Investigating a key structural determinant of health, racism, and related social determinants of health in Massachusetts during the COVID-19 pandemic

A disproportionate burden of the ongoing COVID-19 pandemic is being shouldered by members of racial and ethnic minorities and socially disadvantaged communities. Structural and social determinants of health have been recognized as key contributors to the inequalities observed. Racism, a major structural determinant of health that patterns related social determinants of health, in the USA, warrants further investigation. In this perspective piece we provide an overview of the historical context of racism, followed by preliminary findings from the ongoing COVIDStory study-a cross-sectional study addressing perceptions of COVID-19 and COVID-19 research-that highlights the experiences of non-Hispanic Black and Hispanic identifying adult participants, residing in Worcester Massachusetts, during the COVID-19 pandemic. We then discuss these findings in the context of current and past research considering racism and relevant social determinants of health. Our study results suggest that racism and its residuals (residential segregation, economic insecurity, discrimination, bias, and vigilance) are modern challenges for non-Hispanic Black and Hispanic participants, and these findings are supported by the existing literature. It is our hope that this perspective piece provides additional evidence for action on structural and social determinants affecting the health of minoritized people, especially those living in Massachusetts.

Complicating Narratives of Sexual Minority Mental Health: An Intersectional Analysis of Frequent Mental Distress at the Intersection of Sexual Orientation, Gender Identity, and Race/Ethnicity

Purpose: Research indicates that sexual minority populations experience mental health inequities. However, few studies have examined mental health outcomes in sexual minority populations while including intersecting dimensions of social identity. This study had two objectives: (1) to quantify the prevalence of frequent mental distress among U.S. adults across intersecting social identity categories and (2) to evaluate the contribution of intersectional interactions to observed inequities. Methods: Using data from the Behavioral Risk Factor Surveillance System 2014-2019 (N = 1,024,261), we performed an intersectional multilevel analysis of individual heterogeneity and discriminatory accuracy (I-MAIHDA). Participants were nested in 45 intersectional groups defined by combining 3 sexual orientation (gay/lesbian, bisexual, and heterosexual), 5 gender identity (transgender women, transgender men, gender nonconforming, cisgender women, and cisgender men), and 3 racial/ethnic (non-Hispanic Black, Hispanic/Latinx, and non-Hispanic White) categories. We estimated the predicted probability of frequent mental distress for each stratum. We then calculated the variance partition coefficient (VPC) and proportional change in variance (PCV). Results: We found that multiply marginalized groups tended to have the highest prevalence of frequent mental distress. Groups with racial/ethnic minority individuals were equally represented among low- and high-prevalence groups. The VPC indicated that slightly over 10% of observed variance in prevalence was attributable to group-level differences, while the PCV revealed that a small but meaningful amount of observed heterogeneity in prevalence was due to intersectional interactions between the dimensions of social identity. Conclusion: I-MAIHDA is a promising method for examining the patterning of sexual orientation-based mental health inequities at the population level.

Allostatic Load Among Black Sexual Minority Women

Background: Allostatic load is the physiological deterioration that accumulates as the body responds to stress, resulting in disparities in chronic disease. Although perceptions of stress vary, marginalization and social disadvantage are associated with elevated allostatic load. Allostatic load is understudied in the multiply marginalized populations of sexual minority Black women. Methods: We used data from six waves of the National Health and Nutrition Examination Survey (2001-2010, 2015-2016) to identify heterosexual (n = 78), lesbian (n = 21), and bisexual (n = 57) Black women. We quantified allostatic load using nine biomarkers, and compared mean allostatic load across the three groups, adjusting for age, educational attainment, income, and country of birth to account for possible confounding. Results: We found no significant differences in allostatic load among heterosexual, lesbian, and bisexual Black women. Conclusions: These findings suggest that sexual orientation may not contribute to within-group differences in allostatic load among Black women, a group previously noted to have elevated allostatic load.

Health Care Satisfaction in Relation to Gender Identity: Behavioral Risk Factor Surveillance Survey, 20 States (2014-2018)

BACKGROUND

Health care satisfaction is a key component of patient-centered care. Prior research on transgender populations has been based on convenience samples, and/or grouped all gender minorities into a single category.

OBJECTIVE

The objective of this study was to quantify differences in health care satisfaction among transgender men, transgender women, gender nonconforming, and cisgender adults in a diverse multistate sample.

RESEARCH DESIGN

Cross-sectional analysis of 2014-2018 Behavioral Risk Factor Surveillance System data from 20 states, using multivariable logistic models.

SUBJECTS

We identified 167,468 transgender men, transgender women, gender-nonconforming people, cisgender women, and cisgender men and compared past year health care satisfaction across these groups.

RESULTS

Transgender men and women had the highest prevalence of being "not at all satisfied" with the health care they received (14.6% and 8.6%, respectively), and gender-nonconforming people had the lowest prevalence of being "very satisfied" with their health care (55.7%). After adjustment for sociodemographic characteristics, transgender men were more likely to report being "not at all satisfied" with health care than cisgender men (odds ratio: 4.45, 95% confidence interval: 1.72-11.5) and cisgender women (odds ratio: 3.40, 95% confidence interval: 1.31-8.80).

CONCLUSIONS

Findings indicate that transgender and gender-nonconforming adults report considerably less health care satisfaction relative to their cisgender peers. Interventions to address factors driving these differences are needed.

Aging and COVID-19 in Minority Populations: a Perfect Storm

PURPOSE OF REVIEW

COVID-19 is a major concern for the health and wellbeing of individuals worldwide. As COVID-19 cases and deaths continue to increase in the USA, aging Black and Hispanic populations have emerged as especially at-risk for increased exposure to COVID-19 and susceptibility to severe health outcomes. The current review discusses the weathering hypothesis and the influence of social inequality on the identified health disparities.

RECENT FINDINGS

Aging minoritized populations have endured structural and social inequality over the lifecourse. Consequently, these populations experience weathering, a process that results in physiological dysregulation due to stress associated with persistent disadvantage. Through weathering and continued inequity, aging minoritized populations have an increased risk of exposure and poor health outcomes from COVID-19.

SUMMARY

Current literature and available data suggests that aging minoritized persons experience high rates of COVID-19 morbidity and mortality. The current review hypothesizes and supports that observed disparities are the result of inequalities that especially affect Black and Hispanic populations over the lifecourse. Future efforts to address these disparities should emphasize research that supports governments in identifying at-risk groups, providing accessible COVID-19-related information to those groups, and implementing policy that addresses the structural and social inequities that perpetuate current COVID-19 disparities.