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Goldfarb S, Deichen Hansen M, Day J, Brown Speights JS, Rust G, Harman J. State Variations In Progress Toward Eliminating Disparities In Infant Mortality, 2007-19. Health Aff (Millwood) 2024; 43:1379-1383. [PMID: 39374460 DOI: 10.1377/hlthaff.2024.00285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/09/2024]
Abstract
Progress toward eliminating the Black-White disparity in US infant mortality rates has been slow and highly variable by state. Among thirty-two eligible states, eight had an increase (worsening), and twenty-four had a reduction (improvement) in their Black-White infant mortality rate ratios from 2008 to 2018. These findings necessitate dynamic, multilevel initiatives aimed at preventing Black infant deaths.
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Hing AK, Chantarat T, Fashaw-Walters S, Hunt SL, Hardeman RR. Instruments for racial health equity: a scoping review of structural racism measurement, 2019-2021. Epidemiol Rev 2024; 46:1-26. [PMID: 38412307 PMCID: PMC11405678 DOI: 10.1093/epirev/mxae002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 11/27/2023] [Accepted: 02/21/2024] [Indexed: 02/29/2024] Open
Abstract
Progress toward racial health equity cannot be made if we cannot measure its fundamental driver: structural racism. As in other epidemiologic studies, the first step is to measure the exposure. But how to measure structural racism is an ongoing debate. To characterize the approaches epidemiologists and other health researchers use to quantitatively measure structural racism, highlight methodological innovations, and identify gaps in the literature, we conducted a scoping review of the peer-reviewed and gray literature published during 2019-2021 to accompany the 2018 published work of Groos et al., in which they surveyed the scope of structural racism measurement up to 2017. We identified several themes from the recent literature: the current predominant focus on measuring anti-Black racism; using residential segregation as well as other segregation-driven measures as proxies of structural racism; measuring structural racism as spatial exposures; increasing calls by epidemiologists and other health researchers to measure structural racism as a multidimensional, multilevel determinant of health and related innovations; the development of policy databases; the utility of simulated counterfactual approaches in the understanding of how structural racism drives racial health inequities; and the lack of measures of antiracism and limited work on later life effects. Our findings sketch out several steps to improve the science related to structural racism measurements, which is key to advancing antiracism policies.
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Affiliation(s)
- Anna K Hing
- Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, MN, United States
- Center for Antiracism Research for Health Equity, School of Public Health, University of Minnesota, Minneapolis, MN, United States
- Minnesota Population Center, Institute for Social Research and Data Innovation, University of Minnesota, Minneapolis, MN, United States
| | - Tongtan Chantarat
- Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, MN, United States
- Minnesota Population Center, Institute for Social Research and Data Innovation, University of Minnesota, Minneapolis, MN, United States
| | - Shekinah Fashaw-Walters
- Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, MN, United States
- Center for Antiracism Research for Health Equity, School of Public Health, University of Minnesota, Minneapolis, MN, United States
- Minnesota Population Center, Institute for Social Research and Data Innovation, University of Minnesota, Minneapolis, MN, United States
| | - Shanda L Hunt
- University Libraries, University of Minnesota, Minneapolis, MN, United States
| | - Rachel R Hardeman
- Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, MN, United States
- Center for Antiracism Research for Health Equity, School of Public Health, University of Minnesota, Minneapolis, MN, United States
- Minnesota Population Center, Institute for Social Research and Data Innovation, University of Minnesota, Minneapolis, MN, United States
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Cohen S, Metcalf E, Brown MJ, Ahmed NH, Nash C, Greaney ML. A closer examination of the "rural mortality penalty": Variability by race, region, and measurement. J Rural Health 2024. [PMID: 39198995 DOI: 10.1111/jrh.12876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Revised: 08/13/2024] [Accepted: 08/18/2024] [Indexed: 09/01/2024]
Abstract
BACKGROUND Racial health disparities are well documented and pervasive across the United States. Evidence suggests there is a "rural mortality penalty" whereby rural residents experience poorer health outcomes than their urban counterparts. However, whether this penalty is uniform across demographic groups and U.S. regions is unknown. OBJECTIVE To assess how rural-urban differences in mortality differ by race (Black vs. White), U.S. region, poverty status, and how rural-urban status is measured. METHODS Age-standardized mortality rates (ASMRs)/100,000 by U.S. county (2015-2019) were obtained by race (Black/White) from the CDC Wonder National Vital Statistics System (2015-2019) and were merged with county-level social determinants from the US Census Bureau and County Health Rankings. Multivariable generalized linear models assessed the associations between rurality (index of relative rurality [IRR] decile, rural-urban continuum codes, and population density) and race-specific ASMR, overall, and by Census region and poverty level. RESULTS Overall, average ASMR was significantly higher in rural areas than urban areas for both Black (rural ASMR = 949.1 per 100,000 vs. urban ASMR = 857.7 per 100,000) and White (rural ASMR = 903.0 per 100,000 vs. urban ASMR = 791.6 per 100,000) populations. The Black-White difference was substantially higher (p < 0.001) in urban than in rural counties (65.1 per 100,000 vs. 46.1 per 100,000). Black-White differences and patterns in ASMR varied notably by poverty status and U.S. region. CONCLUSION Policies and interventions designed to reduce racial health disparities should consider and address key contextual factors associated with geographic location, including rural-urban status and socioeconomic status.
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Affiliation(s)
- Steven Cohen
- Associate Professor, Department of Public Health, University of Rhode Island, Kingston, Rhode Island, USA
| | - Emily Metcalf
- Research Assistant, Department of Psychology, University of Rhode Island, Kingston, Rhode Island, USA
| | - Monique J Brown
- Associate Professor, Department of Epidemiology & Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina, USA
| | - Neelam H Ahmed
- Research Assistant, School of Public Health, Brown University, Providence, Rhode Island, USA
| | - Caitlin Nash
- Associate Teaching Professor, Department of Public Health, University of Rhode Island, Kingston, Rhode Island, USA
| | - Mary L Greaney
- Professor & Chairperson, Department of Public Health, University of Rhode Island, Kingston, Rhode Island, USA
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Davis ES, Franks JA, Bhatia S, Kenzik KM. Urban-rural differences in cancer mortality: Operationalizing rurality. J Rural Health 2024; 40:268-271. [PMID: 37644650 PMCID: PMC10902199 DOI: 10.1111/jrh.12792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 08/09/2023] [Accepted: 08/20/2023] [Indexed: 08/31/2023]
Abstract
OBJECTIVE To assess urban-rural differences in cancer mortality across definitions of rurality as (1) established binary cut-points, (2) data-driven binary cut-points, and (3) continuous. METHODS We used Surveillance, Epidemiology, and End Results (SEER) data between 2000 and 2016 to identify incident adult screening-related cancers. Analyses were based on one testing and four validation cohorts (all n = 26,587). Urban-rural status was defined by Rural-Urban Continuum Codes, National Center for Health Statistics codes, and the Index of Relative Rurality. Each was modeled using established binary cut-points, data-driven cut-points, and as continuous. The primary outcome was 5-year cancer-specific mortality. RESULTS Compared to established cut-points, data-driven cut-points classified more patients as rural, resulted in larger White populations in rural areas, and yielded 7%-14% lower estimates of urban-rural differences in cancer mortality. Further, hazard of cancer mortality increased 4%-67% with continuous rurality measures, revealing important between-unit differences. CONCLUSIONS Different cut-points introduce variation in urban-rural differences in mortality across definitions, whereas using urban-rural measures as continuous allows rurality to be conceptualized as a continuum, rather than a simple aggregation. POLICY IMPLICATIONS Findings provide alternative cut-points for multiple measures of rurality and support the consideration of utilizing continuous measures of rurality in order to guide future research and policymakers.
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Affiliation(s)
- Elizabeth S Davis
- Department of Surgery, Boston University/Boston Medical Center, Boston, Massachusetts
| | - Jeffrey A Franks
- Division of Hematology and Oncology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Smita Bhatia
- Division of Pediatric Hematology, Oncology, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama
| | - Kelly M Kenzik
- Department of Surgery, Boston University/Boston Medical Center, Boston, Massachusetts
- Slone Epidemiology Center, Boston University, Boston, Massachusetts
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Kowal S, Ng CD, Schuldt R, Sheinson D, Jinnett K, Basu A. Estimating the US Baseline Distribution of Health Inequalities Across Race, Ethnicity, and Geography for Equity-Informative Cost-Effectiveness Analysis. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2023; 26:1485-1493. [PMID: 37414278 DOI: 10.1016/j.jval.2023.06.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 05/23/2023] [Accepted: 06/12/2023] [Indexed: 07/08/2023]
Abstract
OBJECTIVES Information on how life expectancy, disability-free life expectancy, and quality-adjusted life expectancy varies across equity-relevant subgroups is required to conduct distributional cost-effectiveness analysis. These summary measures are not comprehensively available in the United States, given limitations in nationally representative data across racial and ethnic groups. METHODS Through linkage of US national survey data sets and use of Bayesian models to address missing and suppressed mortality data, we estimate health outcomes across 5 racial and ethnic subgroups (non-Hispanic American Indian or Alaska Native, non-Hispanic Asian and Pacific Islander, non-Hispanic black, non-Hispanic white, and Hispanic). Mortality, disability, and social determinant of health data were combined to estimate sex- and age-based outcomes for equity-relevant subgroups based on race and ethnicity, as well as county-level social vulnerability. RESULTS Life expectancy, disability-free life expectancy, and quality-adjusted life expectancy at birth declined from 79.5, 69.4, and 64.3 years, respectively, among the 20% least socially vulnerable (best-off) counties to 76.8, 63.6, and 61.1 years, respectively, among the 20% most socially vulnerable (worst-off) counties. Considering differences across racial and ethnic subgroups, as well as geography, gaps between the best-off (Asian and Pacific Islander; 20% least socially vulnerable counties) and worst-off (American Indian/Alaska Native; 20% most socially vulnerable counties) subgroups were large (17.6 life-years, 20.9 disability-free life-years, and 18.0 quality-adjusted life-years) and increased with age. CONCLUSIONS Existing disparities in health across geographies and racial and ethnic subgroups may lead to distributional differences in the impact of health interventions. Data from this study support routine estimation of equity effects in healthcare decision making, including distributional cost-effectiveness analysis.
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Affiliation(s)
| | - Carmen D Ng
- Genentech, Inc, South San Francisco, CA, USA
| | | | | | | | - Anirban Basu
- The Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, University of Washington, Seattle, WA, USA; Salutis Consulting LLC, Bellevue, Washington, WA, USA
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Needham BL, Ali T, Allgood KL, Ro A, Hirschtick JL, Fleischer NL. Institutional Racism and Health: a Framework for Conceptualization, Measurement, and Analysis. J Racial Ethn Health Disparities 2023; 10:1997-2019. [PMID: 35994173 PMCID: PMC9395863 DOI: 10.1007/s40615-022-01381-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 07/27/2022] [Accepted: 07/28/2022] [Indexed: 11/28/2022]
Abstract
Despite growing interest in the health-related consequences of racially discriminatory institutional policies and practices, public health scholars have yet to reach a consensus on how to measure and analyze exposure to institutional racism. The purpose of this paper is to provide an overview of the conceptualization, measurement, and analysis of institutional racism in the context of quantitative research on minority health and health disparities in the United States. We begin by providing definitions of key concepts (e.g., racialization, racism, racial inequity) and describing linkages between these ideas. Next, we discuss the hypothesized mechanisms that link exposure to institutional racism with health. We then provide a framework to advance empirical research on institutional racism and health, informed by a literature review that summarizes measures and analytic approaches used in previous studies. The framework addresses six considerations: (1) policy identification, (2) population of interest, (3) exposure measurement, (4) outcome measurement, (5) study design, and (6) analytic approach. Research utilizing the proposed framework will help inform structural interventions to promote minority health and reduce racial and ethnic health disparities.
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Affiliation(s)
- Belinda L. Needham
- Center for Social Epidemiology and Population Health, Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI USA
| | - Talha Ali
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT USA
| | - Kristi L. Allgood
- Center for Social Epidemiology and Population Health, Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI USA
| | - Annie Ro
- Department of Health, Society, and Behavior, University of California-Irvine Program in Public Health, Irvine, CA USA
| | - Jana L. Hirschtick
- Center for Social Epidemiology and Population Health, Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI USA
| | - Nancy L. Fleischer
- Center for Social Epidemiology and Population Health, Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI USA
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Joseph RA. Understanding Facilitators and Barriers to Providing Equity-Oriented Care in the NICU. Neonatal Netw 2023; 42:202-209. [PMID: 37491038 DOI: 10.1891/nn-2022-0049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/05/2023] [Indexed: 07/27/2023]
Abstract
The current study examined the use of immersive technology as a way to improve access to high-quality interpersonal breastfeeding interactions in an undergraduate clinical lactation course. In particular, we investigated the impact of immersive consultation videos and related activities on student self-efficacy, motivational beliefs, and perceived skill level. Results indicate that usability was high, with participants rating videos, interactives, and activities positively. Although no significant improvements in their level of interest or perceived skill were found, students did report a significant increase in self-efficacy and their perceived ability to meet the course learning objectives. Our results demonstrate that high-quality immersive videos can be an important learning tool for teaching clinical skills when access to direct patient care is limited or absent.
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Moorthy GS, Young RR, Smith MJ, White MJ, Hong H, Kelly MS. Racial Inequities in Sepsis Mortality Among Children in the United States. Pediatr Infect Dis J 2023; 42:361-367. [PMID: 36795560 PMCID: PMC10101919 DOI: 10.1097/inf.0000000000003842] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
BACKGROUND Racial inequities influence health outcomes in the United States, but their impact on sepsis outcomes among children is understudied. We aimed to evaluate for racial inequities in sepsis mortality using a nationally representative sample of pediatric hospitalizations. METHODS This population-based, retrospective cohort study used the 2006, 2009, 2012 and 2016 Kids' Inpatient Database. Eligible children 1 month to 17 years old were identified using sepsis-related International Classification of Diseases, Ninth Revision or International Classification of Diseases, Tenth Revision codes. We used modified Poisson regression to evaluate the association between patient race and in-hospital mortality, clustering by hospital and adjusting for age, sex and year. We used Wald tests to assess for modification of associations between race and mortality by sociodemographic factors, geographic region and insurance status. RESULTS Among 38,234 children with sepsis, 2555 (6.7%) died in-hospital. Compared with White children, mortality was higher among Hispanic (adjusted relative risk: 1.09; 95% confidence interval: 1.05-1.14), Asian/Pacific Islander (1.17, 1.08-1.27) and children from other racial minority groups (1.27, 1.19-1.35). Black children had similar mortality to White children overall (1.02, 0.96-1.07), but higher mortality in the South (7.3% vs. 6.4%; P < 0.0001). Hispanic children had higher mortality than White children in the Midwest (6.9% vs. 5.4%; P < 0.0001), while Asian/Pacific Islander children had higher mortality than all other racial categories in the Midwest (12.6%) and South (12.0%). Mortality was higher among uninsured children than among privately insured children (1.24, 1.17-1.31). CONCLUSIONS Risk of in-hospital mortality among children with sepsis in the United States differs by patient race, geographic region and insurance status.
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Affiliation(s)
- Ganga S. Moorthy
- Division of Pediatric Infectious Diseases, Duke University Medical Center, Durham, North Carolina
| | - Rebecca R. Young
- Division of Pediatric Infectious Diseases, Duke University Medical Center, Durham, North Carolina
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina
| | - Michael J. Smith
- Division of Pediatric Infectious Diseases, Duke University Medical Center, Durham, North Carolina
| | - Michelle J. White
- Division of Hospital Medicine, Department of Pediatrics, Duke University Medical Center, Durham, North Carolina
| | - Hwanhee Hong
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Matthew S. Kelly
- Division of Pediatric Infectious Diseases, Duke University Medical Center, Durham, North Carolina
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Steurer MA, Ryckman KK, Baer RJ, Costello J, Oltman SP, McCulloch CE, Jelliffe-Pawlowski LL, Rogers EE. Developing a resiliency model for survival without major morbidity in preterm infants. J Perinatol 2023; 43:452-457. [PMID: 36220984 PMCID: PMC10079534 DOI: 10.1038/s41372-022-01521-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 09/08/2022] [Accepted: 09/12/2022] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Develop and validate a resiliency score to predict survival and survival without neonatal morbidity in preterm neonates <32 weeks of gestation using machine learning. STUDY DESIGN Models using maternal, perinatal, and neonatal variables were developed using LASSO method in a population based Californian administrative dataset. Outcomes were survival and survival without severe neonatal morbidity. Discrimination was assessed in the derivation and an external dataset from a tertiary care center. RESULTS Discrimination in the internal validation dataset was excellent with a c-statistic of 0.895 (95% CI 0.882-0.908) for survival and 0.867 (95% CI 0.857-0.877) for survival without severe neonatal morbidity, respectively. Discrimination remained high in the external validation dataset (c-statistic 0.817, CI 0.741-0.893 and 0.804, CI 0.770-0.837, respectively). CONCLUSION Our successfully predicts survival and survival without major morbidity in preterm babies born at <32 weeks. This score can be used to adjust for multiple variables across administrative datasets.
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Affiliation(s)
- Martina A Steurer
- Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA.
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, USA.
| | - Kelli K Ryckman
- Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, IA, USA
| | - Rebecca J Baer
- California Preterm Birth Initiative, University of California San Francisco, San Francisco, CA, USA
| | - Jean Costello
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, USA
- California Preterm Birth Initiative, University of California San Francisco, San Francisco, CA, USA
| | - Scott P Oltman
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, USA
- California Preterm Birth Initiative, University of California San Francisco, San Francisco, CA, USA
| | - Charles E McCulloch
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, USA
- California Preterm Birth Initiative, University of California San Francisco, San Francisco, CA, USA
| | - Laura L Jelliffe-Pawlowski
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, USA
- California Preterm Birth Initiative, University of California San Francisco, San Francisco, CA, USA
| | - Elizabeth E Rogers
- Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA
- California Preterm Birth Initiative, University of California San Francisco, San Francisco, CA, USA
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Neonatal mortality and disparities within the military health system. J Perinatol 2023; 43:496-502. [PMID: 36635506 DOI: 10.1038/s41372-022-01598-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 12/16/2022] [Accepted: 12/22/2022] [Indexed: 01/13/2023]
Abstract
INTRODUCTION Racial disparity exists in U.S. neonatal mortality; Black, non-Hispanic neonates are at higher risk of death. We aim to examine overall and race-specific neonatal mortality within the Military Health System (MHS). METHODS Retrospective cohort study of infants delivered within the MHS between 2013-2015. Variables were extracted from the Military Health System Data Repository. RESULTS There were 320,283 live births within the MHS from 2013-2015; 588 neonates died, a death rate of 1.84/1000. Cohort neonatal mortality and incidence of preterm delivery (7.2%) were lower than concurrent U.S. STATISTICS Black, non-Hispanic neonates had a 2-fold increased risk of death (OR: 2.11; 95% CI 1.73-2.56, p < 0.001) over White, non-Hispanic neonates. Officer versus enlisted rank conferred no difference in neonatal mortality (OR: 0.88; 95% CI 0.74-1.03). CONCLUSION Neonatal mortality within the MHS is lower than in the U.S. Despite universal insurance coverage and access to care, racial disparity persists. Risk of death is not modified by socioeconomic status. These findings highlight the need for critical examination of healthcare equity within neonatal-perinatal medicine.
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Hoyt BW, Anderson AB, Dingle ME, Dickens JF, Eckel TT, Sterbis JR, Potter BK, Kilcoyne KG. Racial and Gender Diversity of Physicians Accepted to American Military Orthopaedic and Surgical Residencies: An 18-Year Analysis. JB JS Open Access 2023; 8:JBJSOA-D-22-00091. [PMID: 36698988 PMCID: PMC9831158 DOI: 10.2106/jbjs.oa.22.00091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Orthopaedic surgery ranks among the least racially and gender diverse medical/surgical specialties. United States military surgeons train in military or military-funded residency positions to care for a markedly diverse population; however, the composition and diversity of these training programs have not been previously assessed. The purpose of this study was to analyze the trends of physician diversity in military orthopaedics in comparison with other surgical specialties over time. Methods We performed a retrospective cohort study evaluating matriculation into first year of residency training in US military surgical training programs between 2002 and 2020. In total, 9,124 applicants were reviewed. We collected matriculant self-reported race/ethnicity and sex and the medical/specialty program. We considered under-represented minorities as those who reported their race as African American, Indian/Alaskan Native, and Native, other, or who reported ethnicity as Hispanic. We calculated changes in persons accepted to training positions over time and used linear regression to model trends in diversity among orthopaedic matriculating residents when compared with other surgical subspecialities over time. Results Across all surgical subspecialities, the average change in percent women was 0.94% per year for the study period (p < 0.01). The average annual percent women entering orthopaedic surgery residency programs was 14% for the 18-year study period. Across all surgical subspecialties, the average change for accepted applicants from groups underrepresented in medicine (URiM) was 1.01% per year for the study period (p < 0.01). The average annual percent URiM entering orthopaedic surgery residency programs was 17% for the 18-year study period. The annual change of women and URiM entering military orthopaedic residencies was 0.10% and 1.52%, respectively. Conclusions Despite statistically significant improvements, recruitment efforts as used to date fall far short of reversing sexual, racial, and ethnic disparities in military orthopaedic residencies. Orthopaedics has a lower representation of both women and physicians with minority backgrounds when compared with many surgical subspecialties. Additional interventions are still necessary to increase diversity for military orthopaedic surgeons.
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Affiliation(s)
- Benjamin W. Hoyt
- Uniformed Services University Department of Surgery, Bethesda, Maryland,James A Lovell Federal Health Care Center Department of Orthopaedics, North Chicago, Illinois
| | - Ashley B. Anderson
- Uniformed Services University Department of Surgery, Bethesda, Maryland,Fort Belvoir Community Hospital Department of Orthopaedics, Fort Belvoir, Virginia
| | - Marvin E. Dingle
- Uniformed Services University Department of Surgery, Bethesda, Maryland,Carolinas Medical Center Department of Hand & Upper Extremity Surgery, Charlotte, North Carolina
| | - Jon F. Dickens
- Uniformed Services University Department of Surgery, Bethesda, Maryland,Duke University, Department of Orthopaedic Surgery, Durham, North Carolina
| | - Tobin T. Eckel
- Uniformed Services University Department of Surgery, Bethesda, Maryland,Walter Reed National Military Medical Center Department of Orthopaedics, Bethesda, Maryland
| | - Joseph R. Sterbis
- Division of Urology, Department of Surgery, Tripler Army Medical Center, Honolulu, Hawaii
| | - Benjamin K. Potter
- Uniformed Services University Department of Surgery, Bethesda, Maryland,Walter Reed National Military Medical Center Department of Orthopaedics, Bethesda, Maryland,E-mail address for B.K. Potter:
| | - Kelly G. Kilcoyne
- Uniformed Services University Department of Surgery, Bethesda, Maryland,Walter Reed National Military Medical Center Department of Orthopaedics, Bethesda, Maryland
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Alvarez CH. Structural Racism as an Environmental Justice Issue: A Multilevel Analysis of the State Racism Index and Environmental Health Risk from Air Toxics. J Racial Ethn Health Disparities 2023; 10:244-258. [PMID: 34993918 PMCID: PMC9810559 DOI: 10.1007/s40615-021-01215-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 12/16/2021] [Accepted: 12/17/2021] [Indexed: 02/03/2023]
Abstract
Communities of color and poor neighborhoods are disproportionately exposed to more air pollution-a pattern known as environmental injustices. Environmental injustices increase susceptibility to negative health outcomes among residents in affected communities. The structural mechanisms distributing environmental injustices in the USA are understudied. Bridging the literatures on the social determinants of health and environmental justice highlights the importance of the environmental conditions for health inequalities and sheds light on the institutional mechanisms driving environmental health inequalities. Employing a critical quantitative methods approach, we use data from an innovative state racism index to argue that systematic racialized inequalities in areas from housing to employment increase outdoor airborne environmental health risks in neighborhoods. Results of a multilevel analysis in over 65,000 census tracts demonstrate that tracts in states with higher levels of state-level Black-white gaps report greater environmental health risk exposure to outdoor air pollution. The state racism index explains four-to-ten percent of county- and state-level variation in carcinogenic risk and noncarcinogenic respiratory system risks from outdoor air toxics. The findings suggest that the disproportional exposure across communities is tied to systematic inequalities in environmental regulation and other structural elements such as housing and incarceration. Structural racism is an environmental justice issue.
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Affiliation(s)
- Camila H. Alvarez
- grid.266096.d0000 0001 0049 1282Department of Sociology, University of California–Merced, 5200 N. Lake Rd., CA 95343 Merced, USA
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Shukla VV, Carlo WA, Niermeyer S, Guinsburg R. Neonatal resuscitation from a global perspective. Semin Perinatol 2022; 46:151630. [PMID: 35725655 DOI: 10.1016/j.semperi.2022.151630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The majority of perinatal and neonatal mortality occurs in low-resource settings in low- and middle-income countries. Access and quality of care at delivery are major determinants of the health and survival of newborn infants. Availability of basic neonatal resuscitation care at birth has improved, but basic neonatal resuscitation at birth or high-quality care continues to be inaccessible in some settings, leading to persistently high perinatal and neonatal mortality. Low-resource settings of high-income countries and socially disadvantaged communities also suffer from inadequate access to quality perinatal healthcare. Quality improvement, implementation research, and innovation should focus on improving the quality of perinatal healthcare and perinatal and neonatal outcomes in low-resource settings. The current review presents an update on issues confronting universal availability of optimal resuscitation care at birth and provides an update on ongoing efforts to address them.
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Affiliation(s)
- Vivek V Shukla
- University of Alabama at Birmingham, Birmingham, AL, USA
| | - Waldemar A Carlo
- University of Colorado School of Medicine and Colorado School of Public Health, Aurora, CO, USA
| | - Susan Niermeyer
- University of Colorado School of Medicine and Colorado School of Public Health, Aurora, CO, USA
| | - Ruth Guinsburg
- Universidade Federal de São Paulo/Escola Paulista de Medicina, São Paulo, SP, Brazil.
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Evans NM, Hsu YL, Kabasele CM, Kirkland C, Pantuso D, Hicks S. A Qualitative Exploration of Stressors: Voices of African American Women who have Experienced Each Type of Fetal/Infant Loss: Miscarriage, Stillbirth, and Infant Mortality. JOURNAL OF BLACK PSYCHOLOGY 2022. [DOI: 10.1177/00957984221127833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Historically, African American women have experienced racial disparities in miscarriage, stillbirth, and infant mortality rates. Yet, little attention has been given to stressors that African American women may experience prior to, during, and after experiencing fetal/infant loss. This study provided an opportunity for African American women to describe their lived experiences of stressors prior to, during, and after experiencing each type of fetal/infant loss. Semi-structured interviews were conducted with seven African American women. Each participant experienced miscarriage, stillbirth, and infant mortality and were 18 years of age or older. Recruitment occurred in 2019 in a county in Northeast Ohio and data were analyzed using descriptive coding and thematic analysis. Four themes identified how these African American women navigated stressors prior to, during, and after experiencing each type of fetal/infant loss: (a) social support, (b) grief, (c) internal conflict, and (d) pregnancy, delivery, and death of child. Our findings expand the literature by being an innovative study may bring awareness and influence programs that assist African American women during their experience with fetal/infant loss.
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Adkins-Jackson PB, Incollingo Rodriguez AC. Methodological approaches for studying structural racism and its biopsychosocial impact on health. Nurs Outlook 2022; 70:725-732. [PMID: 36154771 PMCID: PMC11298157 DOI: 10.1016/j.outlook.2022.07.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 07/05/2022] [Accepted: 07/12/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Structural racism is a powerful determinant of health that drives health disparities, morbidity, and mortality across racialized and minoritized groups. PURPOSE This article discusses approaches for measuring structural racism and its resultant network of negative biopsychosocial consequences for health and well-being. METHODS We draw on prevailing theoretical models and approaches to characterize both the nature of structural racism and integrated methods for assessing its consequences across mental and physical health. DISCUSSION This article will serve to guide researchers in health-related disciplines to accurately assess the biopsychosocial consequences of structural racism in key populations.
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Affiliation(s)
- Paris B Adkins-Jackson
- Departments of Epidemiology and Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York, NY.
| | - Angela C Incollingo Rodriguez
- Psychological and Cognitive Sciences, Department of Social Science and Policy Studies, Worcester Polytechnic Institute, Worcester, MA.
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WEBSTER JESSICAL, PAUL DAVID, PURTLE JONATHAN, LOCKE ROBERT, GOLDSTEIN NEALD. State-Level Social and Economic Policies and Their Association With Perinatal and Infant Outcomes. Milbank Q 2022; 100:218-260. [PMID: 35128726 PMCID: PMC8932633 DOI: 10.1111/1468-0009.12548] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Policy Points State-level social and economic policies that expand tax credits, increase paid parental leave, raise the minimum wage, and increase tobacco taxes have been demonstrated to reduce adverse perinatal and infant health outcomes. These findings can help prioritize evidence-based legislated policies to improve perinatal and infant outcomes in the United States. CONTEXT Rates of preterm birth and infant mortality are alarmingly high in the United States. Legislated efforts may directly or indirectly reduce adverse perinatal and infant outcomes through the enactment of certain economic and social policies. METHODS We conducted a narrative review to summarize the associations between perinatal and infant outcomes and four state-level US policies. We then used a latent profile analysis to create a social and economic policy profile for each state based on the observed policy indicators. FINDINGS Of 27 articles identified, nine focused on tax credits, eight on paid parental leave, four on minimum wages, and six on tobacco taxes. In all but three studies, these policies were associated with improved perinatal or infant outcomes. Thirty-three states had tax credit laws, most commonly the earned income tax credit (n = 28, 56%). Eighteen states had parental leave laws. Two states had minimum wage laws lower than the federal minimum; 14 were equal to the federal minimum; 29 were above the federal minimum; and 5 did not have a state law. The average state tobacco tax was $1.76 (standard deviation = $1.08). The latent profile analysis revealed three policy profiles, with the most expansive policies in Western and Northeastern US states, and the least expansive policies in the US South. CONCLUSIONS State-level social and economic policies have the potential to reduce adverse perinatal and infant health outcomes in the United States. Those states with the least expansive policies should therefore consider enacting these evidence-based policies, as they have shown a demonstratable benefit in other states.
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Affiliation(s)
| | - DAVID PAUL
- ChristianaCare, Department of PediatricsNewarkDE,Thomas Jefferson University Sidney Kimmel College of MedicinePhiladelphia
| | - JONATHAN PURTLE
- Drexel University Dornsife School of Public HealthPhiladelphia
| | - ROBERT LOCKE
- ChristianaCare, Department of PediatricsNewarkDE,Thomas Jefferson University Sidney Kimmel College of MedicinePhiladelphia
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17
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Eldridge L, Berrigan D. Structural Racism and Triple-Negative Breast Cancer Among Black and White Women in the United States. Health Equity 2022; 6:116-123. [PMID: 35261938 PMCID: PMC8896209 DOI: 10.1089/heq.2021.0041] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/17/2021] [Indexed: 11/13/2022] Open
Affiliation(s)
- Linsey Eldridge
- National Cancer Institute, Center for Global Health, Rockville, Maryland, USA
| | - David Berrigan
- National Cancer Institute, Division of Cancer Control and Population Sciences, Rockville, Maryland, USA
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Badiee RK, Yang SC, Alcon A, Weeks AC, Rosenbluth G, Pomerantz JH. Disparities in Timing of Alveolar Bone Grafting and Dental Reconstruction in Patients With Clefts. Cleft Palate Craniofac J 2022; 60:639-644. [PMID: 35044260 DOI: 10.1177/10556656211073049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
This study sought to identify disparities in the timing of alveolar bone grafting (ABG) surgery and the replacement strategy for missing maxillary lateral incisors for patients with clefts. A retrospective record review identified patients who underwent ABG. Multivariable regression analyzed the independent contribution of each variable. This institutional study was performed at the University of California, San Francisco. Patients who presented under age 12 and underwent secondary ABG between 2012 and 2020 (n = 160). The age at secondary ABG and the recommended dental replacement treatment for each patient, either dental implantation or canine substitution. The average age at ABG was 10.8 ± 2.1 years, 106 (66.3%) patients were not White, and 80 (50.0%) had private insurance. Independent predictors of older age at ABG included an income below $ 50 000 as estimated from ZIP code (β = 15.0 months, 95% CI, 5.7-24.3, P = .002) and identifying as a race other than White (β = 10.1 months, 95% CI, 2.1-18.0, P = .01). After ABG, patients were more likely to undergo dental implantation over canine substitution if they were female (odds ratio [OR] = 4.3, 95% CI, 1.3-17.1, P = .02) or had private insurance (OR = 12.5, 95% CI, 2.2-143.2, P = .01). Patients who were low-income or not White experienced delays in ABG, whereas dental implantation was more likely to be recommended for patients with private insurance. Understanding the sources of disparities in dental reconstruction of cleft deformities may reveal opportunities to improve equity.
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Affiliation(s)
- Ryan K Badiee
- Division of Plastic and Reconstructive Surgery, Department of Surgery, UCSF Craniofacial Center, 8785University of California San Francisco, San Francisco, CA, USA
| | - Stephen C Yang
- Department of Oral and Maxillofacial Surgery, School of Dentistry, 8785University of California San Francisco, San Francisco, CA, USA
| | - Andre Alcon
- Division of Plastic and Reconstructive Surgery, Department of Surgery, UCSF Craniofacial Center, 8785University of California San Francisco, San Francisco, CA, USA
| | - Andrew C Weeks
- Department of Oral and Maxillofacial Surgery, School of Dentistry, 8785University of California San Francisco, San Francisco, CA, USA
| | - Glenn Rosenbluth
- Division of Pediatric Hospital Medicine, Department of Pediatrics, 8785University of California San Francisco, San Francisco, CA, USA.,Division of Orofacial Sciences, School of Dentistry, 8785University of California San Francisco, San Francisco, CA, USA
| | - Jason H Pomerantz
- Division of Plastic and Reconstructive Surgery, Department of Surgery, UCSF Craniofacial Center, 8785University of California San Francisco, San Francisco, CA, USA.,Division of Orofacial Sciences, School of Dentistry, 8785University of California San Francisco, San Francisco, CA, USA.,Program in Craniofacial Biology, 8785University of California San Francisco, San Francisco, CA, USA
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19
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James R, Hesketh MA, Benally TR, Johnson SS, Tanner LR, Means SV. Assessing Social Determinants of Health in a Prenatal and Perinatal Cultural Intervention for American Indians and Alaska Natives. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:11079. [PMID: 34769596 PMCID: PMC8583343 DOI: 10.3390/ijerph182111079] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 10/13/2021] [Accepted: 10/15/2021] [Indexed: 12/03/2022]
Abstract
American Indians and Alaska Natives (AIANs) refer to cultural traditions and values to guide resilient and strength-based practices to address maternal and infant health disparities. METHODS A case study of a culturally-based educational intervention on AIAN maternal and child health. RESULTS Cultural teachings have successfully been applied in AIAN behavioral interventions using talking circles and cradleboards, but maternal and child health interventions are not well-represented in peer-reviewed literature. Zero publications included interventions centered around cradleboards and safe sleep. DISCUSSION There is a need for rigorous published research on culturally based interventions and effectiveness on health outcomes for mothers and babies. CONCLUSIONS This paper discusses how a cradleboard educational intervention incorporates national guidelines to address maternal and infant health while mediating social determinants of health.
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Affiliation(s)
- Rosalina James
- Urban Indian Health Institute, Seattle, WA 98144, USA; (M.A.H.); (T.R.B.); (S.S.J.)
- Seattle Indian Health Board, Seattle, WA 98144, USA
| | - Martell A. Hesketh
- Urban Indian Health Institute, Seattle, WA 98144, USA; (M.A.H.); (T.R.B.); (S.S.J.)
- Seattle Indian Health Board, Seattle, WA 98144, USA
| | - Tia R. Benally
- Urban Indian Health Institute, Seattle, WA 98144, USA; (M.A.H.); (T.R.B.); (S.S.J.)
- School of Public Health, University of Washington, Seattle, WA 98195, USA;
| | - Selisha S. Johnson
- Urban Indian Health Institute, Seattle, WA 98144, USA; (M.A.H.); (T.R.B.); (S.S.J.)
- School of Public Health, University of Washington, Seattle, WA 98195, USA;
| | - Leah R. Tanner
- Native American Women’s Dialogue on Infant Mortality, Seattle, WA 98144, USA;
- Portland Area Consultant, Healthy Native Babies Project, Seattle, WA 98144, USA
| | - Shelley V. Means
- School of Public Health, University of Washington, Seattle, WA 98195, USA;
- Native American Women’s Dialogue on Infant Mortality, Seattle, WA 98144, USA;
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Awad MN, Crusto CA, Hooper LM. Macrointervention processes and strategies for leaders, changemakers, advocates, allies, and targets: A new framework to address macroaggressions in systems. NEW IDEAS IN PSYCHOLOGY 2021. [DOI: 10.1016/j.newideapsych.2021.100858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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