Racism and health care: Experiences of Latinx immigrant women in NYC during COVID-19

Neighborhood deprivation and racial disparities in severe maternal morbidity before and during the COVID-19 pandemic

PURPOSE

To examine whether racial and ethnic disparities in severe maternal morbidity (SMM) increased across all neighborhoods or mainly in resource-deprived neighborhoods before and during the COVID-19 pandemic.

METHODS

This study used Michigan's statewide linked databases from birth records and Medicaid claims between 01/01/2017 and 10/31/2021 (N = 214,406). Neighborhood deprivation was measured with Area Deprivation Index and categorized into tertiles. Multilevel logistic regressions with an interrupted time series approach were used to compare racial and ethnic disparities in SMM pre-pandemic (January 2017-February 2020) and during the pandemic (March 2020-October 2021) in low, medium, and high deprivation neighborhoods.

RESULTS

The Black-White disparity in the most deprived neighborhoods widened during the pandemic (adjusted risk ratio, aRR [95 % CI]: 1.72 [1.54, 1.92]; excess cases [95 % CI]: 201.7 [159.0, 244.5]) compared to pre-pandemic (aRR [95 % CI]: 1.23 [1.12, 1.35]; excess cases [95 % CI]: 75.4 [41.2, 109.5], p < .001), but persisted (not widened) in the least and medium deprived neighborhoods.

CONCLUSIONS

Widening racial and ethnic disparities in SMM during the pandemic were only observed in the most deprived neighborhoods, rather than being universally prevalent across neighborhood contexts. Community-engaged solutions are needed to improve neighborhood conditions and reduce maternal health inequities during times of crisis.

Racial/Ethnic and Nativity Disparities in Gestational Diabetes Mellitus, United States 2018-2021

BACKGROUND

Gestational diabetes mellitus (GDM) is associated with adverse pregnancy and birth complications. Asian populations have the highest risk of GDM, with even greater risk among foreign-born (FB) residents. Socio-political factors, such as heightened anti-Asian racism and travel restrictions during COVID19 may have further increased their risk of GDM. Our study sought to examine the associations between race/ethnicity, nativity status, and GDM rate and changes during COVID19.

METHODS

We used the US National Center for Health Statistics natality administrative data (N = 14,219,719). We estimated GDM and birth rates by race/ethnicity (Asian non-Hispanic [NH], Native Hawaiian/Pacific Islander NH, American Indian and Alaska Native NH, Black NH, White NH, Multiracial NH, and Hispanic/Latina) and nativity status (US-born, Foreign-born). Race/ethnicity was evaluated as a social construct for racial discrimination and nativity was evaluated as a proxy for acculturation-related risk factors. We used multivariable robust Poisson regressions to estimate GDM rates per 100 live births for each racial/ethnic group pre-COVID19 (2018-2019) and during COVID19 (2021) by FB status, adjusting for socioeconomic and major pregnancy risk factors.

RESULTS

In adjusted models, both Asian NH and foreign-born persons had higher rates of GDM compared to White NH (rate ratio [RR]: 2.02, 95% confidence interval [CI]: 2.01, 2.04) and US-born (RR; 1.33, 95% CI: 1.32, 1.34) persons, respectively. Overall GDM rates increased significantly during COVID19 (RR: 1.18, 95% CI: 1.17, 1.18), with Asian US- and foreign-born persons experiencing the greatest absolute increase (US-born: +2.5, 95% CI: 2.4, 2.6; foreign-born: +3.6, 95% CI: 3.5, 3.6) compared to other racial/ethnic groups (US-born: range +1.3-1.7, foreign-born range: +0.5-2.9). Disaggregated by Asian ethnicity, Chinese and Vietnamese persons had the highest GDM rates overall and the greatest increase during COVID19.

CONCLUSION

We found significant disparities in GDM rates by race/ethnicity and nativity status between 2018 and 2021, with Asian and foreign-born persons having the highest rates of GDM. Investigation into potential socio-political and other contributing factors of reproductive health inequities during COVID19 may help explain these disparities.

"The panic stays in your mind…concentrating more on the worries than the relationship": Intimate partnerships during COVID-19 for immigrant women in New York City

Objective

This study examines perceptions of changes in intimate relationships among partnered, immigrant women in New York City during the first year of the COVID-19 pandemic. We pay close attention to how structural oppression, particularly related to undocumented immigration status, shaped women's experiences with their intimate partners during a period of social upheaval.

Background

COVID-19 has exacerbated many existing structural inequities and subsequent stressors that have been shown to have an adverse effect on intimate relationships, including increased economic instability and mental health distress. Immigrant women may be particularly vulnerable to relationship strain because of intersecting social and structural inequities.

Methods

We draw on in-depth, semi-structured interviews among a heterogenous sample of 22 women with varied legal status from Latin America, South and East Asia, and the Middle East.

Results

Findings reveal three primary pathways through which structural inequities shaped women's experiences with intimate partnership strain, including financial and material scarcity; uneven caregiving burdens; and constrained access to support in situations of violence and abuse.

Conclusion

Our analysis demonstrates ways that structural inequity, particularly driven by exclusionary immigration laws, influence intimate partner relationships through the legal status of immigrant women. Understanding how structural oppression shapes immigrant partnerships is essential for the field of family demography and for family-serving professionals in referring clients to resources and services, as well as helping women explore sources of resilience and coping within their families and communities.

Childcare as a social determinant of access to healthcare: a scoping review

Introduction

As health systems strive to screen for and address social determinants of health (SDOH), the role of access to childcare and barriers to healthcare posed by childcare needs remains underexplored. A gap exists in synthesizing existing evidence on the role of access to childcare as a SDOH.

Methods

This scoping review aimed to examine and analyze existing literature on the role of childcare needs as a social determinant of access to healthcare. We conducted a structured literature search across PubMed, Scopus, health policy fora, and professional healthcare societies to inclusively aggregate studies across interdisciplinary sources published between January 2000 and June 2023. Two independent reviewers reviewed results to determine inclusions and exclusions. Studies were coded into salient themes utilizing an iterative inductive approach.

Results

Among 535 search results, 526 met criteria for eligibility screening. Among 526 eligible studies, 91 studies met inclusion criteria for analysis. Five key themes were identified through data analysis: (1) barriers posed by childcare needs to healthcare appointments, (2) the opportunity for alternative care delivery models to overcome childcare barriers, (3) the effect of childcare needs on participation in medical research, (4) the impact of the COVID-19 pandemic on childcare needs, and (5) the disproportionate burden of childcare experienced by vulnerable populations.

Discussion

Childcare needs remain underexplored in existing research. Current evidence demonstrates the relevance of childcare needs as a barrier to healthcare access, however dedicated studies are lacking. Future research is needed to understand mechanisms of childcare barriers in access to healthcare and explore potential interventions.

Characteristics of foreign-born abortion patients in the United States, 2021-2022

OBJECTIVES

This study aimed to examine the characteristics of foreign-born abortion patients compared to those born in the Unites States and to explore whether barriers for foreign-born patients varied by state Medicaid coverage of abortion care.

STUDY DESIGN

We used data from the Guttmacher Institute's 2021-2022 Abortion Patient Survey, a national sample of patients obtaining clinic-based abortion care in the United States. We compared sociodemographic characteristics of foreign- and US born respondents, as well as barriers to care. Among foreign-born patients, we compared those in Medicaid coverage states vs states that restrict Medicaid coverage.

RESULTS

Some 12% of the 6429 respondents were born outside the United States. Compared to US born patients, they were less likely to have Medicaid coverage and more likely to be Asian/Native Hawaiian/Pacific Islander or Hispanic, to have no health insurance, and to have completed the survey in Spanish. In addition, foreign-born patients were more likely to report delays because they did not know where to get an abortion (18.3% vs. 12.6% for US born). Compared to foreign-born patients living in Medicaid coverage states, those in non-Medicaid states reported multiple barriers, particularly related to cost: respondents in non-Medicaid states were three times as likely to pay out of pocket for abortion (75.8% vs 27.4%) and five times more likely to rely on financial assistance (24.1% vs 4.8%).

CONCLUSIONS

Foreign-born abortion patients face knowledge and financial barriers to accessing abortion care compared to those who are US born, and these financial burdens are amplified for those living in non-Medicaid coverage states.

IMPLICATIONS

Abortion patients born outside the United States may have overcome many obstacles to obtain care. Expanding state Medicaid coverage of abortion could reduce cost burdens for foreign-born populations.

Engaging Immigrant Women in Online Journaling as a Mode of Research and Psychosocial Support: Lessons Learned

Online journaling is a methodological tool that has also been shown to have therapeutic benefits for some populations. However, the potential value - and limitations - of online journaling within immigrant communities remain underexplored. We present a proof-of-concept analysis exploring the efficacy and feasibility of engaging immigrant women in an online journaling project. We report on a study that used online journaling as an approach to explore the long-term social impact of the pandemic on South Asian and Latinx immigrant women in New York City. Findings suggest that this method may work particularly well with immigrant women because of the constraints they face in accessing support for mental health distress. The digital nature of online journaling may also promote the inclusion of immigrants in journaling-based studies because of its capacity to offer participants a greater range of options for how, when, and under what circumstances they choose to engage. We highlight study findings, reflect critically on our research process, and offer recommendations for the use of online journaling in future research and community programming. We argue for the role of community-based partnerships in ensuring rich participant engagement.

Community design of the Brooklyn Health Equity Index

Health equity drives quality care. Few reliable metrics that capture patients' perceptions of health equity exist. We report on the development of a patient-centered metric for health systems change in central Brooklyn, which stands out as an outlier in New York City with a disproportionate burden of poverty, disease, and death. A community-engaged, sequential, mixed-methods research design was used. Qualitative interviews were conducted with 80 community and health care stakeholders across central Brooklyn. Candidate items were derived from qualitative themes and examined for face, interpretive validity, and language. Interitem reliability and confirmatory factor analysis was assessed using data collected via text and automated discharge calls among 368 patients from a local hospital. Qualitative data analysis informed the content of 11 draft questions covering 3 broad domains: trust-building, provider appreciation of social determinants of health, and experiences of discrimination. Psychometric testing resulted in a Cronbach's alpha of 0.774 and led to deletion of 1 item, resulting in a 10-item Brooklyn Health Equity Index (BKHI). The 10-item BKHI is a novel, brief, and reliable measure that captures patients' perceptions of inequities and offers a real-time measure for health systems and payors to monitor progress toward advancing health equity.

Responding to structural inequities: Coping strategies among immigrant women during COVID-19

Examining coping strategies and resilience among immigrant communities reflects a commitment to working with immigrant communities to understand their needs while also identifying and building upon their strengths. In the United States, the physical, emotional, and economic impacts of the COVID-19 pandemic intersected with existing structural inequities to produce distinct challenges and stressors related to the pandemic, immigration, caregiving responsibilities, and structural xenophobia. Leveraging an understanding of the multilevel effects of stress, this qualitative study explores individual, interpersonal, and community-level coping strategies immigrant women used to respond to, alleviate, or reduce distress related to these compounding stressors. Using semi-structured in-depth interviews conducted in 2020 and 2021 with 44 first- and second-generation cisgender immigrant women from different national origins and 19 direct service providers serving immigrant communities in New York City, data were coded and analyzed using a constant comparative approach. Four central themes were identified: caregiving as a source of strength, leveraging resources, social connections, and community support. While women described a range of coping strategies they used to manage stressors and challenges, perspectives from direct service providers also connect these coping strategies to the harm-generating institutions, policies, and structures that produce and uphold structural oppression and inequities. Accounts from service providers point to the detrimental long-term effects of prolonged coping, underscoring a duality between resilience and vulnerability. Exploring the coping strategies cisgender immigrant women used to ease distress and promote resilience during a period of heightened structural vulnerability is critical to centering the experiences of immigrant women while simultaneously directing attention towards addressing the fundamental causes of cumulative disadvantage and the systems and structures through which it is transmitted.

Perspectives from the pandemic epicenter: Sexual and reproductive health of immigrant women in New York City

CONTEXT

The United States' response to COVID-19 created a policy, economic, and healthcare provision environment that had implications for the sexual and reproductive health (SRH) of racialized and minoritized communities. Perspectives from heterogenous immigrant communities in New York City, the pandemic epicenter in the United States (US), provides a glimpse into how restrictive social policy environments shape contraception, abortion, pregnancy preferences, and other aspects of SRH for marginalized immigrant communities.

METHODS

We conducted in-depth interviews in 2020 and 2021 with 44 cisgender immigrant women from different national origins and 19 direct service providers for immigrant communities in New York City to explore how immigrants were forced to adapt their SRH preferences and behaviors to the structural barriers of the COVID-19 pandemic. We coded and analyzed the interviews using a constant comparative approach.

RESULTS

Pandemic-related fears and structural barriers to healthcare access shaped shifts in contraceptive use and preferences among our participants. Immigrant women weighed their concerns for health and safety and the potential of facing discrimination as part of their contraceptive preferences. Immigrants also described shifts in their pregnancy preferences as rooted in concerns for their health and safety and economic constraints unique to immigrant communities.

CONCLUSION

Understanding how immigrant women's SRH shifted in response to the structural and policy constraints of the COVID-19 pandemic can reveal how historically marginalized communities will be impacted by an increasingly restrictive reproductive health and immigration policy landscape.

"I thought I was going to die there:" Socio-political contexts and the plight of undocumented Latinx in the COVID-19 pandemic

Since the beginning of the COVID-19 pandemic, certain U.S. population groups have suffered higher rates of infection and mortality than whites, including Latinx. Public health officials blamed these outcomes on overcrowded housing and work in essential industries prior to the vaccine's availability. We sought to illuminate the lived experience of these factors through a qualitative study of undocumented Latinx immigrant workers in the secondary economy (n ​= ​34). This study focuses on the intersectionality of social locations for undocumented Latinx immigrants living in a relatively affluent suburb and working in the construction and service sectors prior to the pandemic. Their narratives revealed how the pandemic created financial precarity through prolonged periods of unemployment and food insecurity. Workers described worry over unpaid bills, and potentially catastrophic episodes in which they treated severe COVID-19 with home remedies. Long spells of unemployment, food insecurity, inability to pay bills and lack of access to healthcare emerged because of socio-political contexts including the nature of low-wage labor and lack of a safety net.

Medical mistrust, discrimination, and COVID-19 vaccine behaviors among a national sample U.S. adults

Background

COVID-19 vaccine uptake has been suboptimal and disparities in uptake have exacerbated health inequities. It has been postulated that mistrust in the healthcare system and experiences of discrimination or unfair treatment in other settings may be barriers to uptake of the COVID-19 vaccine, although few studies to date have investigated medical mistrust and perceived discrimination together.

Method

We conducted a cross-sectional online survey between April 23-May 3, 2021, among a national sample of U.S. adults ages 18 years and older. We assessed receipt of and intention to be vaccinated for COVID-19 and associations with the validated Medical Mistrust Index and Everyday Discrimination Scale.

Results

1449 individuals responded, of whom 70.2% either had ≥1 dose of COVID-19 vaccine or reported that they were 'very' or 'somewhat' likely to be vaccinated in the future. In bivariate analyses, vaccination status was significantly associated with age, race/ethnicity, education, income, employment, marital status, health insurance, and political party affiliation. In multivariable analyses comparing those who had ≥1 vaccine dose or were likely to get vaccinated in the future with those who had not had any vaccine doses or did not intend to be vaccinated, each additional point in the Medical Mistrust Index was independently associated with a 16% decrease in the odds of vaccination (adjusted odds ratio = 0.84; 95% confidence interval = 0.81, 0.86). Discriminatory experiences were not associated with vaccination behavior or intention in bivariate or multivariable analyses.

Conclusions

Medical mistrust is significantly associated with vaccination status and intentions. Increasing uptake of COVID-19 vaccines will likely require substantive efforts on the part of public health and healthcare officials to build trust with those who are not yet fully vaccinated. We recommend that these efforts focus on building the 'trustworthiness' of these entities, an approach that will require a paradigm shift away from a focus on correcting individual beliefs and knowledge, to acknowledging and addressing the root causes underlying mistrust.