Racial residential segregation, socioeconomic disparities, and the White-Black survival gap

Associations Between Racial Residential Segregation and Hypertensive Disorders of Pregnancy among Black women: The Coronary Artery Risk Development in Young Adults Study

Introduction

Black women are at greater risk of hypertensive disorders of pregnancy (HDP). Racial residential segregation (RRS) drives racial health disparities. This study investigates the association between RRS and the onset of HDP among Black parous women in the U.S.

Methods

The Coronary Artery Risk Development in Young Adults study is a cohort of Black and White adults aged 18-30 from four U.S. cities, recruited in 1985 and followed for over 30 years. RRS was measured using the local Getis-Ord Gi∗ statistic, categorizing neighborhoods as high (Gi∗ >1.96), medium (Gi∗ 0-1.96), or low (Gi∗ <0). Among Black women with at least one post-baseline pregnancy, HDP was self-reported as gestational hypertension, preeclampsia, or eclampsia. Generalized mixed models determined the association between RRS and HDP, for pregnancies (n = 941) nested within Black women (n = 598), and adjusting for age, follow-up time, time to pregnancy, education, income, BMI, physical activity, smoking, hypertension, baseline parity, and cumulative pregnancies.

Results

The mean age was 23.1 years (SD: 3.6), with 22.7 % reporting HDP in at least one pregnancy. The cumulative incidence of HDP was 23.0 % in high, 20.6 % in medium, and 23.7 % in low RRS neighborhoods. Fully adjusted models showed no significant association between medium RRS (OR: 1.11; [95 % CI: 0.52, 2.40]) or low RRS (OR: 0.94; [95 % CI: 0.42, 2.16]) compared with high RRS and HDP.

Conclusions

RRS was not associated with HDP among Black women. Future research should consider multifaceted factors through which racial segregation may relate to maternal outcomes.

Treatment of Chlamydia and Gonorrhea in Primary Care and Its Patient-Level Variation: An American Family Cohort Study

PURPOSE

Chlamydia and gonorrhea are the 2 most common bacterial sexually transmitted infections in the United States. Nonadherence to the Centers for Disease Control and Prevention treatment guidelines remains a concern. We examined how well chlamydia and gonorrhea treatment in primary care settings adhered to guidelines.

METHODS

We used electronic health records from the PRIME registry to identify patients with diagnosis codes or positive test results for chlamydia and/or gonorrhea from 2018 to 2022. Outcomes were the first dates of antibiotic administered within 30 days after a positive test result for the infection. Descriptive statistics were calculated for patient sociodemographic characteristics. We used a multivariate parametric accelerated failure time analysis with shared frailty modeling to assess associations between these characteristics and time to treatment.

RESULTS

We identified 6,678 cases of chlamydia confirmed by a positive test and 2,206 cases of gonorrhea confirmed by a positive test; 75.3% and 69.6% of these cases, respectively, were treated. Females, individuals aged 10-29 years, suburban dwellers, and patients with chlamydia-gonorrhea coinfection had higher treatment rates than comparator groups. Chlamydia was infrequently treated with the recommended antibiotic, doxycycline (14.0% of cases), and gonorrhea was infrequently treated with the recommended antibiotic, ceftriaxone (38.7% of cases). Time to treatment of chlamydia was longer for patients aged 50-59 years (time ratio relative to those aged 20-29 years = 1.61; 95% CI, 1.12-2.30) and for non-Hispanic Black patients (time ratio relative to White patients = 1.17; 95% CI, 1.04-1.33).

CONCLUSIONS

Guideline adherence remains suboptimal for chlamydia and gonorrhea treatment across primary care practices. Efforts are needed to develop interventions to improve quality of care for these sexually transmitted infections.

Quantifying associations between socio-spatial factors and cognitive development in the ABCD cohort

Despite the mounting demand for generative population models, their limited generalizability to underrepresented demographic groups hinders widespread adoption in real-world applications. Here we propose a diversity-aware population modeling framework that can guide targeted strategies in public health and education, by estimating subgroup-level effects and stratifying predictions to capture sociodemographic variability. We leverage Bayesian multilevel regression and post-stratification to systematically quantify inter-individual differences in the relationship between socioeconomic status and cognitive development. Post-stratification enhanced the interpretability of model predictions across underrepresented groups by incorporating US Census data to gain additional insights into smaller subgroups in the Adolescent Brain Cognitive Development Study. This ensured that predictions were not skewed by overly heterogeneous or homogeneous representations. Our analyses underscore the importance of combining Bayesian multilevel modeling with post-stratification to validate reliability and provide a more holistic explanation of sociodemographic disparities in our diversity-aware population modeling framework.

Drivers and barriers to health-seeking behaviors and interactions: a qualitative study of Black patients with lung cancer and with peripheral artery disease

OBJECTIVE

To identify factors that may influence health-seeking behaviors and health system interactions from the perspective of Black patients with lung cancer (LC) or peripheral artery disease (PAD).

METHODS

Semi-structured interviews were conducted virtually with Black patients in the United States. Thematic analysis of interview transcripts was performed. The Sense-Think-ACT-Relate (STAR) behavioral framework was used to map emerging themes of drivers and barriers to health-seeking behaviors and health system interactions.

RESULTS

Thirty Black patients with LC (n = 15) and PAD (n = 15) participated in this study. The mean age of participants was 53.4 years, 22 were female, and half lived in an urban area or large city. Factors that shape health-seeking behaviors spanned several framework domains including Trust, Rational and Emotional Associations, Cultural, and Situational. Having a provider who was friendly, knowledgeable, and understood the patient's lived experience was a key driver to seeking care. Barriers to care included patients not recognizing disease symptoms, reservations about seeking care, having previous negative interactions with healthcare systems, and feeling stigmatized or excluded. Situational influences, such as financial cost of accessing and receiving healthcare, also acted as barriers. Similar themes emerged for the LC versus PAD cohorts.

CONCLUSION

Multiple drivers and barriers to health-seeking behaviors exist for Black patients with LC versus PAD, including patients' perceptions of previous health system interactions. Because of known inequities experienced by Black patients, these results highlight the need for interventions that address more than just medical needs but that also encourage patients to seek care when they experience early symptoms and prioritize establishing patient-provider relationships built on trust, respect, and cultural understanding.

Trends and disparities in alcohol-DWI license suspensions by suspension duration, North Carolina, 2007-2016

PURPOSE

To examine trends and potential disparities in North Carolina (NC) driving while impaired by alcohol (alcohol-DWI) license suspensions from 2007-2016. Specific objectives included: 1) examining personal (e.g., race/ethnicity) and contextual (e.g., residential segregation) characteristics of alcohol-DWI license suspensions by suspension duration; and 2) examining trends in annual suspension rates by race/ethnicity, sex, and duration.

METHODS

We linked NC administrative licensing and county-level survey data from several sources from 2007-2016. Suspensions were categorized by duration: 1 to <4 years and 4 years or longer (proxies for initial and repeat suspensions, respectively). We calculated counts, percentages, and suspensions rates (per 1,000 person-years) with 95% confidence intervals, examined trends in annual suspension rates by race/ethnicity, sex, and suspension duration.

RESULTS

We identified 220,471 initial and 41,526 repeat license suspensions. Rates among males were three times that of females. 21-24-year-old (rates: 6.9 per 1,000 person-years for initial; 1.5 for repeat) and Black (4.1 for initial; 1.0 for repeat) individuals had the highest suspension rates. We observed decreases in annual initial and repeat suspension rates among males, but only in repeat suspensions for females during the study period. A substantial decrease in annual initial suspension rates was observed among Hispanic individuals relative to other racial/ethnic groups, while annual repeat suspension rates exhibited large decreases for most racial/ethnic groups. The highest overall suspension rates occurred in counties with higher proportions of the population without health insurance and with the highest levels of Black/White residential segregation.

CONCLUSIONS

Potential disparities by race/ethnicity and sex existed by alcohol-DWI license suspension duration (i.e., initial vs. repeat suspensions) in NC. Contextual characteristics associated with suspensions, including a high degree of residential segregation, may provide indications of underlying structures and mechanisms driving potential disparities in alcohol-DWI outcomes.

School Segregation During Adolescence is Associated with Higher 30-Year Cardiovascular Risk of Black but not White Young Adults

Although cardiovascular disease (CVD) mortality rates are declining for American adults, a disparity remains between non-Hispanic Black and non-Hispanic White adults. Previous research has shown that residential segregation, a form of structural racism, experienced in childhood is associated with later-life racial and ethnic health disparities, including disparities in CVD and its risk factors. However, little is known about the health consequences of exposure to segregated schools, especially among those living in neighborhoods with high concentrations of minoritized people. This study used data from the In-School, Wave I, and Wave IV surveys of the National Longitudinal Study of Adolescent to Adult Health to examine a novel school measure of school racial segregation (Index of the Concentration of Extremes, ICE) as a predictor of Framingham 30-year CVD risk scores. We used General Estimating Equation models to evaluate the association between ICE, measured at Wave I, and two different 30-year CVD risk scores, measured at Wave IV, and examined whether the relationship varied by race. We observed that higher levels of school segregation were associated with a higher 30-year CVD risk among non-Hispanic Black participants while higher segregation was associated with a lower 30-year CVD risk for non-Hispanic White participants. This research suggests that exposure to segregation in the school setting may contribute to observed disparities in CVD among US adults.

Five-Year Relative Survival Rates of Women Diagnosed with Uterine Cancer by County-Level Socioeconomic Status Overall and across Histology and Race/Ethnicity

Understanding socioeconomic factors contributing to uterine cancer survival disparities is crucial, especially given the increasing incidence of uterine cancer, which disproportionately impacts racial/ethnic groups. We investigated the impact of county-level socioeconomic factors on five-year survival rates of uterine cancer overall and by histology across race/ethnicity. We included 333,013 women aged ≥ 30 years with microscopically confirmed uterine cancers (2000-2018) from the Surveillance, Epidemiology, and End Results 22 database followed through 2019. Age-standardized five-year relative survival rates were compared within race/ethnicity and histology, examining the differences across tertiles of county-level percent (%) Collapse

Key Words

• five-year survival
• histologic subtype
• race/ethnic disparity
• race/ethnicity
• socioeconomic status
• uterine cancer

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Affiliation(s)

Akemi T. Wijayabahu Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD 20850, USA; (J.K.M.-A.); (M.S.S.); (M.A.C.)
Jennifer K. McGee-Avila Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD 20850, USA; (J.K.M.-A.); (M.S.S.); (M.A.C.)
Meredith S. Shiels Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD 20850, USA; (J.K.M.-A.); (M.S.S.); (M.A.C.)
Alfonsus Adrian H. Harsono Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL 35233, USA; (A.A.H.H.); (R.C.A.)
Rebecca C. Arend Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL 35233, USA; (A.A.H.H.); (R.C.A.)
Megan A. Clarke Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD 20850, USA; (J.K.M.-A.); (M.S.S.); (M.A.C.)

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The effect of urban racial residential segregation on ovarian cancer diagnosis, treatment, and survival

OBJECTIVE

To investigate the effect of racial residential segregation on disparities between Black and White patients in stage at diagnosis, receipt of surgery, and survival.

METHODS

Subjects included Black and White patients diagnosed with ovarian cancer between 2005 and 2015 obtained from the Surveillance, Epidemiology, and End Results Program. Demographic data were obtained from the 2010 decennial census and 2013 American Community Survey. The exposure of interest was the index of dissimilarity (IOD), a validated measure of segregation. The outcomes of interest included relative risk of advanced stage at diagnosis and surgery for localized disease, 5-year overall and cancer-specific survival.

RESULTS

Black women were more likely to present with Stage IV ovarian cancer when compared to White (32% vs 25%, p < 0.001) and less often underwent surgical resection overall (64% vs 75%, p < 0.001). Increasing IOD was associated with a 25% increased risk of presenting at advanced stage for Black patients (RR 1.25, 95% CI 1.08, 1.45), and a 15% decrease for White patients (RR 0.85, 95% CI 0.73, 0.99). Increasing IOD was associated with an 18% decreased likelihood of undergoing surgical resection for black patients (RR 0.82, 95% CI 0.77, 0.87), but had no significant association for White patients (RR 1.01, 95% CI 0.96, 1.08). When compared to White patients in the lowest level of segregation, Black patients in the highest level of segregation had a 17% higher subhazard of death (HR 1.17, 95% CI 1.07, 1.27), while Black patients in the lowest level of segregation had no significant difference (HR 1.13, 95% CI 0.99, 1.29).

CONCLUSION

Our findings demonstrate the direct harm of historical government mandated segregation on Black women with ovarian cancer.

[Are there differences between men and women with respect to the factors associated with calcium intake?]

The scope of this article is to verify if there are differences in factors associated with calcium intake between men and women. It is based on a study conducted with data from a health survey in a sample of 1641 individuals aged 20 years or more living in the urban area of the city of Campinas, in the State of São Paulo. Calcium intake was obtained from a 24-hour recall (24hr recall method) and analyzed according to sociodemographic variables, health behavior, frequency of meals and body mass index (BMI). The existence of associations was verified by multiple linear regression tests, and it was detected that the profile of associated factors differed between genders. Physical exercise in the leisure context was only associated with calcium intake in males, while skin color, smoking, income, overweight/obesity, and frequency of having breakfast only revealed an association in females. Schooling and having snacks were associated with calcium intake in both sexes. The analysis of the associated factors indicates segments of the female and male population in which the importance of calcium intake needs to be more closely examined. Furthermore, it highlights the importance of conducting health analyses stratified by sex due to the different behavioral patterns that prevail between the sexes.

Diversity-aware Population Models: Quantifying Associations between Socio-Spatial Factors and Cognitive Development in the ABCD Cohort

Population-level analyses are inherently complex due to a myriad of latent confounding effects that underlie the interdisciplinary topics of research interest. Despite the mounting demand for generative population models, the limited generalizability to underrepresented groups hinders their widespread adoption in downstream applications. Interpretability and reliability are essential for clinicians and policymakers, while accuracy and precision are prioritized from an engineering standpoint. Thus, in domains such as population neuroscience, the challenge lies in determining a suitable approach to model population data effectively. Notably, the traditional strata-agnostic nature of existing methods in this field reveals a pertinent gap in quantitative techniques that directly capture major sources of population stratification. The emergence of population-scale cohorts, like the Adolescent Brain Cognitive DevelopmentSM (ABCD) Study, provides unparalleled opportunities to explore and characterize neurobehavioral and sociodemographic relationships comprehensively. We propose diversity-aware population modeling, a framework poised to standardize systematic incorporation of diverse attributes, structured with respect to intrinsic population stratification to obtain holistic insights. Here, we leverage Bayesian multilevel regression and poststratification, to elucidate inter-individual differences in the relationships between socioeconomic status (SES) and cognitive development. We constructed 14 varying-intercepts and varying-slopes models to investigate 3 cognitive phenotypes and 5 sociodemographic variables (SDV), across 17 US states and 5 race subgroups. SDVs exhibited systemic socio-spatial effects that served as fundamental drivers of variation in cognitive outcomes. Low SES was disproportionately associated with cognitive development among Black and Hispanic children, while high SES was a robust predictor of cognitive development only among White and Asian children, consistent with the minorities' diminished returns (MDRs) theory. Notably, adversity-susceptible subgroups demonstrated an expressive association with fluid cognition compared to crystallized cognition. Poststratification proved effective in correcting group attribution biases, particularly in Pennsylvania, highlighting sampling discrepancies in US states with the highest percentage of marginalized participants in the ABCD Study©. Our collective analyses underscore the inextricable link between race and geographic location within the US. We emphasize the importance of diversity-aware population models that consider the intersectional composition of society to derive precise and interpretable insights across applicable domains.

Piloting a Measure of Segregation at the Census Tract Level: Associations with Place and Racial/Ethnic Disparities in Life Expectancy

This study considers residential segregation as a critical driver of racial/ethnic health disparities and introduces a proxy measure of segregation that estimates the degree of segregation at the census tract level with a metric capturing the overrepresentation of a racialized/ethnic group in a census tract in relation to that group's representation at the city level. Using Dallas, Texas as a pilot city, the measure is used to investigate mean life expectancy at birth for relatively overrepresented Hispanic, non-Hispanic white, non-Hispanic Black, and Asian census tracts and examine for significant differences between mean life expectancy in relatively overrepresented census tracts and that group's mean life expectancy at the state level. Multivariable linear regression analysis was utilized to assess how segregation measured at the census tract level associates with life expectancy across different racialized/ethnic groups, controlling for socioeconomic disparities. This study aimed to expose the need to consider the possibility of neighborhood mechanisms beyond socioeconomic characteristics as an important determinant of health and draw attention to the importance of critically engaging the experience of place in examinations of racial and ethnic health disparities. Multivariable linear regression modeling resulted in significant findings for non-Hispanic Black, non-Hispanic white, and Asian groups, indicating increased census tract-level life expectancy for Black and white residents in highly segregated census tracts and decreased life expectancy for residents of tracts in which the Asian community is overrepresented when compared to state means. Unadjusted models demonstrated socioeconomic inequities between first and fourth quartile census tracts and pointed to the importance of mixed methods in health disparities research and the importance of including the voice of community members to account for places of daily lived experience and people's relationships with them.

Factors associated with poor health literacy in older adults: A systematic review

OBJECTIVES

To identify factors associated with poor health literacy in older adults.

METHODS

A systematic literature review was conducted, employing the descriptors "Aged" and "Health Literacy".

PROSPERO - CRD

42022350140.

RESULTS

Out of 23,500 articles screened, 176 were selected. Several factors associated with poor health literacy in older adults were identified, such as sociodemographic (e.g., advanced age, low educational level, non-white population, and others), social (e.g., poor family/social support, loneliness, social isolation, few social activities, and others), economic (e.g., lower income and/or lower socioeconomic status) and health aspects (e.g., poor health, chronic conditions, mental health challenges, hospitalizations, frailty, physical inactivity, cognitive impairment, and others).

CONCLUSIONS

The factors associated with poor health literacy in older adults identified in this review could contribute to future research, support interventions to improve health literacy, and assist professionals in planning educational activities and public policies.

Association between racial residential segregation and Black-White disparities in cardiovascular disease mortality

BACKGROUND

Racial residential segregation is associated with racial health inequities, but it is unclear if segregation may exacerbate Black-White disparities in cardiovascular disease (CVD) mortality. This study aimed to assess associations between Black-White residential segregation, CVD mortality rates among non-Hispanic (NH) Black and NH White populations, and Black-White disparities in CVD mortality.

METHODS

This cross-sectional study analyzed Black-White residential segregation, as measured by county-level interaction index, of US counties, county-level CVD mortality among NH White and NH black adults aged 25 years and older, and county-level Black-White disparities in CVD mortality in years 2014 to 2017. Age-adjusted, county-level NH Black CVD mortality rates and NH White cardiovascular disease mortality rates, as well as group-level relative risk ratios for Black-White cardiovascular disease mortality, were calculated. Sequential generalized linear models adjusted for county-level socioeconomic and neighborhood factors were used to estimate associations between residential segregation and cardiovascular mortality rates among NH Black and NH White populations. Relative risk ratio tests were used to compare Black-White disparities in the most segregated counties to disparities in the least segregated counties.

RESULTS

We included 1,286 counties with ≥5% Black populations in the main analysis. Among adults aged ≥25 years, there were 2,611,560 and 408,429 CVD deaths among NH White and NH Black individuals, respectively. In the unadjusted model, counties in the highest tertile of segregation had 9% higher (95% CI, 1%-20% higher, P = .04) rates of NH Black CVD mortality than counties in the lowest tertile of segregation. In the multivariable adjusted model, the most segregated counties had 15% higher (95% CI, 0.5% to 38% higher, P = .04) rates of NH Black CVD mortality than the least segregated counties. In the most segregated counties, NH Black individuals were 33% more likely to die of CVD than NH White individuals (RR 1.33, 95% CI 1.32 to 1.33, P < .001).

CONCLUSIONS

Counties with increased Black-White residential segregation have higher rates of NH Black CVD mortality and larger Black-White disparities in CVD mortality. Identifying the causal mechanisms through which racial residential segregation widens disparities in CVD mortality requires further study.

Institutional Racism and Health: a Framework for Conceptualization, Measurement, and Analysis

Despite growing interest in the health-related consequences of racially discriminatory institutional policies and practices, public health scholars have yet to reach a consensus on how to measure and analyze exposure to institutional racism. The purpose of this paper is to provide an overview of the conceptualization, measurement, and analysis of institutional racism in the context of quantitative research on minority health and health disparities in the United States. We begin by providing definitions of key concepts (e.g., racialization, racism, racial inequity) and describing linkages between these ideas. Next, we discuss the hypothesized mechanisms that link exposure to institutional racism with health. We then provide a framework to advance empirical research on institutional racism and health, informed by a literature review that summarizes measures and analytic approaches used in previous studies. The framework addresses six considerations: (1) policy identification, (2) population of interest, (3) exposure measurement, (4) outcome measurement, (5) study design, and (6) analytic approach. Research utilizing the proposed framework will help inform structural interventions to promote minority health and reduce racial and ethnic health disparities.

Factors Associated With In-Hospital Death Among Pneumonia Patients in US Hospitals From 2016~2019

BACKGROUND

Pneumonia is one of the leading causes of hospital admission in the United States with a global health burden of about 6.8 million hospitalizations and 1.1 million deaths in patients over 65 years old in 2015. This study aimed to identify possible patient and hospital-related risk factors for in-hospital pneumonia death across US hospitals.

METHODS

The National Inpatient Sample (NIS) was used to identify nationwide pneumonia patients (n=374 766, weighted n=1 873 828) from 2016 to 2019. We examined the characteristics of the study sample and their association with in-hospital death. Multivariate survey logistic regression models were used to identify risk factors.

RESULTS

During the study periods, in-hospital death rates continuously decreased (2.45% in 2016 to 2.19% in 2019). Descriptive statistics showed that patient and hospital factors had varied in-hospital death rates. Survey logistic regression results suggested that male, very low income, non-Medicare, government hospitals, rural hospitals, and specific hospital regions were associated with higher in-hospital death rates than their reference groups.

CONCLUSION

Socioeconomic factors, including income and insurance, are associated with pneumonia mortality. Census region, hospital ownership, and rural location are also related to in-hospital mortality. Such findings in underserved, impoverished, and rural areas to identify possible health disparities.

Association of racial residential segregation with all-cause and cancer-specific mortality in the reasons for geographic and racial differences in stroke (REGARDS) cohort study

•Increased racial residential segregation increased the risk of all-cause mortality among White participants.•Higher interaction lowered the risk of all-cause mortality among White participants.•Higher isolation lowered the risk of cancer mortality among Black participants.

The Impact of the Social Determinants of Health on Disparities in Inflammatory Bowel Disease

The incidence of inflammatory bowel disease (IBD) is rising in racial and ethnic minority groups in the United States, and socioeconomic, racial, and ethnic disparities in IBD are increasingly being identified. In addition, there has been great appreciation for the social determinants of health as contributors to these disparities, and that upstream social determinants of health propagate downstream poor health outcomes in IBD. We propose strategies to achieve health equity in IBD that target the medical trainee, provider, practice, community, industry, and policy levels.

Associations between neighborhood built environment, residential property values, and adult BMI change: The Seattle Obesity Study III

Objective

To examine associations between neighborhood built environment (BE) variables, residential property values, and longitudinal 1- and 2-year changes in body mass index (BMI).

Methods

The Seattle Obesity Study III was a prospective cohort study of adults with geocoded residential addresses, conducted in King, Pierce, and Yakima Counties in Washington State. Measured heights and weights were obtained at baseline (n = 879), year 1 (n = 727), and year 2 (n = 679). Tax parcel residential property values served as proxies for individual socioeconomic status. Residential unit and road intersection density were captured using Euclidean-based SmartMaps at 800 m buffers. Counts of supermarket (0 versus. 1+) and fast-food restaurant availability (0, 1–3, 4+) were measured using network based SmartMaps at 1600 m buffers. Density measures and residential property values were categorized into tertiles. Linear mixed-effects models tested whether baseline BE variables and property values were associated with differential changes in BMI at year 1 or year 2, adjusting for age, gender, race/ethnicity, education, home ownership, and county of residence. These associations were then tested for potential disparities by age group, gender, race/ethnicity, and education.

Results

Road intersection density, access to food sources, and residential property values were inversely associated with BMI at baseline. At year 1, participants in the 3rd tertile of density metrics and with 4+ fast-food restaurants nearby showed less BMI gain compared to those in the 1st tertile or with 0 restaurants. At year 2, higher residential property values were predictive of lower BMI gain. There was evidence of differential associations by age group, gender, and education but not race/ethnicity.

Conclusion

Inverse associations between BE metrics and residential property values at baseline demonstrated mixed associations with 1- and 2-year BMI change. More work is needed to understand how individual-level sociodemographic factors moderate associations between the BE, property values, and BMI change.

•

Strong, inverse cross-sectional relationships between the built environment, residential property values (a proxy for individual socioeconomic status), and measured BMI were observed.

•

Measures of the built environment and residential property values showed modest and inconsistent associations with 1- and 2-year BMI change.

•

There was suggestive evidence that age may moderate the association between urban density and 1- and 2-year BMI change while education may moderate the association between residential property values and 2-year BMI change.

The Affordable Care Act Medicaid Expansion, Social Disadvantage, and the Practice Location Choices of New General Internists

BACKGROUND

A recent study found that states that expanded Medicaid under the Affordable Care Act (ACA) gained new general internists who were establishing their first practices, whereas nonexpansion states lost them.

OBJECTIVE

The objective of this study was to examine the level of social disadvantage of the areas of expansion states that gained new physicians and the areas of nonexpansion states that lost them.

RESEARCH DESIGN

We used American Community Survey data to classify commuting zones as high, medium, or low social disadvantage. Using 2009-2019 data from the AMA Physician Masterfile and information on states' Medicaid expansion status, we estimated conditional logit models to compare where new physicians located during the 6 years following the expansion to where they located during the 5 years preceding the expansion.

SUBJECTS

A total of 32,102 new general internists.

RESULTS

Compared with preexpansion patterns, new general internists were more likely to locate in expansion states after the expansion, a finding that held for high, medium, and low disadvantage areas. We estimated that, between 2014 and 2019, nonexpansion states lost 371 new general internists (95% confidence interval, 203-540) to expansion states. However, 62.5% of the physicians lost by nonexpansion states were lost from high disadvantage areas even though these areas only accounted for 17.9% of the population of nonexpansion states.

CONCLUSIONS

States that opted not to expand Medicaid lost new general internists to expansion states. A highly disproportionate share of the physicians lost by nonexpansion states were lost from high disadvantage areas, potentially compromising access for all residents irrespective of insurance coverage.

Historical redlining and food environments: A study of 102 urban areas in the United States

OBJECTIVE

Unhealthy food environments are disproportionally concentrated in neighborhoods with clustering of racial/ethnic minorities and poverty. This disparity has been blamed, in part, on market self-regulation. This explanation risks overlooking past and current practices of racial segregation that have created and reinforced the obstacles blocking investments from food retailers in marginalized neighborhoods. We fill this gap by investigating how the long-term ramifications of redlining, discriminatory housing practices enacted by federal Home Owner Lending Corporation (HOLC) in the 1930s, has evolved generations later to disproportionally exposing neighborhoods to unhealthy food environments.

METHODS

We overlaid historical redlining maps over 2010 food environment observations at the census tract level to identify areas with less healthy food environments and to assess the historical context of those areas. For 11,651 census tracts within 102 U.S. urban areas, we described the healthiness of food environments as measured by the modified retail food environment index (mRFEI). Using hurdle models with random effects, we further examined the association between redlining housing practice and food environments.

RESULTS

The results indicate that historically redlined neighborhoods show a higher likelihood for unhealthy retail food environments even for census tracts with present-day economic and racial privilege.

CONCLUSION

The current evidence shows how structural discrimination manifested by unjust housing practices and racial residential segregation fueled an uneven food environment where minority neighborhoods disproportionally bore the brunt of restrictive food access. It highlights an urgent need to ameliorate patterns of housing inequality as a fix to unequal food environments.

"As Long as I Got a Breath in My Body": Risk and Resistance in Black Maternal Embodiment

"Mothering while black" in Cleveland, Ohio is a radical act. This highly segregated, highly unequal urban environment is replete with the chronic stressors that degrade well-being and diminish survival for Black mothers and their infants; specifically, a maternal mortality rate two and a half times that of their white counterparts and an infant mortality rate nearly three times that of infants born to white mothers. In the midst of such tragedy and disadvantage, Black mothers strive to love and care for their children in ways that mitigate the toxicity of structural racism. The seventeen pregnant and postpartum Black women in this ethnographic study describe transformational experiences with what we label "betterment:" whereby they center their children's perspective and needs, reconsider their social networks, and focus on the future with an unflinching understanding of the constraints of structural racism. Locating betterment alongside other examples of maternal embodiment and through the rich theoretical lens of Black feminist scholars these participant narratives suggest that the toxic effects of racism and the means to resist them are embodied by Black mothers. A nuanced understanding of Black motherhood disrupts public discourses of blame and responsibility that obscure our collective duty to dismantle structural racism.

Inequalities in Life Expectancy Across North Carolina: A Spatial Analysis of the Social Determinants of Health and the Index of Concentration at Extremes

Health inequalities are characterized by spatial patterns of social, economic, and political factors. Life expectancy (LE) is a commonly used indicator of overall population health and health inequalities that allows for comparison across different spatial and temporal regions. The objective of this study was to examine geographic inequalities in LE across North Carolina census tracts by comparing the performance of 2 popular geospatial health indices: Social Determinants of Health (SDoH) and the Index of Concentration at Extremes (ICE). A principal components analysis (PCA) was used to address multicollinearity among variables and aggregate data into components to examine SDoH, while the ICE was constructed using the simple subtraction of geospatial variables. Spatial regression models were employed to compare both indices in relation to LE to evaluate their predictability for population health. For individual SDoH and ICE components, poverty and income had the strongest positive correlation with LE. However, the common spatial techniques of adding PCA components together for a final SDoH aggregate measure resulted in a poor relationship with LE. Results indicated that both metrics can be used to determine spatial patterns of inequities in LE and that the ICE metric has similar success to the more computationally complex SDoH metric. Public health practitioners may find the ICE metric's high predictability matched with lower data requirements to be more feasible to implement in population health monitoring.

Racial and ethnic disparities in cardiometabolic disease and COVID-19 outcomes in White, Black/African American, and Latinx populations: Social determinants of health

Racial and ethnic-related health disparities in the United States have been intensified by the greater burden of Coronavirus Disease 2019 (COVID-19) in racial and ethnic minority populations. Compared to non-Hispanic White individuals, non-Hispanic Black and Hispanic/Latinx individuals infected by COVID-19 are at greater risk for hospitalization, intensive care unit admission, and death. There are several factors that may contribute to disparities in COVID-19-related severity and outcomes in these minority populations, including the greater burden of cardiovascular and metabolic diseases as discussed in our companion review article. Social determinants of health are a critical, yet often overlooked, contributor to racial and ethnic-related health disparities in non-Hispanic Black and Hispanic/Latinx individuals relative to non-Hispanic White individuals. Thus, the purpose of this review is to focus on the essential role of social factors in contributing to health disparities in chronic diseases and COVID-19 outcomes in minority populations. Herein, we begin by focusing on structural racism as a social determinant of health at the societal level that contributes to health disparities through downstream social level (e.g., occupation and residential conditions) and individual level health behaviors (e.g., nutrition, physical activity, and sleep). Lastly, we conclude with a discussion of practical applications and recommendations for future research and public health efforts that seek to reduce health disparities and overall disease burden.

Historical Redlining and Resident Exposure to COVID-19: A Study of New York City

The Coronavirus Disease 2019 (COVID-19) has been reported to disproportionately impact racial/ethnic minorities in the USA, both in terms of infections and deaths. This racial disparity in the COVID-19 outcomes may result from the segregation of minorities in neighborhoods with health-compromising conditions. We, thus, anticipate that neighborhoods would be especially vulnerable to COVID-19 if they are of present-day economic and racial disadvantage and were redlined historically. To test this expectation, we examined the change of both confirmed COVID-19 cases and deaths from April to July, 2020, in zip code tabulation areas (ZCTAs) in the New York City using multilevel regression analysis. The results indicate that ZCTAs with a higher proportion of black and Hispanic populations are associated with a higher percentage of COVID-19 infection. Historically low-graded neighborhoods show a higher risk for COVID-19 infection, even for ZCTAs with present-day economic and racial privilege. These associations change over time as the pandemic unfolds. Racial/ethnic minorities are bearing the brunt of the COVID-19 pandemic's health impact. The current evidence shows that the pre-existing social structure in the form of racial residential segregation could be partially responsible for the disparities observed, highlighting an urgent need to stress historical segregation and to build a less segregated and more equal society.

A Study Protocol for Increasing Access to Smoking Cessation Treatments for Low-Income Minority Smokers

Background: Smoking rates among low-income patients are double those of the general population. Access to health care is an essential social determinant of health. Federally qualified health care centers (FQHC) are government-supported and community-based centers to increase access to health care for non-insured and underinsured patients. However, barriers to implementation impact adherence and sustainability of evidence-based smoking cessation within FQHC settings. To address this implementation barrier, our multi-disciplinary team proposes Mi QUIT CARE (Mile Square QUIT Community-Access-Referral-Expansion) to establish the acceptability, feasibility, and capacity of an FQHC system to deliver an evidence-based and multi-level intervention to increase patient engagement with a state tobacco quitline. Methods: A mixed-method approach, rooted in an implementation science framework of RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance), will be used in this hybrid effectiveness-implementation design. We aim to evaluate the efficacy of a novel delivery system (patient portal) for increasing access to smoking cessation treatment. In preparation for a future randomized clinical trial of Mi QUIT CARE, we will conduct the following developmental research: (1) Examine the burden of tobacco among patient populations served by our partner FQHC, (2) Evaluate among FQHC patients and health care providers, knowledge, attitudes, barriers, and facilitators related to smoking cessation and our intervention components, (3) Evaluate the use of tailored communication strategies and patient navigation to increase patient portal uptake among patients, and (4) To test the acceptability, feasibility, and capacity of the partner FQHC to deliver Mi QUIT CARE. Discussion: This study provides a model for developing and implementing smoking and other health promotion interventions for low-income patients delivered via patient health portals. If successful, the intervention has important implications for addressing a critical social determinant of cancer and other tobacco-related morbidities. Trial Registration: U.S. National Institutes of Health Clinical Trials, NCT04827420, https://clinicaltrials.gov/ct2/show/NCT04827420.

Poverty, Racism, and the Public Health Crisis in America

The purpose of this article is to discuss poverty as a multidimensional factor influencing health. We will also explicate how racism contributes to and perpetuates the economic and financial inequality that diminishes prospects for population health improvement among marginalized racial and ethnic groups. Poverty is one of the most significant challenges for our society in this millennium. Over 40% of the world lives in poverty. The U.S. has one of the highest rates of poverty in the developed world, despite its collective wealth, and the burden falls disproportionately on communities of color. A common narrative for the relatively high prevalence of poverty among marginalized minority communities is predicated on racist notions of racial inferiority and frequent denial of the structural forms of racism and classism that have contributed to public health crises in the United States and across the globe. Importantly, poverty is much more than just a low-income household. It reflects economic well-being, the ability to negotiate society relative to education of an individual, socioeconomic or health status, as well as social exclusion based on institutional policies, practices, and behaviors. Until structural racism and economic injustice can be resolved, the use of evidence-based prevention and early intervention initiatives to mitigate untoward effects of socioeconomic deprivation in communities of color such as the use of social media/culturally concordant health education, social support, such as social networks, primary intervention strategies, and more will be critical to address the persistent racial/ethnic disparities in chronic diseases.

The Underreporting of Concussion: Differences Between Black and White High School Athletes Likely Stemming from Inequities

Previous studies have found that Black high school athletes have poorer knowledge about concussions and have fewer sports medicine healthcare resources than White athletes, but research on concussion disclosure by race is still needed. Therefore, the purpose of this study was to examine racial differences in concussion reporting behaviors between Black and White high school athletes. This cross-sectional study administered surveys to 577 high school athletes (64.5% Black; 72.3% males; 16.02 ± 1.2 years) from 14 schools (title I, n = 9; non-title I, n = 5). The survey included self-reported items on concussions and bell-ringers experienced during games and practices and the number of these episodes that were reported to an authoritative figure. Reasons for reporting and not reporting were also assessed. Results found that White athletes were more likely to recall experiencing a bell-ringer in games compared with Black athletes. They were also more likely to report a bell-ringer or concussion that occurred in a game. There was a significantly higher proportion of Black athletes compared with White athletes that did not report their bell-ringer experienced in games and concussions experienced in practices. White athletes were more likely than Black athletes to disclose a concussion because they thought they had a concussion, while there were no racial differences in the reasons for not reporting. The findings of this study highlight the critical role that race, as a social determinant of health, may play in concussion reporting in high school athletes. Future public health efforts should seek to further understand and overcome inequities in healthcare resources for concussion education and management.

Association between disparities in intergenerational economic mobility and cause-specific mortality among Black and White persons in the United States

BACKGROUND

Evidence about the association between structural racism and mortality in the United States is limited. We examined the association between ongoing structural racism, measured as inequalities in adulthood income between White and Black children with similar parental household income (economic mobility gap) in a recent birth cohort, and Black-White disparities in death rates (mortality gap) overall and for major causes.

METHODS

Sex-, race/ethnicity-, and county-specific data were used to examine sex-specific associations between economic mobility and mortality gaps for all causes combined, heart diseases, cerebrovascular diseases, chronic obstructive pulmonary disease (COPD), injury/violence, all malignant cancers, and 14 cancer types. Economic mobility data for 1978-1983 birth cohorts and death rates during 2011-2018 were obtained from the Opportunity Atlas and National Center for Health Statistics, respectively. Data from 471 counties were included in analyses of all-cause mortality at ages 30-39 years during 2011-2018 (corresponding to partially overlapping 1978-1983 birth cohorts); and from 1,572 and 1,248 counties in analyses of all-cause and cause-specific mortality in all ages combined, respectively.

RESULTS

In ages 30-39 years, a one percentile increase in the economic mobility gap was associated with a 6.8 % (95 % confidence interval 1.8 %-11.8 %) increase in the Black-White mortality gap among males and a 13.5 % (8.9 %-18.1 %) increase among females, based on data from 471 counties. In all ages combined, the corresponding percentages based on data from 1,572 counties were 10.2 % (7.2 %-13.2 %) among males and 14.8 % (11.4 %-18.2 %) among females, equivalent to an increase of 18.4 and 14.0 deaths per 100,000 in the mortality gap, respectively. Similarly, strong associations between economic mobility gap and mortality gap in all ages were found for major causes of death, notably for potentially preventable conditions, including COPD, injury/violence, and cancers of the lung, liver, and cervix.

CONCLUSIONS

Economic mobility gap conditional on parental income in a recent birth cohort as a marker of ongoing structural racism is strongly associated with Black-White disparities in all-cause mortality and mortality from several causes.

Intergenerational upward mobility and racial differences in mortality among young adults: Evidence from county-level analyses

Inspired by the influential "deaths of despair" narrative, which emphasizes the role of worsening economic opportunity in driving the increasing mortality for non-Hispanic Whites in the recent decades, a rising number of studies have provided suggestive evidence that upward mobility levels across counties may partly explain variations in mortality rates. A gap in the literature is the lack of life-course studies examining the relationship between early-life upward mobility and later-life mortality across counties. Another gap is the lack of studies on how the relationship between upward mobility and mortality across counties varies across diverse sociodemographic populations. This study examines differences across race and sex in the relationship between early-life intergenerational upward mobility and early adulthood mortality at the county level. We use administrative data on upward mobility and vital statistics data on mortality across 3030 counties for those born between 1978 and 1983. We control for a variety of county-level socioeconomic variables in a model with fixed effects for state and year. Subgroup analyses by educational attainment and urban status were also performed for each race-sex combination. Results show strong negative relationships between early-life upward mobility and early adulthood mortality across racial-sex combinations, with a particularly greater magnitude for non-Hispanic Black males. In addition, individuals without a college degree and living in urban counties are particularly affected by early life upward mobility. The findings of this study highlight the vulnerability of less-educated, young urban Black males, due to the intersecting effects of the urban context, education, race, and sex.

Intersection of social vulnerability and residential diversity: Postoperative outcomes following resection of lung and colon cancer

INTRODUCTION

While the impact of demographic factors on postoperative outcomes has been examined, little is known about the intersection between social vulnerability and residential diversity on postoperative outcomes following cancer surgery.

METHODS

Individuals who underwent a lung or colon resection for cancer were identified in the 2016-2017 Medicare database. Data were merged with the Centers for Disease Control and Prevention social vulnerability index and a residential diversity index was calculated. Logistic regression models were utilized to estimate the probability of postoperative outcomes.

RESULTS

Among 55 742 Medicare beneficiaries who underwent lung (39.4%) or colon (60.6%) resection, most were male (46.6%), White (90.2%) and had a mean age of 75.3 years. After adjustment for competing risk factors, both social vulnerability and residential diversity were associated with mortality and other postoperative outcomes. In assessing the intersection of social vulnerability and residential diversity, synergistic effects were noted as patients from counties with low social vulnerability and high residential diversity had the lowest probability of 30-day mortality (3.2%, 95% confidence interval [CI]: 3.0-3.5) while patients from counties with high social vulnerability and low diversity had a higher probability of 30-day postoperative death (5.2%, 95% CI: 4.6-5.8; odds ratio: 1.02, 95% CI: 1.01-1.03).

CONCLUSION

Social vulnerability and residential diversity were independently associated with postoperative outcomes. The intersection of these two social health determinants demonstrated a synergistic effect on the risk of adverse outcomes following lung and colon cancer surgery.

Green spaces mitigate racial disparity of health: A higher ratio of green spaces indicates a lower racial disparity in SARS-CoV-2 infection rates in the USA

There is striking racial disparity in the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection rates in the United States. We hypothesize that the disparity is significantly smaller in areas with a higher ratio of green spaces. County level data on the SARS-CoV-2 infection rates of black and white individuals in 135 of the most urbanized counties across the United States were collected. The total population in these counties is 132,350,027, comprising 40.3% of the U.S. population. The ratio of green spaces by land-cover type in each county was extracted from satellite imagery. A hierarchical regression analysis measured cross-sectional associations between racial disparity in infection rates and green spaces, after controlling for socioeconomic, demographic, pre-existing chronic disease, and built-up area factors. We found a higher ratio of green spaces at the county level is significantly associated with a lower racial disparity in infection rates. Four types of green space have significant negative associations with the racial disparity in SARS-CoV-2 infection rates. A theoretical model with five core mechanisms and one circumstantial mechanism is presented to interpret the findings.

Association of County-Level Racial Diversity and Likelihood of a Textbook Outcome Following Pancreas Surgery

Introduction

Residential racial desegregation has demonstrated improved economic and education outcomes. The degree of racial community segregation relative to surgical outcomes has not been examined.

Patients and Methods

Patients undergoing pancreatic resection between 2013 and 2017 were identified from Medicare Standard Analytic Files. A diversity index for each county was calculated from the American Community Survey. Multivariable mixed-effects logistic regression with a random effect for hospital was used to measure the association of the diversity index level with textbook outcome (TO).

Results

Among the 24,298 Medicare beneficiaries who underwent a pancreatic resection, most patients were male (n = 12,784, 52.6%), White (n = 21,616, 89%), and had a median age of 72 (68–77) years. The overall incidence of TO following pancreatic surgery was 43.3%. On multivariable analysis, patients who resided in low-diversity areas had 16% lower odds of experiencing a TO following pancreatic resection compared with patients from high-diversity communities (OR 0.84, 95% CI 0.72–0.98). Compared with patients who resided in the high-diversity areas, individuals who lived in low-diversity areas had higher odds of 90-day readmission (OR 1.16, 95% CI 1.03–1.31) and had higher odds of dying within 90 days (OR 1.85, 95% CI 1.45–2.38) (both p < 0.05). Nonminority patients who resided in low-diversity areas also had a 14% decreased likelihood to achieve a TO after pancreatic resection compared with nonminority patients in high-diversity areas (OR 0.86, 95% CI 0.73–1.00).

Conclusion

Patients residing in the lowest racial/ethnic integrated counties were considerably less likely to have an optimal TO following pancreatic resection compared with patients who resided in the highest racially integrated counties.

Supplementary Information

The online version contains supplementary material available at 10.1245/s10434-021-10316-3.

Long COVID and Health Inequities: The Role of Primary Care

Policy Points An estimated 700,000 people in the United States have "long COVID," that is, symptoms of COVID-19 persisting beyond three weeks. COVID-19 and its long-term sequelae are strongly influenced by social determinants such as poverty and by structural inequalities such as racism and discrimination. Primary care providers are in a unique position to provide and coordinate care for vulnerable patients with long COVID. Policy measures should include strengthening primary care, optimizing data quality, and addressing the multiple nested domains of inequity.

Impact of Residential Racial Integration on Postoperative Outcomes Among Medicare Beneficiaries Undergoing Resection for Cancer

INTRODUCTION

While social determinants of health may adversely affect various populations, the impact of residential segregation on surgical outcomes remains poorly defined.

OBJECTIVE

The objective of the current study was to examine the association between residential segregation and the likelihood to achieve a textbook outcome (TO) following cancer surgery.

METHODS

The Medicare 100% Standard Analytic Files were reviewed to identify Medicare beneficiaries who underwent resection of lung, esophageal, colon, or rectal cancer between 2013 and 2017. Shannon's integration index, a measure of residential segregation, was calculated at the county level and its impact on composite TO [no complications, no prolonged length of stay (LOS), no 90-day readmission, and no 90-day mortality] was examined.

RESULTS

Among 200,509 patients who underwent cancer resection, the overall incidence of TO was 56.0%. The unadjusted likelihood of achieving a TO was lower among patients in low integration areas [low integration: n = 19,978 (55.0%) vs. high integration: n = 18,953 (59.3%); p < 0.001]. On multivariable analysis, patients residing in low integration areas had higher odds of complications [odds ratio (OR) 1.07, 95% confidence interval (CI) 1.03-1.11], extended LOS (OR 1.13, 95% CI 1.09-1.18), and 90-day mortality (OR 1.29, 95% CI 1.22-1.38) and, in turn, lower odds of achieving a TO (OR 0.87, 95% CI 0.84-0.90) versus patients from highly integrated communities.

CONCLUSION

Patients who resided in counties with a lower integration index were less likely to have an optimal TO following resection of cancer compared with patients who resided in more integrated counties. The data highlight the importance of increasing residential racial diversity and integration as a means to improve patient outcomes.

Stress and parenting during the global COVID-19 pandemic

BACKGROUND

Stress and compromised parenting often place children at risk of abuse and neglect. Child maltreatment has generally been viewed as a highly individualistic problem by focusing on stressors and parenting behaviors that impact individual families. However, because of the global coronavirus disease 2019 (COVID-19), families across the world are experiencing a new range of stressors that threaten their health, safety, and economic well-being.

OBJECTIVE

This study examined the impacts of the COVID-19 pandemic in relation to parental perceived stress and child abuse potential.

PARTICIPANTS AND SETTING

Participants included parents (N = 183) with a child under the age of 18 years in the western United States.

METHOD

Tests of group differences and hierarchical multiple regression analyses were employed to assess the relationships among demographic characteristics, COVID-19 risk factors, mental health risk factors, protective factors, parental perceived stress, and child abuse potential.

RESULTS

Greater COVID-19 related stressors and high anxiety and depressive symptoms are associated with higher parental perceived stress. Receipt of financial assistance and high anxiety and depressive symptoms are associated with higher child abuse potential. Conversely, greater parental support and perceived control during the pandemic are associated with lower perceived stress and child abuse potential. Results also indicate racial and ethnic differences in COVID-19 related stressors, but not in mental health risk, protective factors, perceived stress, or child abuse potential.

CONCLUSION

Findings suggest that although families experience elevated stressors from COVID-19, providing parental support and increasing perceived control may be promising intervention targets.

Stress and parenting during the global COVID-19 pandemic

BACKGROUND

Stress and compromised parenting often place children at risk of abuse and neglect. Child maltreatment has generally been viewed as a highly individualistic problem by focusing on stressors and parenting behaviors that impact individual families. However, because of the global coronavirus disease 2019 (COVID-19), families across the world are experiencing a new range of stressors that threaten their health, safety, and economic well-being.

OBJECTIVE

This study examined the impacts of the COVID-19 pandemic in relation to parental perceived stress and child abuse potential.

PARTICIPANTS AND SETTING

Participants included parents (N = 183) with a child under the age of 18 years in the western United States.

METHOD

Tests of group differences and hierarchical multiple regression analyses were employed to assess the relationships among demographic characteristics, COVID-19 risk factors, mental health risk factors, protective factors, parental perceived stress, and child abuse potential.

RESULTS

Greater COVID-19 related stressors and high anxiety and depressive symptoms are associated with higher parental perceived stress. Receipt of financial assistance and high anxiety and depressive symptoms are associated with higher child abuse potential. Conversely, greater parental support and perceived control during the pandemic are associated with lower perceived stress and child abuse potential. Results also indicate racial and ethnic differences in COVID-19 related stressors, but not in mental health risk, protective factors, perceived stress, or child abuse potential.

CONCLUSION

Findings suggest that although families experience elevated stressors from COVID-19, providing parental support and increasing perceived control may be promising intervention targets.

Racial disparities in parent knowledge of concussion and recognition of signs and symptoms

INTRODUCTION

Concussion is a type of traumatic brain injury that can be sustained through participation in different sports. It is important that a parent be able to identify common and uncommon symptoms of a concussion to ensure the safety and good health of their child. The purpose of this study was to compare knowledge of concussion scores among White and African American parents and guardians.

METHODOLOGY

This cross-sectional study consisted of a single survey of 53 questions that was given to parents/guardians of high school athletes at a preseason parent meeting. Parent and guardian knowledge of concussion was assessed through a series of 45 questions. Participants were asked to correctly identify signs and symptoms of concussion, answer questions regarding the anatomy of a concussion (i.e. a concussion is an injury to the brain), answer true/false questions about general concussion knowledge, select from a list the consequences of multiple concussions and select from a list the consequences of returning to play too soon from a concussion. Knowledge of concussion was calculated by summing correct responses for the 45 knowledge questions. Racial differences were calculated using an ANCOVA, controlling for socioeconomic school type. The statistical significance level was set a priori p ≤ 0.05 for all analyses.

RESULTS

Participants of this study consisted of 176 [115 (65.3%) White, 61 (34.7%) African American] parents/guardians of high school athletes. Significant differences in knowledge of concussion scores between White parents/guardians [38.50 ± 4.55 (85.6% correct)], and African American parents/guardians [35.15 ± 4.97, 78.1% correct)] were identified (F_(1,172) = 4.82, p = 0.03).

CONCLUSION

Knowledge of concussion disparities exist between African American and White parents/guardians. This disparity could cause complications from concussion to surface among children and adolescents participating in sport as their parents/guardians may not be able to correctly identify the signs and symptoms in order to seek proper medical care. Practical Application: Findings from this study highlight quantitative differences in concussion knowledge of parents from different demographics. These findings underline disparities and inequities in access to concussion-health resources that need to be addressed.

Stress and parenting during the global COVID-19 pandemic

BACKGROUND

Stress and compromised parenting often place children at risk of abuse and neglect. Child maltreatment has generally been viewed as a highly individualistic problem by focusing on stressors and parenting behaviors that impact individual families. However, because of the global coronavirus disease 2019 (COVID-19), families across the world are experiencing a new range of stressors that threaten their health, safety, and economic well-being.

OBJECTIVE

This study examined the impacts of the COVID-19 pandemic in relation to parental perceived stress and child abuse potential.

PARTICIPANTS AND SETTING

Participants included parents (N = 183) with a child under the age of 18 years in the western United States.

METHOD

Tests of group differences and hierarchical multiple regression analyses were employed to assess the relationships among demographic characteristics, COVID-19 risk factors, mental health risk factors, protective factors, parental perceived stress, and child abuse potential.

RESULTS

Greater COVID-19 related stressors and high anxiety and depressive symptoms are associated with higher parental perceived stress. Receipt of financial assistance and high anxiety and depressive symptoms are associated with higher child abuse potential. Conversely, greater parental support and perceived control during the pandemic are associated with lower perceived stress and child abuse potential. Results also indicate racial and ethnic differences in COVID-19 related stressors, but not in mental health risk, protective factors, perceived stress, or child abuse potential.

CONCLUSION

Findings suggest that although families experience elevated stressors from COVID-19, providing parental support and increasing perceived control may be promising intervention targets.

Relationship of neighborhood social determinants of health on racial/ethnic mortality disparities in US veterans-Mediation and moderating effects

OBJECTIVE

To examine mediation and moderation of racial/ethnic all-cause mortality disparities among Veteran Health Administration (VHA)-users by neighborhood deprivation and residential segregation.

DATA SOURCES

Electronic medical records for 10/2008-9/2009 VHA-users linked to National Death Index, 2000 Area Deprivation Index, and 2006-2009 US Census.

STUDY DESIGN

Racial/ethnic groups included American Indian/Alaskan Native (AI/AN), Asian, non-Hispanic black, Hispanic, Native Hawaiian/Other Pacific Islander, and non-Hispanic white (reference). We measured neighborhood deprivation by Area Deprivation Index, calculated segregation for non-Hispanic black, Hispanic, and AI/AN using the Isolation Index, evaluated mediation using inverse odds-weighted Cox regression models and moderation using Cox regression models testing for neighborhood*race/ethnicity interactions.

PRINCIPAL FINDINGS

Mortality disparities existed for AI/ANs (HR = 1.07, 95%CI:1.01-1.10) but no other groups after covariate adjustment. Neighborhood deprivation and Hispanic segregation neither mediated nor moderated AI/AN disparities. Non-Hispanic black segregation both mediated and moderated AI/AN disparities. The AI/AN vs. non-Hispanic white disparity was attenuated for AI/ANs living in neighborhoods with greater non-Hispanic black segregation (P = .047). Black segregation's mediating effect was limited to VHA-users living in counties with low black segregation. AI/AN segregation also mediated AI/AN mortality disparities in counties that included or were near AI/AN reservations.

CONCLUSIONS

Neighborhood characteristics, particularly black and AI/AN residential segregation, may contribute to AI/AN mortality disparities among VHA-users, particularly in communities that were rural, had greater black segregation, or were located on or near AI/AN reservations. This suggests the importance of neighborhood social determinants of health on racial/ethnic mortality disparities. Living near reservations may allow AI/AN VHA-users to maintain cultural and tribal ties, while also providing them with access to economic and other resources. Future research should explore the experiences of AI/ANs living in black communities and underlying mechanisms to identify targets for intervention.

Community-engaged and community-based participatory research to promote American Heart Association Life's Simple 7 among African American adults: A systematic review

BACKGROUND

Cardiovascular disease (CVD) is the leading cause of death in the United States and African Americans (AA) have a disproportionately greater burden of CVD as compared to Whites. The American Heart Association (AHA) Life's Simple 7 (LS7) framework outlines goals for attaining ideal cardiovascular health. Yet, there is a lack of evidence summarizing best practices to maximize LS7 attainment. The objective of the present study was to systematically review the extant peer-reviewed literature on community-engaged and community-based participatory research (CBPR) aimed at improving one or more LS7 metrics among AA.

METHODS

PubMed, CINAHL, and Embase databases were searched. We included articles that reported quantitative results for one or more of the following LS7 metrics: physical activity, diet, cholesterol, blood pressure, body mass index, smoking, and glycemia. We included analyses with a greater than 50% AA study population focused on adults (≥18 years of age).

RESULTS

Of the 1008 unique studies identified, 54 met inclusion criteria; 27 of which were randomized controlled trials. 50% of studies assessed more than one LS7 metric but only two studies evaluated all seven of the LS7 metrics. No studies had a high proportion of AA males. 40 studies improved at least one LS7 metric at the study end-point. Formative research was used in many studies to guide intervention design. Studies were of varying quality, but overall rated "fair" using a modified approach to the National Institute of Health quality assessment tool.

CONCLUSION

There is insufficient data to recommend a specific community-engaged or CBPR intervention to improve attainment of LS7 metrics among AA. Future studies using rigorous methodology with increased gender diversity and utilizing the AHA LS7 framework are required to establish a validated program to improve LS7 in AAs.

Obesity and the Built Environment: A Reappraisal

The built environment (BE) has been viewed as an important determinant of health. Numerous studies have linked BE exposure, captured using a variety of methods, to diet quality and to area prevalence of obesity, diabetes, and cardiovascular disease. First-generation studies defined the neighborhood BE as the area around the home. Second-generation studies turned from home-centric to person-centric BE measures, capturing an individual's movements in space and time. Those studies made effective uses of global positioning system tracking devices and mobile phones, sometimes coupled with accelerometers and remote sensors. Activity space metrics explored travel paths, modes, and destinations to assess BE exposure that was both person and context specific. However, as measures of the contextual exposome have become ever more fine-grained and increasingly complex, connections to long-term chronic diseases with complex etiologies, such as obesity, are in danger of being lost. Furthermore, few studies on obesity and the BE have included intermediate energy balance behaviors, such as diet and physical activity, or explored the potential roles of social interactions or psychosocial pathways. Emerging survey-based applications that identify habitual destinations and associated travel patterns may become the third generation of tools to capture health-relevant BE exposures in the long term.

Racial and Ethnic Makeup in Hospital's Social Media and Online Platforms: Visual Representation of Diversity in Images and Videos of Washington, D.C. Hospitals

While hospitals' health promotion via social media has the potential to be a critical source of health information, research shows racial and ethnic disparities exist in health-related knowledge that may be, in part, related to media representation. The purpose of this study is to examine the racial and ethnic representation of people featured in Washington, D.C. hospitals' social media platforms to understand how hospitals embed cultural competency into their health communication. By comparing the diversity of images on hospitals' social media platforms with the demographics of hospitals' neighboring communities, the researchers intend to highlight opportunities to improve targeted health messaging to underserved communities, particularly Black and Hispanic communities. By analyzing the images and videos posted on the three most popular social media platforms - Facebook, Twitter, and YouTube - for a one-month period, the researchers found that Whites and Asians were over-represented while Hispanics were severely under-represented in hospitals' social media representation as compared to the community demographics. Increasing the diversity of minority representation on hospitals' social media-based health promotion may contribute to addressing the social disparities in healthcare.

Low use of routine medical care among African Americans with high CKD risk: the Jackson Heart Study

Background

Use of routine medical care (RMC) is advocated to address ethnic/racial disparities in chronic kidney disease (CKD) risks, but use is less frequent among African Americans. Factors associated with low RMC use among African Americans at risk of renal outcomes have not been well studied.

Methods

We examined sociodemographic, comorbidity, healthcare access, and psychosocial (discrimination, anger, stress, trust) factors associated with low RMC use in a cross-sectional study. Low RMC use was defined as lack of a physical exam within one year among participants with CKD (estimated glomerular filtration rate < 60 mL/min/1.73m² or urine albumin-to-creatinine ratio > 30 mg/g) or CKD risk factors (diabetes or hypertension). We used multivariable logistic regression to estimate the odds of low RMC use at baseline (2000–2004) for several risk factors.

Results

Among 3191 participants with CKD, diabetes, or hypertension, 2024 (63.4%) were ≥ 55 years of age, and 700 (21.9%) reported low RMC use. After multivariable adjustment, age < 55 years (OR 1.61 95% CI 1.31–1.98), male sex (OR 1.71; 1.41–2.07), <high school diploma (OR 1.31; 1.07–1.62), absence of hypertension (OR 1.74; 1.27–2.39) or diabetes (OR 1.34; 1.09–1.65), and tobacco use (OR 1.43; 1.18–1.72) were associated with low RMC use. Low trust in providers (OR 2.16; 1.42–3.27), high stress (OR 1.41; 1.09–1.82), high daily discrimination (OR 1.30; 1.01–1.67) and low burden of lifetime discrimination (OR 1.52; 1.18–1.94), were also associated with low RMC use.

Conclusions

High-risk African Americans who were younger, male, less-educated, and with low trust in providers were more likely to report low RMC use. Efforts to improve RMC use by targeting these populations could mitigate African Americans’ disparities in CKD risks.

Electronic supplementary material

The online version of this article (10.1186/s12882-018-1190-0) contains supplementary material, which is available to authorized users.

Kidney Disease Among African Americans: A Population Perspective

End-stage kidney disease and earlier stages of chronic kidney disease (CKD) represent one of the most dramatic examples of racial/ethnic disparities in health in our nation. African Americans are 3 times more likely to require renal replacement therapy then their non-Hispanic white counterparts. This article describes CKD-related disparities linked to a variety of clinical, socioeconomic, and cultural factors, as well as to select social determinants of health that are defined by social positioning and often by race within the United States. Our advancing understanding of these issues has led to improvements in patient outcomes and is narrowing the gap in disparities across most aspects of CKD and CKD risk factors. There are also extensive data indicating similar improvements in quality measures for patients on dialysis therapy. This article also reviews the state of CKD in African Americans from a population perspective and provides recommendations for the way forward.