How Structural Racism Works - Racist Policies as a Root Cause of U.S. Racial Health Inequities

High impact of quadrivalent human papillomavirus vaccine across racial/ethnic groups: National Health and Nutrition Examination Survey, 2003-2006 and 2015-2018

Human papillomavirus (HPV) causes cervical as well as other cancers. Racial and ethnic disparities in cervical cancer incidence and mortality in the United States are well documented. HPV vaccination has been recommended in the United States since 2006 and is expected to prevent HPV-attributable cancers in all racial/ethnic groups. Quadrivalent HPV vaccine-type (HPV6/11/16/18) and nonvaccine-type cervicovaginal HPV prevalences were estimated from National Health and Nutrition Examination Surveys in 2015-2018 (vaccine era) and 2003-2006 (prevaccine era) data. Prevalence ratios comparing 2015-2018 to 2003-2006 were calculated among sexually experienced Non-Hispanic White (NHW), Non-Hispanic Black (NHB), and Mexican American (MA) females aged 14-24 years. Quadrivalent HPV vaccine-type prevalence declined 82% (CI: 60%-92%) among NHW, 86% (CI: 64%-95%) among NHB, and 100% among MA females, forecasting future reductions in cervical cancer across racial/ethnic groups.

Apolipoprotein E and Alzheimer's disease pathology in African American older adults

The apolipoprotein-E4 (APOE*4) and apolipoprotein-E2 (APOE*2) alleles are more common in African American versus non-Hispanic white populations, but relationships of both alleles with Alzheimer's disease (AD) pathology among African American individuals are unclear. We measured APOE allele and β-amyloid (Aβ) and tau using blood samples and positron emission tomography (PET) images, respectively. Individual regression models tested associations of each APOE allele with Aβ or tau PET overall, stratified by racialized group, and with a racialized group interaction. We included 358 older adults (42% African American) with Aβ PET, 134 (29% African American) of whom had tau PET. APOE*4 was associated with higher Aβ in non-Hispanic white (P < 0.0001), but not African American (P = 0.64) participants; racialized group modified the association between APOE*4 and Aβ (P < 0.0001). There were no other racialized group differences. These results suggest that the association of APOE*4 and Aβ differs between African American and non-Hispanic white populations. Other drivers of AD pathology in African American populations should be identified as potential therapeutic targets.

Racialized economic segregation and inequities in treatment initiation and survival among patients with metastatic breast cancer

PURPOSE

Racialized economic segregation, a form of structural racism, may drive persistent inequities among patients with breast cancer. We examined whether a composite area-level index of racialized economic segregation was associated with real-world treatment and survival in metastatic breast cancer (mBC).

METHODS

We conducted a retrospective cohort study among adult women with mBC using a US nationwide electronic health record-derived de-identified database (2011-2022). Population-weighted quintiles of the index of concentration at the extremes were estimated using census tract data. To identify inequities in time to treatment initiation (TTI) and overall survival (OS), we employed Kaplan-Meier methods and estimated hazard ratios (HR) adjusted for clinical factors.

RESULTS

The cohort included 27,459 patients. Compared with patients from the most privileged areas, those from the least privileged areas were disproportionately Black (36.9% vs. 2.6%) or Latinx (13.2% vs. 2.6%) and increasingly diagnosed with de novo mBC (33.6% vs. 28.9%). Those from the least privileged areas had longer median TTI than those from the most privileged areas (38 vs 31 days) and shorter median OS (29.7 vs 39.2 months). Multivariable-adjusted HR indicated less timely treatment initiation (HR 0.87, 95% CI 0.83, 0.91, p < 0.01) and worse OS (HR 1.19, 95% CI 1.13, 1.25, p < 0.01) among those from the least privileged areas compared to the most privileged areas.

CONCLUSION

Racialized economic segregation is a social determinant of health associated with treatment and survival inequities in mBC. Public investments directly addressing racialized economic segregation and other forms of structural racism are needed to reduce inequities in cancer care and outcomes.

Association of Medicaid Expansion with Reduction in Racial Disparities in the Timely Delivery of Upfront Surgical Care for Patients With Early-Stage Breast Cancer

OBJECTIVE

We evaluated the association between Medicaid expansion and time to surgery among patients with early-stage breast cancer (BC).

BACKGROUND

Delays in surgery are associated with adverse outcomes. It is known that underrepresented minorities are more likely to experience treatment delays. Understanding the impact of Medicaid expansion on reducing racial and ethnic disparities in health care delivery is critical.

METHODS

This was a population-based study including women ages 40 to 64 with stage I-II BC who underwent upfront surgery identified in the National Cancer Database (2010-2017) residing in states that expanded Medicaid on January 1, 2014. Difference-in-difference analysis compared rates of delayed surgery (>90 d from pathological diagnosis) according to time period (preexpansion [2010-2013] and postexpansion [2014-2017]) and race/ethnicity (White vs. racial and ethnic minority), stratified by insurance type (private vs. Medicaid/uninsured). Secondary analyses included logistic and Cox proportional hazards (PH) regression. All analyses were conducted among a cohort of patients in the nonexpansion states as a falsification analysis. Finally, a triple-differences approach compared preexpansion with the postexpansion trend between expansion and nonexpansion states.

RESULTS

Among Medicaid expansion states, 104,569 patients were included (50,048 preexpansion and 54,521 postexpansion). In the Medicaid/uninsured subgroup, Medicaid expansion was associated with a -1.8% point (95% CI: -3.5% to -0.1, P =0.04) reduction of racial disparity in delayed surgery. Cox regression models demonstrated similar findings (adjusted difference-in-difference hazard ratio 1.12 [95% CI: 1.05 to 1.21]). The falsification analysis showed a significant racial disparity reduction among expansion states but not among nonexpansion states, resulting in a triple-difference estimate of -2.5% points (95% CI: -4.9% to -0.1%, P =0.04) in this subgroup.

CONCLUSIONS

As continued efforts are being made to increase access to health care, our study demonstrates a positive association between Medicaid expansion and a reduction in the delivery of upfront surgical care, reducing racial disparities among patients with early-stage BC.

Leveraging Science to Advance Health Equity: Preliminary Considerations for Implementing Health Equity Science at State and Local Health Departments

CONTEXT

In 2021, the Centers for Disease Control and Prevention (CDC) launched CORE, an agency-wide strategy to embed health equity as a foundational component across all areas of the agency's work. The CDC established a definition of health equity science (HES) and principles to guide the development, implementation, dissemination, and use of the HES framework to move beyond documenting inequities to investigating root causes and promoting actionable approaches to eliminate health inequities. The HES framework may be used by state and local health departments to advance health equity efforts in their jurisdictions.

OBJECTIVE

Identify implementation considerations and opportunities for providing technical assistance and support to state and local public health departments in advancing HES.

DESIGN

A series of implementation consultations and multi-jurisdictional facilitated discussions were held with state and local health departments and community partners in 5 states to gather feedback on the current efforts, opportunities, and support needs to advance HES at the state and local levels. The information shared during these activities was analyzed using inductive and deductive methods, validated with partners, and summarized into themes and HES implementation considerations.

RESULTS

Five themes emerged regarding current efforts, opportunities, and support needed to implement HES at state and local health departments. These themes included the following criteria: (1) enhancing the existing health equity evidence base; (2) addressing interdisciplinary public health practice and data needs; (3) recognizing the value of qualitative data; (4) evaluating health equity programs and policies; and (5) including impacted communities in the full life cycle of health equity efforts. Within these themes, we identified HES implementation considerations, which may be leveraged to inform future efforts to advance HES at the state and local levels.

CONCLUSION

Health equity efforts at state and local health departments may be strengthened by leveraging the HES framework and implementation considerations.

Adverse Childhood Experiences and Trajectories of Firearm Exposure in Childhood

OBJECTIVE

To examine the longitudinal relationship between exposure to adverse childhood experiences (ACEs) in early life and trajectories of firearm exposure from early to middle childhood (ages 5-9 years old).

STUDY DESIGN

Data from the Longitudinal Studies of Child Abuse and Neglect (LOGSCAN) study were used. The LONGSCAN study was a prospective study in the United States and contained data from 1354 children from age 4 to age 18 years old. Exposure to ACEs was measured through the wave 1 interview (age 5 years old) and trajectories of firearm exposure were created using data from waves 1 (age 5 years old) and two (age 9 years old).

RESULTS

Two trajectories of firearm exposure in childhood were identified: a low exposure group and a group with persistently-high firearm exposure from ages 5 to 9 years old. ACEs were associated with membership in the high exposure group and children with four or more ACEs had over twice the odds of membership in the high exposure group compared with children with zero ACEs.

CONCLUSION

ACEs exposure in early childhood is associated with persistently-high exposure to firearms from early to middle childhood. This finding highlights the need for pediatricians to consider screening for both ACEs and firearm exposure in routine examinations, as well as the need for future research to identify and evaluate interventions intended to address exposure to adversity and firearms.

Contraceptive Use Among Women Experiencing Intimate Partner Violence and Reproductive Coercion: The Moderating Role of PTSD and Depression

Women experiencing reproductive coercion (RC) report more unintended pregnancies and mental health symptoms that can influence contraceptive use patterns. We examined associations between RC and contraceptive use among intimate partner violence (IPV) exposed women aged 18-35 (N = 283). We tested depression, post-traumatic stress disorder (PTSD), and co-morbid depression and PTSD as effect modifiers. Though no association was found between RC and contraception, PTSD significantly modified this relationship. Among Black women (n = 112), those reporting RC and either PTSD or comorbid PTSD and depression were less likely to use partner-independent contraception compared to those reporting RC without mental health symptoms. PTSD could be a barrier to contraceptive choice among this population.

Healthcare Disparities in Cardiovascular Medicine

There are significant healthcare disparities in cardiovascular medicine that represent a challenge for cardiologists and healthcare policy-makers who wish to provide equitable care. Disparities exist in both the management and outcomes of hypertension, coronary artery disease and its sequelae, and heart failure. These disparities are present along the lines of race, gender, and socioeconomic status. Despite recent efforts to reduce disparity, there are knowledge and research gaps among cardiologists with regards to both the scope of the problem and how to solve it. Solutions include increasing awareness of disparities in cardiovascular health, increasing research for optimal treatment of underserved communities, and public policy changes that reduce disparities in social determinants of health.

Social Determinants and Consequences of Pain: Towards Multilevel, Intersectional, and Life Course Perspectives

Despite wide endorsement of a biopsychosocial framework for pain, social aspects of pain remain rarely addressed in the context of pain prevention and management. In this review, we aim to: 1) examine the broad scope of social determinants and consequences of pain and their interactions across multiple levels of organization, and 2) provide a framework synthesizing existing concepts and potential areas for future work on social aspects of pain, drawing upon socioecological, intersectional, and life course approaches. Integrating interdisciplinary theory and evidence, we outline pathways through which multilevel social factors and pain may affect each other over time. We also provide a brief summary of intrapersonal aspects of pain which are thought to operate at the interface between individuals and the social context. Progressing from micro- to macro-level factors, we illustrate how social determinants of pain can directly or indirectly contribute to pain experiences, expression, risk, prognosis, and impact across populations. We consider: a) at the interpersonal level, the roles of social comparison, social relatedness, social support, social exclusion, empathy and interpersonal conflict; b) at the group or community level, the roles of intimacy groups, task groups, social categories, and loose associations; and c) at the societal level, the roles of political, economic, and cultural systems, as well as their policies and practices. We present examples of multilevel consequences of pain across these levels and discuss opportunities to reduce the burden and inequities of pain by expanding multilevel social approaches in pain research and practice. PERSPECTIVE: Despite wide endorsement of a biopsychosocial framework for pain, social aspects of pain are often unclearly defined, hindering their use in pain prevention, management, and research. We summarize the scope of social aspects of pain and provide a framework synthesizing existing concepts and potential areas for future work.

Racial and geographic disparities in neonatal brain care

In this review, we explore race-based disparities in neonatology and their impact on brain injury and neurodevelopmental outcomes. We discuss the historical context of healthcare discrimination, focusing on the post-Civil War era and the segregation of healthcare facilities. We highlight the increasing disparity in infant mortality rates between Black and White infants, with premature birth being a major contributing factor, and emphasize the role of prenatal factors such as metabolic syndrome and toxic stress in affecting neonatal health. Furthermore, we examine the geographic and historical aspects of racial disparities, including the consequences of redlining and limited access to healthcare facilities or nutritious food options in Black communities. Finally, we delve into the higher incidence of brain injuries in Black neonates, as well as disparities in adverse neurodevelopmental outcome. This evidence underscores the need for comprehensive efforts to address systemic racism and provide equitable access to healthcare resources.

"We don't really address the trauma": Patients' Perspectives on Postpartum Care Needs after Severe Maternal Morbidities

OBJECTIVES

This qualitative study explored experiences of 15 women in New York City who suffered physical, emotional, and socioeconomic consequences of severe maternal morbidity (SMM). This study aimed to increase our understanding of additional burdens these mothers faced during the postpartum period.

METHODS

Qualitative analysis of in-depth interviews (n = 15) with women who had given birth in NYC hospitals and experienced SMM. We focused on how experiences of SMM impacted postpartum recoveries. Grounded theory methodology informed analysis of participants' one-on-one interviews. To understand the comprehensive experience of postpartum recovery after SMM, we drew on theories about social stigma, reproductive equity, and quality of care to shape constant-comparative analysis and data interpretation.

FINDINGS

Three themes were generated from data analysis: 'Caring for my body' defined by challenges during physical recuperation, 'caring for my emotions' which highlighted navigation of mental health recovery, and 'caring for others' defined by care work of infants and other children. Most participants identified as Black, Latinx and/or people of color, and reported the immense impacts of SMM across aspects of their lives while receiving limited access to resources and insufficient support from family and/or healthcare providers in addressing postpartum challenges.

CONCLUSIONS FOR PRACTICE

Findings confirm the importance of developing a comprehensive trauma-informed approaches to postpartum care as a means of addressing SMM consequences.

Historical Structural Racism in the Built Environment and Physical Health among Residents of Allegheny County, Pennsylvania

Historical structural racism in the built environment contributes to health inequities, yet to date, research has almost exclusively focused on racist policy of redlining. We expand upon this conceptualization of historical structural racism by examining the potential associations of probable blockbusting, urban renewal, and proximity to displacement from freeway construction, along with redlining, to multiple contemporary health measures. Analyses linked historical structural racism, measured continuously at the census-tract level using archival data sources, to present-day residents' physical health measures drawn from publicly accessible records for Allegheny County, Pennsylvania. Outcome measures included average life expectancy and the percentage of residents reporting hypertension, stroke, coronary heart disease, smoking, insufficient sleep, sedentary behavior, and no health insurance coverage. Multiple regression analyses were conducted to examine separate and additive associations between structural racism and physical health measures. Redlining, probable blockbusting, and urban renewal were associated with shorter life expectancy and a higher prevalence of cardiovascular conditions, risky health behaviors, and residents lacking health insurance coverage. Probable blockbusting and urban renewal had the most consistent correlations with all 8 health measures, while freeway displacement was not reliably associated with health. Additive models explained a greater proportion of variance in health than any individual structural racism measure alone. Moreover, probable blockbusting and urban renewal accounted for relatively more variance in health compared to redlining, suggesting that research should consider these other measures in addition to redlining. These preliminary correlational findings underscore the importance of considering multiple aspects of historical structural racism in relation to current health inequities and serve as a starting point for additional research.

Enhancing Clinical Decision Support in Nephrology: Addressing Algorithmic Bias Through Artificial Intelligence Governance

There has been a steady rise in the use of clinical decision support (CDS) tools to guide Nephrology, as well as general clinical care. Through guidance set by federal agencies and concerns raised by clinical investigators, there has been an equal rise in understanding whether such tools exhibit algorithmic bias leading to unfairness. This has spurred the more fundamental question of whether sensitive variables such as race should be included in CDS tools. In order to properly answer this question, it is necessary to understand how algorithmic bias arises. We break down three sources of bias encountered when using electronic health record data to develop CDS tools: (1) use of proxy variables, (2) observability concerns and (3) underlying heterogeneity. We discuss how answering the question of whether to include sensitive variables like race often hinges more on qualitative considerations than on quantitative analysis, dependent on the function that the sensitive variable serves. Based on our experience with our own institution's CDS governance group, we show how health system-based governance committees play a central role in guiding these difficult and important considerations. Ultimately, our goal is to foster a community practice of model development and governance teams that emphasizes consciousness about sensitive variables and prioritizes equity.

Development of Neighborhood Trajectories Employing Historic Redlining and the Area Deprivation Index

The role of historic residential redlining on health inequities is intertwined with policy changes made before and after the 1930s that influence current neighborhood characteristics and shape ongoing structural racism in the United States (U.S.). We developed Neighborhood Trajectories which combine historic redlining data and the current neighborhood socioeconomic characteristics as a novel approach to studying structural racism. Home Owners' Loan Corporation (HOLC) neighborhoods for the entire U.S. were used to map the HOLC grades to the 2020 U.S. Census block group polygons based on the percentage of HOLC areas in each block group. Each block group was also assigned an Area Deprivation Index (ADI) from the Neighborhood Atlas®. To evaluate changes in neighborhoods from historic HOLC grades to present degree of deprivation, we aggregated block groups into "Neighborhood Trajectories" using historic HOLC grades and current ADI. The Neighborhood Trajectories are "Advantage Stable"; "Advantage Reduced"; "Disadvantage Reduced"; and "Disadvantage Stable." Neighborhood Trajectories were established for 13.3% (32,152) of the block groups in the U.S., encompassing 38,005,799 people. Overall, the Disadvantage-Reduced trajectory had the largest population (16,307,217 people). However, the largest percentage of non-Hispanic/Latino Black residents (34%) fell in the Advantage-Reduced trajectory, while the largest percentage of Non-Hispanic/Latino White residents (60%) fell in the Advantage-Stable trajectory. The development of the Neighborhood Trajectories affords a more nuanced mechanism to investigate dynamic processes from historic policy, socioeconomic development, and ongoing marginalization. This adaptable methodology may enable investigation of ongoing sociopolitical processes including gentrification of neighborhoods (Disadvantage-Reduced trajectory) and "White flight" (Advantage Reduced trajectory).

Did the Affordable Care Act Promote Racial Equity in Pregnancy-Related Health? A Scoping Review

In the United States, there are profound and persistent racial and ethnic disparities in pregnancy-related health, emphasizing the need to promote racial health equity through public policy. There is evidence that the Affordable Care Act (ACA) increased health insurance coverage, access to health care, and health care utilization, and may have affected some pregnancy-related health outcomes (eg, preterm delivery). It is unclear, however, whether these impacts on pregnancy-related outcomes were equitably distributed across race and ethnicity. Thus, the objective of this study was to fill that gap by summarizing the peer-reviewed evidence regarding the impact of the ACA on racial and ethnic disparities in pregnancy-related health outcomes. The authors conducted a scoping review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR), using broad search terms to identify relevant peer-reviewed literature in PubMed, Web of Science, and EconLit. The authors identified and reviewed n = 21 studies and found that the current literature suggests that the ACA and its components were differentially associated with contraception-related and fertility-related outcomes by race/ethnicity. Literature regarding pregnancy health, birth outcomes, and postpartum health, however, was sparse and mixed, making it difficult to draw conclusions regarding the impact on racial/ethnic disparities in these outcomes. To inform future health policy that reduces racial disparities, additional work is needed to clarify the impacts of contemporary health policy, like the ACA, on racial disparities in pregnancy health, birth outcomes, and postpartum health.

Impact of the COVID-19 Pandemic on Blood Lead Testing in Children in the United States

The study objective was to evaluate the impact of the coronavirus disease (COVID-19) pandemic on pediatric blood lead testing in the United States. Clinical laboratory pediatric (ages <6 years) blood lead level (BLL) tests performed by Quest Diagnostics, January 2019-March 2022, were analyzed. Patients were categorized by age, by sex, and, through matching by ZIP code with US Census data, for race, ethnicity, pre-1950 housing, and poverty estimates. Over 2.8 million results from children (<6 years old) from all 50 states and the District of Columbia were included. Compared to March-May 2019, BLL testing was lower by 53.6% in March-May 2020 and lower by 14.6% in March-May 2021. Testing rebounded more for children in predominantly White non-Hispanic communities and among children living in communities, based on ZIP codes, with the least pre-1950 housing stock and lowest poverty rates. The proportion of children with BLL at or above the United States Centers for Disease Control and Prevention reference values of 3.5 and 5.0 µg/dL fell by 19% and 24%, respectively, in 2021 versus 2019. In conclusion, pediatric BLL testing has rebounded from sharp declines during the early pandemic period but unevenly. Declines in the proportion of children with elevated BLL should be interpreted with caution, as testing rebounds were less robust among communities with the highest risk of lead poisoning, notably communities with the oldest housing stock and higher poverty rates. More public health efforts are needed to address lead toxicity throughout the United States, especially in communities that did not experience a full rebound subsequent to the early COVID-19 pandemic period.

Black-White Disparities in Asthma Hospitalizations and ED Visits Among Medicaid-Enrolled Children

BACKGROUND AND OBJECTIVES

Asthma is a common, potentially serious childhood chronic condition that disproportionately afflicts Black children. Hospitalizations and emergency department (ED) visits for asthma can often be prevented. Nearly half of children with asthma are covered by Medicaid, which should facilitate access to care to manage and treat symptoms. We provide new evidence on racial disparities in asthma hospitalizations and ED visits among Medicaid-enrolled children.

METHODS

We used comprehensive Medicaid claims data from the Transformed Medicaid Statistical Information System. Our study population included 279 985 Medicaid-enrolled children with diagnosed asthma. We identified asthma hospitalizations and ED visits occurring in 2019. We estimated differences in the odds of asthma hospitalizations and ED visits for non-Hispanic Black versus non-Hispanic white children, adjusting for sex, age, Medicaid eligibility group, Medicaid plan type, state, and rurality.

RESULTS

In 2019, among Black children with asthma, 1.2% had an asthma hospitalization and 8.0% had an asthma ED visit compared with 0.5% and 3.4% of white children with a hospitalization and ED visit, respectively. After adjusting for other characteristics, the rates for Black children were more than twice the rates for white children (hospitalization adjusted odds ratio 2.45, 95% confidence interval 2.23-2.69; ED adjusted odds ratio 2.42; 95% confidence interval 2.33-2.51).

CONCLUSIONS

There are stark racial disparities in asthma hospitalizations and ED visits among Medicaid-enrolled children with asthma. To diminish these disparities, it will be important to implement solutions that address poor quality care, discriminatory treatment in health care settings, and the structural factors that disproportionately expose Black children to asthma triggers and access barriers.

Geographic Variation in Racial Disparities in Receipt of High-Dose Influenza Vaccine Among US Older Adults

BACKGROUND

Racial disparities in receipt of high-dose influenza vaccine (HDV) have been documented nationally, but whether small-area geographic variation in such disparities exists remains unknown. We assessed the distribution of disparities in HDV receipt between Black and White traditional Medicare beneficiaries vaccinated against influenza within states and hospital referral regions (HRRs).

METHODS

We conducted a nationally representative retrospective cohort study of 11,768,724 community-dwelling traditional Medicare beneficiaries vaccinated against influenza during the 2015-2016 influenza season (94.3% White and 5.7% Black). Our comparison was marginalized versus privileged racial group measured as Black versus White race. Vaccination and type of vaccine were obtained from Medicare Carrier and Outpatient files. Differences in the proportions of individuals who received HDV between Black and White beneficiaries within states and HRRs were used to measure age- and sex-standardized disparities in HDV receipt. We restricted to states and HRRs with ≥ 100 beneficiaries per age-sex strata per racial group.

RESULTS

We detected a national disparity in HDV receipt of 12.8 percentage points (pps). At the state level, the median standardized HDV receipt disparity was 10.7 pps (minimum, maximum: 2.9, 25.6; n = 30 states). The median standardized HDV receipt disparity among HRRs was 11.6 pps (minimum, maximum: 0.4, 24.7; n = 54 HRRs).

CONCLUSION

Black beneficiaries were less likely to receive HDV compared to White beneficiaries in almost every state and HRR in our analysis. The magnitudes of disparities varied substantially across states and HRRs. Local interventions and policies are needed to target geographic areas with the largest disparities to address these inequities.

Forty years of struggle in North Carolina: Workplace segregation and fatal occupational injury rates

OBJECTIVE

To assess workplace segregation in fatal occupational injury from 1992 to 2017 in North Carolina.

METHODS

We calculated occupational fatal injury rates within categories of occupation, industry, race, age, and sex; and estimated expected numbers of fatalities among Black and Hispanic male workers had they experienced the rates of White male workers. We also estimated the contribution of workforce segregation to disparities by estimating the expected number of fatalities among Black and Hispanic male workers had they experienced the industry and occupation patterns of White male workers. We assessed person-years of life-lost, using North Carolina life expectancy estimates.

RESULTS

Hispanic workers contributed 32% of their worker-years and experienced 58% of their fatalities in construction. Black workers were most overrepresented in the food manufacturing industry. Hispanic males experienced 2.11 (95% CI: 1.86-2.40) times the mortality rate of White males. The Black-White and Hispanic-White disparities were widest among workers aged 45 and older, and segregation into more dangerous industries and occupations played a substantial role in driving disparities. Hispanic workers who suffered occupational fatalities lost a median 47 life-years, compared to 37 among Black workers and 36 among White workers.

CONCLUSIONS

If Hispanic and Black workers experienced the workplace safety of their White counterparts, fatal injury rates would be substantially reduced. Workforce segregation reflects structural racism, which also contributes to mortality disparities. Root causes must be addressed to eliminate disparities.

Choosing to End African American Health Disparities in Patients With Systemic Lupus Erythematosus

Systemic lupus erythematosus (SLE) is three times more common and its manifestations are more severe in African American women compared to women of other races. It is not clear whether this is due to genetic differences or factors related to the physical or social environments, differences in health care, or a combination of these factors. Health disparities in patients with SLE between African American patients and persons of other races have been reported since the 1960s and are correlated with measures of lower socioeconomic status. Risk factors for these disparities have been demonstrated, but whether their mitigation improves outcomes for African American patients has not been tested except in self-efficacy. In 2002, the first true US population-based study of patients with SLE with death certificate records was conducted, which demonstrated a wide disparity between the number of African American women and White women dying from SLE. Five years ago, another study showed that SLE mortality rates in the United States had improved but that the African American patient mortality disparity persisted. Between 2014 and 2021, one study demonstrated racism's deleterious effects in patients with SLE. Racism may have been the unmeasured confounder, the proverbial "elephant in the room"-unnamed and unstudied. The etymology of "risk factor" has evolved from environmental risk factors to social determinants to now include structural injustice/structural racism. Racism in the United States has a centuries-long existence and is deeply ingrained in US society, making its detection and resolution difficult. However, racism being man made means Man can choose to change the it. Health disparities in patients with SLE should be addressed by viewing health care as a basic human right. We offer a conceptual framework and goals for both individual and national actions.

Cohort Study of Downgraded Misdemeanor Convictions and Subsequent Violent Crime: Differences by Defendant Race and Ethnicity

Introduction

Criminal convictions may be imperfect markers of criminalized behavior, in part because of criminal legal system processes (e.g., plea bargaining). In this retrospective cohort study of individuals convicted of misdemeanors, authors compared the risk of subsequent criminal charges for a violent crime among those initially charged with a felony with that among those initially charged with only misdemeanors, overall and by defendant race and ethnicity.

Methods

The study population included individuals aged ≥18 years who were convicted of a misdemeanor in Washington Superior Courts from January 1, 2015 to December 31, 2019. Those with and without initial felony charges were age/gender matched in a 4:1 ratio. The primary outcome was the first subsequent violent crime charge in Washington Superior Courts through December 31, 2020. Data were analyzed with Fine-Gray hazard models from June 2022 to November 2023.

Results

There were 3,841 individuals with initial felony charges and 956 with initial misdemeanor charges only. Median follow-up was 2.4 years for both groups. During follow-up, there were 166 new violent crime charges. In multivariable models, White defendants with initial felony charges had a greater risk of subsequent violent crime charges (subdistribution hazard ratio=2.58; 95% CI=1.24, 5.36) than White defendants with initial misdemeanor charges only. Among Black and Hispanic/Latinx defendants, initial felony versus misdemeanor charges were not associated with subsequent violent crime charges (subdistribution hazard ratio=0.93; 95% CI=0.44, 1.97 among Black defendants; subdistribution hazard ratio=0.49; 95% CI=0.15, 1.57 among Hispanic/Latinx defendants).

Conclusions

Findings suggest differential associations between downgrading of felony charges to misdemeanor convictions and future violent crime charges by defendant race and ethnicity, with implications for inequitable collateral consequences of criminal convictions.

Disparities by Social Determinants of Health: Links Between Long COVID and Cardiovascular Disease

Long COVID has been defined by the World Health Organisation as "continuation or development of new symptoms 3 months after the initial SARS-CoV-2 infection, with these symptoms lasting for at least 2 months with no other explanation." Cardiovascular disease is implicated as a risk factor, concomitant condition, and consequence of long COVID. As well as heterogeneity in definition, presentation, and likely underlying pathophysiology of long COVID, disparities by social determinants of health, extensively studied and described in cardiovascular disease, have been observed in 3 ways. First, underlying long-term conditions, such as cardiovascular disease and its risk factors, are associated with incidence and severity of long COVID, and previously described socioeconomic disparities in these factors are important in exacerbating disparities in long COVID. Second, socioeconomic disparities in management of COVID-19 may themselves lead to distal disparities in long COVID. Third, there are socioeconomic disparities in the way that long COVID is diagnosed, managed, and prevented. Together, factors such as age, sex, deprivation, and ethnicity have far-reaching implications in this new postviral syndrome across its management spectrum. There are similarities and differences compared with disparities for cardiovascular disease. Some of these disparities are in fact, inequalities, that is, rather than simply observed variations, they represent injustices with costs to individuals, communities, and economies. This review of current literature considers opportunities to prevent or at least attenuate these socioeconomic disparities in long COVID and cardiovascular disease, with special challenges for research, clinical practice, public health, and policy in a new disease which is evolving.

Disparities in pediatric hospital use during transition to adult healthcare for young adults with childhood-onset chronic conditions

BACKGROUND

Young adults (YA) with childhood-onset chronic conditions-particularly YA with cystic fibrosis (CF), congenital heart disease (CHD), and sickle cell disease (SCD)-continue to have pediatric hospital admissions. Factors associated with this continued pediatric hospital use remain underexplored.

OBJECTIVE

To determine if pediatric hospital use by YA differed (1) across condition and (2) within each condition by sociodemographic factors.

METHODS

Conducted a cross-sectional analysis of admissions for YA 22-35 years with CF, CHD, and SCD from 2016 to 2020 in the National Inpatient Sample. Admissions for YA with CF, CHD, and SCD were identified by international classification of diseases, 10th revision-clinical modification diagnosis codes. To determine if conditions or sociodemographic factors were associated with YA pediatric hospital use, we used multivariable logistic regression with separate models for the different objectives.

RESULTS

YA with SCD had lower odds of pediatric hospital use compared to YA with CF. Relationships between sociodemographic factors and pediatric hospital use varied. Black YA with both CF and CHD had lower odds of pediatric hospital use than white YA with CF and CHD. For YA with SCD, despite 17,810 (6.5%) having rural residence, zero (0) had pediatric hospital use; whereas YA with CF living in a rural area had greater odds of pediatric hospital use compared to urban residents.

CONCLUSION

YA with SCD used pediatric hospitals less than YA with either CF or CHD. Coupled with our findings that Black YA with CF and CHD had less pediatric hospital use, these data may reflect systematic racial differences within pediatric to adult healthcare transition programs.

Polarized Perspectives on Health Equity: Results from a Nationally Representative Survey on US Public Perceptions of COVID-19 Disparities in 2023

Republicans and Democrats responded to the COVID-19 pandemic in starkly different ways, from their attitudes in 2020 about whether the virus posed a threat to whether the pandemic ended in 2023. The consequences of COVID-19 for health equity have been a central concern in public health, and the concept of health equity has also been beset by partisan polarization. In this article, the authors present and discuss nationally representative survey data from 2023 on US public perceptions of disparities in COVID-19 mortality (building on a previous multiwave survey effort) as well as causal attributions for racial disparities, the contribution of structural racism, and broader attitudes about public health authority. The authors find anticipated gulfs in perspectives between Democrats on the one hand and independents and Republicans on the other. The results offer a somewhat pessimistic view of the likelihood of finding common ground in how the general public understands health inequities or the role of structural racism in perpetuating them. However, the authors show that those who acknowledge racial disparities in COVID-19 are more likely to support state public health authority to act in response to other infectious disease threats. The authors explore the implications of these public opinion data for advocacy, communication, and future needed research.

Geospatial Distribution of Racial Disparities in Influenza Vaccination in Nursing Homes

OBJECTIVES

This study aimed to assess the distribution of racial disparities in influenza vaccination between White and Black short-stay and long-stay nursing home residents among states and hospital referral regions (HRRs).

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

We included short-stay and long-stay older adults residing in US nursing homes during influenza seasons between 2011 and 2018. Included residents were aged ≥65 years and enrolled in Traditional Medicare. Analyses were conducted using resident-seasons, whereby residents could contribute to one or more influenza seasons if they resided in a nursing home across multiple seasons.

METHODS

Our comparison of interest was marginalized vs privileged racial group membership measured as Black vs White race. We obtained influenza vaccination documentation from resident Minimum Data Set assessments from October 1 through June 30 of a particular influenza season. Nonparametric g-formula was used to estimate age- and sex-standardized disparities in vaccination, measured as the percentage point (pp) difference in the proportions of individuals vaccinated between Black and White nursing home residents within states and HRRs.

RESULTS

The study included 7,807,187 short-stay resident-seasons (89.7% White and 10.3% Black) in 14,889 nursing homes and 7,308,111 long-stay resident-seasons (86.7% White and 13.3% Black) in 14,885 nursing homes. Among states, the median age- and sex-standardized disparity between Black and White residents was 10.1 percentage points (pps) among short-stay residents and 5.3 pps among long-stay residents across seasons. Among HRRs, the median disparity was 8.6 pps among short-stay residents and 5.0 pps among long-stay residents across seasons.

CONCLUSIONS AND IMPLICATIONS

Our analysis revealed that the magnitudes of vaccination disparities varied substantially across states and HRRs, from no disparity in vaccination to disparities in excess of 25 pps. Local interventions and policies should be targeted to high-disparity geographic areas to increase vaccine uptake and promote health equity.

The health equity implications of the Health Resources and Services Administration's Ryan White HIV/AIDS Program

OBJECTIVE

Investigate the role of the Ryan White HIV/AIDS Program (RWHAP) - which funds services for vulnerable and historically disadvantaged populations with HIV - in reducing health inequities among people with HIV over a 10-year horizon.

DESIGN

We use an agent-based microsimulation model to incorporate the complexity of the program and long-time horizon.

METHODS

We use a composite measure (the Theil index) to evaluate the health equity implications of the RWHAP for each of four subgroups (based on race and ethnicity, age, gender, and HIV transmission category) and two outcomes (probability of being in care and treatment and probability of being virally suppressed). We compare results with the RWHAP fully funded versus a counterfactual scenario, in which the medical and support services funded by the RWHAP are not available.

RESULTS

The model indicates the RWHAP will improve health equity across all demographic subgroups and outcomes over a 10-year horizon. In Year 10, the Theil index for race and ethnicity is 99% lower for both outcomes under the RWHAP compared to the non-RWHAP scenario; 71-93% lower across HIV transmission categories; 31-44% lower for age; and 73-75% lower for gender.

CONCLUSION

Given the large number of people served by the RWHAP and our findings on its impact on equity, the RWHAP represents an important vehicle for achieving the health equity goals of the National HIV/AIDS Strategy (2022-2025) and the Ending the HIV Epidemic Initiative goal of reducing new infections by 90% by 2030.

The EMPOWER program: a history and guide for increasing diversity using integrated research and education

The prevalence and pervasive nature of emerging chemicals of concern have created widespread environmental injustice apprehensions in vulnerable communities. To alleviate and address these concerns, identifying, engaging, and training a diverse environmental health research workforce will be critical and necessary steps to combat and prevent the consequences of environmental injustice. While there is an obvious need to enhance diversity in environmental health research, this process is hampered by facets of systemic racism that reduce access to educational resources needed to build interest and knowledge in students and teachers. We present here a historical perspective to offer a guide for building programs and relationships with underserved schools to help overcome limiting factors that have plagued certain public school systems. With the proper training and mentorship, the untapped workforce present within these schools will be empowered to understand and address current and emerging environmental health and safety threats. Through this transformative 8-week high school research program, we will develop well-prepared, ethical researchers committed to scientific inquiry, intensive fieldwork, and collaborative problem solving to address environmental health challenges. Following the four-step risk assessment process, students, teachers, and faculty mentors will work collaboratively to identify toxicants, potential hazards and risks, and environmental disparities in urban neighborhoods, which provides the necessary training to formulate critical thinking skills for use in academic or nonacademic careers.NEW & NOTEWORTHY The Engaging Multidisciplinary Professional Opportunities for Women in Environmental Research (EMPOWER) program is a one-of-a-kind research summer experience for minority female high school students in the state of Georgia. In addition, this program provides high school teachers with hands-on experiences that can be adapted to use in the classrooms. This combination of lab and field research immerses participants in understanding urban environmental exposures and their health effects. The EMPOWER program was established to meet the critical need for increasing diversity in science, technology, engineering, and mathematics.

Social Determinants of Health are Associated with Coping of Informal Caregivers of Adults with Heart Failure

We explored the influence of social determinants of health (SDH) risk on stress and coping style in heart failure (HF) caregivers. In this cross-sectional study, data from 250 caregivers were analyzed. Multivariable linear regression analyses were performed to determine the extent to which SDH risk (measured using a modified PRAPARE tool (National Association of Community Health Centers), range 0-22) predicted stress (Perceived Stress Scale, 0-56) and coping style (active (0-45), avoidance (0-30), and minimization (0-30)) while accounting for caregiver burden (HF Caregiver Questionnaire (HF-CQ) 0-100). Multivariable regression analysis with backwards elimination variable selection approach was used to identify which SDH risk factors best predicted coping styles. SDH risk was significantly associated with avoidance and minimization coping styles. Each unit increase in SDH risk was associated with an increase of 0.6 ± 0.2 units (p = .0008) in avoidance and 0.7 ± 0.2 units (p < .0001) in minimization coping style. Race and "supporting others" significantly predicted avoidance coping style; scores were 3.3 ± 0.8 units greater for caregivers who were not White (p < .0001) and 1.4 ± 0.5 units greater (p < .01) for each additional person whom they supported. Race significantly predicted minimization coping style; scores were 4.4 ± 0.7 units greater for caregivers who were not White (p < .0001). Caregivers with higher SDH risk may avoid and minimize to cope with caregiving challenges.

Modifications of the readiness assessment for pragmatic trials tool for appropriate use with Indigenous populations

BACKGROUND

Inequities in health access and outcomes exist between Indigenous and non-Indigenous populations. Embedded pragmatic randomized, controlled trials (ePCTs) can test the real-world effectiveness of health care interventions. Assessing readiness for ePCT, with tools such as the Readiness Assessment for Pragmatic Trials (RAPT) model, is an important component. Although equity must be explicitly incorporated in the design, testing, and widespread implementation of any health care intervention to achieve equity, RAPT does not explicitly consider equity. This study aimed to identify adaptions necessary for the application of the 'Readiness Assessment for Pragmatic Trials' (RAPT) tool in embedded pragmatic randomized, controlled trials (ePCTs) with Indigenous communities.

METHODS

We surveyed and interviewed participants (researchers with experience in research involving Indigenous communities) over three phases (July-December 2022) in this mixed-methods study to explore the appropriateness and recommended adaptions of current RAPT domains and to identify new domains that would be appropriate to include. We thematically analyzed responses and used an iterative process to modify RAPT.

RESULTS

The 21 participants identified that RAPT needed to be modified to strengthen readiness assessment in Indigenous research. In addition, five new domains were proposed to support Indigenous communities' power within the research processes: Indigenous Data Sovereignty; Acceptability - Indigenous Communities; Risk of Research; Research Team Experience; Established Partnership). We propose a modified tool, RAPT-Indigenous (RAPT-I) for use in research with Indigenous communities to increase the robustness and cultural appropriateness of readiness assessment for ePCT. In addition to producing a tool for use, it outlines a methodological approach to adopting research tools for use in and with Indigenous communities by drawing on the experience of researchers who are part of, and/or working with, Indigenous communities to undertake interventional research, as well as those with expertise in health equity, implementation science, and public health.

CONCLUSION

RAPT-I has the potential to provide a useful framework for readiness assessment prior to ePCT in Indigenous communities. RAPT-I also has potential use by bodies charged with critically reviewing proposed pragmatic research including funding and ethics review boards.

Community Voices: A Qualitative Study Exploring Perceptions of Menthol Cigarette Sales Restrictions in Los Angeles County Among Black Adults Who Smoke Menthol Cigarettes

INTRODUCTION

The commercial tobacco industry has long targeted Black communities by making menthol cigarettes not only appealing but affordable through marketing, advertising, and pricing strategies, particularly in the retail environment. Policies that focus on restricting the sale of menthol cigarettes have the potential to significantly reduce the death toll from smoking while also mitigating health inequities and advancing racial equity. However, limited qualitative research exists on the perceptions of menthol cigarette sales restrictions, including local policies, among Black adults who smoke menthol cigarettes.

AIMS AND METHODS

In-depth semi-structured interviews were conducted between January and September 2021 with self-identified non-Hispanic Black adults who reported current menthol cigarette use (n = 26). Participants were asked open-ended questions about awareness and perceptions of the Los Angeles County law banning the retail sale of menthol cigarettes in unincorporated communities, including how it influences their smoking and purchasing behaviors.

RESULTS

We used three thematic categories to structure the results: (1) Are People Aware of Local Menthol Cigarette Sales Restrictions? Levels of Awareness and Strategies to Increase Awareness, (2) Why Ban Menthol? Concerns About Equity and Fairness, and (3) Will Menthol Cigarette Bans Decrease Smoking? Mixed Perceptions About Potential Impact. Most participants (88.5%) had heard about the menthol ban in their communities. Participants described ambivalence towards the ban and identified several factors that hinder support, participation, and well-being, including uncertainty regarding the rationale for banning menthol cigarettes; perceptions that the ban specifically targets Black communities; and concerns regarding government overreach and constraining individual choice. Participants had differing views on whether the ban would likely help them and others who smoke menthol cigarettes reduce or quit smoking. Participants also described situations in which they would purchase menthol cigarettes in another state, country, online, or in the illicit market. Furthermore, participants often viewed the ban as perpetuating criminalization and over-policing of Black communities-arguments used by the commercial tobacco industry to oppose menthol bans.

CONCLUSIONS

Our community-based sample of Black adults who smoke menthol cigarettes face challenges and concerns about local menthol bans. Community-centered interventions, messages, and materials about racial equity in menthol bans, access to free cessation services, and countering commercial tobacco industry interference, in addition to measurable steps toward rectifying injustice from the commercial tobacco industry and repeated exemptions of menthol cigarettes from federal legislation through tangible reparations, would be helpful to this community.

IMPLICATIONS

We sought to add to the literature on flavored nicotine and commercial tobacco policies in the United States by centering the voices of Black adults who smoke menthol cigarettes regarding their awareness, perceptions, and opinions of local laws restricting menthol cigarette retail sales and how such polices influence their smoking and purchasing behaviors. Our findings suggest that Black adults who smoke menthol cigarettes are aware of local laws restricting menthol cigarette retail sales and are ambivalent about the rationale. Our findings have implications for the development and delivery of equity-focused strategies and resources to increase awareness of and rationale for the ban; counter commercial tobacco industry interference; and facilitate smoking cessation among Black adults who experience more combustible tobacco-related morbidity and mortality than their racial/ethnic counterparts. By understanding this relevance, we can also recognize how individual awareness and perceptions are moored within and contextualized by broader social structures and systemic inequities that warrant policy considerations.

Everyday discrimination and satisfaction with nature experiences

Introduction

There is growing interest in creating public green spaces to promote health. Yet, discussions about these efforts often overlook how experiences of chronic discrimination-which may manifest as racism, sexism, or homophobia, and more-could undermine satisfaction with nature experiences.

Methods

Using data from the 2018 wave of the National Opinion Research Center (NORC) General Social Survey (GSS), we quantified associations of frequency of everyday discrimination, operationalized using the Everyday Discrimination Scale (EDS, the primary independent variable), with respondents' perceptions of nature experiences and with their reported time spent in nature. Specifically, we quantified associations with the following three variables: (1) dissatisfaction with day-to-day experiences of nature, (2) not spending as much time as they would like in natural environments, and (3) usually spending at least one day per week in nature. We used survey-weighted robust Poisson models to estimate overall associations, and also stratified analyses by racial/ethnic and gender identity categories.

Results

Of 768 GSS respondents, 14% reported dissatisfaction with nature experiences, 36% reported not spending as much time as they would like in nature, and 33% reported that they did not spend at least one day per week in nature. The median non-standardized EDS, coded such that a higher value indicates greater frequency of discrimination, was 11 (interquartile range: 8, 15). Prevalence of reporting dissatisfaction with day-to-day experiences in nature was 7% higher in association with every one unit increase in EDS score above the median (PR: 1.07, 95% CI: 1.02-1.11). The prevalence of reporting not spending as much time as one would like in nature was 2% higher for every unit increase in higher than median everyday discrimination frequency (PR: 1.02, 95% CI: 1.00-1.05). Higher than median frequency in everyday discrimination was not associated with spending less than one day per week in nature. Race/ethnicity and gender identity did not modify associations.

Conclusion

Greater frequency of everyday discrimination is associated with less satisfaction with experiences in nature. This relationship could undermine efforts to promote health equity through green interventions.

Does structural racism impact receipt of NCCN guideline-concordant breast cancer treatment?

PURPOSE

Disparities in breast cancer survival remain a challenge. We aimed to analyze the effect of structural racism, as measured by the Index of Concentration at the Extremes (ICE), on receipt of National Cancer Center Network (NCCN) guideline-concordant breast cancer treatment.

METHODS

We identified patients treated at two institutions from 2005 to 2017 with stage I-IV breast cancer. Census tracts served as neighborhood proxies. Using 5-year estimates from the American Community Survey, 5 ICE variables were computed to create 5 models, controlling for economic segregation, non-Hispanic Black (NHB) segregation, NHB/economic segregation, Hispanic segregation, and Hispanic/economic segregation. Multi-level logistic regression models were used to determine the association between individual and neighborhood-level characteristics on receipt of NCCN guideline-concordant breast cancer treatment.

RESULTS

5173 patients were included: 55.2% were Hispanic, 27.5% were NHW, and 17.3% were NHB. Regardless of economic or residential segregation, a NHB patient was less likely to receive appropriate treatment [(OR)Model1 0.58 (0.45-0.74); ORModel2 0.59 (0.46-0.78); ORModel3 0.62 (0.47-0.81); ORModel4 0.53 (0.40-0.69); ORModel5 0.59(0.46-0.76); p < 0.05].

CONCLUSION

To our knowledge, this is the first analysis assessing receipt of NCCN guideline-concordant treatment by ICE, a validated measure for structural racism. While much literature emphasizes neighborhood-level barriers to treatment, our results demonstrate that compared to NHW patients, NHB patients are less likely to receive NCCN guideline-concordant breast cancer treatment, independent of economic or residential segregation. Our study suggests that there are potential unaccounted individual or neighborhood barriers to receipt of appropriate care that go beyond economic or residential segregation.

Racial and ethnic diversity in academic nursing leadership: A cross-sectional analysis

BACKGROUND/PURPOSE

To characterize the representation of racial and ethnic minoritized faculty in leadership positions at the top 50 National Institutes of Health-ranked academic nursing institutions.

METHODS

We conducted a cross-sectional observational study to characterize the racial/ethnic composition of academic leaders, including those in diversity, equity, and inclusion (DEI) positions from September 2020 to December 2020.

DISCUSSION

Among the 409 leaders, the sample was predominantly composed of females (86.6%), White leaders (80.9%), affiliated with public institutions (75.1%), and in the southern region (42.1%). Exactly 13.6% were from minoritized groups. Minoritized leaders were less likely to hold dean and higher executive positions than their nonminoritized counterparts (p < .002). DEI leadership positions were mostly concentrated in lower executive positions (e.g., director) and primarily consisted of minoritized leaders (>60%).

CONCLUSION

Underrepresentation of racial and ethnic minoritized individuals in academic nursing leadership persists, necessitating structural interventions within nursing academia to promote inclusivity. Achieving this goal requires a concerted investment in diversifying academic nursing leadership and ensuring positions that minoritized leaders are in, hold weight.

The American Society for Bone and Mineral Research Task Force on clinical algorithms for fracture risk report

Using race and ethnicity in clinical algorithms potentially contributes to health inequities. The American Society for Bone and Mineral Research (ASBMR) Professional Practice Committee convened the ASBMR Task Force on Clinical Algorithms for Fracture Risk to determine the impact of race and ethnicity adjustment in the US Fracture Risk Assessment Tool (US-FRAX). The Task Force engaged the University of Minnesota Evidence-based Practice Core to conduct a systematic review investigating the performance of US-FRAX for predicting incident fractures over 10 years in Asian, Black, Hispanic, and White individuals. Six studies from the Women's Health Initiative (WHI) and Study of Osteoporotic Fractures (SOF) were eligible; cohorts only included women and were predominantly White (WHI > 80% and SOF > 99%), data were not consistently stratified by race and ethnicity, and when stratified there were far fewer fractures in Black and Hispanic women vs White women rendering area under the curve (AUC) estimates less stable. In the younger WHI cohort (n = 64 739), US-FRAX without bone mineral density (BMD) had limited discrimination for major osteoporotic fracture (MOF) (AUC 0.53 (Black), 0.57 (Hispanic), and 0.57 (White)); somewhat better discrimination for hip fracture in White women only (AUC 0.54 (Black), 0.53 (Hispanic), and 0.66 (White)). In a subset of the older WHI cohort (n = 23 918), US-FRAX without BMD overestimated MOF. The Task Force concluded that there is little justification for estimating fracture risk while incorporating race and ethnicity adjustments and recommends that fracture prediction models not include race or ethnicity adjustment but instead be population-based and reflective of US demographics, and inclusive of key clinical, behavioral, and social determinants (where applicable). Research cohorts should be representative vis-à-vis race, ethnicity, gender, and age. There should be standardized collection of race and ethnicity; collection of social determinants of health to investigate impact on fracture risk; and measurement of fracture rates and BMD in cohorts inclusive of those historically underrepresented in osteoporosis research.

Prevalence and Correlates of Unstable Housing Among US Children

Importance

Housing instability is an important public health issue, particularly for children. This study provides nationally representative estimates of unstable housing among US children.

Objective

To examine unstable housing prevalence; differences by sociodemographic characteristics, health, and state of residence; and associations with other hardships.

Design, Setting, and Participants

This survey study examined data from the 2022 National Survey of Children's Health, a population-based, nationally representative survey of randomly selected children whose parent or caregiver responded to an address-based mail or web-based survey. Participants were children aged 0 to 17 years living in households in the 50 US states and District of Columbia (N = 54 103). Bivariate analyses tested for observed differences in unstable housing between groups; logistic regression models tested for significant disparities. Associations between unstable housing and health care and food-related hardships, neighborhood conditions, and adverse childhood experiences were examined.

Exposure

Unstable housing experiences.

Main Outcomes and Measures

Unstable housing, comprising 3 indicators: inability to pay mortgage or rent on time in the past 12 months, 2 or more moves in the past 12 months, and homelessness in the child's lifetime. Analyses were adjusted for child age and family poverty ratio. Secondary analyses examine caregiver-reported stress or worry about eviction, foreclosure, or condemned housing in the past 12 months. Weighted prevalence estimates accounted for probability of selection and nonresponse.

Results

In 2022, 17.1% (95% CI, 16.4%-17.8%) of children living in US households, representing more than 12.1 million children, experienced 1 or more forms of unstable housing: 14.1% (95% CI, 13.4%-14.7%) lived in households that were unable to pay mortgage/rent, 2.9% (95% CI, 2.6%-3.3%) moved frequently, and 2.5% (95% CI, 2.2%-2.8%) experienced lifetime homelessness. Additionally, 9.0% (95% CI, 8.5%-9.5%) of children had caregivers who reported stress/worry over housing. Prevalence of unstable housing varied across states (range, 12.0%-26.6%). Unstable housing was highest among American Indian or Alaska Native children (27.9%; 95% CI, 21.3%-35.6%), Black or African American children (30.4%; 95% CI, 27.8%-33.1%), and Native Hawaiian or Pacific Islander children (27.6%; 95% CI, 16.6%-42.1%) and also differed by special health care needs, family poverty ratio, caregiver education and unemployment status, and whether the family rented or owned their home. Unstable housing was associated with all other types of hardships examined.

Conclusions and Relevance

This study found that 1 in 6 US children experienced unstable housing, varying by state and sociodemographic factors. The prevalence is likely underestimated because the sample excluded children who are currently institutionalized or experiencing homelessness. Results may help move the field toward a unified national definition of unstable housing for families with children and lead to clinically appropriate and evidence-based screening and interventions to support housing stability and improve children's health.

Community and household-level incarceration and its association with mental health in a racially/ethnically diverse sample of families

This study examines the association between community incarceration rates, household incarceration, and the mental health of parents and children. Participant families had children ages 5-9 (n = 1307) from the African American, Latinx, Hmong, Somali/Ethiopian, Native American, and White communities in the Twin Cities, Minnesota. Linear mixed models were used to estimate associations between parent and child mental health, household incarceration exposure, and census tract race, ethnicity and gender-specific incarceration rates matched to the family's home address and race/ethnicity. Findings indicated that living in census tracts with elevated incarceration rates of men from your same racial or ethnic group was significantly associated with psychological distress in parents and externalizing behaviors in boys, regardless of household exposure to incarceration. The association between incarceration rates and externalizing behaviors was only observed among girls with exposure to household incarceration. Policies that deconstruct pervasive racism in penal systems are needed to improve population mental health.

Racial and Socioeconomic Disparities in Laminoplasty Versus Laminectomy With Fusion in Patients With Cervical Spondylosis

STUDY DESIGN

A retrospective cohort study using prospectively collected data.

OBJECTIVE

The aim of this study was to investigate preoperative differences in racial and socioeconomic factors in patients undergoing laminoplasty (LP) versus laminectomy and fusion (LF) for degenerative cervical myelopathy (DCM).

SUMMARY OF BACKGROUND DATA

DCM is prevalent in the United States, requiring surgical intervention to prevent neurological degeneration. While LF is utilized more frequently, LP is an emerging alternative. Previous studies have demonstrated similar neurological outcomes for both procedures. However, treatment selection is primarily at the discretion of the surgeon and may be influenced by social determinants of health that impact surgical outcomes.

MATERIALS AND METHODS

The Quality Outcome Database (QOD), a national spine registry, was queried for adult patients who underwent either LP or LF for the management of DCM. Covariates associated with socioeconomic status, pain and disability, and demographic and medical history were collected. Multivariate logistic regression was performed to assess patient factors associated with undergoing LP versus LF.

RESULTS

Of 1673 DCM patients, 157 (9.4%) underwent LP and 1516 (90.6%) underwent LF. A significantly greater proportion of LP patients had private insurance (P<0.001), a greater than high school level education (P<0.001), were employed (P<0.001), and underwent primary surgery (P<0.001). LP patients reported significantly lower baseline neck/arm pain and Neck Disability Index (P<0.001). In the multivariate regression model, lower baseline neck pain [odds ratio (OR)=0.915, P=0.001], identifying as non-Caucasian (OR=2.082, P<0.032), being employed (OR=1.592, P=0.023), and having a greater than high school level education (OR=1.845, P<0.001) were associated with undergoing LP rather than LF.

CONCLUSIONS

In DCM patients undergoing surgery, factors associated with patients undergoing LP versus LF included lower baseline neck pain, non-Caucasian race, higher education, and employment. While symptomatology may influence the decision to choose LP over LF, there may also be socioeconomic factors at play. The trend of more educated and employed patients undergoing LP warrants further investigation.

Incorporating Anti-racist Principles Throughout the Research Lifecycle: A Position Statement from the Society of General Internal Medicine (SGIM)

Biomedical research has advanced medicine but also contributed to widening racial and ethnic health inequities. Despite a growing acknowledgment of the need to incorporate anti-racist objectives into research, there remains a need for practical guidance for recognizing and addressing the influence of ingrained practices perpetuating racial harms, particularly for general internists. Through a review of the literature, and informed by the Research Lifecycle Framework, this position statement from the Society of General Internal Medicine presents a conceptual framework suggesting multi-level systemic changes and strategies for researchers to incorporate an anti-racist perspective throughout the research lifecycle. It begins with a clear assertion that race and ethnicity are socio-political constructs that have important consequences on health and health disparities through various forms of racism. Recommendations include leveraging a comprehensive approach to integrate anti-racist principles and acknowledging that racism, not race, drives health inequities. Individual researchers must acknowledge systemic racism's impact on health, engage in self-education to mitigate biases, hire diverse teams, and include historically excluded communities in research. Institutions must provide clear guidelines on the use of race and ethnicity in research, reject stigmatizing language, and invest in systemic commitments to diversity, equity, and anti-racism. National organizations must call for race-conscious research standards and training, and create measures to ensure accountability, establishing standards for race-conscious research for research funding. This position statement emphasizes our collective responsibility to combat systemic racism in research, and urges a transformative shift toward anti-racist practices throughout the research cycle.

Social Network Characteristics Associated with More Frequent HIV and STI Prevention Conversations: The N2 Cohort Study in Chicago

Black cisgender sexually minoritized men (SMM) and transgender women (TW) are subgroups at highest risk of HIV and sexually transmitted infections (STIs) in the US. We sought to identify factors facilitating continued conversations - social reinforcement - surrounding HIV/STI prevention among this subgroup. Participants were recruited in Chicago from 2018 to 2019 from community health spaces. Participants provided information about themselves (level 2) and ⩽5 confidants (level 1). We used multinomial multilevel modeling to identify associations with HIV/STI prevention conversation frequency. A total of 370 participants provided information on 987 confidants (mean = 2.6). We found significantly positive associations between having biweekly or more often HIV/STI prevention conversations and a confidant being a kin family member, older by 15 years or more, racially homophilous, and emotionally close. Future interventions should harness social networks by including components that consider racial homophily, respect for elders, and strong ties, in addition to applying kin family systems interventions approaches and decreasing stigma surrounding HIV/STIs.

Charting the Advocacy Landscape: A Qualitative Content Analysis of Syllabi in Public Health Graduate Education

CONTEXT

Addressing public health challenges necessitates policy approaches, but concerns persist about public health graduates' preparedness to advocate.

OBJECTIVE

This qualitative study sought to assess advocacy content and skills taught to Master of Public Health students enrolled in US accredited schools and programs of public health (SPPHs) by analyzing 98 course syllabi submitted to the Council on Education for Public Health (CEPH) between 2019 and 2021. Syllabi were submitted by SPPHs during their (re)accreditation process to demonstrate compliance with CEPH's advocacy competency requirement.

DESIGN

Qualitative content analysis study. Syllabi were analyzed using MAXQDA Qualitative Data Analysis Software using a 2-coder approach.

SETTING

SPPHs accredited by CEPH.

PARTICIPANTS

Ninety-eight syllabi submitted to CEPH by 22 schools of public health and 54 programs of public health.

MAIN OUTCOME MEASURES

Exemplary language from advocacy courses and assignments and aggregate frequency of syllabi advocacy content and skills.

RESULTS

Most advocacy courses (61%) were survey, health policy, or health care delivery courses, covering policy (66%), policy communication (46%), coalition-building (45%), lobbying (36%), community organizing (33%), and media advocacy (24%) skills. Only 7% prioritized advocacy skill instruction, and 10% addressed how to advocate in an equitable way.

CONCLUSIONS

Defining public health advocacy and essential skills is crucial. Issuing competency guidelines, supporting advocacy faculty, offering standardized training, and expanding experiential learning are important first steps. More research is needed on how academic institutions are incorporating equity skill training into courses, whether separate from or combined with advocacy skills.

2024 Alzheimer's disease facts and figures

This article describes the public health impact of Alzheimer's disease (AD), including prevalence and incidence, mortality and morbidity, use and costs of care and the ramifications of AD for family caregivers, the dementia workforce and society. The Special Report discusses the larger health care system for older adults with cognitive issues, focusing on the role of caregivers and non-physician health care professionals. An estimated 6.9 million Americans age 65 and older are living with Alzheimer's dementia today. This number could grow to 13.8 million by 2060, barring the development of medical breakthroughs to prevent or cure AD. Official AD death certificates recorded 119,399 deaths from AD in 2021. In 2020 and 2021, when COVID-19 entered the ranks of the top ten causes of death, Alzheimer's was the seventh-leading cause of death in the United States. Official counts for more recent years are still being compiled. Alzheimer's remains the fifth-leading cause of death among Americans age 65 and older. Between 2000 and 2021, deaths from stroke, heart disease and HIV decreased, whereas reported deaths from AD increased more than 140%. More than 11 million family members and other unpaid caregivers provided an estimated 18.4 billion hours of care to people with Alzheimer's or other dementias in 2023. These figures reflect a decline in the number of caregivers compared with a decade earlier, as well as an increase in the amount of care provided by each remaining caregiver. Unpaid dementia caregiving was valued at $346.6 billion in 2023. Its costs, however, extend to unpaid caregivers' increased risk for emotional distress and negative mental and physical health outcomes. Members of the paid health care and broader community-based workforce are involved in diagnosing, treating and caring for people with dementia. However, the United States faces growing shortages across different segments of the dementia care workforce due to a combination of factors, including the absolute increase in the number of people living with dementia. Therefore, targeted programs and care delivery models will be needed to attract, better train and effectively deploy health care and community-based workers to provide dementia care. Average per-person Medicare payments for services to beneficiaries age 65 and older with AD or other dementias are almost three times as great as payments for beneficiaries without these conditions, and Medicaid payments are more than 22 times as great. Total payments in 2024 for health care, long-term care and hospice services for people age 65 and older with dementia are estimated to be $360 billion. The Special Report investigates how caregivers of older adults with cognitive issues interact with the health care system and examines the role non-physician health care professionals play in facilitating clinical care and access to community-based services and supports. It includes surveys of caregivers and health care workers, focusing on their experiences, challenges, awareness and perceptions of dementia care navigation.

Association of Historical Housing Discrimination and Colon Cancer Treatment and Outcomes in the United States

PURPOSE

In the 1930s, the federally sponsored Home Owners' Loan Corporation (HOLC) used racial composition in its assessment of areas worthy of receiving loans. Neighborhoods with large proportions of Black residents were mapped in red (ie, redlining) and flagged as hazardous for mortgage financing. Redlining created a platform for systemic disinvestment in these neighborhoods, leading to barriers in access to resources that persist today. We investigated the association between residing in areas with different HOLC ratings and receipt of quality cancer care and outcomes among individuals diagnosed with colon cancer-a leading cause of cancer deaths amenable to early detection and treatment.

METHODS

Individuals who resided in zip code tabulation areas in 196 cities with HOLC rating and were diagnosed with colon cancer from 2007 to 2017 were identified from the National Cancer Database and assigned a HOLC grade (A, best; B, still desirable; C, definitely declining; and D, hazardous and mapped in red). Multivariable logistic regression models investigated association of area-level HOLC grade and late stage at diagnosis and receipt of guideline-concordant care. The product-limit method evaluated differences in time to adjuvant chemotherapy. Multivariable Cox proportional hazard models investigated differences in overall survival (OS).

RESULTS

There were 149,917 patients newly diagnosed with colon cancer with a median age of 68 years. Compared with people living in HOLC A areas, people living in HOLC D areas were more likely to be diagnosed with late-stage disease (adjusted odds ratio, 1.06 [95% CI, 1.00 to 1.12]). In addition, people living in HOLC B, C, and D areas had 8%, 16%, and 24% higher odds of not receiving guideline-concordant care, including lower receipt of surgery, evaluation of ≥12 lymph nodes, and chemotherapy. People residing in HOLC B, C, or D areas also experienced delays in initiation of adjuvant chemotherapy after surgery. People residing in HOLC C (adjusted hazard ratio [aHR], 1.09 [95% CI, 1.05 to 1.13]) and D (aHR, 1.13 [95% CI, 1.09 to 1.18]) areas had worse OS, including 13% and 20% excess risk of death for individuals diagnosed with early- and 6% and 8% for late-stage disease for HOLC C and D, respectively.

CONCLUSION

Historical housing discrimination is associated with worse contemporary access to colon cancer care and outcomes.

Hospice Readmission, Hospitalization, and Hospital Death Among Patients Discharged Alive from Hospice

Importance

Transitions in care settings following live discharge from hospice care are burdensome for patients and families. Factors contributing to risk of burdensome transitions following hospice discharge are understudied.

Objective

To identify factors associated with 2 burdensome transitions following hospice live discharge, as defined by the Centers for Medicare & Medicaid Services.

Design, Setting, and Participants

This population-based retrospective cohort study included a 20% random sample of Medicare fee-for-service beneficiaries using 2014 to 2019 Medicare claims data. Data were analyzed from April 22, 2023, to March 4, 2024.

Exposure

Live hospice discharge.

Main Outcomes and Measures

Multivariable logistic regression examined associations among patient, health care provision, and organizational characteristics with 2 burdensome transitions after live hospice discharge (outcomes): type 1, hospice discharge, hospitalization within 2 days, and hospice readmission within 2 days; and type 2, hospice discharge, hospitalization within 2 days, and hospital death.

Results

This study included 115 072 Medicare beneficiaries discharged alive from hospice (mean [SD] age, 84.4 [6.6] years; 71892 [62.5%] female; 5462 [4.8%] Hispanic, 9822 [8.5%] non-Hispanic Black, and 96 115 [83.5%] non-Hispanic White). Overall, 10 381 individuals (9.0%) experienced a type 1 burdensome transition and 3144 individuals (2.7%) experienced a type 2 burdensome transition. In adjusted models, factors associated with higher odds of burdensome transitions included identifying as non-Hispanic Black (type 1: adjusted odds ratio [aOR], 1.47; 95% CI, 1.36-1.58; type 2: aOR, 1.70; 95% CI, 1.51-1.90), hospice stays of 7 days or fewer (type 1: aOR, 1.13; 95% CI, 1.06-1.21; type 2: aOR, 1.71; 95% CI, 1.53-1.90), and care from a for-profit hospice (type 1: aOR, 1.78; 95% CI, 1.62-1.96; type 2: aOR, 1.32; 95% CI, 1.15-1.52). Nursing home residence (type 1: aOR, 0.66; 95% CI, 0.61-0.72; type 2: aOR, 0.47; 95% CI, 0.40-0.54) and hospice stays of 180 days or longer (type 1: aOR, 0.63; 95% CI, 0.59-0.68; type 2: aOR, 0.60; 95% CI, 0.52-0.69) were associated with lower odds of burdensome transitions.

Conclusion and Relevance

This retrospective cohort study of burdensome transitions following live hospice discharge found that non-Hispanic Black race, short hospice stays, and care from for-profit hospices were associated with higher odds of experiencing a burdensome transition. These findings suggest that changes to clinical practice and policy may reduce the risk of burdensome transitions, such as hospice discharge planning that is incentivized, systematically applied, and tailored to needs of patients at greater risk for burdensome transitions.

Cumulative Systolic Blood Pressure and Incident Stroke Type Variation by Race and Ethnicity

Importance

Stroke risk varies by systolic blood pressure (SBP), race, and ethnicity. The association between cumulative mean SBP and incident stroke type is unclear, and whether this association differs by race and ethnicity remains unknown.

Objective

To examine the association between cumulative mean SBP and first incident stroke among 3 major stroke types-ischemic stroke (IS), intracerebral hemorrhage (ICH), and subarachnoid hemorrhage (SAH)-and explore how these associations vary by race and ethnicity.

Design, Setting, and Participants

Individual participant data from 6 US longitudinal cohorts (January 1, 1971, to December 31, 2019) were pooled. The analysis was performed from January 1, 2022, to January 2, 2024. The median follow-up was 21.6 (IQR, 13.6-31.8) years.

Exposure

Time-dependent cumulative mean SBP.

Main Outcomes and Measures

The primary outcome was time from baseline visit to first incident stroke. Secondary outcomes consisted of time to first incident IS, ICH, and SAH.

Results

Among 40 016 participants, 38 167 who were 18 years or older at baseline with no history of stroke and at least 1 SBP measurement before the first incident stroke were included in the analysis. Of these, 54.0% were women; 25.0% were Black, 8.9% were Hispanic of any race, and 66.2% were White. The mean (SD) age at baseline was 53.4 (17.0) years and the mean (SD) SBP at baseline was 136.9 (20.4) mm Hg. A 10-mm Hg higher cumulative mean SBP was associated with a higher risk of overall stroke (hazard ratio [HR], 1.20 [95% CI, 1.18-1.23]), IS (HR, 1.20 [95% CI, 1.17-1.22]), and ICH (HR, 1.31 [95% CI, 1.25-1.38]) but not SAH (HR, 1.13 [95% CI, 0.99-1.29]; P = .06). Compared with White participants, Black participants had a higher risk of IS (HR, 1.20 [95% CI, 1.09-1.33]) and ICH (HR, 1.67 [95% CI, 1.30-2.13]) and Hispanic participants of any race had a higher risk of SAH (HR, 3.81 [95% CI, 1.29-11.22]). There was no consistent evidence that race and ethnicity modified the association of cumulative mean SBP with first incident stroke and stroke type.

Conclusions and Relevance

The findings of this cohort study suggest that cumulative mean SBP was associated with incident stroke type, but the associations did not differ by race and ethnicity. Culturally informed stroke prevention programs should address modifiable risk factors such as SBP along with social determinants of health and structural inequities in society.

Lessons Learned from Immigrant Health Cohorts: A Review of the Evidence and Implications for Policy and Practice in Addressing Health Inequities among Asian Americans, Native Hawaiians, and Pacific Islanders

The health of Asian Americans, Native Hawaiians, and Pacific Islanders (AANHPI) is uniquely impacted by structural and social determinants of health (SSDH) shaped by immigration policies and colonization practices, patterns of settlement, and racism. These SSDH also create vast heterogeneity in disease risks across the AANHPI population, with some ethnic groups having high disease burden, often masked with aggregated data. Longitudinal cohort studies are an invaluable tool to identify risk factors of disease, and epidemiologic cohort studies among AANHPI populations have led to seminal discoveries of disease risk factors. This review summarizes the limited but growing literature, with a focus on SSDH factors, from seven longitudinal cohort studies with substantial AANHPI samples. We also discuss key information gaps and recommendations for the next generation of AANHPI cohorts, including oversampling AANHPI ethnic groups; measuring and innovating on measurements of SSDH; emphasizing the involvement of scholars from diverse disciplines; and, most critically, engaging community members to ensure relevancy for public health, policy, and clinical impact.

Incidence, risk factors, and a prognostic nomogram for distant metastasis in endometrial cancer: A SEER-based study

OBJECTIVE

To evaluate the metastatic pattern, identify the risk factors, and establish a nomogram for predicting prognosis of endometrial cancer (EC) with distant metastasis.

METHODS

A retrospective cohort study of women diagnosed with EC was conducted according to the Surveillance, Epidemiology, and End Results (SEER) database during 2010-2017. Multivariate logistic analysis and Cox analysis were performed to identify the risk factors in promoting distant metastasis and predictors associated with overall survival (OS) in this particular subpopulation. A nomogram was then constructed and validated by the concordance index (C-index), the area under the receiver operating characteristic curve (AUC), calibration plots, and decision curve analysis.

RESULTS

A total of 2799 cases of distant metastasis in EC patients were identified, with an overall incidence rate of 3.74% from 2010 to 2017. Black race, unmarried status, non-endometrioid histologic types, and grade IV were significant risk factors for distant metastasis in EC patients. Meanwhile, race, histology, grade, metastasis status, surgery, lymphadenectomy, and chemotherapy were identified as independent prognostic factors for OS. A nomogram to predict 1-, 3-, and 5-year OS was established, and presented favorable accuracy and clinical applicability. Patients were further divided into high- and low-risk groups according to the model.

CONCLUSION

The nomogram was developed as a highly accurate, individualized tool to better predict the prognosis of EC patients with distant metastasis, which would help clinicians to identify high-risk patients, and adjust and tailor their treatment strategies.

Ramifications of Precarious Employment for Health and Health Inequity: Emerging Trends from the Americas

Precarious employment (PE), which encompasses the power relations between workers and employers, is a well-established social determinant of health that has strong ramifications for health and health inequity. In this review, we discuss advances in the measurement of this multidimensional construct and provide recommendations for overcoming continued measurement challenges. We then evaluate recent evidence of the negative health impacts of PE, with a focus on the burgeoning studies from North America and South America. We also establish the role of PE in maintaining and perpetuating health inequities and review potential policy solutions to help alleviate its health burden. Last, we discuss future research directions with a call for a better understanding of the heterogeneity within PE and for research that focuses both on upstream drivers that shape PE and its impacts on health, as well as on the mechanisms by which PE causes poor health.

All in the Family? A Systematic Review and Meta-analysis of Parenting and Family Environment as Risk Factors for Attention-Deficit/Hyperactivity Disorder (ADHD) in Children

Parenting and family environment have significant impact on child development, including development of executive function, attention, and self-regulation, and may affect the risk of developmental disorders including attention-deficit/hyperactivity disorder (ADHD). This paper examines the relationship of parenting and family environment factors with ADHD. A systematic review of the literature was conducted in 2014 and identified 52 longitudinal studies. A follow-up search in 2021 identified 7 additional articles, for a total of 59 studies that examined the association of parenting factors with ADHD outcomes: ADHD overall (diagnosis or symptoms), ADHD diagnosis specifically, or presence of the specific ADHD symptoms of inattention and hyperactivity/impulsivity. For parenting factors that were present in three or more studies, pooled effect sizes were calculated separately for dichotomous or continuous ADHD outcomes, accounting for each study's conditional variance. Factors with sufficient information for analysis were parenting interaction quality (sensitivity/warmth, intrusiveness/reactivity, and negativity/harsh discipline), maltreatment (general maltreatment and physical abuse), parental relationship status (divorce, single parenting), parental incarceration, and child media exposure. All factors showed a significant direct association with ADHD outcomes, except sensitivity/warmth which had an inverse association. Parenting factors predicted diagnosis and overall symptoms as well as inattentive and hyperactive symptoms when measured, but multiple factors showed significant heterogeneity across studies. These findings support the possibility that parenting and family environment influences ADHD symptoms and may affect a child's likelihood of being diagnosed with ADHD. Prevention strategies that support parents, such as decreasing parenting challenges and increasing access to parent training in behavior management, may improve children's long-term developmental health.