Discrimination and Multimorbidity Among Black Americans: Findings from the National Survey of American Life

A Latent Class Analysis of Pre-Pregnancy Multimorbidity Patterns in a Delivery Cohort at a Safety-Net Hospital

Background: Multimorbidity affects approximately 1 in 3 adults and is associated with adverse health outcomes. However, there is a paucity of information describing patterns of multimorbidity among the birthing population. The objective of this study was to describe the clustering of pre-pregnancy chronic conditions in the birthing population by age, race and ethnicity, insurance status, and parity using latent class analysis (LCA). Study design: We conducted a retrospective cohort study of deliveries using medical record data between 2015 and 2019. Multimorbidity was defined as having at least two chronic conditions before the start of the index pregnancy, using adapted versions of obstetric comorbidity indices. The final LCA model was selected based on clinical interpretability and statistical fit. We also compared the distribution of sociodemographic factors across classes. Results: Of 6,455 deliveries, 1,870 (29%) deliveries were to patients with multimorbidity. LCA resulted in a 3-class model: Class 1 (45% of individuals with multimorbidity) was characterized by mood/anxiety and substance use disorders; class 2 (39%) was defined by body mass index ≥30 kg/m2 and chronic hypertension; and class 3 (16%) was characterized by reproductive conditions and infertility. Individuals who were <25 years or non-Hispanic White were more frequently in class 1; individuals who were ≥35 years or non-Hispanic Black were disproportionately in class 2. Nulliparas and individuals with private insurance were more frequently in class 3. Conclusion: Multimorbidity is prevalent in pregnancy and distinct chronic condition clusters vary across sociodemographic sub-groups, demonstrating the need for integrative approaches to periconceptional care for birthing individuals with multimorbidity.

Impact of Multimorbidity on Symptom Burden and Symptom Clusters in Patients Receiving Chemotherapy

BACKGROUND

Detailed information on patient characteristics and symptom burden associated with multimorbidity in oncology patients is extremely limited. Purposes were to determine the prevalence of low (≤ 2) and high (≥ 3) multimorbidity in a sample of oncology outpatients (n = 1343) undergoing chemotherapy and evaluate for differences between the two multimorbidity groups in demographic and clinical characteristics; the occurrence, severity, and distress of 38 symptoms; and the stability and consistency of symptom clusters.

METHODS

Using the Self-Administered Comorbidity Questionnaire, patients were classified into low and high multimorbidity groups. Memorial Symptom Assessment Scale was used to assess the occurrence, severity, and distress of 38 symptoms prior to the patients' second or third cycle of chemotherapy. For each multimorbidity group, symptom clusters based on occurrence rates were identified using exploratory factor analysis.

RESULTS

Compared to the low group (61.4%), patients in the high group (38.6%) were older, had fewer years of education, were less likely to be married or partnered, less likely to be employed, and had a lower annual income. In addition, they had a higher body mass index, poorer functional status, were a longer time since their cancer diagnosis, and were more likely to have received previous cancer treatments and have metastatic disease. Patients in the low and high groups reported 12.7 (±6.7) and 15.9 (±7.5) concurrent symptoms, respectively. Eight and seven symptom clusters were identified for the low and high groups, respectively. Psychological, gastrointestinal, weight gain, hormonal, and respiratory clusters were stable across multimorbidity groups. Weight gain and respiratory clusters were consistent. Three unstable clusters were identified in the low group and two in the high group.

CONCLUSIONS

Findings suggest that higher multimorbidity is associated with various social determinants of health and a higher symptom burden. Differences between multimorbidity groups may be related to aging, treatments, and/or comorbid conditions.

Psychosocial and Structural Correlates of Tobacco Use Among Black Young Adults

INTRODUCTION

U.S.- and foreign-born Black young adults often have different cultural backgrounds and experiences that can an affect the types of, extent of, and response to the psychosocial stressors encountered. This study examined whether psychosocial and structural stressors are similarly related to any and polytobacco (i.e., 2 or more tobacco products) use among subgroups of Black young adults in the U.S.

METHODS

Cross sectional data were collected in 2023 from 445 Black young adults (aged 18-25 years) in the U.S. Stratified regression models were used to examine the association of psychosocial (mental health adversity, race-related adversity, concerns about societal issues) and structural (food insecurity and housing insecurity) stressors with past 6-month any and polytobacco use among U.S.- and foreign-born Black young adults.

RESULTS

Race-related adversity was associated with higher odds of polytobacco use (than odds of nonuse) among both U.S.- (AOR=1.36, 95% CI=1.06, 1.74) and foreign- (AOR=2.18, 95% CI=1.18, 4.03) born Black young adults. Food insecurity was associated with higher odds of polytobacco use among foreign-born Black young adults (AOR=1.92, 95% CI=1.13, 3.27) and any tobacco use among both U.S.- (AOR=1.36, 95% CI=1.04, 1.79) and foreign- (AOR=1.47, 95% CI=1.01, 2.17) born Black young adults. However, concern about societal issues was associated with reduced odds of polytobacco use in both groups.

CONCLUSIONS

In all models, experiences of racism and discrimination (race-related adversity) were linked to higher odds of polytobacco use, whereas concern about societal issues was protective. However, there were nativity differences in the association of food insecurity with any and polytobacco use. Findings support the need for culturally/ethnically conscious tobacco prevention strategies that address the underlying psychosocial and structural drivers of tobacco use among Black young adult subgroups.

Experiences of and reactions to race-based differential treatment with multiple chronic conditions by race: Evidence from the South Carolina behavioral risk factor surveillance systems surveys prior to the COVID-19 pandemic

Background

Multiple chronic conditions (MCCs) are of increasing public health concern. There remain significant gaps in understanding the relationship between racial discrimination as a determinant of MCC burden. This study examines the association between race-based differential treatment and MCC prevalence by race.

Methods

We analyzed data from Black and White adults who completed the South Carolina Behavioral Risk Factor Surveillance System (2016-2017) survey Reactions to Race optional module (n=18,047). MCCs were summed and categorized (0; 1; 2-3; 4+ conditions). Racial discrimination was operationalized across multiple domains: experiences of race-based differential treatment in work settings and in healthcare settings, and emotional and physical reactions to race-based differential treatment. Multinomial logistic regression models were stratified by race and adjusted for confounders.

Results

Overall, 63.7% of Black and 60.4% of White adults had ≥2 MCC. Experiences of race-based differential treatment in work and health care settings and emotional reactions to race-based differential treatment were associated with a higher risk of MCCs among Black and White adults.

Conclusions

Our findings suggest that experiences and reactions to race-based differential treatment were associated with greater MCC burden among Black and White adults. This adds to a growing literature highlighting the importance of examining racial discrimination as a key factor contributing to the MCC burden within populations. Future research should interrogate potential social mechanisms identifying high MCC risk within racial groups.

Racial inequalities in the development of multimorbidity of chronic conditions: results from a Brazilian prospective cohort

BACKGROUND

The occurrence of multimorbidity and its impacts have differentially affected population subgroups. Evidence on its incidence has mainly come from high-income regions, with limited exploration of racial disparities. This study investigated the association between racial groups and the development of multimorbidity and chronic conditions in the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil).

METHODS

Data from self-reported white, brown (pardos or mixed-race), and black participants at baseline of ELSA-Brasil (2008-2010) who were at risk for multimorbidity were analysed. The development of chronic conditions was assessed through in-person visits and self-reported diagnosis via telephone until the third follow-up visit (2017-2019). Multimorbidity was defined when, at the follow-up visit, the participant had two or more morbidities. Cumulative incidences, incidence rates, and adjusted incidence rate ratios (IRRs) were estimated using Poisson models.

RESULTS

Over an 8.3-year follow-up, compared to white participants: browns had a 27% greater incidence of hypertension and obesity; and blacks had a 62% and 45% greater incidence, respectively. Blacks also had 58% more diabetes. The cancer incidence was greater among whites. Multimorbidity affected 41% of the participants, with a crude incidence rate of 57.5 cases per 1000 person-years (ranging from 56.3 for whites to 63.9 for blacks). Adjusted estimates showed a 20% higher incidence of multimorbidity in black participants compared to white participants (IRR: 1.20; 95% CI: 1.05-1.38).

CONCLUSIONS

Significant racial disparities in the risk of chronic conditions and multimorbidity were observed. Many associations revealed a gradient increase in illness risk according to darker skin tones. Addressing fundamental causes such as racism and racial discrimination, alongside considering social determinants of health, is vital for comprehensive multimorbidity care. Intersectoral, equitable policies are essential for ensuring health rights for historically marginalized groups.

Ethnic differences in multimorbidity after accounting for social-economic factors, findings from The Health Survey for England

BACKGROUND

Social-economic factors and health behaviours may be driving variation in ethnic health inequalities in multimorbidity including among distinct ethnic groups.

METHODS

Using the cross-sectional nationally representative Health Surveys for England 2011-18 (N = 54 438, aged 16+), we performed multivariable logistic regression on the odds of having general multimorbidity (≥2 longstanding conditions) by ethnicity [British White (reference group), White Irish, Other White, Indian, Pakistani, Bangladeshi, Chinese, African, Caribbean, White mixed, Other Mixed], adjusting for age, sex, education, area deprivation, obesity, smoking status and survey year. This was repeated for cardiovascular multimorbidity (N = 37 148, aged 40+: having ≥2 of the following: self-reported diabetes, hypertension, heart attack or stroke) and multiple cardiometabolic risk biomarkers (HbA1c ≥6.5%, raised blood pressure, total cholesterol ≥5mmol/L).

RESULTS

Twenty percent of adults had general multimorbidity. In fully adjusted models, compared with the White British majority, Other White [odds ratio (OR) = 0.63; 95% confidence interval (CI) 0.53-0.74], Chinese (OR = 0.58, 95% CI 0.36-0.93) and African adults (OR = 0.54, 95% CI 0.42-0.69), had lower odds of general multimorbidity. Among adults aged 40+, Pakistani (OR = 1.27, 95% CI 0.97-1.66; P = 0.080) and Bangladeshi (OR = 1.75, 95% CI 1.16-2.65) had increased odds, and African adults had decreased odds (OR = 0.63, 95% CI 0.47-0.83) of general multimorbidity. Risk of cardiovascular multimorbidity was higher among Indian (OR = 3.31, 95% CI 2.56-4.28), Pakistani (OR = 3.48, 95% CI 2.52-4.80), Bangladeshi (OR = 3.67, 95% CI 1.98-6.78), African (OR = 1.61, 95% CI 1.05-2.47), Caribbean (OR = 2.18, 95% CI 1.59-2.99) and White mixed (OR = 1.98, 95% CI 1.14-3.44) adults. Indian adults were also at risk of having multiple cardiometabolic risk biomarkers.

CONCLUSION

Ethnic inequalities in multimorbidity are independent of social-economic factors. Ethnic minority groups are particularly at risk of cardiovascular multimorbidity, which may be exacerbated by poorer management of cardiometabolic risk requiring further investigation.

Managing medical and psychiatric multimorbidity in older patients

Aging increases susceptibility both to psychiatric and medical disorders through a variety of processes ranging from biochemical to pharmacologic to societal. Interactions between aging-related brain changes, emotional and psychological symptoms, and social factors contribute to multimorbidity - the presence of two or more chronic conditions in an individual - which requires a more patient-centered, holistic approach than used in traditional single-disease treatment guidelines. Optimal treatment of older adults with psychiatric and medical multimorbidity necessitates an appreciation and understanding of the links between biological, psychological, and social factors - including trauma and racism - that underlie physical and psychiatric multimorbidity in older adults, all of which are the topic of this review.

Everyday Discrimination, Neighborhood Perceptions, and Incidence of Activity Limitations Among Middle-Aged and Older African Americans

OBJECTIVES

This study aims to examine the relationship between everyday discrimination, neighborhood perceptions, and the incidence of daily activity limitations (i.e., activities of daily living [ADL] and instrumental activities of daily living [IADL]) among middle-aged and older African Americans. This study also examines whether neighborhood perceptions moderate the association between discrimination and the incidence of daily activity limitations.

METHODS

Data were from the 2006 to 2016 waves of the Health and Retirement Study. African Americans aged 50 or older free of ADL limitations (N = 1,934) and IADL limitations (N = 2,007) at baseline were selected. Cox proportional hazards regression models were performed to test the study aims. Multiple imputations were applied to handle missing data.

RESULTS

One-unit increase in everyday discrimination was associated with a 25% (p < .05) higher risk of ADL limitation onset. Perceived neighborhood social cohesion and physical disadvantage moderated the association between discrimination and IADL limitation onset.

DISCUSSION

Everyday discrimination represents a significant stressor that negatively affects older African Americans' performance of daily activities. Community-level efforts that improve neighborhood perceptions are needed to alleviate the negative effects of discrimination on the incidence of activity limitations.

Racial Discrimination and Multimorbidity Among Older Adults in Colombia: A National Data Analysis

INTRODUCTION

Multimorbidity is a prevalent worldwide problem among older adults. Our objective was to assess the association between life-course racial discrimination and multimorbidity among older adults in Colombia.

METHODS

We used data from the SABE (Salud, Bienestar y Envejecimiento) Colombia Study in 2015 (N = 18,873), a national cross-sectional survey among adults aged 60 years or older. The outcome was multimorbidity, defined as having 2 or more chronic conditions. The main independent variables were 3 racial discrimination measures: 1) everyday racial discrimination (yes or no), 2) childhood racial discrimination score (scored from 0 [never] to 3 [many times]), and 3) situations of racial discrimination in the last 5 years (scored from 0 to 4 as a sum of the number of situations [group activities, public places, inside the family, health centers]). Other variables were sociodemographic characteristics, diseases, economic or health adversity during childhood, and functional status. We used weighted logistic regression analyses to adjust for differences between groups.

RESULTS

Multivariate logistic regression models showed that multimorbidity was significantly associated with experiencing everyday racial discrimination (OR, 2.21; 95% CI, 1.62-3.02), childhood racial discrimination (OR, 1.27; 95% CI, 1.10-1.47), and the number of situations of racial discrimination (OR= 1.56; 95% CI, 1.22-2.00). Multimorbidity was also independently associated with multimorbidity during childhood.

CONCLUSION

Racial discrimination experiences were associated with higher odds of multimorbidity among older adults in Colombia. Strategies to decrease life course experiences of racial discrimination may improve the health of older adults.

Global and regional prevalence of multimorbidity in the adult population in community settings: a systematic review and meta-analysis

BACKGROUND

Knowing the prevalence of multimorbidity among adults across continents is a crucial piece of information for achieving Sustainable Development Goal 3.4, which calls for reducing premature death due to non-communicable diseases. A high prevalence of multimorbidity indicates high mortality and increased healthcare utilization. We aimed to understand the prevalence of multimorbidity across WHO geographic regions among adults.

METHODS

We performed a systematic review and meta-analysis of surveys designed to estimate the prevalence of multimorbidity among adults in community settings. We searched PubMed, ScienceDirect, Embase and Google Scholar databases for studies published between January 1, 2000, and December 31, 2021. The random-effects model estimated the pooled proportion of multimorbidity in adults. Heterogeneity was quantified using I² statistics. We performed subgroup analyses and sensitivity analyses based on continents, age, gender, multimorbidity definition, study periods and sample size. The study protocol was registered with PROSPERO (CRD42020150945).

FINDINGS

We analyzed data from 126 peer-reviewed studies that included nearly 15.4 million people (32.1% were male) with a weighted mean age of 56.94 years (standard deviation of 10.84 years) from 54 countries around the world. The overall global prevalence of multimorbidity was 37.2% (95% CI = 34.9-39.4%). South America (45.7%, 95% CI = 39.0-52.5) had the highest prevalence of multimorbidity, followed by North America (43.1%, 95% CI = 32.3-53.8%), Europe (39.2%, 95% CI = 33.2-45.2%), and Asia (35%, 95% CI = 31.4-38.5%). The subgroup study highlights that multimorbidity is more prevalent in females (39.4%, 95% CI = 36.4-42.4%) than males (32.8%, 95% CI = 30.0-35.6%). More than half of the adult population worldwide above 60 years of age had multimorbid conditions (51.0%, 95% CI = 44.1-58.0%). Multimorbidity has become increasingly prevalent in the last two decades, while the prevalence appears to have stayed stable in the recent decade among adults globally.

INTERPRETATION

The multimorbidity patterns by geographic regions, time, age, and gender suggest noticeable demographic and regional differences in the burden of multimorbidity. According to insights about prevalence among adults, priority is required for effective and integrative interventions for older adults from South America, Europe, and North America. A high prevalence of multimorbidity among adults from South America suggests immediate interventions are needed to reduce the burden of morbidity. Furthermore, the high prevalence trend in the last two decades indicates that the global burden of multimorbidity continues at the same pace. The low prevalence in Africa suggests that there may be many undiagnosed chronic illness patients in Africa.

FUNDING

None.

Longitudinal Examination of an Ethnic Paradox of Stress and Mental Health in Older Black and Latinx Adults

OBJECTIVES

To explain the ethnic paradox of mental health in aging, we evaluated whether Black and Latinx older adults experience (1) fewer depressive symptoms (DepSx), but more physical problems, and (2) greater psychological resilience as a result of life stressors than White older adults.

METHODS

DepSx, physical health, and recent stress were obtained biennially from 25,893 older adults (77% White, 15% Black, 9% Latinx) in the U.S. Health and Retirement Study, across 16 years. Psychological resilience, lifetime stress, and discrimination experiences were available for 13,655 individuals. We conducted mixed-effects and linear regression analyses.

RESULTS

For Blacks and Latinxs, experiencing more-than-usual stress events was associated with less increase in DepSx compared to Whites, although on average Blacks and Latinxs experience more DepSx. Black adults showed worse physical health than White adults and weaker effects of stress on psychological resilience despite experiencing more stress of all types. Findings were mixed for Latinxs.

CONCLUSIONS

Studying effects of time-varying stress on changes in health and multiple stressors on psychological resilience by race/ethnicity elucidates mechanisms for later-age health disparities.

CLINICAL IMPLICATIONS

Cross-sectional evaluations of stress and psychological health in a clinical setting may provide incomplete appraisals of health risks for Black and Latinx older Americans.

Temporal Trends in Racial and Ethnic Disparities in Multimorbidity Prevalence in the United States, 1999-2018

BACKGROUND

Disparities in multimorbidity prevalence indicate health inequalities, as the risk of morbidity does not intrinsically differ by race/ethnicity. This study aimed to determine if multimorbidity differences by race/ethnicity are decreasing over time.

METHODS

Serial cross-sectional analysis of the National Health Interview Survey, 1999-2018. Included individuals were ≥18 years old and categorized by self-reported race, ethnicity, age, and income. The main outcomes were temporal trends in multimorbidity prevalence based on the self-reported presence of ≥2 of 9 common chronic conditions.

FINDINGS

The study sample included 596,355 individuals (4.7% Asian, 11.8% Black, 13.8% Latino/Hispanic, and 69.7% White). In 1999, the estimated prevalence of multimorbidity was 5.9% among Asian, 17.4% among Black, 10.7% among Latino/Hispanic, and 13.5% among White individuals. Prevalence increased for all racial/ethnic groups during the study period (P ≤ .001 for each), with no significant change in the differences between them. In 2018, compared with White individuals, multimorbidity was more prevalent among Black individuals (+2.5 percentage points) and less prevalent among Asian and Latino/Hispanic individuals (-6.6 and -2.1 percentage points, respectively). Among those aged ≥30 years, Black individuals had multimorbidity prevalence equivalent to that of Latino/Hispanic and White individuals aged 5 years older, and Asian individuals aged 10 years older.

CONCLUSIONS

From 1999 to 2018, a period of increasing multimorbidity prevalence for all the groups studied, there was no significant progress in eliminating disparities between Black individuals and White individuals. Public health interventions that prevent the onset of chronic conditions in early life may be needed to eliminate these disparities.

Ethnic inequities in multimorbidity among people with psychosis: a retrospective cohort study

AIMS

Research shows persistent ethnic inequities in mental health experiences and outcomes, with a higher incidence of illnesses among minoritised ethnic groups. People with psychosis have an increased risk of multiple long-term conditions (MLTC; multimorbidity). However, there is limited research regarding ethnic inequities in multimorbidity in people with psychosis. This study investigates ethnic inequities in physical health multimorbidity in a cohort of people with psychosis.

METHODS

In this retrospective cohort study, using the Clinical Records Interactive Search (CRIS) system, we identified service-users of the South London and Maudsley NHS Trust with a schizophrenia spectrum disorder, and then additional diagnoses of diabetes, hypertension, low blood pressure, overweight or obesity and rheumatoid arthritis. Logistic and multinomial logistic regressions were used to investigate ethnic inequities in odds of multimorbidity (psychosis plus one physical health condition), and multimorbidity severity (having one or two physical health conditions, or three or more conditions), compared with no additional health conditions (no multimorbidity), respectively. The regression models adjusted for age and duration of care and investigated the influence of gender and area-level deprivation.

RESULTS

On a sample of 20 800 service-users with psychosis, aged 13-65, ethnic differences were observed in the odds for multimorbidity. Controlling for sociodemographic factors and duration of care, compared to White British people, higher odds of multimorbidity were found for people of Black African [adjusted Odds Ratio = 1.41, 95% Confidence Intervals (1.23-1.56)], Black Caribbean [aOR = 1.79, 95% CI (1.58-2.03)] and Black British [aOR = 1.64, 95% CI (1.49-1.81)] ethnicity. Reduced odds were observed among people of Chinese [aOR = 0.61, 95% CI (0.43-0.88)] and Other ethnic [aOR = 0.67, 95% CI (0.59-0.76)] backgrounds. Increased odds of severe multimorbidity (three or more physical health conditions) were also observed for people of any Black background.

CONCLUSIONS

Ethnic inequities are observed for multimorbidity among people with psychosis. Further research is needed to understand the aetiology and impact of these inequities. These findings support the provision of integrated health care interventions and public health preventive policies and actions.

Double, Triple, and Quadruple Jeopardy: Entering Pregnancy With Two or More Multimorbid Diagnoses and Increased Risk of Severe Maternal Morbidity and Postpartum Readmission

INTRODUCTION

Multimorbidity, the presence of two or more chronic disease diagnoses, is associated with an increased risk of mortality and high health care costs in the general population and older adults. However, little evidence is available about the prevalence and impact of multimorbidity in obstetric populations. The goal of this analysis was to estimate the association between multimorbidity and severe maternal morbidity (SMM) and 90-day postpartum readmission in an obstetric cohort in Atlanta, Georgia.

STUDY DESIGN

We conducted a retrospective cohort study of livebirths and stillbirths at Grady Memorial Hospital, from October 2015 to April 2021. To determine preexisting chronic conditions, we linked information on births to inpatient diagnoses within the prior year. Multimorbidity was defined as the presence of two or more chronic disease diagnoses at birth or within the prior year. We conducted multivariable log binomial regression to estimate risk ratios and 95% confidence intervals for the crude and adjusted (for age, race/ethnicity, parity, and insurance) association between multimorbidity (two or more chronic conditions vs. zero or one) and SMM (at or within 42 days after birth) or 90-day postpartum readmission for any reason.

RESULTS

Of 14,225 included births, 10.1% were to patients with multimorbidity. Overall, SMM complicated 7.5% of births, and the 90-day readmission rate was 2.4%. Both SMM and readmission were more common among women with multimorbidity (SMM, 18.6% among women with multimorbidity compared with 6.3% without; 90-day readmission, 5.4% compared with 2.1%). Adjusting for potential confounders, multimorbidity was associated with increased risk of SMM (adjusted risk ratio, 2.9; 95% confidence interval, 2.5-3.0) and readmission (adjusted risk ratio, 2.2; 95% confidence interval, 1.7-2.9).

CONCLUSIONS

Individuals entering pregnancy with two or more chronic diseases were at an increased risk of SMM and postpartum readmission compared with individuals with one or zero chronic disease diagnoses.

Association between incarceration and psychotic experiences in a general population sample

Incarceration of individuals with mental disorders is an important public health topic. While incarceration appears to be associated with schizophrenia and related psychotic disorders, to the best of our knowledge, no study has examined the association between incarceration and psychotic experiences (PEs). The present study aimed to examine whether individuals with PEs had higher odds of incarceration among a general population sample using data from Baltimore and New York City (N = 974). We fitted three regression models to examine the association between incarceration and PEs, using hierarchical adjustments for sociodemographic factors, adverse childhood experiences, and neighborhood disruption. The odds ratio (OR) for incarceration was attenuated with inclusion of more covariates in the model but remained statistically significant even at the highest level of adjustment (OR = 2.12, 95% CI = 1.30 to 3.46). Findings were similar when individually examining delusional mood, delusions of reference and persecution, and hallucination. For delusions of control, a significant association was not found in the highest level of adjustment. The present study provides novel information on the association between incarceration and PEs, adjusted for sociodemographic and psychosocial confounders. Taken in the context of prior studies, these data further support the need to address the high prevalence of psychosis across all aspects of the criminal justice system. Future studies should employ longitudinal data and objective outcome measurements.

National Trends in Racial and Ethnic Disparities in Antihypertensive Medication Use and Blood Pressure Control Among Adults With Hypertension, 2011-2018

Poor hypertension awareness and underuse of guideline-recommended medications are critical factors contributing to poor hypertension control. Using data from 8095 hypertensive people aged ≥18 years from the National Health and Nutrition Examination Survey (2011-2018), we examined recent trends in racial and ethnic differences in awareness and antihypertensive medication use, and their association with racial and ethnic differences in hypertension control. Between 2011 and 2018, age-adjusted hypertension awareness declined for Black, Hispanic, and White individuals, but the 3 outcomes increased or did not change for Asian individuals. Compared with White individuals, Black individuals had a similar awareness (odds ratio, 1.20 [0.96-1.45]) and overall treatment rates (1.04 [0.84-1.25]), and received more intensive antihypertensive medication if treated (1.41 [1.27-1.56]), but had a lower control rate (0.72 [0.61-0.83]). Asian and Hispanic individuals had significantly lower awareness rates (0.69 [0.52-0.85] and 0.74 [0.59-0.89]), overall treatment rates (0.72 [0.57-0.88] and 0.69 [0.55-0.82]), received less intensive medication if treated (0.60 [0.50-0.72] and 0.86 [0.75-0.96]), and had lower control rates (0.66 [0.54-0.79] and 0.69 [0.57-0.81]). The racial and ethnic differences in awareness, treatment, and control persisted over the study period and were consistent across age, sex, and income strata. Lower awareness and treatment were significantly associated with lower control in Asian and Hispanic individuals (P<0.01 for all) but not in Black individuals. These findings highlight the need for interventions to improve awareness and treatment among Asian and Hispanic individuals, and more investigation into the downstream factors that may contribute to the poor hypertension control among Black individuals.