Differences in Cesarean Rates for Nulliparous, Term, Singleton, Vertex Births Among Racial and Ethnic Groups and States Before and After Stay-at-Home Orders During the COVID-19 Pandemic, United States, 2017-2021

OBJECTIVES

Evidence is limited on differences in cesarean rates for nulliparous, term, singleton, vertex (NTSV) births across racial and ethnic groups at the national and state level during the COVID-19 pandemic. We assessed changes in levels and trends of NTSV cesarean rates before and after stay-at-home orders (SAHOs) were implemented in the United States (1) overall, (2) by racial and ethnic groups, and (3) by 50 US states from January 2017 through December 2021.

METHODS

We used birth certificate data from 2017 through 2021, restricted to hospital births, to calculate monthly NTSV cesarean rates for the United States and for racial and ethnic groups and to calculate quarterly NTSV cesarean rates for the 50 states. We used interrupted time-series analysis to measure changes in NTSV cesarean rates before and after implementation of SAHOs (March 1 through May 31, 2020).

RESULTS

Of 6 022 552 NTSV hospital births, 1 579 645 (26.2%) were cesarean births. Before implementation of SAHOs, NTSV cesarean rates were declining in the United States overall; were declining among births to non-Hispanic Asian, non-Hispanic Black, Hispanic, and non-Hispanic White women; and were declining in 6 states. During the first month of implementation of SAHOs in May 2020, monthly NTSV rates increased in the United States by 0.55%. Monthly NTSV rates increased by 1.20% among non-Hispanic Black women, 0.90% among Hispanic women, and 0.28% among non-Hispanic White women; quarterly NTSV rates increased in 6 states.

CONCLUSION

In addition to emergency preparedness planning, hospital monitoring, and reporting of NTSV cesarean rates to increase provider awareness, reallocation and prioritization of resources may help to identify potential strains on health care systems during public health emergencies such as the COVID-19 pandemic.

The Association of Hypertensive Disorders of Pregnancy with Infant Mortality, Preterm Delivery, and Small for Gestational Age

Gestational hypertension, preeclampsia, eclampsia, and chronic hypertension (CHTN) are associated with adverse infant outcomes and disproportionately affect minoritized race/ethnicity groups. We evaluated the relationships between hypertensive disorders of pregnancy (HDP) and/or CHTN with infant mortality, preterm delivery (PTD), and small for gestational age (SGA) in a statewide cohort with a diverse racial/ethnic population. All live, singleton deliveries in South Carolina (2004-2016) to mothers aged 12-49 were evaluated for adverse outcomes: infant mortality, PTD (20 to less than <37 weeks) and SGA (<10th birthweight-for-gestational-age percentile). Logistic regression models adjusted for sociodemographic, behavioral, and clinical characteristics. In 666,905 deliveries, mothers had superimposed preeclampsia (HDP + CHTN; 1.0%), HDP alone (8.0%), CHTN alone (1.8%), or no hypertension (89.1%). Infant mortality risk was significantly higher in deliveries to women with superimposed preeclampsia, HDP, and CHTN compared with no hypertension (relative risk [RR] = 1.79, 1.39, and 1.48, respectively). After accounting for differing risk by race/ethnicity, deliveries to women with HDP and/or CHTN were more likely to result in PTD (RRs ranged from 3.14 to 5.25) or SGA (RRs ranged from 1.67 to 3.64). As CHTN, HDP and superimposed preeclampsia confer higher risk of adverse outcomes, prevention efforts should involve encouraging and supporting mothers in mitigating modifiable cardiovascular risk factors.

Racial differences in setting of implantable cardioverter-defibrillator placement in older adults with heart failure and association with disparate post-implant outcomes

Background

Implantable cardioverter-defibrillator (ICD) placement in heart failure (HF) patients during or early after (≤90 days) unplanned cardiovascular hospitalizations has been associated with poor outcomes. Racial and ethnic differences in this "peri-hospitalization" ICD placement have not been well described.

Methods

Using a 20% random sample of Medicare beneficiaries, we identified older (≥66 years) patients with HF who underwent ICD placement for primary prevention from 2008 to 2018. We investigated racial and ethnic differences in frequency of peri-hospitalization ICD placement using modified Poisson regression. We utilized Kaplan-Meier analyses and Cox regression to investigate the association of peri-hospitalization ICD placement with differences in all-cause mortality and hospitalization (HF, cardiovascular and all-cause) within and between race and ethnicity groups for up to 5-year follow-up.

Results

Among the 61,710 beneficiaries receiving ICDs (35% female, 82% White, 10% Black, 6% Hispanic), 44% were implanted peri-hospitalization. Black [adjusted rate ratio (RR) 95% Confidence Interval (95% CI): 1.16 (1.12, 1.20)] and Hispanic [RR (95% CI): 1.10 (1.06, 1.14)] beneficiaries were more likely than White beneficiaries to have ICD placement peri-hospitalization. Peri-hospitalization ICD placement was associated with an at least 1.5× increased risk of death, 1.5× increased risk of re-hospitalization and 1.7× increased risk of HF hospitalization during 3-year follow-up in fully adjusted models. Although beneficiaries with peri-hospitalization placement had the highest mortality and readmission rates 1- and 3-year post-implant (log-rank p < 0.0001), the magnitude of the associated risk did not differ significantly by race and ethnicity (p = NS for interaction).

Conclusions

ICD implantation occurring during the peri-hospitalization period was associated with worse prognosis and occurred at higher rates among Black and Hispanic compared to White Medicare beneficiaries with HF during the period under study. The risk associated with peri-hospitalization ICD placement did not differ by race and ethnicity. Future paradigms aimed at enhancing real-world effectiveness of ICD therapy and addressing disparate outcomes should consider timing and setting of ICD placement in HFrEF patients who otherwise meet guideline eligibility.

Racial and ethnic differences in barriers to care among US adults with chronic inflammatory skin diseases: A cross-sectional study of the All of Us Research Program

BACKGROUND

Research on racial and ethnic differences in barriers to care among patients with chronic inflammatory skin diseases (CISDs) is limited.

OBJECTIVE

To investigate the prevalence of a broad range of barriers to care among patients with CISDs across different racial and ethnic groups.

METHODS

A cross-sectional study was conducted using survey data from participants with CISDs in the All of Us Research Program. Multivariable regression was used to analyze the relationship between race and ethnicity and experiencing barriers to care.

RESULTS

Our study included 16,986 patients with CISDs. Compared to White patients, Black and Hispanic patients were significantly more likely to delay care because of cost and a broad range of additional structural barriers, including transportation, work, childcare, adult care, living in a rural area, and the lack of health care workforce diversity. However, associations between race and ethnicity and many barriers to care were substantially attenuated after controlling for insurance, income, and education.

LIMITATIONS

The population studied was not a representative sample of US adults, and responses were not specific to dermatologic care.

CONCLUSION

Racial and ethnic minority patients with CISDs, especially Black and Hispanic patients, are disproportionately affected by a broad range of barriers to care.

Who's Helping Whom? Examination of Care Arrangements for Racial and Ethnic Diverse People Living With Dementia in the Community

Objective: To address notions around care arrangements for Black and Hispanic people living with dementia (PLwD), the study examined if racial and ethnic differences exist for community-dwelling PLwD. Methods: Using cross-sectional data from the 2015 National Health and Aging Trends Study, we used Pearson's chi-square and mean comparison to examine differences among a sample of n = 863 community-dwelling White, Black, and Hispanic older PLwD. Results: Black PLwD were less likely than White PLwD to use paid help (26.8% vs. 32.6%), but Hispanic PLwD were most likely to use paid help (46.2%, p < 0.05). Black and Hispanic older adults were more often receiving help from a child (65.8% and 72.2%, respectively; p = 0.01) or other family member (40.3% and 31.0%, respectively; p < 0.01). Discussion: Our findings highlight the important role of familial support in care provision for Black and Hispanic communities. Caregiving supports should be intentional in centering services on the family, not a sole caregiver.

Confluence of law enforcement, mental health, and race

Disparities in victimization by law enforcement for both people of color and individuals with mental health disorders is gaining national attention following the deaths of George Floyd, Sandra Bland, TAmir Rice, and many others. Despite this, the discussion around the intersectionality of race, psychiatric illness, and law enforcement is still in its infancy, the purpose of this article is to discuss the confluence of race and psychiatric illness as vulnerabilities in various contacts with law enforcement in order to further highlight this issue and to ignite further needed research on this topic. Possible solutions such as police-hiring practices, bias training, and trauma-informed policing will be discussed.

Drinking among college student athletes during the COVID-19 pandemic

Objective: To investigate demographics, sport type, athletic identity, and COVID-19 sport season cancelation in relation to alcohol consumption among college student athletes shortly after the pandemic emerged. Participants: College student athletes recruited from U.S. athletic departments. Methods: Survey data were collected from 5,915 college student athletes in April/May 2020. Results: Being female, Latinx, and in a relationship were associated with lower alcohol consumption. Among males, team sport participation was related to greater alcohol consumption. Among females, athletic identity was inversely related to drinking, which was moderated by sport type, such that alcohol consumption was lower as athletic identity strengthened in individual (vs. team) sport athletes. However, we did not find a relationship of COVID-19 sport season cancelation with drinking. Conclusions: Our gender-specific findings are novel and generalizable based on a large, national sample of college student athletes, and may inform strategies for alcohol consumption education among college team sport athletes.

Racial and Ethnic Minorities Have a Lower Prevalence of Airflow Obstruction than Non-Hispanic Whites

Racial and ethnic disparities in chronic obstructive pulmonary disease (COPD) are not well-studied. Our objective was to examine differences in limited COPD-related outcomes between three minority groups-African Americans (AAs), Hispanics, and American Indians (AIs) versus non-Hispanic Whites (NHWs), as the referent group, in separate cohorts. Separate cross-sectional evaluations were performed of three US-based cohorts of subjects at risk for COPD: COPDGene Study with 6,884 NHW and 3,416 AA smokers; Lovelace Smokers' Cohort with 1,598 NHW and 378 Hispanic smokers; and Mining Dust Exposure in the United States Cohort with 2,115 NHW, 2,682 Hispanic, and 2,467 AI miners. Prebronchodilator spirometry tests were performed at baseline visits using standard criteria. The primary outcome was the prevalence of airflow obstruction. Secondary outcomes were self-reported physician diagnosis of COPD, chronic bronchitis, and modified Medical Research Council dyspnea score. All minority groups had a lower prevalence of airflow obstruction than NHWs (adjusted ORs varied from 0.29 in AIs to 0.85 in AAs; p < 0.01 for all analyses). AAs had a lower prevalence of chronic bronchitis than NHWs. In our study, all minority groups had a lower prevalence of airflow obstruction but a greater level of self-reported dyspnea than NHWs, and covariates did not explain this association. A better understanding of racial and ethnic differences in smoking-related and occupational airflow obstruction may improve prevention and therapeutic strategies.

Racial Differences in Prevalence and Clinical Characteristics of Asthma-Chronic Obstructive Pulmonary Disease Overlap

Background: This study examined the differences in the prevalence and clinical features of asthma–chronic obstructive pulmonary disease (COPD) overlap (ACO) with identical diagnostic criteria by race and ethnicity in two nationwide cohorts of COPD.

Methods: We used data from the Korean COPD Subgroup Study (KOCOSS) and phase I of the US Genetic Epidemiology of COPD (COPDGene) study. We defined ACO by satisfying bronchodilator response (BDR) >15% and 400 ml and/or blood eosinophil count ≥300/μl.

Results: The prevalences of ACO according to ethnicity were non-Hispanic white (NHW), 21.4%; African American (AA), 17.4%; and Asian, 23.8%. Asian patients with ACO were older, predominantly male, with fewer symptoms, more severe airflow limitation, and fewer comorbidities than NHW and AA patients. During 1-year follow-up, exacerbations occurred in 28.2, 22.0, and 48.4% of NHW, AA, and Asian patients with ACO, respectively. Compared to patients with non-ACO from the same racial group, the risk for exacerbation was significantly higher in NHW and Asian patients with ACO [adjusted incident rate ratio (aIRR), 1.17; 95% CI, 1.01–1.36, and aIRR, 1.37; 95% CI, 1.09–1.71 for NHW and Asian patients with ACO, respectively]. Inhaled corticosteroid (ICS) reduced the risk for future exacerbation in total patients with ACO but the effect was not significant in each racial group.

Conclusions: The prevalence of ACO was similar in the two cohorts using the same diagnostic criteria. The risk for future exacerbation was significantly higher in ACO, and the use of ICS reduced the risk for exacerbation in total patients with ACO.

COVID-19 Cases and Death in Nursing Homes: The Role of Racial and Ethnic Composition of Facilities and Their Communities

OBJECTIVES

To examine the extent to which the racial and ethnic composition of nursing homes (NHs) and their communities affects the likelihood of COVID-19 cases and death in NHs, and whether and how the relationship between NH characteristics and COVID-19 cases and death varies with the racial and ethnic composition of the community in which an NH is located.

METHODS AND DESIGN

Centers for Medicare & Medicare Services Nursing Home COVID-19 data were linked with other NH- or community-level data (eg, Certification and Survey Provider Enhanced Reporting, Minimum Data Set, Nursing Home Compare, and the American Community Survey).

SETTING AND PARTICIPANTS

NHs with more than 30 occupied beds (N=13,123) with weekly reported NH COVID-19 records between the weeks of June 7, 2020, and August 23, 2020. Measurements and model: Weekly indicators of any new COVID-19 cases and any new deaths (outcome variables) were regressed on the percentage of black and Hispanic residents in an NH, stratified by the percentage of blacks and Hispanics in the community in which the NH was located. A set of linear probability models with NH random effects and robust standard errors were estimated, accounting for other covariates.

RESULTS

The racial and ethnic composition of NHs and their communities were both associated with the likelihood of having COVID-19 cases and death in NHs. The racial and ethnic composition of the community played an independent role in the likelihood of COVID-19 cases and death in NHs, even after accounting for the COVID-19 infection rate in the community (ie, daily cases per 1000 people in the county). Moreover, the racial and ethnic composition of a community modified the relationship between NH characteristics (eg, staffing) and the likelihoods of COVID-19 cases and death.

CONCLUSIONS AND IMPLICATIONS

To curb the COVID-19 outbreaks in NHs and protect vulnerable populations, efforts may be especially needed in communities with a higher concentration of racial and ethnic minorities. Efforts may also be needed to reduce structural racism and address social risk factors to improve quality of care and population health in communities of color.

Racial and Ethnic Disparities in Pain Management of Children With Limb Fractures or Suspected Appendicitis: A Retrospective Cross-Sectional Study

Objective: To evaluate whether racial/ethnical differences in analgesia administration existed in two different cohorts of children with painful conditions: children with either limb fracture or suspected appendicitis. Methods: Retrospective cross-sectional analysis of children visiting a pediatric emergency department (Boston Children Hospital) for limb fracture or suspected appendicitis from 2011 to 2015. We computed the proportion of children that received any analgesic treatment and any opioid analgesia. We performed multivariable logistic regressions to investigate race/ethnicity differences in analgesic and opioid administration, after adjusting for pain score, demographics and visit covariates. Results: Among the 8,347 children with a limb fracture and the 4,780 with suspected appendicitis, 65.0 and 60.9% received any analgesic treatment, and 35.9 and 33.4% an opioid analgesia, respectively. Compared to White non-Hispanic Children, Black non-Hispanic children and Hispanic children were less likely to receive opioid analgesia in both the limb fracture cohort [Black: aOR = 0.61 (95% CI, 0.50-0.75); Hispanic aOR = 0.66 (95% CI, 0.55-0.80)] and in the suspected appendicitis cohort [Black: aOR = 0.75 (95% CI, 0.58-0.96); Hispanic aOR = 0.78 (95% CI, 0.63-0.96)]. In the limb fracture cohort, Black non-Hispanic children and Hispanic children were more likely to receive any analgesic treatment (non-opioid or opioid) than White non-Hispanic children [Black: aOR = 1.63 (95% CI, 1.33-2.01); Hispanic aOR = 1.43 (95% CI, 1.19-1.72)]. Conclusion: Racial and ethnic disparities exist in the pain management of two different painful conditions, which suggests true inequities in health care delivery. To provide equitable analgesic care, emergency departments should monitor variation in analgesic management and develop appropriate universal interventions.

Lack of Racial Survival Differences in Metastatic Prostate Cancer in National Cancer Data Base (NCDB): A Different Finding Compared to Non-metastatic Disease

Background: Inconsistent findings have been reported in the literature regarding racial differences in survival outcomes between African American and white patients with metastatic prostate cancer (mPCa). The current study utilized a national database to determine whether racial differences exist among the target population to address this inconsistency.

Methods: This study retrospectively reviewed prostate cancer (PCa) patient data (N = 1,319,225) from the National Cancer Database (NCDB). The data were divided into three groupings based on the metastatic status: (1) no metastasis (N = 318,291), (2) bone metastasis (N = 29,639), and (3) metastases to locations other than bone, such as brain, liver, or lung (N = 952). Survival probabilities of African American and white PCa patients with bone metastasis were examined through parametric proportional hazards Weibull models and Bayesian survival analysis. These results were compared to patients with no metastasis or other types of metastases.

Results: No statistically supported racial disparities were observed for African American and white men with bone metastasis (p = 0.885). Similarly, there were no racial disparities in survival for those men suffering from other metastases (liver, lung, or brain). However, racial disparities in survival were observed among the two racial groups with non-metastatic PCa (p < 0.001) or when metastasis status was not taken into account (p < 0.001). The Bayesian analysis corroborates the finding.

Conclusion: This research supports our previous findings and shows that there are no racial differences in survival outcomes between African American and white patients with mPCa. In contrast, racial disparities in the survival outcome continue to exist among non-metastatic PCa patients. Further research is warranted to explain this difference.

Racial and Ethnic Differences in Longitudinal Patterns of Family Mealtimes: Link to Adolescent Fruit and Vegetable Consumption

OBJECTIVE

To examine the longitudinal patterns of family mealtimes across racial/ethnic groups and to investigate whether the associations between longitudinal patterns of family mealtimes, baseline family and demographic characteristics, and healthy food consumption in adolescence differ by race/ethnicity.

METHODS

Data from the Early Childhood Longitudinal Study spanning from kindergarten to eighth grade were used for this study. Longitudinal patterns of family mealtimes and their link to baseline characteristics and healthy food consumption in adolescence, as defined by fruit and vegetable intakes, were determined using latent growth curves.

RESULTS

From childhood to adolescence, family mealtimes were stable among Asian families. Although Hispanic families displayed a downward pattern, mealtimes declined more steeply in non-Hispanic white and black families. The links among family mealtimes, baseline characteristics, and healthy food consumption were not observed equally across racial/ethnic groups.

CONCLUSIONS AND IMPLICATIONS

Differences in longitudinal patterns of family mealtimes and in the association between family mealtimes and adolescent healthy food consumption across racial/ethnic groups call for targeted intervention in this nutritionally vulnerable period.

Racial/ethnic differences moderate associations of coping strategies and posttraumatic stress disorder symptom clusters among women experiencing partner violence: a multigroup path analysis

BACKGROUND

Past research underscores the key role of coping strategies in the development, maintenance, and exacerbation of posttraumatic stress disorder (PTSD) symptoms. The goal of the current study was to extend existing literature by examining whether race/ethnicity moderates the relations among coping strategies (social support, problem-solving, avoidance) and PTSD symptom clusters (intrusion, avoidance, numbing, arousal).

METHODS

Participants were 369 community women (134 African Americans, 131 Latinas, 104 Whites) who reported bidirectional aggression with a current male partner. Multigroup path analysis was utilized to test the moderating role of race/ethnicity in a model linking coping strategies to PTSD symptom clusters.

RESULTS

The strength and direction of relations among coping strategies and PTSD symptom clusters varied as a function of race/ethnicity. Greater social support coping was related to more arousal symptoms for Latinas and Whites. Greater problem-solving coping was related to fewer arousal symptoms for Latinas. Greater avoidance coping was related to more symptoms across many of the PTSD clusters for African Americans, Latinas, and Whites, however, these relations were strongest for African Americans.

CONCLUSION

Results provide support for the moderating role of race/ethnicity in the relations among coping strategies and PTSD symptom clusters, and highlight potential targets for culturally informed PTSD treatments.

Pathways to Hazardous Drinking Among Racially and Socioeconomically Diverse Lesbian Women: Sexual Minority Stress, Rumination, Social Isolation, and Drinking to Cope

Lesbian women engage in more hazardous drinking than heterosexual women yet we know relatively little about what explains this disparity. In the present study, race, socioeconomic status, minority stress, general psychological processes and distress were examined as pathways to hazardous drinking among young (18-35 years) Black and non-Hispanic White lesbian women. We used the psychological mediation framework adaptation of minority stress theory and the reserve capacity model as theoretical underpinnings of the conceptual model in the current study. Self-identified lesbian participants (N= 867) completed a one-time online survey that assessed race, socioeconomic status, perceived sexual minority discrimination, proximal minority stress (concealment, internalized homophobia, lack of connection to lesbian community), rumination, social isolation, psychological distress, drinking to cope, and hazardous drinking. Cross-sectional results demonstrated that being Black was associated with hazardous drinking via sequential mediators of rumination, psychological distress, and drinking to cope. Socioeconomic status was associated with hazardous drinking via sequential mediators of sexual minority discrimination, proximal minority stress, rumination, social isolation, psychological distress, and drinking to cope. Understanding these pathways can aid researchers and clinicians studying and working with lesbians who are at risk for hazardous drinking.

Exploring Discrimination and Mental Health Disparities Faced By Black Sexual Minority Women Using a Minority Stress Framework

Black sexual minority women are triply marginalized due to their race, gender, and sexual orientation. We compared three dimensions of discrimination-frequency (regularity of occurrences), scope (number of types of discriminatory acts experienced), and number of bases (number of social statuses to which discrimination was attributed)-and self-reported mental health (depressive symptoms, psychological well-being, and social well-being) between 64 Black sexual minority women and each of two groups sharing two of three marginalized statuses: (a) 67 White sexual minority women and (b) 67 Black sexual minority men. Black sexual minority women reported greater discrimination frequency, scope, and number of bases and poorer psychological and social well-being than White sexual minority women and more discrimination bases, a higher level of depressive symptoms, and poorer social well-being than Black sexual minority men. We then tested and contrasted dimensions of discrimination as mediators between social status (race or gender) and mental health outcomes. Discrimination frequency and scope mediated the association between race and mental health, with a stronger effect via frequency among sexual minority women. Number of discrimination bases mediated the association between gender and mental health among Black sexual minorities. Future research and clinical practice would benefit from considering Black sexual minority women's mental health in a multidimensional minority stress context.

Racial and ethnic differences in factors related to workplace violence victimization

Workplace violence (WPV) is a significant public health concern affecting all racial or ethnic groups. This study examined whether different racial/ethnic groups differed in vulnerability to WPV exposure and utilization of resources at the workplace. This cross-sectional research focused on White, Black, and Asian nursing employees (N = 2,033) employed in four health care institutions in a mid-Atlantic U.S. metropolitan area. Whereas childhood physical abuse was significantly related to risk of WPV among workers from all racial/ethnic backgrounds, intimate partner abuse was a significant factor for Asians and Whites. Blacks and Asians were found to be less likely than Whites to be knowledgeable about WPV resources or use resources to address WPV. Services to address past trauma, and education and training opportunities for new workers may reduce risk of WPV and promote resource utilization among minority workers.

Health Risk Behavior and Sexual Assault Among Ethnically Diverse Women

Sexual assault is associated with a number of health risk behaviors in women. It has been hypothesized that these risk behaviors, such as hazardous drinking, may represent women's attempts to cope with psychological distress, such as symptoms of depression and anxiety. However, extant research has failed to evaluate these relationships among ethnic minority samples or identify the mechanisms responsible for this association. The current study examined sexual assault history and two health risk behaviors (hazardous drinking and engaging in sexual behavior to regulate negative affect) in a diverse sample of 1,620 college women. Depression and anxiety were examined as mediators of the relationship between sexual assault and health risk behaviors. There was evidence of moderated mediation, such that for European American women, but not for ethnic minority women, both forms of psychological distress were significant mediators of the sexual assault/hazardous drinking relationship. In contrast, among all ethnic groups, the relationship between sexual assault and both forms of psychological distress was mediated by the use of sexual behavior as an affect regulation strategy. Results support a need to evaluate the assault experiences of ethnically diverse women, as well as the impact of the assault on their postassault experiences including health risk behaviors and psychological adjustment. Additionally, results suggest that practitioners should carefully assess health risk behaviors among victims of sexual assault and be aware that there may be differences in the risk factors and motives for these behaviors among women of various ethnic backgrounds.