Improving The Measurement Of Structural Racism To Achieve Antiracist Health Policy

Shifting paradigms: A collective and structural strategy for addressing healthcare inequity

Healthcare inequity is a persistent systemic problem, yet many solutions have historically focused on "debiasing" individuals. Individualistic strategies fit within a competency-based medical education and assessment paradigm, whereby professional values of social accountability, patient safety, and healthcare equity are linked to an individual clinician's competence. Unfortunately, efforts to realise the conceptual linkages between medical education curricula and goals to improve healthcare equity fail to address the institutional values, policies, and practices that enable structural racism. In this article, we explore alternative approaches that target collective and structural causes of health inequity. We first describe the structural basis of healthcare inequity by identifying the ways in which institutional culture, power and privilege erode patient-centred care and contribute to epistemic injustice. We then outline some reasons that stereotypes, which are a culturally supported foundation for discrimination, bias and racism in healthcare, cannot be modified effectively through individualistic strategies or education curricula. Finally, we propose a model that centres shared values for leadership by individuals and institutions with consistency in goal setting, knowledge translation, and talent development. Figure 1 summarises the key recommendations. We have provided cases to supplement this work and facilitate discussion about the model's application to practice.

The Relationships Among Neighborhood Disadvantage, Mental Health and Developmental Disabilities Diagnoses, and Race/Ethnicity in a U.S. Urban Location

Childhood health disparities by race have been found. Neighborhood disadvantage, which may result from racism, may impact outcomes. The aim of the study is to describe the distribution of mental health (MH) and developmental disabilities (DD) diagnosis across Child Opportunity Index (COI) levels by race/ethnicity. A cross-sectional study using 2022 outpatient visit data for children < 18 years living in the Louisville Metropolitan Area (n = 115,738) was conducted. Multivariable logistic regression analyses examined the association between diagnoses and COI levels, controlling for sex and age. Almost 18,000 children (15.5%) had a MH or DD (7,905 [6.8%]) diagnosis. In each COI level, the prevalence of MH diagnosis was lower for non-Hispanic (N-H) Black than for N-H White children. In adjusted analyses, there were no significant associations between diagnoses and COI for non-White children for MH or DD diagnoses. The odds of receiving a MH [OR: 1.74 (95% CI: 1.62, 1.87)] and DD [OR: 1.69 (95% CI: 1.51, 1.88)] diagnosis were higher among N-H White children living in Very Low compared to Very High COI areas. Current findings suggest that COI does not explain disparities in diagnosis for non-White children. More research is needed to identify potential multi-level drivers such as other forms of racism. Identifying programs, policies, and interventions to reduce childhood poverty and link children and families to affordable, family-centered, quality community mental and physical health resources is needed to ensure that families can build trusting relationships with the providers while minimizing stigma.

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.

Cannabis and opioid perceptions, co-use, and substitution among patients across 4 NCI-Designated Cancer Centers

Prescription opioids are used for managing pain in persons with cancer, however, there are socioeconomic and racial disparities in medication access. Cannabis is increasingly used for cancer symptom management and as an opioid alternative. Limited data are available about patterns of opioid and cannabis use among patients with cancer. We used survey data from 4 National Cancer Institute-designated cancer centers in 3 states (n = 1220) to assess perceptions, use of cannabis and opioids for pain, their substitution, and racial and ethnic differences in each outcome. Compared with White patients, Black patients were less likely to use opioids for pain (odds ratio [OR] = 0.66; P = .035) and more likely to report that cannabis was more effective than opioids (OR = 2.46; P = .03). Race effects were mitigated (P > .05) after controlling for socioeconomic factors. Further research is needed to understand cannabis and opioid use patterns and how overlapping social determinants of health create a disadvantage in cancer symptom management for Black patients.

Parents Experiences of Racism in the Neonatal Intensive Care Unit

Few studies have investigated parent's experiences with racism in the neonatal intensive care unit (NICU). Our objective was to explore how parents perceive their interactions with NICU staff and if/how racism in the NICU was experienced. Parents of infants receiving care in an urban NICU completed fixed choice surveys regarding their experiences and demographics, with 6 open-ended questions to elaborate on their fixed-choice responses. Using a constant comparative method informed by Constructivist Grounded Theory, we identified 3 main themes from the comments provided by 97 respondents: Care and harm coexisting, racism often manifesting as neglectful care, and the power differential is most impactful during times of parent advocacy. Parents spoke positively regarding their experiences and also reported disparate treatment attributed to their racial/ethnic identity. Racism was experienced by inappropriate comments and apathy toward parent requests, occurring during intimate interactions between staff and parents. Descriptions of parental advocacy efforts highlighted the lack of power they held in relation to the NICU staff. We recommend strengthening the focus on equity and mitigating power imbalances in the NICU.

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 racial residential segregation and screening uptake for colorectal and cervical cancer among Black and White patients in five US health care systems

BACKGROUND

Despite increased recognition that structural racism contributes to poorer health outcomes for racial and ethnic minorities, there are knowledge gaps about how current patterns of racial residential segregation are associated with cancer screening uptake. The authors examined associations between Black residential segregation and screening for colorectal cancer (CRC) and cervical cancer among non-Hispanic Black and non-Hispanic White adults.

METHODS

This was a retrospective study of CRC and cervical cancer screening-eligible adults from five health care systems within the Population-Based Research to Optimize the Screening Process (PROSPR II) Consortium (cohort entry, 2010-2012). Residential segregation was measured using site-specific quartiles of the Black local isolation score (LIS). The outcome was receipt of CRC or cervical cancer screening within 3 years of cohort entry (2010-2015). Logistic regression was used to calculate associations between the LIS and screening completion, adjusting for patient-level covariates.

RESULTS

Among CRC (n = 642,661) and cervical cancer (n = 163,340) screening-eligible patients, 456,526 (71.0%) and 106,124 (65.0%), respectively, received screening. Across PROSPR sites, living in neighborhoods with higher LIS tended to be associated with lower odds of CRC screening (Kaiser Permanente Northern California: adjusted odds ratio [aOR] LIS trend in Black patients, 0.95 [p < .001]; aOR LIS trend in White patients, 0.98 [p < .001]; Kaiser Permanente Southern California: aOR LIS trend in Black patients, 0.98 [p = .026]; aOR LIS trend in White patients, 1.01 [p = .023]; Kaiser Permanente Washington: aOR LIS trend in White patients, 0.97 [p = .002]. However, for cervical cancer screening, associations with the LIS varied by site and race (Kaiser Permanente Washington: aOR LIS trend in White patients, 0.95 [p < .001]; Mass General Brigham: aOR LIS trend in Black patients, 1.12 [p < .001]; aOR LIS trend in White patients, 1.03 [p < .001]).

CONCLUSIONS

Across five diverse health care systems, the direction of the association between Black residential segregation and screening varied by PROSPR site, race, and screening type. Additional research, including studies that examine multiple dimensions of segregation and structural racism using intersectional approaches, are needed to further disentangle these relationships.

Racial Composition of Social Environments Over the Life Course Using the Pictorial Racial Composition Measure: Development and Validation Study

BACKGROUND

Studies investigating the impact of racial segregation on health have reported mixed findings and tended to focus on the racial composition of neighborhoods. These studies use varying racial composition measures, such as census data or investigator-adapted questions, which are currently limited to assessing one dimension of neighborhood racial composition.

OBJECTIVE

This study aims to develop and validate a novel racial segregation measure, the Pictorial Racial Composition Measure (PRCM).

METHODS

The PRCM is a 10-item questionnaire of pictures representing social environments across adolescence and adulthood: neighborhoods and blocks (adolescent and current), schools and classrooms (junior high and high school), workplace, and place of worship. Cognitive interviews (n=13) and surveys (N=549) were administered to medically underserved patients at a primary care clinic at the Barnes-Jewish Hospital. Development of the PRCM occurred across pilot and main phases. For each social environment and survey phase (pilot and main), we computed positive versus negative pairwise comparisons: mostly Black versus all other categories, half Black versus all other categories, and mostly White versus all other categories. We calculated the following validity metrics for each pairwise comparison: sensitivity, specificity, correct classification rate, positive predictive value, negative predictive value, positive likelihood ratio, negative likelihood ratio, false positive rate, and false negative rate.

RESULTS

For each social environment, the mostly Black and mostly White dichotomizations generated better validity metrics relative to the half Black dichotomization. Across all 10 social environments in the pilot and main phases, mostly Black and mostly White dichotomizations exhibited a moderate-to-high sensitivity, specificity, correct classification rate, positive predictive value, and negative predictive value. The positive likelihood ratio values were >1, and the negative likelihood ratio values were close to 0. The false positive and negative rates were low to moderate.

CONCLUSIONS

These findings support that using either the mostly Black versus other categories or the mostly White versus other categories dichotomizations may provide accurate and reliable measures of racial composition across the 10 social environments. The PRCM can serve as a uniform measure across disciplines, capture multiple social environments over the life course, and be administered during one study visit. The PRCM also provides an added window into understanding how structural racism has impacted minoritized communities and may inform equitable intervention and prevention efforts to improve lives.

How structural racism, neighborhood deprivation, and maternal characteristics contribute to inequities in birth outcomes

Decades of disparities in health between infants born to Black and White mothers have persisted in recent years, despite policy initiatives to improve maternal and reproductive health for Black mothers. Although scholars have increasingly recognized the critical role that structural racism plays in driving health outcomes for Black people, measurement of this relationship remains challenging. This study examines trends in preterm birth and low birth weight between 2007 and 2018 separately for births to Black and White mothers. Using a multivariate regression model, we evaluated potential factors, including an index of racialized disadvantage as well as community- and individual-level factors that serve as proxy measures for structural racism, that may contribute to White-Black differences in infant health. Finally, we assessed whether unequal effects of these factors may explain differences in birth outcomes. We found that differences in the effects of these factors appear to explain about half of the underlying disparity in infant health.

Using a Latent Variable Method to Develop a Composite, Multidimensional Measure of Structural Racism at the City Level

INTRODUCTION

Although structural racism is strongly related to racial health disparities, we are not aware of any composite, multidimensional measure of structural racism at the city level in the United States. However, many of the policies, programs, and institutions that create and maintain structural racism are located at the city level. To expand upon previous research, this paper uses a novel measure to measure structural racism at the city level for the non-Hispanic Black population.

METHODS

We used confirmatory factor analysis to model the latent construct of structural racism for 776 U.S. cities. The model included six indicators across five dimensions: racial segregation, incarceration, educational attainment, employment, and economic status. We generated factor scores that weighted the indicators in order to produce the best model fit. The resulting factor scores represented the level of structural racism in each city. We demonstrated the utility of this measure by demonstrating its strong correlation with Black-White disparities in firearm homicide rates.

RESULTS

There were profound differences in the magnitude of structural racism across cities. There were also striking differences in the magnitude of the racial disparity in firearm homicide across cities. Structural racism was a significant predictor of the magnitude of these racial disparities in firearm homicide. Each one standard deviation increase in the structural racism factor score increased the firearm homicide rate ratio by a factor of approximately 1.2 (95% confidence interval, 1.1-1.3).

CONCLUSIONS

These new measures can be utilized by researchers to relate structural racism to racial health disparities at the city level.

Spatial and spatio-temporal statistical implications for measuring structural racism: A review of three widely used residential segregation measures

Social determinants of health are the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning and quality of life outcomes and risks - these social determinants of health often aid in explaining the racial and ethnic health inequities present in the United States (US). The root cause of these social determinants of health has been tied to structural racism, and residential segregation is one such domain of structural racism that allows for the operationalization of the geography of structural racism. This review focuses on three residential segregation measures that are often utilized to capture segregation as a function of race/ethnicity, income, and simultaneously race/ethnicity and income. Empirical findings related to the spatial and spatio-temporal heterogeneity of these residential segregation measures are presented. We also discuss some of the implications of utilizing these three residential segregation measures.

Adverse Infant Health Outcomes Increased After the 2016 U.S. Presidential Election Among Non-White U.S.-born and Foreign-born Mothers

Macro-level events such as elections can improve or harm population health across existing axes of stratification through policy changes and signals of inclusion or threat. This study investigates whether rates of, and disparities in, adverse birth outcomes between racialized and nativity groups changed after Donald Trump's November 2016 election, a period characterized by increases in xenophobic and racist messages, policies, and actions in the United States. Using data from 15,568,710 U.S. births between November 2012 and November 2018, we find that adverse birth outcomes increased after Trump's election among U.S.- and foreign-born mothers racialized as Black, Hispanic, and Asian and Pacific Islander (API), compared with the period encompassing the two Obama presidencies. Results for Whites suggest no change or a slight decrease in adverse outcomes following Trump's election, yet this finding was not robust to checks for seasonality. Black-White, Hispanic-White, and API-White disparities in adverse birth outcomes widened among both U.S.- and foreign-born mothers after Trump's election. Our findings suggest that Trump's election was a racist and xenophobic macro-level political event that undermined the health of infants born to non-White mothers in the United States.

Incorporating Anti-racist Principles Throughout the Research Lifecycle: A Position Statement from the Society of General Internal Medicine (SGIM)

Biomedical research has advanced medicine but also contributed to widening racial and ethnic health inequities. Despite a growing acknowledgment of the need to incorporate anti-racist objectives into research, there remains a need for practical guidance for recognizing and addressing the influence of ingrained practices perpetuating racial harms, particularly for general internists. Through a review of the literature, and informed by the Research Lifecycle Framework, this position statement from the Society of General Internal Medicine presents a conceptual framework suggesting multi-level systemic changes and strategies for researchers to incorporate an anti-racist perspective throughout the research lifecycle. It begins with a clear assertion that race and ethnicity are socio-political constructs that have important consequences on health and health disparities through various forms of racism. Recommendations include leveraging a comprehensive approach to integrate anti-racist principles and acknowledging that racism, not race, drives health inequities. Individual researchers must acknowledge systemic racism's impact on health, engage in self-education to mitigate biases, hire diverse teams, and include historically excluded communities in research. Institutions must provide clear guidelines on the use of race and ethnicity in research, reject stigmatizing language, and invest in systemic commitments to diversity, equity, and anti-racism. National organizations must call for race-conscious research standards and training, and create measures to ensure accountability, establishing standards for race-conscious research for research funding. This position statement emphasizes our collective responsibility to combat systemic racism in research, and urges a transformative shift toward anti-racist practices throughout the research cycle.

Rural hospital and obstetric unit closures as social determinants of racial and ethnic maternal health disparities: A scoping review

AIMS

To synthesize literature examining (1) rural hospital or obstetric unit closures as a social determinant of maternal/infant health outcomes and (2) closures as a social determinant of racial/ethnic disparities in maternal/infant health outcomes.

DESIGN

Scoping review.

DATA SOURCES

MEDLINE, OVID/Embase and CINAHL were searched systematically to identify sources from 31 July 2003 to 31 July 2023. The Arksey and O'Malley methodology for scoping reviews was used.

RESULTS

Four studies from the United States and Australia documented the impact of rural hospital or obstetric unit closures on maternal/infant health outcomes, such as increased births in hospitals without obstetric units, out-of-hospital births or babies born before arrival, preterm birth, infant mortality and sociocultural risks that contribute to clinical risk. No eligible studies investigated hospital or obstetric unit closure as a social determinant of racial disparities in rural maternal/infant health outcomes.

CONCLUSION

Despite significant racial and ethnic rural maternal health disparities, associations between rural closures and maternal health outcomes for racial and ethnic minorities are understudied. More research is needed to understand the extent to which rural closures, a social determinant of health, could disproportionately, negatively affect the health of racially and ethnically minoritized women.

IMPLICATIONS FOR THE PROFESSION AND PATIENT CARE

Rural women have a greater risk of maternal and infant mortality and morbidity compared with urban women, and the impact of rural closures on racial and ethnic maternal health disparities is not well documented. Research about the impact of rural closures on maternal health disparities could inform policy to assure essential obstetric care is available for rural populations globally.

IMPACT

Findings provide a call to action for research to understand relationships between rural closures and racial and ethnic maternal health disparities, which is especially important for serving rural Non-Hispanic Black and American Indian/Alaska Native women.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Negligence in biomedical research: an anti-racist approach for substance use researchers

Racism is embedded in the fabric of society at structural, disciplinary, hegemonic, and interpersonal levels, working as a mechanism that drives health disparities. In particular, stigmatized views of substance use get entangled with racialization, serving as a tool to uphold oppressive systems. While national health institutions have made commitments to dismantle these systems in the United States, anti-racism has not been integrated into biomedical research practice. The ways in which substance use researchers use and interpret race data-without engaging in structural racism as a mechanism of health inequity-can only be described as inadequate. Drawing upon concepts from the Public Health Critical Race praxis, QuantCrit, and an anti-racism research framework, we recommend a set of guidelines to help biomedical researchers conceptualize and engage with race more responsibly in substance use research.

Measuring variation in infant mortality and deaths of despair by US congressional district in Pennsylvania: a methodological case study

Many ecological studies examine health outcomes and disparities using administrative boundaries such as census tracts, counties, or states. These boundaries help us to understand the patterning of health by place, along with impacts of policies implemented at these levels. However, additional geopolitical units (units with both geographic and political meaning), such as congressional districts (CDs), present further opportunities to connect research with public policy. Here we provide a step-by-step guide on how to conduct disparities-focused analysis at the CD level. As an applied case study, we use geocoded vital statistics data from 2010-2015 to examine levels of and disparities in infant mortality and deaths of despair in the 19 US CDs of Pennsylvania for the 111th-112th (2009-2012) Congresses and 18 CDs for the 113th-114th (2013-2016) Congresses. We also provide recommendations for extending CD-level analysis to other outcomes, states, and geopolitical boundaries, such as state legislative districts. Increased surveillance of health outcomes at the CD level can help prompt policy action and advocacy and, hopefully, reduce rates of and disparities in adverse health outcomes.

Society of Family Planning Research Practice Support: Strategies and considerations for addressing race and racism in quantitative family planning studies

OBJECTIVES

Family planning researchers have not critically engaged with topics of race, racism, and associated concepts like ethnicity. This lack of engagement contributes to the reproduction of research that reifies racial hierarchies rather than illuminate and interrupt the processes by which racism affects health. This Research Practice Support paper lays out considerations and best practices for addressing race and racism in quantitative family planning research.

STUDY DESIGN

We are scholars with racialized identities and expertise in racial health equity in family planning research. We draw from scholarship and guidance across disciplines to examine common shortcomings in the use and analysis of race and racism and propose practices for rigorous use of these concepts in quantitative family planning research.

RESULTS

We recommend articulating the role of race and racism in the development of the research question, authorship and positionality, study design, data collection, analytic approach, and interpretation of analyses. Definitions of relevant concepts and additional resources are provided.

CONCLUSIONS

Family planning and racism are inextricably linked. Failing to name and analyze the pathways through which structural racism affects family planning, and the people who need or want to plan if, when, or how to become pregnant or parent may reproduce harmful and incorrect beliefs about the causes of health inequities and the attributes of Black, Indigenous, and other people racialized as non-White. Family planning researchers should critically study racism and race with procedures grounded in appropriate and articulated theory, evidence, and analytic approaches.

IMPLICATIONS

Family planning research can better contribute to efforts to eliminate racialized health inequities and avoid perpetuating harmful beliefs and conceptualizations of race by ensuring that they study race and racism with procedures grounded in appropriate and articulated theory, evidence, and analytic approaches.

Leveraging biosocial methods to examine and address structural determinants of health and promote health equity

BACKGROUND

Biosocial approaches in nursing research have largely focused on the ways that social determinants of health influence individual-level outcomes, including symptom management, family and social support, and educational interventions.

PURPOSE

Theoretical, methodological, and practical strategies are needed to expand current biosocial methods for nursing science and focus on upstream, structural determinants of health and the policies that underlie health inequities.

METHODS

This paper summarizes presentations given at the 2023 Council for the Advancement of Nursing Science Advanced Methods Conference, Biosocial Methods to Advance Health Equity, in a panel titled "Individual, community, systems and policy related to biosocial methods."

DISCUSSION

Nurses are uniquely positioned to examine upstream, structural determinants of health by leveraging expertise in biosocial methods, collaborating with interdisciplinary researchers and community members, and advocating for policy change. By conducting theory-grounded biosocial research, nurse researchers can significantly advance scientific knowledge and promote health equity for individuals and communities.

CONCLUSION

Nurse scientists are conducting research using biosocial methods and provide recommendations for expansion of this approach in the field.

Identifying and Predicting Subgroups of Veterans With Mild Traumatic Brain Injury Based on Distinct Configurations of Postconcussive Symptom Endorsement: A Latent Class Analysis

OBJECTIVE

To identify distinct subgroups of veterans with mild traumatic brain injury (mTBI) based on configurations of postconcussive symptom (PCS) endorsement, and to examine predictors of subgroup membership.

SETTING

Outpatient Veterans Health Administration (VHA).

PARTICIPANTS

Veterans with clinician-confirmed mTBI who completed the Neurobehavioral Symptom Inventory (NSI), determined using the Comprehensive Traumatic Brain Injury Evaluation database. Individuals who tended to overreport symptoms were excluded via an embedded symptom validity scale.

DESIGN

Retrospective cohort study leveraging national VHA clinical data from 2012 to 2020. Latent class analysis (LCA) with a split-sample cross-validation procedure was used to identify subgroups of veterans. Multinomial logistic regression was used to examine predictors of subgroup membership.

MAIN MEASURES

Latent classes identified using NSI items.

RESULTS

The study included 72 252 eligible veterans, who were primarily White (73%) and male (94%). The LCA supported 7 distinct subgroups of veterans with mTBI, characterized by diverging patterns of risk for specific PCS across vestibular (eg, dizziness), somatosensory (eg, headache), cognitive (eg, forgetfulness), and mood domains (eg, anxiety). The most prevalent subgroup was Global (20.7%), followed by Cognitive-Mood (16.3%), Headache-Cognitive-Mood (H-C-M; 16.3%), Headache-Mood (14.2%), Anxiety (13.8%), Headache-Sleep (10.3%), and Minimal (8.5%). The Global class was used as the reference class for multinomial logistic regression because it was distinguished from others based on elevated risk for PCS across all domains. Female (vs male), Black (vs White), and Hispanic veterans (vs non-Hispanic) were less likely to be members of most subgroups characterized by lesser PCS endorsement relative to the Global class (excluding Headache-Mood).

CONCLUSION

The 7 distinct groups identified in this study distill heterogenous patterns of PCS endorsement into clinically actionable phenotypes that can be used to tailor clinical management of veterans with mTBI. Findings reveal empirical support for potential racial, ethnic, and sex-based disparities in PCS among veterans, informing efforts aimed at promoting equitable recovery from mTBI in this population.

Race and Ethnicity Reporting in Occupational Therapy Research Among Autistic Youth

Historically marginalized racial and ethnic groups are underrepresented in autism research broadly; however, patterns of inclusion in occupational therapy research are unknown.In this secondary data analysis, we examined race and ethnicity reporting across articles included in a systematic review of evidence related to occupational therapy practice with autistic individuals <18 years (2013-2021).Two team members reached >90% interrater coding agreement in race and ethnicity reporting across articles in ADLs/IADLs, education/work, play, sleep, and social participation in clinics, homes/communities, and schools.Intervention outcomes of ADL/IADLs (66.7%) and play (66.7%) had low rates of reporting, while social participation in schools (100%) and education/work (100%) had higher rates of reporting. Sample diversity was greatest among research in schools and most limited in clinic-based settings.Systemic racism that limits individuals' participation in occupational therapy research perpetuates racial and ethnic health inequities among autistic children and adolescents.

Considerations for Subgroup Analyses in Cluster-Randomized Trials Based on Aggregated Individual-Level Predictors

In research assessing the effect of an intervention or exposure, a key secondary objective often involves assessing differential effects of this intervention or exposure in subgroups of interest; this is often referred to as assessing effect modification or heterogeneity of treatment effects (HTE). Observed HTE can have important implications for policy, including intervention strategies (e.g., will some patients benefit more from intervention than others?) and prioritizing resources (e.g., to reduce observed health disparities). Analysis of HTE is well understood in studies where the independent unit is an individual. In contrast, in studies where the independent unit is a cluster (e.g., a hospital or school) and a cluster-level outcome is used in the analysis, it is less well understood how to proceed if the HTE analysis of interest involves an individual-level characteristic (e.g., self-reported race) that must be aggregated at the cluster level. Through simulations, we show that only individual-level models have power to detect HTE by individual-level variables; if outcomes must be defined at the cluster level, then there is often low power to detect HTE by the corresponding aggregated variables. We illustrate the challenges inherent to this type of analysis in a study assessing the effect of an intervention on increasing COVID-19 booster vaccination rates at long-term care centers.

Facility-Level and Racial Disparities in Access to Inpatient Psychiatric Occupational Therapy Services in the Veterans Health Administration

IMPORTANCE

Veterans receiving inpatient psychiatric services with limitations in activities of daily living (ADLs) benefit from occupational therapy, yet disparities in access are unknown.

OBJECTIVE

To investigate whether ADL limitations, an indicator of occupational therapy need, was associated with inpatient psychiatric occupational therapy utilization in the Veterans Health Administration (VHA) and whether this relationship differs by facility characteristics.

DESIGN

Secondary analysis of VHA data. Modified Poisson regression modeled occupational therapy utilization as a function of ADL limitations, facility characteristics, and covariates. Interactions estimated whether the relationship between ADL limitations and occupational therapy utilization differed across facility characteristics.

SETTING

VHA inpatient psychiatric setting.

PARTICIPANTS

Veterans receiving VHA inpatient psychiatric care from 2015 to 2020 (N = 133,844).

OUTCOMES AND MEASURES

Occupational therapy utilization.

RESULTS

Veterans with ADL limitations were more likely to receive occupational therapy. Veterans receiving care in facilities with higher complexity and greater inpatient psychiatric care quality were more likely to receive occupational therapy. Additionally, Black veterans were less likely to receive occupational therapy relative to their White, non-Hispanic counterparts. Interactions indicated that the extent to which ADL limitations drove access to occupational therapy utilization was weaker within facilities with higher complexity and care quality.

CONCLUSIONS AND RELEVANCE

Veterans with ADL limitations were more likely to access inpatient psychiatric occupational therapy, suggesting that such services are generally allocated to veterans in need. However, findings indicate disparities in access across patient-level (e.g., Black race) and facility-level (e.g., facility complexity) factors, informing efforts to eliminate barriers to accessing these valuable services. Plain-Language Summary: This is the first study, to our knowledge, to examine disparities in access to inpatient psychiatric occupational therapy in the Veterans Health Administration (VHA). The study findings show that access to inpatient psychiatric occupational therapy is partly driven by the needs of the patient. However, nonclinical factors, such as a patient's race and the characteristics of the facility at which they receive care (complexity, number of psychiatric beds available, and the quality of psychiatric care), are also important drivers of access. Identifying factors influencing access to these valuable services is the first step in developing strategies that reduce barriers to access for veterans in need.

Neighborhood Socioeconomic Deprivation and Health Care Costs in Older Community-Dwelling Adults: Importance of Functional Impairment and Frailty

BACKGROUND

Low neighborhood socioeconomic status is associated with adverse health outcomes, but its association with health care costs in older adults is uncertain.

OBJECTIVES

To estimate the association of neighborhood Area Deprivation Index (ADI) with total, inpatient, outpatient, skilled nursing facility (SNF), and home health care (HHC) costs among older community-dwelling Medicare beneficiaries, and determine whether these associations are explained by multimorbidity, phenotypic frailty, or functional impairments.

DESIGN

Four prospective cohort studies linked with each other and with Medicare claims.

PARTICIPANTS

In total, 8165 community-dwelling fee-for-service beneficiaries (mean age 79.2 years, 52.9% female).

MAIN MEASURES

ADI of participant residence census tract, Hierarchical Conditions Category multimorbidity score, self-reported functional impairments (difficulty performing four activities of daily living), and frailty phenotype. Total, inpatient, outpatient, post-acute SNF, and HHC costs (US 2020 dollars) for 36 months after the index examination.

KEY RESULTS

Mean incremental annualized total health care costs adjusted for age, race/ethnicity, and sex increased with ADI ($3317 [95% CI 1274 to 5360] for the most deprived vs least deprived ADI quintile, and overall p-value for ADI variable 0.009). The incremental cost for the most deprived vs least deprived ADI quintile was increasingly attenuated after separate adjustment for multimorbidity ($2407 [95% CI 416 to 4398], overall ADI p-value 0.066), frailty phenotype ($1962 [95% CI 11 to 3913], overall ADI p-value 0.22), or functional impairments ($1246 [95% CI -706 to 3198], overall ADI p-value 0.29).

CONCLUSIONS

Total health care costs are higher for older community-dwelling Medicare beneficiaries residing in the most socioeconomically deprived areas compared to the least deprived areas. This association was not significant after accounting for the higher prevalence of phenotypic frailty and functional impairments among residents of socioeconomically deprived neighborhoods.

Trends and structural factors affecting health equity in the United States at the local level, 1990-2019

Health equity is fundamental to improving the health of populations, but in recent decades progress towards this goal has been mixed. To better support this mission, a deeper understanding of the local heterogeneity within population-level health equity is vital. This analysis presents trends in average health and health equity in the United States at the local level from 1990 to 2019 using three different health outcomes: mortality, self-reported health status, and healthy days. Furthermore, it examines the association between these measures of average health and health equity with several structural factors. Results indicate growing levels of geographic inequality disproportionately impacting less urbanized parts of the country, with rural counties experiencing the largest declines in health equity, followed by Medium and Small Metropolitan counties. Additionally, lower levels of health equity are associated with poorer local socioeconomic context, including several measures that are proxies for structural racism. Altogether, these findings strongly suggest social and economic factors play a pivotal role in explaining growing levels of geographic health inequality in the United States. Policymakers invested in improving health equity must adopt holistic and upstream approaches to improve and equalize economic opportunity as a means of fostering health equity.

Residential Redlining, Neighborhood Trajectory, and Equity of Breast and Colorectal Cancer Care

OBJECTIVE

To determine the influence of structural racism, vis-à-vis neighborhood socioeconomic trajectory, on colorectal and breast cancer diagnosis and treatment.

BACKGROUND

Inequities in cancer care are well-documented in the United States but less is understood about how historical policies like residential redlining and evolving neighborhood characteristics influence current gaps in care.

METHODS

This retrospective cohort study included adult patients diagnosed with colorectal or breast cancer between 2010 and 2015 in 7 Indiana cities with available historic redlining data. Current neighborhood socioeconomic status was determined by the Area Deprivation Index. Based on historic redlining maps and the current Area Deprivation Index, we created 4 "neighborhood trajectory" categories: advantage stable, advantage reduced, disadvantage stable, and disadvantage reduced. Modified Poisson regression models estimated the relative risks (RRs) of neighborhood trajectory on cancer stage at diagnosis and receipt of cancer-directed surgery (CDS).

RESULTS

A final cohort derivation identified 4862 cancer patients with colorectal or breast cancer. Compared with "advantage stable" neighborhoods, "disadvantage stable" neighborhood was associated with a late-stage diagnosis for both colorectal and breast cancer [RR = 1.30 (95% CI: 1.05-1.59); RR = 1.41 (1.09-1.83), respectively]. Black patients had a lower likelihood of receiving CDS in "disadvantage reduced" neighborhoods [RR = 0.92 (0.86-0.99)] than White patients.

CONCLUSIONS

Disadvantage stable neighborhoods were associated with late-stage diagnoses of breast and colorectal cancer. "Disadvantage reduced" (gentrified) neighborhoods were associated with racial inequity in CDS. Improved neighborhood socioeconomic conditions may improve timely diagnosis but could contribute to racial inequities in surgical treatment.

The neurophysiological consequences of racism-related stressors in Black Americans

Racism-related stressors, from experiences of both implicit and explicit racial discrimination to systemic socioeconomic disadvantage, have a cumulative impact on Black Americans' health. The present narrative review synthesizes peripheral (neuroendocrine and inflammation markers), psychophysiological (heart-rate variability, skin conductance), and neuroimaging (structural and functional) findings that demonstrate unique associations with racism-related stress. Emerging evidence reveals how racism-related stressors contribute to differential physiological and neural responses and may have distinct impacts on regions involved with threat and social processing. Ultimately, the neurophysiological effects of racism-related stress may confer biological susceptibility to stress and trauma-related disorders. We note critical gaps in the literature on the neurophysiological impact of racism-related stress and outline additional research that is needed on the multifactorial interactions between racism and mental health. A clearer understanding of the interactions between racism-related stress, neurophysiology, and stress- and trauma-related disorders is critical for preventative efforts, biomarker discovery, and selection of effective clinical treatments for Black Americans.

Health consequences of structural sexism: Conceptual foundations, empirical evidence and priorities for future research

A nascent body of work has begun exploring the health consequences of structural sexism. This article provides an overview of the concept of structural sexism and an elaboration of the potential pathways connecting it to health. Next, it reviews existing measurement approaches and the current state of empirical evidence on the relationship between structural sexism and health in the United States. Finally, it highlights key priorities for future research, which include: expanding and refining measures, increasing public data availability, broadening the scope of inquiry to include a wider range of outcomes, exploring mechanisms, incorporating intersectionality, and applying a life course lens.

Aging, Race, and Health Disparities: Recommendations From the Research Centers Collaborative Network

Racial disparities in adverse health outcomes with aging have been well described. Yet, much of the research focuses on racial comparisons, with relatively less attention to the identification of underlying mechanisms. To address these gaps, the Research Centers Collaborative Network held a workshop on aging, race, and health disparities to identify research priorities and inform the investigation, implementation, and dissemination of strategies to mitigate disparities in healthy aging. This article provides a summary of the key recommendations and highlights the need for research that builds a strong evidence base with both clinical and policy implications. Successful execution of these recommendations will require a concerted effort to increase participation of underrepresented groups in research through community engagement and partnerships. In addition, resources to support and promote the training and development of health disparities researchers will be critical in making health equity a shared responsibility for all major stakeholders.

Engaging Antiracist And Decolonial Praxis To Advance Equity In Oregon Public Health Surveillance Practices

Public health surveillance and data systems in the US remain an unnamed facet of structural racism. What gets measured, which data get collected and analyzed, and how and by whom are not matters of happenstance. Rather, surveillance and data systems are productions and reproductions of political priority, epistemic privilege, and racialized state power. This has consequences for how communities of color are represented or misrepresented, viewed, and valued and for what is prioritized and viewed as legitimate cause for action. Surveillance and data systems accordingly must be understood as both an instrument of structural racism and an opportunity to dismantle it. Here, we outline a critique of standard surveillance systems and practice, drawing from the social epidemiology, critical theory, and decolonial theory literatures to illuminate matters of power germane to epistemic and procedural justice in the surveillance of communities of color. We then summarize how community partners, academics, and state health department data scientists collaborated to reimagine survey practices in Oregon, engaging public health critical race praxis and decolonial theory to reorient toward antiracist surveillance systems. We close with a brief discussion of implications for practice and areas for continued consideration and reflection.

Nutrition facts, drug facts, and model facts: putting AI ethics into practice in gun violence research

OBJECTIVE

Firearm injury research necessitates using data from often-exploited vulnerable populations of Black and Brown Americans. In order to reduce bias against protected attributes, this study provides a theoretical framework for establishing trust and transparency in the use of AI with the general population.

METHODS

We propose a Model Facts template that is easily extendable and decomposes accuracy and demographics into standardized and minimally complex values. This framework allows general users to assess the validity and biases of a model without diving into technical model documentation.

EXAMPLES

We apply the Model Facts template on 2 previously published models, a violence risk identification model and a suicide risk prediction model. We demonstrate the ease of accessing the appropriate information when the data are structured appropriately.

DISCUSSION

The Model Facts template is limited in its current form to human based data and biases. Like nutrition facts, it will require educational programs for users to grasp its full utility. Human computer interaction experiments should be conducted to ensure model information is communicated accurately and in a manner that improves user decisions.

CONCLUSION

The Model Facts label is the first framework dedicated to establishing trust with end users and general population consumers. Implementation of Model Facts into firearm injury research will provide public health practitioners and those impacted by firearm injury greater faith in the tools the research provides.

Examining the relationship between social determinants of health, measures of structural racism and county-level overdose deaths from 2017-2020

INTRODUCTION

Despite being an important determinant of health outcomes, measures of structural racism are lacking in studies examining the relationship between the social determinants of health (SDOH) and overdose deaths. The aim of this study is to examine the association between per capita revenue generated from fines and forfeitures, a novel measure of structural racism, and other SDOH with county-level overdose deaths from 2017-2020.

METHODS

This longitudinal analysis of 2,846 counties from 2017-2020 used bivariate and multivariate Generalized Estimating Equations models to estimate associations between county overdose mortality rates and SDOH characteristics, including the fines and forfeitures measure.

RESULTS

In our multivariate model, higher per capita fine and forfeiture revenue (5.76; CI: 4.76, 6.78), households receiving food stamps (1.15; CI: 0.77, 1.53), residents that are veterans (1.07; CI: 0.52, 1.63), substance use treatment availability (4.69; CI: 3.03, 6.33) and lower population density (-0.002; CI: -0.004, -0.001) and percent of Black residents (-0.7`; CI: -1.01, -0.42) were significantly associated with higher overdose death rates. There was a significant additive interaction between the fines and forfeitures measure (0.10; CI: 0.03, 0.17) and the percent of Black residents.

CONCLUSIONS

Our findings suggest that structural racism, along with other SDOH, is associated with overdose deaths. Future research should focus on connecting individual-level data on fines and forfeitures to overdose deaths and other health outcomes, include measures of justice-related fines, such as court fees, and assess whether interventions aimed at increasing economic vitality in disadvantaged communities impact overdose deaths in a meaningful way.

Structural gendered racism and preterm birth inequities in the United States

Structural gendered racism - the "totality of interconnectedness between structural racism and sexism" - is conceptualized as a fundamental cause of the persistent preterm birth inequities experienced by Black and Indigenous people in the United States. Our objective was to develop a state-level latent class measure of structural gendered racism and examine its association with preterm birth among all singleton live births in the US in 2019. Using previously-validated inequity indicators between White men and Black women across 9 domains (education, employment, poverty, homeownership, health insurance, segregation, voting, political representation, incarceration), we conducted a latent profile analysis to identify a latent categorical variable with k number of classes that have similar values on the observed continuous input variables. Racialized group-stratified multilevel modified Poisson regression models with robust variance and random effects for state assessed the association between state-level classes and preterm birth. We found four distinct latent classes that were all characterized by higher levels of disadvantage for Black women and advantages for White men, but the magnitude of that difference varied by latent class. We found preterm birth risk among Black birthing people was higher across all state-level latent classes compared to White birthing people, and there was some variation of preterm birth risk across classes among Black but not White birthing people. These findings further emphasize the importance of understanding and interrogating the whole system and the need for multifaceted policy solutions.

Influence of early childhood parental hostility and socioeconomic stress on children's internalizing symptom trajectories from childhood to adolescence

Introduction

Children and adolescents with elevated internalizing symptoms are at increased risk for depression, anxiety, and other psychopathology later in life. The present study examined the predictive links between two bioecological factors in early childhood-parental hostility and socioeconomic stress-and children's internalizing symptom class outcomes, while considering the effects of child sex assigned at birth on internalizing symptom development from childhood to adolescence.

Materials and Methods

The study used a sample of 1,534 children to test the predictive effects of socioeconomic stress at ages 18 and 27 months; hostile parenting measured at child ages 4-5; and sex assigned at birth on children's internalizing symptom latent class outcomes at child ages 7-9, 10-12, 13-15, and 16-19. Analyses also tested the mediating effect of parenting on the relationship between socioeconomic stress and children's symptom classes. Other covariates included parent depressive symptoms at child ages 4-5 and child race and ethnicity.

Results

Analyses identified three distinct heterogenous internalizing symptom classes characterized by relative symptom levels and progression: low (35%); moderate and increasing (41%); and higher and increasing (24%). As anticipated, higher levels of parental hostility in early childhood predicted membership in the higher and increasing symptom class, compared with the low symptom class (odds ratio (OR) = .61, 95% confidence interval (CI) [.48,.77]). Higher levels of early childhood socioeconomic stress were also associated with the likelihood of belonging to the higher-increasing symptom class compared to the low and moderate-increasing classes (OR = .46, 95% CI [.35,.60] and OR = .56, 95% CI [.44,.72], respectively). The total (c = .61) and direct (c' = .57) effects of socioeconomic stress on children's symptom class membership in the mediation analysis were significant (p <.001).

Discussion

Study findings suggest that intervening on modifiable bioecological stressors-including parenting behaviors and socioeconomic stressors-may provide important protective influences on children's internalizing symptom trajectories.

Combining artificial neural networks and a marginal structural model to predict the progression from depression to Alzheimer's disease

Introduction

Decades of research in population health have established depression as a likely precursor to Alzheimer's disease. A combination of causal estimates and machine learning methods in artificial intelligence could identify internal and external mediating mechanisms that contribute to the likelihood of progression from depression to Alzheimer's disease.

Methods

We developed an integrated predictive model, combining the marginal structural model and an artificial intelligence predictive model, distinguishing between patients likely to progress from depressive states to Alzheimer's disease better than each model alone.

Results

The integrated predictive model achieved substantial clinical relevance when using the area under the curve measure. It performed better than the traditional statistical method or a single artificial intelligence method alone.

Discussion

The integrated predictive model could form a part of a clinical screening tool that identifies patients who are likely to progress from depression to Alzheimer's disease for early behavioral health interventions. Given the high costs of treating Alzheimer's disease, our model could serve as a cost-effective intervention for the early detection of depression before it progresses to Alzheimer's disease.

Prevalence and risk factors of low birth weight in the United States: An analysis of 2016-2021 data

BACKGROUND

Low birthweight (LBW), infants weighing less than 2,500 g, is a global health concern associated with high infant morbidity and mortality rates. This study investigates LBW prevalence and its relation to maternal sociodemographic characteristics and lifestyle behaviors factors in the United States (US).

METHODS

This analysis used the National Survey of Children's Health (NSCH) data from 2016 to 2021, including n = 225,443 children aged 0-17 years. 18,131 had LBW (<2,500 g), and 2810 had very LBW (VLBW) (<1,500 g). Logistic regression calculated odds ratios (OR) using LBW as the dependent variable, adjusting for various factors.

RESULTS

Between 2016 and 2021 in the United States, LBW prevalence averaged 9.31%, with VLBW at 1.50%. Mothers aged 18-35, White, had the lowest LBW (7.63%) and VLBW (1.17%) rates. Mothers aged ≤18 years, black, had the highest LBW (15.45%) and VLBW infants (4.70%). Maternal age emerged as a significant LBW factor, with an OR of 1.27 for ≤18 and 1.19 for >35. Children in poor health had the highest OR (2.87). Race/ethnicity and other disparities were observed.

CONCLUSION

Our study highlights LBW risk among non-White mothers with specific criteria, emphasizing the need for continued exploration of intersectional targets for change that are exacerbating LBW disparities among marginalized populations which may be artificially attributed to biologic determinants and individual-level risk factors. In-depth analysis of repressive structures at the root of inequalities demand continued research on macro levels of influence. Customized healthcare reform holds the greatest potential to disrupt the patterns contributing to poor health outcomes among LBW children, and will ultimately maximize the reach and effectiveness of health promotion strategies and clinical practices aimed to improve universal maternal and infant health.

Recommendations for the responsible use and communication of race and ethnicity in neuroimaging research

The growing availability of large-population human biomedical datasets provides researchers with unique opportunities to conduct rigorous and impactful studies on brain and behavioral development, allowing for a more comprehensive understanding of neurodevelopment in diverse populations. However, the patterns observed in these datasets are more likely to be influenced by upstream structural inequities (that is, structural racism), which can lead to health disparities based on race, ethnicity and social class. This paper addresses the need for guidance and self-reflection in biomedical research on conceptualizing, contextualizing and communicating issues related to race and ethnicity. We provide recommendations as a starting point for researchers to rethink race and ethnicity choices in study design, model specification, statistical analysis and communication of results, implement practices to avoid the further stigmatization of historically minoritized groups, and engage in research practices that counteract existing harmful biases.

Structural Racism and Use of Labor Neuraxial Analgesia Among Non-Hispanic Black Birthing People

OBJECTIVE

To assess the association between structural racism and labor neuraxial analgesia use.

METHODS

This cross-sectional study analyzed 2017 U.S. natality data for non-Hispanic Black and White birthing people. The exposure was a multidimensional structural racism index measured in the county of the delivery hospital. It was calculated as the mean of three Black-White inequity ratios (ratios for lower education, unemployment, and incarceration in jails) and categorized into terciles, with the third tercile corresponding to high structural racism. The outcome was the labor neuraxial analgesia rate. Adjusted odds ratios and 95% CIs of neuraxial analgesia associated with terciles of the index were estimated with multivariate logistic regression models. Black and White people were compared with the use of an interaction term between race and ethnicity and the racism index.

RESULTS

Of the 1,740,716 birth certificates analyzed, 396,303 (22.8%) were for Black people. The labor neuraxial analgesia rate was 77.2% for Black people in the first tercile of the racism index, 74.7% in the second tercile, and 72.4% in the third tercile. For White people, the rates were 80.4%, 78.2%, and 78.2%, respectively. For Black people, compared with the first tercile of the racism index, the second tercile was associated with 18.4% (95% CI, 16.9-19.9%) decreased adjusted odds of receiving neuraxial analgesia and the third tercile with 28.3% (95% CI, 26.9-29.6%) decreased adjusted odds. For White people, the decreases were 13.4% (95% CI, 12.5-14.4%) in the second tercile and 15.6% (95% CI, 14.7-16.5%) in the third tercile. A significant difference in the odds of neuraxial analgesia was observed between Black and White people for the second and third terciles.

CONCLUSION

A multidimensional index of structural racism is associated with significantly reduced odds of receiving labor neuraxial analgesia among Black people and, to a lesser extent, White people.

Medical educators' perception of race in clinical practice

BACKGROUND

While several medical societies endorse race as a social construct, it is still often used as a biological trait in medical education. How medical educators employ race while teaching is likely impacted by their beliefs as to what race represents and its relevance in clinical care. Understanding these beliefs is necessary to guide medical education curriculum reform.

METHODS

This was a qualitative survey study, conducted in June 2020, of Georgetown University Medical Center faculty. As part of the survey, faculty were asked to rate, on a 5-point Likert scale, the extent to which they perceived race as a biological trait and its importance in clinical care. Self-identified clinical or preclinical faculty (N = 147) who believed that race had any importance were asked to provide an example illustrating its significance. Free-text responses were coded using content analysis with an inductive approach and contextualized by faculty's perspectives on the biological significance of race.

RESULTS

There were 130 (88%) responses categorized into two major themes: race is important for [1] screening, diagnosing, and treating diseases and [2] contextualizing patients' experiences and health behaviors. Compared to faculty who perceived race as biological, those who viewed race as strictly social were more likely to report using race to understand or acknowledge patients' exposure to racism. However, even among these faculty, explanations that suggested biological differences between racial groups were prevalent.

CONCLUSIONS

Medical educators use race primarily to understand diseases and frequently described biological differences between racial groups. Efforts to reframe race as sociopolitical may require education that examines race through a global lens, accounting for the genetic and cultural variability that occurs within racial groups; greater awareness of the association between structural racism and health inequities; movement away from identity-based risk stratification; and incorporation of tools that appraise race-based medical literature.

Culturally safe healthcare: changing the lens from provider control to patient agency

BACKGROUND AND GOAL

Marginalized patients often feel unwelcome in healthcare. The concept of culturally safe healthcare (CSH) represents an important paradigm shift from provider control to patients who feel safe voicing health concerns and believe that they are heard by providers. This study has five goals: review works describing CSH, identify CSH themes, describe provider behaviors associated with CSH, describe interventions, and discuss how health communication can advance CSH.

METHODS

A scoping review was conducted for articles published between 2019 and 2023 following modified PRISMA guidelines. Online databases included Pubmed (Medline), CINAHL, Web of Science, Google Scholar, and Redalyc. Thematic analysis was also conducted.

RESULTS

Twenty-one articles meeting inclusion criteria were identified and analyzed. Of these, five explained features of CSH, four were empirical studies, seven were content analyses, and five were interventions. Five themes were identified including (1) how patients perceive CSH, (2) sociocultural determinants of health inequity, (3) mistrust of care providers, (4) issues with the biomedical model of healthcare, and (5) the importance of provider-patient allyship. Care provider communication behaviors fostering CSH were discussed. Three CSH interventions were highlighted. Finally, there was a discussion for how health communication scholars can contribute to CSH.

CONCLUSIONS

CSH offers a paradigm shift from provider control to marginalized patients' experience of patient-provider communication. Recommendations for how health communication scholars can contribute to the implementation of CSH included developing guiding theories and measurement, evaluation of CSH outcomes, and conducting focus groups with patients to assess the meaning of cultural safety.

A Scoping Review of Neighborhoods and Cognitive Health Disparities Among US Midlife and Older Adults

Objectives: The neighborhood environment may be an important determinant of racial/ethnic disparities in cognitive function. To understand how neighborhoods are linked to cognition across racial/ethnic groups, this scoping review organizes research investigating relationships between multiple neighborhood domains and cognitive function in diverse samples of US midlife and older adults. Methods: PubMed/MEDLINE, Web of Science, and CAHL were used to extract quantitative disparities-focused studies (n = 17) that included US adults ages 50+, racial/ethnic minoritized populations, cognitive dependent variable(s), and neighborhood-level independent variable(s) published from January 2010 to October 2021. Results: Studies demonstrate variation within and between racial/ethnic groups in how neighborhood factors are associated with cognition. Economically and socially advantaged neighborhoods were associated with better cognition. Findings were mixed for built and neighborhood composition measures. Discussion: More research with greater racial/ethnic representation is needed to disentangle which aspects of the neighborhood are most salient for specific cognitive function domains across diverse populations.

COVID-19's Unequal Toll: Differences in Health-Related Quality of Life by Gendered and Racialized Groups

We examine whether the COVID-19 pandemic was associated with changes to daily activity limitations due to poor physical or mental health and whether those changes were different within and between gendered and racialized groups. We analyze 497,302 observations across the 2019 and 2020 waves of the Centers for Disease Control and Prevention Behavioral Risk Factor Surveillance System survey. Among White men and women, the COVID-19 pandemic was associated with fewer days of health-related activity limitations and decreased frequent activity limitation (≥14 days in the past month) compared to the prepandemic period. By contrast, Latina and Black women experienced increased days of activity limitation and greater likelihood of frequent activity limitation, and these changes were significantly different than for White women. These findings are robust to the inclusion of structural inequality measures and demonstrate how systemic racism and sexism likely exacerbate a myriad of pandemic-related health problems.

Expert Views on State Policies to Improve Engagement and Retention in Treatment for Opioid Use Disorder: A Qualitative Analysis of an Online Modified Delphi Process

OBJECTIVES

The aim of this study was to examine expert views on the effectiveness and implementability of state policies to improve engagement and retention in treatment for opioid use disorder (OUD).

METHODS

We conducted a 3-round modified Delphi process using the online ExpertLens platform. Participants included 66 experts on OUD treatment policies. Experts commented on 14 hypothetical state policies targeting treatment engagement and quality of care. Using the GRADE Evidence-to-Decision framework, we conducted reflexive thematic analysis to develop patterns of meaning from the dataset.

RESULTS

Only policies for providing continued access to evidence-based treatment for highly at-risk populations, settings, and periods were seen as effective in meaningfully reducing population-level opioid-related overdose mortality. Experts commented that, although the general public increasingly supports policies expanding medications for OUD and evidence-based care, ongoing stigma about OUD encourages public acceptance of punitive and paternalistic policies. Experts viewed all policies as at least moderately feasible given the current infrastructure and resources, with affordability reliant on long-term cost savings from reduced opioid-related harms. Equitability depended on whether experts perceived a policy as inherently equitable in its design as well as concerns about the potential for inequitable implementation due to structural oppression and interpersonal biases in criminal-legal, healthcare, and other systems.

CONCLUSIONS

Experts believe that supportive (rather than punitive) policies improve engagement and retention in OUD treatment. States could prioritize implementing supportive policies that are patient-centered and take a harm-reduction approach to enhance medications for OUD access and utilization. States could consider deimplementing punitive policies that are coercive, take an abstinence-only approach, and use punitive and restrictive measures.

Leisure engagement in older age is related to objective and subjective experiences of aging

Leisure engagement has potential to slow health and functional decline in older age. However, the benefits of different leisure domains for different aspects of aging remains unclear. In 8771 older adults from the Health and Retirement Study (a longitudinal panel study), we measured engagement in physical, creative, cognitive, and community activities. Outcome-wide analyses used 23 aging experiences across seven domains eight years later (daily functioning, physical fitness, long-term physical health problems, heart health, weight, sleep, subjective perceptions of health). Physical activity was related to more positive experiences in all domains but heart health eight years later. Creative engagement was positively related to aging experiences in four domains longitudinally. Cognitive and community engagement were less consistently related to aging experiences. Physical and creative activities may influence important aging metrics, reducing age-related decline and keeping older adults functionally independent for longer, potentially limiting increasing healthcare costs.

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.

The Colonial History of Systemic Racism: Insights for Psychological Science

The psychological study of systemic racism can benefit from the converging insights of "Black Marxism" and development economics, which illustrate how modern systemic racism is rooted in the political and economic institutions established during the historical period of European colonization. This article explores how these insights can be used to study systemic racism and challenge scientific racism in psychology by rethinking traditional research paradigms to incorporate the histories of race, class, and capitalism. Antiracism strategies that make use of these histories are also discussed, which include disrupting the psychological processes that sustain racist systems.

Organized abandonment under racial capitalism: Measuring accountable actors of structural racism for public health research and action

Understanding the shifting nature of structural racism historically and across institutions is vital for effective action towards racial health equity. While public health research on structural racism is rapidly increasing, most studies are missing the interdependence of policies and institutional practices over time that shape power imbalances and lead to entrenched health inequities. Here, we discuss Ruth Wilson Gilmore's concept of organized abandonment - the intentional disinvestment in communities which, in turn, creates opportunities for extraction, revenue generation, and carceral enforcement to fill the cracks of a compromised social infrastructure - to encourage action-oriented public health research that is grounded in history and an understanding of racial capitalism. We present a case example using publicly-available data on redlining, gentrification and policing in Seattle, Washington. We mapped the intersections of redlining and gentrification and estimated their neighborhood-level association with police activity using Bayesian spatial Poisson regression models. We found that histories of racist housing policies like redlining and processes of gentrification are interdependent and shape contemporary neighborhood racial and economic segregation and police activity. Compared to structurally advantaged neighborhoods, police stops were higher in neighborhoods that were 1) historically disinvested (i.e. redlined) and remain low-income and structurally disadvantaged and 2) formerly industrial and business districts that were not redlined and are now gentrified. Notably, we found that policing practices were significantly more intensive in neighborhoods that were both high redlined and gentrified. Together, these findings illustrate how the place-based racialized processes of dispossession, displacement and policing are deeply intertwined to maintain racial capitalism. Our findings also highlight the importance of examining multiple racialized processes simultaneously to fill critical gaps in the existing literature that are necessary for sustainable solutions to address structural racism.

The use of race terms in epigenetics research: considerations moving forward

The field of environmental epigenetics is uniquely suited to investigate biologic mechanisms that have the potential to link stressors to health disparities. However, it is common practice in basic epigenetic research to treat race as a covariable in large data analyses in a way that can perpetuate harmful biases without providing any biologic insight. In this article, we i) propose that epigenetic researchers open a dialogue about how and why race is employed in study designs and think critically about how this might perpetuate harmful biases; ii) call for interdisciplinary conversation and collaboration between epigeneticists and social scientists to promote the collection of more detailed social metrics, particularly institutional and structural metrics such as levels of discrimination that could improve our understanding of individual health outcomes; iii) encourage the development of standards and practices that promote full transparency about data collection methods, particularly with regard to race; and iv) encourage the field of epigenetics to continue to investigate how social structures contribute to biological health disparities, with a particular focus on the influence that structural racism may have in driving these health disparities.

Structural Racism, Mass Incarceration, and Racial and Ethnic Disparities in Severe Maternal Morbidity

Importance

Racial and ethnic inequities in the criminal-legal system are an important manifestation of structural racism. However, how these inequities may influence the risk of severe maternal morbidity (SMM) and its persistent racial and ethnic disparities remains underinvestigated.

Objective

To examine the association between county-level inequity in jail incarceration rates comparing Black and White individuals and SMM risk in California.

Design, Setting, and Participants

This population-based cross-sectional study used state-wide data from California on all live hospital births at 20 weeks of gestation or later from January 1, 1997, to December 31, 2018. Data were obtained from hospital discharge and vital statistics records, which were linked with publicly available county-level data. Data analysis was performed from January 2022 to February 2023.

Exposure

Jail incarceration inequity was determined from the ratio of jail incarceration rates of Black individuals to those of White individuals and was categorized as tertile 1 (low), tertile 2 (moderate), tertile 3 (high), with mean cutoffs across all years of 0 to 2.99, 3.00 to 5.22, and greater than 5.22, respectively.

Main Outcome and Measures

This study used race- and ethnicity-stratified mixed-effects logistic regression models with birthing people nested within counties and adjusted for individual- and county-level characteristics to estimate the odds of non-blood transfusion SMM (NT SMM) and SMM including blood transfusion-only cases (SMM; as defined by the Centers for Disease Control and Prevention SMM index) associated with tertiles of incarceration inequity.

Results

This study included 10 200 692 births (0.4% American Indian or Alaska Native, 13.4% Asian or Pacific Islander, 5.8% Black, 50.8% Hispanic or Latinx, 29.6% White, and 0.1% multiracial or other [individuals who self-identified with ≥2 racial groups and those who self-identified as "other" race or ethnicity]). In fully adjusted models, residing in counties with high jail incarceration inequity (tertile 3) was associated with higher odds of SMM for Black (odds ratio [OR], 1.14; 95% CI, 1.01-1.29 for NT SMM; OR, 1.20, 95% CI, 1.01-1.42 for SMM), Hispanic or Latinx (OR, 1.24; 95% CI, 1.14-1.34 for NT SMM; OR, 1.20; 95% CI, 1.14-1.27 for SMM), and White (OR, 1.02; 95% CI, 0.93-1.12 for NT SMM; OR, 1.09; 95% CI, 1.02-1.17 for SMM) birthing people, compared with residing in counties with low inequity (tertile 1).

Conclusions and Relevance

The findings of this study highlight the adverse maternal health consequences of structural racism manifesting via the criminal-legal system and underscore the need for community-based alternatives to inequitable punitive practices.

Impacts of compounding drought and heatwave events on child mental health: insights from a spatial clustering analysis

BACKGROUND

Concurrent heatwave and drought events may have larger health impacts than each event separately; however, no US-based studies have examined differential mental health impacts of compound drought and heatwave events in pediatric populations.

OBJECTIVE

To examine the spatial patterns of mood disorders and suicide-related emergency department (ED) visits in children during heatwave, drought, and compound heatwave and drought events. We tested whether the occurrence of compound heatwave and drought events have a synergistic (multiplicative) effect on the risk of mental health related outcomes in children as compared to the additive effect of each individual climate hazard. Lastly, we identified household and community-level determinants of geographic variability of high psychiatric burden.

METHODS

Daily counts of psychiatric ED visits in North Carolina from 2016 to 2019 (May to Sept) for pediatric populations were aggregated at the county scale. Bernoulli cluster analyses identified high-risk spatial clusters of psychiatric morbidity during heatwave, drought, or compound heatwave and drought periods. Multivariate adaptive regression models examined the individual importance of household and community-level determinants in predicting high-risk clustering of mood disorders or suicidality across the three climate threats.

RESULTS

Results showed significant spatial clustering of suicide and mood disorder risks in children during heatwave, drought, and compound event periods. Periods of drought were associated with the highest likelihood of spatial clustering for suicide and mood disorders, where the risk of an ED visit was 4.48 and 6.32 times higher, respectively, compared to non-drought periods. Compounding events were associated with a threefold increase in both suicide and mood disorder-related ED visits. Community and household vulnerability factors that most contributed to spatial clustering varied across climate hazards, but consistent determinants included residential segregation, green space availability, low English proficiency, overcrowding, no broadband access, no vehicle access, housing vacancy, and availability of housing units.

CONCLUSION

Findings advance understanding on the locations of vulnerable pediatric populations who are disproportionately exposed to compounding climate stressors and identify community resilience factors to target in public health adaptation strategies.