Structural Interventions to Reduce and Eliminate Health Disparities

Tracking the Uneven Outcomes of COVID-19 on Racial and Ethnic Groups: Implications for Health Policy

The socioeconomic shocks of the first COVID-19 pandemic wave disproportionately affected vulnerable groups. But did that trend continue to hold during the Delta and Omicron waves? Leveraging data from the Johns Hopkins Coronavirus Resource Center, this paper examines whether demographic inequalities persisted across the waves of COVID-19 infections. The current study utilizes fixed effects regressions to isolate the marginal relationships between socioeconomic factors with case counts and death counts. Factors include levels of urbanization, age, gender, racial distribution, educational attainment, and household income, along with time- and state-specific COVID-19 restrictions and other time invariant controls captured via fixed effects controls. County-level health outcomes in large metropolitan areas show that despite higher incidence rates in suburban and exurban counties, urban counties still had disproportionately poor outcomes in the latter COVID-19 waves. Policy makers should consider health disparities when developing long-term public health regulatory policies to help shield low-income households from the adverse effects of COVID-19 and future pandemics.

Physical Activity Among Utah Cancer Survivors: Analysis From a Population-Based Statewide Survey

BACKGROUND

Regular physical activity improves cancer survivors' health-related quality of life and physical function. We estimated the proportion of Utah cancer survivors meeting U.S. Department of Health and Human Services guidelines for weekly physical activity (aerobic plus strength exercise) and identify sociodemographic, cancer, and health-related factors associated with meeting guidelines.

METHODS

Survivors randomly sampled from Utah Cancer Registry records were surveyed from 2018 to 2022 to ascertain physical activity. We calculated the percent of survivors meeting guidelines and conducted logistic regression to assess predictors of meeting guidelines. Analyses were weighted to account for complex survey sample design and nonresponse and age adjusted.

RESULTS

Among Utah cancer survivors, 20.7% (95% CI, 18.5%-23.2%) met guidelines for both aerobic activity and strength exercise. 22.4% reported no aerobic exercise in a typical week, and 59.4% reported no strength exercise. Survivors 75 or older were less likely to meet physical activity guidelines than those under 55 (adjusted odds ratio: 0.40; 95% CI, 0.25-0.65). Survivors with a bachelor's degree or higher were more likely to meet physical activity guidelines than those without a college degree. Individuals with poorer overall health were less likely to report sufficient physical activity. Individuals treated with both chemotherapy and radiation had decreased odds of meeting guidelines compared to no treatment (adjusted odds ratio: 0.54; 95% CI, 0.29-0.99).

CONCLUSIONS

Most Utah cancer survivors, and particularly those who received multiple modes of adjuvant treatment, are not participating in sufficient physical activity to improve longevity and quality of life after cancer.

Racial and economic segregation and diabetes mortality in the USA, 2016-2020

BACKGROUND

The purpose of this study was to examine the association between racial and economic segregation and diabetes mortality among US counties from 2016 to 2020.

METHODS

We conducted a cross-sectional ecological study that combined county-level diabetes mortality data from the National Vital Statistics System and sociodemographic information drawn from the 2016-2020 American Community Survey (n=2380 counties in the USA). Racialized economic segregation was measured using the Index Concentration at the Extremes (ICE) for income (ICEincome), race (ICErace) and combined income and race (ICEcombined). ICE measures were categorised into quintiles, Q1 representing the highest concentration and Q5 the lowest concentration of low-income, non-Hispanic (NH) black and low-income NH black households, respectively. Diabetes was ascertained as the underlying cause of death. County-level covariates included the percentage of people aged ≥65 years, metropolitan designation and population size. Multilevel Poisson regression was used to estimate the adjusted mean mortality rate and adjusted risk ratios (aRR) comparing Q1 and Q5.

RESULTS

Adjusted mean diabetes mortality rate was consistently greater in counties with higher concentrations of low-income (ICEincome) and low-income NH black households (ICEcombined). Compared with counties with the lowest concentration (Q1), counties with the highest concentration (Q5) of low-income (aRR 1.96; 95% CI 1.81 to 2.11 for ICEincome), NH black (aRR 1.32; 95% CI 1.18 to 1.47 for ICErace) and low-income NH black households (aRR 1.70; 95% CI 1.56 to 1.84 for ICEcombined) had greater diabetes mortality.

CONCLUSION

Racial and economic segregation is associated with diabetes mortality across US counties.

Interventions to improve equity in emergency departments for Indigenous people: A scoping review

BACKGROUND

Disparities in health outcomes, including increased chronic disease prevalence and decreased life expectancy for Indigenous people, have been shown across settings affected by white settler colonialism including Canada, the United States, Australia, and New Zealand. Emergency departments (EDs) represent a unique setting in which urgent patient need and provider strain interact to amplify inequities within society. The aim of this scoping review was to map the ED-based interventions aimed at improving equity in care for Indigenous patients in EDs.

METHODS

This scoping review was conducted using the procedures outlined by Arksey and O'Malley and guidance on conducting scoping reviews from the Joanna Briggs Institute. A systematic search of MEDLINE, CINAHL, SCOPUS, and EMBASE was conducted.

RESULTS

A total of 3636 articles were screened by title and abstract, of which 32 were screened in full-text review and nine articles describing seven interventions were included in this review. Three intervention approaches were identified: the introduction of novel clinical roles, implementation of chronic disease screening programs in EDs, and systems/organizational-level interventions.

CONCLUSIONS

Relatively few interventions for improving equity in care were identified. We found that a minority of interventions are aimed at creating organizational-level change and suggest that future interventions could benefit from targeting system-level changes as opposed to or in addition to incorporating new roles in EDs.

A Hybrid Pragmatic and Factorial Cluster Randomized Controlled Trial for an Anti-racist, Multilevel Intervention to Improve Mental Health Equity in High Schools

Systemic racism is pervasive in US society and disproportionately limits opportunities for education, work, and health for historically marginalized and minoritized racial and ethnic groups, making it an urgent issue of social justice. Because systemic racism is a social determinant of health prevalent across multiple social and institutional structures, it requires multilevel intervention approaches using effective designs and analytic methods to measure and evaluate outcomes. Racism is a fundamental cause of poor health outcomes, including mental health outcomes; thus, mental health services and programs that address racism and discrimination are key to promoting positive mental health of racial and ethnic minority youth. While multilevel interventions are well-suited for improving outcomes like youth mental health disparities, their evaluation poses unique methodological challenges, requiring specialized design and analytic approaches. There has been limited methodological guidance provided to researchers on how to test multilevel interventions using approaches that balance methodological rigor, practicality, and acceptability across stakeholder groups, especially within communities most affected by systemic racism. This paper addresses this gap by providing an example of how to rigorously evaluate a hypothetical, theoretically based, multilevel intervention promoting mental health equity in three US school systems using an anti-racist approach intervening at the macro- (i.e., school system), meso- (i.e., school), and micro- (i.e., family and student) levels to improve mental health in adolescents. We describe the design, sample size considerations, and analytic methods to comprehensively evaluate its effectiveness while exploring the extent to which the components interact synergistically to improve outcomes. The methodological approach proposed can be adapted to other multilevel interventions that include strategies addressing macro-, meso-, and micro-levels of influence.

Provision of Stroke Care Services by Community Disadvantage Status in the US, 2009-2022

Importance

Stroke center certification is granted to facilities that demonstrate distinct capabilities for treating patients with stroke. A thorough understanding of structural discrimination in the provision of stroke centers is critical for identifying and implementing effective interventions to improve health inequities for socioeconomically disadvantaged populations.

Objective

To determine whether (1) hospitals in socioeconomically disadvantaged communities (defined using the Area Deprivation Index) are less likely to adopt any stroke certification and (2) adoption rates differ between entry-level (acute stroke-ready hospitals) and higher-level certifications (primary, thrombectomy capable, and comprehensive) by community disadvantage status.

Design, Setting, and Participants

This cohort study used newly collected stroke center data merged with data from the American Hospital Association, Healthcare Cost Report Information datasets, and the US Census. All general acute hospitals in the continental US between January 1, 2009, and December 31, 2022, were included. Data analysis was conducted from July 2023 to May 2024.

Main Outcomes and Measures

The primary outcome was the likelihood of hospitals adopting stroke care certification. Cox proportional hazard and competing risk models were used to estimate the likelihood of a hospital becoming stroke certified based on the socioeconomic disadvantage status of the community.

Results

Among the 5055 hospitals studied from 2009 to 2022, 2415 (47.8%) never achieved stroke certification, 602 (11.9%) were certified as acute stroke-ready hospitals, and 2038 (40.3%) were certified as primary stroke centers or higher. When compared with mixed-advantage communities, adoption of any stroke certification was most likely to occur near the most advantaged communities (hazard ratio [HR], 1.24; 95% CI, 1.07-1.44) and least likely near the most disadvantaged communities (HR, 0.43; 95% CI, 0.34-0.55). Adoption of acute stroke-ready certification was most likely in mixed-advantage communities, while adoption of higher-level certification was more likely in the most advantaged communities (HR,1.41; 95% CI, 1.22-1.62) and less likely for the most disadvantaged communities (HR, 0.31; 95% CI, 0.21-0.45). After adjusting for population size and hospital capacity, compared with mixed-advantage communities, stroke certification adoption hazard was still 20% lower for relatively disadvantaged communities (adjusted HR, 0.80; 95% CI, 0.73-0.87) and 42% lower for the most disadvantaged communities (adjusted HR, 0.58; 95% CI, 0.45-0.74).

Conclusions and Relevance

In this cohort study examining hospital adoption of stroke services, when compared with mixed-advantage communities, hospitals located in the most disadvantaged communities had a 42% lower hazard of adopting any stroke certification and relatively disadvantaged communities had a 20% lower hazard of adopting any stroke certification. These findings suggest that there is a need to support hospitals in disadvantaged communities to obtain stroke certification as a way to reduce stroke disparities.

Leveraging Science to Advance Health Equity: Preliminary Considerations for Implementing Health Equity Science at State and Local Health Departments

CONTEXT

In 2021, the Centers for Disease Control and Prevention (CDC) launched CORE, an agency-wide strategy to embed health equity as a foundational component across all areas of the agency's work. The CDC established a definition of health equity science (HES) and principles to guide the development, implementation, dissemination, and use of the HES framework to move beyond documenting inequities to investigating root causes and promoting actionable approaches to eliminate health inequities. The HES framework may be used by state and local health departments to advance health equity efforts in their jurisdictions.

OBJECTIVE

Identify implementation considerations and opportunities for providing technical assistance and support to state and local public health departments in advancing HES.

DESIGN

A series of implementation consultations and multi-jurisdictional facilitated discussions were held with state and local health departments and community partners in 5 states to gather feedback on the current efforts, opportunities, and support needs to advance HES at the state and local levels. The information shared during these activities was analyzed using inductive and deductive methods, validated with partners, and summarized into themes and HES implementation considerations.

RESULTS

Five themes emerged regarding current efforts, opportunities, and support needed to implement HES at state and local health departments. These themes included the following criteria: (1) enhancing the existing health equity evidence base; (2) addressing interdisciplinary public health practice and data needs; (3) recognizing the value of qualitative data; (4) evaluating health equity programs and policies; and (5) including impacted communities in the full life cycle of health equity efforts. Within these themes, we identified HES implementation considerations, which may be leveraged to inform future efforts to advance HES at the state and local levels.

CONCLUSION

Health equity efforts at state and local health departments may be strengthened by leveraging the HES framework and implementation considerations.

Listening Sessions to Shape the Innovative NIH ComPASS Common Fund Program to Advance Health Equity

The National Institutes of Health (NIH) recognized the need for a research program to address the underlying structural factors that impact health. To inform the development of the NIH Common Fund Community Partnerships to Advance Science for Society (ComPASS) Program, NIH obtained input through community listening sessions. Through its design, ComPASS recognizes the essential role of community organizations as the lead in addressing persistent structural and social challenges to accelerate progress toward advancing health equity. (Am J Public Health. 2024;114(7):685-689. https://doi.org/10.2105/AJPH.2024.307656).

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.

Assessing Health Equity in Partnership with Children's Mental Health Organizations: Considerations Before the Implementation of Parenting Programs

Objectives

Understanding and addressing how an individual's social, political, economic, and cultural context affects their ability to achieve optimal health is essential to designing and implementing interventions. Before evaluating two parenting programs, in partnership with four children's mental health organizations, we used the Health Equity Impact Assessment tool (HEIA) to identify groups that may experience unintended health impacts, as well as generated mitigation strategies to address these impacts.

Methods

HEIA activities included a review of the published literature, a review of organizational documents, key informant interviews with staff (n = 12) and other related community service providers (n = 7), and a geographic information systems analysis. All sources of evidence were considered and analyzed using reflective thematic analysis. Summary reports were shared with all partners.

Results

A range of groups were identified as at risk of experiencing unintended health impacts, including caregivers who are racialized, immigrants, Indigenous, living with mental health issues or addictions, dealing with intellectual challenges and/or low literacy levels, survivors of childhood trauma, single parent families, or families experiencing financial difficulties. Unintended health impacts were sorted into 6 main themes which fell under the overarching themes of accessibility of the programs and cultural appropriateness. Mitigation strategies as well as innovative strategies already being applied by participating organizations are discussed.

Conclusion

Although this HEIA focused on parenting programs, the findings address equity issues applicable to the provision of a wide spectrum of children's mental health services.

Addressing COVID-19 and Health Literacy Disparities Among Correctional Facility Residents Through Dialogue-Based Education

Carceral communities face heightened COVID-19-related risks while simultaneously experiencing medical mistrust and limited access to health information and services. Health education programs that incorporate dialogue-based, participatory learning models have been shown to motivate health behavior and increase health knowledge in carceral settings. To increase health literacy and change COVID-19-related health behavior among jail residents in the United States, a local health department developed a dialogue-based education program centered around COVID-19 prevention, misinformation, and navigating health care systems. Dialogue-based health information sessions took place in person in a county jail. Pre- and postsurveys gauged the sessions' influence on self-reported health literacy and behavior intention. Overall, 595 residents collectively attended 43 facilitated discussions. Key findings indicate that dialogue-based education can temper medical mistrust, influencing COVID-19 preventive behaviors and increasing health literacy in a carceral setting.

Study protocol for transforming health equity research in integrated primary care: Antiracism as a disruptive innovation

Among the consequences of systemic racism in health care are significant health disparities among Black/African American individuals with comorbid physical and mental health conditions. Despite decades of studies acknowledging health disparities based on race, significant change has not occurred. There are shockingly few evidence-based antiracism interventions. New paradigms are needed to intervene on, and not just document, racism in health care systems. We are developing a transformative paradigm for new antiracism interventions for primary care settings that integrate mental and physical health care. The paradigm is the first of its kind to integrate community-based participatory research and systems science, within an established model of early phase translation to rigorously define new antiracism interventions. This protocol will use a novel application of systems sciences by combining the qualitative systems sciences methods (group model building; GMB) with quantitative methods (simulation modeling) to develop a comprehensive and community-engaged view of both the drivers of racism and the potential impact of antiracism interventions. Community participants from two integrated primary health care systems will engage in group GMB workshops with researchers to 1) Describe and map the complex dynamic systems driving racism in health care practices, 2) Identify leverage points for disruptive antiracism interventions, policies and practices, and 3) Review and prioritize a list of possible intervention strategies. Advisory committees will provide feedback on the design of GMB procedures, screen potential intervention components for impact, feasibility, and acceptability, and identify gaps for further exploration. Simulation models will be generated based on contextual factors and provider/patient characteristics. Using Item Response Theory, we will initiate the process of developing core measures for assessing the effectiveness of interventions at the organizational-systems and provider levels to be tested under a variety of conditions. While we focus on Black/African Americans, we hope that the resulting transformative paradigm can be applied to improve health equity among other marginalized groups.

Distilling the Fundamentals of Evidence-Based Public Health Policy

Public health policy interventions are associated with many important public health achievements. To provide public health practitioners and decision makers with practical approaches for examining and employing evidence-based public health (EBPH) policy interventions, we describe the characteristics and benefits that distinguish EBPH policy interventions from programmatic interventions. These characteristics include focusing on health at a population level, focusing on upstream drivers of health, and involving less individual action than programmatic interventions. The benefits of EBPH policy interventions include more sustained effects on health than many programs and an enhanced ability to address health inequities. Early childhood education and universal preschool provide a case example that illustrates the distinction between EBPH policy and programmatic interventions. This review serves as the foundation for 3 concepts that support the effective use of public health policy interventions: applying core component thinking to understand the population health effects of EBPH policy interventions; understanding the influence of existing policies, policy supports, and the context in which a particular policy is implemented on the effectiveness of that policy; and employing a systems thinking approach to identify leverage points where policy implementation can have a meaningful effect.

Disaggregation of Green Space Access, Walkability, and Behavioral Risk Factor Data for Precise Estimation of Local Population Characteristics

BACKGROUND

Social and Environmental Determinants of Health (SEDH) provide us with a conceptual framework to gain insights into possible associations among different human behaviors and the corresponding health outcomes that take place often in and around complex built environments. Developing better built environments requires an understanding of those aspects of a community that are most likely to have a measurable impact on the target SEDH. Yet data on local characteristics at suitable spatial scales are often unavailable. We aim to address this issue by application of different data disaggregation methods.

METHODS

We applied different approaches to data disaggregation to obtain small area estimates of key behavioral risk factors, as well as geospatial measures of green space access and walkability for each zip code of Allegheny County in southwestern Pennsylvania.

RESULTS

Tables and maps of local characteristics revealed their overall spatial distribution along with disparities therein across the county. While the top ranked zip codes by behavioral estimates generally have higher than the county's median individual income, this does not lead them to have higher than its median green space access or walkability.

CONCLUSION

We demonstrated the utility of data disaggregation for addressing complex questions involving community-specific behavioral attributes and built environments with precision and rigor, which is especially useful for a diverse population. Thus, different types of data, when comparable at a common local scale, can provide key integrative insights for researchers and policymakers.

Associations Between Neighborhood Racialized Economic Segregation with Cardiometabolic Health and Cortisol in a Racially/Ethnically Diverse Sample of Children from Minneapolis-St. Paul

Introduction

Past research shows that structural racism contributes to disparities in cardiometabolic health among racially/ethnically minoritized populations.

Methods

This cross-sectional study examined the correlation between census tract-level racialized economic segregation and child health metrics among a racially and ethnically diverse cohort of 350 children (ages 6.5-13.8) from Minneapolis-St. Paul, MN.

Results

A consistent cardiometabolic and cortisol outcome gradient was observed across the index of concentration at the extremes tertiles, such that health risk factors increased as tract privilege decreased.

Conclusion

Racialized economic segregation was associated with less favorable child health outcomes, underscoring the potential importance of place-based interventions for promoting children's health.

Sugar tax and product reformulation proposals reduce the perceived legitimacy of health-promotion institutions: a randomized population-based survey experiment

BACKGROUND

Structural nutrition interventions like a sugar tax or a product reformulation are strongly supported among the public health community but may cause a considerable backlash (e.g. inspiring aversion to institutions initiating the interventions among citizens). Such a backlash potentially undermines future health-promotion strategies. This study aims to uncover whether such backlash exists.

METHODS

We fielded a pre-registered randomized, population-based survey experiment among adults from the Longitudinal Internet Studies for the Social Sciences panel (n = 1765; based on a random sampling of the Dutch population register). Participants were randomly allocated to the control condition (brief facts about health-information provision/nudging), or one of two experimental groups (the same facts, expanded with either a proposed sugar tax on or reformulation of sugar-sweetened beverages). Ordinary least squares regression was used to estimate the proposed interventions' effects on four outcome variables: trust in health-promotion institutions involved; perceptions that these institutions have citizens' well-being in mind (i.e. benevolence); perceptions that these institutions' perspectives are similar to those of citizens (i.e. alignment of perspectives); and attitudes toward nutrition information.

RESULTS

Trust, perceived benevolence and perceived alignment of perspectives were affected negatively by a proposed sugar tax (-0.24, 95% CI -0.38 to -0.10; -0.15, -0.29 to -0.01; -0.15, -0.30 to 0.00) or product reformulation (-0.32, -0.46 to -0.18; -0.24, -0.37 to -0.11; -0.18, 0.33 to -0.03), particularly among the non-tertiary educated respondents.

CONCLUSIONS

Sugar taxes or product reformulations may delegitimize health-promotion institutions, potentially causing public distancing from or opposition to these bodies. This may be exploited by political and commercial parties to undermine official institutions.

TRIAL REGISTRATION

https://osf.io/qr9jy/?view_only=5e2e875a1fc348f3b28115b7a3fdfd90. Registered 3 February 2022.

The Dynamic Nature of the Socioeconomic Determinants of Cardiovascular Health: A Narrative Review

Despite decades of social epidemiologic research, health inequities remain pervasive and ubiquitous in Canada and elsewhere. One reason may be our use of socioeconomic measurement, which has often relied on single point-in-time exposures. To explore the extent to which researchers have incorporated dynamic socioeconomic measurement into cardiovascular health outcome evaluations, we performed a narrative review. We estimated the prevalence of socioeconomic longitudinal cardiovascular research studies that identified socioeconomic exposures at 2 or more points in time between the years of 2019 and 2023. We defined cardiovascular outcome studies as those that examined coronary artery disease, myocardial infarction, acute coronary syndrome, stroke, heart failure, cardiac arrhythmias, cardiac death, cardiometabolic factors, transient ischemic attacks, peripheral artery disease, or hypertension. Socioeconomic exposures included individual income, neighbourhood income, intergenerational social mobility, education, occupation, insurance status, and economic security. Seven percent of socioeconomic cardiovascular outcome studies have measured socioeconomic status at 2 or more points in time throughout the follow-up period, hypothesized mechanisms by which dynamic socioeconomic measures affected outcome focused on social mobility, accumulation, and critical period theories. Insights, implications, and future directions are discussed, in which we highlight ways in which postal code data can be better used methodologically as a dynamic socioeconomic measure. Future research must incorporate dynamic socioeconomic measurement to better inform root causes, interventions, and health-system designs if health equity is to be improved.

Underutilization of Transcatheter Aortic Valve Replacement in Northern Plains American Indians with Severe Aortic Stenosis

INTRODUCTION

Transcatheter aortic valve replacement (TAVR) has overtaken surgical aortic valve replacement and revolutionized the treatment strategy for aortic valve replacement. Little is known on the disparities among minorities, especially American Indians (AI), undergoing this procedure. We explore TAVR outcomes to identify disparities at our institution.

METHODS

Retrospective chart review was completed on patients who underwent TAVR at a North Dakota community hospital between 2012 and 2021. There were 1133 non-AI and 20 AI patients identified (n = 1153). AI patients were identified by enrollment in nationally recognized tribes, Indian Health Service (IHS), or who self-identified as AI. Patient demographics, preoperative characteristics, procedural information, and outcomes were collected. United States 2020 census data was used for state-wide population racial percentages. Unpaired two tail t test assuming unequal variance and chi-squared tests were used to evaluate data and identify disparities between AI and non-AI.

RESULTS

AI presented at an earlier age (71 vs. 79; p = .001) with higher rates of diabetes (60% vs. 35%; p = .018) and history of smoking (100% vs. 60%; p ≤ .001) than Caucasian/white (C/W). The Society of Thoracic Surgery (STS) risk scores (3.2% vs. 4.6%; p = .054) and aortic valve mean gradients were lower among AI (42.8 mmHg vs. 47.5 mmHg; p = .010). For those deceased, AI had significantly shorter lifespans post-TAVR compared to C/W (374 days vs. 755 days; p = .004). AI from North Dakota had fewer TAVR procedures performed than expected (4 actual vs. 32 expected; p < .001).

CONCLUSIONS

AI undergoing TAVR presented earlier, with higher rates of diabetes and smoking, lower STS risk scores, and lesser aortic valve gradients than C/W. The number of TAVR procedures performed on AI from North Dakota was lower than anticipated despite a nearly 10-year period and the disparities experienced by AI who could have otherwise benefited from TAVR.

The Community As A Full Partner: A New Model For Public Health

The COVID-19 pandemic demonstrated a need to strengthen the US public health system by shifting toward much greater community engagement and leadership. In November and December 2023, we conducted separate online surveys of community-based organizations and large metropolitan health departments to identify barriers and opportunities for building a public health system with strong community partnerships. Identified barriers included mistrust, siloed health departments with structural challenges in funding community-based organizations, and insufficient shared decision making. The surveys helped inform our six policy recommendations: establish state and local community councils to formalize the roles of community-based organizations in public health decision making; dedicate funding to these organizations; offer funding that is not limited to a specific disease or condition; simplify procurement and reporting processes directed to community-based organizations; create a training and technical assistance program for these organizations; and increase public health worker diversity, including sustainable funding for community health workers.

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

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

Community Culture Survey - Revised: Measuring neighborhood culture and exploring geographic, socioeconomic, and cultural determinants of health in samples across the United States and in Thailand

Objectives

Research on links between social, geographic, and cultural determinants of health has been thwarted by inadequate measures of culture. The purpose of this study was to improve the measurement of community culture, defined as shared patterns of attitudes and behaviors among people within a neighborhood that distinguish it from others, and to examine dimensions of culture, independent of socioeconomic and demographic factors, and their relationships with health.

Study design

A survey research design with correlational analyses was used.

Methods

A survey packet including the Community Culture Survey - Revised (CCS-R), demographic, health, and other individual-level measures was administered through convenience sampling across the United States (US) and to a sample in Thailand from 2016 to 2018. US county-level variables were obtained from zip codes.

Results

1930 participants from 49 US states (n = 1592) and Thailand (n = 338) completed all CCS-R items, from which 12 subscales were derived: Social Support & Connectedness, Responsibility for Self & Others, Family Ties & Duties, Social Distress, Urban Diversity, Discontinuity, Church-Engaged, External Resource-Seeking, Locally Owned Business-Active, Power Deference, Next Generation Focus, and Self-Reliance. Neighborhood culture subscale scores varied more by geography than by participant's demographics. All subscales predicted one or more health indicator, and some of these relationships were significant after adjusting for participant age and county-level socioeconomic variables. Most of the significant differences on subscales by race/ethnicity were no longer significant after adjusting for participant's age and county-level socioeconomic variables. Most rural/urban and regional differences in culture within the US persisted after these adjustments. Based on correlational analyses, Social Support & Connectedness and Responsibility for Self & Others were the best predictors of participants' overall health and quality of life, and Responsibility for Self & Others was the best predictor (inversely) of the CDC's measures of social vulnerability.

Conclusions

Neighborhood culture is measurable, multi-dimensional, distinct from race/ethnicity, and related to health even after controlling for age and socioeconomic factors. The CCS-R is useful for advancing research and practice addressing the complex interactions between individuals, their neighborhood communities, and health outcomes.

Digital pathology, deep learning, and cancer: a narrative review

Background and Objective

Cancer is a leading cause of morbidity and mortality worldwide. The emergence of digital pathology and deep learning technologies signifies a transformative era in healthcare. These technologies can enhance cancer detection, streamline operations, and bolster patient care. A substantial gap exists between the development phase of deep learning models in controlled laboratory environments and their translations into clinical practice. This narrative review evaluates the current landscape of deep learning and digital pathology, analyzing the factors influencing model development and implementation into clinical practice.

Methods

We searched multiple databases, including Web of Science, Arxiv, MedRxiv, BioRxiv, Embase, PubMed, DBLP, Google Scholar, IEEE Xplore, Semantic Scholar, and Cochrane, targeting articles on whole slide imaging and deep learning published from 2014 and 2023. Out of 776 articles identified based on inclusion criteria, we selected 36 papers for the analysis.

Key Content and Findings

Most articles in this review focus on the in-laboratory phase of deep learning model development, a critical stage in the deep learning lifecycle. Challenges arise during model development and their integration into clinical practice. Notably, lab performance metrics may not always match real-world clinical outcomes. As technology advances and regulations evolve, we expect more clinical trials to bridge this performance gap and validate deep learning models' effectiveness in clinical care. High clinical accuracy is vital for informed decision-making throughout a patient's cancer care.

Conclusions

Deep learning technology can enhance cancer detection, clinical workflows, and patient care. Challenges may arise during model development. The deep learning lifecycle involves data preprocessing, model development, and clinical implementation. Achieving health equity requires including diverse patient groups and eliminating bias during implementation. While model development is integral, most articles focus on the pre-deployment phase. Future longitudinal studies are crucial for validating models in real-world settings post-deployment. A collaborative approach among computational pathologists, technologists, industry, and healthcare providers is essential for driving adoption in clinical settings.

Clustering of Social Determinants of Health as an Indicator of Meaningful Subgroups within an African American Population: Application of Latent Class Analysis

BACKGROUND

Health disparities between people who are African American (AA) versus their White counterparts have been well established, but disparities among AA people have not. The current study introduces a systematic method to determine subgroups within a sample of AA people based on their social determinants of health.

METHODS

Health screening data collected in the West Side of Chicago, an underserved predominantly AA area, in 2018 were used. Exploratory latent class analysis was used to determine subgroups of participants based on their responses to 16 variables, each pertaining to a specific social determinant of health.

RESULTS

Four unique clusters of participants were found, corresponding to those with "many unmet needs", "basic unmet needs", "unmet healthcare needs", and "few unmet needs".

CONCLUSION

The findings support the utility of analytically determining meaningful subgroups among a sample of AA people and their social determinants of health. Understanding the differences within an underserved population may contribute to future interventions to eliminate health disparities.

"We're one small piece of the puzzle": evaluating the impact of short-term funding for tier two weight management services

Introduction

Overweight and obesity are a global health epidemic and many attempts have been made to address the rising prevalence. In March 2021 the UK government announced £100 million of additional funding for weight management provisions. Of this, £30.5 million was split across local authorities in England to support the expansion of tier two behavioural weight management services for adults. The present work aimed to explore how this funding was used within the Yorkshire and Humber region to consolidate learning, collate best practice, and provide recommendations for future funding use.

Method

One-hour semi-structured interviews were conducted with 11 weight management service commissioners representing 9 of the 15 local authorities in the region. Interviews were recorded, transcribed and analysed using an established health inequality framework. From this, recommendations were co-developed with the commissioner group to establish best practice for future funding use.

Results

Commissioners recognised that targeted weight management services were only one small piece of the puzzle for effectively managing obesity. Therefore, recommendations include targeting underserved communities, focussing on early prevention, addressing weight management in a whole systems context, and embracing innovative and holistic approaches to weight management.

Discussion

Current short-term funding and restrictive commissioning processes of tier two services prevents sustainable and innovative weight management practice which is detrimental to patients, falls short of addressing health inequalities and negatively impacts staff health and wellbeing.

Equity and justice in health

BACKGROUND

While justice is promised to all U.S. citizens, the truth is that the pathway to equity and justice in health is riddled with obstacles for many marginalized and minoritized groups. The United States ranks lower on crucial health measures than its high-income peer countries, reflecting differences in health outcomes for marginalized and minoritized populations.

PURPOSE

Promoting equity and justice in health is vital as health shapes the daily experiences of individuals and communities, specifically those from marginalized and minoritized backgrounds.

METHOD

This paper highlights the health care system and sociopolitical factors contributing to the longstanding structural barriers that impede health and the need for structural competence, advocacy, and activism in the nursing workforce.

DISCUSSION

Understanding systemic issues underlying health inequities provides an opportunity to develop targeted strategies to eliminate practices perpetuating inequities and pave the way for everyone to have a fair and just opportunity to be as healthy as possible.

CONCLUSION

Specific education, practice, research, and policy recommendations can advance equity and justice in health.

Analyzing Trends in Mental and Behavioral Health Support for Children: A Comprehensive Study Using National Survey of Children's Health Database

Objective This study aimed to explore mental and behavioral health support trends for children aged 3-17, analyzing treatment and counseling using United States data from the 2016-2020 National Survey of Children's Health (NSCH) database. Methods Employing a retrospective observational design, we systematically retrieved and analyzed NSCH Database data from 2016 to 2020. The focus was on understanding mental and behavioral health treatment percentages over time, specifically targeting demographic variations such as age groups, gender, race/ethnicity, and the federal poverty level percentage. Graphical representation utilized Excel, summarizing results based on aggregated data for distinct time intervals, highlighting the importance of mental and behavioral health support for children aged 3-17. Results The study identified significant temporal trends in mental and behavioral health treatment, revealing notable fluctuations across demographic and socio-economic variables. Of the 22,812 participants, 51.7% (CI: 50.2-53.1%, n=12,686) received treatment, exposing disparities. Gender differences were evident, with higher treatment rates in females (53.7%, CI: 51.6-55.9%, n=6,166) than males (50.1%, CI: 48.2-52.0%, n=6,520). Age-specific patterns indicated lower intervention rates in younger children (33.5%, CI: 28.6-38.8%, n=447, ages 3-5) compared to adolescents (58.1%, CI: 56.2-59.9%, n=8, 222 ages 12-17). Conclusion The conclusion highlights significant temporal fluctuations and pronounced demographic disparities. Findings underscore varying prevalence rates among age groups, genders, racial/ethnic backgrounds, and socio-economic status categories. This study provides valuable insights for policymakers, healthcare professionals, and researchers, informing targeted interventions to enhance mental and behavioral health support for United States children.

Stress Accumulation, Depressive Symptoms, and Sleep Problems among Black Americans in the Rural South

Centuries of systemic racism in the United States have led to Black Americans facing a disproportionate amount of life stressors. These stressors can have negative effects on mental and physical health, contributing to inequities throughout the lifespan. The current study used longitudinal data from 692 Black adults in the rural South to examine the ways in which neighborhood stress, financial strain, and interpersonal experiences of racial discrimination operate independently and in tandem to impact depressive symptoms and sleep problems over time. Findings provided strong support for univariate and additive stress effects and modest support for multiplicative stress effects. Results underscore how multiple stressors stemming from systemic racism can undermine health among Black Americans and highlight the need for further research on factors that promote well-being in the face of these stressors.

A Development and Implementation of a Preconception Counseling Program for Black Women and Men in the Southeastern United States: A Pilot Protocol

Introduction

Racial/ethnic disparities in maternal mortality rates represent one of the most significant areas of disparities amongst all conventional population perinatal health measures in the U.S. The alarming trends and persistent disparities of outcomes by race/ethnicity and geographic location reinforce the need to focus on ensuring quality and safety of maternity care for all women. Despite complex multilevel factors impacting maternal mortality and morbidity, there are evidence-based interventions that, when facilitated consistently and properly, are known to improve the health of mothers before, during and after pregnancy. The objective of this project is to test implementation of pre-conception counseling with father involvement in community-based settings to improve cardiovascular health outcomes before and during pregnancy in southeastern United States.

Methods and Analysis

This study has two components: a comprehensive needs and assets assessment and a small-scale pilot study. We will conduct a community informed needs and assets assessment with our diverse stakeholders to identify opportunities and barriers to preconception counseling as well as develop a stakeholder-informed implementation plan. Next, we will use the implementation plan to pilot preconception counseling with father involvement in community-based settings. Finally, we will critically assess the context, identify potential barriers and facilitators, and iteratively adapt the way preconception counseling can be implemented in diverse settings. Results of this research will support future research focused on identifying barriers and opportunities for scalable and sustainable public health approaches to implementing evidence-based strategies that reduce maternal morbidity and mortality in the southeastern United States' vulnerable communities.

Discussion

Findings will demonstrate that preconception counseling can be implemented in community health settings in the southeastern United States. Furthermore, this study will build the capacity of community-based organizations in addressing the preconception health of their clients. We plan for this pilot to inform a larger scaled-up clinical trial across community health settings in multiple southeastern states.

Does the Association Between Concussion Measures and Social Context Factors Differ in Black and White Parents?

CONTEXT

Middle school (MS) parents may benefit from education supporting timely concussion identification and care-seeking in their young children (aged approximately 10 to 15 years). However, such education may not consider individual needs and different social context factors, including lower socioeconomic status, disadvantaged social determinants of health, and different racial and ethnic backgrounds.

OBJECTIVES

To examine the relationship between social context factors and concussion knowledge, attitudes, and communication in MS parents and to explore the possible role of race and ethnicity (Black or White) as an effect measure modifier.

DESIGN

Cross-sectional study.

SETTING

Online survey.

PATIENTS OR OTHER PARTICIPANTS

A nationally representative sample of MS parents who completed an online survey (n = 1248).

MAIN OUTCOME MEASURE(S)

Parent outcomes were a history of concussion education, concussion symptom knowledge and attitudes, and communication with children about concussion. Main exposures were parental race and ethnicity (Black or White) and social context factors. Uni- and multivariable statistical analyses were performed to achieve the study aims.

RESULTS

Black parents were more likely than White parents to have received concussion education (69.5% versus 60.5%, P = .009), although median concussion knowledge scores were higher for White parents than for Black parents (40 versus 37, P < .001). Few associations were found for social context factors with concussion knowledge, attitudes, and communication in Black and White parents separately.

CONCLUSIONS

Among MS parents, race and ethnicity may not influence the association between social context factors and concussion-related knowledge, attitudes, or communication. However, differences were present by race and ethnicity regarding previous concussion education and other parental outcomes, concussion symptom knowledge in particular.

Resilience is an Adverse Event: A Critical Discussion of Resilience Theory in Health Services Research and Public Health

Resilience, the individual trait of being able to persist and cope with, often recurrent, negative experiences, has experienced an explosion in recent years as a topic of study. In this commentary, we critique this surge and problematize the co-occurring development of the "resilience as treatment" paradigm. We show that resilience is an expectation foisted primarily on historically and contemporarily oppressed and excluded populations often in response to systemic and structural forms of discrimination. We argue that this represents a fundamental mismatch of intervention and problem; offering an individual-level solution to a structural toxin. In doing so, we re-contextualize resilience as an adverse event, more analogous to scar tissue than a reliable treatment paradigm. Our essay concludes with offering alternatives to resilience that originate with the holistic trauma and liberation health frameworks. These paradigms are united in that, in contrast to resilience, they emphasize healing from structural violence, rather than adapting to it.

General surgery textbooks and surgical disparities

INTRODUCTION

Some academic textbooks have previously disseminated simplistic or even incorrect conceptions of race. Propagation of such ideas in General Surgery could contribute to gaps in quality of care received by minority patients. This study aims to determine whether General Surgery textbooks provide a thorough understanding of racial disparities.

METHODS

General Surgery texts were drawn from Doody's list, an industry-standard list of textbooks for medical education. Technical guides, atlases, and books for non-General Surgery professionals were excluded. Passages mentioning medical differences amongst racial and ethnic groups were extracted. Six binary classifications were made, based on whether passages (a) described interventions to alleviate difference; (b) addressed environmental mediators of difference; (c) described the contribution of racism or discrimination; (d) used causal language to connect race to difference; (e) referred to known, heritable genetic mechanisms; and (f) directly provided a reference. Types of intervention were also extracted. A heuristic scale was calculated granting one point each for classifications a-c and losing one point for classification d. Three authors performed classifications, and raw agreement and Cohen's kappa were used to assess inter-rater reliability.

RESULTS

Thirteen textbooks from Doody's list contained 511 passages discussing medical differences among racial/ethnic groups. Among passages, 25% discussed white people, 22% Black people/African Americans, 19% Asians, 9% Latinos, 4% Jewish/Ashkenazi people, 3% Native Americans, and 18% other. Fifteen passages (2.9%) used language indicating race was the cause of medical difference, and only two explicitly discussed racism or discrimination. Most passages (370, 72.3%) received a scale of 0. 120 (23.5%) received a scale of 1, eight (1.2%) received a scale of 2, and zero received a scale of 3. The mean passage scale was 0.24 and is not changing with time (regression coefficient -0.006/year, p = 0.538). Agreement was 91.2% across all categories and overall Kappa was 0.62.

CONCLUSIONS

General Surgery textbooks do not provide readers with scientifically thorough understanding of health disparities. Teaching more comprehensive conceptions, including systemic causes and the role of racism, may prevent reflexive association of minority patients with poor outcomes. Future editions should include these details where disparities are discussed in an independent, comprehensive section.

Measuring Local-Area Racial Segregation for Medicare Hospital Admissions

Importance

Considerable racial segregation exists in US hospitals that cannot be explained by where patients live. Approaches to measuring such segregation are limited.

Objective

To measure how and where sorting of older Black patients to different hospitals occurs within the same health care market.

Design, Setting, and Participants

This retrospective cross-sectional study used 2019 Medicare claims data linked to geographic data. Hospital zip code markets were based on driving time. The local hospital segregation (LHS) index was defined as the difference between the racial composition of a hospital's admissions and the racial composition of the hospital's market. Assessed admissions were among US Medicare fee-for-service enrollees aged 65 or older living in the 48 contiguous states with at least 1 hospitalization in 2019 at a hospital with at least 200 hospitalizations. Data were analyzed from November 2022 to January 2024.

Exposure

Degree of residential segregation, ownership status, region, teaching hospital designation, and disproportionate share hospital status.

Main Outcomes and Measures

The LHS index by hospital and a regional LHS index by hospital referral region.

Results

In the sample of 1991 acute care hospitals, 4 870 252 patients (mean [SD] age, 77.7 [8.3] years; 2 822 006 [56.0%] female) were treated, including 11 435 American Indian or Alaska Native patients (0.2%), 129 376 Asian patients (2.6%), 597 564 Black patients (11.9%), 395 397 Hispanic patients (7.8), and 3 818 371 White patients (75.8%). In the sample, half of hospitalizations among Black patients occurred at 235 hospitals (11.8% of all hospitals); 878 hospitals (34.4%) exhibited a negative LHS score (ie, admitted fewer Black patients relative to their market area) while 1113 hospitals (45.0%) exhibited a positive LHS (ie, admitted more Black patients relative to their market area); of all hospitals, 79.4% exhibited racial admission patterns significantly different from their market. Hospital-level LHS was positively associated with government hospital status (coefficient, 0.24; 95% CI, 0.10 to 0.38), while New York, New York; Chicago, Illinois; and Detroit, Michigan, hospital referral regions exhibited the highest regional LHS measures, with hospital referral region LHS scores of 0.12, 0.16, and 0.21, respectively.

Conclusions and Relevance

In this cross-sectional study, a novel measure of LHS was developed to quantify the extent to which hospitals were admitting a representative proportion of Black patients relative to their market areas. A better understanding of hospital choice within neighborhoods would help to reduce racial inequities in health outcomes.

Differences in provider recommendations for Black/African American and White patients with irritable bowel syndrome

BACKGROUND

Health disparities and barriers to equitable care for patients from racial and ethnic minority backgrounds are common. We sought to evaluate disparities in management recommendations among Black/African American (AA) patients seeking care for IBS.

METHODS

We assembled a retrospective cohort of patients at two tertiary care centers who were self-identifying as Black/AA and attended a first gastroenterology consult for IBS. These patients were age- and sex-matched to White controls with IBS also attending an initial gastroenterology consult. Retrospective chart review determined patient demographics, income, comorbidities, as well as provider management recommendations including pharmacologic therapies and non-pharmacologic interventions.

KEY RESULTS

Among 602 IBS patients ages 14-88 (M ± SD = 43.6 ± 18.6 years) with IBS, those who identified as Black/AA (n = 301) had a lower estimated mean income and were significantly more likely to have a number of specific chronic medical conditions. Black/AA patients were significantly less likely to have implemented dietary changes for symptoms prior to receiving a diagnosis of IBS from a gastroenterologist. Black/AA patients were also less likely to receive a referral to a dietician within 1 year following their diagnosis of IBS (p = 0.01). Black/AA patients were prescribed pharmacologic therapy more often for constipation (41.9% vs. 34.6%, p = 0.01). It was more common for White patients to present at the initial encounter having already initiated a neuromodulator (41.9% vs. 27.9%, p < 0.001).

CONCLUSION & INFERENCES

Management recommendations for IBS appear to vary by race, specifically for dietary advice and referrals.

Trying to Do What's Best: Maternal Perspectives About Toddler Sleep Health Among an Underresourced Sample of Mothers With Diverse Racial and Ethnic Identities

INTRODUCTION

This study describes mothers' knowledge, attitudes, beliefs, and practices about their toddler's sleep health among an underresourced sample of mothers with diverse racial and ethnic identities.

METHOD

This was a descriptive qualitative study with 16 mothers and their 12- to 36-month-old child. Mothers completed a semistructured, audio-recorded interview about their toddler's sleep health. Data were analyzed using inductive content analysis on the basis of established methods.

RESULTS

Mothers self-identified as 18.8% Black, 43.8% White, 12.5% multiracial, 25.0% other race, and 37.5% Hispanic. Of the mothers, 80.0% reported a past year household income of ≤ $40,000. A core construct, "Trying to do What's Best," emerged from the interview data, and this construct included three domains: Getting Good Sleep, Getting Thrown Off, and Rolling With It.

DISCUSSION

Findings support future strengths-based and multilevel sleep health-promoting interventions.

Food Insecurity, Neighborhood Food Environment, and Health Disparities: State of the Science, Research Gaps and Opportunities

Food insecurity and the lack of access to affordable, nutritious food are associated with poor dietary quality and an increased risk of diet-related diseases, including cardiovascular disease, diabetes, and certain types of cancer. Those of lower socioeconomic status and racial and ethnic minority groups experience higher rates of food insecurity, are more likely to live in under-resourced food environments, and continue to bear the greatest burden of diet-related chronic diseases in the United States. Despite the growing body of literature in this area, there are still significant gaps in our understanding of the various pathways that link food insecurity and neighborhood food environments to racial/ethnic and socioeconomic disparities in health and the most effective intervention strategies to address these disparities. To better understand the science in this area, the National Institutes of Health, in collaboration with the Centers for Disease Control (CDC) and Prevention and the United States Department of Agriculture (USDA), convened a virtual 3-d workshop 21-23 September 2021: Food Insecurity, Neighborhood Food Environment, and Nutrition Health Disparities: State of the Science. The workshop brought together a diverse group of researchers, practitioners, policymakers, and federal partners with expertise in nutrition, the food environment, health and social policy, and behavioral and social sciences. The workshop had the following 3 research objectives: 1) summarize the state of the science and knowledge gaps related to food insecurity, neighborhood food environments, and nutrition health disparities, 2) identify research opportunities and strategies to address research gaps, and 3) examine evidence-based interventions and implementation approaches to address food insecurity and neighborhood food environments to promote health equity. This article summarizes workshop proceedings and describes research gaps and future opportunities that emerged from discussions.

Racial disparities in stroke incidence in the Women's Health Initiative: Exploring biological, behavioral, psychosocial, and social risk factors

Background

- Disparities in incident stroke risk among women by race and ethnicity persist. Few studies report the distribution and association of stroke risk factors by age group among a diverse sample of women.

Methods

- Data from the Women's Health Initiative (WHI) Observational Study collected between 1993 and 2010 were used to calculate cumulative stroke incidence and incidence rates among non-Hispanic African American (NHAA), non-Hispanic white (NHW), and Hispanic white or African American (HWAA) women by age group in participants aged ≥50 years at baseline (N = 77,247). Hazard ratios (HRs) and 95% CIs for biological, behavioral, psychosocial, and socioeconomic factors overall and by race or ethnicity were estimated using sequential Cox proportional hazard regression models.

Results

- Average follow-up time was 11.52 (SD, 3.48) years. The incident stroke rate was higher among NHAA (306 per 100,000 person-years) compared to NHW (279/100,000py) and HWAA women (147/100,000py) overall and in each age group. The disparity was largest at ages >75 years. The association between stroke risk factors (e.g., smoking, BMI, physical activity) and incident stroke varied across race and ethnicity groups. Higher social support was significantly associated with decreased stroke risk overall (HR:0.84, 95% CI, 0.76, 0.93); the degree of protection varied across race and ethnicity groups. Socioeconomic factors did not contribute additional stroke risk beyond risk conferred by traditional and psychosocial factors.

Conclusions

- The distribution and association of stroke risk factors differed between NHAA and NHW women. There is a clear need for stroke prevention strategies that address factors driving racial disparities in stroke risk.

Connected Community Classification (C3): Development, Validation, and Geospatial Application for Population Health Promotion and Equity

CONTEXT

Social determinants of health (SDOH) impact population health. Leveraging community-level strengths related to SDOH through a social infrastructure perspective can optimize health behaviors and health outcomes to promote health equity.

OBJECTIVE

Our aims were to develop, validate, and apply the Connected Community Classification (C3) as comprehensive community-level measure of protective SDOH and structural factors in the Four Corners states region of the United States.

DESIGN

C3 was developed using an iterative principal component analysis of publicly available data mapped to 5 SDOH domains. Regional clustering of C3 by zip code tabulation area (ZCTA) was identified using spatial autocorrelation methods.

MAIN OUTCOMES

In adjusted spatial autoregressive models, we analyzed the association of C3 with high-risk health behaviors and chronic disease prevalence using publicly available data for population-level estimates of fruit and vegetable intake, physical activity, obesity, smoking, alcohol use, coronary heart disease (CHD), diabetes, and cancer.

RESULTS

C3 was found to be reliable and valid; a C3 value of 10 indicates communities with greater connection (high), while a value of 1 indicates communities with greater separation (low) to social infrastructure. Lower connection, as measured by C3, was significantly inversely associated with lower fruit and vegetable intake, lower physical activity, and higher rates of obesity, smoking, CHD, diabetes, and cancer. C3 was significantly positively associated with heavy alcohol use.

CONCLUSIONS

These findings demonstrate that communities connected to social infrastructure have better population health outcomes. C3 captures protective community attributes and can be used in future applications to assist health researchers, practitioners, nonprofits, and policymakers to advance social connection and health equity in geographically diverse underserved regions.

Characteristics of patients seeking fertility care in a low-income setting

OBJECTIVE

Patients face challenges accessing fertility treatment due to barriers such as financial burdens, delayed referral to Reproductive Endocrinologists (REI), low medical literacy, language barriers and numerous other health disparities. Medicaid in New York offers coverage for office visits, blood tests, hysterosalpingograms (HSGs), and pelvic ultrasounds for infertility. The aim of this study is to delineate the characteristics of this underserved population and determine their ability to complete the initial fertility workup.

METHODS

This was a retrospective study of all patients seeking fertility care at a single resident/fellow REI clinic in New York from September 2020 - January 2022.

RESULTS

During the study period, 87 patients (avg age = 35.2y) sought care at the resident/fellow clinic over 126 appointments. The majority of patients had Medicaid insurance and most primary languages spoken included English (70.1%), Spanish (21.8%), and Bengali (3.4%). Documented Race was comprised of mostly Other (46%), African American (21.8%), Asian (17.2%), and White (11.5%). The majority of patients completed a lab workup (70-80%). Fewer patients underwent a scheduled HSG (59.8%) and patients' partners completed a semen analysis (SA) (27.6%). Overall, there was a significant difference in the ability to complete the initial infertility workup (lab tests vs. HSG vs. SA) across all groups regardless of age, insurance type, primary language spoken, race and ethnicity (p<0.05).

CONCLUSIONS

Completing the fertility workup, particularly the male partner workup and imaging studies, can present challenges for underserved patients with infertility. Understanding which patient characteristics and societal factors restrict access to fertility care requires further investigation to improve access to fertility care in underserved communities.

Climate and environmental changes exacerbate health disparities in pregnant people and their offspring. How can we protect women and their babies?

BACKGROUND

The effects of climate and environmental changes (CEC) are being felt globally and will worsen over the next decade unless significant changes are made on a global level. Climate change is having serious consequences for health, particularly for vulnerable women and their offspring and less resilient individuals in communities with socioeconomic inequalities. To protect human health from CEC effects, efforts need to be directed toward building resilience strategies. Building political and economic power, as well as directly addressing CEC-related challenges, are critical components of climate resilience. Effective communication and tailored methods to engage women in preventive strategies are also necessary to ameliorate the deleterious effects of CEC on women's health. Furthermore, women from marginalized communities face more CEC-associated challenges.

CONCLUSIONS

Therefore, effective policies and programs targeting these at-risk populations-are crucial to improve the overall state of global health. In closing, it is time to increase awareness of the effects of CECs on women's health and their transgenerational effects in order to ensure that all people, regardless of race, ethnicity, education and income are protected from the detrimental effects of CECs.

HIV Prevention and Treatment Interventions for Black Men Who Have Sex With Men in Canada: Scoping Systematic Review

BACKGROUND

Black men who have sex with men (MSM) experience disproportionately high HIV incidence globally. A comprehensive, intersectional approach (race, gender, and sexuality or sexual behavior) in understanding the experiences of Black MSM in Canada along the HIV prevention and care continuums has yet to be explored.

OBJECTIVE

This scoping review aims to examine the available evidence on the access, quality, gaps, facilitators, and barriers of engagement and identify interventions relevant to the HIV prevention and care continuum for Black MSM in Canada.

METHODS

We conducted a systematic database search, in accordance with the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) checklist, of the available studies on HIV health experience and epidemiology concerning Black MSM living with or without HIV in Canada and were published after 1983 in either English or French. Searched databases include MEDLINE, Excerpta, Cumulative Index to Nursing and Allied Health Literature, the Cochrane Library, the NHUS Economic Development Database, Global Health, PsycInfo, PubMed, Scopus, and Web of Science. From the 3095 articles identified, 19 met the inclusion criteria and were analyzed.

RESULTS

Black MSM in Canada consistently report multiple forms of stigma and lack of community support contributing to an increased HIV burden. They experience discrimination based on their intersectional identities while accessing HIV preventative and treatment interventions. Available data demonstrate that Black MSM have higher HIV incidences than Black men who have sex with women (MSW) and White MSM, and low preexposure prophylaxis knowledge and HIV literacy. Black MSM experience significant disparities in HIV prevention and care knowledge, access, and use. Structural barriers, including anti-Black racism, homophobia, and xenophobia, are responsible for gaps in HIV prevention and care continuums, poor quality of care and linkage to HIV services, as well as a higher incidence of HIV.

CONCLUSIONS

Considering the lack of targeted interventions, there is a clear need for interventions that reduce HIV diagnoses among Black MSM, increase access and reduce structural barriers that significantly affect the ability of Black MSM to engage with HIV prevention and care, and address provider's capacity for care and the structural barriers. These findings can inform future interventions, programming, and tools that may alleviate this HIV inequity.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1136/bmjopen-2020-043055.

Disparities and social determinants of periodontal diseases

Periodontal diseases are highly prevalent in populations worldwide and are a major global public health problem, with major negative impacts on individuals and communities. This study investigates evidence of disparities in periodontal diseases by age groups, gender, and socioeconomic factors. There is ample evidence that these diseases disproportionally affect poorer and marginalized groups and are closely associated with certain demographics and socioeconomic status. Disparities in periodontal health are associated with social inequalities, which in turn are caused by old age, gender inequality, income and education gaps, access to health care, social class, and other factors. In health care, these factors may result in some individuals receiving better and more professional care compared to others. This study also reviews the potential causes of these disparities and the means to bridge the gap in disease prevalence. Identifying and implementing effective strategies to eliminate inequities among minorities and marginalized groups in oral health status and dental care should be prioritized in populations globally.

Achieving Equity in Childhood Vaccination: A Mixed-Methods Study of Immunization Programs, Policies, and Coverage in 3 US States

OBJECTIVE

In this study, we sought to understand patterns of childhood vaccinations in the United States across socioeconomic and racial/ethnic groups over a 12-year period to identify interventions that improve immunization equity and inform public health practice.

DESIGN

We conducted an explanatory, sequential, mixed-methods study. US state- and county-level immunization data were analyzed to understand trends in immunization coverage among racial/ethnic groups. Qualitative interviews with public health and community leaders were used to explain trends, gain insight into routine childhood immunization interventions, and understand local contexts and data limitations.

PARTICIPANTS AND SETTING

Secondary data were used from the National Immunization Survey-Child (NIS) public use data sets (2007 and 2019). Eligible participants for qualitative interviews were routine childhood immunization stakeholders from selected counties in North Carolina, Washington, and Arizona.

MAIN OUTCOME MEASURE

Our integrated findings report trends and probability of children aged 19 months to 3 years being fully vaccinated (measles-mumps-rubella [MMR], diphtheria and tetanus toxoids and acellular pertussis [DTaP], hepatitis B [Hep B]), interventions, and recommendations to improve routine childhood immunization coverage and equity.

RESULTS

Vaccination coverage remained high and relatively stable between 2007 and 2019; however, there were differences across racial/ethnic groups. Public health leaders identified key interventions that effectively improved vaccine equity and coverage, including data quality improvement, tailored interventions for specific populations, multisector partnerships, addressing common barriers, and data limitations. Participants also identified the critical role of state policies, public health funding, and community vaccine norms.

CONCLUSIONS

Variability persists in vaccination coverage and equity across states, race/ethnicity, and socioeconomic status despite decades of interventions. Vaccine stakeholders should use our findings to improve coverage and reduce disparities. Equitable improvements can be realized through policy change, data tracking/infrastructure improvements, and tailored interventions. Furthermore, local partners are critical in improving vaccine coverage and equitable interventions to disrupt disparities that long hold true for vaccine-preventable diseases.

Across-Agency Partnerships and Within-Agency Capacities Facilitate Holistic, Tailored Approaches to Addressing Food Insecurity: A Qualitative Study

BACKGROUND

Capacity-oriented approaches have the potential to reduce food insecurity (FI) and promote nutrition and health equity in low-resource settings.

OBJECTIVE

The objective of this study was to identify multilevel capacities in San Diego County, CA that key informants from diverse food- and nutrition-related stakeholder agencies perceived to be helping to address FI.

DESIGN

Trained qualitative interviewers conducted face-to-face, semi-structured interviews (30-60 minutes) with key informants. The Socioecological Model and a capacity-oriented approach informed interview guides.

PARTICIPANTS/SETTING

Participants were key informants (n = 23) from diverse purposively sampled stakeholder agencies (n = 16) providing food or nutrition services and programs across San Diego County. Interviews were conducted between April 2019 and December 2021.

ANALYSES PERFORMED

Interviews were audio-recorded, transcribed verbatim, and checked for accuracy. The research team conducted thematic content analysis to identify themes.

RESULTS

Two interrelated themes, within-agency capacities and across-agency partnerships, collectively appeared to influence each individual agency's ability to provide tailored, holistic care to their clients and, thus, expand each agency's reach and impact to address the 4 domains of food security (ie, quantity, quality, psychological, and social). Multilevel (ie, individual, interpersonal, organizational, and macro) within-agency human, social, and cultural capital (eg, volunteers, staff-client relationships, and cultural competency) positively influenced the reach and impact of the individual agencies by enabling them to provide clients with personalized, holistic care. Alongside within-agency capacities, multilevel (ie, interpersonal, organizational, community, and macro levels) across-agency partnerships allowed individual agencies to address FI more effectively and holistically by connecting clients to other services (eg, housing and mental health) related to the circumstances of FI.

CONCLUSIONS

In San Diego County, multilevel capacities in the form of within-agency capacities and across-agency partnerships collectively influenced the effectiveness of stakeholder agencies in addressing the 4 domains of FI among at-risk households. Future research should consider how to evaluate the impact of these existing capacities on FI.

Community and Healthcare Perspectives on Implementing Hypertension Interventions for a Multiethnic Safety-Net Population

Objective

To synthesize community and healthcare informants' perspectives on contextual considerations and tailoring recommendations for high-quality, sustainable implementation of evidence-based practices (EBPs) for managing hypertension (HTN) in a multiethnic safety-net population.

Design

Structured focus-group discussions and semistructured qualitative interviews.

Background

High-quality, sustainable implementation of HTN-related EBPs can promote equitable care. Implementation challenges extend beyond individual patients to span multiple levels of context. Few studies have systematically engaged community and healthcare perspectives to inform the design of HTN intervention trials.

Setting

A large safety-net healthcare system.

Participants/Methods

We conducted four structured discussions with each of five race- or ethnicity-specific community action boards (CABs) to understand community members' HTN-related norms, assets, needs, and experiences across local healthcare systems. We interviewed 41 personnel with diverse roles in our partnered healthcare system to understand the system's HTN-related strengths and needs. We solicited EBP tailoring recommendations from both groups. We summarized the findings using rapid content analysis.

Results

Participants identified contextual considerations spanning seven themes: social determinants, healthcare engagement, clinical interaction, system operations, standardization, patient education, and partnerships and funding. They offered tailoring recommendations spanning nine themes: addressing complex contexts, addressing social needs, system operations, healthcare system training and resources, linguistic and cultural tailoring, behavioral engagement, relational engagement, illness-course engagement, and community partnerships.

Conclusions

Engaging community and healthcare informants can ground implementation in the policy, community, healthcare system, clinical, and interpersonal contexts surrounding diverse patients at risk for disparities. Such grounding can reframe inequitable implementation as a multilevel social problem facing communities and healthcare systems, rather than individuals.

Distinct moderating pathways for psychosocial risk and resilience in the association of neighborhood disadvantage with incident heart failure among Black persons

Objective

To assess whether psychosocial factors moderate the associations between neighborhood disadvantage and incident heart failure (HF).

Methods

Among 1448 Non-Hispanic (NH) Black persons dually enrolled in two community-based cohorts in Jackson, Mississippi who were free of HF as of January 1, 2000, 336 HF events classified by reviewer panel accrued through December 31, 2017. Multilevel, multivariable Cox regression models were used to examine whether optimism and negative affect moderated the associations of two measures of neighborhood characteristics (the national Area Deprivation Index (ADI) and perceived neighborhood problems) on incident hospitalized HF.

Results

Optimism moderated the association of the ADI with incident HF. Compared to participants reporting the lowest tertile of optimism, those in the highest tertile of optimism had a 29% lower rate of HF associated with increasing ADI in fully adjusted models. We found no evidence for a moderating effect of negative affect.

Conclusions

This study supports optimism as a source of resilience to the detrimental effects of neighborhood disadvantage on HF risk. Population-level strategies to promote sociocultural antecedents to optimism may serve as a viable method of reducing the disproportionate burden of HF among NH Black persons.

Use of Adolescent "Community Researchers" to Address Obesity Among Mexican Immigrant Families

Background: Mexican-American immigrants have a disparate prevalence of overweight/obesity, and obesogenic illness. One approach is to train immigrant adolescents as "community researchers." Aims: (1) Design a program to train community researchers to address obesity among Mexican immigrant families and (2) identify the key components of a successful program. Methods: The content included an overview of community research/citizen science; obesity and food insecurity; study design and data collection and analysis for nutrition and physical activity. The students concluded by analyzing the results of group concept mapping (GCM) activities. Results: Post-session class discussions reflected an increased understanding of weekly topics. Analysis of GCM data suggests that members of the Mexican immigrant community may use emotional eating as a way to manage structural stigma, eventually leading to truncal obesity, T2DM and increased cardiovascular risk. Conclusions: Adolescents of Mexican heritage can have a major impact in promoting healthy lifestyles in their communities.

When resilience is not enough: Imagining novel approaches to supporting Black youth navigating racism

The narrative surrounding the impact racism has had on the well-being of Black youth has shifted across sociocultural and historical context. Early discourse around these topics were problem-saturated, focusing on deficits "within" Black youth. Over time, an important narrative shift occurred: greater attention was paid to the inherent assets of Black youth, their families, and communities, including how racial-ethnic protective factors such as racial socialization afforded them resilience. What resulted was decades of research seeking to understand the mechanisms that allow Black youth to bounce back in spite of racism-related adversity. Notwithstanding the viable practice and policy implications that have emerged from such inquiry, at what point does our focus on the resilience of Black youth - whether individual or multisystemic - fall short? It is with this question in mind that this paper challenges those committed to the optimal development of Black youth to consider yet another narrative shift: one that stands upon the legacy of cultural ecological frameworks and the seminal models underlying resilience research, and calls us toward not supporting Black youth's adaptation to racism, but toward collective efforts to transform our approach, pushing back against the perniciousness of racism.