Race, Place, And Structural Racism: A Review Of Health And History In Washington, D.C

Equity in Heart Failure Care: A Get With the Guidelines Analysis of Between- and Within-Hospital Differences in Care by Sex, Race, Ethnicity, and Insurance

BACKGROUND

Disparities in guideline-based quality measures likely contribute to differences in heart failure (HF) outcomes. We evaluated between- and within-hospital differences in the quality of care across sex, race, ethnicity, and insurance for patients hospitalized for HF.

METHODS

This retrospective analysis included patients hospitalized for HF across 596 hospitals in the Get With the Guidelines-HF registry between 2016 and 2021. We evaluated performance across 7 measures stratified by patient sex, race, ethnicity, and insurance. We evaluated differences in performance with and without adjustment for the treating hospital. We also measured variation in hospital-specific disparities.

RESULTS

Among 685 227 patients, the median patient age was 72 (interquartile range, 61-82) and 47.2% were women. Measure performance was significantly lower (worse) for women compared with men for all 7 measures before adjustment. For 4 of 7 measures, there were no significant sex-related differences after patient-level adjustment. For 20 of 25 other comparisons, racial and ethnic minorities and Medicaid/uninsured patients had similar or higher (better) adjusted measure performance compared with White and Medicare/privately insured patients, respectively. Angiotensin receptor neprilysin inhibitor measure performance was significantly lower for Asian, Hispanic, and Medicaid/uninsured patients, and cardiac resynchronization therapy implant/prescription was lower among women and Black patients after hospital adjustment, indicating within-hospital differences. There was hospital-level variation in these differences. For cardiac resynchronization therapy implantation/prescription, 278 hospitals (46.6%) had ≥2% lower implant/prescription for Black versus White patients compared with 109 hospitals (18.3%) with the same or higher cardiac resynchronization therapy implantation/prescription for Black patients.

CONCLUSIONS

HF quality measure performance was equitable for most measures. There were within-hospital differences in angiotensin receptor neprilysin inhibitor and cardiac resynchronization therapy implant/prescription for historically marginalized groups. The magnitude of hospital-specific disparities varied across hospitals.

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.

Navigating Homelessness Assistance While Pregnant: A Rapid Qualitative Research-to-Policy Collaboration in Washington, DC

Background

Homelessness during pregnancy contributes to adverse pregnancy and infant outcomes from birth through early childhood. Washington, DC, a microcosm of structural inequities in the United States, has persistent racial disparities in perinatal outcomes and housing insecurity.

Methods

Grounded in a reproductive justice framework, we explored the lived experience of navigating homelessness assistance while pregnant to inform recommendations for a collaborative policy and practice change effort. We conducted 20 individual interviews with DC residents who experienced homelessness during pregnancy. We analyzed the data using thematic analysis and an action-oriented approach.

Results

Our analysis resulted in three main recommendation areas for policy and practice change: (1) timely and meaningful access to safe and stable housing in pregnancy; (2) care coordination for services and referrals that support physical, mental, and social well-being; and (3) access to a living wage and affordable housing.

Discussion

Access to stable housing is critical to ensure that pregnant and parenting people can have and raise children in a safe and sustainable environment-key tenets of reproductive justice. Housing support must be meaningfully accessible, including service delivery that accommodates the complex social histories and competing demands that accompany housing insecurity.

Health Equity Implications

This study informed the development of strategic recommendations, catalyzed a new model for multisector collaboration, and influenced a system-wide practice change to expand access to robust housing supports for pregnant people. Policy and practice change require sustained leveraging of political will to promote economic justice and ensure that residents can achieve safe, sustainable, and affordable housing.

Race-ethnicity and sex differences in 1-year survival following percutaneous coronary intervention among Medicare fee-for-service beneficiaries

RATIONALE

Existing literature describing differences in survival following percutaneous coronary intervention (PCI) by patient sex, race-ethnicity and the role of socioeconomic characteristics (SEC) is limited.

AIMS AND OBJECTIVES

Evaluate differences in 1-year survival after PCI by sex and race-ethnicity, and explore the contribution of SEC to observed differences.

METHODS

Using a 20% sample of Medicare claims data for beneficiaries aged 65+, we identified fee-for-service patients who received PCI from 2007 to 2015. We performed logistic regression to assess how sex and race-ethnicity relate to procedural indication, inpatient versus outpatient setting, and 1-year mortality. We evaluated whether these relationships are moderated by sequentially controlling for factors including age, comorbidities, presence of acute myocardial infarction (AMI), county SEC, medical resource availability and inpatient versus outpatient procedural status.

RESULTS

We identified 300,491 PCI procedures, of which 94,863 (31.6%) were outpatient. There was a significant transition to outpatient PCI during the study period, especially for men compared with women and White patients compared with Black patients. Black patients were 3.50 percentage points (p < 0.001) and women were 3.41 percentage points (p < 0.001) more likely than White and male patients to undergo PCI at the time of AMI, which typically occurs in the inpatient setting. Controlling for age and calendar year, Black patients were 2.87 percentage points more likely than non-Hispanic White patients to die within 1 year after PCI. After controlling for Black-White differences in comorbidities, the differences in 1-year mortality decreased to 0.95 percentage points, which then became nonsignificant when further controlling for county resources and state of residence.

CONCLUSION

Women were more likely to experience PCI in the setting of AMI and had less transition to outpatient care during the period. Black patients experienced higher 1-year mortality following PCI, which is explained by differences in baseline comorbidities, county medical resources, and state of residence.

Social Connectedness as a Determinant of Health in African-American Low-Income Families with Young Children: A Cross-Sectional Cohort Study

OBJECTIVE

This cross-sectional study aimed to assess the level of social connectedness (SC) in African-American low-income families with young children attending a pediatric primary care clinic and examine its relationships with food insecurity and parental well-being.

METHODS

This cross-sectional analysis used data from the Healthy Children and Families program, a cohort intervention study addressing food insecurity, conducted by an urban pediatric clinic serving low-income predominantly African-American families. Twenty-seven families completed baseline screening tools, including the Social Provisions Scale five-question short form (SPS-5) to measure SC, a modified version of the United States Department of Agriculture (USDA) Household Food Security Survey Module six-item short form to assess food insecurity, and the Parental Stress Index Short Form to measure parental stress. Descriptive statistics, correlations, and partial correlations were conducted to analyze the data.

RESULTS

The average SPS-5 composite score was 14.5 on a scale of 5 to 20. Moderate negative correlations were identified between SC and food insecurity, weaker when controlled for parental stress. Strong negative correlations were identified between SC and parental stress that held when controlled for food insecurity.

CONCLUSION

In this study, we propose a conceptual framework highlighting the complex interplay of social connectedness with other social determinants of child health. The findings align with the 2023 Surgeon General's Advisory on the epidemic on the healing effects of social connection and provide insight into the value of incorporating SC assessments into routine screenings in pediatric primary care settings. Further research is needed to explore causal relationships and evaluate the effectiveness of interventions designed to enhance SC in diverse populations.

Assessing Acceptability: The Role of Understanding Participant, Neighborhood, and Community Contextual Factors in Designing a Community-Tailored Cooking Intervention

BACKGROUND

Cooking is an identified dietary strategy that is positively associated with optimal diet quality. Prior to initiating cooking interventions, evaluating the prospective acceptability of the intervention among community members living within low food access areas and understanding geospatial food shopping locations may aid in designing community-tailored interventions.

METHODS

A sequential mixed methods study was conducted to determine the prospective acceptability of a planned community-located cooking intervention among African American adults living in a low food access area and with at least one cardiovascular disease risk factor. A semi-structured guide was used to conduct five virtual focus groups. Qualitative data were analyzed using thematic analysis and validated through participant check-in interviews. Survey responses were analyzed based on descriptive data. Geospatial analysis of participant locations that were reported for food shopping was conducted to show food environment utilization.

RESULTS

Focus groups with study participants (n = 20, all female, mean age 60.3, SD 9.3, mean cooking frequency per week 4.0, food insecure n = 7) were conducted between March and April, 2021. Thematic analysis of the focus group transcripts identified five main themes as follows: (A) Barriers to Cooking (family and caregiving, transportation, COVID-19 pandemic, time availability, household composition); (B) Motivators for Cooking (family, caregiving, health, enjoyment, COVID-19 pandemic); (C) Strategies (food shopping, social support, social media, meal planning); (D) Neighborhood (gentrification, perceived safety, stigmatization, disparities in grocery stores); (E) and Acceptability of the Intervention (reasons to participate, barriers, recruitment, intervention delivery). Participant validation interviews confirmed the themes and subthemes as well as the illustrative quotes. Geospatial analysis showed a majority of locations were outside of the participants' residential areas.

CONCLUSIONS

Prospective acceptability of a community-tailored cooking intervention found that the planned intervention could be modified to address individual level factors, such as caregiving and health, community contextual factors, such as perceived safety, and the general health needs of the community.

How do Cancer Patients in Economically Marginalized Neighborhoods Decide Where to Seek Care: Perspectives From Cancer Patients and Healthcare Professionals

BACKGROUND

The quality of cancer care affects patient outcomes. It is therefore important to understand what factors and/or barriers shape a cancer patient's decision about where to seek care. We sought to understand factors influencing decision-making for historically marginalized communities in a large metropolitan area with multiple options for cancer care, including a National Cancer Institute (NCI)-designated comprehensive cancer center.

METHODS

We conducted semi-structured interviews with cancer patients from economically marginalized neighborhoods in Washington D.C., and with healthcare professionals who work with patients from these areas. Participants were recruited through flyers, social media posts, and word of mouth. Two researchers analyzed the data using a combination of inductive and deductive approaches supported by the ATLAS. ti software.

RESULTS

A total of 15 interviews were conducted. Analysis revealed 3 major factors influencing where patients decide to seek care: health insurance, transportation, and prioritization of needs. Participants repeatedly identified navigating the bureaucracy of insurance enrollment and high medical costs as prohibitive to seeking care. Transportation was often mentioned in terms of convenience of use and proximity to the care center. Prioritization of needs refers to circumstances such as unstable housing, poverty, and mental illness, that some patients prioritize over seeking quality cancer care. Across these themes 2 findings arose: a discrepancy between stated and actual factors in choosing an oncologist, and the extent to which a cancer patient is able to choose their oncologist.

CONCLUSION

This study helps explain some of the factors that influence how cancer patients in urban settings choose an oncology center, and the barriers which prohibit access.

AIMS OF THE STUDY

This study aimed to understand how cancer patients decide where to seek treatment.

Integrating Lawyers Into Perinatal Care Teams to Address Unmet, Health-Harming Legal Needs

Across the United States, historically imposed structural, social, and environmental variables are intimately connected to poor obstetric outcomes and high maternal and infant mortality rates among Black pregnancy-capable people. Efforts to diminish the effect of these variables include integrating screening for social determinants of health during the perinatal period and treating them with social services, mental health support, and other referrals, including connections to community-based resources. Although helpful, some of these social determinants cannot be overcome without legal advocacy. Medical-legal partnerships, which integrate lawyers into health care, fill this gap. This commentary by an interprofessional team of authors relies on the experience of an established MLP. We posit that unmet legal needs of perinatal patients merit ongoing monitoring and intervention. We explain the rationale for perinatal practice medical-legal partnerships and share implementation suggestions from a high-intensity safety-net urban hospital.

Using nursing science to advance policy and practice in the context of social and structural determinants of health

BACKGROUND

Social and structural determinants of health play a large role in health inequities.

PURPOSE

To highlight how nursing science can be used to advance policy and practice in the context of social and structural determinants of health.

METHODS

This paper reports on the author's keynote presentation from the 2022 State of The Science Conference on Social and Structural Determinants of Health presented by the Council for the Advancement of Nursing Science. Key concepts are overviewed and defined, followed by examples of two community-engaged research projects with findings that inform practice and policy. The author concludes with individual-, social- and structural-level recommendations as a clarion call for nurses to use research to eliminate health inequities and promote justice for all.

CONCLUSION

What we know is, in part, only as good as what we do with that knowledge. When lives are at stake, gone are the days of knowing something and failing to act on that knowledge.

'They've all endorsed it…but I'm just not there:' a qualitative exploration of COVID-19 vaccine hesitancy reported by Black and Latinx individuals

OBJECTIVE

We sought to examine reasons for vaccine hesitancy among online communities of US-based Black and Latinx communities to understand the role of historical racism, present-day structural racism, medical mistrust and individual concerns about vaccine safety and efficacy.

DESIGN

A qualitative study using narrative and interpretive phenomenological analysis of online bulletin board focus groups.

SETTING

Bulletin boards with a focus-group-like setting in an online, private, chat-room-like environment.

PARTICIPANTS

Self-described vaccine hesitant participants from US-based Black (30) and Latinx (30) communities designed to reflect various axes of diversity within these respective communities in the US context.

RESULTS

Bulletin board discussions covered a range of topics related to COVID-19 vaccination. COVID-19 vaccine hesitant participants expressed fears about vaccine safety and doubts about vaccine efficacy. Elements of structural racism were cited in both groups as affecting populations but not playing a role in individual vaccine decisions. Historical racism was infrequently cited as a reason for vaccine hesitancy. Individualised fears and doubts about COVID-19 (short-term and long-term) safety and efficacy dominated these bulletin board discussions. Community benefits of vaccination were not commonly raised among participants.

CONCLUSIONS

While this suggests that addressing individually focused fear and doubts are central to overcoming COVID-19 vaccine hesitancy in Black and Latinx groups, addressing the effects of present-day structural racism through a focus on community protection may also be important.

Power, place, and access: Why history is at the center of black D.C. residents of wards 7 and 8 decisions to receive the COVID-19 vaccine

Vaccines have played an essential role in curbing case and mortality rates due to SARS-CoV-2 in the United Sates. Still, many communities display high rates of unwillingness or inability to get a COVID-19 vaccine, limiting overall vaccination efforts and contributing to viral spread. Black Americans have expressed skepticism towards vaccines because of limited access to the technology, mistrust in its safety and efficacy, and a lack of confidence in the healthcare authorities that distribute it. This article investigates how Black residents of Wards 7 and 8 in Washington, D.C. thought about COVID-19 vaccination and why or why not they decided to vaccinate. These Wards' vaccination rates were markedly lower than those from Wards 1-6, which have substantially higher populations of White residents, affluence, access, and resources. This study involved 31 interviews with Ward 7 and 8 residents recruited through snowball sampling. We found that residents navigated the dual perceived risks of coronavirus infection and vaccination through three key frames: their relationship to their place or location, their desires to maintain autonomy over their health, and their abilities to access COVID-19 vaccines. This case study advances knowledge of vaccine utilization among marginalized communities, and how this phenomenon varies depending on local social, cultural, and political dynamics. Moreover, this research has implications for vaccine rollout efforts and the D.C. health system, as it reveals gaps in confidence and care that undermine health outcomes for Black residents.

Modern Day Consequences of Historic Redlining: Finding a Path Forward

There is emerging evidence that structural racism is a major contributor to poor health outcomes for ethnic minorities. Structural racism captures upstream historic racist events (such as slavery, black code, and Jim Crow laws) and more recent state-sanctioned racist laws in the form of redlining. Redlining refers to the practice of systematically denying various services (e.g., credit access) to residents of specific neighborhoods, often based on race/ethnicity and primarily within urban communities. Historical redlining is linked to increased risk of diabetes, hypertension, and early mortality due to heart disease with evidence suggesting it impacts health through suppressing economic opportunity and human capital, or the knowledge, skills, and value one contributes to society. Addressing structural racism has been a rallying call for change in recent years-drawing attention to the racialized impact of historical policies in the USA. Unfortunately, the enormous scope of work has also left people feeling incapable of effecting the very change they seek. This paper highlights a path forward by briefly discussing the origins of historical redlining, highlighting the modern-day consequences both on health and at the societal level, and suggest promising initiatives to address the impact.

Risk Factors for Human Papillomavirus-Associated Cancers Among People Living with HIV in Washington, District of Columbia

District of Columbia (DC) has high rates of HIV infection and human papillomavirus (HPV)-associated cancers. People living with HIV (PLWH) are at risk for developing HPV-associated cancers. Previous studies identified factors that may further increase the risk of HPV-associated cancer among PLWH such as age, race/ethnicity, sex, risk factor for HIV transmission, stage of HIV infection, and age at HIV diagnosis. The extent to which PLWH in DC are affected by HPV-associated cancers has not previously been well described, and to our knowledge, the relationship between bacterial sexually transmitted infections (STIs) and subsequent development of HPV-associated cancer among PLWH in DC has not been explored. This was a retrospective case-control analysis of surveillance data on cancer, STIs, and HIV in Washington, DC from 1996 to 2015. There were 20,744 PLWH included in this study, of whom 335 (1.6%) had been diagnosed with an HPV-associated cancer. Among males living with HIV (MLWH), for every additional STI per 10 person-years, risk of developing an HPV-associated cancer increased by 11%. Exposure to STIs was not a significant risk factor for HPV-associated cancer among females. Ever being diagnosed with stage three HIV infection increased risk of HPV-associated cancers among males by 109% and females living with HIV by 111%. STI exposures were associated with HPV-associated cancers among MLWH in DC and ever being diagnosed with advanced HIV infection was associated with HPV-associated cancers among all PLWH. Clinicians treating MLWH should ensure their patients receive primary HPV infection prevention and HPV-associated cancer screenings.

Rates Of Preterm Birth And Low Birthweight: An Analysis Of Racial And Ethnic Populations

Using National Center for Health Statistics data (2016-20), we evaluated variation in low birthweight and prematurity among racial and ethnic subcategories. Disparities as large as 2.3-fold among rates of low birthweight for "multiple race" subcategories underscore the need for granular data stratification and analysis by racial and ethnic subcategories to address the root causes of inequities in infant outcomes.

Community Health Improvement: Social Care Is Healthcare

Like many communities across the United States, St. Louis, Missouri, faces stark inequities in health outcomes, including wellness, quality of life, and life expectancy. These inequities are the result of social systems and policies that have robbed generations of St. Louisans of opportunity. BJC HealthCare's (BJC's) commitment to becoming a catalyst for community health by helping to eliminate health disparities led to the launch of its community health improvement strategy. This article details the community-driven and evidence-informed process that BJC used to create a multiyear, proactive approach to addressing the social and economic factors that are the root causes of health inequities. It examines areas of opportunity through which the strategy will drive change and explores lessons learned and promising practices for other healthcare institutions to consider as they advance health equity.

Health disparities in rheumatoid arthritis

Rheumatoid arthritis (RA) is an autoimmune disease characterized by joint inflammation that involves symmetric polyarthritis of small and large joints. Autoimmune rheumatic diseases represent a significant socioeconomic burden as they are among the leading causes of death and morbidity due to increased risk of cardiovascular disease. Health disparities in patients with rheumatoid arthritis affect outcomes, prognosis, and management of the disease.

Engaging Public Health Critical Race Praxis in Local Social Determinants of Health Research: The Youth Health Equity and Action Research Training Program in Portland, OR—yHEARTPDX

The social determinants of health (SDH) have long been considered a core mechanism through which racial health inequities are (re)produced and incubated in the U.S. Moreover, scholars have expressly—and appropriately—named structural racism as a precursor to inequities associated with SDH. However, while research on racial health inequities—SDH-related or otherwise—continues to grow, communities of color remain grossly underrepresented as public health researchers and practitioners. Additionally, although SDH are experienced in a very local sense, much research and practice fails to more deeply and thoroughly engage and center local community knowledges. Thus, much work around SDH and racial health inequities presents, ironically, as structurally racist itself—being done/led mostly by White scholars and in ways that do not “center the margins”. Moreover, in the context of public health practice, youth perspective is seldom centered within local health department (LHD) community SDH assessment efforts. With these challenges in mind, this paper introduces and discusses the development of the youth health equity and action research training (yHEART) program as a model for public health researchers/practitioners to engage public health critical race praxis (PHCRP) to better understand and respond to local SDH in communities of color. Specifically, we highlight the significance of PHCRP principles of “voice” and “social construction of knowledge” in advancing antiracism in research and LHD practice related to local SDH. First, we articulate core conceptual and theoretical groundings that informed the yHEART program’s development and animate its ongoing training and research activities. Second, we outline the program’s core training components and overall process, and provide some brief illustrative examples of work completed during the program’s first iteration—yHEART PDX, Vol.I: Youth Participatory Research on Local Social Determinants of Health. We then close with a discussion that reflects on program strengths, challenges, and implications for SDH and racial health equity research/practice in light of growing calls for an antiracist public health.