Life Course Approaches to the Causes of Health Disparities

Physician Perspectives on Responding to Clinician-Perpetuated Interpersonal Racism Against Black Patients with Serious Illness

BACKGROUND

Racism negatively affects clinical outcomes in Black patients, but uncertainty remains among physicians regarding how to address interpersonal anti-Black racism incidences involving them to facilitate racial healing and promote accountability.

OBJECTIVE

Elicit physician perspectives on addressing concerns from Black patients about interpersonal racism involving them or their team.

PARTICIPANTS

Twenty-one physician subspecialists at an urban academic medical center.

APPROACH

We conducted one-on-one semi-structured interviews to help inform the development of a clinician-facing component of a program to address the distress of racism experienced by Black patients with serious illness. We asked clinicians to describe experiences discussing racism with patients and identify additional resources to support these conversations.

MAIN MEASURES

Physician perspectives, including barriers and facilitators, to promote racial healing and clinician accountability when discussing clinician-perpetuated interpersonal racism with Black patients.

KEY RESULTS

Of the 21 participating physicians, 67% were women with a mean age of 44.2 years and mean of 10.8 years of experience as an attending physician. Four identified as Asian, three identified as Black, and 14 identified as White. Participants largely felt unprepared to discuss racism with their patients, especially if the harm was caused by them or their team. Participants felt patients should be given tools to discuss concerns about racism with their clinicians, but worried about adding additional burdens to Black patients to call out racism. Participants believed programs and processes with both patient- and clinicians-facing components had the potential to empower patients while providing resources and tools for clinicians to engage in these highly sensitive discussions without perpetuating more harm.

CONCLUSIONS

Addressing and improving communication about interpersonal racism in clinical settings are challenging. Dual-facing programs involving patients and clinicians may help provide additional resources to address experiences of interpersonal racism and hold clinicians accountable.

An Annual Symposium on Disparities in Milwaukee, WI, with a 2023 Focus on Older Adults with Cancer

PURPOSE OF REVIEW

Cancer-related inequities are prevalent in Wisconsin, with lower survival rates for breast, colorectal, and lung cancer patients from marginalized communities. This manuscript describes the ongoing efforts at the Medical College of Wisconsin and potential pathways of community engagement to promote education and awareness in reducing inequities in cancer care.

RECENT FINDINGS

While some cancer inequities are related to aggressive disease biology, health-related social risks may be addressed through community-academic partnerships via an open dialogue between the community members and academic faculty. To develop potential pathways of community-academic partnerships, an annual Cancer Disparities Symposium concept evolved as a pragmatic and sustainable model in an interactive learning environment. In this manuscript, we describe the programmatic development and execution of the annual Cancer Disparities Symposium, followed by highlights from this year's meeting focused on geriatric oncology as discussed by the speakers.

"I Want Everybody to Know as Much of My Life Story as They Can": Life Stories of Former Foster Youth

The power of stories shared by young people in foster care is well-documented. Largely left unexplored is a story of foster care that is told within a fuller context of the life course. Using narrative and life history methods, this study sought to retrospectively identify and connect life experiences in histories of young people and explore how systems are portrayed. Twelve adults formerly in foster care completed three interviews each and nominated six professionals from foster care for an interview. A three-phase analytical process identified and displayed themes across six developmental stages. Results suggest that life stories contained adversities that were: (1) intergenerational, (2) chronic, (3) complex, and (4) structural. The participants intentionally acted to try to mitigate adversities by accessing opportunities for prosocial pathways. These exploratory findings challenge child welfare policy and practice to attend to young people's life stories and their conceptions of systems that advance well-being.

Age of migration and common mental disorders among migrants in early adulthood: a Norwegian registry study

BACKGROUND

Younger age of migration is associated with higher risk of psychotic disorders but the relationship between age of migration and common mental disorders is less clear. This study investigates the association between age of migration and diagnosed common mental disorders among migrants living in Norway.

METHODS

Using national Norwegian register data from 2008 to 2019, we compared the odds of a common mental disorder diagnosis in healthcare services during early adulthood among non-migrants, descendants and migrants with different ages of migration and lengths of stay. We also investigated differences in the relationship for different migrant groups and for men and women.

RESULTS

Descendants and childhood migrants with ≥ 19 years in Norway had higher odds of common mental disorders than non-migrants, while those migrating during adolescence with ≥ 19 years in Norway had similar odds. Those migrating during emerging and early adulthood had lower odds. Overall among migrants, the relationship between age of migration and common mental disorders was more pronounced for migrants < 19 years in Norway than ≥ 19 years and for non-refugees compared with refugees, especially men.

CONCLUSIONS

Descendants and childhood migrants with long stays may have higher odds of common mental disorders due to the associated stress of growing up in a bicultural context compared with non-migrants. Age of migration has a negative association with diagnosed common mental disorders but much of this effect may attenuate over time. The effect appears weaker for refugees, and particularly refugee men, which may reflect higher levels of pre-migration trauma and stress associated with the asylum-seeking period for those arriving as adults. At the same time, migrants, especially those arriving as adults, experience barriers to care. This could also explain the particularly low odds of diagnosed common mental disorders among adult migrants, especially those with shorter stays.

Grandparents' educational attainment is associated with grandchildren's epigenetic-based age acceleration in the National Growth and Health Study

We examined three generations (grandparents, mothers, and grandchildren) to assess the association between grandparents' educational attainment and their grandchildren's epigenetic-based age acceleration and whether the association was mediated by parental educational attainment and mothers' life course health-related factors. Mothers were recruited to the NHLBI Growth and Health Study at 9-10 years and followed for 10 years (1987-1998). Mothers were then re-contacted three decades later (ages 37-42) to participate in the National Growth and Health Study (NGHS), and health information from their youngest child (i.e., grandchildren; N = 241, ages 2-17) was collected, including their saliva samples to calculate epigenetic age. Five epigenetic-based age acceleration measures were included in this analysis, including four epigenetic clock age accelerations (Horvath, Hannum, GrimAge, and PhenoAge) and DunedinPACE. Grandparents reported their highest education during the initial enrollment interviews. Parental educational attainment and mothers' life course health-related factors (childhood BMI trajectories, adult cardiovascular health behavioral risk score, and adult c-reactive protein) are included as mediators. Grandparents' education was significantly associated with Horvath age acceleration (b = -0.32, SE = 0.14, p = 0.021). Grandchildren with college-degree grandparents showed significantly slower Horvath age accelerations than those without college degrees. This association was partially mediated by parental education and mothers' health-related factors, especially adult cardiovascular health behavioral risk score and CRP, but not mothers' childhood BMI trajectory. This ability to conserve the speed of biological aging may have considerable consequences in shaping health trajectories across the lifespan.

Cerina: cognitive-behavioural therapy-based mobile application for managing GAD symptoms among Ulster University Students in Northern Ireland - a protocol for a pilot feasibility randomised controlled trial

INTRODUCTION

University students are one of the most vulnerable populations for anxiety disorders worldwide. In Northern Ireland, anxiety disorders appear to be more common among the university student population due to the population demographics across the region. Despite the need, these students show less inclination to access the widely available on-campus well-being services and other external professional services. Digital cognitive-behavioural therapy (CBT) aims to bridge this gap between the need for psychological help and access to it. However, challenges such as limited reach, low adoption, implementation barriers and poor long-term maintenance are mainstay issues resulting in reduced uptake of digital CBT. As a result, the potential impact of digital CBT is currently restricted. The proposed intervention 'Cerina' is a scalable CBT-based mobile app with an interactive user interface that can be implemented in university settings if found to be feasible and effective.

METHODS AND ANALYSIS

The study is a single-blind pilot feasibility randomised controlled trial aiming to test the feasibility and preliminary effects of Cerina in reducing Generalised Anxiety Disorder (GAD) symptoms. Participants are 90 Ulster University students aged 18 and above with self-reported GAD symptoms. They will be allocated to two conditions: treatment (ie, access to Cerina for 6 weeks) and a wait-list control group (ie, optional on-campus well-being services for 6 weeks). Participants in the wait-list will access Cerina 6 weeks after their randomisation and participants in both conditions will be assessed at baseline, at 3 (mid-assessment) and 6 weeks (postassessment). The primary outcome is the feasibility of Cerina (ie, adherence to the intervention, its usability and the potential to deliver a full trial in the future). The secondary outcomes include generalised anxiety, depression, worry and quality of life. Additionally, participants in both conditions will be invited to semistructured interviews for process evaluation.

ETHICS AND DISSEMINATION

Ethical approval for the study has been granted by the Ulster University Research Ethics Committee (ID: FCPSY-22-084). The results of the study will be disseminated through publications in scientific articles and presentations at relevant conferences and/or public events.

TRIAL REGISTRATION NUMBER

NCT06146530.

Application of a Heuristic Framework for Multilevel Interventions to Eliminate the Impact of Unjust Social Processes and Other Harmful Social Determinants of Health

There is consensus about the importance of developing a strong cadre of effective multilevel interventions to eliminate the impacts of unjust social processes, such as structural racism and other harmful social determinants of health (SDOH), on health inequities in the USA. However, the available cadre of rigorously evaluated evidence-based interventions for SDOH mitigation remains underdeveloped relative to the magnitude of historic and current health inequities. The proposed manuscript addresses this gap in two ways: first, by introducing a heuristic framework to inform decisions in multilevel intervention development, study design, and selection of analytic methods and, second, by providing a roadmap for future applications of the framework in multilevel intervention research through an exemplar application using the ongoing NIH-funded evaluation study of the Nurse-Community-Family Partnership (NCFP) intervention. NCFP leverages individual, family, institutional, and system factors to shape COVID-19 mitigation outcomes at the individual and household levels. NCFP takes an approach informed by the heuristic framework to addressing and mitigating unjust social processes and other harmful SDOH. We discuss the application of a two-arm parallel explanatory group randomized trial to evaluate the efficacy of NCFP in improving the primary (COVID-19 testing uptake) and secondary (adoption of COVID-19 control measures, COVID-19 vaccine uptake, mutual aid capacity, etc.) outcomes at the individual and household levels. The analysis approach relies on random-intercept models, and we calculate the variance partitioning coefficient to estimate the extent to which household- and individual-level variables contribute to the outcome, allowing examination of NCFP effects at multiple levels.

Activating Life Course Theory through a Whole System Prevention Framework to Address the Wicked Problem of Maternal and Infant Morbidity and Mortality

BACKGROUND

Racial/ethnic disparities in maternal and infant morbidity and mortality (MIM&M) is a wicked problem that is reinforced and perpetuated by our system[s] of care. Life Course Theory (LCT) helps to explain drivers of health disparities, but its application is challenged. An upstream approach that promotes systemic change requires the implementation of an expanded prevention framework that includes primordial and quaternary prevention.

RESEARCH DESIGN

We developed an innovative expanded Whole System Prevention Framework (WSPF) that incorporates LCT, prevention (including primordial and quaternary prevention) and systems thinking.

STUDY SAMPLE

We implemented this new conceptual Framework with two Healthy Start community partnerships through training, service mapping, and strategic planning to address upstream drivers of MIM&M.

DATA COLLECTION AND ANALYSIS

Service mapping revealed few Healthy Start upstream activities/services with the predominance being delivered downstream at the program (microsystem) level.

RESULTS

Service mapping provided a snapshot of the current service distribution of services across the systems. The preponderance were primary, secondary and tertiary prevention activities (75.5% and 65.6%) delivered at the program level (58.2% and 68%), revealing opportunities for upstream strategies to promote equity. The implementation process provided a new way to frame strategic planning and develop upstream strategies to promote health equity and reduce MIM&M.

CONCLUSION

The Whole System Prevention Framework and its implementation methodology could be applied to address other wicked problems.

Material hardship and telomere length in children

Telomere length (TL) serves as a biomarker of exposure to stressors, including material hardship. Data from the Future of Families and Child Wellbeing Study (1998-2015) were utilized to determine whether prior material hardship was associated with shorter salivary TL at years 9 and 15. 49% of the year 9 study population were female, 49% were Black, and 25% were Hispanic. At year 9 (N = 1990), regression analyses found a significant association between prior material hardship and shorter TL (β = -.005, p < .01). Additionally, at year 15 (N = 1874), material hardship experienced during infancy and toddlerhood was associated with shorter TL (β = -.009, p < .01), pointing toward infancy and toddlerhood as a sensitive period.

Dietary Quality and Diet-Related Factors Among Emerging Adults (18-23 y) in the United States Are a Cause for Concern: National Health and Nutrition Examination Survey 2015-2018

BACKGROUND

Poor dietary quality is a risk factor for diet-related chronic disease and suboptimal nutritional patterns often begin early in the life course. Although the dietary intakes of young children, adolescents, and middle-aged and older adults are well established, much less is known about emerging adults, who represent a unique time point in life, as they are undergoing significant changes in food environments, autonomy, finances, and caregiver and parental involvement.

OBJECTIVES

This study aimed to examine dietary quality, as assessed via the Healthy Eating Index (HEI), by demographic, socioeconomic, and health-related characteristics among emerging adults (18-23 y) in the United States who participated in the 2015-2018 National Health and Nutrition Examination Survey (NHANES).

METHODS

NHANES data were collected via a household interview and 2 24-h dietary recalls (24HR). Usual dietary intakes from the 24HRs were approximated using the multivariate National Cancer Institute Method to compute mean HEI-2015 overall and component scores (range: 0-100; higher scores indicating higher dietary quality).

RESULTS

Overall dietary quality among emerging adults (HEI-2015: 50.3 ± 1.3) was significantly lower than other adults (≥24 y) (HEI-2015: 56.3 ± 0.5; P < 0.0001) in the United States, with differences primarily driven by lower intakes of whole fruit, vegetables, and whole grains and higher intakes of sodium, refined grains, and saturated fat. Few differences in HEI-2015 scores were noted across population subgroups by sex, food security, family income, and food assistance program participation, except for added sugar; intakes of added sugar were significantly higher among women, food insecure, and food assistance program participants than those in their counterparts, respectively.

CONCLUSIONS

Dietary quality is poor among emerging adults in the United States and persists across all population subgroups, suggesting a significant need for tailored public health interventions to improve dietary quality among this population. Future research investigating to what extent emerging adults prioritize healthful behaviors and exploring other indicators for identifying nutritionally vulnerable subgroups may be impactful for identifying disparities among this life stage.

Social Determinants and Consequences of Pain: Toward Multilevel, Intersectional, and Life Course Perspectives

Despite wide endorsement of a biopsychosocial framework for pain, social aspects of pain remain rarely addressed in the context of pain prevention and management. In this review, we aim to 1) examine the broad scope of social determinants and consequences of pain and their interactions across multiple levels of organization, and 2) provide a framework synthesizing existing concepts and potential areas for future work on social aspects of pain, drawing upon socioecological, intersectional, and life course approaches. Integrating interdisciplinary theory and evidence, we outline pathways through which multilevel social factors and pain may affect each other over time. We also provide a brief summary of intrapersonal aspects of pain, which are thought to operate at the interface between individuals and the social context. Progressing from micro- to macrolevel factors, we illustrate how social determinants of pain can directly or indirectly contribute to pain experiences, expression, risk, prognosis, and impact across populations. We consider 1) at the interpersonal level, the roles of social comparison, social relatedness, social support, social exclusion, empathy, and interpersonal conflict; 2) at the group or community level, the roles of intimacy groups, task groups, social categories, and loose associations; and 3) at the societal level, the roles of political, economic, and cultural systems, as well as their policies and practices. We present examples of multilevel consequences of pain across these levels and discuss opportunities to reduce the burden and inequities of pain by expanding multilevel social approaches in pain research and practice. PERSPECTIVE: Despite wide endorsement of a biopsychosocial framework for pain, social aspects of pain are often unclearly defined, hindering their use in pain prevention, management, and research. We summarize the scope of social aspects of pain and provide a framework synthesizing existing concepts and potential areas for future work.

Collaborative Modeling to Compare Different Breast Cancer Screening Strategies: A Decision Analysis for the US Preventive Services Task Force

Importance

The effects of breast cancer incidence changes and advances in screening and treatment on outcomes of different screening strategies are not well known.

Objective

To estimate outcomes of various mammography screening strategies.

Design, Setting, and Population

Comparison of outcomes using 6 Cancer Intervention and Surveillance Modeling Network (CISNET) models and national data on breast cancer incidence, mammography performance, treatment effects, and other-cause mortality in US women without previous cancer diagnoses.

Exposures

Thirty-six screening strategies with varying start ages (40, 45, 50 years) and stop ages (74, 79 years) with digital mammography or digital breast tomosynthesis (DBT) annually, biennially, or a combination of intervals. Strategies were evaluated for all women and for Black women, assuming 100% screening adherence and "real-world" treatment.

Main Outcomes and Measures

Estimated lifetime benefits (breast cancer deaths averted, percent reduction in breast cancer mortality, life-years gained), harms (false-positive recalls, benign biopsies, overdiagnosis), and number of mammograms per 1000 women.

Results

Biennial screening with DBT starting at age 40, 45, or 50 years until age 74 years averted a median of 8.2, 7.5, or 6.7 breast cancer deaths per 1000 women screened, respectively, vs no screening. Biennial DBT screening at age 40 to 74 years (vs no screening) was associated with a 30.0% breast cancer mortality reduction, 1376 false-positive recalls, and 14 overdiagnosed cases per 1000 women screened. Digital mammography screening benefits were similar to those for DBT but had more false-positive recalls. Annual screening increased benefits but resulted in more false-positive recalls and overdiagnosed cases. Benefit-to-harm ratios of continuing screening until age 79 years were similar or superior to stopping at age 74. In all strategies, women with higher-than-average breast cancer risk, higher breast density, and lower comorbidity level experienced greater screening benefits than other groups. Annual screening of Black women from age 40 to 49 years with biennial screening thereafter reduced breast cancer mortality disparities while maintaining similar benefit-to-harm trade-offs as for all women.

Conclusions

This modeling analysis suggests that biennial mammography screening starting at age 40 years reduces breast cancer mortality and increases life-years gained per mammogram. More intensive screening for women with greater risk of breast cancer diagnosis or death can maintain similar benefit-to-harm trade-offs and reduce mortality disparities.

A blueprint for a new commercial driving epidemiology: An emerging paradigm grounded in integrative exposome and network epistemologies

Excess health and safety risks of commercial drivers are largely determined by, embedded in, or operate as complex, dynamic, and randomly determined systems with interacting parts. Yet, prevailing epidemiology is entrenched in narrow, deterministic, and static exposure-response frameworks along with ensuing inadequate data and limiting methods, thereby perpetuating an incomplete understanding of commercial drivers' health and safety risks. This paper is grounded in our ongoing research that conceptualizes health and safety challenges of working people as multilayered "wholes" of interacting work and nonwork factors, exemplified by complex-systems epistemologies. Building upon and expanding these assumptions, herein we: (a) discuss how insights from integrative exposome and network-science-based frameworks can enhance our understanding of commercial drivers' chronic disease and injury burden; (b) introduce the "working life exposome of commercial driving" (WLE-CD)-an array of multifactorial and interdependent work and nonwork exposures and associated biological responses that concurrently or sequentially impact commercial drivers' health and safety during and beyond their work tenure; (c) conceptualize commercial drivers' health and safety risks as multilayered networks centered on the WLE-CD and network relational patterns and topological properties-that is, arrangement, connections, and relationships among network components-that largely govern risk dynamics; and (d) elucidate how integrative exposome and network-science-based innovations can contribute to a more comprehensive understanding of commercial drivers' chronic disease and injury risk dynamics. Development, validation, and proliferation of this emerging discourse can move commercial driving epidemiology to the frontier of science with implications for policy, action, other working populations, and population health at large.

Linking Adverse Experiences to Pregnancy and Birth Outcomes: A Life Course Analysis of Racial and Ethnic Disparities Among Low-Income Women

Racial and ethnic disparities in birth outcomes have persisted in the United States for decades, though the causes remain poorly understood. The life course perspective posits that poorer outcomes of Black birthing people stem from heightened exposure to stressors early in life and cumulative exposure to stressors over time. Despite its prominence, this perspective has seldom been investigated empirically. We analyzed longitudinal data gathered from 1319 women in low-income households in Wisconsin who received perinatal home visiting services. Variable- and person-centered analyses were performed to assess whether 15 adverse childhood experiences (ACEs) and 10 adverse adult experiences (AAEs) were associated, alone and in combination, with pregnancy loss, preterm birth, and low birth weight among Hispanic (i.e., Latinx) and non-Hispanic Black and White participants. As expected, there were disparities in preterm birth and low birth weight, and both ACEs and AAEs were linked to poorer pregnancy and birth outcomes. Unexpectedly, bivariate and multivariate analyses showed that the associated effects of ACEs and AAEs were most robust for non-Hispanic White women. A latent class analysis produced four patterns of life course adversity, and multigroup latent class analyses confirmed that, compared to White women, higher-adversity class assignments were associated with less robust effects for Hispanic women, and even less robust effects for Black women. We discuss interpretations of the paradoxical findings, including the possibility that alternative sources of stress such as interpersonal and structural racism may better account for the reproductive disparities that disproportionately affect Black birthing people.

Biopsychosocial factors in oral and systemic diseases: a scoping review

Background

The association between chronic oral diseases and other major systemic health conditions, commonly referred to as the oral-systemic health connection, has been previously studied with several underlying common risk factors and pathways linking both groups of diseases. Psychosocial factors contribute to an increased susceptibility to chronic oral and non-oral diseases. The aim of this review is to summarize the current state of knowledge on the role of psychosocial stress in chronic oral and systemic diseases.

Methods

A search strategy was built and a literature search was conducted using four databases (CINAHL, Embase, Medline, PsycINFO). A combination of search terms related to psychosocial stress, systemic disease, and oral conditions were used. Studies were eligible for inclusion if they included human adults (aged 18 years and older), included psychosocial factors as an exposure measure, and outcome measures of both an oral and systemic condition. Only English-language articles were considered. Pilot testing of the data extraction form and calibration were conducted and data were extracted independently by one researcher.

Results

A total of fifteen articles out of eighty full-text articles screened were determined to be eligible for inclusion in this review. Periodontal disease was the most commonly studied oral disease, measured in 53% of included articles, with the most commonly studied systemic diseases being of mental health conditions (40%) and diabetes (47%). Psychosocial stress was measured using a range of psychometric indicators and/or biomarkers, including perceived stress, individual behaviours, childhood adversity, and cortisol. In total, fourteen studies found a positive association between measures of psychosocial stress and oral-systemic health.

Conclusion

Psychosocial stress may be a common contributor to both chronic oral and non-oral diseases.

Examining the Impact of Race and Poverty on the Relationship Between Purpose in Life and Functional Health: Insights from the HANDLS Study

INTRODUCTION

While research has shown a positive association between a higher sense of purpose in life and functional health, there is a gap in understanding its benefits for racially minoritized and low SES individuals. This study aimed to investigate the correlation between purpose in life and physical functional health in a diverse sample, hypothesizing that purpose in life would be negatively associated with functional difficulties, with potentially stronger associations in White and high SES groups.

METHODS

Data from the Healthy Aging in Neighborhoods of Diversity across the Life Span (HANDLS) study were utilized (166 participants, mean age 59.44 [SD = 8.28], 59.6% females, 65.06% Black participants, 40.36% below poverty). Purpose in life was measured by Ryff's Psychological Well-being Purpose in Life subscale. Functional health was measured by functional difficulties in mobility and daily living. Race (Black and White) and poverty status (above and below) were used as moderators to probe the purpose-functional health association using zero-inflated Poisson regression while adjusting for age, education, depressive symptomology, and previous functional difficulties in four hierarchical models.

RESULTS

Results showed that purpose in life was negatively associated with functional difficulty, indicating fewer difficulties in mobility and daily activities among those with a high sense of purpose. While the association did not remain significant after including previous functional difficulty as a covariate in Model 4, suggesting that race may not be a consistent moderator, poverty status remained a consistent moderator. The association was stronger for individuals above the poverty level.

DISCUSSION

These findings underscore the complex interplay between purpose in life, race, poverty status, and functional health, emphasizing the importance of considering socioeconomic factors in interventions aimed at eliminating functional health disparities among diverse adult populations.

Harnessing Resilience in the Healthy Ageing Discourse: Insights from Attappadi Indigenous Older Adults, Kerala, India

In this "Decade of Healthy Ageing," the integration of resilience into the healthy aging discourse becomes paramount, particularly in the context of indigenous communities grappling with the enduring effects of historical oppression, persistent poverty, and health disparities in their aging journey. Employing a phenomenological lens, this study seeks to derive the resilient characteristics exhibited by the Attappadi indigenous older adults of Kerala, aiming to explore the role of resilience in their pursuit of healthy aging. In-depth phenomenological interviews (n = 34), observation, and document analysis have revealed four key themes: A life course marked by adversities, Embracing the unyielding strength within, Personal resilience catalysts, and Extrinsic resilience catalysts. The participants exhibited a reasonably well-functioning collective, given their persistent adversities in their life course. Narratives illuminated a notable connection between the presence of resilience characteristics and the overall functioning of older adults. From a social work standpoint on resilience, this article underscores the vital interplay between individual agency and environmental factors in addressing adversity. The article advocates culturally sensitive, asset-based strategies to strengthen indigenous older adults' intrinsic and extrinsic resilience to ensure that they are not left behind in the global pursuit of healthy aging.

Social Determinants of Health and Cancer Care: An ASCO Policy Statement

ASCO's new policy statement on SDOH supports practices that sustain and advance cancer health equity.

Disparities in Cardiovascular Disease-Related Outcomes Among Cancer Survivors in the United States: A Systematic Review of the Literature

BACKGROUND

Cancer and cardiovascular disease (CVD) are major causes of morbidity and mortality in the United States (US). Cancer survivors have increased risks for CVD and CVD-related mortality due to multiple factors including cancer treatment-related cardiotoxicity. Disparities are rooted in differential exposure to risk factors and social determinants of health (SDOH), including systemic racism. This review aimed to assess SDOH's role in disparities, document CVD-related disparities among US cancer survivors, and identify literature gaps for future research.

METHODS

Following the Peer Review of Electronic Search Strategies (PRESS) guidelines, MEDLINE, PsycINFO, and Scopus were searched on March 15, 2021, with an update conducted on September 26, 2023. Articles screening was performed using the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) 2020, a pre-defined Population, Exposure, Comparison, Outcomes, and Settings (PECOS) framework, and the Rayyan platform. A modified version of the Newcastle-Ottawa Scale was used to assess the risk of bias, and RAW Graphs for alluvial charts. This review is registered with PROSPERO under ID #CRD42021236460.

RESULTS

Out of 7,719 retrieved articles, 24 were included, and discussed diverse SDOH that contribute to CVD-related disparities among cancer survivors. The 24 included studies had a large combined total sample size (n=7,704,645; median=19,707). While various disparities have been investigated, including rural-urban, sex, socioeconomic status, and age, a notable observation is that non-Hispanic Black cancer survivors experience disproportionately adverse CVD outcomes when compared to non-Hispanic White survivors. This underscores historical racism and discrimination against non-Hispanic Black individuals as fundamental drivers of CVD-related disparities.

CONCLUSIONS

Stakeholders should work to eliminate the root causes of disparities. Clinicians should increase screening for risk factors that exacerbate CVD-related disparities among cancer survivors. Researchers should prioritise the investigation of systemic factors driving disparities in cancer and CVD and develop innovative interventions to mitigate risk in cancer survivors.

Beyond Public Health and Private Choice: Breastfeeding, Embodiment and Public Health Ethics

The key objective of this paper is to emphasize the importance of acknowledging breastfeeding as an embodied social practice within interventions related to breastfeeding and lactation and illustrate how this recognition holds implications for public health ethics debates. Recent scholarship has shown that breastfeeding and lactation support interventions undermine women's autonomy. However, substantial discourse is required to determine how to align with public health goals while also recognizing the embodied experiences of breastfeeding and lactating individuals. Presently, interventions in this realm predominantly revolve around health-related messaging and the promotion of individual behaviors, often neglecting the systemic and structural factors that influence choices and practices. I closely examine breastfeeding interventions in India, in particular Mothers' Absolute Affection health promotion program, along with breastfeeding narratives. I argue that for such interventions to evolve, they must acknowledge the intrinsic embodied social nature of breastfeeding during their design and implementation. Furthermore, it is important to emphasize that achieving equity and justice objectives necessitates moving beyond the confines of both conventional public health frameworks and frameworks solely centered on private choices. Instead, a more encompassing approach that embraces the concept of embodiment should be adopted.

Poverty and birth cohort effects of experiencing the 2007-2009 Great Recession during adolescence on major depressive episodes and mental health treatment of young adults in the United States

PURPOSE

Household economic adversity during adolescence is hypothesized to be a risk factor for poor mental health later in life. To test this hypothesis, we conducted a quasi-experimental analysis of an economic shock, the Great Recession of 2007-2009. We tested if going through adolescence during the Great Recession was associated with increased risk of major depressive episodes (MDE) and mental health treatment in young adulthood with potential moderation by household poverty to explore differences by economic adversity.

METHODS

We analyzed data on young adults age 18-29 years from the 2005-2019 National Survey on Drug Use and Health (N = 145,394). We compared participants who were adolescents during the recession to those followed-up prior to the recession. Regression analysis tested effect modification by household poverty status.

RESULTS

Adolescent exposure to the Great Recession was associated with higher likelihood of MDE during young adulthood (aOR = 1.30, 95% CI = 1.23, 1.37); there was no relationship with mental health treatment. Effects on MDE were stronger among those in households with higher incomes compared to those living in poverty.

CONCLUSION

Findings support the hypothesis that exposure to the Great Recession during adolescence may have increased risk for MDE, but raise questions about whether the mechanism of this association is economic distress.

Antenatal anxiety symptoms outperform antenatal depression symptoms and suicidal ideation as a risk factor for postpartum suicidal ideation

BACKGROUND AND OBJECTIVES

Suicidal ideation (SI) during the postpartum phase is linked with suicide, a leading cause of death during this period. Antenatal depression and anxiety symptoms have both been linked with increased risk for postpartum SI. However, research aimed at examining the relative contributions of antenatal anxiety and depression symptoms towards postpartum SI remains nascent. In this study, we investigated the relative contribution of antenatal anxiety symptoms, depression symptoms, and SI towards postpartum SI.

DESIGN

These data are from a longitudinal study in which American mothers were assessed during pregnancy and again at six- to eight weeks postpartum.

METHODS

Data were analyzed using correlations and logistic regression models.

RESULTS

Antenatal anxiety symptoms and antenatal depression symptoms were significantly correlated with postpartum SI. Results from a logistic regression model indicated that antenatal anxiety symptoms (T1; OR = 1.185 [1.125, 1.245], p = .004), but not antenatal depression symptoms (T1; OR = 1.018 [0.943, 1.093], p = .812) or antenatal SI (T1; OR = 1.58 [0.11, 22.29], p = 0.73), were significantly associated with postpartum SI.

CONCLUSIONS

Antenatal anxiety symptoms, depression symptoms, and SI were positively associated with postpartum SI. When examined simultaneously, anxiety symptoms during the antenatal phase (but not depression symptoms or SI) predicted SI in the postpartum phase.

Racial/ethnic disparities in sleep health among adolescents in South Korea: The role of substance use behaviours

AIM

To examine the relationship between racial/ethnic disparities and substance use behaviours (alcohol and tobacco use) and their impact on the sleep health of South Korean adolescents.

DESIGN

Secondary analysis of cross-sectional study data from the 2021 Korea Youth Risk Behaviour Web-based Survey dataset.

METHODS

Given that Korean society has historically linked its racial/ethnic identity to a shared bloodline, we categorized 2644 adolescents from the Korea Youth Risk Behaviour Web-based Survey based on their racial/ethnic status, determined by their parents' birthplaces. Using multiple linear regression, we investigated whether the impact of racial/ethnic disparities on sleep health (sleep duration, debt, and timing) varies depending on substance use behaviours (alcohol and tobacco use) after controlling for age, sex, household economic status, depressed mood, suicidal ideation, perceived excessive stress, and anxiety level.

RESULTS

Despite no statistical differences in sleep health and the prevalence of substance use between racial/ethnic groups, racial/ethnic minority adolescents experienced greater sleep debt than racial/ethnic majority adolescents when consuming alcohol. Moreover, racial/ethnic minority adolescents were more likely to report psychosocial distress and had lower parental education level.

CONCLUSION

Racial/ethnic minority adolescents were more vulnerable to the detrimental effects of alcohol use on sleep health compared to racial/ethnic majority adolescents. This heightened vulnerability may be attributed to the more pronounced psychosocial challenges and the lower socioeconomic status of parents in the racial/ethnic minority group.

IMPACT

Racial/ethnic disparities are concerning in South Korea, particularly since the negative effects of substance use on sleep health are intensified among racial/ethnic minority adolescents. Nurses and other healthcare providers should recognize the importance of addressing the social disadvantages linked to racial/ethnic disparities. Beyond just advocating for the cessation of substance use, it is crucial to address these underlying issues to reduce sleep disparities among South Korean adolescents.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

The Role of Racism in Childhood Obesity

PURPOSE OF REVIEW

Obesity rates continue to rise among children and have shown persistent racial disparities. Racism plays a potentially essential and actionable role in these disparities. This report reviews some mechanisms through which racism may shape childhood obesity.

RECENT FINDINGS

From the youngest ages, disparities in childhood obesity prevalence are already present. Racism may shape intergenerational and prenatal factors that affect obesity and various stressors and environments where children grow up. The relationships between clinicians and patients may also be shaped by everyday racism and legacies of past racism, which may affect obesity prevalence and treatment efficacy. Comprehensive data on the extent to which racism shapes childhood obesity is limited. However, compelling evidence suggests many ways through which racism ultimately does affect childhood obesity. Interventions to address racism at multiple points where it shapes childhood obesity, including intergenerational and prenatal mechanisms, may help to close disparities.

Association Between Changes in Racial Residential and School Segregation and Trends in Racial Health Disparities, 2000-2020: A Life Course Perspective

INTRODUCTION

Most studies of the relationship between racial segregation and racial health disparities have focused on residential segregation. School-based racial segregation is an additional form of segregation that may be associated with racial disparities in health. This study examines the relationship between both residential segregation and school segregation and racial health disparities among non-Hispanic Black compared to non-Hispanic White persons at the county level in the United States. It also examines the relationship between changes in residential and school segregation and subsequent trajectories in a variety of racial health disparities across the life course.

METHODS

Using the CDC WONDER Multiple Case of Death database, we derived an annual estimate of race-specific death rates and rate ratios for each county during the period 2000-2020. We then examined the relationship between baseline levels of residential and school segregation in 1991 as well as changes between 1991-2000 and the trajectories of the observed racial health disparities between 2000 and 2020. We used latent trajectory analysis to identify counties with similar patterns of residential and school segregation over time and to identify counties with similar trajectories in each racial health disparity. Outcomes included life expectancy, early mortality (prior to age 65), infant mortality, firearm homicide, total homicide, and teenage pregnancy rates.

RESULTS

During the period 1991-2020, racial residential segregation remained essentially unchanged among the 1051 counties in our sample; however, racial school segregation increased during this period. Increases in school segregation from 1991 to 2000 were associated with higher racial disparities in each of the health outcomes during the period 2000-2020 and with less progress in reducing these disparities.

CONCLUSION

This paper provides new evidence that school segregation is an independent predictor of racial health disparities and that reducing school segregation-even in the face of high residential segregation-could have a long-term impact on reducing racial health disparities. Furthermore, it suggests that the health consequences of residential segregation have not been eliminated from our society but are now being exacerbated by a new factor: school-based segregation. Throughout this paper, changes in school-based segregation not only show up as a consistent significant predictor of greater racial disparities throughout the life course, but at times, an even stronger predictor of health inequity than residential segregation.

Constructing Residential Histories in a General Population-Based Representative Sample

Research on neighborhoods and health typically measures neighborhood context at a single point in time. However, neighborhood exposures accumulate over the life course, influenced by both residential mobility and neighborhood change, with potential implications for estimating the impact of neighborhoods on health. Commercial databases offer fine-grained longitudinal residential address data that can enrich life-course spatial epidemiology research, and validated methods for reconstructing residential histories from these databases are needed. Our study draws on unique data from a geographically diverse, population-based representative sample of adult Wisconsin residents and the LexisNexis (New York, New York) Accurint, a commercial personal profile database, to develop a systematic and reliable methodology for constructing individual residential histories. Our analysis demonstrated that creating residential histories across diverse geographical contexts is feasible, and it highlights differences in the information obtained from available residential histories by age, education, race/ethnicity, and rural/urban/suburban residency. Researchers should consider potential address data availability and information biases favoring socioeconomically advantaged individuals and their implications for studying health inequalities. Despite these limitations, LexisNexis data can generate varied residential exposure metrics and be linked to contextual data to enrich research into the contextual determinants of health at varied geographic scales.

Using the life course health development model to address pediatric mental health disparities

TOPIC

Early-life experiences, the transmission of health and disease within families, and the influence of cumulative risks as well as protective factors throughout life shape the trajectory of health, including mental health. Long-term health trajectories established early in life are influenced by biologic, social, and environmental factors. Negative trajectories may be more salient if exposures to adversity occur during critical developmental periods.

PURPOSE

The purpose of this brief is to (a) review pediatric health disparities related to depression and the intergenerational transmission of pediatric depression using a Life Course Health Development (LCHD) model and (b) provide recommendations for pediatric mental health research.

SOURCES

Peer-reviewed papers available for PubMed, CINAL, and Medline. Other sources include published books, papers, and gray materials.

CONCLUSIONS

The LCHD model is a perspective to guide and foster new scientific inquiry about the development of mental health outcomes over the life course. The model enables synthesis of mental health, nursing, and public health, linking mental health prevention, risk reduction, and treatment in children.

Positive childhood experiences serve as protective factors for mental health in pandemic-era youth with adverse childhood experiences

BACKGROUND

While adverse childhood experiences (ACEs) predict poorer mental health across the life course, positive childhood experiences (PCEs) predict better mental health. It is unclear whether PCEs protect against poor mental health outcomes and promote mental well-being in pandemic-era adolescents with ACEs.

METHODS

We examined the individual and joint contributions of ACEs and PCEs to mental health and well-being (MHW) in eleventh-grade British Columbian adolescents (N = 8864) during the fifth wave of COVID-19. We used a novel measure of ACEs that included community- and societal-level ACEs in addition to ACEs experienced at home to investigate the role of social and structural determinants of mental health in supporting the MHW of pandemic-era adolescents. A series of two-way ANCOVAs were conducted comparing MHW outcomes between adolescents with and without ACEs. Interaction effects were examined to investigate whether PCEs moderated the association between ACEs and MHW.

RESULTS

Adolescents with no ACEs had significantly better MHW than those with one or more ACE. Having six or more PCEs was associated with better MHW in adolescents with and without ACEs. PCEs significantly moderated the association between ACEs and depression. Effect sizes were larger for PCEs than ACEs in relation to depression, mental well-being, and life satisfaction.

CONCLUSIONS

PCEs may protect against depression among adolescents with ACEs and promote MHW among all pandemic-era adolescents. These findings emphasize the importance of addressing social determinants of mental health to mitigate the impact of ACEs and promote PCEs as part of a public health approach to MHW.

Voices of Identity: Exploring Identity Development and Transformation among Urban American Indian/Alaska Native Emerging Adults

Emerging adulthood shapes personal, professional, and overall well-being through identity exploration. This study addresses a gap in the minority identity literature by investigating how urban AI/AN emerging adults think about their identity and discussing challenges and protective factors associated with exploring their identity holistically. This mixed-methods study created a sampling framework based on discrimination experiences, cultural identity, social network support, mental health, and problematic substance use. We recruited 20 urban AI/AN emerging adults for interviews. We sought to gain deeper insights into their experiences and discussions surrounding identity formation and exploration. We provide descriptives for demographic characteristics and conducted a thematic analysis of the qualitative data from the interviews. Four themes emerged: a) being an urban AI/AN emerging adult means recognizing that one's identity is multifaceted; b) a multifaceted identity comes with tension of living in multiple worlds; c) the trajectory of one's identity grows over time to a deeper desire to connect with Native American culture; and d) understanding one's Native American background affects one's professional trajectory. Findings underscore the importance of developing programs to support well-being and identity development through cultural connection for urban AI/AN emerging adults.

Physician Perspectives on Addressing Anti-Black Racism

Importance

Uncertainty remains among clinicians regarding processes to address and resolve conflict around anti-Black racism.

Objective

To elicit clinicians' perceptions of their role in addressing concerns about anti-Black racism among Black patients with serious illness as well as their families.

Design, Setting, and Participants

In this qualitative study, one-on-one semistructured interviews were conducted with 21 physicians at an academic county hospital between August 1 and October 31, 2022. Participants were provided clinical scenarios where anti-Black racism was a concern of a patient with serious illness. Participants were asked open-ended questions about initial impressions, prior similar experiences, potential strategies to address patients' concerns, and additional resources to support these conversations. A framework based on restorative justice was used to guide qualitative analyses.

Main Outcomes and Measures

Perspectives on addressing anti-Black racism as described by physicians.

Results

A total of 21 medical subspecialists (mean [SD] age, 44.2 [7.8] years) participated in the study. Most physicians were women (14 [66.7%]), 4 were Asian (19.0%), 3 were Black (14.3%), and 14 were White (66.7%). Participants identified practices that are normalized in clinical settings that may perpetuate and exacerbate perceptions of anti-Black racism. Using provided scenarios and personal experiences, participants were able to describe how Black patients are harmed as a result of these practices. Last, participants identified strategies and resources for addressing Black patients' concerns and facilitating conflict resolution, but they stopped short of promoting personal or team accountability for anti-Black racism.

Conclusions and Relevance

In this qualitative study, physicians identified resources, skills, and processes that partially aligned with a restorative justice framework to address anti-Black racism and facilitate conflict resolution, but did not provide steps for actualizing accountability. Restorative justice and similar processes may provide space within a mediated setting for clinicians to repair harm, provide accountability, and facilitate racial healing.

Health Disparities Among Older Adults: An Introduction to the Special Issue

The problem of health disparities across the lifespan and in older adulthood has gained recent attention by the National Institute on Aging (NIA) and other organizations and researchers. These disparities are of significant interest as they greatly impact health, life span, and quality-of-life for countless individuals and create economic burden on societies. Given the critical nature of this problem, this special issue will focus on health disparities for older adults across the lifespan. This introductory article will lay the groundwork for subsequent works on disparities among older ethnic minorities, women, lesbian, gay, bisexual, and trans, as well as rural elders. Concepts critical to an understanding of the topic such as social determinants of health, marginalization, and intersectionality will also be discussed.

Nutrition in a lifecourse perspective: From molecular aspects to public health approaches

This Special Issue covers a variety of topics related to nutrition from a lifecourse perspective, addressing diet in sensitive periods (preconception, pregnancy and infancy/toddlerhood), in different contexts, spanning from molecular nutrition to settings and gatekeepers of diet in these sensitive periods. It highlights challenges and research gaps within the field.

Association of Childhood Adversity With Frailty and the Mediating Role of Unhealthy Lifestyle: A Lifespan Analysis

OBJECTIVES

Childhood adversity and lifestyle have been associated with frailty in later life, but not much is known about factors that may explain these associations. Therefore, this study aims to investigate the association of childhood adversity with frailty, and the mediating role of unhealthy lifestyle in the association.

METHODS

This lifespan analysis included 152,914 adults aged 40-69 years old from the UK Biobank. We measured childhood adversity with five items: physical neglect, emotional neglect, sexual abuse, physical abuse, and emotional abuse through online mental health survey. Frailty was measured by the frailty index; an unhealthy lifestyle score (range: 0-5) was calculated based on unhealthy body mass index, smoking, alcohol consumption, physical inactivity, and unhealthy diet at the baseline survey. Multiple logistic regression and mediation analysis were performed.

RESULTS

A total of 10,078 participants (6.6%) were defined as having frailty. Participants with any childhood adversity had higher odds of frailty. For example, in the fully adjusted model, with a one-point increase in cumulative score of childhood adversity, the odds of frailty increased by 38% (odds ratio: 1.38; 95% Confidence Interval: 1.36, 1.40). Unhealthy lifestyle partially mediated the associations of childhood adversity with frailty (mediation proportion: 4.4%-7.0%). The mediation proportions were largest for physical (8.2%) and sexual (8.1%) abuse.

CONCLUSIONS

Childhood adversity was positively associated with frailty, and unhealthy lifestyle partially mediated the association. This newly identified pathway highlights the potential of lifestyle intervention strategies among those who experienced childhood adversity (in particular, physical, and sexual abuse) to promote healthy aging.

Micronutrient Deficiencies in Older Adults in Latin-America: A Narrative Review

BACKGROUND

The population in Latin America and Caribbean (LAC) has experienced a major demographic transition with increased numbers of older adults (OA). This change brings opportunities in the public health sector to implement health prevention interventions and delay the onset of geriatric syndromes. Micronutrients play an important role in the maintenance of biological function which contributes to longevity. Micronutrient deficiencies (MD) in OA increase the risk for onset of chronic comorbidities and geriatric syndromes.

AIM

To review and summarize the existing data on micronutrient status in OA in the LAC region and discuss the gaps and challenges in public health approaches to address deficiencies.

METHODS

Literature review in Medline for records describing nutritional biomarkers in older adults (≥ 60y) from community dwelling and population-based studies in LAC.

RESULTS

Few countries (including Chile, Ecuador, Costa Rica, Brazil, and Mexico) have documented one or more nutritional deficiencies for OA in national health surveys, however across the entire region, evidence of micronutrient levels is scarce. Some surveys have documented a high prevalence and large heterogeneity in the prevalence of vitamin D followed by B12 deficiency, being the 2 MDs most studied due their effects on cognition, frailty, and bone mineral density in the OA population. Other MD including C, E, A, copper, zinc, iron, and selenium have also been reported.

CONCLUSION

Information on the micronutrient status in OA from LAC is poorly documented. Research and capacity building initiatives in the region are crucial to develop tailored strategies that address the specific nutritional needs and challenges faced by the ageing population in Latin-America.

Social Determinants of Mental and Behavioral Health

Both mental illness and overall mental health are determined by a complicated interplay of life experiences and genetic predisposition. While genetic predisposition is difficult to modify, many of the life experiences that worsen mental health and exacerbate serious mental illness are associated with social policies and cultural norms that are changeable. Now that we have identified these associations, it is time to rigorously test scalable interventions to address these risks. These interventions will need to focus on high-impact stages in life (like childhood) and will need to address risk beyond the individual by focusing on the family and community.

Nurse-led approaches to address social determinants of health and advance health equity: A new framework and its implications

BACKGROUND

The U.S. health care system is burdened by inefficiencies, longstanding health inequities, and unstainable costs. Within the nursing profession and the broader health care sector, there is growing recognition of the need for a paradigm shift that addresses persistent structural problems and advances health equity.

PURPOSE

Despite evidence of the importance of the social determinants of health (SDOH) in shaping inequitable health outcomes, practical tools for applying SDOH theory in the development of effective nurse-led programs to mitigate harmful SDOH remain scarce.

METHODS

We synthesize extant SDOH literature into a heuristic framework for conceptualizing core SDOH mechanisms, constructs, and principles.

FINDINGS

To illustrate how nurse scientists can use the framework to guide the development of programs for SDOH mitigation, we outline a three-step exemplar application to the U.S. Latino HIV epidemic.

DISCUSSION

Our framework can inform a paradigm shift toward nurse-led, multi-level SDOH mitigation across practice, education, and research.

Family-Centered Prevention to Reduce Discrimination-Related Depressive Symptoms Among Black Adolescents: Secondary Analysis of a Randomized Clinical Trial

Importance

Racial discrimination undermines the mental health of Black adolescents. Preventive interventions that can attenuate the effects of exposure to racial discrimination are needed.

Objective

To investigate whether participation in the Strong African American Families (SAAF) program moderates Black adolescents' depressive symptoms associated with experience of racial discrimination.

Design, Setting, and Participants

This secondary analysis used data from a community-based randomized clinical trial of SAAF (SAAF vs no treatment control). Participants were followed up at 10, 22, and 34 months after the baseline assessment. Assessment staff were blind to participant condition. Participants in this trial lived in 7 rural counties in Georgia. SAAF was delivered at local community centers. Eligible families had a child aged 11 to 12 years who self-identified as African American or Black. The joint influence of random assignment to SAAF and exposure to racial discrimination was investigated. Data were analyzed from September 2022 to March 2023.

Intervention

SAAF is a 7-session (14 hours) family skills training intervention that occurs over 7 weeks. Small groups of caregivers and their adolescents participate in a structured curriculum targeting effective parenting behavior, adolescent self-regulation, and Black pride.

Main Outcomes and Measures

The main outcome was adolescent-reported depressive symptoms, assessed at 34 months via the 20-item Center for Epidemiologic Studies Depression Scale for Children.

Results

Of 825 families screened randomly from public school lists, 472 adolescents (mean [SD] age, 11.6 years; 240 [50.8%] female) were enrolled and randomized to SAAF (252 participants) or a no treatment control (220 participants). Exposure to racial discrimination at age 13 years was associated with increased depressive symptoms at age 14 years (β = 0.23; 95% CI, 0.13 to 0.34; P < .001). Interaction analyses indicated that the experimental condition significantly moderated the association of racial discrimination with depressive symptoms: (β = -0.27; 95% CI, -0.47 to -0.08; P = .005). Probing the interaction with simple slopes at ±SD revealed that for the control group, racial discrimination was significantly associated with depressive symptoms (β = 0.39; 95% CI, 0.23 to 0.54; P < .001), while for the SAAF group, there was no association between racial discrimination and depressive symptoms (β = 0.12; P = .09).

Conclusions and Relevance

This randomized clinical trial found that the SAAF intervention reduced the incidence of racism-associated mental health symptoms among Black adolescents. SAAF is recommended for dissemination to health care practitioners working with rural Black adolescents.

Trial Registration

ClinicalTrials.gov Identifier: NCT03590132.

Association of personality traits with dental visit procrastination by Japanese university students

BACKGROUND

Procrastination is a psychological trait that causes individuals to put off doing things that need to be done. It has recently shown to result in the worsening of symptoms due to delays in seeking medical care. However, it is not clear how perception of dental disease influences dental visits. This study examined the associations of procrastination and personality traits with delayed dental visits for both acute and chronic conditions.

METHODS

Of 599 university students queried, the data of 549 subjects (mean age 19.7 years) were analyzed. A general procrastination scale (GPS), the Big Five personality traits, and oral hygiene habits were used for analysis. The participants were asked about illness awareness conditions related to dental disease, perception of pain in the oral region due to acute oral symptoms and chronic symptoms. The participants were asked the number of days until they decided that treatment was required. Based on the bimodal shape of the distribution, those who answered at least eight days for acute or chronic conditions were classified as the procrastination (P) group and the others as the non-procrastination (Non-P) group.

RESULTS

Significant differences in GPS scores were found between the groups for both acute and chronic conditions, with significant differences in the Big Five traits of extraversion, agreeableness, and neuroticism for an acute condition and extraversion, openness, and neuroticism for a chronic condition. There were no significant differences regarding oral hygiene habits between the groups for either condition. Next, using a Bayesian network, the probabilistic causal relations among procrastination, the Big Five traits, and delays in dental visits for both acute and chronic conditions were analyzed. Among the Big Five traits, conscientiousness and neuroticism were directly related to GPS score. Interestingly, agreeableness was directly related to delays in dental visits only for an acute condition and showed a negative effect, while dental student status had a positive effect on delays in dental visits.

CONCLUSIONS

The results showed that procrastination and dentistry department are factors that directly influence delays in dental visits, while agreeableness, a Big Five trait, has a negative effect on individuals with an acute condition.

Pacific Islands Families Study: Household Food Security during Pregnancy and Secondary School Educational Achievement

Nutritional environment in early life is a key factor for brain development and function. It is important to understand the relationship between nutrition in early life and academic achievement in adolescence. The birth cohort of the Pacific Islands Families (PIF) study was born in the year 2000. When their child was six weeks old, mothers were asked questions concerning food security over the past year. Two binary measures of food security were derived as previously used in PIF and also by the Ministry of Health (MOH). In 2020, records of academic achievement from the National Certificate of Educational Achievement (NCEA) for 649 (317 female, 332 male) cohort members showed progressive achievement at levels 1, 2, and 3 of NCEA and allowed University Entrance (UE) to be assessed. The prevalence of food insecurity was not different for sex but high at 29% and 42% using the PIF and MOH definitions of food insecurity, respectively. More females (27%) than males (18%) achieved UE as their highest qualification, and more males (40%) than females (31%) achieved NCEA levels 1 or 2 as their highest qualification. UE was achieved by 25% of those born into food-secure households and 17% from food-insecure households. Logistic regression demonstrated that the odds of achieving UE were 1.8-fold (95% CI 1.2, 2.6, p = 0.003) higher in females than males and, independently, 1.6-fold (95% CI 1.1, 2.5 p = 0.026) higher if the household was food secure. This work emphasises the importance of maternal and early-life food security for subsequent academic achievement and the well-being of future generations.

Living with chronic headaches: A qualitative study from an outpatient pain clinic in Norway

BACKGROUND

Although headache is considered a frequently experienced type of pain, the challenges, experiences, and perceptions of people suffering from chronic headaches are poorly understood. The aim of this study was to gain subjective information regarding these aspects in daily life, in order to answer the research question "What is life like with a chronic headache?"

METHODOLOGY

Semi-structured, in-depth interviews were conducted with 16 patients who suffered from chronic headaches. Five main domains were explored: emotions related to headaches; trauma/stressful events; behavioural changes, relationships, and coping mechanisms.

ANALYSIS AND INTERPRETATION

Participants reported that pain restricted their lives in many ways, including not being able to work, loss of status, identity, freedom, intimate relationships and friends. The majority believed that psychological and/or physiological trauma was the reason for their headaches. New information that emerged from this study was how common life events not usually considered major traumas, initiated and maintained symptoms. Shame and feelings of stigmatization appeared to be strongly associated with chronic pain, leading to a scenario where thriving, contentment and enjoyment were often lacking.

MAIN RESULTS

This study provided an in-depth understanding of how chronic headache adversely affects the lives of sufferers. Chronic headaches restrict sufferers' lives, resulting in emotional and behavioural changes and a high level of disability. The complexity of chronic headaches in clinical practice is hugely underestimated, and poorly understood by society in general.

Intersectionality and public understandings of health inequity in England: learning from the views and experiences of young adults

OBJECTIVES

Attempts to reduce health inequities in England frequently prioritise some equity dimensions over others. Intersectionality highlights how different dimensions of inequity interconnect and are underpinned by historic and institutionalised power imbalances. We aimed to explore whether intersectionality could help us shed light on young adults' understanding of health inequities.

STUDY DESIGN

The study incorporatedqualitative thematic analysis of primary data.

METHODS

Online focus groups with young adults (n = 25) aged 18-30 living in three English regions (Greater London; South Yorkshire/Midlands; North-East England) between July 2020 and March 2021. Online semistructured interviews (n = 2) and text-based communication was conducted for participants unable to attend online groups.

RESULTS

Young adults described experiencing discrimination, privilege, and power imbalances driving health inequity and suggested ways to address this. Forms of inequity included cumulative, within group, interacting, and the experience of privilege alongside marginalisation. Young adults described discrimination occurring in settings relevant to social determinants of health and said it adversely affected health and well-being.

CONCLUSION

Intersectionality, with its focus on discrimination and identity, can help public health stakeholders engage with young adults on health equity. An upstream approach to improving health equity should consider multiple and intersecting forms of discrimination along with their cultural and institutional drivers.

Social mobility and perinatal depression in Black women

Background

Higher socioeconomic position is associated with better birth outcomes and maternal mental health, although this relationship is less consistent for Black women. The literature is limited on the impact of social mobility across the life course on mental health of pregnant women. This study examines the impact of perceived financial status across the life-course on depressive symptoms during pregnancy among Black women.

Methods

Data were from the Life-course Influences of Fetal Environments (LIFE) retrospective cohort study among pregnant Black women in metropolitan Detroit, Michigan. Depressive symptoms in the two weeks prior to birth were assessed using the Center for Epidemiologic Studies Depression (CES-D) scale. Social mobility was determined at three intervals over the life course using self-report of financial status during childhood, adolescence, and current age in pregnancy.

Results

1,410 pregnant women participated, ranging in age from 18 to 45 years old. CES-D scores ranged from 0 to 53 (mean = 15.3) and 26% of the sample reported high depressive symptoms. In each age interval, higher financial status was associated with significant protective effect on depressive symptoms, and the magnitude of the effect increased across the life course. Trajectory analysis demonstrated that both the upward (4.51; 95% CI, 2.43-6.6) and downward (4.04; 95% CI, 2.62-5.46 and 3.09; 95% CI, 1.57-4.62) life-course social mobility groups had increased mean CES-D scores compared to the static social mobility group.

Conclusion

This study describes the importance of previous childhood and current financial status effects on mental health in Black pregnant women.

Perspectives of Infant Mortality from African American Community Members

Introduction

Infant mortality (IM) is often used to determine overall population health and well-being. Health disparities exist with African American (AA) infants having higher rates of IM than White infants. The purpose of this study was to examine the knowledge, attitudes, and perceptions of members in an AA community regarding IM, which can be used to develop interventions.

Methods

A qualitative descriptive design guided this study. A county in the state of Indiana was the setting from which the researchers enrolled participants in this study. The participants consisted of 16 AA community members who were recruited from a local agency and who had completed an educational program on IM. Through semistructured phone interviews, participants described their understanding of IM. The data analysis of the transcribed interviews was performed via content analysis to yield overall themes from the data.

Results

The analysis identified three themes describing AA Community members' perspectives on IM: (1) Shying Away from the Topic of Infant Mortality; (2) Receiving Misinformation from Family Members; and (3) Considering Infant Mortality as Unpreventable.

Discussion

The findings of this study suggest that participants avoided the topic of IM, often received misinformation from family members, and believed infant death could not be prevented. Health care providers should have an open and culturally competent discussion about issues of IM, engage family members, and support community-based initiatives and education for members in AA communities.

A life course health development model of HIV vulnerabilities and resiliencies in young transgender women in Peru

BACKGROUND

Globally transgender women (TW) are at heightened vulnerability for HIV infection. In Lima Peru, sharp increases in HIV prevalence are seen among TW ages 25 years and older highlighting the need for early HIV prevention efforts for young TW. This study conducted in-depth qualitative interviews to elucidate the social and developmental contexts of HIV vulnerability for young TW in Lima Peru.

METHODS

Between November 2019 and February 2020, young TW ages 16-24 years (n = 21) in Lima Peru were purposively sampled using in-person (e.g., face-to-face outreach) and online (e.g., social media, networking websites) social network-based methods. Interviews were conducted in Spanish and a rapid qualitative analysis was conducted using a modified immersion crystallization methodology to identify themes.

RESULTS

Five themes emerged, informing the conceptualization of a Life Course Health Development Model of HIV Vulnerabilities and Resiliencies: (1) interpersonal contexts (family, school, partners, sexual debut, trans mothers); (2) structural vulnerabilities (poverty, educational constraints, migration, hostile environments, sex work, police violence); (3) concomitant mental health and psychosocial factors (discrimination, violence, depression, suicidality, substance use, life hopes/dreams/future expectations); (4) gender affirmation processes (gender identity development, hormones, surgery, legal name/gender marker change); (5) HIV prevention and treatment barriers (PrEP uptake, HIV care, condom use, risk reduction).

CONCLUSIONS

Young TW experience formidable developmental challenges associated with transphobia, violence, and pre-maturely facing accelerated milestones. Developmentally and culturally appropriate interventions to mitigate HIV vulnerability in Peru are needed, including those that consider co-occurring stigma-related conditions in adolescence and young adulthood.

Home Visits With A Registered Nurse Did Not Affect Prenatal Care In A Low-Income Pregnant Population

There is an urgent need to improve maternal and neonatal health outcomes and decrease their racial disparities in the US. Prenatal nurse home visiting programs could help achieve this by increasing the use and quality of prenatal care and facilitating healthy behaviors during pregnancy. We conducted a randomized controlled trial of 5,670 Medicaid-eligible pregnant people in South Carolina to evaluate how a nurse home visiting program affected prenatal health care and health outcomes. We compared outcomes between the treatment and control groups and found little evidence of statistically significant differences in the intensity of prenatal care use, receipt of guideline-based prenatal care services, other health care use, or gestational weight gain. Nor did we find treatment effects in subgroup analyses of socially vulnerable participants (46.9 percent of the sample) or non-Hispanic Black participants (52.0 percent of the sample). Compared with the broader Medicaid population, our trial participants had more health and social risk factors, more engagement with prenatal care, and similar pregnancy outcomes. Delivering intensive nurse home visiting programs to the general Medicaid population might not be an efficient method to improve prenatal care for those who need the most support during pregnancy.

Early socioeconomic status, social mobility and cognitive trajectories in later life: A life course perspective

Using the Chinese Longitudinal Healthy Longevity Survey (CLHLS) from 2008 to 2018 accompanied by the growth curve model, we examined the association between early socioeconomic status, social mobility, and divergent cognitive trajectories in later life within a society undergoing significant transformation. The study confirmed a positive relationship between socioeconomic status in early life and cognitive ability in later life. However, socioeconomic status in adulthood is associated with better cognitive ability in old age compared to that in childhood. Meanwhile, upward social mobility mitigates the negative correlation between socioeconomic disadvantage in early life and cognitive ability in later life. In addition, the inequality in socioeconomic status at earlier stages resulted in heterogeneous cognitive trajectories, with the double cumulative disadvantage effect resulting from education being particularly noteworthy. Thus, Chinese health policy should focus on the earlier stages of life, actively promoting inclusive family policies and improving the family's role in protecting childhood from an adverse environment. Simultaneously, education and employment fairness should be strengthened to accelerate social mobility and enhance the "Health Repair Mechanism" of the second life course.

Perspectives About Racism and Patient-Clinician Communication Among Black Adults With Serious Illness

Importance

Black patients with serious illness experience higher-intensity care at the end of life. Little research has used critical, race-conscious approaches to examine factors associated with these outcomes.

Objective

To investigate the lived experiences of Black patients with serious illness and how various factors may be associated with patient-clinician communication and medical decision-making.

Design, Setting, and Participants

In this qualitative study, one-on-one, semistructured interviews were conducted with 25 Black patients with serious illness hospitalized at an urban academic medical center in Washington State between January 2021 and February 2023. Patients were asked to discuss experiences with racism, how those experiences affected the way they communicated with clinicians, and how racism impacted medical decision-making. Public Health Critical Race Praxis was used as framework and process.

Main Outcomes and Measures

The experience and of racism and its association, as described by Black patients who had serious illness, with patient-clinician communication and medical decision-making within a racialized health care setting.

Results

A total of 25 Black patients (mean [SD] age, 62.0 [10.3] years; 20 males [80.0%]) with serious illness were interviewed. Participants had substantial socioeconomic disadvantage, with low levels of wealth (10 patients with 0 assets [40.0%]), income (annual income <$25 000 among 19 of 24 patients with income data [79.2%]), educational attainment (mean [SD] 13.4 [2.7] years of schooling), and health literacy (mean [SD] score in the Rapid Estimate of Adult Literacy in Medicine-Short Form, 5.8 [2.0]). Participants reported high levels of medical mistrust and high frequency of discrimination and microaggressions experienced in health care settings. Participants reported epistemic injustice as the most common manifestation of racism: silencing of their own knowledge and lived experiences about their bodies and illness by health care workers. Participants reported that these experiences made them feel isolated and devalued, especially if they had intersecting, marginalized identities, such as being underinsured or unhoused. These experiences were associated with exacerbation of existing medical mistrust and poor patient-clinician communication. Participants described various mechanisms of self-advocacy and medical decision-making based on prior experiences with mistreatment from health care workers and medical trauma.

Conclusions and Relevance

This study found that Black patients' experiences with racism, specifically epistemic injustice, were associated with their perspectives on medical care and decision-making during serious illness and end of life. These findings suggest that race-conscious, intersectional approaches may be needed to improve patient-clinician communication and support Black patients with serious illness to alleviate the distress and trauma of racism as these patients near the end of life.

Can Early Disadvantage Be Overcome? A Life Course Approach to Understanding How Disadvantage, Education, and Social Integration Impact Mortality into Middle Adulthood Among a Black American Cohort

Health equity research has identified fundamental social causes of health, many of which disproportionately affect Black Americans, such as early life socioeconomic conditions, neighborhood disadvantage, and racial discrimination. However, the role of life course factors in premature mortality among Black Americans has not been tested extensively in prospective samples into later adulthood. To better understand how social factors at various life stages impact mortality, this study examines the effect of life course poverty, neighborhood disadvantage, and discrimination on mortality and factors that may buffer their effect (i.e., education, social integration) among the Woodlawn cohort (N = 1242), a community cohort of urban Black Americans followed since 1966. Taking a life course perspective, we analyze mortality data for deaths through age 58 years old, as well as data collected at ages 6, 16, 32, and 42. At age 58, 204 (16.4%) of the original cohort have died, with ages of death ranging from 9 to 58.98 (mean = 42.9). Cox proportional hazard models adjusting for confounders show statistically significant differences in mortality risk based on timing and persistence of poverty; those who were never poor or poor only in early life had lower mortality risk at ages 43-58 than those who were persistently poor from childhood to adulthood. Education beyond high school and high social integration were shown to reduce the risk of mortality more for those who did not experience poverty early in their life course. Findings have implications for the timing and content of mortality prevention efforts that span the full life course.

Geographic Patterns of Dementia in the United States: Variation by Place of Residence, Place of Birth, and Subpopulation

OBJECTIVES

The prevalence of dementia varies geographically in the United States. However, the extent to which this variation reflects contemporary place-based experiences versus embodied exposures from earlier in the life course remains unclear, and little is known regarding the intersection of place and subpopulation. This study, therefore, evaluates whether and how risk for assessed dementia varies by place of residence and birth, overall and by race/ethnicity and education.

METHODS

We pool data from the 2000 to 2016 waves of the Health and Retirement Study, a nationally representative panel survey of older U.S. adults (n = 96,848 observations). We estimate the standardized prevalence of dementia by Census division of residence and birth. We then fit logistic regression models of dementia on region of residence and birth, adjusting for sociodemographic characteristics, and examine interactions between region and subpopulation.

RESULTS

The standardized prevalence of dementia ranges from 7.1% to 13.6% by division of residence and from 6.6% to 14.7% by division of birth, with rates highest throughout the South and lowest in the Northeast and Midwest. In models accounting for region of residence, region of birth, and sociodemographic covariates, Southern birth remains significantly associated with dementia. Adverse relationships between Southern residence or birth and dementia are generally largest for Black and less-educated older adults. As a result, sociodemographic disparities in predicted probabilities of dementia are largest for those residing or born in the South.

DISCUSSION

The sociospatial patterning of dementia suggests its development is a lifelong process involving cumulated and heterogeneous lived experiences embedded in place.