The legacy of slavery and contemporary declines in heart disease mortality in the U.S. South

Does everyday discrimination account for the increased risk of vasomotor symptoms in Black women?: the Study of Women's Health Across the Nation (SWAN)

OBJECTIVES

Vasomotor symptoms (VMS), including hot flashes and night sweats, are hallmark symptoms of the menopause transition. Previous research has documented greater frequency, duration, and severity of VMS in Black women compared with women from other racial/ethnic groups, even after accounting for other factors. This analysis examined the association between discrimination and VMS and the extent to which discrimination accounts for the disproportionate burden of VMS in Black women.

METHODS

Using available discrimination and VMS data from the SWAN cohort study (n = 2,377, 48% White, 32% Black, 6% Japanese, 4% Chinese, and 9% Hispanic women) followed approximately yearly in midlife from premenopause (42-52 y) through postmenopause (~20 y), we assessed concurrent associations between discrimination and VMS frequency in the past 2 weeks using weighted generalized mixed models. We also assessed associations between chronic discrimination across first four visits and VMS trajectories from premenopause to postmenopause using weighted multinomial logistic regression. Models were adjusted for known risk factors for VMS.

RESULTS

Higher levels of discrimination were associated with concurrent reporting of any (odds ratio [OR], 1.57 [1.31-1.89]) and frequent (≥6 d) VMS (OR, 1.55 [1.21-1.99]). After adjustment, associations remained significant for any (OR, 1.30 [1.09-1.54]) but not frequent VMS. For any VMS trajectories, chronic discrimination was associated with "continuously high" (OR, 1.69 [1.03-2.77]) and "high pre-FMP-decline post-FMP" (OR, 1.70 [1.01-2.88]) versus "FMP-onset low" trajectories. After adjusting for discrimination, odds of reporting any, frequent, and of being in the "continuously high" any VMS trajectory remained elevated for Black versus White women.

CONCLUSIONS

Discrimination is associated with greater concurrent risk of any (but not frequent) VMS, and chronic discrimination is associated with a continuously high reporting of any VMS over time, independent of known risk factors. Adjusting for discrimination attenuates but does not eliminate the increased risk of VMS for Black women.

Spatiotemporal Changes in the Slavery-Inequality Relationship: The Diffusion of the Legacy of Slavery

Despite the persistence of relationships between historical racist violence and contemporary Black-White inequality, research indicates, in broad strokes, that the slavery-inequality relationship in the United States has changed over time. Identifying the timing of such change across states can offer insights into the underlying processes that generate Black-White inequality. In this study, we use integrated nested Laplace approximation models to simultaneously account for spatial and temporal features of panel data for Southern counties during the period spanning 1900 to 2018, in combination with data on the concentration of enslaved people from the 1860 census. Results provide the first evidence on the timing of changes in the slavery-economic inequality relationship and how changes differ across states. We find a region-wide decline in the magnitude of the slavery-inequality relationship by 1930, with declines traversing the South in a northeasterly-to-southwesterly pattern over the study period. Different paces in declines in the relationship across states suggest the expansion of institutionalized racism first in places with the longest-standing overt systems of slavery. Results provide guidance for further identifying intervening mechanisms-most centrally, the maturity of racial hierarchies and the associated diffusion of racial oppression across institutions, and how they affect the legacy of slavery in the United States.

Historical Redlining and Heart Failure Outcomes Following Hospitalization in the Southeastern United States

BACKGROUND

Historical redlining, a discriminatory lending practice, is an understudied component of the patient risk environment following hospital discharge. We investigated associations between redlining, patient race, and outcomes following heart failure hospitalization.

METHODS AND RESULTS

We followed a hospital-based cohort of Black and White patients using electronic medical records for acute heart failure hospitalizations between 2010 and 2018 (n=6800). Patient residential census tracts were geocoded according to the 1930s Home Owners' Loan Corporation map grades (A/B: best/still desirable, C: declining, D: redlined). We used Poisson regression to analyze associations between Home Owners' Loan Corporation grade and 30-day outcomes (readmissions, mortality, and their composite). One-third of patients resided in historically redlined tracts (n=2034). In race-stratified analyses, there was a positive association between historically declining neighborhoods and composite readmissions and mortality for Black patients (risk ratio [RR], 1.24 [95% CI, 1.003-1.54]) and an inverse association between redlined neighborhoods and 30-day readmissions among White patients (RR, 0.58 [95% CI, 0.39-0.86]). Examining racial disparities across Home Owners' Loan Corporation grades, Black patients had higher 30-day readmissions (RR, 1.86 [95% CI, 1.31-2.65]) and composite readmissions and mortality (RR, 1.32 [95% CI, 1.04-1.65]) only in historically redlined neighborhoods.

CONCLUSIONS

Historical redlining had potentially mixed impacts on outcomes by race, such that residing in less desirable neighborhoods was associated with an elevated risk of an adverse outcome following heart failure hospitalization in Black patients and a reduced risk in White patients. Moreover, racial disparities in patient outcomes were present only in historically redlined neighborhoods. Additional research is needed to explore observed heterogeneity in outcomes.

(Un)safe Spaces: The Relationship Between Slavery and Sexual Victimization of Black Women

Research exploring the correlates of sexual victimization has found sexual victimization to be associated with both individual- and contextual-level factors, including age, gender, poverty, and size of the female population. However, to date, research has been limited in exploring how historical factors, such as slavery, may be associated with the contemporary prevalence of sexual victimization of women. Historical accounts have often suggested that enslaved women often experienced sexual victimization during their enslavement. Despite these accounts, research has been limited in empirically exploring the relationship between slavery and the sexual victimization of Black women. Using the 1860 U.S. Census and the 2019 National Incidence-Based Reporting System, multilevel logistic regression analyses are employed to explore whether slavery is consequential for contemporary instances of Black female sexual victimization. In line with the "legacy effect" framework, the findings from the current study suggest that Black women are significantly more likely to be sexually victimized in counties characterized by larger enslaved populations in 1860. These findings illuminate how historical institutions, despite being outlawed, have contemporary consequences, particularly for Black women. These findings, discussions, avenues for future research, and policy implications are discussed below.

The role of cultural competency training to address health disparities in surgical settings

BACKGROUND

Disparities in health care delivered to marginalized groups are unjust and result in poor health outcomes that increase the cost of care for everyone. These disparities are largely avoidable and health care providers, have been targeted with education and specialised training to address these disparities.

SOURCES OF DATA

In this manuscript we have sought out both peer-reviewed material on Pubmed, as well as policy statements on the potential role of cultural competency training (CCT) for providers in the surgical care setting. The goal of undertaking this work was to determine whether there is evidence that these endeavours are effective at reducing disparities.

AREAS OF AGREEMENT

The unjustness of health care disparities is universally accepted.

AREAS OF CONTROVERSY

Whether the outcome of CCT justifies the cost has not been effectively answered.

GROWING POINTS

These include the structure/content of the CCT and whether the training should be delivered to teams in the surgical setting.

AREAS TIMELY FOR DEVELOPING RESEARCH

Because health outcomes are affected by many different inputs, should the effectiveness of CCT be improvement in health outcomes or should we use a proxy or a surrogate of health outcomes.

Structural Racism and Health Stratification: Connecting Theory to Measurement

Less than 1% of studies on racialized health inequities have empirically examined their root cause: structural racism. Moreover, there has been a disconnect between the conceptualization and measurement of structural racism. This study advances the field by (1) distilling central tenets of theories of structural racism to inform measurement approaches, (2) conceptualizing U.S. states as racializing institutional actors shaping health, (3) developing a novel latent measure of structural racism in states, (4) using multilevel models to quantify the association between structural racism and five individual-level health outcomes among respondents from the Health and Retirement Study (N = 9,020) and the Behavioral Risk Factor Surveillance System (N = 308,029), and (5) making our measure of structural racism publicly available to catalyze research. Results show that structural racism is consistently associated with worse health for Black people but not White people. We conclude by highlighting this study's contributions (theoretical, methodological, and substantive) and important avenues for future research on the topic.

Perceived Religious Influence on Health Is Associated with Beneficial Health Behaviors in Members of Predominantly Black Churches

Background

Cardiovascular disease is the leading cause of death in the United States, and Black populations are disproportionately affected. Black populations also have high rates of religiosity, which may be an important health motivator, but mechanisms are unclear.

Objective

We examined the relationship between perceived religious influence on health and cardiovascular health behaviors, risk factors, and confidence participating in medical care in Black church congregants.

Methods

We surveyed 302 members of 13 churches with predominantly Black congregations in New Orleans, Louisiana. Participants reported if religious beliefs had an influence on their health and if they avoided harmful behaviors because of religion. Fruit and vegetable intake, physical activity, smoking status, confidence asking questions to health care providers, understanding treatment plans and self-reported hypertension, hypercholesterolemia, and diabetes were assessed. Logistic regression was used adjusting for age, sex, and education.

Results

Survey respondents were 77% female with a median age of 66 years, and 72%, 56%, and 37% reported hypertension, hypercholesterolemia, and diabetes, respectively. Perceived religious influence on health was positively associated with fruit and vegetable intake, physical activity, and confidence asking questions to health care providers. Avoiding harmful behaviors because of religion was positively associated with physical activity. There was no association between perceived religious influence on health and smoking, hypertension, hypercholesterolemia, or diabetes.

Conclusion

Perceived religious influence on health was associated with beneficial cardiovascular health behaviors and confidence participating in medical care. These findings can inform the design and delivery of interventions to reduce cardiovascular disease among Black religious communities.

Birth in the U.S. Plantation South and Racial Differences in all-cause mortality in later life

The American South has been characterized as a Stroke Belt due to high cardiovascular mortality. We examine whether mortality rates and race differences in rates reflect birthplace exposure to Jim Crow-era inequalities associated with the Plantation South. The plantation mode of agricultural production was widespread through the 1950s when older adults of today, if exposed, were children. We use proportional hazards models to estimate all-cause mortality in Non-Hispanic Black and White birth cohorts (1920-1954) in a sample (N = 21,941) drawn from REasons for Geographic and Racial Differences in Stroke (REGARDS), a national study designed to investigate Stroke Belt risk. We link REGARDS data to two U.S. Plantation Censuses (1916, 1948) to develop county-level measures that capture the geographic overlap between the Stroke Belt, two subregions of the Plantation South, and a non-Plantation South subregion. Additionally, we examine the life course timing of geographic exposure: at birth, adulthood (survey enrollment baseline), neither, or both portions of life. We find mortality hazard rates higher for Black compared to White participants, regardless of birthplace, and for the southern-born compared to those not southern-born, regardless of race. Race-specific models adjusting for adult Stroke Belt residence find birthplace-mortality associations fully attenuated among White-except in one of two Plantation South subregions-but not among Black participants. Mortality hazard rates are highest among Black and White participants born in this one Plantation South subregion. The Black-White mortality differential is largest in this birthplace subregion as well. In this subregion, the legacy of pre-Civil War plantation production under enslavement was followed by high-productivity plantation farming under the southern Sharecropping System.

Structural racism through Sundown towns and its relationship to COVID-19 local risk and racial and ethnic diversity

"Sundown towns" across the US prevented racial and ethnic minorities from living and working within their borders as they forced minorities to leave these towns after sunset. The objective of this study was to explore the relationship between sundown town status, COVID-19 local risk index and racial and ethnic diversity. A multi-level hierarchical model was used to examine the effect of historical segregation through sundown towns status on present day COVID-19 local risk index and city-level diversity. Over 2,400 Sundown towns were cataloged across the United States, with the greatest density in the Midwest. Sundown towns, which historically excluded racial and ethnic minorities, had significantly less city-level diversity and lower COVID-19 local risk index compared to non-Sundown towns. Findings show that Sundown towns perpetuate residual segregation which continues to impact current inequities in COVID-19 risk among racial and ethnic minorities at the neighborhood level. We recommend that public health officials for pandemic preparedness should devote greater resources to these historically segregated racial and ethnic minority areas because of the historic structural racism that has placed these places at higher risk.

Wealth index association with self-reported oral health between white and non-white older Brazilians

This cross-sectional study aimed to identify the association between self-reported oral health status and a wealth index among white and non-white older adults in Brazil. Data from individual assessments of 9,365 Brazilians aged 50 years or older were analyzed. Poisson regression models were performed to estimate the prevalence ratio between wealth index and self-reported oral health among whites and non-whites adjusted for intermediate and proximal determinants. The total prevalence of poor self-reported oral health on white and non-white individuals was 41.6% (95%CI: 40.0-43.4) and 48% (95%CI: 47.1-49.8) respectively. The adjusted analysis showed that, for whites, the wealth index is associated with self-reported oral health since individuals in the 3rd, 4th, and 5th quintiles have 25% (PR = 0.75; 95%CI: 0.65-0.88), 20% (PR = 0.80; 95%CI: 0.67-0.95), and 39% (PR = 0.61; 95%CI: 0.50-0.75) lower prevalence of poor self-reported oral health than those in the poorest quintile. For non-white individuals, the wealth index is associated with self-reported oral health only for those in the 5th quintile, with 25% (PR = 0.85; 95%CI: 0.72-0.99) lower prevalence of poor self-reported oral health than those in the poorest quintile. The wealth index showed different effects on self-reported oral health among whites and non-whites. Socioeconomic status indicators may reflect racial inequalities due to the historical legacy of institutional discrimination. This study highlights the importance of developing policies to combat racial inequities and how these can contribute to better oral health conditions for the older Brazilian population.

Core issues, case studies, and the need for expanded Legacy African American genomics

Introduction: Genomic studies of Legacy African Americans have a tangled and convoluted history in western science. In this review paper, core issues affecting African American genomic studies are addressed and two case studies, the New York African Burial Ground and the Gullah Geechee peoples, are presented to highlight the current status of genomic research among Africa Americans. Methods: To investigate our target population's core issues, a metadatabase derived from 22 publicly accessible databases were reviewed, evaluated, and synthesized to identify the core bioethical issues prevalent during the centuries of the African American presence in North America. The sequence of metadatabase development included 5 steps: identification of information, record screening and retention of topic relevant information, identification of eligibility via synthesis for concept identifications, and inclusion of studies used for conceptual summaries and studies used for genetic and genomic summaries. To these data we added our emic perspectives and specific insights from our case studies. Results: Overall, there is a paucity of existing research on underrepresent African American genomic diversity. In every category of genomic testing (i.e., diagnostic, clinical predictive, pharmacogenomic, direct-to-consumer, and tumor testing), African Americans are disproportionately underrepresented compared to European Americans. The first of our case studies is from the New York African Burial Ground Project where genomic studies of grave soil derived aDNA yields insights into the causes of death of 17^th and 18^th Century African Americans. In the second of our case studies, research among the Gullah Geechee people of the Carolina Lowcountry reveals a connection between genomic studies and health disparities. Discussion: African Americans have historically borne the brunt of the earliest biomedical studies used to generate and refine primitive concepts in genetics. As exploited victims these investigations, African American men, women, and children were subjected to an ethics-free western science. Now that bioethical safeguards have been added, underrepresented and marginalized people who were once the convenient targets of western science, are now excluded from its health-related benefits. Recommendations to enhance the inclusion of African Americans in global genomic databases and clinical trials should include the following: emphasis on the connection of inclusion to advances in precision medicine, emphasis on the relevance of inclusion to fundamental questions in human evolutionary biology, emphasis on the historical relevance of inclusion for Legacy African Americans, emphasis on the ability of inclusion to foster expanded scientific expertise in the target population, ethical engagement with their descendants, and increase the number of science researchers from these communities.

Structural racism theory, measurement, and methods: A scoping review

Introduction

Epidemiologic and public health interest in structural racism has grown dramatically, producing both increasingly sophisticated questions, methods, and findings, coupled with concerns of atheoretical and ahistorical approaches that often leave the actual production of health or disease ambiguous. This trajectory raises concerns as investigators adopt the term "structural racism" without engaging with theories and scholars with a long history in this area. This scoping review aims to build upon recent work by identifying current themes about the incorporation of structural racism into (social) epidemiologic research and practice with respect to theory, measurement, and practices and methods for trainees and public health researchers who are not already deeply grounded in this work.

Methods

This review uses methodological framework and includes peer-review articles written in English published between January 2000-August 2022.

Results

A search of Google Scholar, manual collection, and referenced lists identified a total of 235 articles; 138 met the inclusion criteria after duplicates were removed. Results were extracted by, and organized into, three broad sections: theory, construct measurement, and study practice and methods, with several themes summarized in each section.

Discussion

This review concludes with a summary of recommendations derived from our scoping review and a call to action echoing previous literature to resist an uncritical and superficial adoption of "structural racism" without attention to already existing scholarship and recommendations put forth by experts in the field.

Social Determinants of Cardiovascular Health: A Longitudinal Analysis of Cardiovascular Disease Mortality in US Counties From 2009 to 2018

Background Disparities in cardiovascular disease (CVD) outcomes persist across the United States. Social determinants of health play an important role in driving these disparities. The current study aims to identify the most important social determinants associated with CVD mortality over time in US counties. Methods and Results The authors used the Agency for Healthcare Research and Quality's database on social determinants of health and linked it with CVD mortality data at the county level from 2009 to 2018. The age-standardized CVD mortality rate was measured as the number of deaths per 100 000 people. Penalized generalized estimating equations were used to select social determinants associated with county-level CVD mortality. The analytic sample included 3142 counties. The penalized generalized estimating equation identified 17 key social determinants of health including rural-urban status, county's racial composition, income, food, and housing status. Over the 10-year period, CVD mortality declined at an annual rate of 1.08 (95% CI, 0.74-1.42) deaths per 100 000 people. Rural counties and counties with a higher percentage of Black residents had a consistently higher CVD mortality rate than urban counties and counties with a lower percentage of Black residents. The rural-urban CVD mortality gap did not change significantly over the past decade, whereas the association between the percentage of Black residents and CVD mortality showed a significant diminishing trend over time. Conclusions County-level CVD mortality declined from 2009 through 2018. However, rural counties and counties with a higher percentage of Black residents continued to experience higher CVD mortality. Median income, food, and housing status consistently predicted higher CVD mortality.

Navigating a hyperracialized space: exploring the intersections of whiteness, social control, and mental health in st. louis county, missouri

Places marred by a legacy of racial violence have contemporary implications for racial and ethnic minorities. However, there is limited work examining how racial and ethnic minorities perceive and navigate these spaces and how they may affect their health. We examine the daily lives of Black residents of St. Louis County, living in what we refer to as a hyperracialized space, or areas characterized by multiple forms of violence, to understand how navigating a hyperracialized space impacts how Black residents negotiate space and make meaning of their health. Qualitative interviews (n = 20) revealed three themes: (1) Whiteness and the maintenance of a hyperracialized space, (2) unspoken rules of police encounters and the embodiment of self-regulation, (3) and hypervigilance. Narratives reveal how individuals and institutions concretize a hyperracialized space through social control. Moreover, participants discussed how their environment influenced how they interacted with and navigated space, the toll of which elicited hypervigilance.

Race/Ethnicity and Duration of Anesthesia for Pediatric Patients in the US: a Retrospective Cohort Study

BACKGROUND

Previous literature has demonstrated adverse patient outcomes associated with racial/ethnic disparities in health services. Because patients/parents and providers care about the duration of anesthesia, this study focuses on this outcome.

OBJECTIVES

To determine the association between race/ethnicity and duration under anesthesia.

RESEARCH DESIGN

In this retrospective cohort study of data from the Multicenter Perioperative Outcomes Group, White non-Latino was the reference and was compared with Black non-Latino children, Latino, Asian, Native American, Other, and "Unknown" race children.

SUBJECTS

Children aged 3 to 17 years.

OUTCOMES

Induction duration (primary outcome), procedure-end duration, and total duration under anesthesia (secondary outcomes).

RESULTS

Of 37,596 eligible cases, 9,610 cases with complete data were analyzed. The sample consisted of 6,894 White non-Latino patients, 1,021 Black non-Latino patients, 50 Latino patients, 287 Asian patients, 26 Native American patients, 57 "Other" race patients, and 1,275 patients of "Unknown" race. The mean induction time was 11.9 min (SD 5.6 min). In adjusted analysis, Black non-Latino patients had 5% longer induction and procedure-end durations than White non-Latino children (exponentiated beta coefficient [Exp (β)] 1.05, 95% CI: 1.02-1.08, p < 0.01 and Exp (β) 1.08, 95% CI 1.04-1.13, p < 0.01 respectively).

CONCLUSIONS

White non-Latino children had shorter induction and procedure-end durations than Black children. The differences in induction and procedure-end time were small but may be meaningful on a population-health level.

Impact of Federal, State, and Local Housing Policies on Disparities in Cardiovascular Disease in Black/African American Men and Women: From Policy to Pathways to Biology

Racist and discriminatory federal, state, and local housing policies significantly contribute to disparities in cardiovascular disease incidence and mortality for individuals that self-identify as Black or African American. Here we highlight three key housing policies - "redlining," zoning, and the construction of highways - which have wrought a powerful, sustained, and destructive impact on cardiovascular health in Black/African American communities. Redlining and highway construction policies have restricted access to quality health care, increased exposure to carcinogens such as PM_2.5, and increased exposure to extreme heat. At the root of these policy decisions are longstanding, toxic societal factors including racism, segregation, and discrimination, which also serve to perpetuate racial inequities in cardiovascular health. Here, we review these societal and structural factors and then link them with biological processes such as telomere shortening, allostatic load, oxidative stress, and tissue inflammation. Lastly, we focus on the impact of inflammation on the immune system and the molecular mechanisms by which the inflamed immune microenvironment promotes the formation of atherosclerotic plaques. We propose that racial residential segregation and discrimination increases tissue inflammation and cytokine production, resulting in dysregulated immune signaling, which promotes plaque formation and cardiovascular disease. This framework has the power to link structural racism not only to cardiovascular disease, but also to cancer.

Social Determinants of Cardiovascular Disease

Social determinants of health (SDoH), which encompass the economic, social, environmental, and psychosocial factors that influence health, play a significant role in the development of cardiovascular disease (CVD) risk factors as well as CVD morbidity and mortality. The COVID-19 pandemic and the current social justice movement sparked by the death of George Floyd have laid bare long-existing health inequities in our society driven by SDoH. Despite a recent focus on these structural drivers of health disparities, the impact of SDoH on cardiovascular health and CVD outcomes remains understudied and incompletely understood. To further investigate the mechanisms connecting SDoH and CVD, and ultimately design targeted and effective interventions, it is important to foster interdisciplinary efforts that incorporate translational, epidemiological, and clinical research in examining SDoH-CVD relationships. This review aims to facilitate research coordination and intervention development by providing an evidence-based framework for SDoH rooted in the lived experiences of marginalized populations. Our framework highlights critical structural/socioeconomic, environmental, and psychosocial factors most strongly associated with CVD and explores several of the underlying biologic mechanisms connecting SDoH to CVD pathogenesis, including excess stress hormones, inflammation, immune cell function, and cellular aging. We present landmark studies and recent findings about SDoH in our framework, with careful consideration of the constructs and measures utilized. Finally, we provide a roadmap for future SDoH research focused on individual, clinical, and policy approaches directed towards developing multilevel community-engaged interventions to promote cardiovascular health.

Improving The Measurement Of Structural Racism To Achieve Antiracist Health Policy

Antiracist health policy research requires methodological innovation that creates equity-centered and antiracist solutions to health inequities by centering the complexities and insidiousness of structural racism. The development of effective health policy and health equity interventions requires sound empirical characterization of the nature of structural racism and its impact on public health. However, there is a disconnect between the conceptualization and measurement of structural racism in the public health literature. Given that structural racism is a system of interconnected institutions that operates with a set of racialized rules that maintain White supremacy, how can anyone accurately measure its insidiousness? This article highlights methodological approaches that will move the field forward in its ability to validly measure structural racism for the purposes of achieving health equity. We identify three key areas that require scholarly attention to advance antiracist health policy research: historical context, geographical context, and theory-based novel quantitative and qualitative methods that capture the multifaceted and systemic properties of structural racism as well as other systems of oppression.

Historical redlining and cardiovascular health: The Multi-Ethnic Study of Atherosclerosis

We investigated historical redlining, a government-sanctioned discriminatory policy, in relation to cardiovascular health (CVH) and whether associations were modified by present-day neighborhood physical and social environments. Data included 4,779 participants (mean age 62 y; SD = 10) from the baseline sample of the Multi-Ethnic Study of Atherosclerosis (MESA; 2000 to 2002). Ideal CVH was a summary measure of ideal levels of seven CVH risk factors based on established criteria (blood pressure, fasting glucose, cholesterol, body mass index, diet, physical activity, and smoking). We assigned MESA participants' neighborhoods to one of four grades (A: best, B: still desirable, C: declining, and D: hazardous) using the 1930s federal Home Owners' Loan Corporation (HOLC) maps, which guided decisions regarding mortgage financing. Two-level hierarchical linear and logistic models, with a random intercept to account for participants nested within neighborhoods (i.e., census tracts) were used to assess associations within racial/ethnic subgroups (non-Hispanic White, non-Hispanic Black, Hispanic, and non-Hispanic Chinese). We found that Black adults who lived in historically redlined areas had a 0.82 (95% CI -1.54, -0.10) lower CVH score compared to those residing in grade A (best) neighborhoods, in a given neighborhood and adjusting for confounders. We also found that as the current neighborhood social environment improved the association between HOLC score and ideal CVH weakened (P < 0.10). There were no associations between HOLC grade and CVH measures or effect modification by current neighborhood conditions for any other racial/ethnic group. Results suggest that historical redlining has an enduring impact on cardiovascular risk among Black adults in the United States.

Proving the proverbial gadfly: situating the historical and racial context of Southern medical works by Mary Louise Marshall

Health sciences librarianship has historically benefited from avoiding critical conversations around the role of race in the profession, reflected through a select few number of articles on the topic. The purpose of this study was to add to this body of literature and apply a critical librarianship framework on the early scholarly record of health sciences librarianship and the legacy of integration within the Medical Library Association (MLA). Three Southern medical works and the integration views of Mary Louise Marshall, the longest-serving president of MLA from 1941 to 1946, were thematically and textually analyzed to redress the profession's long-standing legacy with Whiteness and Black, Indigenous, and People of Color (BIPOC) representation. In reframing the historic past of MLA both through Marshall's works and her views, the goal is to acknowledge ways in which the profession has impeded progress and present steps to remedy appropriate outreach for the future.

Evolutionary perspectives on African North American genetic diversity: Origins and prospects for future investigations

African-descended peoples of the Americas represent an amalgamation of West, Central, and Southeast African regional and ethnic groups with modest gene flow from specific non-African populations. Despite 16+ generations of residence in the Americas, there is a deficit of evolutionary knowledge about these populations. Focusing on Legacy African American, the African North American descendants of survivors of the transatlantic trade in enslaved Africans, we report on emic evolutionary perspectives of their self-identity gleaned from our interviews of 600 individuals collected over 2 years. Gullah-Geechee peoples of Carolina Coastal regions are a model case study due to their historical antiquity, substantial African retentions, relative geospatial isolation, and proposed progenitor status to other Legacy African American microethnic groups. We identify salient research questions for future studies that will begin to bridge the evolutionary gaps in our knowledge of these diverse peoples and the historical evidence for specific evolutionary processes.

Race and other sociodemographic categories are differentially linked to multiple dimensions of interpersonal-level discrimination: Implications for intersectional, health research

Objectives

To examine whether intersections of race with other key sociodemographic categories contribute to variations in multiple dimensions of race- and non-race-related, interpersonal-level discrimination and burden in urban-dwelling African Americans and Whites.

Methods

Data from 2,958 participants aged 30–64 in the population-based Healthy Aging in Neighborhoods of Diversity across the Life Span (HANDLS) study were used to estimate up to four-way interactions of race, age, gender, and poverty status with reports of racial and everyday discrimination, discrimination across multiple social statuses, and related lifetime discrimination burden in multiple regression models.

Results

We observed that: 1) African Americans experienced all forms of discrimination more frequently than Whites, but this finding was qualified by interactions of race with age, gender, and/or poverty status; 2) older African Americans, particularly African American men, and African American men living in poverty reported the greatest lifetime discrimination burden; 3) older African Americans reported greater racial discrimination and greater frequency of multiple social status-based discrimination than younger African Americans; 4) African American men reported greater racial and everyday discrimination and a greater frequency of social status discrimination than African American women; and, 5) White women reported greater frequency of discrimination than White men. All p’s < .05.

Conclusions

Within African Americans, older, male individuals with lower SES experienced greater racial, lifetime, and multiple social status-based discrimination, but this pattern was not observed in Whites. Among Whites, women reported greater frequency of discrimination across multiple social statuses and other factors (i.e., gender, income, appearance, and health status) than men. Efforts to reduce discrimination-related health disparities should concurrently assess dimensions of interpersonal-level discrimination across multiple sociodemographic categories, while simultaneously considering the broader socioecological context shaping these factors.

Sociodemographic and Service Use Characteristics of Abortion Fund Cases from Six States in the U.S. Southeast

Abortion funds are key actors in mitigating barriers to abortion access, particularly in contexts where state-level abortion access restrictions are concentrated. Using 2017–2019 case management data from a regional abortion fund in the southeastern U.S., we described the sociodemographic and service use characteristics of cases overall (n = 9585) and stratified by state of residence (Alabama, Florida, Georgia, Mississippi, South Carolina, and Tennessee). Overall, cases represented people seeking abortion fund assistance who predominately identified as non-Hispanic Black (81%), 18–34 years of age (84%), publicly or uninsured (87%), having completed a high school degree or some college (70%), having one or more children (77%), and as Christian (58%). Most cases involved an in-state clinic (81%), clinic travel distance under 50 miles (63%), surgical abortion (66%), and pregnancy under 13 weeks’ gestation (73%), with variation across states. The median abortion fund contribution pledge was $75 (interquartile range (IQR): 60–100), supplementing median caller contributions of $200 (IQR: 40–300). These data provide a unique snapshot of a population navigating disproportionate, intersecting barriers to abortion access, and abortion fund capacity for social care and science. Findings can inform abortion fund development, data quality improvement efforts, as well as reproductive health, rights and justice advocacy, policy, and research.

Incorporating Measures of Structural Racism into Population Studies of Reproductive Health in the United States: A Narrative Review

Purpose: Black women in the United States face poor outcomes across reproductive health measures-from pregnancy outcomes to gynecologic cancers. Racial health inequities are attributable to systemic racism, but few population studies of reproductive health outcomes integrate upstream measures of systemic racism, and those who do are limited to maternal and infant health outcomes. Advances in understanding and intervening on the pathway from racism to reproductive health outcomes are limited by a paucity of methodological guidance toward this end. We aim to fill this gap by identifying quantitative measures of systemic racism that are salient across reproductive health outcomes. Methods: We conducted a review of literature from 2000 to 2019 to identify studies that use quantitative measures of exposure to systemic racism in population reproductive health studies. We analyzed the catalog of literature to identify cohesive domains and measures that integrate data across domains. For each domain, we contextualize its use within population health research, describe metrics currently in use, and present opportunities for their application to reproductive health research. Results: We identified four domains of systemic racism that may affect reproductive health outcomes: (1) civil rights laws and legal racial discrimination, (2) residential segregation and housing discrimination, (3) police violence, and (4) mass incarceration. Multiple quantitative measures are available for each domain. In addition, a multidimensional measure exists and additional domains of systemic racism are salient for future development into distinct measures. Conclusion: There are quantitative measures of systemic racism available for incorporation into population studies of reproductive health that investigate hypotheses, including and beyond those related to maternal and infant health. There are also promising areas for future measure development, such as the child welfare system and intersectionality. Incorporating such measures is critical for appropriate assessment of and intervention in racial inequities in reproductive health outcomes.

The multidimensional clustering of health and its ecological risk factors

A diverse set of research has examined the ways in which population-level health and its ecological risk factors are embedded within self-reinforcing structures. Syndemic theory, for example, focuses on the co-occurrence of multiple diseases, whereas the spatial diffusion literature highlights the concentration of poor health among communities sharing geographic boundaries. This study combines these related but disciplinarily-isolated perspectives to examine the clustering of population-level health and its determinants across four dimensions: co-occurrence, spatial, temporal, and social network. Using data on U.S. county-level health outcomes and health factors from the Robert Wood Johnson Foundation's County Health Rankings, this study estimates associations between health outcomes within communities and the co-occurrence of community-level factors theorized to influence ecological health. Not only do health outcomes and their ecological risk factors cluster within counties, but also between geographically adjacent counties and counties connected via migration network pathways. Moreover, the self-reinforcing structures uncovered across the co-occurrence, spatial and network dimensions persist over time, and this clustering has consequences on county health and well-being. Rather than adopting the perspective that either health and its community-level factors should be broadly targeted and detached from local context or communities are different, have unique needs and thus should be treated in isolation, the approach advanced in this study identifies shared vulnerabilities in a way that allows for the development of knowledge networks between communities dealing with similar issues.

Stress and Cardiometabolic Disease Risk for Indigenous Populations throughout the Lifespan

BACKGROUND

Indigenous people experience the greatest cardiometabolic disease disparity in the Unites States, yet high cardiometabolic disease risk factors do not fully explain the extent of the cardiometabolic disease disparity for Indigenous people. Stress, trauma, and racism occur at high rates within Indigenous communities and have not been well explored as significant contributors to cardiometabolic disease disparities despite emerging literature, and therefore will be described here.

METHODS

This descriptive study explores the relationship between cardiometabolic disease risks and Indigenous-specific stressors (e.g., early childhood stress and trauma, adulthood stress and trauma, and historical and intergenerational trauma) using current literature. Indigenous-specific protective factors against cardiometabolic disease are also reviewed.

RESULTS

Increasing research indicates that there is a relationship between Indigenous-specific stressful and traumatic life experiences and increased cardiometabolic disease risk. Mental health and psychophysiology play an important role in this relationship. Effective interventions to reduce cardiometabolic disease risk in Indigenous communities focus on ameliorating the negative effects of these stressors through the use of culturally specific health behaviors and activities.

CONCLUSIONS

There is increasing evidence that cultural connection and enculturation are protective factors for cardiometabolic disease, and may be galvanized through Indigenous-led training, research, and policy change.

Understanding stigma and food inequity: a conceptual framework to inform research, intervention, and policy

There is increasing understanding that stigma associated with poverty, race, nationality, gender, obesity, and other intersecting, socially devalued characteristics is a key social determinant of health that plays a role in food inequities; yet, the processes linking stigma with food inequities are poorly defined. Building on prior conceptual and empirical stigma research in public health, this paper introduces The Stigma and Food Inequity Framework. Supporting empirical evidence for the associations proposed by the framework is reviewed. The framework proposes that stigma is manifested at the structural (e.g., neighborhood infrastructure and targeted marketing) and individual (e.g., internalized stigma and stereotypes) levels. These stigma manifestations are associated with food inequities via a series of mediating mechanisms, including access to resources, the home food environment, and psychosocial and behavioral processes, which ultimately undermine healthy food consumption, contribute to food insecurity, and impact diet quality. The framework further proposes that processes linking stigma with food inequities are situated within contexts of history, culture, and human development. Future directions to address stigma and enhance food equity include the value of addressing the broad range of underlying structural stigma manifestations when creating policy to promote food equity.

Excess 30-Day Heart Failure Readmissions and Mortality in Black Patients Increases With Neighborhood Deprivation

BACKGROUND

Longstanding racial disparities in heart failure (HF) outcomes exist in the United States, in part, due to social determinants of health. We examined whether neighborhood environment modifies the disparity in 30-day HF readmissions and mortality between Black and White patients in the Southeastern United States.

METHODS

We created a geocoded retrospective cohort of patients hospitalized for acute HF within Emory Healthcare from 2010 to 2018. Quartiles of the Social Deprivation Index characterized neighborhood deprivation at the census tract level. We estimated the relative risk of 30-day readmission and 30-day mortality following an index hospitalization for acute HF. Excess readmissions and mortality were estimated as the absolute risk difference between Black and White patients within each Social Deprivation Index quartile, adjusted for geographic clustering, demographic, clinical, and hospital characteristics.

RESULTS

The cohort included 30 630 patients, mean age 66 years, 48% female, 53% Black. Compared with White patients, Black patients were more likely to reside in deprived census tracts and have higher comorbidity scores. From 2010 to 2018, 29.4% of Black and 23.0% of White patients experienced either a 30-day HF readmission or 30-day death (P<0.001). Excess in composite 30-day HF readmissions and mortality for Black patients ranged from 3.9% (95% CI, 1.5%-6.3%; P=0.0002) to 6.8% (95% CI, 4.1%-9.5%; P<0.0001) across Social Deprivation Index quartiles. Accounting for traditional risk factors did not eliminate the Black excess in combined 30-day HF readmissions or mortality in any of the neighborhood quartiles.

CONCLUSIONS

Excess 30-day HF readmissions and mortality are present among Black patients in every neighborhood strata and increase with progressive neighborhood socioeconomic deprivation.

Associations between historical redlining and birth outcomes from 2006 through 2015 in California

BACKGROUND

Despite being one of the wealthiest nations, disparities in adverse birth outcomes persist across racial and ethnic lines in the United States. We studied the association between historical redlining and preterm birth, low birth weight (LBW), small-for-gestational age (SGA), and perinatal mortality over a ten-year period (2006-2015) in Los Angeles, Oakland, and San Francisco, California.

METHODS

We used birth outcomes data from the California Office of Statewide Health Planning and Development between January 1, 2006 and December 31, 2015. Home Owners' Loan Corporation (HOLC) Security Maps developed in the 1930s assigned neighborhoods one of four grades that pertained to perceived investment risk of borrowers from that neighborhood: green (grade A) were considered "Best", blue (grade B) "Still Desirable", yellow (grade C) "Definitely Declining", and red (grade D, hence the term "redlining") "Hazardous". Geocoded residential addresses at the time of birth were superimposed on HOLC Security Maps to assign each birth a HOLC grade. We adjusted for potential confounders present at the time of Security Map creation by assigning HOLC polygons areal-weighted 1940s Census measures. We then employed propensity score matching methods to estimate the association of historical HOLC grades on current birth outcomes. Because tracts graded A had almost no propensity of receiving grade C or D and because grade B tracts had low propensity of receiving grade D, we examined birth outcomes in the three following comparisons: B vs. A, C vs. B, and D vs. C.

RESULTS

The prevalence of preterm birth, SGA and mortality tended to be higher in worse HOLC grades, while the prevalence of LBW varied across grades. Overall odds of mortality and preterm birth increased as HOLC grade worsened. Propensity score matching balanced 1940s census measures across contrasting groups. Logistic regression models revealed significantly elevated odds of preterm birth (odds ratio (OR): 1.02, 95% confidence interval (CI): 1.00-1.05), and SGA (OR: 1.03, 95% CI: 1.00-1.05) in the C vs. B comparison and significantly reduced odds of preterm birth (OR: 0.93, 95% CI: 0.91-0.95), LBW (OR: 0.94-95% CI: 0.92-0.97), and SGA (OR: 0.94, 95% CI: 0.92-0.96) in the D vs. C comparison. Results differed by metropolitan area and maternal race.

CONCLUSION

Similar to prior studies on redlining, we found that worsening HOLC grade was associated with adverse birth outcomes, although this relationship was less clear after propensity score matching and stratifying by metropolitan area. Higher odds of preterm birth and SGA in grade C versus grade B neighborhoods may be caused by higher-stress environments, racial segregation, and lack of access to resources, while lower odds of preterm birth, SGA, and LBW in grade D versus grade C neighborhoods may due to population shifts in those neighborhoods related to gentrification.

Associations between historical residential redlining and current age-adjusted rates of emergency department visits due to asthma across eight cities in California: an ecological study

BACKGROUND

Asthma disproportionately affects communities of colour in the USA, but the underlying factors for this remain poorly understood. In this study, we assess the role of historical redlining as outlined in security maps created by the Home Owners' Loan Corporation (HOLC), the discriminatory practice of categorising neighbourhoods on the basis of perceived mortgage investment risk, on the burden of asthma in these neighbourhoods.

METHODS

We did an ecological study of HOLC risk grades and asthma exacerbations in California using the security maps available for the following eight cities: Fresno, Los Angeles, Oakland, Sacramento, San Diego, San Jose, San Francisco, and Stockton. Each census tract was categorised into one of four risk levels (A, B, C, or D) on the basis of the location of population-weighted centroids on security maps, with the worst risk level (D) indicating historical redlining. We obtained census tract-level rates of emergency department visits due to asthma from CalEnviroScreen 3.0. We assessed the relationship between risk grade and log-transformed asthma visit rates between 2011 and 2013 using ordinary least squares regression. We included potential confounding variables from the 2010 Census and CalEnviroScreen 3.0: diesel exhaust particle emissions, PM_2·5, and percent of the population living below 2 times the federal poverty level. We also built random intercept and slope models to assess city-level variation in the relationship between redlining and asthma.

FINDINGS

In the 1431 census tracts assessed (64 [4·5%] grade A, 241 [16·8%] grade B, 719 [50·2%] grade C, and 407 [28·4%] grade D), the proportion of the population that was non-Hispanic black and Hispanic, the percentage of the population living in poverty, and diesel exhaust particle emissions all significantly increased as security map risk grade worsened (p<0·0001). The median age-adjusted rates of emergency department visits due to asthma were 2·4 times higher in census tracts that were previously redlined (median 63·5 [IQR 34·3] visits per 10 000 residents per year [2011-13]) than in tracts at the lowest risk level (26·5 [18·4]). In adjusted models, redlined census tracts were associated with a relative risk of 1·39 (95% CI 1·21-1·57) in rates of emergency department visits due to asthma compared with that of lowest-risk census tracts.

INTERPRETATION

Historically redlined census tracts have significantly higher rates of emergency department visits due to asthma, suggesting that this discriminatory practice might be contributing to racial and ethnic asthma health disparities.

FUNDING

National Heart Lung Blood Institute.

Interactive Relations Across Dimensions of Interpersonal-Level Discrimination and Depressive Symptoms to Carotid Intimal-Medial Thickening in African Americans

OBJECTIVE

This study aimed to examine within-race interactions of multiple dimensions of self-reported discrimination with depressive symptoms in relation to carotid intimal-medial thickness (IMT), a subclinical marker of atherosclerosis prospectively implicated in stroke incidence, in middle-aged to older African American and white adults.

METHODS

Participants were a socioeconomically diverse group of 1941 African Americans (56.5%) and whites from the Healthy Aging in Neighborhoods of Diversity across the Life Span study (30-64 years old, 47% men, 45.2% with household income <125% federal poverty threshold) who underwent carotid IMT measurement. Discrimination was assessed across four dimensions (everyday, frequency across various social statuses, racial, and lifetime burden). The Center for Epidemiologic Studies Depression scale was used to assess depressive symptoms.

RESULTS

In cross-sectional hierarchical regression analyses, two interactions were observed in African Americans: more frequent discrimination across various social statuses (b < 0.001, p = .006) and a higher lifetime discrimination burden (b < 0.001, p = .02) were each related to thicker carotid IMT in those with greater depressive symptoms. No significant findings were observed within whites.

CONCLUSIONS

Among African Americans, those reporting high levels of discrimination and depressive symptoms have increased carotid atherosclerosis and may be at greater risk for clinical end points compared with those reporting one or neither of these risk factors. Findings suggest that assessment of interactive relationships among social and psychological factors may elucidate novel pathways for cardiovascular disease, including stroke, among African Americans.

Accessing Pre-exposure Prophylaxis (PrEP): Perceptions of Current and Potential PrEP Users in Birmingham, Alabama

Limited studies to date assess barriers to and facilitators of PrEP uptake and utilization using a patient-centered access to care framework, among diverse socio-demographic groups, or in the U.S. Deep South, an area with disproportionate HIV burden. We examine perceptions of PrEP access in qualitative interviews with 44 current and potential PrEP users in Birmingham, Alabama. Participants were 32 years old on average, 66% Black, 66% gay or lesbian, 70% male, and 66% single. Perceived barriers to PrEP access included: lack of PrEP awareness and advertisement; sexuality-related stigma; time and resource constraints; and concerns about the adequacy and technical quality of PrEP services. Perceived facilitators to PrEP access were: PrEP-related information gathering and sharing; increased dialogue and visibility around PrEP; social, programmatic, and clinical support; and, lastly, self-preservation; personal motivation; and treatment self-efficacy. Results point to opportunities to address complex barriers to equitable PrEP access using multilevel and multimodal solutions.

Characteristics of and Trends in HIV Diagnoses in the Deep South Region of the United States, 2012-2017

HIV prevention goals in the United States include reducing new HIV infections among people in the South Census region (commonly referred as the South). Using data reported to the National HIV Surveillance System, we examined trends in HIV diagnoses in the South, including the Deep South and Other South, during 2012-2017. Although diagnosis rates declined in all regions during the time period, declines were greater in all other regions compared to the Deep South, with the exception of the West region. Moreover, the South continues to have a diagnosis rate 50% higher (65% higher in the Deep South) than that of any other region. Diagnoses in the Deep South increased among some groups, including men who have sex with men, persons aged 25-34 years and Hispanics/Latinos. These findings highlight the need to further strengthen interventions in the South, particularly among communities of color and young adults.

Ethical Challenges and Lessons Learned from Qualitative Research with Low-Income African American Women Living with HIV in the South

African American women living with HIV (WLWH) in the U.S. South encounter heightened marginalization due to the complex intersections of race, gender, poverty, and HIV status. Social vulnerabilities experienced by individuals and communities in daily life have the potential to sharpen ethical tensions in the context of research. Thus, conducting ethical research requires attention to the contextual challenges and concerns of diverse research populations to tailor participant protections to a particular sociocultural context. Using principles from the Belmont Report, the present report draws on data from a qualitative study with 42 African American WLWH in the South by highlighting the first author's accounts of ethical challenges that emerged during data collection. Findings suggest that engaging participants in their natural environments can inform the development of ethical research strategies germane to women's lived experiences. Study findings also contribute to empirical guidance for investigators engaging marginalized populations in scientific research.

Racial Inequalities in Oral Health

Together with other social categories, race has been at the core of much scholarly work in the area of humanities and social sciences, as well as a host of applied disciplines. In dentistry, debates have ranged from the use of race as a criterion for the recommendation of specific dental procedures to a means of assessing inequalities in a variety of outcomes. What is missing in these previous discussions, though, is a broader understanding of race that transcends relations with genetic makeup and other individual-level characteristics. In this review, we provide readers with a critique of the existing knowledge on race and oral health by answering the following 3 guiding questions: (1) What concepts and ideas are connected with race in the field of dentistry? (2) What can be learned and what is absent from the existing literature on the topic? (3) How can we enhance research and policy on racial inequalities in oral health? Taken together, the reviewed studies rely either on biological distinctions between racial categories or on other individual characteristics that may underlie racial disparities in oral health. Amidst a range of individual-level factors, racial inequalities have often been attributed to lower socioeconomic status and “health-damaging” cultural traits, for instance, patterns of and reasons for dental visits, dietary habits, and oral hygiene behaviors. While this literature has been useful in documenting large and persistent racial gaps in oral health, wider sociohistorical processes, such as systemic racism, as well as their relationships with economic exploitation, social stigmatization, and political marginalization, have yet to be operationalized among studies on the topic. A nascent body of research has recently begun to address some of these factors, but limited attention to structural theories of racism means that many more studies are needed to effectively mitigate racial health differentials.