Race, life course socioeconomic position, racial discrimination, depressive symptoms and self-rated health

Building Financial Capability and Assets to Reduce Poverty and Health Disparities: Race/Ethnicity Matters

BACKGROUND

Evidence has documented racial wealth inequity as one of the key pathways linking structural racism and racial health inequity. Most prior studies on the wealth-health relationship use net worth as the measure of wealth. This approach provides little evidence on the most effective interventions as various types of assets and debt affect health differently. This paper examines how U.S. young adults' wealth components (e.g., financial assets, nonfinancial assets, secured debt, and unsecured debt) are associated with physical and mental health, and if the associations differ by race/ethnicity.

METHODS

Data were drawn from the National Longitudinal Survey of Youth 1997. Health outcomes were measured by mental health inventory and self-rated health. Logistic regressions and ordinary least square regressions were used to assess the association between wealth components and physical and mental health.

RESULTS

I found that financial assets and secured debt were positively associated with self-rated health and mental health. Unsecured debt was negatively associated with mental health only. The positive associations between financial assets and health outcomes were significantly weaker for non-Hispanic Black respondents. Unsecured debt was protective of self-rated health for non-Hispanic Whites only. For Black young adults, unsecured debt had more severe negative health consequences compared to other racial/ethnic groups.

CONCLUSION

This study provides a nuanced understanding of the complex relationship among race/ethnicity, wealth components, and health. Findings could inform asset building and financial capability policies and programs to effectively reduce racialized poverty and health disparities.

The independent and joint effect of socioeconomic status and Multiracial status on the prevalence and frequency of substance use and depression among U.S. adolescents

AIM

While the United States is becoming increasingly Multiracial, much is still unknown about the behavioral health of these growing new generations of Multiracial Americans. To narrow this research gap, this study investigated the prevalence/frequency of substance use and major depressive episodes [MDE] among non-Hispanic Multiracial [NHM] adolescents compared to their non-Hispanic White [NHW] counterparts and whether racial differences vary by socioeconomic status.

METHODS

We analyzed data from the 2015-2019 National Survey on Drug Use and Health (N = 3,645 NHM and 34,776 NHW adolescents aged 12-17). Average Marginal Effects derived from logistic regression and negative binomial regression were used to examine (1) differences in six outcomes (past-month use of alcohol, cannabis, or drugs other than cannabis [DOTC], past-year MDE, and the frequency of alcohol and cannabis use among past-month users) by Multiracial status; (2) the moderation effect of family income on these associations.

RESULTS

Compared to high-income NHW adolescents, high-income NHM adolescents reported significantly higher prevalence of past-month cannabis and DOTC use, and past-year MDE. No racial differences were observed at other income levels. Furthermore, moderation analyses indicated that the effect of Multiracial status on MDE was larger in the highest income group compared to the lowest income group.

CONCLUSION

Our findings suggested that NHM adolescents, particularly those from high income families, exhibit increased prevalence of drug use and depression than NHW adolescents. As the US becomes more diverse, there is a need to further examine the social and structural factors driving the identified racial differences.

How Education Shapes Indigenous Health Inequalities in the USA and Mexico

Indigenous peoples around the world face significant health disparities relative to the dominant groups in their countries, yet the magnitude and patterns of health disparities vary across countries. We use data from the National Health Interview Survey and Mexican Family Life Survey to examine the health of Indigenous peoples in Mexico and American Indians and Alaska Natives in the USA and to evaluate how they fare relative to the majority populations in their countries (non-Indigenous Mexicans and non-Hispanic Whites, respectively). We assess disparities in self-rated health and activity limitations, with a focus on how Indigenous health disparities intersect with educational gradients in health. Regression analyses reveal three primary findings. First, Indigenous health disparities are larger in the USA than in Mexico. Second, differences in educational attainment account for most of the differences between Indigenous and non-Indigenous populations in Mexico, but less than half in the USA. Third, in both countries, health is moderated by educational attainment such that between-group disparities are largest at the highest levels of education. However, for Indigenous Mexicans there is a "cross-over" in which Indigenous Mexicans report better health at the lowest level of education. Overall, this study finds a weak relationship between education and Indigenous health, and raises the question about the validity of using traditional measures of SES in Indigenous contexts.

Reasons for Suicide in Black Young Adults: A Latent Class Analysis

BACKGROUND

Suicides have increased among Black youth in the US, though it remains unclear if these trends persist into young adulthood. Further, even less is known about the reasons why individuals begin to consider suicide as a viable option. The current study aims to redress these gaps by identifying specific reasons for suicide among a sample of 264 Black young adults who reported experiencing suicidal thoughts within the past 2 weeks.

METHODS

Participants were recruited from an online panel. Reasons for suicide were measured using eight individual items/indicators. Latent class analysis was used to detect underlying patterns in Black young adults' reasons for considering suicide.

RESULTS

The most commonly reported reason for considering suicide among the entire sample was feeling hopeless about the future. Black women were more likely to report considering suicide because they could not live up to other's expectations and because they felt lonely and sad. Findings for the 3-class model were retained. The first class is described as the "Somewhat hopeless and other reasons" class (n = 85; 32%). The second class is "Accomplished but extremely lonely and sad" (n = 24; 9%). The third class is described as "Pronounced feelings of failure, hopelessness, being overwhelmed, and lack of accomplishment" and includes 59% of the sample (n = 155).

CONCLUSIONS

Culturally grounded clinical treatments and interventions are needed to meet the specific mental health needs of Black young adults. A particular focus on identifying factors that drive feelings of hopelessness and failure is warranted.

The mental health toll of the Great Migration: a comparison of mental health outcomes among descendants of African American migrators

INTRODUCTION

Research is beginning to examine the health outcomes of migrators of the Great Migration, a movement of up to eight million African Americans from the South to the North and West during the twentieth century. However, sparse evidence exists studying the health outcomes of the descendants of Great Migration movers. The aim for this study was to compare the lifetime prevalence of mental health disorders by migration status.

METHODS

We used a sample of 3183 African American adults from the National Survey of American Life (2001-2003). Using birthplaces of participants and their mothers, we classified adults as (1) Southern stayers, (2) migrators to the South, (3) migrators to the North or (4) Northern stayers. The outcomes were lifetime prevalence of any mental health, mood, anxiety, and substance use disorders. We used weighted log-Poisson regression models and adjusted for demographic characteristics and socioeconomic status.

RESULTS

Migrators to the North and Northern stayers had higher risks of any lifetime mental health, mood, anxiety, and substance use disorders compared to Southern stayers in the adjusted models. Migrators to the North and Northern stayers were more likely to report perceived discrimination.

CONCLUSION

This study suggests that migrating families to the North may have experienced mental health adversities.

Superwoman Schema and self-rated health in black women: Is socioeconomic status a moderator?

BACKGROUND

The Superwoman Schema (SWS) construct elucidates Black women's socialization to be strong, suppress their emotions, resist vulnerability, succeed despite limited resources, and help others at their own expense. Drawing from intersectionality and social psychological research on self-schemas, this study examined the extent to which SWS was associated with Black women's self-rated health. We also investigated whether socioeconomic status (SES) moderated the association between SWS, its five dimensions, and self-rated health.

METHODS

Data were from the Mechanisms Underlying Stress and Emotions (MUSE) in African-American Women's Health Study, a cohort of African American self-identified women. SWS was assessed using Giscombé's 35-item Superwoman Schema Scale. Socioeconomic status was measured by household income and educational attainment. Ordered logistic regression models were used and statistical interactions were run to test for moderation (N = 408).

RESULTS

First, SWS dimension "obligation to help others" was associated with worse self-rated health (p < .05). Second, household income, but not education, moderated the association between SWS and self-rated health (p < .05): SWS overall was associated with worse self-rated health among higher income women but better self-rated health among lower income women. Third, income moderated the association between SWS dimension "obligation to present an image of strength" and self-rated health (p < .05): presenting strength was associated with better self-rated health for lower income women only. Fourth, moderation results revealed that SWS dimension "obligation to help others" was inversely associated with self-rated health particularly among higher income women.

CONCLUSIONS

Findings speak to the complex interplay between SES and SWS dimensions as they relate to Black women's perceived health.

Discrimination and bladder health among women in the CARDIA cohort study: Life course and intersectionality perspectives

OBJECTIVE

This study examines whether discriminatory experiences are associated with lower urinary tract symptoms (LUTS) and their impact among 972 women in the Coronary Artery Risk Development in Young Adults (CARDIA) cohort study, which recruited participants from 4 cities in the United States.

METHOD

Exposure to discrimination was assessed 3 times (1992-93, 2000-01, 2010-11) and averaged across assessments. Participants separately reported whether they experienced discrimination on the basis of their gender, race or color, and socioeconomic position or social class. For each social identity, discrimination was assessed in 6-7 settings (e.g., when getting a job, medical care, or housing). At different time points, women who reported discriminatory experiences for a given social identity were asked how frequently the discrimination occurred and how stressful experience(s) were. Following the 2010-11 assessment, data on LUTS and their impact were collected. Women were classified into bladder health versus mild, moderate, or severe symptoms/impact clusters.

RESULTS

More Black than White women reported discriminatory experiences across all social identities and most settings. Perceived stress of discriminatory experiences did not differ between Black and White women. In analyses stratified by race and social identity, White women reported LUTS/impact with discriminatory experiences in more settings, more frequent discriminatory experiences across settings, and each additional social identity for which discrimination was experienced. Black women reported LUTS/impact with more frequent discriminatory experiences across settings. For Black women, greater perceived stress of both gender and race discrimination were associated with LUTS/impact. For White women, only greater perceived stress of race discrimination was associated with LUTS/impact.

CONCLUSIONS

This is one of the first studies to examine discrimination in relation to LUTS/impact. Additional research is needed to better understand differences in how discriminatory experiences based on potentially intersecting identities may be related to bladder health among women.

Allostatic load in the US general population: Race and educational intersection

Objectives

Educational attainment is a protective factor against poor health, but high educational attainment has a weaker effect on black people than on white people; this pattern has been called marginalization-related diminished returns (MDRs). Using a national sample of white people and black people 25 years and above, this study estimates the association between high educational attainment and allostatic load between black people and white people, and within each group.

Study design

This cross-sectional study uses data from the National Health and Nutrition Examination Survey (NHANES) between 1999 and 2016, including 2761 black people and 7058 white people. The outcome variable of interest was the Allostatic Load Scale (AL). We created the allostatic load scale by using 8 biomarkers, then created a binary variable (if ALS≥4 as 1 and ALS<4 as 0) to present elevated AL.

Methods

We used several weighted modified Poisson regression models controlling for educational attainment (a predictor) and race (a moderator variable), age, sex, and marital status. We also controlled the models for smoking and drinking status as health behavior variables. As a sensitivity analysis, we ran several sets of regression analysis using the AL scale as a continuous outcome variable.

Results

We found an inverse association between AL and educational attainment. The interaction between race and education has resulted in an inverse association between AL and educational attainment, with a weaker association in black people than in white people. We found similar findings by running regression models with AL as a continuous variable.

Conclusions

We observed a weaker association between educational attainment and AL in black people than in white people, suggesting that educational attainment has more robust protection against allostatic load for white people than black people.

Black-White Differences in Offspring Educational Attainment and Older Parents' Dementia

Emerging research documents the health benefits of having highly educated adult offspring. Yet less is known about whether those advantages vary across racial groups. This study examines how offspring education is tied to parents' dementia risk for Black and White parents in the United States. Using data from the Health and Retirement Study, findings suggest that children's education does not account for the Black-White gap in dementia risk. However, results confirm that parental race moderates the relationship between children's education and dementia risk and that the association between children's education and parents' dementia risk is strongest among less-educated parents. Among less-educated parents, higher levels of children's attainment prevent the risk of dementia onset for Black parents, but low levels of offspring schooling increase dementia risk among White parents. The study highlights how offspring education shapes the cognitive health of social groups differently and points to new avenues for future research.

Perceived Neighborhood Racial Composition and Depressive Symptoms Among Black Americans Across Adulthood: Evaluating the Role of Psychosocial Risks and Resources

Objectives: To evaluate the relationships between perceived neighborhood racial composition (PNRC), psychosocial risks and resources, and depressive symptoms among young (ages 22-35), middle-aged (ages 36-49), and older (ages 50+) Black Americans. Methods: Full sample and age-stratified linear regression models estimated the PNRC-depressive symptoms association and the extent to which it persisted after accounting for psychosocial risks (i.e., neighborhood disorder, other social stressors) and resources (i.e., mastery, social support, racial identity) among 627 Black Americans in the Nashville Stress and Health Study. Results: Living in racially integrated and predominately White neighborhoods was associated with elevated depressive symptoms. While psychosocial risks and resources explained a substantial portion of these associations, patterns varied across age groups. Discussion: PNRC impacts depressive symptoms among Black Americans by shaping psychosocial risks and resources. Findings underscore interconnections between contextual and psychosocial factors, as well as the distinct mental health significance of these processes across stages of adulthood.

The impact of perceived everyday discrimination and income on racial and ethnic disparities in PTSD, depression, and anxiety among veterans

OBJECTIVES

Black and Hispanic/Latinx individuals experience a greater burden of mental health symptoms as compared to White individuals in the general population. Examination of ethnoracial disparities and mechanisms explaining these disparities among veterans is still in its nascence. The current study examined perceived everyday discrimination and income as parallel mediators of the association between race/ethnicity and PTSD, depression, and general anxiety symptoms in a sample of White, Black, and Hispanic/Latinx veterans stratified by gender.

METHODS

A random sample of 3,060 veterans living across the U.S. (oversampled for veterans living in high crime communities) completed a mail-based survey. Veterans completed self-report measures of perceived discrimination via the Everyday Discrimination Scale, PTSD symptoms via the Posttraumatic Stress Disorder Checklist-5, depressive symptoms via the Patient Health Questionnaire, and anxiety symptoms via the Generalized Anxiety Disorder Questionnaire.

RESULTS

Models comparing Black vs. White veterans found that the significant effect of race on PTSD, depression, and anxiety symptoms was mediated by both perceived discrimination and income for both male and female veterans. Results were less consistent in models comparing Hispanic/Latinx vs. White veterans. Income, but not perceived discrimination, mediated the relationship between ethnicity/race and depression and anxiety symptoms, but only among women.

CONCLUSIONS

Results suggest that discrimination and socioeconomic status are important mechanisms through which marginalized social status negatively impacts mental health.

Sex and ethnic/racial differences in disordered eating behaviors and intuitive eating among college student

Introduction

Eating behaviors encompass disordered eating behaviors (e.g., overeating, binge eating, and associated symptoms of binge eating) and intuitive eating. Certain disordered eating behaviors, including binge eating, are more prevalent among female and ethnic/racial-minority college students than male and/or non-Hispanic White college students. However, sex and ethnic/racial differences among college students with other disordered eating (e.g., associated symptoms of binge eating) and intuitive eating behaviors remain unclear.

Methods

In 2022, 887 college students (Mage = 20.9 ± 2.6 years) self-reported their sex, ethnicity/race, disordered eating behaviors (e.g., overeating, binge eating, associated symptoms of binge eating), and intuitive eating. To examine sex and ethnic/racial differences among these students, we used modified Poisson regressions for students who reported disordered eating and linear regressions for students who reported intuitive eating.

Results

Except for overeating, disordered eating behaviors were more prevalent among female [adjusted prevalence ratio (aPR) = 1.3-1.8] than male college students after adjusting for sociodemographic variables, whereas intuitive eating scores did not differ by sex. Across ethnic/racial groups, disordered eating was more prevalent among all ethnic/racial-minority college students (aPR = 1.2-2.3) than non-Hispanic White college students after adjusting for sociodemographic variables. Moreover, non-Hispanic Black or African American college students had higher intuitive eating scores than non-Hispanic White college students (adjusted β = 0.7, 95% CI = -0.2, 1.6).

Conclusion

In our sample, notable differences emerged in the prevalence of disordered eating behaviors and mean scores by sex and ethnicity/race, while differences in intuitive eating scores emerged based on ethnicity/race.

Black-White differences in perceived lifetime discrimination by education and income in the MIDUS Study in the U.S

There is growing evidence on the negative effects of perceived discrimination on health outcomes and their interactions with indicators of socioeconomic status. However, less has been studied on whether income and education lead individuals of a different race to encounter different discriminatory experiences in their lifetime. Using data from the national survey of the Midlife Development in the United States-MIDUS 1 (1995-1996) and MIDUS Refresher (2011-2014)-on eight measures of perceived lifetime discrimination, this study compares discriminatory experiences of Black and White persons in two time periods. We applied generalized structural equation models and generalized linear models to test multiplicative effects of income and education by race on lifetime discrimination. In both periods, we find substantive disparities between White and Black people in all types of lifetime discrimination, with Black people reporting much higher levels of discrimination. Such disparities exacerbated in the top cohorts of society, yet these associations have changed in time, with White individuals reporting increasing levels of discrimination. Results show that, for Black people in the mid-1990s, perceived discrimination increased as education and income increased. This finding persisted for education by the early 2010s; income effects changed as now both, low- and high-income Black people, reported the highest levels of discrimination. These findings highlight a policy conundrum, given that increasing income and education represent a desirable course of action to improve overall discrimination and health outcomes. Yet, we show that they may unintendingly exacerbate racial disparities in discrimination. We also show that the U.S. is moving toward a stagnation period in health outcomes improvement, with racial disparities in discrimination shrinking at the expense of a deterioration of whites' lifetime discriminatory experiences. Our results highlight the need for a multi-systems policy approach to prevent all forms of discrimination including those due to historical, institutional, legal, and sociopolitical structures.

Social mobility and perinatal depression in Black women

Background

Higher socioeconomic position is associated with better birth outcomes and maternal mental health, although this relationship is less consistent for Black women. The literature is limited on the impact of social mobility across the life course on mental health of pregnant women. This study examines the impact of perceived financial status across the life-course on depressive symptoms during pregnancy among Black women.

Methods

Data were from the Life-course Influences of Fetal Environments (LIFE) retrospective cohort study among pregnant Black women in metropolitan Detroit, Michigan. Depressive symptoms in the two weeks prior to birth were assessed using the Center for Epidemiologic Studies Depression (CES-D) scale. Social mobility was determined at three intervals over the life course using self-report of financial status during childhood, adolescence, and current age in pregnancy.

Results

1,410 pregnant women participated, ranging in age from 18 to 45 years old. CES-D scores ranged from 0 to 53 (mean = 15.3) and 26% of the sample reported high depressive symptoms. In each age interval, higher financial status was associated with significant protective effect on depressive symptoms, and the magnitude of the effect increased across the life course. Trajectory analysis demonstrated that both the upward (4.51; 95% CI, 2.43-6.6) and downward (4.04; 95% CI, 2.62-5.46 and 3.09; 95% CI, 1.57-4.62) life-course social mobility groups had increased mean CES-D scores compared to the static social mobility group.

Conclusion

This study describes the importance of previous childhood and current financial status effects on mental health in Black pregnant women.

Perceived Racial/Ethnic Discrimination, Citizenship Status, and Self-Rated Health Among Immigrant Young Adults

Both racial/ethnic discrimination and citizenship status are manifestations of racism. Few empirical studies have examined the role of multiple stressors and how both stressors are interlinked to influence health among immigrant young adults. Informed by the theory of stress proliferation, the current study seeks to examine the interplay between perceived racial/ethnic discrimination and citizenship status on health. We used the third wave of the Children of Immigrants Longitudinal Study (CILS) to examine the influence of perceived racial/ethnic discrimination and citizenship status on self-rated health (SRH) among immigrant young adults (N = 3344). Perceived racial/ethnic discrimination was initially associated with SRH. After adjusting for both predictors, those experiencing perceived racial/ethnic discrimination and non-citizen youth were less likely to report better health than youth who did not report perceived racial/ethnic discrimination or citizen youth. In fully adjusted multivariate regression models, racial/ethnic discrimination remained significant, while citizenship status was no longer associated with SRH. To test stress proliferation, an interaction term was included to assess whether the relationship between perceived racial/ethnic discrimination and SRH varied by citizenship status. The interaction term was significant; non-citizen young adults who experienced racial/ethnic discrimination were less likely to report better health in comparison to citizen young adults and those who did not report perceived racial/ethnic discrimination. Results suggest that the interplay between perceived racial/ethnic discrimination and citizenship status may be influential for health among immigrant young adults. These findings underscore the need for further assessment of the role of stress proliferation on immigrant young adults' health.

High Systolic Blood Pressure of High-Income African American Children

BACKGROUND

According to the Minorities' Diminished Returns (MDRs) theory, racism may reduce the health returns of family socioeconomic status (SEP) resources such as family income for racial minorities, particularly African Americans, compared to Whites. However, we are unaware of any previous studies on racial variation in the protective effects of family income on children's blood pressure.

AIM

We conducted this study to compare the overall effects of family income on pre-adolescents' systolic and diastolic blood pressure, test racial variation in this effect, and investigate whether racial variation in this regard is due to racial differences in body mass index.

METHODS

In this cross-sectional study, we analyzed data from 4007 racially diverse US children 9-10 years old. The independent variable was family income measured as a three-level categorical variable: less than $50 K USD, 50-100 K USD, and 100 + K USD. The primary outcomes were systolic and diastolic blood pressure measured up to three times at 1-min time intervals. Body mass index was the mediator. Mixed-effects regression models were used for data analysis to adjust for data nested to the centers, families, and individuals. Age, gender, parental education, family structure, and Latino ethnicity were covariates.

RESULTS

In the pooled sample and in the absence of interaction terms in the model, family income did not show an inverse association with children's systolic (for 100 + K USD family income: β =  - 0.71, p = 0.233 and for 50-100 K USD family income: β = 0.01, p = 0.989) or diastolic blood pressure (for 100 + K USD family income: β =  - 0.66, p = 0.172 and for 50-100 K USD family income: β = 0.23, p = 0.600). However, race showed a significant interaction with family income on systolic blood pressure (for 50-100 K USD × African American: β = 2.75, p = 0.034), suggesting higher systolic blood pressure of African American adolescents from high-income backgrounds. Racial variation in the protective effect of family income on systolic BP was no more significant (for 50-100 K USD × African American: β = 2.14, p = 0.149) after we controlled for body mass index (BMI), which was higher for African American than White adolescents.

CONCLUSION

The association between high family income and reduced systolic blood pressure in pre-adolescence might be weaker for African Americans compared to Whites, a difference that African American adolescents' higher body mass index can explain.

Are Distressed Black Women Also Depressed? Implications for a Mental Health Paradox

PURPOSE

Recent research suggests the determinants of and links between psychological distress and psychiatric disorder are distinct among Black Americans. Yet, these associations have not been explored among Black women, despite the unique social experiences, risks, and mental health patterns they face. The present study assessed the sociodemographic and psychosocial determinants of distress and disorder and evaluated the distress-disorder association, including whether it was conditional on sociodemographic and psychosocial characteristics among Black women.

METHODS

Data were from 328 Black women in the Nashville Stress and Health Study, a cross-sectional community epidemiologic survey of Blacks and Whites in Nashville, Tennessee, and was used to assess the correlates of distress (CES-D depressive symptoms scale) and major depressive disorder (MDD; based on the CIDI). Multinomial logistic regression models estimated the extent to which greater distress was associated with higher risk of "chronic" or "resolved MDD".

RESULTS

Stress exposure and marital status were associated with greater distress, while stress exposure and childhood SES were associated with elevated disorder risk. Although increased distress was associated with greater disorder risk, significant interactions indicated these associations depend on differences in age and adult socioeconomic status within this population.

CONCLUSIONS

This study identifies distinct correlates of distress and disorder and shows that the distress-disorder association varies among subgroups of Black women. Results have important implications for public health research and practice, as they highlight the factors that matter most for the mental health outcomes of Black women.

Racialized Health Inequities: Quantifying Socioeconomic and Stress Pathways Using Moderated Mediation

Racism drives population health inequities by shaping the unequal distribution of key social determinants of health, such as socioeconomic resources and exposure to stressors. Research on interrelationships among race, socioeconomic resources, stressors, and health has proceeded along two lines that have largely remained separate: one examining differential effects of socioeconomic resources and stressors on health across racialized groups (moderation processes), and the other examining the role of socioeconomic resources and stressors in contributing to racial inequities in health (mediation processes). We conceptually and analytically integrate these areas using race theory and a novel moderated mediation approach to path analysis to formally quantify the extent to which an array of socioeconomic resources and stressors-collectively and individually-mediate racialized health inequities among a sample of older adults from the Health and Retirement Study. Our results yield theoretical contributions by showing how the socioeconomic status-health gradient and stress processes are racialized (24% of associations examined varied by race), substantive contributions by quantifying the extent of moderated mediation of racial inequities (approximately 70%) and the relative importance of various social factors, and methodological contributions by showing how commonly used simple mediation approaches that ignore racialized moderation processes overestimate-by between 5% and 30%-the collective roles of socioeconomic status and stressors in accounting for racial inequities in health.

Life-Course Mobility in Socioeconomic Position and High Depressive Symptoms Among Young Black Women: The SELF Study

BACKGROUND

Current literature on the association between mobility in socioeconomic position (SEP) and depression demonstrates mixed findings, with variation in the benefits of upward SEP by racial group and ethnic background. No study has examined life-course SEP mobility and depressive symptoms among Black women in the United States.

METHODS

Our cohort included 1,612 Black women enrolled in the Study of Environment, Lifestyle and Fibroids between 2010 and 2012 and followed for 5 years. We used data on socioeconomic indicators at childhood and adulthood and used latent class analysis to create a life-course SEP mobility measure (persistently low, downward, upward, and persistently high). Using the 11-item Center for Epidemiologic Studies Depression Scale (CES-D), we assessed high (≥9) versus low depressive symptoms. Multivariable log risk models were used to produce risk ratios (RRs) and 95% confidence intervals (CIs).

RESULTS

Of the participants, 37% had high depressive symptoms. Persistently low (RR, 1.56; 95% CI, 1.31-1.86) and downward (RR, 1.36; 95% CI, 1.14-1.63) SEP mobility was associated with high depressive symptoms after adjustment for age, adult social support, and marital status. There was evidence of an effect measure modification by adult social support, with a stronger association among those who reported high adult social support compared with low adult social support.

CONCLUSIONS

These findings suggest directing mental health resources to people experiencing low SEP at any stage in life, especially those with low SEP in adulthood, to aid in the management of depressive symptoms.

Intersecting Early-Life Selection Mechanisms: Socio-Historical Changes in Racially Stratified Effects of Education on Functional Limitations in the United States

OBJECTIVE

Scant research has focused on the role of sociohistorical changes in shaping intersecting early-life selection mechanisms and their impacts on racially stratified effects of education on health across cohorts.

METHOD

Drawing from the Health and Retirement Survey, this study fitted negative binomial regression models to assess the impacts of childhood socioeconomic status (SES) on the relationship between education and functional limitations for Black and White adults across birth cohorts (n = 16,269, born 1931-1959).

RESULTS

The disparities between Black adults and White adults in impacts of childhood SES on both education and functional limitations were more pronounced in recent cohorts. The racial stratification in the impacts of education on functional limitations was documented across cohorts. However, after adjusting for childhood SES, this stratification narrowed considerably in recent cohorts.

DISCUSSION

This study underscores the role of a sociohistorical context in shaping the effects of education on health at the intersection of race and cohort.

Understanding the Impact of Contemporary Racism on the Mental Health of Middle Class Black Americans

Evidence from previous research indicates that while socioeconomic status (SES) narrows Black-White health inequities, these inequities do not completely disappear, and in some cases, worsen. Why do Black-White health inequities persist, even when controlling for SES? It is critical to examine how perceptions of unfair treatment, especially those that are nuanced and subtle, affect the mental health of Black Americans with greater levels of SES. This study, using a new sample composed exclusively of college-educated Black Americans, investigated whether experiences related to racism were associated with poorer mental health. Qualtrics provided the sample from their nationwide panelists that met the research criteria. Inclusion criteria included the following: (1) self-identified as Black or African American; (2) at least 24 years old; (3) completed a 4-year college degree or higher. The findings from this study indicated that the effects of unfair treatment are significantly associated with poorer mental health. These findings highlight the insidious nature of contemporary racism as the everyday experiences of unfair treatment have a tremendous effect on depressive symptoms among this sample of college-educated Black Americans. Efforts to simply improve SES among historically marginalized groups will not bring about health equity. Findings from this study indicate that there are mental health costs associated with upward social mobility. It is likely that these costs, particularly the experience of everyday unfair treatment, likely diminish the social, economic and health returns on the human capital.

Impact of COVID-19 pandemic on the mental health of university students in the United Arab Emirates: a cross-sectional study

BACKGROUND

The COVID-19 pandemic had a significant impact on the mental well-being of students worldwide. There is a scarcity of information on the mental health impact of the COVID-19 pandemic on university students in the United Arab Emirates (UAE). This study aimed to investigate the mental health impact of the COVID-19, including depression, anxiety and resilience among a sample of university students in the UAE.

METHODS

A cross-sectional study using an online survey was conducted from September to November 2021. The patient health questionnaire (PHQ-9), generalized anxiety disorder-7 (GAD-7) and Connor-Davidson Resilience Scale (CD-RISC-10) were used to assess depression, anxiety, and resilience. The COVID-19 impact was assessed using a list of questions.

RESULTS

Only, 798 students completed the survey and were analyzed for this study. Overall, 74.8% of the students were females, 91.2% were never married, and 66.3% were UAE-nationals. Based on PHQ-9 and GAD-7 cut-off scores (≥ 10), four out of ten of the students self-reported moderate to severe depression (40.9%) and anxiety (39.1%). Significantly higher mean PHQ-9 and GAD-7 scores were found among students who were impacted by COVID-19 than those non-impacted (mean PHQ-9 = 9.51 ± 6.39 and 6.80 ± 6.34; p = 0.001, respectively) and (mean GAD-7 = 9.03 ± 6.00 and 8.54 ± 6.02; respectively, p < 0.001). Female students who were impacted by COVID-19 had statistically significant higher depression and anxiety scores (mean PHQ-9 of 9.14 ± 5.86 vs. 6.83 ± 6.25, respectively; p < 0.001) than the non-impacted females (mean GAD-7 of 9.57 ± 6.32 vs. 5.15 ± 3.88, respectively; p = 0.005). Never married students had significantly higher PHQ-9 and GAD-7 scores than ever-married (9.31 ± 6.37 vs. 6.93 ± 5.47, P = 0.003) and (8.89 ± 6.11 vs. 7.13 ± 5.49, respectively; p = 0.017).

CONCLUSIONS

The results of this study demonstrate that the COVID-19 pandemic has negatively impacted the mental health of this sample of university students in terms of depression and anxiety. The results highlight the need to adopt culturally appropriate interventions for university students and focus on vulnerable groups.

Social Determinants of Mental, Physical, and Oral Health of Middle-Aged and Older African Americans in South Los Angeles

BACKGROUND

A growing body of research suggests that financial difficulties could weaken the protective effects of socioeconomic status (SES) indicators, including education and income, on the health status of marginalized communities, such as African Americans.

AIM

We investigated the separate and joint effects of education, income, and financial difficulties on mental, physical, and oral self-rated health (SRH) outcomes in African American middle-aged and older adults.

METHODS

This cross-sectional study enrolled 150 middle-aged and older African Americans residing in South Los Angeles. Data on demographic factors (age and gender), socioeconomic characteristics (education, income, and financial difficulties), and self-rated health (mental, physical, and oral health) were collected. Three linear regression models were used to analyze the data.

RESULTS

Higher education and income were associated with a lower level of financial strain in a bivariate analysis. However, according to multivariable models, only financial difficulties were associated with poor mental, physical, and oral health. As similar patterns emerged for all three health outcomes, the risk associated with financial difficulties seems robust.

CONCLUSIONS

According to our multivariable models, financial strain is a more salient social determinant of health within African American communities than education and income in economically constrained urban environments such as South Los Angeles. While education and income lose some protective effects, financial strain continues to deteriorate the health of African American communities across domains.

Immigration Status, Socioeconomic Status, and Self-Rated Health in Europe

The literature has established a protective effect of socioeconomic status (SES) indicators on health. However, at least in the US, these SES indicators tend to generate fewer health gains for marginalized groups including immigrants. As this literature mainly originated in the US, it is necessary to study whether these indicators similarly correlate with the health of foreign-born and native-born individuals in Europe. The current study was based on the Marginalization-related Diminished Returns (MDRs) theory and compared the effects of three SES indicators, namely parental education, own education and income, on self-rated health (SRH) of immigrant and native-born individuals. We used data from the European Social Survey 2020 (ESS 2020). Participants included 14,213 individuals who identified as either native-born (n = 9052) or foreign-born (n = 508). Education, income, and parental education were the independent variables. Self-rated health (SRH) was the outcome. Age and sex were covariates. Linear regression and logistic regression were used for data analysis. Overall, high education, income, and parental education were associated with lower odds of poor SRH. We documented a statistical interaction between immigration status and parental education, indicating a weaker inverse association between parental education and poor SRH for foreign-born than native-born individuals. The links between some but not all SES indicators vary across foreign-born and native-born individuals in Europe. Host countries seem to undervalue the parental educational attainment of foreign-born families. Future research should explore the role of time, period, cohort and country of origin as well as host country and associated policies in equalizing returns of SES indicators on the health of population subgroups. The results are important given that most studies on MDRs are developed in the US, and less is known about Europe. The results are also very important given the growing anti-immigrant sentiment and nationalist movements in Europe and the rest of the world.

Factors associated with polypharmacy and the high risk of medication-related problems among older community-dwelling adults in European countries: a longitudinal study

Background

Polypharmacy can be defined as using five or more medications simultaneously. “Medication-related problems”, an extension of polypharmacy, includes inappropriate prescribing, poor adherence, overdosage, underdosage, inappropriate drug selection, inadequate monitoring, adverse drug effects, and drug interactions. Polypharmacy and the high risk of medication-related problems among older people are associated with adverse health consequences due to drug-drug interactions, drug-disease interactions, and adverse drug effects. This study aims to assess the factors associated with polypharmacy and the high risk of medication-related problems among community-dwelling older people in the Netherlands, Greece, Croatia, Spain, United Kingdom.

Method

This longitudinal study used baseline and follow-up data from 1791 participants of the Urban Health Center European project. Polypharmacy and the risk of medication-related problems were evaluated at baseline and follow-up using the Medication Risk Questionnaire. We studied factors in the domains (a) sociodemographic characteristics, (b) lifestyle and nutrition, and (c) health and health care use. Hierarchical logistic regression analyses were used to examine the factors associated with polypharmacy and the high risk of medication-related problems.

Results

Mean age was 79.6 years (SD ± 5.6 years); 60.8% were women; 45.2% had polypharmacy, and 41.8% had a high risk of medication-related problems. Women participants had lower odds of polypharmacy (OR = 0.55;95%CI:0.42–0.72) and a high risk of medication-related problems (OR = 0.50; 95%CI:0.39–0.65). Participants with a migration background (OR = 1.67;95%CI:1.08–2.59), overweight (OR = 1.37; 95%CI:1.04–1.79) and obesity (OR = 1.78;95%CI:1.26–2.51) compared to ‘normal weight’, with lower physical HRQoL (OR = 0.96, 95%CI:0.95–0.98), multi-morbidity (OR = 3.73, 95%CI:2.18–6.37), frailty (OR = 1.69, 95%CI:1.24–2.30), visited outpatient services (OR = 1.77, 95%CI: 1.09–2.88) had higher odds of polypharmacy. The associations with the high risk of medication-related problems were similar.

Conclusions

Multiple factors in demography, lifestyle, nutrition, and health care use are associated with polypharmacy and the high risk of medication-related problems. Polypharmacy is a single element that may reflect the number of medications taken. The broader content of medication-related problems should be considered to assess the context of medication use among older people comprehensively. These provide starting points to improve interventions to reduce polypharmacy and high risk of medication-related problems. In the meantime, health professionals can apply these insights to identify subgroups of patients at a high risk of polypharmacy and medication-related problems.

Trial registration

The intervention of the UHCE project was registered in the ISRCTN registry as ISRCTN52788952. The date of registration is 13/03/2017.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03536-z.

Vicarious structural racism and infant health disparities in Michigan: The Flint Water Crisis

Building on nascent literature examining the health-related effects of vicarious structural racism, we examined indirect exposure to the Flint Water Crisis (FWC) as a predictor of birth outcomes in Michigan communities outside of Flint, where residents were not directly exposed to lead-contaminated water. Using linear regression models, we analyzed records for all singleton live births in Michigan from 2013 to 2016, excluding Flint, to determine whether birth weight (BW), gestational age (GA), and size-for-gestational-age (SzGA) decreased among babies born to Black people, but not among babies born to White people, following the highly publicized January 2016 emergency declaration in Flint. In adjusted regression models, BW and SzGA were lower for babies born to both Black and White people in the 37 weeks following the emergency declaration compared to the same 37-week periods in the previous 3 years. There were no racial differences in the association of exposure to the emergency declaration with BW or SzGA. Among infants born to Black people, GA was 0.05 weeks lower in the 37-week period following the emergency declaration versus the same 37-week periods in the previous 3 years (95% CI: -0.09, -0.01; p = 0.0177), while there was no change in GA for infants born to White people following the emergency declaration (95% CI: -0.01, 0.03; p = 0.6962). The FWC, which was widely attributed to structural racism, appears to have had a greater impact, overall, on outcomes for babies born to Black people. However, given the frequency of highly publicized examples of anti-Black racism over the study period, it is difficult to disentangle the effects of the FWC from the effects of other racialized stressors.

Is educational mobility harmful for health?

"Mobility effects" research to date provides mixed evidence about the health consequences of social mobility and pays limited attention to race differences in mobility effects. To address this gap in the literature, this study explores the association between downward mobility and upward mobility with health and how these associations vary between Black people and White people. Diagonal reference models are used to estimate the effects of intergenerational educational mobility on self-rated health and mortality using data from the U.S. General Social Survey (1972-2016) with linked mortality records (1978-2014). Results show that downward mobility is associated with worse self-rated health and higher mortality risk. Downward mobility appears more damaging to the health of White people relative to Black people. Upward mobility appears less beneficial to the health of Black people. These findings indicate that social mobility itself is consequential for health and suggest that downward mobility is detrimental to health.

The enduring effects of racism on health: Understanding direct and indirect effects over time

Experiences of racism and racial discrimination are associated with poorer mental and physical health outcomes for people from minoritised ethnic groups. One mechanism by which racism leads to poor health is through reduced socio-economic resources, but the evidence documenting the direct and indirect effects of racism on health via socio-economic inequality over time is under-developed. The central aims of this paper are to better understand how racism affects health over time, by age, and via the key mechanism of socio-economic inequality. This paper analyses large-scale, nationally representative data from the UK Household Longitudinal Study (Understanding Society) 2009–2019. Findings from longitudinal structural equation models clearly indicate the enduring effects of racism on health, which operate over time both directly and indirectly through lower income and poorer prior health. Repeated exposure to racism severely and negatively impacts the health of people from minoritised ethnic groups. These findings make an important contribution to the existing evidence base, demonstrating the enduring effects of racism on health over time and across age groups.

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We examine the role of racism as a key driver of ethnic inequalities in health.

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We examine the direct and indirect effects of racism on mental and physical health.

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Racism severely and negatively impacts health over time and across the life course.

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Repeated exposure to racism leads to accumulation of disadvantage and poorer health.

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Policy and academic debates must focus on the fundamental role of racism on health.

Discrimination and Sleep Impairment in American Indians and Alaska Natives

BACKGROUND

Sleep impairment may be a key pathway through which discrimination undermines health. Links between discrimination and sleep in American Indians and Alaska Natives (AI/AN) have not been established. Further, it is unclear if such links might depend on the timing of discrimination or if socioeconomic status (SES) might buffer the impact of discrimination.

PURPOSE

To investigate associations between interpersonal discrimination and sleep impairment in urban AI/AN, for both lifetime and recent discrimination, and controlling for other life stressors. Education and income, indices of SES, were tested as potential moderators.

METHODS

A community sample of urban AI/AN (N = 303, 18-78 years old, 63% female) completed self-report measures of sleep impairment, lifetime and recent discrimination, depressive symptoms, perceived stress, other life stressors (childhood adversity and past year major events), and socio-demographic characteristics.

RESULTS

Lifetime discrimination was associated with impaired sleep in AI/AN after adjustment for socio-demographic characteristics, recent depressive symptoms, perceived stress, and other life stressors. Past-week discrimination was associated with sleep in unadjusted but not adjusted models. Education, but not income, was found to buffer the effects of both lifetime and past-week discrimination on sleep in adjusted models.

CONCLUSION

Lifetime discrimination uniquely accounts for sleep impairment and may be especially harmful in those with less education. These findings suggest targeting interventions to those most in need. Limitations include the cross-sectional nature of the data. Longitudinal and qualitative work is needed to understand how education may buffer the effects of discrimination on sleep and perhaps other health problems in AI/AN.

Neighborhood Socioeconomic Deprivation and Health Care Utilization of Medically Complex Children

OBJECTIVES

To assess the association between neighborhood socioeconomic deprivation and health care utilization in a cohort of children with medical complexity (CMC).

METHODS

Cross-sectional study of children aged <18 years receiving care in our institution's patient-centered medical home (PCMH) for CMC in 2016 to 2017. Home addresses were assigned to census tracts and a tract-level measure of socioeconomic deprivation (Deprivation Index with range 0-1, higher numbers represent greater deprivation). Health care utilization outcomes included emergency department visits, hospitalizations, inpatient bed days, and missed PCMH clinic appointments. To evaluate the independent association between area-level socioeconomic deprivation and utilization outcomes, multivariable Poisson and linear regression models were used to control for demographic and clinical covariates.

RESULTS

The 512 included CMC lived in neighborhoods with varying degrees of socioeconomic deprivation (median 0.32, interquartile range 0.26-0.42, full range 0.12-0.82). There was no association between area-level deprivation and emergency department visits (adjusted risk ratio [aRR] 0.98; 95% confidence interval [CI]: 0.93 to 1.04), hospitalizations (aRR 0.97; 95% CI: 0.92 to 1.01), or inpatient bed-days (aRR 1.00, 95% CI: 0.80 to 1.27). However, there was a 13% relative increase in the missed clinic visit rate for every 0.1 unit increase in Deprivation Index (95% CI: 8%-18%).

CONCLUSIONS

A child's socioeconomic context is associated with their adherence to PCMH visits. Our PCMH for CMC includes children living in neighborhoods with a range of socioeconomic deprivation and may blunt effects from harmful social determinants. Incorporating knowledge of the socioeconomic context of where CMC and their families live is crucial to ensure equitable health outcomes.

Are Experiences of Racial Discrimination Associated with Postpartum Depressive Symptoms? A Multistate Analysis of Pregnancy Risk Assessment Monitoring System Data

Background: Postpartum depression (PPD) is a serious public health crisis disproportionately affecting women of color. We examine whether interpersonal racial discrimination is associated with higher odds of postpartum depressive symptoms (PPDS) among women of color and how it may vary by race/ethnicity and maternal educational attainment. Materials and Methods: We present a secondary analysis of cross-sectional data from Pregnancy Risk Assessment Monitoring System (PRAMS) postnatal surveys conducted in nine jurisdictions between 2012 and 2015 that included a question about being upset by experiences of racial discrimination within 12 months before giving birth. Results: Being upset by racial discrimination was associated with nearly three times higher odds of PPDS. Among women of color with at least some college education, the higher odds of PPDS associated with racial discrimination were greater than threefold, and for women with less than a high school education were less than twofold. Conclusion: Addressing risk factors for PPD, including racial discrimination, may inform strategies to reduce racial disparities in maternal mental health.

Contextualizing Educational Disparities in Health: Variations by Race/Ethnicity, Nativity, and County-Level Characteristics

Educational disparities in health are well documented, yet the education-health relationship is inconsistent across racial/ethnic and nativity groups. These inconsistencies may arise from characteristics of the early life environments in which individuals attain their education. We evaluate this possibility by investigating (1) whether educational disparities in cardiometabolic risk vary by race/ethnicity and nativity among Black, Hispanic, and White young adults; (2) the extent to which racial/ethnic-nativity differences in the education-health relationship are contingent on economic, policy, and social characteristics of counties of early life residence; and (3) the county characteristics associated with the best health at higher levels of education for each racial/ethnic-nativity group. Using data from the National Longitudinal Study of Adolescent to Adult Health, we find that Black young adults who achieve high levels of education exhibit worse health across a majority of contexts relative to their White and Hispanic counterparts. Additionally, we observe more favorable health at higher levels of education across almost all contexts for White individuals. For all other racial/ethnic-nativity groups, the relationship between education and health depends on the characteristics of the early life counties of residence. Findings highlight place-based factors that may contribute to the development of racial/ethnic and nativity differences in the education-health relationship among U.S. young adults.

Heterogeneous Mediation Analysis on Epigenomic PTSD and Traumatic Stress in a Predominantly African American Cohort

DNA methylation (DNAm) has been suggested to play a critical role in post-traumatic stress disorder (PTSD), through mediating the relationship between trauma and PTSD. However, this underlying mechanism of PTSD for African Americans still remains unknown. To fill this gap, in this article, we investigate how DNAm mediates the effects of traumatic experiences on PTSD symptoms in the Detroit Neighborhood Health Study (DNHS) (2008-2013) which involves primarily African Americans adults. To achieve this, we develop a new mediation analysis approach for high-dimensional potential DNAm mediators. A key novelty of our method is that we consider heterogeneity in mediation effects across subpopulations. Specifically, mediators in different subpopulations could have opposite effects on the outcome, and thus could be difficult to identify under a traditional homogeneous model framework. In contrast, the proposed method can estimate heterogeneous mediation effects and identifies subpopulations in which individuals share similar effects. Simulation studies demonstrate that the proposed method outperforms existing methods for both homogeneous and heterogeneous data. We also present our mediation analysis results of a dataset with 125 participants and more than 450,000 CpG sites from the DNHS study. The proposed method finds three subgroups of subjects and identifies DNAm mediators corresponding to genes such as HSP90AA1 and NFATC1 which have been linked to PTSD symptoms in literature. Our finding could be useful in future finer-grained investigation of PTSD mechanism and in the development of new treatments for PTSD.

Ethnic inequalities in health in later life, 1993–2017: the persistence of health disadvantage over more than two decades

Ethnic inequalities in health and wellbeing across the early and mid-lifecourse have been well-documented in the United Kingdom. What is less known is the prevalence and persistence of ethnic inequalities in health in later life. There is a large empirical gap focusing on older ethnic minority people in ethnicity and ageing research. In this paper, we take a novel approach to address data limitations by harmonising six nationally representative social survey datasets that span more than two decades. We investigate ethnic inequalities in health in later life, and we examine the effects of socio-economic position and racial discrimination in explaining health inequalities. The central finding is the persistence of stark and significant ethnic inequalities in limiting long-term illness and self-rated health between 1993 and 2017. These inequalities tend to be greater in older ages, and are partially explained by contemporaneous measures of socio-economic position, racism, and discrimination. Future data collection endeavours must better represent older ethnic minority populations and enable more detailed analyses of the accumulation of socio-economic disadvantage and exposure to racism over the lifecourse, and its effects on poorer health outcomes in later life.

Development and validation of a polysocial risk score for atherosclerotic cardiovascular disease

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Social determinants of health may improve identification of atherosclerotic cardiovascular disease – beyond traditional risk factors.

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We provide the first, validated, polysocial risk score – the PsRS – for atherosclerotic cardiovascular disease.

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PsRS is a robust tool to quantify cumulative social disadvantage.

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PsRS offers unique opportunities to improve cardiovascular risk prediction algorithms.

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Our findings may help highlight, and address disparities in cardiovascular disease.

Objective

To date, the extent to which social determinants of health (SDOH) may help identify individuals with atherosclerotic cardiovascular disease (ASCVD) – beyond traditional risk factors – has not been quantified using a cumulative social disadvantage approach. The objective of this study was to develop, and validate, a polysocial risk score (PsRS) for prevalent ASCVD in a nationally representative sample of adults in the United States (US).

Methods

We used data from the 2013–2017 National Health Interview Survey. A total of 38 SDOH were identified from the database. Stepwise and criterion-based selection approaches were applied to derive PsRS, after adjusting for traditional risk factors. Logistic regression models were fitted to assign risk scores to individual SDOH, based on relative effect size magnitudes. PsRS was calculated by summing risk scores for individual SDOH, for each participant; and validated using a separate validation cohort.

Results

Final sample comprised 164,696 adults. PsRS included 7 SDOH: unemployment, inability to pay medical bills, low income, psychological distress, delayed care due to lack of transport, food insecurity, and less than high school education. PsRS ranged from 0–20 and exhibited excellent calibration and discrimination. Individuals with the highest PsRS (5^th quintile) had nearly 4-fold higher ASCVD prevalence, relative to those with the lowest risk scores (1^st quintile). Area under receiver operating curve (AU-ROC) for PsRS with SDOH alone was 0.836. Addition of SDOH to the model with only demographic and clinical risk factors (AU-ROC=0.852) improved overall discriminatory power, with AU-ROC for final PsRS (demographics + clinical + SDOH) = 0.862.

Conclusions

Cumulatively, SDOH may help identify individuals with ASCVD, beyond traditional cardiovascular risk factors. In this study, we provide a unique validated PsRS for ASCVD in a national sample of US adults. Future study should target development of similar scores in diverse populations, and incorporate longitudinal study designs.

Structural Intersectionality as a New Direction for Health Disparities Research

This article advances the field by integrating insights from intersectionality perspectives with the emerging literatures on structural racism and structural sexism-which point to promising new ways to measure systems of inequality at a macro level-to introduce a structural intersectionality approach to population health. We demonstrate an application of structural intersectionality using administrative data representing macrolevel structural racism, structural sexism, and income inequality in U.S. states linked to individual data from the Behavioral Risk Factor Surveillance System to estimate multilevel models (N = 420,644 individuals nested in 76 state-years) investigating how intersecting dimensions of structural oppression shape health. Analyses show that these structural inequalities: (1) vary considerably across U.S. states, (2) intersect in numerous ways but do not strongly or positively covary, (3) individually and jointly shape health, and (4) are most consistently associated with poor health for black women. We conclude by outlining an agenda for future research on structural intersectionality and health.

The effect of racial discrimination on mental and physical health: A propensity score weighting approach

RATIONALE

The preponderance of research documents the negative consequences of racial discrimination for the mental and physical well-being across several racial/ethnic groups including Black Americans, Hispanic Americans, and Asian Americans. Despite this large body of research, few studies have attempted to evaluate racial discrimination as a casual factor of worse health among racial minority groups. The current study utilized nationally representative data to estimate the causal effect of racial discrimination on cardiovascular disease (CVD), self-rated physical health (SRH), body mass index (BMI), depression disorder, and substance use disorder. In addition, we examined whether the effect of racial discrimination on health was moderated by socio-demographic characteristics (i.e., age, race/ethnicity, sex, socioeconomic status, marital status, geographic location, and health insurance coverage).

METHODS

Data were from the combined National Survey of American Life and the National Latino and Asian American Study. We applied a propensity score weighting approach to estimate the differences between individuals who reported ever (N = 4358) or never (N = 1836) experiencing racial discrimination on a list of health outcomes (e.g., CVD, SRH, BMI, depression disorder, and substance use disorder).

RESULTS

Participants who reported ever experiencing racial discrimination were about 5 % higher CVD risk, had 0.12 points lower SRH, a 3 % higher probability of a depression disorder, and a 2 % higher probability of a substance use disorder. Moderation effects by race/ethnicity, sex, socioeconomic status, geographic region, and health insurance coverage were found.

CONCLUSION

Our study represents one of the first attempts to apply a propensity score weighting approach to causally link racial discrimination to worse health for racial minority individuals. This study adds to a larger body of research documenting the negative association between racial discrimination and health.

Social Determinants of Health and Cardiovascular Disease: Current State and Future Directions Towards Healthcare Equity

PURPOSE OF REVIEW

We sought to examine the role of social and environmental conditions that determine an individual's behaviors and risk of disease-collectively known as social determinants of health (SDOH)-in shaping cardiovascular (CV) health of the population and giving rise to disparities in risk factors, outcomes, and clinical care for cardiovascular disease (CVD), the leading cause of death in the United States (US).

RECENT FINDINGS

Traditional CV risk factors have been extensively targeted in existing CVD prevention and management paradigms, often with little attention to SDOH. Limited evidence suggests an association between individual SDOH (e.g., income, education) and CVD. However, inequities in CVD care, risk factors, and outcomes have not been studied using a broad SDOH framework. We examined existing evidence of the association between SDOH-organized into 6 domains, including economic stability, education, food, neighborhood and physical environment, healthcare system, and community and social context-and CVD. Greater social adversity, defined by adverse SDOH, was linked to higher burden of CVD risk factors and poor outcomes, such as stroke, myocardial infarction (MI), coronary heart disease, heart failure, and mortality. Conversely, favorable social conditions had protective effects on CVD. Upstream SDOH interact across domains to produce cumulative downstream effects on CV health, via multiple physiologic and behavioral pathways. SDOH are major drivers of sociodemographic disparities in CVD, with a disproportionate impact on socially disadvantaged populations. Efforts to achieve health equity should take into account the structural, institutional, and environmental barriers to optimum CV health in marginalized populations. In this review, we highlight major knowledge gaps for each SDOH domain and propose a set of actionable recommendations to inform CVD care, ensure equitable distribution of healthcare resources, and reduce observed disparities.

The Coronary Artery Risk Development In Young Adults (CARDIA) Study: JACC Focus Seminar 8/8

The CARDIA (Coronary Artery Risk Development in Young Adults) study began in 1985 to 1986 with enrollment of 5,115 Black or White men and women ages 18 to 30 years from 4 US communities. Over 35 years, CARDIA has contributed fundamentally to our understanding of the contemporary epidemiology and life course of cardiovascular health and disease, as well as pulmonary, renal, neurological, and other manifestations of aging. CARDIA has established associations between the neighborhood environment and the evolution of lifestyle behaviors with biological risk factors, subclinical disease, and early clinical events. CARDIA has also identified the nature and major determinants of Black-White differences in the development of cardiovascular risk. CARDIA will continue to be a unique resource for understanding determinants, mechanisms, and outcomes of cardiovascular health and disease across the life course, leveraging ongoing pan-omics work from genomics to metabolomics that will define mechanistic pathways involved in cardiometabolic aging.

Race, Lifetime SES, and Allostatic Load among Older Adults

BACKGROUND

Prior research demonstrates that Black Americans receive fewer health benefits at high levels of SES relative to Whites. Yet, few studies have considered the role of lifetime SES (i.e. changes in SES from childhood to adulthood) in shaping these patterns among older adults. This study investigates the extent to which racial disparities in allostatic load (AL), an indicator of accelerated physiological aging, vary across levels of lifetime SES among Black and White adults aged 50+.

METHODS

With data from the Nashville Stress and Health Study, modified Poisson regression models were used to assess racial differences in the odds of high AL (4+ high-risk biomarkers) among Black and White older adults (N=518) within each level of lifetime SES (i.e., stable low SES, upward mobility, downward mobility, stable high SES).

RESULTS

Stable high SES was associated with greater odds of high AL; there was not a significant association between other lifetime SES trajectories and AL. However, the magnitude of racial disparities varied across levels of lifetime SES, with a significant Black-White difference in AL observed only among upwardly mobile (OR=1.76, 95% CI=1.24-2.51) and high SES groups (OR=2.22, 95% CI=1.37-3.58).

CONCLUSIONS

Our study demonstrates that racial disparities in AL among older adults depends on individuals' lifetime SES trajectories, and that older Black Americans receive fewer health benefits for achieving higher SES. These findings underscore the need to evaluate socioeconomic resources across the life course to clarify the extent of racial disparities among aging populations.

Navigating the mental health system: Narratives of identity and recovery among people with psychosis across ethnic groups

There is consistent evidence that members of the black Caribbean population in the UK are more likely to have coercive relationships with mental health services, typified by high levels of police involvement and compulsory treatment. This research has relied upon a medical epidemiological framework that has enumerated differences in service use but failed to unravel the complex interplay of individual, social, and cultural factors that inform the pathway to care. The purpose of this study was to explore the journey through mental health services from the perspective of individuals from the black Caribbean and majority white British population to help understand variation in the use of mental health services. Individual interviews were conducted with 17 black Caribbean, 15 white British, and 3 non-British white people with psychosis as part of AESOP-10, a 10 year follow up of an ethnically diverse cohort of individuals with first episode psychosis in the UK. Thematic narrative analysis identified three overarching narrative categories: 'losing self within the system' narratives gave primacy to individuals' identity as a chronic psychiatric patient with participants unable to break the cycle of service use; 'steadying self through the system' narratives combined recognition of the value of psychiatry and its limitations with the ability to access psychological therapy and protect valued social roles; 'finding strength beyond the system' narratives challenged negative dominant discourses and emphasised social, interpersonal and intrapersonal factors in recovery. We found variation in narratives across ethnic groups with 'losing self within the system' and 'finding strength beyond the system' narratives most common, though not exclusive to, black Caribbean participants. Distress appeared rooted in social structures that disadvantage black people, and psychiatry appeared to be experienced as a further form of oppression, that initially provoked resistance and fear, and over time, resignation to the identity of psychiatric patient.

Parents' Perceived Neighborhood Safety and Children's Cognitive Performance: Complexities by Race, Ethnicity, and Cognitive Domain

BACKGROUND AIM

To examine racial/ethnic variations in the effect of parents' subjective neighborhood safety on children's cognitive performance.

METHODS

This cross-sectional study included 10,027 children from the Adolescent Brain Cognitive Development (ABCD) study. The exposure variable was parents' subjective neighborhood safety. The outcomes were three domains of children's cognitive performance: general cognitive performance, executive functioning, and learning/memory. We used mixed-effects regression models for data analysis.

RESULTS

Overall, parents' subjective neighborhood safety was positively associated with children's executive functioning, but not general cognitive performance or learning/memory. Higher parents' subjective neighborhood safety had a more positive influence on the executive functioning of non-Hispanic White than Asian American children. Higher parents' subjective neighborhood safety was associated with higher general cognitive performance and learning/memory for non-White children relative to non-Hispanic White children.

CONCLUSION

The race/ethnicity of children moderates the association between neighborhood safety and cognitive performance. This becomes more complicated, as the patterns seem to differ across race/ethnicity and cognitive domains. It is unknown whether the observed racial/ethnic variations in the effect of neighborhood safety on cognitive performance are due to neighborhood characteristics such as residential segregation. Addressing neighborhood inequalities is needed if we wish to reduce racial/ethnic inequities in the cognitive development of children.

Parental Educational Attainment, the Superior Temporal Cortical Surface Area, and Reading Ability among American Children: A Test of Marginalization-Related Diminished Returns

BACKGROUND

Recent studies have shown that parental educational attainment is associated with a larger superior temporal cortical surface area associated with higher reading ability in children. Simultaneously, the marginalization-related diminished returns (MDRs) framework suggests that, due to structural racism and social stratification, returns of parental education are smaller for black and other racial/ethnic minority children compared to their white counterparts.

PURPOSE

This study used a large national sample of 9-10-year-old American children to investigate associations between parental educational attainment, the right and left superior temporal cortical surface area, and reading ability across diverse racial/ethnic groups.

METHODS

This was a cross-sectional analysis that included 10,817 9-10-year-old children from the Adolescent Brain Cognitive Development (ABCD) study. Parental educational attainment was treated as a five-level categorical variable. Children's right and left superior temporal cortical surface area and reading ability were continuous variables. Race/ethnicity was the moderator. To adjust for the nested nature of the ABCD data, mixed-effects regression models were used to test the associations between parental education, superior temporal cortical surface area, and reading ability overall and by race/ethnicity.

RESULTS

Overall, high parental educational attainment was associated with greater superior temporal cortical surface area and reading ability in children. In the pooled sample, we found statistically significant interactions between race/ethnicity and parental educational attainment on children's right and left superior temporal cortical surface area, suggesting that high parental educational attainment has a smaller boosting effect on children's superior temporal cortical surface area for black than white children. We also found a significant interaction between race and the left superior temporal surface area on reading ability, indicating weaker associations for Alaskan Natives, Native Hawaiians, and Pacific Islanders (AIAN/NHPI) than white children. We also found interactions between race and parental educational attainment on reading ability, indicating more potent effects for black children than white children.

CONCLUSION

While parental educational attainment may improve children's superior temporal cortical surface area, promoting reading ability, this effect may be unequal across racial/ethnic groups. To minimize the racial/ethnic gap in children's brain development and school achievement, we need to address societal barriers that diminish parental educational attainment's marginal returns for middle-class minority families. Social and public policies need to go beyond equal access and address structural and societal barriers that hinder middle-class families of color and their children. Future research should test how racism, social stratification, segregation, and discrimination, which shape the daily lives of non-white individuals, take a toll on children's brains and academic development.

Recovery From Mobility Limitation in Middle-Aged African Americans: The Jackson Heart Study

BACKGROUND

Despite evidence that African Americans shoulder a high burden of mobility limitation, little is known about factors associated with recovery.

METHOD

Participants from the Jackson Heart Study underwent 3 in-person exams from 2000 to 2013. Mobility limitations were assessed over this period by self-reported limitations in walking half a mile or climbing stairs during annual phone calls. The outcome of interest, recovery from mobility limitation, was defined as no mobility limitation the year following an incident event. Candidate predictor variables were assessed in logistic regression models, including sociodemographic, psychosocial, and health measures. Inverse probability weights were used to address missing data in the outcome.

RESULTS

Among 4526 participants (mean [SD] age = 54.5 (12.8) years) without a mobility limitation at baseline, 1445 (32%) had an incident mobility limitation over 12 years of follow-up, and 709 (49%) reported recovery from mobility limitation by 1 year later. Low income and daily discrimination were associated with a lower likelihood of recovery even after adjustment for covariates. In adjusted models, greater comorbidity was associated with a lower likelihood of recovering (p-value for trend = .05). History of heart failure and cancer were associated with a lower likelihood of recovering from mobility limitation (OR: 0.52, 95% CI: 0.29, 0.94 and OR: 0.74, 95% CI: 0.55, 1.00). Adiposity, smoking status, and physical activity were not associated with recovery from mobility limitation.

CONCLUSION

Half of incident mobility limitations in this population of middle-aged African Americans were transient. Adverse sociodemographic factors and comorbidities were associated with lower likelihood of recovery.

Parental Education and Children’s Sleep Problems: Minorities’ Diminished Returns

Background and aims: While increased parental education reduces children’s sleep problems, less is known about racial variation in such protection. According to Minorities’ Diminished Returns (MDRs) theory, economic resources such as parental education show weaker health effects for minority groups such as Blacks and Latinos than non-Latino Whites, which is due to racism and social stratification. In this study, we investigated the association between parental education and children’s sleep problems, as a proxy of sleep problems, by race. Methods: This cross-sectional study included 11718 American children aged 9-10. All participants were recruited to the Adolescent Brain Cognitive Development (ABCD) study. The independent variable was parental education, a five-level nominal variable. The dependent variable – sleep problems, was a continuous variable. Race/ethnicity was the effect modifier. Age, sex, and marital status were the covariates. Mixed-effects regression models were used for data analysis. Results: Parental education was associated with children’s sleep problems. However, there was a weaker inverse association seen in non-Latino Black and Latino families compared to non-Latino White families. This was documented by a significant statistical interaction between race and ethnicity and parental education on children’s sleep problems. Conclusion: Diminished protective effect of parental education on children’s sleep problems for non-Latino Black and Latino families compared to non-Latino White families is similar to the MDRs in other domains. Worse than expected sleep may contribute to higher-than-expected health risks of middle-class Black and Latino children.

Money Protects White but Not African American Men against Discrimination: Comparison of African American and White Men in the Same Geographic Areas

To compare African American (AA) and non-Hispanic White men living in same residential areas for the associations between educational attainment and household income with perceived discrimination (PD). The National Survey of American Life (NSAL), a nationally representative study, included 1643 men who were either African American (n = 1271) or non-Hispanic White (n = 372). We compared the associations between the two race groups using linear regression. In the total sample, high household income was significantly associated with lower levels of PD. There were interactions between race and household income, suggesting that the association between household income and PD significantly differs for African American and non-Hispanic White men. For non-Hispanic White men, household income was inversely associated with PD. For African American men, however, household income was not related to PD. While higher income offers greater protection for non-Hispanic White men against PD, African American men perceive higher levels of discrimination compared to White males, regardless of income levels. Understanding the role this similar but unequal experience plays in the physical and mental health of African American men is worth exploring. Additionally, developing an enhanced understanding of the drivers for high-income African American men’s cognitive appraisal of discrimination may be useful in anticipating and addressing the health impacts of that discrimination. Equally important to discerning how social determinants work in high-income African American men’s physical and mental health may be investigating the impact of the mental health and wellbeing of deferment based on perceived discrimination of dreams and aspirations associated with achieving high levels of education and income attainment of Black men.

Black-White Differences in the Link Between Offspring College Attainment and Parents' Depressive Symptom Trajectories

This study examines whether the relationship between children's college attainment and their parents' mental health differs for Black and White parents as they age. Data come from the U.S. Health and Retirement Study (HRS) and multilevel growth curve models are used to assess parents' depressive symptom trajectories. Results indicated that parents over age 50 whose children all completed college had significantly lower initial levels of depressive symptoms than those with no college-educated children. The initial benefit was stronger for Blacks than Whites. Results stratified further by parents' education show that Black parents at nearly all levels of schooling experienced stronger returns to their mental health from children's college completion compared to White parents, for whom only those with a high school education showed an inverse association between offspring education and depression symptoms. The findings underscore how offspring education is a potential resource for reducing disparities in health across families.

The Relationship of Race, Psychosocial Stress and Resiliency Indicators to Neurocognitive Impairment among Older Americans Enrolled in the Health and Retirement Survey: A Cross-Sectional Study

Background: Race/ethnicity, toxic stress (TS), resilience-promoting factors (RPFs), and their interactions were investigated in relationship to neurocognitive impairment (NI) in a nationally representative sample of adult Americans ≥50 years enrolled in the Health and Retirement Study (HRS) between 2012 and 2014. Methods: NI was defined as physician diagnosis of Alzheimer’s disease/dementia or HRS total cognition score ≤ 10. Race/ethnicity (i.e., African American, White, or Other), TS (i.e., everyday discrimination and chronic stressors), and mastery (as indicator of RPF) were self-reported. Multivariable logistic regression models estimated race-, TS-, RPF-associated odds ratios (ORs), and 95% confidence intervals (CI) for NI adjusting for socio-demographic confounders. Results: 6317 respondents interviewed between the years 2012 and 2014, age range 55–104 years old, 83% White, 13% Black and 4% Other race were included in the study. Chronic stress (OR = 1.88, 95% CI: 1.42–2.48), discrimination (OR = 3.31, 95% CI: 2.12–5.19) and low mastery (OR = 1.85, 95% CI: 1.38–2.48) were each associated with higher NI risk while low mastery was associated with higher NI risk in discrimination and race/ethnicity dependent manner. Specifically, low mastery-associated risk for NI was evident among adults that denied experiencing discrimination (OR = 2.01, 95% CI: 1.51–2.68), but absent among those that experienced discrimination (OR = 0.72, 95% CI: 0.32–1.62). Further, AA race was associated with NI risk but only among adults with high mastery (OR = 2.00, 95% CI: 1.20–3.35). Conclusions: Discrimination, chronic stress, and low mastery were associated with worse cognition. Persisting cognitive disadvantage for AA vs. White/Other race only among high mastery adults suggests that adverse social experiences may counteract mastery-associated cognitive benefits among AA population. TS reduction through policies that promote equal treatment by race/ethnicity in social life, health, justice, and economic systems may promote successful cognitive aging.