Conceptual approaches to the study of health disparities

Residential Segregation and Colorectal Cancer Screening in the United States, 2010 to 2018

BACKGROUND

Residential segregation limits the access to resources, primarily because of disinvestment. This study evaluated the association between residential segregation and colorectal cancer screening in the United States and whether findings differed by race and ethnicity.

METHODS

Restricted National Health Interview Survey data (2010-2018) were used to ascertain colorectal cancer screening adherence per US Preventive Services Task Force recommendations. Residential segregation was operationalized using the Index of Concentration at the Extremes (ICE), based on income, race, and ethnicity information obtained from the 2014 to 2018 American Community Survey estimates for counties. Multivariable logistic regression models with robust variance estimators accounting for within-county correlation were used. Analyses were stratified by race and ethnicity and weighted to represent the US population.

RESULTS

In this cross-sectional study (n = 44,690), participants residing in less advantaged counties had lower colorectal cancer screening adherence than those residing in the most advantaged counties [Q1 vs. Q5, OR (95% confidence interval): ICE income, 0.77 (0.70-0.86); ICE race, 0.86 (0.77-0.96); ICE race + income, 0.75 (0.67-0.84)]. In analyses stratified by race and ethnicity, we observed that overall findings were mostly driven by White people and estimates were less precise with no clear gradients among racial and ethnic minoritized groups. Among Black participants, colorectal cancer screening did not vary across quintiles of economic segregation.

CONCLUSIONS

Residential segregation was associated with colorectal cancer screening.

IMPACT

Interventions aimed at improving colorectal cancer screening uptake in the United States should address structural barriers present in areas with higher concentrations of low-income minoritized racial and ethnic groups and how features of residential segregation might differentially affect racial and ethnic groups.

Physical Activity and Eating Habits Are Related to Chronic Disease in the Basic Livelihood Security Program

OBJECTIVES

Chronic diseases are a significant public health issue, especially for socioeconomically vulnerable population groups. The purpose of this study is to compare the prevalence of chronic diseases in people receiving and not receiving BLS and to determine the prevalence of chronic diseases according to the physical activity and dietary habits of people receiving BLS.

METHODS

Data were derived from the sixth to ninth waves (2014-2022) of the Korea National Health and Nutrition Examination Survey (KNHANES), focusing on 15,041 participants aged 65 and older. Demographic characteristics, dietary intake, physical activity, and chronic disease status were assessed. Multivariate logistic regression analysis was used to calculate odds ratios for chronic diseases according to physical activity and dietary habits.

RESULTS

The BLS group exhibited higher prevalence rates of hypertension and diabetes, along with lower dietary intake of energy, protein, fat, carbohydrates, dietary fiber, and vitamin C, compared to the non-BLS group. A below-average intake of energy and carbohydrates was associated with increased odds of hypertension and diabetes, particularly in the BLS group. For dietary fiber, a significant association with diabetes was found only in the BLS group. Sedentary behavior exceeding 9 h per day was linked to higher odds of chronic diseases in both groups, with stronger associations in the BLS group. Limited walking frequency (less than 1 day per week) further exacerbated risks.

CONCLUSIONS

BLS recipients demonstrated higher chronic disease prevalence, poorer dietary habits, and more sedentary behavior compared to non-recipients. The associations between lifestyle factors and chronic diseases were generally more substantial in the BLS group, suggesting the need for targeted interventions to improve dietary quality and physical activity patterns in this vulnerable population.

Making end-of-life health disparities in the U.S. visible through family bereavement narratives

Objective

End-of-life experiences can have important implications for the meaning-making and communication of bereaved family members, particularly due to (in)access to formal healthcare services (i.e., palliative care and hospice). Grounded in Communicated Narrative Sense-Making theory, this study extends knowledge about how the stories told about end-of-life by bereaved family members affect and reflect their sense-making, well-being and importantly, potential disparities in end-of-life care.

Methods

Semi-structured interviews with 25 bereaved individuals were conducted regarding their experiences with the terminal illness and death of an immediate family member. Using a framework of family bereavement narratives, a cross-case data analysis demonstrated qualitative patterns between (in)access to end-of-life care and how participants framed bereavement stories.

Results

Four themes illustrated the continuum of communication that families engaged in when making sense of end-of-life experiences, including reflections on silence, tempered frustrations, comfort with care, and support from beyond.

Innovation

This innovative qualitative connection between family members' bereavement stories and end-of-life care emphasizes the importance of employing a health equity lens within hospice and palliative care, especially in addressing the important aim of comprehensively supporting families even when illness ends. This study demonstrates that access to, quality of, and imagining beyond current structures for EOL may be vital factors for facilitating effective sense-making for the dying and their family systems.

Conclusion

These findings illustrate the potential interconnections between (in)access to end-of-life care, sense-making, and communication for individuals and families experiencing terminal illness and bereavement.

Conceptual frameworks for the integration of genetic and social epidemiology in complex diseases

Uncovering the root causes of complex diseases requires complex approaches, yet many studies continue to isolate the effects of genetic and social determinants of disease. Epidemiologic efforts that under-utilize genetic epidemiology methods and findings may lead to incomplete understanding of disease. Meanwhile, genetic epidemiology studies are often conducted without consideration of social and environmental context, limiting the public health impact of genomic discoveries. This divide endures despite shared goals and increases in interdisciplinary data due to a lack of shared theoretical frameworks and differing language. Here, we demonstrate that bridging epidemiological divides does not require entirely new ways of thinking. Existing social epidemiology frameworks including Ecosocial theory and Fundamental Cause Theory, can both be extended to incorporate principles from genetic epidemiology. We show that genetic epidemiology can strengthen, rather than detract from, efforts to understand the impact of social determinants of health. In addition to presenting theoretical synergies, we offer practical examples of how genetics can improve the public health impact of epidemiology studies across the field. Ultimately, we aim to provide a guiding framework for trainees and established epidemiologists to think about diseases and complex systems and foster more fruitful collaboration between genetic and traditional epidemiological disciplines.

Patients with type 2 diabetes and surgical foot wounds: Overtrust in primary care physicians, isolation, and difficulties contemplating the future

AIMS

In Europe, 27 % of patients with a podiatric complication of diabetes are referred to a specialized structure for surgery after more than 3 months' disease progression. Our study aimed to analyze access to healthcare and future self-projection in patients with severe diabetic foot conditions.

METHODS

We performed a qualitative study with semi-structured interviews in patients hospitalized with diabetic foot conditions requiring surgical treatment. We collected quantitative data on the diabetes characteristics, levels of social precariousness, anxiety and depression.

RESULTS

We conducted 13 interviews with 2 females and 11 males; mean age 62.7 years. Five had undergone surgical debridement, six toe amputation, and two mid-tarsal amputation. Most were socioeconomically deprived and/or isolated. Three discourse themes emerged: 1) heterogeneity in the care pathway, with systemic barriers, negligence or overtrust 2) relationship between social support and the ability to project oneself into the future, 3) poverty of speech.

CONCLUSIONS

Education should emphasize the importance of prompt referral to a specialized structure after the onset of a wound. The lack of support from loved ones and social support appeared to be associated with patients' failure to plan for their future. We advocate for a psychological evaluation and support for all these patients.

Social mechanisms behind the poor health of marginalized Roma: Novel insights and implications from four ethnographic studies in Slovakia

Roma represent one of the largest ethnic groups facing marginalization worldwide. However, significant knowledge gaps persist regarding: A) the social mechanisms supporting health-endangering practices among Roma; B) the social mechanisms adversely affecting their use of health services; and C) the social determinants underlying both above pathways. To fill these gaps, we conducted a series of four explorative ethnographic studies spanning over ten years. Beginning in 2004, the series involved 260 participants, including segregated Roma and health services staff in Slovakia. Of the four studies, two addressed gap A, two addressed gap B, and all addressed gap C. Regarding pathway A, we found that Roma in segregated Roma enclaves can be socialized into ethnically framed racialized ideologies that oppose the cultural standards of local non-Roma life, including certain healthy practices. This adherence to counter-cultural ideals of Roma identity increases specific health and care challenges. Regarding pathway B, we discovered that health service frontliners frequently lack any organizational support to better understand and accommodate the current living conditions and practices of segregated Roma, as well as their own and others' racism and professional expectations regarding equity. This lack of support leads many frontliners to become cynical about segregated Roma over their careers, resulting in health services being less effective and exacerbating health problems for both Roma and the frontliners themselves. Concerning pathway C, we found that the societal omnipresence of antigypsyism - racist and racialized anti-Roma ideas and sentiments - serves as a prominent driver of both the above pathways. We conclude that much of the unfavorable health status of Roma can be understood via a systems perspective that embraces structural racism.

Neighborhood Racial and Ethnic Predominance, Child Opportunity, and Violence-Related Mortality among Children and Adolescents in Chicago

Our objective was to determine whether Child Opportunity Index (COI), a measure of neighborhood socioeconomic and built environment specific to children, mediated the relationship of census tract Black or Hispanic predominance with increased rates of census tract violence-related mortality. The hypothesis was that COI would partially mediate the relationship. This cross-sectional study combined data from the American Community Survey 5-year estimates, the COI 2.0, and the Illinois Violent Death Reporting System 2015-2019 for the City of Chicago. Individuals ages 0-19 years were included. The primary exposure was census tract Black, Hispanic, White, and other race predominance (> 50% of population). The primary outcome was census tract violence-related mortality. A mediation analysis was performed to evaluate the role of COI as a potential mediator. Multivariable logistic regression modeling census tract violence-related mortality demonstrated a direct effect of census tract Black predominance (adjusted odds ratio [aOR] 2.59, 95% confidence interval [CI] 1.30-5.14) on violence-related mortality compared to White predominance. There was no association of census tract Hispanic predominance with violence-related mortality compared to White predominance (aOR 1.57, 95% CI 0.88-2.84). Approximately 64.9% (95% CI 60.2-80.0%) of the effect of census tract Black predominance and 67.9% (95% CI 61.2-200%) of the effect of census tract Hispanic predominance on violence-related mortality was indirect via COI. COI partially mediated the effect of census tract Black and Hispanic predominance on census tract violence-related mortality. Interventions that target neighborhood social and economic factors should be considered to reduce violence-related mortality among children and adolescents.

Addressing Hypertension Disparities via Systems Dynamics: Insights From Community Health Connections

Background and objective Hypertension remains a major public health challenge in the United States, disproportionately affecting various demographic groups. Significant disparities persist in hypertension prevalence and control due to interactions between socioeconomic factors, healthcare access, and systemic inequities. In this study, we aimed to determine the impact of socioeconomic and healthcare factors on hypertension control among patients at Community Health Connections (CHC), a Federally Qualified Health Center serving 36 communities in North Central Massachusetts, and identify effective interventions using systems dynamics modeling to promote health equity. Materials and methods This was a retrospective observational study using data from 2023 CHC patients, and the National Health and Nutrition Examination Survey (NHANES) 2011-2014. Systems dynamics modeling was employed to visualize interactions among factors influencing hypertension outcomes. The study included 4,870 CHC patients. Participants were selected based on clinical records and comprised 3,690 White participants (76%), 464 Black/African American participants (10%), 108 Asian participants (2%), and 608 classified as Other/Non-reported (12%). The cohort included 2,490 males (51%) and 2,380 females (49%). Socioeconomic factors (e.g., race, age, insurance status) and healthcare access were the study variables. The primary outcome was hypertension control, defined as a blood pressure reading of <140/90 mmHg. The study measured control rates across different demographic groups and assessed the impact of socioeconomic and healthcare factors on these rates. Results Among the 4,870 CHC patients, 3,007 (62%) achieved hypertension control. The overall hypertension control rate varied significantly by race: White: 68.6%, Black/African American: 61.6%, Asian: 63.2%, and Other/Non-reported: 65.6%. Insured patients had a control rate of 67.7%, compared to 37.5% for uninsured patients (p<0.001). Systems dynamics models illustrated how socioeconomic disparities and healthcare access issues amplify health inequities. Key interventions identified include, but are not limited to, multidisciplinary care teams, community health worker programs, and telehealth services. Conclusions Addressing hypertension disparities among CHC patients requires a systemic approach integrating socioeconomic, healthcare, and policy-related interventions. Systems dynamics modeling provides a framework for designing and implementing targeted interventions, enhancing health equity, and improving hypertension control outcomes in underserved populations. Further research is needed to test the effectiveness of these interventions before their broad implementation.

S. S. Exploring the acceptance of robotic assisted surgery among the Indian population: An empirical investigation

Background

Technology has completely transformed healthcare, starting with X-ray machines and MRIs to telehealth and robotic surgeries to e-health records. The launch of minimally invasive surgery (MIS) serves as a milestone in medical history, offering benefits such as smaller incisions, shorter hospital stays, and faster recovery, making it a preferred surgical option. This study mainly explores patients' willingness to adopt robot-assisted surgery (RAS) technology in a surgical intervention and is assessed in the backdrop of the Technology Acceptance Model (TAM).

Methods

This research project employs a post-positivist research philosophy and a cross-sectional research design. A structured, pre-tested questionnaire was used to collect data from 280 respondents.

Results

The results revealed that trust had a significant impact on Perceived Usefulness (β = 0.099) and Perceived Ease of Use (β = .157), and eHealth literacy had a significant impact on Perceived Ease of Use (β = 0.438) and Perceived Usefulness (β = 0.454). Additionally, Perceived Usefulness partially influenced behavioral intention (β = 0.123), and attitude had a significant influence on behavioral intention (β = 0.612). The analysis revealed an insignificant impact of eHealth literacy on Perceived Usefulness (β = 0.067). The Standard Root Mean Square Residual (SRMR) value was <0.8. Mediation analysis also revealed partial mediation between the constructs. The SRMR rating of this model is 0.067, indicating that it fits the data well.

Conclusion

This study revealed that a patient's intention will be high if he or she believes that RAS is beneficial in treating his or her ailment. In comparison, information related to RAS is clearly known, and it does not directly affect selection intention. eHealth literacy is a significant antecedent to patients' behavioral intention. Hence, the healthcare industry must devise strategies to promote the acceptance of RAS at all levels.

Qualitative research on undergraduate nursing students' recognition and response to short videos' health disinformation

Background

With the popularity of the internet, short videos have become an indispensable tool to obtain health information. However, avoiding health disinformation owing to the openness of the Internet is difficult for users. Disinformation may endanger the health and lives of users.

Objective

With a focus on the process of identifying short videos' health disinformation and the factors affecting the accuracy of identification, this study aimed to investigate the identification methods, coping strategies, and the impact of short videos' health disinformation on undergraduate nursing students. The findings will provide guidance to users on obtaining high-quality and healthy information, in addition to reducing health risks.

Methods

Semi-structured in-depth interviews were conducted with 22 undergraduate nursing students in October 2022, and data were collected for collation and content analyses.

Results

The techniques used to identify short videos that include health disinformation as well as how undergraduate nursing students perceived these videos' features are among the study's findings. The failure factors in identification, coping paths, and adverse impacts of short videos on health disinformation were analyzed. The platform, the material itself, and the students' individual characteristics all have an impact on their identifying behavior.

Conclusions

Medical students continue to face many obstacles in identifying and responding to health disinformation through short videos. Preventing and stopping health disinformation not only requires individual efforts to improve health literacy and maintain rational thinking, it also requires the joint efforts of short video producers, relevant departments, and platforms.

Chronic Kidney Disease Is Associated With Increased All-Cause Mortality Risk Among Older Black Adults

Background and Objectives

Older patients diagnosed with chronic kidney disease (CKD) have a higher risk of all-cause mortality than the general population. However, there is limited information available on how CKD relates to all-cause mortality among Black adults in the United States. We aimed to investigate how CKD relates to all-cause mortality risk among older Black adults.

Research Design and Methods

This study draws on a subsample of self-identified Black participants (N = 1 393) from the Health and Retirement Study ages 52 to 96 who completed the anthropomorphic and biomarker supplement in 2006/2008. Our measure of CKD derives from serum cystatin C-based using dried blood spots, and all-cause mortality derives from the National Death Index and a key informant within the household from 2006 to 2019.

Results

Twenty-nine percent of respondents died during the study period, whereas 31% had CKD. The mean age of the entire sample is 64.52. Results from our Cox proportional hazards models showed that CKD was independently associated with an increased risk of death from all causes among older Black participants in a model that adjusted for demographics, behavioral, clinical, and health characteristics.

Discussion and Implications

Results from our study confirm that CKD is associated with increased risk of death from all causes among older Black adults. Future studies should examine whether changes in CKD over time relate to all-cause mortality risk among older Black adults.

Assessing the Influence of Redlining on Intergenerational Wealth and Body Mass Index Through a Quasi-experimental Framework

BACKGROUND

Higher levels of body mass index (BMI), particularly for those who have obesity defined as class II and III, are correlated with excess risk of all-cause mortality in the USA, and these risks disproportionately affects marginalized communities impacted by systemic racism. Redlining, a form of structural racism, is a practice by which federal agencies and banks disincentivized mortgage investments in predominantly racialized minority neighborhoods, contributing to residential segregation. The extent to which redlining contributes to current-day wealth and health inequities, including obesity, through wealth pathways or limited access to health-promoting resources, remains unclear. Our quasi-experimental study aimed to investigate the generational impacts of redlining on wealth and body mass index (BMI) outcomes.

METHODS

We leveraged the Panel Study of Income Dynamics (PSID) and Home Owners' Loan Corporation (HOLC) maps to implement a geographical regression discontinuity design, where treatment assignment is randomly based on the boundary location of PSID grandparents in yellowlined vs. redlined areas and used outcome measures of wealth and mean BMI of grandchildren. To estimate our effects, we used a continuity-based approach and applied data-driven procedures to identify the most appropriate bandwidths for a valid estimation and inference.

RESULTS

In our fully adjusted model, grandchildren with grandparents living in redlined areas had lower average household wealth (β =  - $35,419; 95% CIrbc - $37,423, - $7615) and a notably elevated mean BMI (β = 7.47; 95% CIrbc - 4.00, 16.60), when compared to grandchildren whose grandparents resided in yellowlined regions.

CONCLUSION

Our research supports the idea that redlining, a historical policy rooted in structural racism, is a key factor contributing to disparities in wealth accumulation and, conceivably, body mass index across racial groups.

Exploring ethnic and racial differences in intraocular pressure and glaucoma: The Canadian Longitudinal Study on aging

Purpose

To determine whether self-reported race/ethnicity is associated with intraocular pressure (IOP) and glaucoma and to explore whether any associations are due to social, behavioral, genetic, or health differences.

Design

Cross-sectional analysis of population-based data.

Methods

We used the Canadian Longitudinal Study on Aging Comprehensive Cohort, which consists of 30,097 adults aged 45-85 years. Race/ethnicity was self-reported. Corneal-compensated intraocular pressure (IOP) was measured in mmHg using the Reichert Ocular Response Analyzer. Participants were asked to report if they have ever had a diagnosis of glaucoma and whether they used eye care in the past year. A glaucoma polygenic risk score (PRS) was calculated. Logistic and linear regression models were used.

Results

Black individuals had higher mean IOP levels (beta coefficient (β) = 1.46; 95% confidence interval [CI], 0.62, 2.30) while Chinese, Japanese and Korean (β = -1.00; 95% CI, -1.63, -0.38) and Southeast Asian and Filipino individuals (β = -1.56; 95% CI, -2.68, -0.43) had lower mean IOP levels as compared to White individuals after adjustment for sociodemographic, behavioral, genetic, and health-related variables. Black people were more likely to report glaucoma as compared to White people after adjustment (odds ratio [OR] = 2.43; 95% CI, 1.27, 4.64).

Conclusion

Racial and ethnic differences in IOP and glaucoma were identified. Adjusting for sociodemographic, behavioral, genetic, and health-related variables did not fully explain these differences. Longitudinal research is needed to further explore the reasons for these differences and to understand their relevance to disease pathogenesis and progression.

Patterns and predictors of racial/ethnic disparities in HIV care continuum in the Southern USA: protocol for a population-based cohort study

INTRODUCTION

Health disparities exist at every step of the HIV care continuum (HCC) among racial/ethnic minority population. Such racial/ethnic disparities may have significantly delayed the progress in HCC in the Southern US states that are strongly represented among geographic focus areas in the 2019 federal initiative titled 'Ending the HIV Epidemic: A Plan for America'. However, limited efforts have been made to quantify the long-term spatiotemporal variations of HCC disparities and their contributing factors over time, particularly in the context of COVID-19 pandemic. This project aims to identify the spatiotemporal patterns of racial disparities of each HCC outcome and then determine the contribution of contextual features for temporal change of disparities in HCC.

METHODS AND ANALYSIS

This cohort study will use statewide HIV cohort data in South Carolina, including all people living with HIV (PLWH) who were diagnosed with HIV in 2005-2020. The healthcare encounter data will be extracted from longitudinal EHR from six state agencies and then linked to aggregated county-level community and social structural-level data (eg, structural racism, COVID-19 pandemic) from multiple publicly available data sources. The South Carolina Revenue of Fiscal and Affairs will serve as the honest broker to link the patient-level and county-level information. We will first quantify the HCC-related disparities by creating a county-level racial/ethnic disparity index (RDI) for each key HCC outcomes (eg, HIV testing, timely diagnosis), examine the temporal patterns of each RDI over time and then using geographical weighted lasso model examine which contextual factors have significant impacts on the change of county-level RDI from 2005 to 2020.

ETHICS AND DISSEMINATION

The study was approved by the Institutional Review Board at the University of South Carolina (Pro00121718) as a Non-Human Subject study. The study's findings will be published in peer-reviewed journals and disseminated at national and international conferences and through social media.

Analysis of social determinants of health and individual factors found in health equity frameworks: Applications to injury research

INTRODUCTION

This research evaluated existing health equity frameworks as they relate to social determinants of health (SDOHs) and individual factors that may impact injury outcomes and identify gaps in coverage using the Healthy People (HP) 2030 key domains.

METHODS

The study used a list of health equity frameworks sourced from previous literature. SDOHs and individual factors from each framework were identified and categorized into the Healthy People 2030 domains. Five injury topic areas were used as examples for how SDOHs and individual factors can be compared to injury topic-specific health disparities to identify health equity frameworks to apply to injury research.

RESULTS

The study identified 59 SDOHs and individual factors from the list of 33 health equity frameworks. The number of SDOHs and individual factors identified varied by Healthy People 2030 domain: Neighborhood and Built Environment contained 16 (27.1%) SDOHs and individual actors, Social and Community Context contained 22 (37.3%), Economic Stability contained 10 (16.9%), Healthcare Access and Quality contained 10 (16.9%), and Education Access and Quality contained one (1.7%). Twenty-three (39.0%) SDOHs/individual factors related to traumatic brain injury, thirteen (22.0%) related to motor vehicle crashes and suicide, 11 (18.6%) related to drowning and older adult falls. Eight frameworks (24.2%) covered all HP 2030 key domains and may be applicable to injury topics.

CONCLUSIONS

Incorporating health equity into research is critical. Health equity frameworks can provide a way to systematically incorporate health equity into research. The findings from this study may be useful to health equity research by providing a resource to injury and other public health fields.

PRACTICAL APPLICATIONS

Health equity frameworks are a practical tool to guide injury research, translation, evaluation, and program implementation. The findings from this study can be used to guide the application of health equity frameworks in injury research for specific topic areas.

A health equity framework to support the next generation of cancer population simulation models

Over the past 2 decades, population simulation modeling has evolved as an effective public health tool for surveillance of cancer trends and estimation of the impact of screening and treatment strategies on incidence and mortality, including documentation of persistent cancer inequities. The goal of this research was to provide a framework to support the next generation of cancer population simulation models to identify leverage points in the cancer control continuum to accelerate achievement of equity in cancer care for minoritized populations. In our framework, systemic racism is conceptualized as the root cause of inequity and an upstream influence acting on subsequent downstream events, which ultimately exert physiological effects on cancer incidence and mortality and competing comorbidities. To date, most simulation models investigating racial inequity have used individual-level race variables. Individual-level race is a proxy for exposure to systemic racism, not a biological construct. However, single-level race variables are suboptimal proxies for the multilevel systems, policies, and practices that perpetuate inequity. We recommend that future models designed to capture relationships between systemic racism and cancer outcomes replace or extend single-level race variables with multilevel measures that capture structural, interpersonal, and internalized racism. Models should investigate actionable levers, such as changes in health care, education, and economic structures and policies to increase equity and reductions in health-care-based interpersonal racism. This integrated approach could support novel research approaches, make explicit the effects of different structures and policies, highlight data gaps in interactions between model components mirroring how factors act in the real world, inform how we collect data to model cancer equity, and generate results that could inform policy.

Mechanism substitution in preventive innovations: Dissecting the reproduction of health inequalities in the United States

In the last three decades, numerous studies in different countries have corroborated the main postulates of the Fundamental Cause Theory (FCT), providing evidence showing how health inequalities are reproduced as society increases its capacity to control disease and/or avoid its consequences through preventive innovations. However, documenting the reproductive logic proposed by the theory requires the development of a dynamic analytical approach to consider socioeconomic disparities in the incorporation of multiple preventive innovations over time, which could act as mediating mechanisms of the durable relationship between socioeconomic status and health/mortality. This study draws on data from different waves of the National Health Interview Survey and the National Health and Nutrition Examination Survey to analyze the diffusion processes of various innovations in the U.S. The results of the study show that educational inequalities emerge, are amplified, and are reduced by the continuous diffusion of preventive innovations, supporting the meta-hypothesis of substitution of mediating mechanisms according to the interconnections of FCT and Diffusion of Innovation Theory.

Socioecological determinants of child oral health-A scoping review

OBJECTIVES

Child oral health is a result of interactions between multilevel influences within a complex system. Understanding those interactions informs conceptualizing a socioecological framework of important influences on oral health. This paper aimed to present a scoping review on the determinants of dental caries and their interactions in childhood and adolescence.

METHODS

The two review questions were as follows: Which factors are determinants of child dental caries? and, How do determinants interact within and across socioecological levels? The three main electronic databases for biomedical records, PubMed, Web of Science and Scopus were searched, followed by reference check. The search and screening/selection procedures followed an a priori strategy and inclusion/exclusion criteria were specified in advance. The main components of the strategy were participants, concept and context. Following the final selection, eligible studies were assessed with quality appraisal tools for the risk of methodologic biases. Determinants reported in the included studies were then assigned to the micro-, meso-, exo- or macro-systems levels in a socioecological framework. Interactions between determinants were also identified and reported.

RESULTS

A total of 100 studies were included after removal of duplicates, screening on the title/abstracts and full-text assessment among 3313 records initially identified. A higher number of studies included were cross-sectional studies published in recent years. The majority of determinants found to influence child dental health were assigned to microsystem level within the framework. However, determinants were found at all levels and interactions were reported within and between socioecological levels. Determinants identified in the scoping review represent factors at different socioecological levels that influence child oral health.

CONCLUSION

Application of a socioecological model through a complex systems approach should lead to valid and robust progress towards practical solutions for better child oral health globally.

A Rubric to Center Equity in Obstetrics and Gynecology Research

The Steering Committee for the Obstetrics & Gynecology special edition titled "Racism in Reproductive Health: Lighting a Path to Health Equity" formed a working group to create an equity rubric. The goal was to provide a tool to help researchers systematically center health equity as they conceptualize, design, analyze, interpret, and evaluate research in obstetrics and gynecology. This commentary reviews the rationale, iterative process, and literature guiding the creation of the equity rubric.

Environmental neurodevelopment toxicity from the perspective of Bronfenbrenner's bioecological model: a case study of toxic metals

A growing body of literature reports the need for an integrated approach to study the effects of the physical environment on the neurodevelopment of children. Assessment of the true neurotoxicity of pollutants cannot be performed separately from the ecological and multidimensional contexts in which they act. In this study, from the perspective of the Bronfenbrenner's bioecological model, a conceptual model was developed that encompasses the social and biological characteristics of children from the gestational period to childhood, considering exposure to toxic metals. First, we present the toxicity of the main metals and some concept notions that we used in our framework, such as social and structural determinants of health, allostatic load, embodiment, and epigenetic concepts. Then, the main aspects of the Bronfenbrenner's bioecological model, which allow integration of the gene-social relationship in addition to the physical environment, where these metals act, are explained. Finally, we present and discuss the conceptual framework showing how, in real life, biological and social factors may together influence the neurodevelopment of children. Although this model is based on a group of contaminants, it opens new horizons on how environmental sciences, such as neurotoxicology and environmental epidemiology, can articulate with the theoretical models from human sciences to provide a broader approach to study the effects on human neurodevelopment.

Determinants of Inequities in Neurologic Disease, Health, and Well-being: The NINDS Social Determinants of Health Framework

A National Institute of Neurological Disorders and Stroke working group developed the Determinants of Inequities in Neurological Disease, Health, and Well-being framework. Our goal was to guide and inspire a new generation of neurologic research that pushes the field to design and test new approaches in pursuit of health equity, population health, and social justice. We seek to expand the lens of those looking to reduce or eliminate racial, socioeconomic status, and other inequities in neurologic disease, health, and well-being to improve our collective ability to create research, programs, and policies that lead to larger, more impactful, and more sustainable change in neurologic disease patterns. In this context, we outline a framework that includes and highlights "upstream" factors in the hopes of enhancing the focus of research, programmatic, and policy efforts to reduce and eliminate inequities in neurologic health and well-being. We explicitly discuss racism and other structural factors to clarify that social determinants are not natural and unchangeable. Populations with a disproportionate burden of neurologic disease are not inherently deficient, despite what some approaches to framing health inequities imply. The framework is presented linearly, but the pathways linking the determinants of neurologic disease, health, and well-being are far more complex than those demonstrated by the arrows included in the figure. The framework highlights the different levels and scale of causation, including the structural and intermediary social determinants and their impact on neurologic health. We offer this framework to refine efforts to contextualize the interpretation of neurologic research findings and suggest new avenues for their application. We illustrate how behavioral and biological factors occur in a social and economic context, factors that have been understudied as points of intervention to reduce inequities in neurologic disease. Considering social and structural determinants of health provides promising new opportunities to achieve neurologic health equity, reach social justice, and improve our science. Extending our work in this fashion is not simply about health equity or social justice but to fundamentally improve the quality of neurologic research by enhancing underlying theory and improving study design and implementation.

Association between socio-economic status and estimated atherosclerotic cardiovascular disease risk: results from a middle-aged population-based study

OBJECTIVES

The association between cardiovascular disease (CVD) risk and socio-economic status (SES) remains poorly studied. The purpose of this study was to investigate the relationship between SES and estimated 10-year atherosclerotic cardiovascular disease (ASCVD) risk among the general UK Biobank population.

STUDY DESIGN

This was a population-based study.

METHODS

Among 311,928 volunteers (47.7% men) of the UK Biobank population, SES was assessed by a questionnaire, and ASCVD risk was calculated using pooled cohort equation models. Associations between SES and ASCVD risk were estimated using multiple gender-specific regressions.

RESULTS

The findings from this study showed that men had higher estimated 10-year ASCVD risk than women (8.6% vs 2.7%; P < 0.001), higher education level (38.3% vs 36.2%; P < 0.001), higher income level (31.0% vs 25.1%; P < 0.001), higher levels of employment (65.4% vs 60.5%; P < 0.001) and higher scores of Townsend deprivation (P < 0.001). Using the multiple logistic regression model, a decreased 10-year ASCVD risk in men was associated with high income level (odds ratio [OR] = 0.64 [95% confidence interval {CI} 0.61-0.68]; P < 0.001), high educational level (OR = 0.71 [95% CI 0.68-0.74]; P < 0.001), higher Townsend deprivation quintile (OR = 0.81 [95% CI 0.78-0.85]; P < 0.001) and employed status (OR = 0.74 [95% CI 0.69-0.80]; P < 0.001). The same results were observed in women, with high income level (OR = 0.68 [95% CI 0.55-0.68]; P < 0.001), high educational level (OR = 0.87 [95% CI 0.82-0.93]; P < 0.001), higher Townsend deprivation quintile (OR = 0.74 [95% CI 0.69-0.80]; P < 0.001) and employed status (OR = 0.53 [95% CI 0.45-0.63]; P < 0.001) being associated with a lower 10-year ASCVD risk. When considering the false discovery rate logworth analysis, SES factors presented a similar contribution to CVD risk as lifestyle factors.

CONCLUSIONS

Health policies should consider the SES factors identified in this study, in addition to traditional risk factors, when designing prevention campaigns for CVD. Further research is required to improve the ASCVD risk prediction models among different SES variables.

An Agenda for Advancing Research and Prevention at the Nexus of Work Organization, Occupational Stress, and Mental Health and Well-Being

Work characteristics and worker well-being are inextricably connected. In particular, the characteristics of work organization shape and perpetuate occupational stress, which contributes to worker mental health and well-being outcomes. Consequently, the importance of understanding and addressing connections between work organization, occupational stress, and mental health and well-being-the focus of this Special Issue-increasingly demand attention from those affected by these issues. Thus, focusing on these issues in the long-haul truck driver (LHTD) sector as an illustrative example, the purpose of this commentary is as follows: (1) to outline current research approaches and the extant knowledge base regarding the connections between work organization, occupational stress, and mental health; (2) to provide an overview of current intervention strategies and public policy solutions associated with the current knowledge base to protect and promote worker mental health and well-being; and (3) to propose a two-pronged agenda for advancing research and prevention for workers during the 21st century. It is anticipated that this commentary, and this Special Issue more broadly, will both echo numerous other calls for building knowledge and engaging in this area and motivate further research within complementary current and novel research frameworks.

Social Determinants, Blood Pressure Control, and Racial Inequities in Childbearing Age Women With Hypertension, 2001 to 2018

Background Hypertension is an important modifiable risk factor of serious maternal morbidity and mortality. Social determinants of health (SDoH) influence hypertension outcomes and may contribute to racial and ethnic differences in hypertension control. Our objective was to assess SDoH and blood pressure (BP) control by race and ethnicity in US women of childbearing age with hypertension. Methods and Results We studied women (aged 20-50 years) with hypertension (systolic BP ≥140 mm Hg or diastolic BP ≥90 mm Hg or use of antihypertensive medication) in the National Health and Nutrition Examination Surveys 2001 to 2018. SDoH and BP control (systolic BP <140 mm Hg and diastolic BP <90 mm Hg) were examined by race and ethnicity (White race, Black race, Hispanic ethnicity, and Asian race). Using multivariable logistic regression, odds of uncontrolled BP by race and ethnicity were modeled, adjusting for SDoH, health factors, and modifiable health behaviors. Responses on hunger and affording food determined food insecurity status. Across women of childbearing age with hypertension (N=1293), 59.2% were White race, 23.4% were Black race, 15.8% were Hispanic ethnicity, and 1.7% were Asian race. More Hispanic and Black women experienced food insecurity than White women (32% and 25% versus 13%; both P<0.001). After SDoH, health factor, and modifiable health behavior adjustment, Black women maintained higher odds of uncontrolled BP than White women (odds ratio, 2.31 [95% CI, 1.08-4.92]), whereas Asian and Hispanic women showed no difference. Conclusions We identified racial inequities in uncontrolled BP and food insecurity among women of childbearing age with hypertension. Further exploration beyond the SDoH measured is needed to understand the inequity in hypertension control in Black women.

Diabetes-Related Quality of Life: Learning From Individuals Making Lifestyle Changes to Improve Type 2 Diabetes Control

PURPOSE

The purpose of this study was to explore how treatment adherence and lifestyle changes required for glycemic control in type 2 diabetes (T2D) are related to quality of life (QoL) among predominantly ethnic minority and socioeconomically disadvantaged adults engaged in making changes to improve T2D self-management.

METHODS

Adults with T2D in New York City were recruited for the parent study based on recent A1C (≥7.5%) and randomly assigned to 1 of 2 arms, receiving educational materials and additional self-management support calls, respectively. Substudy participants were recruited from both arms after study completion. Participants (N = 50; 62% Spanish speaking) were interviewed by phone using a semistructured guide and were asked to define QoL and share ways that T2D, treatment, self-management, and study participation influenced their QoL. Interviews were analyzed using thematic analysis.

RESULTS

QoL was described as a multidimensional health-related construct with detracting and enhancing factors related to T2D. Detracting factors included financial strain, symptom progression and burden, perceived necessity to change cultural and lifestyle traditions, and dietary and medical limitations. Enhancing factors included social support, diabetes education, health behavior change, sociocultural connection.

CONCLUSION

QoL for diverse and socioeconomically disadvantaged adults with T2D is multifaceted and includes aspects of health, independence, social support, culture, and lifestyle, which may not be captured by existing QoL measures. Findings may inform the development of a novel QoL measure for T2D.

The role of energy balance related behaviors in socioeconomic inequalities in childhood body mass index: A comparative analysis of Germany, the Netherlands, the United Kingdom, and the United States

Socioeconomic inequalities in childhood Body Mass Index (BMI) are becoming increasingly more pronounced across the world. Although countries differ in the direction and strength of these inequalities, cross-national comparative research on this topic is rare. This paper draws on harmonized longitudinal cohort data from four wealthy countries-Germany, the Netherlands, the United Kingdom (UK), and the United States (US)-to 1) map cross-country differences in the magnitude of socioeconomic inequalities in childhood BMI, and 2) to examine cross-country differences in the role of three energy-balance-related behaviors-physical activity, screen time, and breakfast consumption-in explaining these inequalities. Children were aged 5-7 at our first timepoint and were followed up at age 8-11. We used data from the German National Educational Panel Study, the Dutch Generation R study, the UK Millennium Cohort Study and the US Early Childhood Longitudinal-Kindergarten Study. All countries revealed significant inequalities in childhood BMI. The US stood out in having the largest inequalities. Overall, inequalities between children with low versus medium educated parents were smaller than those between children with high versus medium educated parents. The role of energy-balance-related behaviors in explaining inequalities in BMI was surprisingly consistent. Across countries, physical activity did not, while screen time and breakfast consumption did play a role. The only exception was that breakfast consumption did not play a role in the US. Cross-country differences emerged in the relative contribution of each behavior in explaining inequalities in BMI: Breakfast consumption was most important in the UK, screen time explained most in Germany and the US, and breakfast consumption and screen time were equally important in the Netherlands. Our findings suggest that what constitutes the most effective policy intervention differs across countries and that these should target both children from medium as well as low educated families.

Toolkit article: Approaches to measuring social inequities in health in human biology research

Across populations, human morbidity and mortality risks generally follow clear gradients, with socially-disadvantaged individuals and groups tending to have higher morbidity and mortality at all life stages relative to those more socially advantaged. Anthropologists specialize in understanding the proximate and ultimate factors that shape variation in human biological functioning and health and are therefore well-situated to explore the relationships between social position and health in diverse ecological and cultural contexts. While human biologists have developed sophisticated methods for assessing health using minimally-invasive methods, at a disciplinary level, we have room for conceptual and methodological improvement in how we frame, measure, and analyze the social inequities that might shape health inequities. This toolkit paper elaborates on some steps human biologists should take to enhance the quality of our research on health inequities. Specifically, we address: (1) how to frame unequal health outcomes (i.e., inequalities vs. disparities vs. inequities) and the importance of identifying our conceptual models of how these inequities emerge; (2) how to measure various axes of social inequities across diverse cultural contexts, and (3) approaches to community collaboration and dissemination. We end by discussing (4) future directions in human biology research of health inequities, including understanding the ultimate causes of sensitivity to social inequities and transitioning from research to action.

A stakeholder-driven framework for measuring potential change in the health risks of people who inject drugs (PWID) during the COVID-19 pandemic

BACKGROUND

People who inject drugs (PWID) have likely borne disproportionate health consequences of the COVID-19 pandemic. PWID experienced both interruptions and changes to drug supply and delivery modes of harm reduction, treatment, and other medical services, leading to potentially increased risks for HIV, hepatitis C virus (HCV), and overdose. Given surveillance and research disruptions, proximal, indirect indicators of infectious diseases and overdose should be developed for timely measurement of health effects of the pandemic on PWID.

METHODS

We used group concept mapping and a systems thinking approach to produce an expert stakeholder-generated, multi-level framework for monitoring changes in PWID health outcomes potentially attributable to COVID-19 in the U.S. This socio-ecological measurement framework elucidates proximal and distal contributors to infectious disease and overdose outcomes, many of which can be measured using existing data sources.

RESULTS

The framework includes multi-level components including policy considerations, drug supply/distribution systems, the service delivery landscape, network factors, and individual characteristics such as mental and general health status and service utilization. These components are generally mediated by substance use and sexual behavioral factors to cause changes in incidence of HIV, HCV, sexually transmitted infections, wound/skin infections, and overdose.

CONCLUSION

This measurement framework is intended to increase the quality and timeliness of research on the impacts of COVID-19 in the context of the current pandemic and future crises. Next steps include a ranking process to narrow the drivers of change in health risks to a concise set of indicators that adequately represent framework components, can be written as measurable indicators, and are quantifiable using existing data sources, as well as a publicly available web-based platform for summary data contributions.

Research translation: A pathway for health inequity

In a context of social inequity, research translation naturally furthers health inequity. As Fundamental Cause Theory (FCT) explains-and an associated empirical literature illustrates-those with more resources benefit earlier and more from scientific innovation than those with fewer resources. Therefore, research translation of its own course creates and widens health disparities based on socioeconomic status and race/ethnicity. Yet, the conversation about research translation has yet to center this critical reality, undermining our efforts to address heath inequity. Moving toward sustainable health equity requires that we build the evidence base for, prioritize, and institutionalize translation approaches that center the needs and assets of low-resource populations (with community engagement helping toward that end). However, even the impact of that approach will be limited if we as a society do not mobilize knowledge to address social inequity and the many ways in which it shapes health. The health research community should engage the FCT paradigm to think critically about resource allocation among different kinds of research and action. Moreover, in our contributions to discussions about the road to health equity, we must be forthcoming about the reality FCT describes and the limitations it indicates for achieving health equity through translation of biomedical, clinical, health services, and health behavior research alone.

Socioeconomic status and modification of atherosclerotic cardiovascular disease risk prediction: epidemiological analysis using data from the atherosclerosis risk in communities study

OBJECTIVE

Examine whether the relationship between the pooled cohort equations (PCE) predicted 10-year risk for atherosclerotic cardiovascular disease (ASCVD) and absolute risk for ASCVD is modified by socioeconomic status (SES).

DESIGN

Population-based longitudinal cohort study-Atherosclerosis Risk in Communities (ARIC)-investigating the development of cardiovascular disease across demographic subgroups.

SETTING

Four communities in the USA-Forsyth County, North Carolina, Jackson, Mississippi, suburbs of Minneapolis, Minnesota and Washington County, Maryland.

PARTICIPANTS

We identified 9782 ARIC men and women aged 54-73 without ASCVD at study visit 4 (1996-1998).

PRIMARY OUTCOME MEASURES

Risk ratio (RR) differences in 10-year incident hospitalisations or death for ASCVD by SES and PCE predicted 10-year ASCVD risk categories to assess for risk modification. SES measures included educational attainment and census-tract neighbourhood deprivation using the Area Deprivation Index. PCE risk categories were 0%-5%, >5%-10%, >10%-15% and >15%. SES as a prognostic factor to estimate ASCVD absolute risk categories was further investigated as an interaction term with the PCE.

RESULTS

ASCVD RRs for participants without a high school education (referent college educated) increased at higher PCE estimated risk categories and was consistently >1. Results indicate education is both a risk modifier and delineates populations at higher ASCVD risk independent of PCE. Neighbourhood deprivation did modify association but was less consistent in direction of effect. However, for participants residing in the most deprived neighbourhoods (referent least deprived neighbourhoods) with a PCE estimated risk >10%-15%, risk was significantly elevated (RR 1.65, 95% CI 1.05 to 2.59). Education and neighbourhood deprivation inclusion as an interaction term on the PCE risk score was statistically significant (likelihood ratio p≤0.0001).

CONCLUSIONS

SES modifies the association between PCE estimated risk and absolute risk of ASCVD. SES added into ASCVD risk prediction models as an interaction term may improve our ability to predict absolute ASCVD risk among socially disadvantaged populations.

Disparities in Geographic Access to Cardiac Rehabilitation in Los Angeles County

Background Exercise-based cardiac rehabilitation (CR) is known to reduce morbidity and mortality for patients with cardiac conditions. Sociodemographic disparities in accessing CR persist and could be related to the distance between where patients live and where CR facilities are located. Our objective is to determine the association between sociodemographic characteristics and geographic proximity to CR facilities. Methods and Results We identified actively operating CR facilities across Los Angeles County and used multivariable Poisson regression to examine the association between sociodemographic characteristics of residential proximity to the nearest CR facility. We also calculated the proportion of residents per area lacking geographic proximity to CR facilities across sociodemographic characteristics, from which we calculated prevalence ratios. We found that racial and ethnic minorities, compared with non-Hispanic White individuals, more frequently live ≥5 miles from a CR facility. The greatest geographic disparity was seen for non-Hispanic Black individuals, with a 2.73 (95% CI, 2.66-2.79) prevalence ratio of living at least 5 miles from a CR facility. Notably, the municipal region with the largest proportion of census tracts comprising mostly non-White residents (those identifying as Hispanic or a race other than White), with median annual household income <$60 000, contained no CR facilities despite ranking among the county's highest in population density. Conclusions Racial, ethnic, and socioeconomic characteristics are significantly associated with lack of geographic proximity to a CR facility. Interventions targeting geographic as well as nongeographic factors may be needed to reduce disparities in access to exercise-based CR programs. Such interventions could increase the potential of CR to benefit patients at high risk for developing adverse cardiovascular outcomes.

Health equity guiding frameworks and indices in injury: A review of the literature

BACKGROUND

In early 2021, CDC released the CORE Health Equity Strategy, which resolves to integrate a comprehensive health equity approach to the work of the Agency. One priority of the Injury Center's Division of Injury Prevention is to move health equity research in injury forward. The purpose of this research is to perform an initial exploration of health equity guiding frameworks and indices to better understand which of these has been applied to injury research topics.

METHODS

A PubMed and CINAHL search of meta-analysis and systematic review articles was conducted from January 1998 through April 2022. Articles of any type and additional frameworks/indices were also identified from staff knowledge of the literature. Books were also considered, where accessible. The following areas were reviewed for each resource: population addressed, guiding framework/index, other health equity variables, gaps identified, and whether the articles addressed an injury topic.

FINDINGS

The PubMed/CINAHL search produced 230 articles, and an additional 29 articles and 8 books were added from previous knowledge of the literature, resulting in a total of 267 resources for review. There were 60 frameworks/indices compiled that were relevant to health equity. Out of all the resources, three reported on an injury topic and used the PROGRESS-Plus framework, the WHO Social Determinants of Health Conceptual Framework, and a social-ecological framework.

CONCLUSIONS

This study found there were many frameworks/indices for measuring health equity; however, there were few injury-related meta-analysis and systematic review articles. Some frameworks/indices may be more appropriate than others for measuring health equity in injury topic areas, depending on which social determinants of health (SDOHs) they address.

PRACTICAL APPLICATIONS

Measuring health equity in injury and other public health research areas can help build a foundation of evidence. Moving forward, injury researchers can consider the frameworks/indices identified through this study in their health equity injury research.

Barriers and Promotors to Health Service Utilization for Pelvic Floor Disorders in the United States: Systematic Review and Meta-analysis of Qualitative and Quantitative Studies

IMPORTANCE

We need a systematic approach to understanding health service utilization behavior in women with pelvic floor symptoms in the United States.

OBJECTIVES

The aim of this study was to determine the prevalence of pelvic floor care utilization and identify its barriers and promotors using Andersen's model, which theorizes care-seeking behavior with individual care needs, resources, predispositions, and macrostructures.

DESIGN

This was a systematic search of studies on care-seeking patterns in women with symptomatic pelvic floor disorders, which included pelvic organ prolapse, lower urinary tract symptoms, and anal incontinence. We then performed meta-analyses with random-effects models and descriptive analysis to determine utilization rate and the impact of each identified determinant.

RESULTS

The pooled utilization rate was 37% (95% confidence interval [CI], 30%-45%). Determinants were identified across all domains except at the macrostructure level. For individual care needs, increased symptom severity or duration and a history of depression (odds ratio [OR], 1.27; 95% CI, 1.07-1.51) were associated with higher utilization. In the resources domain, having social support and established primary/secondary care were promotors, whereas higher income and employed status trended as barriers. Under predispositions, age ≥50 years (OR, 1.29; 95% CI, 1.05-1.60), and pelvic floor awareness were associated with utilization, whereas Asian (OR, 0.60; 95% CI, 0.51-0.72) and Black (OR, 0.77; 95% CI, 0.55-1.08) women as well as women experiencing fear, misinformation, or normalization of pelvic floor disorders had decreased utilization.

CONCLUSIONS

This review identified a low utilization rate for pelvic floor care and revealed multilayered, actionable items affecting care-seeking behavior. It highlights the need for more inclusive and multifaceted approaches in future pelvic floor disparity research and equity interventions.

Psychosocial Stress and Hypothalamic-Pituitary-Adrenal Axis Stress Reactivity: Variations by Race and Socioeconomic Status Among Adults at Risk of Diabetes

OBJECTIVE

Although stress is posited to play a key role in health disparities, the extent to which commonly used self-report psychosocial stress measures are related to neurobiological stress processes, especially across diverse populations, is unresolved. This study examined how two measures of psychosocial stress, perceived stress and domain-specific stress, covary with the acute neurobiological stress response.

METHODS

The Richmond Stress and Sugar Study includes a racially and socioeconomically diverse cohort of adults at risk for type 2 diabetes ( n = 125; mean age = 57 years, 48% Black, and 61% high neighborhood socioeconomic status [SES]). Hypothalamic-pituitary-adrenal axis reactivity was assessed by salivary cortisol response to the Trier Social Stress Test (TSST), a laboratory stressor.

RESULTS

Higher perceived stress was associated with a lower cortisol response to the TSST (-7.5%; 95% confidence interval [CI] = -13.1% to -1.5%) but was not associated with cortisol recovery after the TSST (3%; 95% CI = -0.6% to 6.8%). In contrast, domain-specific stress was not associated with cortisol response (-2.1%; 95% CI = -20.7% to 20.9%) but was inversely associated with cortisol recovery (3.7%; 95% CI = 0.6% to 7.0%). SES modified these associations: both perceived stress and domain-specific stress were associated with TSST cortisol response only among participants from high-SES neighborhoods. There was minimal evidence of effect modification by race.

CONCLUSIONS

Both self-report measures of psychosocial stress were associated with hypothalamic-pituitary-adrenal axis reactivity to an acute stressor. These associations varied by perceived versus domain-specific measurement scales and by neighborhood SES. Further efforts to refine stress measures and clarify biological linkages between social status and health are needed.

Mitigating structural racism to reduce inequities in sepsis outcomes: a mixed methods, longitudinal intervention study

BACKGROUND

Sepsis affects 1.7 million patients in the US annually, is one of the leading causes of mortality, and is a major driver of US healthcare costs. African American/Black and LatinX populations experience higher rates of sepsis complications, deviations from standard care, and readmissions compared with Non-Hispanic White populations. Despite clear evidence of structural racism in sepsis care and outcomes, there are no prospective interventions to mitigate structural racism in sepsis care, nor are we aware of studies that report reductions in racial inequities in sepsis care as an outcome. Therefore, we will deliver and evaluate a coalition-based intervention to equip health systems and their surrounding communities to mitigate structural racism, driving measurable reductions in inequities in sepsis outcomes. This paper presents the theoretical foundation for the study, summarizes key elements of the intervention, and describes the methodology to evaluate the intervention.

METHODS

Our aims are to: (1) deliver a coalition-based leadership intervention in eight U.S. health systems and their surrounding communities; (2) evaluate the impact of the intervention on organizational culture using a longitudinal, convergent mixed methods approach, and (3) evaluate the impact of the intervention on reduction of racial inequities in three clinical outcomes: a) early identification (time to antibiotic), b) clinical management (in-hospital sepsis mortality) and c) standards-based follow up (same-hospital, all-cause sepsis readmissions) using interrupted time series analysis.

DISCUSSION

This study is aligned with calls to action by the NIH and the Sepsis Alliance to address inequities in sepsis care and outcomes. It is the first to intervene to mitigate effects of structural racism by developing the domains of organizational culture that are required for anti-racist action, with implications for inequities in complex health outcomes beyond sepsis.

Structural Racism and Quantitative Causal Inference: A Life Course Mediation Framework for Decomposing Racial Health Disparities

Quantitative studies of racial health disparities often use static measures of self-reported race and conventional regression estimators, which critics argue is inconsistent with social-constructivist theories of race, racialization, and racism. We demonstrate an alternative counterfactual approach to explain how multiple racialized systems dynamically shape health over time, examining racial inequities in cardiometabolic risk in the National Longitudinal Study of Adolescent to Adult Health. This framework accounts for the dynamics of time-varying confounding and mediation that is required in operationalizing a "race" variable as part of a social process (racism) rather than a separable, individual characteristic. We decompose the observed disparity into three types of effects: a controlled direct effect ("unobserved racism"), proportions attributable to interaction ("racial discrimination"), and pure indirect effects ("emergent discrimination"). We discuss the limitations of counterfactual approaches while highlighting how they can be combined with critical theories to quantify how interlocking systems produce racial health inequities.

Prevalence of Overweight and Obesity in Children of Immigrant Origin in Spain: A Cross-Sectional Study

Social determinants of health are a major contributing factor to health inequalities and have important effects on the health of the population. The aim of the study was to estimate the prevalence of overweight/obesity in native and immigrant children aged 2-14 years residing in Spain, and to explore its relationship with socioeconomic factors, habits, and living and health conditions. This study used data from the 2017 Spanish National Health Survey, which collects health information on the population residing in Spain. Multivariate logistic regression models were fitted to estimate the risk of overweight/obesity controlling for the variables of interest. The final sample consisted of 2351 households. Children of immigrant origin had a significantly higher overall prevalence of overweight and/or obesity than natives, both in boys (40.5% vs. 29.5%) and girls (44.8% vs. 30.3%), and a higher adjusted risk of overweight/obesity (OR = 1.67). In addition, it has been observed that children of immigrant origin were at higher risk of consuming sugary soft drinks, exercising less, and using screens more. In conclusion, the increased risk of having different habits that may contribute to developing excess weight and of having overweight/obesity in children with a migrant background should guide public health policies and interventions, emphasizing those groups at higher risk and incorporating considerations of socioeconomic inequalities.

The data will not save us: Afropessimism and racial antimatter in the COVID-19 pandemic

The Trump Administration's governance of COVID-19 racial health disparities data has become a key front in the viral war against the pandemic and racial health injustice. In this paper, I analyze how the COVID-19 pandemic joins an already ongoing racial spectacle and system of structural gaslighting organized around "racial health disparities" in the United States and globally. The field of racial health disparities has yet to question the domain assumptions that uphold its field of investigation; as a result, the entire reform program called for by racial health disparities science is already featured on the menu of the white supremacist power structure. The societal infrastructure that produces scientific knowledge about patterns of health and disease in the human population needs to confront its structural position as part of the racial spectacle organized around racial health disparities in the United States. This paper offers an interpretation of racial antimatter to explain why the data will not save us in the COVID-19 pandemic, drawing on articulations of racial spectacle and structural gaslighting within critical race theory and Afropessimist thought. By positioning events in the COVID-19 pandemic together within the same racially speculative frame, I show how the collection of racial health disparities data came up against white supremacists' political ambitions in a time-space where the demand for human life to matter and the iterative regeneration of racial antimatter collided. This paper highlights the need for ongoing analysis of the unfolding and future spectacles organized around racial health disparities.

The Magnitude and Potential Causes of Sex Disparities in Statin Therapy in Veterans with Type 2 Diabetes: A 10-year Nationwide Longitudinal Cohort Study

BACKGROUND

Past research has shown that women eligible for statin therapy are less likely than their male counterparts to receive any statin therapy or be prescribed a statin at the guideline-recommended intensity. We compared statin treatment in men and women veterans from a national cohort of older veterans with type 2 diabetes.

METHODS

The Veterans Health Administration Corporate Data Warehouse and Centers for Medicare and Medicaid Services data were used to create a unique dataset and perform a longitudinal study of veterans with type 2 diabetes from 2007 to 2016. Mixed-effects logistic regression was used to model the association between the primary exposure (sex) and statin use.

RESULTS

The study included 714,212 veterans with diabetes, including 9,608 women, with an overall mean age of 75.9 years. In the unadjusted model for any statin use, women veterans had a 14% significantly lower odds of having any statin use compared with men. After adjusting for all covariates, including markers of Veterans Administration care use (service-connected disability rating, Veterans Administration use, and primary care visits) that serve as proxies for access and mental health comorbidities (depression and psychiatric disorder), this disparity narrowed from 14% to 3% and was no longer statistically significant. In the model for high-intensity statin therapy (high-intensity vs. low or none), women were 10% less likely than men to use high-intensity statins in the base model that included only time and sex. After adjusting for all measured covariates, the direction of the association changed and women had 16% higher odds of high-intensity statin use compared with men (odds ratio, 1.16; 95% confidence interval, 1.03-1.31).

CONCLUSIONS

Consistent with prior research, in the unadjusted analysis a significant sex disparity was observed in statin use, with lower rates observed in women. For the outcome of any statin use, after adjustment for covariates that included variables that are proxies for access as well as psychiatric and depression comorbidities, this disparity lost statistical significance and narrowed. In the high-intensity statin versus low or none model, the direction of the association changed after controlling for measured covariates and women had a 16% higher odds of high-intensity statin use compared with men. This study highlights a persistent health disparity in lipid-lowering therapy for women veterans. Additional research is needed to further elucidate the reasons for and develop interventions to mitigate this persistent sex disparity in cholesterol management for veterans with diabetes.

Identifying the link between chemical exposures and breast cancer in African American women via integrated in vitro and exposure biomarker data

Among women, breast cancer is the most prevalent form of cancer worldwide and has the second highest mortality rate of any cancer in the United States. The breast cancer related death rate is 40 % higher in non-Hispanic Black women compared to non-Hispanic White women. The incidence of triple negative breast cancer (TNBC), an aggressive subtype of breast cancer for which there is no targeted therapy, is also approximately three times higher for Black, relative to, White women. The drivers of these differences are poorly understood. Here, we aimed to identify chemical exposures which play a role in breast cancer disparities. Using chemical biomonitoring data from the National Health and Nutrition Examination Survey (NHANES) and biological activity data from the EPA's ToxCast program, we assessed the toxicological profiles of chemicals to which US Black women are disproportionately exposed. We conducted a literature search to identify breast cancer targets in ToxCast to analyze the response of chemicals with exposure disparities in these assays. Forty-three chemical biomarkers are significantly higher in Black women. Investigation of these chemicals in ToxCast resulted in 32,683 assays for analysis, 5172 of which contained nonzero values for the concentration at which the dose-response fitted model reaches the cutoff considered "active". Of these chemicals BPA, PFOS, and thiram are most comprehensively assayed. 2,5-dichlorophenol, 1,4-dichlorobenzene, and methyl and propyl parabens had higher biomarker concentrations in Black women and moderate testing and activity in ToxCast. The distribution of active concentrations for these chemicals in ToxCast assays are comparable to biomarker concentrations in Black women NHANES participants. Through this integrated analysis, we identify that multiple chemicals, including thiram, propylparaben, and p,p' DDE, have disproportionate exposures in Black women and have breast cancer associated biological activity at human exposure relevant doses.

Understanding and Responding to Health Literacy as a Social Determinant of Health

Evidence of a social gradient in health literacy has been found in all reported national population surveys. Health literacy is a midstream determinant of health but not a panacea for addressing health inequities created by the maldistribution of opportunity and resources. It is possible to optimize the contribution health literacy makes in mediating the causes and effects of established social determinants of health. Existing interventions demonstrate the feasibility of improving health literacy among higher-risk populations, but research remains underdeveloped and effects on health inequity are largely untested. Future health literacy intervention research should focus on (a) improving the quality of health communication that reaches a diversity of populations, especially by improving frontline professional skills and support; (b) enabling people to develop transferable skills in accessing, understanding, analyzing, and applying health information; and (c) ensuring that priority is proportionate to need by reaching and engaging the population groups who are disproportionately affected by low health literacy.

Reframing racial and ethnic disparities in atopic dermatitis in Black and Latinx populations

Black people in the United States experience greater atopic dermatitis (AD) prevalence, severity, and persistence when compared with White people. Although very little published literature describes AD in the Latinx population, additional differences in severity, persistence, and age of onset exist in contrast to White people. Thus far, genetic polymorphisms associated with increased risk and/or severity of AD are less common among Black people, so should confer reduced, rather than the observed increased, AD risk among Black people. Little is known regarding genetic risk factors in Latinx people. In contrast, there is consistent evidence that socioeconomic, environmental, and health care factors influence AD prevalence, severity, and/or persistence, and these same risk factors are more common among racial and ethnic minority populations as a result of racism. Researchers too often pursue genetic explanations for racial and ethnic AD disparities when the evidence points to the importance of contextual, rather than genetic, causes of these disparities. Reframing the prevailing view that innate differences among racial and ethnic groups are responsible for these disparities by emphasizing the role of racism and its downstream effects on contextual factors will be a critical first step toward shrinking these disparities.

Cigarette use and binge drinking among Korean adolescents: examining the moderating role of multicultural status

Cigarette is usually used conjointly with alcohol however its impact may vary with how much alcohol is being consumed. Besides the general use of alcohol, this study specifically focused on identifying the association between cigarette use and binge drinking of Korean adolescents. Furthermore, it aims to testify whether the multicultural status plays a moderating role in this relationship, and to discover other problem behavior theory constructs that may be associated with binge drinking of the Korean adolescents. Using the nationally representative data from the 2018 Korea Youth Health Risk Survey, 60,040 students were selected to perform chi-square, t-test, and hierarchical multiple regression. There was a strong association between cigarette use and binge drinking, and multicultural status had the moderating effect in this relationship. More specifically, adolescents from the multicultural families had higher levels of cigarette use and binge drinking than the non-multicultural adolescents. Besides these main findings, covariates such as suicidal ideation, sexual intercourse, e-cigarette use, and harmful experiences from the alcohol use of others were found to be the additional significant factors of Korean adolescents' binge drinking. Based on these findings, author suggests for the combined interventions for alcohol and tobacco, and raise awareness on the possible health disparities that could occur between multicultural families and non-multicultural families in South Korea.

Mental health issues and health disparities amid COVID-19 outbreak in China: Comparison of residents inside and outside the epicenter

The Coronavirus Disease-2019 (COVID-19) has exerted an impact on not only individuals who have contracted the virus but also the general public. This study compared the mental health condition of residents in the epicenter province of Hubei with that of other Chinese residents during the initial stage of the COVID-19 outbreak, and to examine emerging issues revolving around health disparities in disease prevention. A survey was administered in February 2020 to 433 Chinese adults spanning 28 regions across China. Participants residing in Hubei reported lower levels of affective and cognitive well-being than those in other regions. Perceived behavioral control and healthy lifestyle maintenance were associated with both dimensions of well-being and sleep quality for all participants. Income level was positively associated with facemask use and healthy lifestyle maintenance. These results indicate that Hubei residents reported poorer mental health than those of other regions, but perceived behavioral control and healthy lifestyle maintenance correlate with better mental health across regions. The likelihood of undertaking preventive measures for COVID-19 tends to be greater among residents with higher income, reflecting the need to address the oft-neglected concerns of health disparities in preventing this highly contagious novel disease.

Geographical heterogeneity across England in associations between the neighbourhood built environment and body mass index

Effects of residential neighbourhood environments on health may vary across geographical space, with differences in local contexts influencing how much a given neighbourhood characteristic matters for the health of local residents. Linking UK Biobank data from 302,952 urban-dwelling adults in England, collected between 2006 and 2010, to publicly available Local Authority-level data, we examined (a) whether cross-sectional associations between body mass index (BMI) and two characteristics of the neighbourhood built environment (availability of formal physical activity facilities near home, and fast-food proximity) vary by Local Authority (LA), and (b) whether cross-level interactions with LA-level physical features (natural landcover) and socio-cultural attributes (local obesity norms) reveal evidence of effect modification by these features of the wider contexts in which neighbourhoods are located. We found variation across urban England in the relationship between availability of neighbourhood formal physical activity facilities and BMI, and some evidence suggesting this association was stronger among people living in areas with less natural landcover, especially in areas outside of London. We also found that the relationship between proximity of fast-food stores to people's homes and BMI varied geographically across England. Local descriptive obesity norms were not an important modifier of this association. This paper highlights the importance of considering potential geographical heterogeneity in relationships between the built environment and health, and the implications for generalisability of research findings. By seeking to better understand sources of geographical heterogeneity, we may be able to better adapt and target built environment interventions for population health improvement.

Does postponing retirement affect cognitive function? A counterfactual experiment to disentangle life course risk factors

Evidence suggests that contemporaneous labor force participation affects cognitive function; however, it is unclear whether it is employment itself or endogenous factors related to individuals’ likelihood of employment that protects against cognitive decline. We exploit innovations in counterfactual causal inference to disentangle the effect of postponing retirement on later-life cognitive function from the effects of other life-course factors. With the U.S. Health and Retirement Study (1996–2014, n = 20,469), we use the parametric g-formula to estimate the effect of postponing retirement to age 67. We also study whether the benefit of postponing retirement is affected by gender, education, and/or occupation, and whether retirement affects cognitive function through depressive symptoms or comorbidities. We find that postponing retirement is protective against cognitive decline, accounting for other life-course factors (population: 0.34, 95% confidence interval (CI): 0.20,0.47; individual: 0.43, 95% CI: 0.26,0.60). The extent of the protective effect depends on subgroup, with the highest educated experiencing the greatest mitigation of cognitive decline (individual: 50%, 95% CI: 32%,71%). By using innovative models that better reflect the empirical reality of interconnected life-course processes, this work makes progress in understanding how retirement affects cognitive function.

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Research is inconclusive as to employments' protection against cognitive decline.

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Causal inference models can better reflect interconnected life-course processes.

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The parametric g-formula shows a substantial protective effect of ongoing employment.

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Protective effect holds for all subgroups, but is greatest for the highest educated.

Transdisciplinary Perspectives on Precision Medicine

Purpose: The Precision Medicine Health Disparities Collaborative fosters collaboration between researchers with diverse backgrounds in precision medicine and health disparities research, to include training at the interface between genomics and health disparities. Understanding how perceptions about precision medicine differ by background may inform activities to better understand such differences. Methods: We conducted a cross-sectional survey of Center members and beyond. Data were collected on categories of educational background, current activities, and level of agreement with 20 statements related to genomics and health disparities. Respondents categorized their background and activities as social/behavioral, genetics, both, or neither. Fisher's exact test was used to assess levels of agreement in response to each statement. Statistically significant associations were further analyzed using ordinal logistic regression adjusting for age, self-identified race/ethnicity, and gender. Results: Of 130 respondents, 50 (38%) identified educational backgrounds and current activities as social-behavioral or genomic 55 (42%). Respondents differed by educational background on the statement Lifestyle and other life experiences influence how genes impact disease risk (p=0.0009). Respondents also differed by current activities on the statement Reducing disparities in access to health care will make precision medicine more effective (p=0.0008), and on Racism and discrimination make me concerned about how genetic test results will be used (p=0.0011). Conclusions: Respondents who differed on prior education and current activities, whether social behavioral science or human genomics, were associated with different perceptions regarding precision medicine and health disparities. These results identify potential barriers and opportunities to strengthen transdisciplinary collaboration.