequities in neighborhood exposures to traffic-related air pollution. Emerging evidence suggests that structural racism may influence neighborhood exposures to air pollutants. However, existing research has largely focused on residential racial segregation, one indicator of structural racism. This study developed a multidimensional measure of structural racism to examine the relationship between structural racism and estimated cancer risk from air pollutants in Georgia.

METHODS

Carcinogenic air toxics data were obtained from the US Environmental Protection Agency's 2019 Air Toxics Screening Assessment and sociodemographic data from the American Community Survey. Guided by stakeholder input, county-level data on residential segregation, education, employment, incarceration, economic status, political participation, and homeownership were used to create a multidimensional county-level structural racism index. Relative risks (RRs) were estimated for associations between structural racism and elevated (top 10% in Georgia) estimated cancer risk from air toxics.

RESULTS

Multilevel analyses revealed a significant association between multidimensional structural racism and exposure to carcinogenic traffic-related air pollutants. Neighborhoods in the highest quartile of structural racism exhibited an elevated cancer risk from traffic-related air pollutants (RR, 7.84; 95% CI, 5.11-12.05) compared to neighborhoods with lower levels of structural racism.

CONCLUSIONS

Multidimensional structural racism was associated with estimated cancer risk from traffic-related air pollution in Georgia. Findings can inform future studies and policy interventions that address racial inequalities in exposure to traffic-related air pollution.

Association Between Neighborhood Deprivation in Early Pregnancy and Gestational Diabetes Mellitus

OBJECTIVE

To evaluate whether having a pregnancy in a deprived neighborhood was associated with an increased risk of gestational diabetes mellitus (GDM) compared with having a pregnancy in the least-deprived neighborhoods.

METHODS

This was a retrospective observational cohort study of pregnant individuals within Kaiser Permanente Northern California from 2011 to 2018 with residential history from prepregnancy through 24 weeks of gestation and clinical data from prepregnancy through delivery. The primary outcome was a diagnosis of GDM. Neighborhood deprivation was characterized with an index aggregating multiple indicators of Census tract-level sociodemographic information. Mediation analysis using inverse odds ratio weighting estimated the mediation effects of prepregnancy body mass index (BMI), gestational weight gain, smoking tobacco, and illegal drug use before GDM diagnosis.

RESULTS

Overall, 214,375 pregnant individuals were included, and 11.3% had a diagnosis of GDM. Gestational diabetes prevalence increased with neighborhood deprivation from 10.0% in the lowest Neighborhood Deprivation Index quintile to 12.7% in the highest quintile. Compared with pregnant individuals in the least deprived neighborhoods (quintile 1), pregnant individuals in quintiles 2-5 had elevated risk of GDM (relative risk [95% CI]) when adjusted for maternal age, parity, insurance type, and residential history (quintile 2, 1.17 [1.10-1.23]; quintile 3, 1.38 [1.30-1.46]; quintile 4, 1.54 [1.45-1.63]; quintile 5, 1.71 [1.62-1.82]). There was a dose-response relationship between relative risk of GDM and increasing quintile of neighborhood deprivation ( P for trend <.001). Prepregnancy BMI mediated 45.8% (95% CI, 40.9-50.7%) of the association. Other potential mediators were found to mediate a small if not negligible proportion of this association (2.4-3.6%).

CONCLUSION

Neighborhood deprivation was associated with GDM, and a considerable proportion of this relationship was mediated by prepregnancy BMI.

Original Research: Exploring Black Nurses' Perceptions of Workplace Safety and Personal Health

PURPOSE

This study aimed to assess the perceptions of nurses who self-identify as Black or African American regarding their workplace health and safety and to explore how these perceptions are associated with their perceived personal health.

BACKGROUND

Nurses practicing in unhealthy work environments can experience poorer physical and mental health. Recent civil unrest and ongoing dialogue about structural and systemic racism have prompted calls for greater efforts to understand the workplace perceptions and experiences of ethnic minority nurses, and how these influence nurses' personal well-being. But there is a dearth of relevant evidence concerning these nurses, including Black nurses.

METHODS

This cross-sectional, descriptive study involved analysis of secondary data collected from May 1, 2017, through December 31, 2019, by the American Nurses Association's HealthyNurse Survey (N = 19,131). We employed descriptive, bivariate, and multivariate analyses to examine the data for the 1,143 respondents who both self-identified as Black or African American and responded to all items concerning the major variable of personal health.

RESULTS

Overall, respondents reported a slight tendency to agree or strongly agree that their practice environments were safe. When looking at various factors explaining personal health, the perception of workplace health and safety was found to be a significant contributing factor.

CONCLUSIONS

The study findings suggest that, among Black nurses, perceptions about workplace health and safety are associated with perceived personal health. These findings underscore the importance of fostering healthy work environments.

Food for thought: The intersection between SNAP stigma, food insecurity, and gender

The Supplemental Nutrition Assistance Program (SNAP) helps millions of families with low incomes to afford and purchase food each year. Prior research has noted that welfare stigma-negative stereotypes about people who participate in public assistance programs-can limit SNAP participation. Stigma may also contribute to worse mental health among subgroups like male participants; qualitative evidence suggests males may struggle to accept public assistance benefits due to norms surrounding gender roles. Yet there is little research about who is most likely to experience stigma, how stigma relates to food insecurity, whether this relationship varies by gender identity, and whether stigma is associated with online shopping (which may protect against stigma). To address these gaps, we analyzed a national survey of 1383 SNAP participants about their experiences of SNAP stigma, food insecurity, and online shopping. In adjusted models, we found that male participants had 40% higher odds (95% CI: 1.09-1.80) of reporting any stigma experience compared to female participants. SNAP participants reporting stigma had over three times the odds (OR: 3.54, 95% CI: 2.60-4.81) of reporting food insecurity relative to those not reporting stigma, and male participants reporting stigma had nearly three times higher odds of food insecurity than female participants reporting stigma (OR: 2.94, 95% CI: 1.53, 5.66). In addition, stigma was not significantly associated with shopping online or using SNAP benefits online. In this national sample of SNAP participants, male respondents had greater odds of welfare stigma, experiences of stigma were associated with greater odds of food insecurity, male respondents experiencing stigma had greater odds of food insecurity compared to female respondents, and stigma was not associated with online shopping behaviors. Efforts to reframe public assistance may be needed to destigmatize programs like SNAP to both improve program uptake among non-participants and improve health outcomes among participants.

The diabetes cardiovascular outcomes trials and racial and ethnic minority enrollment: impact, barriers, and potential solutions

Type 2 diabetes (T2D) affects millions of individuals worldwide and is a well-documented risk factor for cardiovascular (CV) disease and chronic kidney disease, both of which are leading causes of mortality. Racial and ethnic minority groups in the US, including but not limited to Hispanic/Latino, non-Hispanic Black, and Southeast Asian individuals, are disproportionately burdened by both T2D and its adverse outcomes. In recent years, there have been numerous cardiovascular outcomes trials (CVOTs) on novel antidiabetic therapies, including the dipeptidyl peptidase-4 inhibitors, glucagon-like peptide-1 (GLP-1) receptor agonists (RAs), and sodium-glucose cotransporter-2 (SGLT2) inhibitors. CVOTs's initial aim was to demonstrate the cardiovascular safety of these drugs. Unexpected CV and kidney protective effects were found, specifically among the GLP-1 RAs and the SGLT2 inhibitors. These benefits informed the new paradigm of the management of patients with T2D. However, some experts argued that the lack of racial and ethnic minority group representation in these trials represented a challenge. While the downstream effects of this lack of representation must be further elucidated, it is clear and recognized that efforts need to be made to include a more representative sample in future CVOTs, specifically including individuals from those groups most burdened by T2D and its complications, if clinicians are to have an accurate picture of the benefits and potential pitfalls of utilizing these drugs in a real-world setting. In this comprehensive review, we briefly summarize the significant findings from the CVOTs, report the lack of representation of Hispanic/Latino, non-Hispanic Black, and Southeast Asian individuals in the CVOTs, investigate the barriers to recruiting racial and ethnic minority groups into clinical trials, and suggest potential solutions to overcome these obstacles at the patient-, provider-, and sponsor/system-level in future trials.

Characteristics of interventions that address racism in the United States and opportunities to integrate equity principles: a scoping review

BACKGROUND

As a driver of racial and health inequities, racism is deeply ingrained in the interconnected systems that affect health and well-being. Currently, no common frame is employed across researchers, interventionists, and funders to design, implement, and evaluate comprehensive interventions to address racism. Consequently, there is a need to examine the characteristics of interventions implemented in the United States that address racism across social and structural determinants of health and socio-ecological levels. Additionally, we utilized a Health Equity Action Research (HEART) framework to assess how interventions integrate equity principles.

METHODS

This scoping review examined the characteristics of multi-level interventions that addressed racism and appraised the interventions using a Health Equity Action Research frame. A comprehensive search strategy was conducted across nine electronic databases between 24 October 2022 through 15 November 2022. Records were included if they were available in English, discussed or evaluated a multi-level intervention or program conducted in the United States, and discussed or evaluated the intervention or program regarding the health and well-being of racialized and ethnically minoritized groups.

RESULTS

A total of 13,391 records were identified, of which 91 met the eligibility criteria and were included in the analysis. Most records reported the racialized group impacted by an intervention, of which the majority were racialized as African American or Black (n = 42) and Hispanic or Latino/a/x (n = 18). Eighty-one (89%) of interventions reported health outcomes and concentrated on the individual level. Most funders reported across the records, and 86 (51%) were a federal agency or department. A further 43 (25%) were private foundations, 12 (7%) were nonprofit organizations, 10 (6%) were private universities, and 4 (2%) were public universities. Regarding alignment with the HEART framework, 14% of interventions reported a mixed-methods approach, 45% reported community engagement, and less than 1% reported researcher self-reflection.

CONCLUSIONS

Most interventions prioritized people who are racialized as Black and report health outcomes. Since intervention designs, objectives, and methodological approaches vary, no standard frame defines racism and health equity. Applying the HEART framework offers a standard approach for interventionists and researchers to examine power, integrate community voice, and self-reflect to advance health equity.

The intersection of systemic lupus erythematosus with social and occupational environments among black adults: A qualitative study

BACKGROUND

Black people have disproportionately high morbidity and mortality due to systemic lupus erythematosus (SLE). Features of social and occupational environments can protect against poor health outcomes.

OBJECTIVE

We aimed to characterize how SLE intersects with interpersonal relationships and employment among Black adults to inform tailored care approaches and public policies that could alleviate racial inequities in SLE.

METHODS

We used a qualitative, interpretive description approach that involved semi-structured interviews with Black adults who had SLE. The interview guide included questions about SLE diagnosis, impacts on day-to-day life, and symptom management. We analyzed the de-identified transcripts using inductive, thematic analysis with input from representatives of the study population. Our theme development focused on how SLE (i.e., symptoms, severity, management) intersected with interpersonal relationships and employment.

RESULTS

This study included 30 interviews (97 % female, age range = 18-65 years). Among participants, 30 % were not working due to unemployment or disability and 23 % reported a lack of emotional support. Our analysis resulted in three main themes: 1) The bi-directional relationship between employment and SLE; 2) The positive and negative effects of connecting with other people who have SLE; and 3) The moderating role of relationships with family and friends, and the impact on self-identity.

CONCLUSIONS

This study describes features of social and occupational environments that influence SLE management and wellbeing. Our results highlight directions for further study that could identify and address how systemic racism affects race-based inequities in SLE.

PROGRESS: A Patient-centered Engagement Infrastructure and Multi-level Approach to Enrich Diversity, Equity, and Inclusion in a National Randomized Online Behavioral Pain Treatment Study

Twenty percent of individuals experience chronic pain worldwide posing significant challenges to those living with it. Pain research is crucial for developing and characterizing effective strategies to reduce the burden of chronic pain. Traditional research approaches often yield homogeneous study samples that poorly generalize and have unknown applicability across diverse patient populations. The Pain Relief with Online Groups that Empower Skills-based Symptom Reduction (PROGRESS) study aims to address disparities in pain research engagement and patient outcomes through the intentional inclusion of people with varied backgrounds and experiences of pain, and through a multilevel design informed by diverse stakeholder recommendations. The composition of three advisory boards (Patient Engagement and Diversity Board, Local Patient Advisory Board, and the National Patient Advisory Panel) prioritized diversity in patient/expert advisor background, geographic location, race, and ethnicity. Our engagement approach aligns with the Foundational Expectations for Partnerships in Research by Patient-Centered Outcomes Research Institute (PCORI), which emphasizes diverse representation, early and ongoing engagement, dedicated funds for advisor compensation, collaborative decision making, meaningful participation, and continuous assessment. The first 24 months of study advisor engagement has yielded multiple recruitment strategies resulting in a study population enriched with a breadth of identities within PROGRESS (e.g., inclusive patient-facing materials). Lessons learned underscore the importance of investing time in building patient and stakeholder relationships, trust, and embracing diverse viewpoints amongst the study team. PROGRESS demonstrates the potential of diverse patient-centered engagement to support evidence-based outcomes and practices that are more inclusive, equitable, and representative of the broader population. PERSPECTIVE: The PROGRESS study demonstrates how diverse patient engagement and inclusive advisory boards enhance research outcomes. By aligning with PCORI standards and employing innovative recruitment strategies, it highlights the vital role of stakeholder relationships and diverse perspectives. Key lessons learned emphasize adaptive strategies and continuous feedback for advancing equitable pain research.

How to leverage implementation research for equity in global health

Implementation research (IR) is important for addressing equity in global health. However, there is limited knowledge on how to operationalize IR for health equity, and pathways for improving health equity through IR in global health settings. This paper provides an overview of guidance and frameworks for thinking about health equity as part of IR while noting the gaps in how this guidance and frameworks apply to global health. It proposes an approach to guide implementation teams in the application of IR for achieving equity in global health considering these gaps. It describes key equity considerations for different aspects of IR (i.e., implementation contexts, strategies, outcomes, and research designs). These considerations can be applied prospectively and retrospectively, and at different stages of IR. The paper further describes causal pathways, intervention levers, and strategies for achieving health equity in global health settings through IR. Central to these pathways is the power asymmetries among different actors involved in IR in global health and how these contribute to health inequities. The paper suggests recommendations and strategies for shifting the balance of power among these actors while addressing the structural and systemic determinants of health inequities as part of IR. Explicit considerations for health equity as part of implementation research and practice are needed for the achievement of global health goals. Such explicit considerations should look back as much as possible, and entail defining and analyzing health inequities and intervening on the underlying causes and mechanisms of health inequities as part of IR on a routine basis.

Handoffs and Equity: Impact of a Patient Distribution Model on Handoffs for Black Patients

BACKGROUND

Hospital medicine patient distribution models (PDM) assign patients to inpatient services on hospital admission. Models balance tradeoffs including patient handoffs, physician wellness, subspecialty care, and other factors to ensure optimal outcomes; however, equity is rarely considered. Handoffs during inpatient care can result in medical error and worse patient outcomes. This study evaluates the impact of a PDM that prioritizes use of specialty care services and an overflow service (OS) during high census on racial inequities in handoff frequency.

METHODS

A single-center retrospective cohort study of inpatient encounters on hospital medicine services from July 2017 to December 2019 was conducted. The primary exposures included being discharged by a general medicine service (GMS) or cared for by an OS. The primary outcome was handoffs per day of stay, analyzed by multivariable regression adjusted for age, gender, race, ethnicity, insurance, discharge from GMS, and care from OS.

RESULTS

A total of 4165 inpatient hospitalizations with the majority of their stay on a hospital medicine service were reviewed. Patients discharged by GMS (78.2% vs. 58.1%, p < .001) and cared for by OS (78.7% vs. 67.0%, p < .001) were more likely to identify as Black. Multivariable analysis showed a handoff risk ratio of 1.53 (p < .001) for OS patients and 1.06 (p = .01) if discharged from GMS, but race alone did not significantly affect risk of handoffs.

CONCLUSION

The PDM prioritization drove increased handoffs disproportionately for Black patients. Multivariable analysis showed that race alone did not contribute to increased handoffs suggesting the creation of a systemic bias in patient care.

Structural racism: A concept analysis

BACKGROUND

Despite the broad agreement that structural racism is problematic, there remains significant confusion as to what structural racism means and how to research it.

PURPOSE

Perform a comprehensive concept analysis of structural racism and propose an operational definition.

METHODS

Walker and Avant's eight-step, iterative method was used for conducting the concept analysis.

DISCUSSION

Structural racism has five defining attributes: oppressive racial ideologies, dynamic state, inverse-related influence, temporality, and a false sense of "racial equity." Structural racism has six antecedents: explicit racial bias, implicit racial bias, racial discrimination, institutional racism, cultural racism, and systemic racism. There are three consequences of structural racism: group categorization, unequal treatment, and racial inequities.

CONCLUSION

To combat and defeat the historical and ongoing impact of structural racism, conceptual clarity must be established. Only then can an operational definition be proposed and instruments developed that correspond with the nature of structural racism.

Cardio-Oncology and Heart Failure: a Scientific Statement From the Heart Failure Society of America

Heart failure and cancer remain 2 of the leading causes of morbidity and mortality, and the 2 disease entities are linked in a complex manner. Patients with cancer are at increased risk of cardiovascular complications related to the cancer therapies. The presence of cardiomyopathy or heart failure in a patient with new cancer diagnosis portends a high risk for adverse oncology and cardiovascular outcomes. With the rapid growth of cancer therapies, many of which interfere with cardiovascular homeostasis, heart failure practitioners need to be familiar with prevention, risk stratification, diagnosis, and management strategies in cardio-oncology. This Heart Failure Society of America statement addresses the complexities of heart failure care among patients with active cancer diagnoses and cancer survivors. Risk stratification, monitoring and management of cardiotoxicity are presented across stages A through D heart failure, with focused discussion on heart failure with preserved ejection fraction and special populations, such as survivors of childhood and young-adulthood cancers. We provide an overview of the shared risk factors between cancer and heart failure, highlighting heart failure as a form of cardiotoxicity associated with many different cancer therapeutics. Finally, we discuss disparities in the care of patients with cancer and cardiac disease and present a framework for a multidisciplinary-team approach and critical collaboration among heart failure, oncology, palliative care, pharmacy, and nursing teams in the management of these complex patients.

Interventions addressing systemic racism in the US: A scoping review

Previous studies have reported on the health impact of systemic racism among historically oppressed populations. In fact, there is an emerging body of literature, including systematic reviews, which describe the negative health consequences of systemic racism among racial/ethnic minoritized groups in the US. Less is known, however, about effective intervention strategies to address systemic racism and the resulting health inequities. This scoping review was conducted to synthesize the published literature on U.S.-based interventions designed to improve health equity by addressing systemic racism. The Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for scoping review (PRISMA-ScR) checklist was used to report this review. We searched six databases (MEDLINE, CINAHL, PsycINFO, Sociological Abstracts, Web of Science Core Collection, and Scopus) to examine the intervention studies. A total of 172 articles were included in review. These interventions were classified by typology which included healing-centered approaches, community-based interventions targeting health disparities, diversity, equity, inclusion (DEI) efforts, anti-racism training interventions, and policy interventions. The findings from this review have important implications for the development, testing, and scaling of interventions designed to addressed systemic racism.

A Shift in Approach to Addressing Public Health Inequities and the Effect of Societal Structural and Systemic Drivers on Social Determinants of Health

Social determinants of health (SDOH) are the conditions in which people are born, grow, live, work, and age that influence health outcomes, and structural and systemic drivers of health (SSD) are the social, cultural, political, and economic contexts that create and shape SDOH. With the integration of constructs from previous examples, we propose an SSD model that broadens the contextual effect of these driving forces or factors rooted in the Centers for Disease Control and Prevention's SDOH framework. Our SSD model (1) presents systems and structures as multidimensional, (2) considers 10 dimensions as discrete and intersectional, and (3) acknowledges health-related effects over time at different life stages and across generations. We also present an application of this SSD model to the housing domain and describe how SSD affect SDOH through multiple mechanisms that may lead to unequal resources, opportunities, and consequences contributing to a disproportionate burden of disease, illness, and death in the US population. Our enhanced SDOH framework offers an innovative and promising model for multidimensional, collaborative public health approaches toward achieving health equity and eliminating health disparities.

Experiences of Racism in Health Care and Medical Mistrust Shape Cancer Prevention and Control Behaviors Among Black Residents of Black Hawk County, Iowa: A Qualitative Study

BACKGROUND

Non-Hispanic Black Iowans have substantially higher incidence of and mortality from cancer than their non-Hispanic White (NHW) counterparts in all but the oldest age groups; rates are particularly high in Black Hawk County, which contains the city of Waterloo, a highly segregated city with a documented history of redlining and distinct racial differences in the social drivers of health.

OBJECTIVE

To gather perspectives on race, racism, healthcare, and engagement with cancer prevention and control behaviors, among Black individuals living in Black Hawk County, Iowa.

METHODS

We conducted semi-structured interviews with 20 individuals (10 male, 10 female), questions included experiences in healthcare and feelings towards the healthcare system, trust of the healthcare system, experiences of racism or other perceived biases within healthcare, and how experiences of racism/bias and/or feelings towards the healthcare system impact desire or ability to participate in cancer prevention and control activities.

RESULTS

Almost all interviewees reported both positive and negative experiences in healthcare. Nine themes emerged from analysis of the interviews: everyday racism and racism in healthcare, medical mistrust, need for more Black healthcare professionals, communication with healthcare professionals, need to break down cultural stigma around cancer, need and desire for community education around health and cancer, ability to choose, self-advocacy, and social support.

CONCLUSIONS

There are substantial barriers for Black individuals engaging with cancer prevention and control behaviors in Iowa. Multi-level interventions are needed to address structural, healthcare facility, and individual-level barriers to care; interventions may build on existing resiliencies within the community.

Improving Health Outcomes for African American Men with Kidney Disease: A Patient-Centered Approach to Cultural Competence

In the United States, African American (AA) men disproportionately experience kidney failure, representing 16.6% of all cases in 2018-more than double their percentage in the general population. This significant health disparity arises from socioeconomic factors, access issues, and higher disease prevalence. The article highlights the importance of adopting a patient-centered and culturally competent approach to improve health outcomes for AA men with kidney disease. It advocates for ongoing research and educational efforts to enhance cultural competence in healthcare settings. By exploring current practices and the benefits of culturally informed training, the article underscores the crucial role of cultural competence in advancing healthcare equity. It calls for healthcare institutions to not just adopt, but actively implement, patient-centered and culturally sensitive care models, promoting social justice and better health outcomes for all.

Race as a Risk Marker, Not a Risk Factor: Revising Race-Based Algorithms to Protect Racially Oppressed Patients

Emerging consensus in the medical and public health spheres encourages removing race and ethnicity from algorithms used in clinical decision-making. Although clinical algorithms remain appealing given their promise to lighten the cognitive load of medical practice and save time for providers, they risk exacerbating existing health disparities. Race is a strong risk marker of health outcomes, yet it is not a risk factor. The use of race as a factor in medical algorithms suggests that the effect of race is intrinsic to the patient or that its effects can be distinct or separated from other social and environmental variables. By contrast, incisive public health analysis coupled with a race-conscious perspective recognizes that race serves as a marker of countless other dynamic variables and that structural racism, rather than race, compromises the health of racially oppressed individuals. This perspective offers a historical and theoretical context for the current debates regarding the use of race in clinical algorithms, clinical and epidemiologic perspectives on "risk," and future directions for research and policy interventions that combat color-evasive racism and follow the principles of race-conscious medicine.

Research Priorities in Pediatric Asthma Morbidity: Addressing the Impacts of Systemic Racism on Children with Asthma in the United States. An Official American Thoracic Society Workshop Report

Background: In the United States, Black and Latino children with asthma are more likely than White children with asthma to require emergency department visits or hospitalizations because of an asthma exacerbation. Although many cite patient-level socioeconomic status and access to health care as primary drivers of disparities, there is an emerging focus on a major root cause of disparities-systemic racism. Current conceptual models of asthma disparities depict the historical and current effects of systemic racism as the foundation for unequal exposures to social determinants of health, environmental exposures, epigenetic factors, and differential healthcare access and quality. These ultimately lead to biologic changes over the life course resulting in asthma morbidity and mortality. Methods: At the 2022 American Thoracic Society International Conference, a diverse panel of experts was assembled to identify gaps and opportunities to address systemic racism in childhood asthma research. Panelists found that to examine and address the impacts of systemic racism on children with asthma, researchers and medical systems that support biomedical research will need to 1) address the current gaps in our understanding of how to conceptualize and characterize the impacts of systemic racism on child health, 2) design research studies that leverage diverse disciplines and engage the communities affected by systemic racism in identifying and designing studies to evaluate interventions that address the racialized system that contributes to disparities in asthma health outcomes, and 3) address funding mechanisms and institutional research practices that will be needed to promote antiracism practices in research and its dissemination. Results: A thorough literature review and expert opinion discussion demonstrated that there are few studies in childhood asthma that identify systemic racism as a root cause of many of the disparities seen in children with asthma. Community engagement and participation in research studies is essential to design interventions to address the racialized system in which patients and families live. Dissemination and implementation studies with an equity lens will provide the multilevel evaluations required to understand the impacts of interventions to address systemic racism and the downstream impacts. To address the impacts of systemic racism and childhood asthma, there needs to be increased training for research teams, funding for studies addressing research that evaluates the impacts of racism, funding for diverse and multidisciplinary research teams including community members, and institutional and financial support of advocating for policy changes based on study findings. Conclusions: Innovative study design, new tools to identify the impacts of systemic racism, community engagement, and improved infrastructure and funding are all needed to support research that will address impacts of systemic racism on childhood asthma outcomes.

Inequities in Patient Access to Care Among Asian American, Native Hawaiian, and Pacific Islander Adults in Medicaid

BACKGROUND

Despite decades of advocacy for disaggregated data collection and reporting for Asian American, Native Hawaiian, and Pacific Islander (AA and NHPI) people, significant gaps remain in our ability to understand AA and NHPI individuals' access to care. We assess inequities in access to care measures between non-Hispanic White and AA and NHPI adult Medicaid enrollees.

METHODS

We used the 2014-15 Nationwide Adult Medicaid Consumer Assessment of Healthcare Providers and Systems, the first-and-only nationally representative sample of Medicaid enrollees. Our main outcomes were access to needed care, access to a personal doctor, timely access to a checkup, and timely access to specialty care. Using multivariable linear probability models, we assessed the relationship between racial/ethnic group and our outcomes, both in the aggregate and disaggregated into ten racial/ethnic groups, and adjusted for enrollee-level sociodemographic characteristics, health status, and state-level Medicaid expansion status.

RESULTS

In aggregate, AA and NHPI enrollees reported worse access to care than White enrollees on all four metrics (p < 0.001). The magnitude of disparities varied across the ten AA and NHPI ethnic groups. Disparities relative to White enrollees were particularly large in magnitude, roughly 1.5 to 2 times greater, for Chinese, Korean, and Vietnamese enrollees than for the aggregated AA and NHPI group.

CONCLUSIONS

Despite comparable insurance coverage, there were inequities in multiple access to care metrics between non-Hispanic White and AA and NHPI Medicaid enrollees. Collection of disaggregated health data on AA and NHPI patients reveals important variation in access to care by ethnic group.

To what extent could eliminating racial discrimination reduce inequities in mental health and sleep problems among Aboriginal and Torres Strait Islander children? A causal mediation study

Background

Racism is a fundamental cause of health inequities for Aboriginal and Torres Strait Islander children. We estimated the potential reduction in inequities in Aboriginal and Torres Strait Islander children's mental health and sleep problems if interpersonal racial discrimination was eliminated.

Methods

We drew on cross-sectional data from the Speak Out Against Racism (SOAR; N = 2818) and longitudinal data from the Longitudinal Study of Australian Children (LSAC; N = 8627). The SOAR was completed in 2017 and the LSAC followed children from 2004 to 2014 in the kindergarten cohort and from 2008 to 2018 in the birth cohort. Exposure: Aboriginal and Torres Strait Islander status (Aboriginal and Torres Strait Islander/Anglo-European), a proxy measure of structural racism (SOAR: 10-15 years; LSAC: 4-5 years); Mediator: interpersonal racial discrimination (yes/no) (SOAR: 10-15 years; LSAC: 12-13 years); Outcomes: mental health problems (yes/no) and sleep problems (yes/no) (SOAR: 10-15 years; LSAC: 14-15 years). An interventional effects causal mediation approach was used.

Findings

Aboriginal and Torres Strait Islander children had higher prevalence of mental health problems (SOAR: 40.1% versus 13.5%; LSAC: 25.3% versus 7.6%) and sleep problems (SOAR: 28.5% versus 18.4%; LSAC: 14.0% versus 9.9%) than Anglo-European children. Hypothetical interventions eliminating Aboriginal and Torres Strait Islander children's experiences of interpersonal racial discrimination could reduce 42.4% and 48.5% of mental health and sleep inequities in SOAR (equivalent to 11.2% and 4.7% absolute reductions) and 25.6% and 1.6% of mental health and sleep inequities in LSAC (equivalent to 5.5% and 0.1% absolute reductions). Absolute remaining inequities were similar across both studies for both outcomes.

Interpretation

Targeted policy interventions that eliminate racial discrimination against Aboriginal and Torres Strait Islander children could have high potential to reduce inequities in mental health and sleep problems. Addressing racism and racial discrimination needs a multi-component and multi-level approach directed by Aboriginal and Torres Strait Islander communities.

Funding

National Health and Medical Research Council of Australia and Medical Research Future Fund of Australia.

Race-Related and Mental Health Factors of Powder Cocaine Use Among Black Incarcerated Men

Incarceration disproportionately impacts Black men in the United States, which can have compounding effects on mental health and substance use among this population. Cocaine use, in particular, carries higher severity of dependence and overdose risks among Black Americans, though research examining cocaine use correlates among Black incarcerated men is limited. The present study examines race-related and mental health correlates of powder cocaine use among a sample of incarcerated Black men (n = 208) using the General Strain Theory. Specifically, the present study was a secondary analysis examining race-related stress, psychological distress (i.e., anxiety and depression), and stigma about receiving psychological help as correlates of lifetime powder cocaine use. Results indicated that the likelihood of lifetime powder cocaine use was higher among those reporting lifetime psychological distress and greater race-related stress. Stigma about receiving psychological help was not significantly associated with lifetime powder cocaine use among this sample. Results of this study have important implications for substance use treatment interventions. Identifying adaptive coping strategies to manage anxiety and depression symptoms and race-related stress among incarcerated Black men may help reduce rates of cocaine use among this population and increase successful reintegration into the community post-incarceration.

The effect of mailed outreach on FIT completion among patients aged 45-50 in a safety net healthcare system

PURPOSE

Colorectal cancer screening is recommended starting at age 45, but there has been little research on strategies to promote screening in patients younger than 50.

METHODS

An outreach program quasi-randomly assigned patients aged 45-50 without recent fecal immunochemical test (FIT), colonoscopy or contraindications to screening to two intervention arms: electronic outreach with email and text (electronic outreach only) versus electronic outreach plus mailed outreach with FIT, an instructional letter and a prepaid return envelope (mailed + electronic outreach). In response to known disparities in screening uptake, all Black patients were assigned to receive mailed + electronic outreach.

RESULTS

Among patients quasi-randomly assigned to an intervention (non-Black patients), the 180-day FIT completion rate was 18.8% in the electronic outreach only group (n = 1,318) and 25.0% in the mailed + electronic outreach group (n = 1,364) (difference 6.2% [95% CI 3.0, 9.4]). FIT completion was 16.6% among Black patients (n = 469), 8.4% (95% CI 4.1, 12.6) lower than among non-Black patients also assigned to mailed + electronic outreach.

CONCLUSION

Among patients aged 45-50, mailed + electronic outreach had a greater effect on FIT completion than electronic outreach alone. Crossover between intervention groups likely lead to an underestimation of the effect of mailed outreach.

Decolonization and antiracism: intersecting pathways to global health equity

In this paper, as Black scholars, we address ways that interventions designed to promote equity in health can create pathways for coupling decolonization with antiracism by drawing on the intersection of the health of Africans and African Americans. To frame this intersection, we offer the Public Health Critical Race Praxis (PHCRP) and the PEN-3 Cultural Model as antiracism and decolonization tools that can jointly advance research on colonization and racism globally. We argue that racism is a global reality; PHCRP, an antiracism framework, and PEN-3, a decolonizing framework, can guide interventions to promote equity for Africans and African Americans.

Physical Limitations, Health Rumination/Worry, and Depressive Symptoms: Gender Differences among African Americans

Although studies have documented the relationships between physical health, health rumination/worry, and mental health, few investigations have assessed these linkages within African American communities. Using a community-based sample of residents in historically lower-income, African American communities (N = 306), this study assesses the mediating role of health rumination/worry in the physical limitation-depressive symptom relationship, and the moderating effect of gender on the relationship between health rumination/worry-depressive symptoms. Findings demonstrate that health rumination/worry explains half of the physical limitation-depressive symptom relationship, and the relationship between health rumination/worry and depressive symptoms is stronger for African American men than women. The findings underscore the importance of intersectional research for policy efforts aimed at reducing mental health morbidities within African American communities.

Social Vulnerability Index and All-Cause Mortality After Acute Ischemic Stroke, Medicare Cohort 2020-2023

Background

Inequities in stroke outcomes have existed for decades, and the COVID-19 pandemic amplified these inequities.

Objectives

This study examined the association between social vulnerability and all-cause mortality among Medicare beneficiaries hospitalized with acute ischemic stroke (AIS) during COVID-19 pandemic periods.

Methods

We analyzed data on Medicare fee-for-service beneficiaries aged ≥65 years hospitalized with AIS between April 1, 2020, and December 31, 2021 (followed until December 31, 2023) merged with county-level data from the 2020 Centers for Disease Control and Prevention/Agency for Toxic Substances and Disease Registry's Social Vulnerability Index (SVI). We used a Cox proportional hazard model to examine the association between SVI quartile and all-cause mortality.

Results

Among 176,123 Medicare fee-for-service beneficiaries with AIS, 29.9% resided in the most vulnerable counties (SVI quartile 4), while 14.9% resided in counties with least social vulnerability (SVI quartile 1). AIS Medicare beneficiaries living in the most vulnerable counties had the highest proportions of adults aged 65 to 74 years, non-Hispanic Black or Hispanic, severe stroke at admission, a history of COVID-19, and more prevalent comorbidities. Compared to those living in least vulnerable counties, AIS Medicare beneficiaries living in most vulnerable counties had significantly higher all-cause mortality (adjusted HR: 1.11, 95% CI: 1.08-1.14). The pattern of association was largely consistent in subgroup analyses by age group, sex, and race and ethnicity.

Conclusions

Higher social vulnerability levels were associated with increased all-cause mortality among AIS Medicare beneficiaries. To improve outcomes and address disparities, it may be important to focus efforts toward addressing social vulnerability.

Differences in Medication Use by Gender and Race in Hospitalized Persons Living with Dementia

The purpose of this study was to describe differences in treatment of White versus Black older adults, males versus females, and those living at home, assisted living, or nursing home communities with regard to the use of psychotropic, pain, and cardiovascular medications. Baseline data from the first 352 participants in the study, implementation of Function-Focused Care for Acute Care Using the Evidence Integration Triangle, were used. Data included age, gender, race, comorbidities, admission diagnosis, and living location prior to hospitalization, the Saint Louis University Mental Status exam, the modified Charlson Comorbidity Index, the Pain Assessment in Advanced Dementia scale, the Confusion Assessment Method, and medications prescribed. Generalized linear mixed model analyses were done, controlling for race or gender (depending on which comparison analysis was being done), age, cognitive status, hospital, delirium, and comorbidities. Medication use was significantly higher for White older adults, compared to Black older adults, for antidepressants, anxiolytics, non-opioid pain medications, and opioids and lower for antihypertensives. Females received more anxiolytics than their male counterparts. There were differences in medication use by living location with regard to non-opioid pain medication, antipsychotics, statins, and anticoagulants. The findings provide some current information about differences in medication use across groups of individuals and can help guide future research and hypothesis testing for approaches to minimizing these differences in treatment.

Intersectionality and the Association Between State-Level Structural Racism, Binge Alcohol Consumption, and Smoking Status Among Black Americans

BACKGROUND

Structural racism is associated with alcohol and tobacco use among Black Americans. There is a need to understand how this relationship differs within varying groups of Black Americans. This study assessed the moderating roles of age, gender, and income in the association between structural racism and binge alcohol consumption and tobacco smoking status among Black Americans.

METHODS

A state-level index of structural racism was merged with data from a national probability sample of 1946 Black Americans. Hierarchical linear and logistic regression models tested associations between structural racism (measured by residential segregation, and economic, incarceration, and educational inequities) and binge alcohol use and smoking status among Black Americans by stratified by age, gender, and income. Moderating effects of age, gender, and income were tested using slope estimate comparisons.

RESULTS

Results indicated statistically significant positive associations between incarceration disparities and binge drinking and smoking status among Black Americans below age 65. An inverse association was detected between education disparities and smoking status among Black Americans below age 65 and among higher-income Black Americans. Age, gender, and income were not significant moderators of these associations.

CONCLUSIONS

Age, gender, and income do not moderate the association between state-level structural racism and binge alcohol or tobacco use behaviors among the current sample of Black Americans.

IMPACT

Addressing structural racism may have implications for reducing participation in binge drinking and tobacco use behaviors among Black Americans, regardless of their age, gender, or income. This has implications for healthy equity and cancer prevention and control.

Exploring Barriers to Effective COVID-19 Risk Mitigation, Recovery, and Chronic Disease Self-Management: A Qualitative Multilevel Perspective

Introduction

Many research activities have focused on SARS-CoV-2 infection and subsequent COVID-19 respiratory illness during the pandemic. However, significant racial inequities emerged months after the COVID-19 pandemic began. The similarity between racial/ ethnic disparities in COVID-19 and those for other diseases raised awareness about the context for risk exposure and healthcare access. The purpose of this study is to examine social and structural determinants of health among COVID-19 survivors, carepartners, and the perspectives of healthcare stakeholders who experienced disruption during the early pandemic.

Material and methods

A purposive sample of interviews (n=9) and focus groups (n=10) were used to collect data regarding knowledge of barriers to effective COVID-19 risk mitigation, recovery, and chronic disease self-management. This included nurses, physicians, COVID-19 survivors and their carepartners, public health, and community leaders connected with the healthcare systems in rural counties of South Carolina.

Results

Five major themes were identified across the subgroups. The themes: The COVID-19 Illness Trajectory Added Major Health Challenges and Stressors, Access to Care Is Lacking, Support is Needed for COVID-19 Survivors and Care Partners, Support Must be Distributed Equitably, and Racism and Structural Issues Affect Stress reflect the strengths, opportunities, and inequities perceived within these groups.

Conclusion

This research is the first qualitative study focused on COVID-19 survivor-carepartner dyads that consider the intersectionality of race/ ethnicity, geography, and health that is known to occur when engaging healthcare systems. The themes illustrate the need for infectious disease prevention at all socioecological levels: structural/ systemic, community, organizational/ institutional, interpersonal, and individual.

Neighborhood environments and psychological distress 6-years later: results from the San Diego HCHS/SOL community and surrounding areas study

PURPOSE

The current study examined associations of social and built features of neighborhood environments with psychological distress 6 years later and whether these associations were explained by stress and social factors, among Hispanic/Latino adults from the HCHS/SOL and SOL CASAS Ancillary Study.

METHODS

In the SOL CASAS Ancillary Study, HCHS/SOL San Diego participants' baseline (2008-2011) home addresses were geocoded, neighborhoods were defined using 800 m radial buffers, and variables representing neighborhood socioeconomic deprivation, social disorder, walkability, and greenness were created. Psychological distress (anxiety and depression symptoms) and proposed pathway variables chronic stress, social support, and family cohesion were assessed at HCHS/SOL Visit 2 (2014-2017).

RESULTS

On average, the population (n = 2785) was 39.47 years old, 53.3% were women, and 92.3% were of Mexican heritage. In complex survey regression analyses that accounted for sociodemographic covariates, the complex sampling design, and sample weights, greater baseline neighborhood socioeconomic deprivation predicted lower family cohesion at Visit 2 (B = -0.99, 95% CI [-1.97, -0.06]). Path models showed indirect associations of baseline neighborhood socioeconomic deprivation with Visit 2 psychological distress through family cohesion (MacKinnon's 95% CI depression [0.001, 0.026]; 3.9% of the variance accounted for; anxiety [0.00071, 0.019] 3.0% of the variance accounted for).

CONCLUSIONS

Among adults of mostly Mexican heritage from the San Diego, CA area, neighborhood deprivation indirectly predicted later psychological distress through family cohesion. No other effects of neighborhood variables were observed.

Association Between Neighborhood Context and Psychotropic Polypharmacy Use Among High-Need Children

OBJECTIVE

The authors explored whether neighborhood context is associated with psychotropic polypharmacy and psychotherapy among a cohort of children with high needs for psychiatric and general medical care.

METHODS

Electronic health record data from a large health care system were used in a cross-sectional design to examine psychotropic polypharmacy and psychotherapy in 2015-2019 among children ages 2-17 years (N=4,017) with geocoded addresses. Inclusion criteria were a diagnosis of a mental health condition, an intellectual and developmental disability, or a complex medical condition and one or more clinical encounters annually over the study period. Polypharmacy was defined as two or more psychotropic drug class prescriptions concurrently for ≥60 days. Psychotherapy was defined as receipt of any psychotherapy or adaptive behavior treatment. Neighborhood context (health, environment, education, and wealth) was measured with the Child Opportunity Index. Multilevel generalized linear mixed models with random intercept for census tracts were used to assess the associations between individual and neighborhood characteristics and psychotropic polypharmacy and psychotherapy.

RESULTS

Moderate (vs. low) child opportunity was associated with higher odds of polypharmacy (adjusted OR [AOR]=1.79, 95% CI=1.19-2.67). High (vs. low) child opportunity was associated with higher odds of psychotherapy (AOR=2.15, 95% CI=1.43-3.21). Black (vs. White) race (AOR=0.51, 95% CI=0.37-0.71) and Hispanic ethnicity (AOR=0.44, 95% CI=0.26-0.73) were associated with lower odds of polypharmacy.

CONCLUSIONS

Among high-need children, neighborhood Child Opportunity Index, race, and ethnicity were significantly associated with treatment outcomes in analyses adjusted for clinical factors. The findings underscore concerns about structural disparities and systemic racism and raise questions about access.

Barriers and Enablers for Equitable Healthy Food Access in Baltimore Carryout Restaurants: A Qualitative Study in Healthy Food Priority Areas

Black neighborhoods in the U.S., historically subjected to redlining, face inequitable access to resources necessary for health, including healthy food options. This study aims to identify the enablers and barriers to promoting equitable healthy food access in small, independently owned carryout restaurants in under-resourced neighborhoods to address health disparities. Thirteen in-depth interviews were conducted with restaurant owners in purposively sampled neighborhoods within Healthy Food Priority Areas (HFPAs) from March to August 2023. The qualitative data were analyzed using inductive coding and thematic analysis with Taguette software (Version 1.4.1). Four key thematic domains emerged: interpersonal, sociocultural, business, and policy drivers. Owners expressed mixed perspectives on customers' preferences for healthy food, with some perceiving a community desire for healthier options, while others did not. Owners' care for the community and their multicultural backgrounds were identified as potential enablers for tailoring culturally diverse menus to meet the dietary needs and preferences of their clientele. Conversely, profit motives and cost-related considerations were identified as barriers to purchasing and promoting healthy food. Additionally, owners voiced concerns about taxation, policy and regulation, information access challenges, and investment disparities affecting small business operations in HFPAs. Small restaurant businesses in under-resourced neighborhoods face both opportunities and challenges in enhancing community health and well-being. Interventions and policies should be culturally sensitive, provide funding, and offer clearer guidance to help these businesses overcome barriers and access resources needed for an equitable, healthy food environment.

Use of Hematopoietic Cell Transplant for Hematologic Cancers by Race, Ethnicity, and Age

Importance

Utilization of hematopoietic cell transplantation (HCT) for hematologic cancers previously demonstrated race, ethnicity, and age-based disparities.

Objective

To evaluate utilization over time by race, ethnicity, and age to determine if disparities persist in light of recent significant increases in HCT volume.

Design, Setting, and Participants

This US population-based retrospective cohort study includes patients who received transplants from January 2009 to December 2018. Data collection and cleaning occurred from February 2019 to November 2021, and data analysis occurred from January 2022 to October 2023. Method 1 restricted the analysis to Surveillance, Epidemiology and End Results (SEER) reporting areas for cases and transplants. Method 2 applied SEER age-, race-, and ethnicity-specific incidence rates to corresponding US census population and included all transplants reported to the Center for International Blood and Marrow Transplant Research. Race and ethnicity groups were hierarchically defined as Hispanic (any race), non-Hispanic White, non-Hispanic Black, and non-Hispanic Other (Asian and American Indian).

Exposure

Receipt of HCT.

Main Outcomes and Measures

Utilization rate of autologous or allogeneic HCT for patients with hematologic cancers by age, race, and ethnicity.

Results

From 2009 to 2018, 136 280 HCTs were analyzed for 6 hematologic cancers comprising 16.7% pediatric/adolescent/young adults (0-39 years), 83.3% adults (40-84 years), 58% male, 10.3% Hispanic, 11.4% non-Hispanic Black, 3.8% non-Hispanic Other, and 74.5% non-Hispanic White patients, with 49 385 allogeneic and 86 895 autologous HCTs performed. HCT utilization increased over time for all disease, age, race, and ethnic groups. From 2017 to 2018, adult (40-84 years) allogeneic transplant utilization for acute myeloid leukemia and myelodysplastic syndrome (MDS) was similar for Hispanic and non-Hispanic White or Other patients but was lower for non-Hispanic Black patients (acute myeloid leukemia: 19% vs 13%; MDS: 9%-10% vs 5%). Similarly, autologous transplant utilization for lymphoma was similar for all race and ethnicity groups; however, autologous transplant for multiple myeloma was highest for non-Hispanic White patients and lower for all other groups (31% vs 26%-27%). In patients aged 0 to 39 years, utilization of allogeneic transplant for acute lymphoblastic leukemia was highest in Hispanic patients, followed by non-Hispanic White, Black, and Other races (acute lymphoblastic leukemia: 19%, 18%, 17%, and 16%, respectively).

Conclusions and Relevance

In this cohort study of autologous and allogeneic transplant utilization for hematologic cancers, disparities persisted for non-Hispanic Black patients. Hispanic, non-Hispanic Other, and younger age groups had increased utilization over time that was on par with non-Hispanic White patients in the most recent cohort.

Mediators of racial and ethnic inequities in clinical trial participation among patients with cancer, 2011-2023

BACKGROUND

Although racially and ethnically minoritized populations are less likely to participate in cancer trials, it is unknown whether social determinants of health (SDOH) explain these inequities. Here we identify SDOH factors that contribute to racial and ethnic inequities in clinical trial participation among patients with 22 common cancers.

METHODS

This retrospective cohort study used electronic health record data (2011-2023) linked to neighborhood (US Census tract) data from multiple sources. Patients were followed from diagnosis to clinical study drug receipt (proxy for trial participation), death, or last recorded activity. Associations were assessed using Cox proportional hazards models adjusted for clinical factors (year of diagnosis, age, sex, performance status, disease stage, cancer type). To elucidate which area-level SDOH underlie racial and ethnic inequities, mediation analysis was performed using nonlinear multiple additive regression tree models.

RESULTS

This study included 250 105 patients (64.7% non-Latinx White, 8.9% non-Latinx Black, 5.2% Latinx). Black and Latinx patients were more likely to live in economically or socially marginalized areas (eg, disproportionately minoritized [measure of segregation], limited English proficiency, low vehicle ownership) than White patients. Black (3.7%; hazard ratio = 0.55, 95% confidence interval [CI] = 0.52 to 0.60) and Latinx patients (4.4%; hazard ratio = 0.63, 95% CI = 0.58 to 0.69) were less likely to participate in trials than White patients (6.3%). Fewer patients in economically or socially marginalized neighborhoods participated in trials. Mediators explained 62.2% (95% CI = 49.5% to 74.8%) of participation inequities between Black and White patients; area-level SDOH-including segregation (29.9%, 95% CI = 21.2% to 38.6%) and vehicle ownership (11.6%, 95% CI = 7.0% to 16.1%)-were the most important mediators. Similarly, Latinx-White participation inequities were mediated (65.1%, 95% CI = 49.8% to 80.3%) by area-level SDOH, such as segregation (39.8%, 95% CI = 28.3% to 51.3%), limited English proficiency (11.6%, 95% CI = 2.8% to 20.4%), and vehicle ownership (9.6%, 95% CI = 5.8% to 13.5%).

CONCLUSIONS

To improve racial and ethnic diversity in cancer trials, efforts to address barriers related to adverse neighborhood SDOH factors are necessary.

Patients, colleagues, systems, and self: Exploring layers of physician emotions in caring for pregnant people who use substances and their newborns

INTRODUCTION

Pregnant people who use substances experience significant stigma, including in healthcare settings, where physicians make high-stakes decisions about treatment plans, resource allocation, and even a person's ability to parent. Previous psychology research has demonstrated the influence of emotions on decision-making, as well as on the development and expression of stigma. Yet the specific content of physician emotions, as well as approaches to processing these emotions, has been relatively under-examined. We sought to better understand the emotional experiences of physicians who practice in safety-net labor and delivery/inpatient settings to inform strategies to facilitate more humanizing, equitable care.

METHODS

From March 2021 to June 2022, the study team conducted semi-structured interviews with 24 San Francisco Bay Area-based physicians (obstetrics-gynecology, pediatrics, family medicine) caring for pregnant people who use substances and/or their newborns. We used deductive and inductive coding and identified themes regarding the nature, etiology, and processing of physician emotions.

RESULTS

Physicians described experiencing a range of emotions related to interpersonal (patients, colleagues), systems-level, and internal dynamics. Emotions such as anger, sadness, frustration, and helplessness resulted from their deep care and empathy for patients, witnessing stigmatizing colleague behaviors, disagreement with punitive systems, and recognition of their own limitations in effecting change. Few participants identified strategies for processing these emotions, and several described efforts to disengage from their emotional experience to preserve their sense of well-being and professionalism.

CONCLUSIONS

Physicians caring for pregnant people who use substances and their newborns experienced intense, multi-layered emotions. This study posits that additional efforts to support physician emotional processing and structural competency could improve healthcare experiences and outcomes for pregnant people who use substances.

Racial/Ethnic Differences in Adverse Childhood Experiences and Mental Health

INTRODUCTION

Racial/ethnic differences exist in the prevalence of adverse childhood experiences (ACEs). However, few studies have examined racial/ethnic differences in the association between ACEs and poor mental health outcomes in young adulthood.

METHODS

Data on 10 self-reported, recalled ACEs (prior to age 18) and current symptoms of depression, anxiety, post-traumatic stress disorder, and sleep problems in early adulthood were collected from 2,020 young adults (age 20-23 years) between January and June 2021 enrolled in a Southern California prospective community-based cohort. Logistic regression models run in 2022-2023 evaluated the association of cumulative (0, 1, 2, 3, 4+ ACEs), grouped (abuse, neglect, household dysfunction), and individual ACE exposure with mental health outcomes; interaction models tested for differences by race/ethnicity.

RESULTS

All ACE exposures (cumulative, grouped, individual ACEs) were associated with increased odds of most mental health symptoms. Significant differences by race/ethnicity emerged for individual and grouped (but not cumulative) ACEs. For example, associations of any abuse-related ACE and emotional and physical abuse with depressive symptoms were greater for Hispanic participants than for those of another race/ethnicity. Further, associations of emotional abuse with sleep problems were greater for Hispanic participants than for Asian American and Pacific Islander participants (interaction ps<0.05). Though not significant, the association of familial incarceration with depression symptoms was higher for AAPI participants than for other racial/ethnic groups (interaction p-value=0.06).

CONCLUSIONS

Evaluation of individual and grouped ACEs reveals important racial/ethnic heterogeneity in associations with mental health outcomes. Findings have implications for targeted prevention efforts for racial/ethnic groups at higher risk for poor mental health.

NPCC4: Tail risk, climate drivers of extreme heat, and new methods for extreme event projections

We summarize historic New York City (NYC) climate change trends and provide the latest scientific analyses on projected future changes based on a range of global greenhouse gas emissions scenarios. Building on previous NPCC assessment reports, we describe new methods used to develop the projections of record for sea level rise, temperature, and precipitation for NYC, across multiple emissions pathways and analyze the issue of the "hot models" associated with the 6th phase of the Coupled Model Intercomparison Project (CMIP6) and their potential impact on NYC's climate projections. We describe the state of the science on temperature variability within NYC and explain both the large-scale and regional dynamics that lead to extreme heat events, as well as the local physical drivers that lead to inequitable distributions of exposure to extreme heat. We identify three areas of tail risk and potential for its mischaracterization, including the physical processes of extreme events and the effects of a changing climate. Finally, we review opportunities for future research, with a focus on the hot model problem and the intersection of spatial resolution of projections with gaps in knowledge in the impacts of the climate signal on intraurban heat and heat exposure.

Individual-Level Experiences of Structural Inequity and Their Association with Subjective and Objective Sleep Outcomes in the Adolescent Brain Cognitive Development Study

PURPOSE

Research has documented that adolescent sleep is impacted by various stressors, including interpersonal experiences and structural disadvantage. This study extends existing knowledge by empirically examining interconnected individual experiences of structural inequity and assessing its association with subjective and objective sleep outcomes.

METHODS

We utilized data from the Adolescent Brain and Cognitive Development Study to identify seven conceptual domains of structural inequity: perceived discrimination, low school inclusivity, neighborhood safety, unmet medical needs, legal problems, material hardship, and housing insecurity. We operationalized experiences of structural inequity as latent classes, a cumulative exposure, and each domain separately. Sleep disturbances were measured using the Sleep Disturbance Scale, and sleep duration was assessed using Fitbits. Mixed effects linear regression estimated the association between our measures of structural inequity, longitudinal sleep disturbances, and cross-sectional sleep duration.

RESULTS

Latent class analysis revealed common exposure profiles (low risk, interpersonal, and systemic) of experiences of structural inequity across our sample. In longitudinal models, structural inequity was associated with higher Sleep Disturbance Scale scores, whether measured as latent classes, a cumulative exposure, or individual domains. Individuals with interpersonal exposures, those with at least one exposure, and those with legal problems, material hardship, and housing insecurity had lower mean sleep duration.

DISCUSSION

Results are consistent with literature that frames structural inequity as a lifelong determinant of sleep disturbance and duration. Adolescence represents a crucial time for interventions aimed at improving sleep and redressing inequities throughout the life course; our work can inform the development of policies and interventions toward this end.