Socioeconomic disparities in health outcomes in the United States in the late 2010s: results from four national population-based studies

Childhood Maltreatment and Physical Health in College Students: Physical Activity and Binge Eating as Moderators

Child maltreatment leads to pervasive physical health problems. For individuals with a child maltreatment history, physiological risk factors for future disease are apparent by young adulthood. The current study explored the role that physical activity and binge eating may have in the trajectory from child maltreatment to poor adult health. We administered the following measures to 100 female and male college students: resting heart rate assessment, symptoms of illness, and the Childhood Trauma Questionnaire (CTQ-SF) to assess maltreatment history. After this session, participants wore a Fitbit that provided physical activity data (low, moderate, and vigorous activity, and total steps) in a free-living environment for a period of 10 days. Physical activity moderated the pathway between maltreatment history and both resting heart rate and symptoms of illness. In individuals with higher CTQ scores, more low-intensity physical activity and total steps were related to fewer symptoms of illness and lower resting heart rate, respectively. Binge-eating behavior moderated the pathway between maltreatment and symptoms of illness, such that greater binge-eating behavior was associated with more self-reported illness symptoms in participants with higher CTQ scores. These findings suggest that on-campus interventions targeting physical activity and healthy eating behaviors will improve the long-term health of young adults with maltreatment history.

Racial, Ethnic, and Socioeconomic Trends in Microtia and Anotia Care

This study aims to investigate the effects of ethnic, racial, and socioeconomic differences on outcomes for patients undergoing surgical management for microtia or anotia in the United States. Using the Pediatric Health Information System (PHIS) database, 2928 patients presenting for primary microtia or anotia reconstruction between 2017 and 2023 were analyzed. The majority of patients were non-White (55.2%, 1617/2928), with a significant proportion identifying as Hispanic/Latino (48.5%, 1421/2928). Non-White patients were more likely to present at a later age for surgery (10.8 versus 9.4 y; P=0.036), reside in urban areas (90.4% versus 82.2%, P<0.01), and live in households with incomes below the national median (71.7% versus 69.1%; P=0.13). Similarly, Hispanic/Latino patients presented at an older age (10.7 versus 9.0 y; P<0.01), were more frequently located in urban areas (90.6% versus 82.6%; P<0.01), and more likely to live in households with incomes below the national median (79.2% versus 61.8%; P<0.01). In the United States, the majority of patients presenting for primary reconstruction of microtia or anotia are non-White and Hispanic/Latino. This suggests an increased prevalence in these populations. Non-White and Hispanic/Latino patients are more likely to live in households with incomes below the national median and are more likely to present at a later age for primary reconstructive procedures. Multidisciplinary care teams should prioritize the development and implementation of targeted outreach programs to improve timely access to care for at-risk populations.

Unveiling trends in urinary tract cancer mortality among older adults in the United States (1999-2022): a CDC WONDER perspective

BACKGROUND

Urinary tract cancers (UTCs), including bladder cancer, remain a significant public health challenge, particularly among individuals aged 75 and older. Despite declining bladder cancer-specific mortality rates between 2015 and 2020, the broader trends in UTC mortality and associated demographic disparities remain underexplored.

METHODS

We analyzed mortality data from 1999 to 2022 using the CDC WONDER database. UTC deaths were identified using ICD- 10 codes C64 to C68. Age-adjusted mortality rates (AAMRs) per 100,000 population were calculated, stratified by sex, race/ethnicity, and census regions. Joinpoint regression identified annual percent changes (APCs) to assess temporal trends.

RESULTS

From 1999 to 2022, 477,157 UTC deaths were recorded, 66% of which occurred among individuals aged 75 and older. The AAMR increased from 97.1 in 1999 to 103.5 in 2022, with a rise between 1999 and 2007 (APC: 0.63%), a decline from 2007 to 2019 (APC: - 0.33%), and a resurgence from 2019 to 2022 (APC: 2.42%). Older males exhibited higher AAMRs than females (178.7 vs. 53.6 in 2022), and Whites had the highest AAMR (108.5) among racial groups. The Western region recorded the highest AAMR (84.3) during the study period.

CONCLUSION

The resurgence in UTC mortality post- 2019 highlights emerging challenges, particularly among older males, Whites, and residents of the Western region. Targeted interventions, including improved screening and equitable healthcare access, are essential to mitigate these disparities and improve outcomes.

The Relationship Between Socioeconomic Status and Omphalocele Prevalence

BACKGROUND

The omphalocele is a congenital malformation associated with chromosomal abnormalities, however the exact etiology is unknown. Current research has found maternal obesity, diabetes, and African American race as risk factors for omphalocele development and may point to a social determinant of health causative factor. Here we investigate the socioeconomic characteristics of patients with an omphalocele diagnosis and consider epigenetics as the facilitator in its manifestation.

METHODS

This cross-sectional study used data from the 2019 National Kids' Inpatient Database to investigate patients with an omphalocele diagnosis, generating roughly 1400 data points where median household income (MHI), race, sex, and hospital region were investigated using chi-square analysis and held to a statistically significant p-value of <0.05.

RESULTS

Chi-square analysis found a significant difference within MHI, race, sex, and region in omphalocele incidence. MHI quartiles were $1-47,999 (37 % of patients), $48,000-60,999 (23 %), $61,000-81,999 (22 %), and $82,000+ (18 %), Χ2 (3) = 24.973, p < 0.001. Reported race included White (51.2 %), Black (22.3 %), Hispanic (17.7 %), Asian/Pacific Islander (2.9 %), Native American (0.3 %), and other (5.6 %), Χ2 (5) = 34.739, p < 0.001. Males compromised 55.1 % of patients and Females 44.9 %, Χ2 (1) = 24.005, p < 0.001. Hospital region included the Northeast (15.0 %), Midwest (21.4 %), South (45.2 %), and West (18.4 %), Χ2 (3) = 26.379, p < 0.001.

CONCLUSIONS

This is the first study to show a lower MHI and Southern geographic region is associated with higher incidence of omphaloceles. Further research is necessary to determine the link between socioeconomic status and omphalocele development with epigenetics as the possible mechanism.

LEVEL OF EVIDENCE

Retrospective Study.

LEVEL OF EVIDENCE

III.

Association Between Census Tract-Level Poverty and Non-White Race with Location of Coal Ash Disposal Pits in the United States

Coal ash is a byproduct of coal-fired power plants, and the management and disposal of coal ash in coal ash pits is an environmental health concern. Evidence suggests that socioeconomically disadvantaged communities are more likely to bear the burden of these environmental hazards. However, limited studies have investigated the relationship between socioeconomic status and residential proximity to coal ash pits. We examined associations between census tract poverty and non-white race with the likelihood of having coal ash pits within the census tract. We obtained coal ash pit location and census tract-level data (2017-2021) of the percentage of the population living at or below the federal poverty level and the percentage of the population's non-white race for 82,805 census tracts in the contiguous United States. We implemented multivariable logistic regression models to examine associations between non-white race, poverty, and the likelihood of having one or more coal ash pits in a census tract. Secondary analyses among tracts with at least one coal ash pit evaluated the associations between poverty, non-white race, and the likelihood of having multiple coal ash pits. Models additionally adjusted for census tract region. Census tracts in the highest quartile of poverty were over two times as likely to have one or more coal ash pits (OR = 2.23, 95% CI: 1.52, 3.25). Tracts in the highest quartile of the non-white population had 90% lower odds of having one or more coal ash pits as compared to the lowest quartile (OR = 0.10, 95% CI: 0.06, 0.17). Census tracts with higher levels of poverty were more likely to have one or more coal ash pits, and census tracts with higher non-white populations were less likely to have one or more coal ash pits, suggesting that these associations are complex and indicate an environmental justice issue.

Characterizing pharmacy deserts and designing a model to minimize inequities in pharmacy distribution in Virginia

BACKGROUND

Pharmacy closures have become increasingly prevalent in the United States in recent years. Previous literature highlights socioeconomic and racial disparities in the distribution of pharmacy deserts.

OBJECTIVES

To identify and characterize pharmacy deserts in Virginia and to simulate potential locations to minimize inequities in pharmacy distribution.

METHODS

This cross-sectional study used active pharmacy permits data from the Virginia Board of Pharmacy to identify census tracts considered pharmacy deserts by simultaneously satisfying 2 criteria: 1) low-income status (>20% residents living below the federal poverty line, or median household income <80% of a local comparator); and 2) low-access to pharmacies (distance >1, 5, or 10 miles for urban, suburban, and rural census tracts, respectively). Demographic and socioeconomic characteristics of desert vs. nondesert tracts were compared using Wilcoxon rank-sum tests. Locations within identified pharmacy deserts were randomly generated in 10,000 independent iterations.

RESULTS

Of 2198 census tracts, 51 were considered pharmacy deserts, and 69 met the low-access criterion only. Pharmacy deserts were significantly more common in urban census tracts (5.5%), followed by rural (2.9%), and suburban (0.1%). Compared to nondesert, pharmacy desert tracts had significantly lower percentage of residents under 18 year-old, greater percentage of Black residents, uninsured, with Medicare or Medicaid coverage only, lower median household income, and greater percentage of residents living in poverty. Through geospatial simulation, 44 locations were identified where adding pharmacy services could significantly improve access, each potentially benefiting over 10,000 individuals.

CONCLUSION

Fifty-one tracts in Virginia, primarily in urban areas, were considered pharmacy deserts. Compared to nondeserts, pharmacy desert status was associated with a lower proportion of residents under 18 year-old, greater proportion of Black and uninsured/publicly insured residents, and high poverty level, highlighting disparities in pharmacy access. Geospatial simulation identified several locations where placement of pharmacy services could benefit the largest number of residents living in desert tracts.

The Effect of Community-Level Socioeconomic Status on Surgical Outcomes Following Revision Lumbar Fusion

BACKGROUND

The purpose of this study is to determine the impact of community-level socioeconomic status (SES) on surgical outcomes and patient-reported outcome measures (PROMs) following revision lumbar fusion.

METHODS

Adult patients who underwent revision lumbar fusion surgery from 2011-2021 were grouped by Distressed Community Index (DCI) into Prosperous, Comfortable, Mid-tier, and At-Risk/Distressed cohorts. Demographics, surgical information, and PROMs were compared based on DCI community status. Outcome measures were collected preoperatively, 3 months postoperatively, and 1 year postoperatively.

RESULTS

Eight hundred fifty three patients were included in the final cohort. There was no difference in terms of surgical approach or utilization of a staged procedure between the patient groups. Readmission (P = 0.752) and reoperation rates (P = 0.467) were similar across all community groups. Furthermore, for patients who required reoperation, the incision and drainage or revision surgery rate in each cohort was not statistically different (P = 0.902). Prosperous community patients reported significantly lower Visual Analog Scale Back pain preoperatively in comparison to patients from other DCI communities. All groups experienced a similar degree of postoperative improvement in Visual Analog Scale Back scores (P = 0.271). There were no other differences in preoperative or postoperative PROMs analyzed.

CONCLUSIONS

While there are socioeconomic differences based on DCI, community-level SES was not predictive of worse surgical outcomes following revision lumbar fusion. Patients from the most distressed communities were able to achieve similar improvement after revision surgery. This should encourage spine surgeons to feel comfortable discussing an indicated revision lumbar procedure with patients, and not view SES as a barrier to successful outcomes.

Changes in public awareness of the social determinants of health over 15 years in Wisconsin, United States

Objective

To investigate 15-year changes in public awareness of the social determinants of health (SDoH) between 2007 and 2023.

Methods

A 2007 survey of 1172 Wisconsin, U.S. adults is compared to a 2023 survey of 1631 Wisconsin adults. In both surveys, respondents were asked to rate 16 factors regarding how strongly each impacts health. Regression analyses examine how demographic factors differentiate responses in both survey years.

Results

In both 2007 and 2023, the four most highly rated factors affecting health were: personal health practices, stress, health insurance, and access to affordable health care. Between 2007 and 2023, there was little or no increase, and even some decrease, in endorsement of many social determinants of health like income, education, housing, and social support. Older adults, women, and those with lower income were generally more likely to endorse the SDoH in both years. Party identification was the demographic factor that most strongly differentiated responses, with Democrats rating more highly many of the social determinants of health than either Republicans or Independents in both years. This differentiation by party identification was even stronger in 2023 than 2007.

Conclusions

Despite consistent research documenting the social determinants of health, growing health care and policy attention to the social determinants of health, and population exposure to a variety of social determinants during the COVID-19 pandemic, there is little or no increase in public recognition of the social determinants of health, and notable increasing partisan divides.

Neighborhood disadvantage and pain-related experiences in a pain psychology clinic: The mediating roles of pain catastrophizing and pain-related fear

This study investigated the relationship between neighborhood disadvantage, measured by the Area Deprivation Index (ADI), and pain-related variables in a pain psychology clinic. We also examined the sequential mediating roles of pain catastrophizing and pain-related fear on these relationships. Participants (N = 509) completed questionnaires assessing usual pain intensity, fatigue, emotional distress, and interference with daily activities. The mean ADI score was 32.57 (SD = 22.65), with scores ranging from 1 to 100. Linear regression analysis, adjusting for age and gender, revealed that higher ADI (i.e., less advantage) was significantly associated with higher scores on pain-related variables (pain intensity: B = 0.026, p < .001; fatigue: B = 0.018, p < .001; emotional distress: B = 0.020, p < .001; interference with daily activities: B = 0.014, p = .006). Sequential mediation analysis revealed pain catastrophizing and pain-related fear mediated these relationships, with significant indirect effects for fatigue (B = 0.001, 95% CI [0.000, 0.002]) and interference with daily activities (B = 0.001, 95% CI [0.001, 0.003]) - but not pain intensity or emotional distress. Pain catastrophizing alone mediated neighborhood disadvantage-pain relationship for all variables. The results suggest that neighborhood disadvantage is associated with higher scores on pain-related experiences and that consistent with the fear avoidance model, pain catastrophizing and pain-related fear may play a role in these relationships for fatigue and interference with daily activities. These findings underscore that neighborhood disadvantage is associated with worse pain-related experiences and highlight the importance of considering neighborhood factors in chronic pain management. PERSPECTIVE: This study identifies potential pathways linking neighborhood disadvantage to chronic pain variables, highlighting the roles of pain catastrophizing and pain-related fear. The findings underscore the need for a holistic approach to pain management that recognizes both individual cognitive-emotional factors and the broader social context in which pain occurs.

A composite socioeconomic deprivation index from All of Us survey data: associations with health outcomes and disparities

Socioeconomic deprivation - defined as a lack of social, economic and material resources - is associated with poor health outcomes and health disparities between population groups. The All of Us Research Program is a longitudinal cohort study of diverse participants from the United States, with demographic and social determinants of health data gleaned from participant surveys and health outcome data derived from electronic health records. We developed a composite index of socioeconomic deprivation (iSDI) using a cohort of 202,919 All of Us participants - based on education, employment, health insurance, housing, and income data - and we associated iSDI with health outcomes and disparities. iSDI is significantly associated with 970 out of 1,755 (55.3%) health conditions modeled here, with 661 positive and 309 negative associations. Mental disorders and circulatory diseases show the highest proportion of positive associations with iSDI, whereas neoplasms and congenital anomalies show the highest proportion of negative associations. Black (0.55) and Hispanic (0.52) All of Us participants show higher average iSDI values compared to White (0.29) and Asian (0.24) participants; although the majority of iSDI variation is found within (76.8%) rather than between (23.2%) groups. iSDI mediates 213 out of 399 (53.5%) Black health disparity conditions and 173 out of 297 (58.2%) Hispanic health disparity conditions. The composite socioeconomic deprivation index (iSDI) developed here is associated with a wide variety of health outcomes and disparities in the All of Us cohort, and we make participant iSDI values available on the Researcher Workbench to support future studies on social determinants of health.

Nonalcoholic Fatty Liver Disease and Ethnicity: Lessons Learned from the Arab Population in Israel

Non-alcoholic fatty liver disease (NAFLD) is the most common liver disease. We aimed to investigate the potential similarities and differences regarding the disease among Arabs and Jews. Retrospective study included all patients older than 18 years with NAFLD diagnosis according to ICD-10 codes. Data regarding demographics, comorbidities, and outcomes were retrieved using the MdClone platform from "Clalit" in Israel. Data concerning 34,090 Arab patients and 173,500 Jewish patients with NAFLD were included. Arab patients were significantly younger at diagnosis (35.0 ± 13 years vs. 43.6 ± 15 years, p < 0.001) and had higher rates of obesity and diabetes mellitus (69.5% vs. 56.5% and 27.0% vs. 22.7%, p < 0.001, respectively). Arab patients had higher rates of cirrhosis and portal hypertension-related complications (2.5% vs. 2.0%, p < 0.001), esophageal varices (0.9% vs. 0.5%, p < 0.001), spontaneous bacterial peritonitis (0.3% vs. 0.1%, p < 0.001), and hepatorenal syndrome (0.3% vs. 0.1%, p < 0.001). There was no significant difference in the prevalence of hepatocellular carcinoma between study groups (0.4% vs. 0.5%, p = 0.156). Liver transplantation was performed in 0.2% of Arab NAFLD patients compared to 0.07% of Jewish NAFLD patients (p < 0.001). Lower rates of all-cause mortality were found among the Arab NAFLD patients versus Jewish NAFLD patients (7.7% versus 11.5%, p < 0.001). According to the Cox regression model, Arab ethnicity is a risk factor for death with OR of 1.36. Significant differences regarding comorbidities, complications, liver transplantations rates, and all-cause mortality were found among NAFLD patients of different ethnicities, hence specific population need specific consideration in prevention, early diagnosis and follow up.

Racial and Ethnic Disparities and the National Burden of COVID-19 on Inpatient Hospitalizations: A Retrospective Study in the United States in the Year 2020

BACKGROUND

Since January 2020, COVID-19 has affected more than 100 million people in the U.S. Previous studies on racial and ethnic disparities related to characteristics and outcomes of COVID-19 patients have been insightful. However, appropriate epidemiologic age-standardization of the disease burden and disparities for hospitalization data are lacking.

OBJECTIVE

To identify and describe racial and ethnic disparities for primary COVID-19 hospitalizations in the U.S. in 2020.

METHODS

In this nationally representative observational study, we use the National Inpatient Sample to quantify racial and ethnic disparities in COVID-19 hospitalizations. Descriptive statistics for patient characteristics, common comorbidities, age-standardized hospitalization rates, inpatient complications, and mortality among COVID-19 hospitalizations were contrasted by race and ethnicity.

RESULTS

There were 1,058,815 primary COVID-19 hospitalizations in 2020. Of those, 47.2% were female, with median age of 66 (IQR, 54, 77). Overall inpatient mortality rate was 11.1%. When compared to White patients, Black, Hispanic, and Native American patients had higher age-standardized hospitalization rate ratios of 2.42 (95% CI 2.40-2.43), 2.26 (2.25-2.28), and 2.51 (2.46-2.56), respectively. Non-White patients had increased age-adjusted rates for procedures and complications. Factors associated with inpatient mortality include age, male sex, Hispanic or Native American race or ethnicity, lower income, Medicaid, heart failure, arrhythmias, coagulopathy, and chronic liver disease.

CONCLUSIONS

Marginalized populations in the U.S. had over twice the COVID-19 hospitalization rate relative to White patients. Age-adjusted mortality rates were highest for Black, Hispanic, and Native American patients. Careful consideration for vulnerable populations is encouraged during highly communicable respiratory pandemics.

Evidence-Based Therapist-Supported Digital Mental Health Intervention for Patients Experiencing Medical Multimorbidity: A Retrospective Cohort Intent-to-Treat Study

OBJECTIVE

Multimorbidity or the co-occurrence of multiple health conditions is increasing globally and is associated with significant psychological complications. It is unclear whether digital mental health (DMH) interventions for patients experiencing multimorbidity are effective, particularly given that this patient population faces more treatment resistance. The goal of the current study was to examine the impact of smartphone-delivered DMH interventions for patients presenting with elevated internalizing symptoms that have reported multiple lifetime medical conditions.

METHODS

This preregistered (see https://osf.io/vh2et/ ) retrospective cohort intent-to-treat study with 2819 patients enrolled in a therapist-supported DMH intervention examined the associations between medical multimorbidity (MMB) and mental health outcomes.

RESULTS

Results indicated that more MMB was significantly associated with greater presenting mental health symptom severity. MMB did not have a deleterious influence on depressive symptom trajectories across treatment, although having one medical condition was associated with a steeper decrease in anxiety symptoms compared to patients with no medical conditions. Finally, MMB was not associated with time to dropout, but was associated with higher dropout and was differentially associated with fewer beneficial treatment outcomes, although this is likely attributable to higher presenting symptom severity, rather than lesser symptom reductions during treatment.

CONCLUSIONS

Overall, the Meru Health Program was associated with large effect size decreases in depressive and anxiety symptoms regardless of the number of MMB. Future DMH treatments and research might investigate tailored barrier reduction and extended treatment lengths for patients experiencing MMB to allow for greater treatment dose to reduce symptoms below clinical outcome thresholds.

Lower socioeconomic status may help explain racial disparities in asthma and atopic dermatitis prevalence: A mediation analysis

BACKGROUND

Racial disparities in atopic disease (atopic dermatitis [AD], asthma, and allergies) prevalence are well documented. Despite strong associations between race and socioeconomic deprivation in the United States, and socioeconomic status (SES) and atopic diseases, the extent to which SES explains these disparities is not fully understood.

OBJECTIVE

We sought to identify racial disparities in childhood atopic disease prevalence and determine what proportion of those disparities is mediated by SES.

METHODS

This study used the National Health Interview Survey (2011-2018) to investigate AD, asthma, and respiratory allergy prevalence in Black and White children and the extent to which measures of SES explain any identified disparities.

RESULTS

By race, prevalences were as follows: AD, White 11.8% (95% CI: 11.4%, 12.2%) and Black 17.4% (95% CI: 16.6%, 18.3%); asthma prevalence, White 7.4% (95% CI: 7.0%, 7.7%) and Black 14.3% (95% CI: 13.5%, 15.0%); respiratory allergy, White 11.4% (95% CI: 11.0%, 11.9%) and Black 10.9% (95% CI: 10.3%, 11.6%). The percentage of the disparity between racial groups and disease prevalence explained by a multivariable measure of SES was 25% (95% CI: 15%, 36%) for Black versus White children with AD and 47% (95% CI: 40%, 54%) for Black versus White children with asthma.

CONCLUSIONS

In a nationally representative US population, Black children had higher prevalence of AD and asthma than White children did and similar prevalence of respiratory allergy; a multivariable SES measure explained a proportion of the association between Black versus White race and AD and a much larger proportion for asthma.

Development of food literacy in children and adolescents: implications for the design of strategies to promote healthier and more sustainable diets

Food literacy has emerged as a key individual trait to promote the transformation of food systems toward healthy and sustainable diets. Childhood and adolescence are key periods for establishing the foundations of eating habits. Different food literacy competencies are acquired as children develop different cognitive abilities, skills, and experiences, contributing to the development of critical tools that allow them to navigate a complex food system. Thus, the design and implementation of programs to support the development of food literacy from early childhood can contribute to healthier and more sustainable eating habits. In this context, the aim of the present narrative review is to provide an in-depth description of how different food literacy competencies are developed in childhood and adolescence, integrating the extensive body of evidence on cognitive, social, and food-related development. Implications for the development of multisectoral strategies to target the multidimensional nature of food literacy and promote the development of the 3 types of competencies (relational, functional, and critical) are discussed.