Socioeconomic Stability Buffers Racial Discrimination Effect on Depression in a Marginalized Community

Childhood Factors Associated With Unnatural Death Through Midadulthood

Importance

Life expectancy is decreasing in the US. Without national efforts to address factors that support policies and programs directed at children living in areas of concentrated poverty, life expectancy will likely continue to decline while costs and suffering associated with unnatural deaths will increase.

Objective

To identify which childhood factors are associated with death from unnatural causes through midadulthood.

Design, Setting, and Participants

For this cohort study, longitudinal data on childhood characteristics came from a group-randomized intervention trial implemented in Baltimore City Public Schools, Baltimore, Maryland (baseline 1985-1986; all students entering first grade were selected to participate at age 6 years). Participants were followed up to midadulthood with a National Death Index search through December 31, 2020. Data analysis was performed from February to May 2023.

Exposures

Exposures included individual factors (ie, sociodemographic characteristics, teacher-reported aggressive behavior, self-reported depression, anxiety, early alcohol and cannabis use, and assaultive violence exposure), family and peer factors (ie, household structure and education level, deviant peer affiliation, and parental monitoring), and neighborhood factors (ie, rates of neighborhood assault and public assistance).

Main Outcomes and Measures

The main outcome was unnatural death, defined as death due to unintentional injury, suicide, and homicide. A National Death Index search ascertained participants who died by age 41 to 42 years and cause of death. Multivariable Cox proportional hazards models were used to identify whether the exposures were independently associated with future mortality by unnatural causes.

Results

The initial trial included 2311 children, and longitudinal data were available for 2180 participants (median [IQR] age in first grade, 6.3 [6.0-6.5] years; 1090 female [50.0%]; 1461 Black [67.0%]; 1168 received free or reduced lunch in first grade [53.6%]). A total of 111 male participants (10.2%) and 29 female participants (2.7%) died; among those who died, 96 male participants (86.5%) and 14 female participants (48.3%) died of unnatural causes. Two factors remained significantly associated with mortality from unnatural causes: female sex was associated with reduced risk (hazard ratio, 0.13; 95% CI, 0.08-0.22), and neighborhood public assistance was associated with increased risk (hazard ratio, 1.89; 95% CI, 1.09-3.30).

Conclusions and Relevance

In this urban population-based cohort study, no modifiable risk factors of mortality at the level of the individual (eg, depression or anxiety and substance use) or the family (eg, household education level) were identified. However, the degree of neighborhood poverty in early childhood was significantly associated with death by unnatural causes in early adulthood, suggesting that economic policies are needed to advance health equity in relation to premature mortality.

Emotional Distress in a Marginalized Population as a Function of Household-Level Social Determinants of Health

Low-income, underrepresented communities of color are disproportionally affected by emotional distress. Little is known about malleable, household-level determinants of emotional distress, addressable by feasible, stigma-neutral interventions. The present study addressed this knowledge gap by analyzing secondary data from a cross-sectional community needs assessment survey in a marginalized urban community (N = 677). Relying on dominance analyses, authors found that, on average, the largest household-level contributions to respondents' emotional distress included exposures to fellow household members' alcohol use and anger-driven behaviors. Both determinants are arguably feasible to address via household-level interventions and community-level preventive efforts. Household members' physical and serious mental illness and drug use were moderately associated with respondents' emotional distress; household cohesion and communications, residential overcrowding, and child behavior played a minimal role. Article concludes with a discussion of public health implications of the results.

Ethnic differences in respiratory disease for Native Hawaiians and Pacific Islanders: Analysis of mediation processes in two community samples

OBJECTIVE

The prevalence of asthma and chronic obstructive pulmonary disorder (COPD) is elevated for Native Hawaiians but the basis for this differential is not well understood. We analyze data on asthma and COPD in two samples including Native Hawaiians Pacific Islanders, and Filipinos to determine how ethnicity is related to respiratory disease outcomes.

METHODS

We analyzed the 2016 and 2018 Behavioral Risk Factor Surveillance Survey (BRFSS), a telephone survey of participants ages 18 and over in the State of Hawaii. Criterion variables were a diagnosis of asthma or COPD by a health professional. Structural equation modeling tested how five hypothesized risk factors (cigarette smoking, e-cigarette use, second-hand smoke exposure, obesity, and financial stress) mediated the ethnic differential in the likelihood of disease. Age, sex, and education were included as covariates.

RESULTS

Structural modeling with 2016 data showed that Native Hawaiian ethnicity was related to higher levels of the five risk factors and each risk factor was related to a higher likelihood of respiratory disease. Indirect effects were statistically significant in almost all cases, with direct effects to asthma and COPD also observed. Mediation effects through comparable pathways were also noted for Pacific Islanders and Filipinos. These findings were replicated with data from the 2018 survey.

CONCLUSIONS

Native Hawaiian and Pacific Islander ethnicity is associated with greater exposure to five risk factors and this accounts in part for the ethnic differential in respiratory disease outcomes. The results support a social-ecological model of health disparities in this population. Implications of the findings for preventive interventions are discussed.