Trends in American Indian/Alaskan native self-reported stroke prevalence and associated modifiable risk factors in the United States from 2011-2021

BACKGROUND

Stroke prevalence varies by race/ethnicity, as do the risk factors that elevate the risk of stroke. Prior analyses have suggested that American Indian/Alaskan Natives (AI/AN) have higher rates of stroke and vascular risk factors.

METHODS

We included biyearly data from the 2011-2021 Behavioral Risk Factor Surveillance System (BRFSS) surveys of adults (age ≥18) in the United States. We describe survey-weighted prevalence of stroke per self-report by race and ethnicity. In patients with self-reported stroke (SRS), we also describe the prevalence of modifiable vascular risk factors.

RESULTS

The weighted number of U.S. participants represented in BRFSS surveys increased from 237,486,646 in 2011 to 245,350,089 in 2021. SRS prevalence increased from 2.9% in 2011 to 3.3% in 2021 (p<0.001). Amongst all race/ethnicity groups, the prevalence of stroke was highest in AI/AN at 5.4% and 5.6% in 2011 and 2021, compared to 3.0% and 3.4% for White adults (p<0.001). AI/AN with SRS were also the most likely to have four or more vascular risk factors in both 2011 and 2021 at 23.9% and 26.4% compared to 18.2% and 19.6% in White adults (p<0.001).

CONCLUSION

From 2011-2021 in the United States, AI/AN consistently had the highest prevalence of self-reported stroke and highest overall burden of modifiable vascular risk factors. This persistent health disparity leaves AI/AN more susceptible to both incident and recurrent stroke.

The neurophysiological consequences of racism-related stressors in Black Americans

Racism-related stressors, from experiences of both implicit and explicit racial discrimination to systemic socioeconomic disadvantage, have a cumulative impact on Black Americans' health. The present narrative review synthesizes peripheral (neuroendocrine and inflammation markers), psychophysiological (heart-rate variability, skin conductance), and neuroimaging (structural and functional) findings that demonstrate unique associations with racism-related stress. Emerging evidence reveals how racism-related stressors contribute to differential physiological and neural responses and may have distinct impacts on regions involved with threat and social processing. Ultimately, the neurophysiological effects of racism-related stress may confer biological susceptibility to stress and trauma-related disorders. We note critical gaps in the literature on the neurophysiological impact of racism-related stress and outline additional research that is needed on the multifactorial interactions between racism and mental health. A clearer understanding of the interactions between racism-related stress, neurophysiology, and stress- and trauma-related disorders is critical for preventative efforts, biomarker discovery, and selection of effective clinical treatments for Black Americans.

Hospitalisation and mortality among privately insured individuals with COVID-19 in the United States: The role of intellectual disabilities and Neurogenetic disorders

BACKGROUND

Individuals with intellectual disabilities (IDs) and neurogenetic conditions (IDNDs) are at greater risk for comorbidities that may increase adverse outcomes for this population when they have coronavirus disease 2019 (COVID-19). The study aims are to examine the population-level odds of hospitalisation and mortality of privately insured individuals with COVID-19 with and without IDNDs IDs, controlling for sociodemographics and comorbid health conditions.

METHODS

This is a retrospective, cross-sectional study of 1174 individuals with IDs and neurogenetic conditions within a population of 752 237 de-identified, privately insured, US patients diagnosed with COVID-19 between February 2020 and September 2020. Odds of hospitalisation and mortality among COVID-19 patients with IDNDs adjusted for demographic characteristics, Health Resources and Services Administration region, states with Affordable Care Act and number of comorbid health conditions were analysed.

RESULTS

Patients with IDNDs overall had higher rates of COVID-19 hospitalisation than those without IDNDs (35.01% vs. 12.65%, P < .0001) and had higher rates of COVID-19 mortality than those without IDNDs (4.94% vs. .88%, P < .0001). Adjusting for sociodemographic factors only, the odds of being hospitalised for COVID-19 associated with IDNDs was 4.05 [95% confidence interval (CI) 3.56-4.61]. Adjusting for sociodemographic factors and comorbidity count, the odds of hospitalisation for COVID-19 associated with IDNDs was 1.42 (95% CI 1.25-1.61). The odds of mortality from COVID-19 for individuals with IDNDs adjusted for sociodemographic factors only was 4.65 (95% CI 3.47-6.24). The odds of mortality from COVID-19 for patients with IDNDs adjusted for sociodemographic factors and comorbidity count was 2.70 (95% CI 2.03-3.60). A major finding of the study was that even when considering the different demographic structure and generally higher disease burden of patients with IDNDs, having a IDND was an independent risk factor for increased hospitalisation and mortality compared with patients without IDNDs.

CONCLUSIONS

Individuals with IDNDs had significantly higher odds of hospitalisation and mortality after adjusting for sociodemographics. Results remained significant with a slight attenuation after adjusting for sociodemographics and comorbidities. Adjustments for comorbidity count demonstrated a dose-response increase in odds of both hospitalisation and mortality, illustrating the cumulative effect of health concerns on COVID-19 outcomes. Together, findings highlight that individuals with IDNDs experience vulnerability for negative COVID-19 health outcomes with implications for access to comprehensive healthcare.

Adjudications and tinkering with care for socially vulnerable patients with type 2 diabetes in general practice

OBJECTIVE

To analyse the mechanisms at play in the adjudications made by professionals and socially vulnerable patients with type 2 diabetes about their eligibility for care.

DESIGN, SETTING AND SUBJECTS

The study included 14 patients and 10 health professionals in seven general practice surgeries in deprived areas in Greater Copenhagen. The study data consist of 17 semi-structured interviews with patients and 22 with health professionals immediately after observation of 23 consultations. Our analytical approach was inspired by Systematic Text Condensation and the concept of 'candidacy' for access to health care.

RESULTS

Adjudications of patients not being candidates for services were common, but we also found that both patients and health professionals worked to align the services to the needs of the patients. This could include using services differently than was intended by the providers or by changing routines to make it easier for patients to use the services. We discuss these processes as 'tinkering'. This usually implies that the best individual solution for the patient is aimed for, and in this study, the best solution sometimes meant not focusing on diabetes.

CONCLUSION

The study adds to existing knowledge about access to services for socially vulnerable patients by demonstrating that both patients and professionals in general practice engage in tinkering processes to make services work.

Agents of Change: Geriatrics Workforce Programs Addressing Systemic Racism and Health Equity

Many factors affect how individuals and populations age, including race, ethnicity, and diversity, which can contribute to increased disease risk, less access to quality healthcare, and increased morbidity and mortality. Systemic racism-a set of institutional policies and practices within a society or organization that perpetuate racial inequalities and discrimination-contributes to health inequities of vulnerable populations, particularly older adults. The National Association for Geriatrics Education (NAGE) recognizes the need to address and eliminate racial disparities in healthcare access and outcomes for older adults who are marginalized due to the intersection of race and age. In this paper, we discuss an anti-racist framework that can be used to identify where an organization is on a continuum to becoming anti-racist and to address organizational change. Examples of NAGE member Geriatric Workforce Enhancement Programs (GWEPs) and Geriatrics Academic Career Awards (GACAs) activities to become anti-racist are provided to illustrate the framework and to guide other workforce development programs and healthcare institutions as they embark on the continuum to become anti-racist and improve the care and health of vulnerable older adults.

Exploring the "Urban Advantage" in Access to Immunization Services: A Comparison of Zero-Dose Prevalence Between Rural, and Poor and Non-poor Urban Households Across 97 Low- and Middle-Income Countries

Urban children are more likely to be vaccinated than rural children, but that advantage is not evenly distributed. Children living in poor urban areas face unique challenges, living far from health facilities and with lower-quality health services, which can impact their access to life-saving vaccines. Our goal was to compare the prevalence of zero-dose children in poor and non-poor urban and rural areas of low- and middle-income countries (LMICs). Zero-dose children were those who failed to receive any dose of a diphtheria-pertussis-tetanus (DPT) containing vaccine. We used data from nationally representative household surveys of 97 LMICs to investigate 201,283 children aged 12-23 months. The pooled prevalence of zero-dose children was 6.5% among the urban non-poor, 12.6% for the urban poor, and 14.7% for the rural areas. There were significant differences between these areas in 43 countries. In most of these countries, the non-poor urban children were at an advantage compared to the urban poor, who were still better off or similar to rural children. Our results emphasize the inequalities between urban and rural areas, but also within urban areas, highlighting the challenges faced by poor urban and rural children. Outreach programs and community interventions that can reach poor urban and rural communities-along with strengthening of current vaccination programs and services-are important steps to reduce inequalities and ensure that no child is left unvaccinated.

Barriers and facilitators to transition from pediatric to adult healthcare for immigrant youth with chronic health conditions

PURPOSE

The objective of this study was to investigate the experience of first- and second- generation immigrant youth living with chronic health conditions in Canada, their parents or caregivers, and healthcare and service providers who care for immigrant youth, regarding the transition from pediatric to adult healthcare.

DESIGN AND METHODS

We conducted semi-structured individual interviews and focus groups. Youth were 1st or 2nd generation immigrants, aged 16-25, with pediatric-onset chronic health conditions. Parents or caregivers had raised youth children as described. Providers delivered healthcare or other services to immigrant populations. Thematic analysis was conducted of all transcripts.

RESULTS

Twenty youth, 14 parents/caregivers and five service providers participated. Most participants described healthcare transition as very difficult to navigate. Two major themes emerged across participant narratives: 1. Barriers to transition: lack of family experience in Canada, language, discrimination, financial strain, stigma, and long wait times. Some of these barriers are specific to newcomer families, but others are generalizable to the Canadian population. 2. Facilitators of transition: youth independence, youth acting as cultural bridges within their families, and cross-sector support between healthcare, education, social work and settlement services.

CONCLUSIONS

Immigrant youth and their families face a broad range of barriers to healthcare transition. The collaborative nature of cross-sector support effectively addressed some of the barriers faced by newcomer families.

PRACTICE IMPLICATIONS

Clinicians should provide immigrant youth and their families with accessible information about the health condition and how to navigate the adult healthcare system prior to transition, particularly when language barriers exist.

Reasons for non-participation in cancer rehabilitation: a scoping literature review

BACKGROUND

Rehabilitation plays an important role in addressing the many challenges of living with cancer, but a large proportion of people with cancer do not participate in available cancer rehabilitation. Hence, reasons for non-participation in cancer rehabilitation need to be explored.

OBJECTIVE

The present study undertakes a scoping review of research examining reasons for non-participation in cancer rehabilitation among people with cancer.

DESIGN

A systematic search was conducted in PubMed, Scopus and CINAHL for articles published until July 2023. Included studies were hand searched for relevant references and citations.

ELIGIBILITY CRITERIA

Method: Studies with qualitative, quantitative or mixed-method design.

POPULATION

Studies targeting adults (> 18) living with cancer, not participating in rehabilitation. Program type: The review included all studies defining program as rehabilitation but excluded clinical trials.

OUTCOME

Studies examining reasons for non-participation in available rehabilitation.

DATA EXTRACTION

The extracted data included author(s)/year of publication, aim, population, information, rehabilitation type and main reasons for non-participation.

RESULTS

A total of nine studies were included (n = 3 quantitative, n = 2 qualitative, n = 4 mixed methods). Reasons for non-participation included physical, psychosocial and practical aspects. The main reason across studies was 'no need for public support' related to receiving sufficient support from family and friends. All studies focused on individual reasons, and structural conditions were rarely present.

CONCLUSION

Research within this field is sparse. Future research should explore how individual reasons for non-participation relate to structural conditions, especially among people in socially disadvantaged positions living with cancer.

The Influence of Social and Developmental Factors on the Timing of Autism Spectrum Disorder Diagnosis of Preschool-Aged Children: Evidence from a Specialized Chilean Center

We investigated the influence of developmental and social factors on the age of autism diagnosis (AoD) in a cohort of toddlers living in Chile. A cross-sectional study was conducted among 509 preschool children diagnosed with autism spectrum disorder [M = 40.2 months (SD = 8.6), girls: 32%] in the neurodevelopmental unit of a university clinic in Santiago, Chile (2015-2023). Structural changes in the annual trend of AoD were tested. Generalized linear models (gamma distribution) with and without interaction terms were used for the multivariate analysis, adjusting for gender, residential area, year of diagnosis, developmental variables (language regression, delayed walking, and use of expressive verbal language), and primary caregiver age and education level (CEL). 95% confidence intervals of the unstandardized regression coefficients (B) were calculated using 1000 bootstrap resampling to estimate associations. AoD increased between 2021-2022 and decreased in 2023. Female gender (B = 2.72 [1.21-4.23]), no history of language regression (B = 3.97 [1.66-6.28]), and the presence of expressive verbal language at diagnosis (B = 1.57 [0.05-3.08]) were associated with higher AoD. Children whose caregivers had tertiary education were diagnosed earlier than those with ≤ 12 years of formal education. Although the influence of CEL increased with caregiver age, differences between CEL groups were significant only for caregivers aged ≥ 30 years. Improved education and early screening for clinical features of autism among healthcare professionals and the community, with a focus on young children without highly apparent developmental concerns and those from vulnerable social groups, are warranted.

Uncovering physical activity trade-offs in transportation policy: A spatial agent-based model of Bogotá, Colombia

BACKGROUND

Transportation policies can impact health outcomes while simultaneously promoting social equity and environmental sustainability. We developed an agent-based model (ABM) to simulate the impacts of fare subsidies and congestion taxes on commuter decision-making and travel patterns. We report effects on mode share, travel time and transport-related physical activity (PA), including the variability of effects by socioeconomic strata (SES), and the trade-offs that may need to be considered in the implementation of these policies in a context with high levels of necessity-based physical activity.

METHODS

The ABM design was informed by local stakeholder engagement. The demographic and spatial characteristics of the in-silico city, and its residents, were informed by local surveys and empirical studies. We used ridership and travel time data from the 2019 Bogotá Household Travel Survey to calibrate and validate the model by SES. We then explored the impacts of fare subsidy and congestion tax policy scenarios.

RESULTS

Our model reproduced commuting patterns observed in Bogotá, including substantial necessity-based walking for transportation. At the city-level, congestion taxes fractionally reduced car use, including among mid-to-high SES groups but not among low SES commuters. Neither travel times nor physical activity levels were impacted at the city level or by SES. Comparatively, fare subsidies promoted city-level public transportation (PT) ridership, particularly under a 'free-fare' scenario, largely through reductions in walking trips. 'Free fare' policies also led to a large reduction in very long walking times and an overall reduction in the commuting-based attainment of physical activity guidelines. Differential effects were observed by SES, with free fares promoting PT ridership primarily among low-and-middle SES groups. These shifts to PT reduced median walking times among all SES groups, particularly low-SES groups. Moreover, the proportion of low-to-mid SES commuters meeting weekly physical activity recommendations decreased under the 'freefare' policy, with no change observed among high-SES groups.

CONCLUSIONS

Transport policies can differentially impact SES-level disparities in necessity-based walking and travel times. Understanding these impacts is critical in shaping transportation policies that balance the dual aims of reducing SES-level disparities in travel time (and time poverty) and the promotion of choice-based physical activity.

"Lord Knows What's Being Done with My Blood!": Black Women's Perceptions of Biospecimen Donation for Clinical Research in the United States

PURPOSE

Black women are underrepresented in clinical research and clinical trials. Knowledge gaps lead to biased clinical practice and care. There is a small but growing body of literature on Black women's perceptions about participation when biospecimen donation is sought by researchers. This is the first known study to investigate willingness to participate in clinical research involving biospecimen donation among Black women of reproductive age in the United States.

METHODS

This cross-sectional study recruited 496 Black women (ages 18-49) from a research crowdsourcing platform. Participants completed a 46-item online survey which asked about their willingness to provide blood samples for clinical health research and reasons for their willingness or for any unwillingness. Descriptive statistics and thematic analysis method were used to analyze the data.

RESULTS

Less than half (44%) of participants reported willingness to provide blood samples for clinical research. The most common concerns of those expressing unwillingness to provide samples were "fear of blood sample being misused" and "distrust with the health researchers handling the samples." We identified six qualitative themes from the analysis of participants' open-ended responses. The most important factors include a desire for integrity and transparency in research, institutional racism contributing to mistrust, and adequate compensation and clearly defined benefits to participation.

CONCLUSIONS

The recruitment and engagement of Black women in clinical biospecimen research should involve transparent, trustworthy, and anti-racist practices and informed respect for Black women's autonomy. There is a need to address Black women's concerns about exploitative profits and mistrust of academic and medical institutions.

Food security status and cardiometabolic health by sex/gender and race/ethnicity among adults in the United States

BACKGROUND

Minoritized racial/ethnic groups and women in the United States (US) are disproportionately burdened by food insecurity, which likely contributes to disparities in cardiovascular health (CVH). Disparities are projected to widen due to the worsening climate crisis that is straining the agricultural system including food supplies. Nonetheless, studies have not investigated the relationship between food security status and 'ideal' CVH in a large, nationally-representative and racially/ethnically diverse US sample.

METHODS AND RESULTS

We investigated household food security status in relation to 'ideal' CVH among US adults (N = 157,001) using 2014-2018/2020 National Health Interview Survey data. Food security status was defined as very low, low, marginal, or high. A summed score of 4 health behaviors and 3 clinical factors totaling 7 different measures was dichotomized (yes/no) to assess modified 'ideal' CVH (mICVH). Using Poisson regression with robust variance, we estimated prevalence ratios (PRs) and 95% CIs of mICVH by household food security status. We stratified models by sex/gender and race/ethnicity. Very low food security prevalence was higher among non-Hispanic (NH)-Black (8.0%) compared to Hispanic/Latinx (5.1%), NH-White (3.1%) and NH-Asian (1.7%) adults. The association between very low versus high food security and mICVH was stronger among women (PR = 0.23 [95% CI: 0.17-0.31]) than men (PR = 0.48 [95% CI: 0.35-0.66]). Compared to NH-White adults with high food security, racially/ethnically minoritized groups with very low to high food security were generally less likely (range: [PRvery low = 0.25[95% CI: 0.14-0.44] - [PRhigh = 0.88 [95% CI: 0.79-0.97]) to meet mICVH criteria.

CONCLUSIONS

Food insecurity was associated with lower mICVH prevalence and racially/ethnically minoritized groups were disproportionately burdened.

"Hypertension is such a difficult disease to manage": federally qualified health center staff- and leadership-perceived readiness to implement a technology-facilitated team-based hypertension model

BACKGROUND

Despite decades of evidence demonstrating the efficacy of hypertension care delivery in reducing morbidity and mortality, a majority of hypertension cases remain uncontrolled. There is an urgent need to elucidate and address multilevel facilitators and barriers clinical staff face in delivering evidence-based hypertension care, patients face in accessing it, and clinical systems face in sustaining it. Through a rigorous pre-implementation evaluation, we aimed to identify facilitators and barriers bearing the potential to affect the planned implementation of a multilevel technology-facilitated hypertension management trial across six primary care sites in a large federally qualified health center (FQHC) in New York City.

METHODS

During a dedicated pre-implementation period (3-9 months/site, 2021-2022), a capacity assessment was conducted by trained practice facilitators, including (1) online anonymous surveys (n = 124; 70.5% of eligible), (2) hypertension training analytics (n = 69; 94.5% of assigned), and (3) audio-recorded semi-structured interviews (n = 67; 48.6% of eligible) with FQHC leadership and staff. Surveys measured staff sociodemographic characteristics, adaptive reserve, evidence-based practice attitudes, and implementation leadership scores via validated scales. Training analytics, derived from end-of-course quizzes, included mean score and number attempts needed to pass. Interviews assessed staff-reported facilitators and barriers to current hypertension care delivery and uptake; following audio transcription, trained qualitative researchers employed a deductive coding approach, informed by the Consolidated Framework for Implementation Research (CFIR).

RESULTS

Most survey respondents reported moderate adaptive reserve (mean = 0.7, range = 0-1), evidence-based practice attitudes (mean = 2.7, range = 0-4), and implementation leadership (mean = 2.5, range = 0-4). Most staff passed training courses on first attempt and demonstrated high scores (means > 80%). Findings from interviews identified potential facilitators and barriers to implementation; specifically, staff reported that complex barriers to hypertension care, control, and clinical communication exist; there is a recognized need to improve hypertension care; in-clinic challenges with digital tool access imposes workflow delays; and despite high patient loads, staff are motivated to provide high-quality cares.

CONCLUSIONS

This study serves as one of the first to apply the CFIR to a rigorous pre-implementation evaluation within the understudied context of a FQHC and can serve as a model for similar trials seeking to identify and address contextual factors known to impact implementation success.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03713515 , date of registration: October 19, 2018.

Distribution of Edentulism by the Macro Determinants of Health in 204 Countries and Territories: An Analysis of the Global Burden of Disease Study

OBJECTIVE

To carry out a comprehensive description of edentulism estimates by the macro determinants of health in 2000, 2010 and 2019 worldwide.

METHODS

This ecological study analyzed data from the Global Burden of Disease Study (GBD) to describe the incidence rate, prevalence rate and years lived with disability (YLDs) rate due to edentulism by macro determinants of health (governance, macroeconomic policy, social policy, public policies, societal values), for 204 countries and territories. The estimates were reported as rates (cases/100,000 people), for people of both sexes aged 55 years or older.

RESULTS

Countries belonging to the least privileged categories of the macro determinants showed the lowest prevalence rate, incidence rate, and YLD rate due to edentulism for all exposures. Countries with low government expenditure on health showed the lowest prevalence rate of edentulism in 2000 (18,972.1; 95 %CI 15,960.0 - 21,984.3) and 2010 (16,646.8; 95 %CI: 14,218.3-19,075.4) than those with high government expenditure on health in 2000 (25,196.6; 95 %CI: 23,226.9 - 27,166.2) and 2010 (21,014.7; 95 %CI: 19,317.9 - 22,711.5). Countries with low SDI showed the lowest YLDs in 2000 (321.0, 95 %CI: 260.1- 381.9), 2010 (332.0; 95 %CI: 267.7-396.3), and 2019 (331.6; 95 %CI: 266.6-396.5).

CONCLUSION

The findings point to persistent inequalities in the distribution of edentulism between countries worldwide. The most privileged countries, with higher economic development, better governance, and better social and public policies, have shown higher rates of edentulism.

CLINICAL SIGNIFICANCE

This model must be reconsidered by advancing toward upstream and midstream strategies, beyond its conventional downstream clinical interventions.

Considering inequities in national dementia strategies: breadth, depth, and scope

BACKGROUND

Considering that dementia is an international public health priority, several countries have developed national dementia strategies outlining initiatives to address challenges posed by the disease. These strategies aim to improve the care, support, and resources available to meet the needs of persons living with dementia and their care partners and communities. Despite the known impact of social determinants of health on dementia risk, care, and outcomes, it is unclear whether dementia strategies adequately address related inequities. This study aimed to describe whether and how national dementia strategies considered inequities associated with social determinants of health.

METHODS

We conducted an environmental scan of the national dementia strategies of countries that are part of the Organisation for Economic Cooperation and Development (OECD). Included strategies had to be accessible in English or French. Sub-national or provincial plans were excluded. We synthesised information on strategies' considerations of inequity through a thematic analysis.

RESULTS

Of the 15 dementia strategies that met inclusion criteria, 13 mentioned at least one inequity (M = 2.4, median = 2, range:0-7) related to Race/Ethnicity; Religion; Age; Disability; Sexual Orientation/Gender Identity; Social Class; or Rurality. Age and disability were mentioned most frequently, and religion most infrequently. Eleven strategies included general inequity-focused objectives, while only 5 had specific inequity-focused objectives in the form of tangible percentage changes, deadlines, or allocated budgets for achieving equity-related goals outlined in their strategies.

CONCLUSIONS

Understanding if and how countries consider inequities in their dementia strategies enables the development of future strategies that adequately target inequities of concern. While most of the strategies mentioned inequities, few included tangible objectives to reduce them. Countries must not only consider inequities at a surface-level; rather, they must put forth actionable objectives that intend to lessen the impact of inequities in the care of all persons living with dementia.

Trapped in vicious cycles: unraveling the health experiences and needs of adults living with socioeconomic insecurity

BACKGROUND

This study explores the role of health in daily life and needs of Dutch adults (aged 25-49) experiencing one or more forms of socioeconomic insecurity stemming from their financial, housing, or employment situations.

METHODS

28 in-depth, semi-structured interviews were conducted in the Netherlands between October 2022 and February 2023. The interview guide included questions on participants' socioeconomic situation, the role of health in their daily lives, their health-related and broader needs. Data was interpreted using inductive reflexive thematic analysis. An advisory board consisting of adults with lived experiences of socioeconomic insecurity were consulted at multiple stages of the study (recruitment, interview guide, interpretation of results).

RESULTS

Housing insecurity was widely experienced by participants. When asked about their financial situation, most participants expressed having no issues getting by, but later on, described vigorous efforts to minimize expenses. Participants' narratives revealed four key themes in relation to the role of health in daily life and associated needs. Firstly, socioeconomic insecurity led to diminished control over life, which led to the disruption of routines. Secondly, experiencing socioeconomic insecurity compelled participants to prioritize stress reduction and mental health improvement through calming yet potentially damaging coping mechanisms. Thirdly, those who experienced little opportunity for improvement in their already long-lasting socioeconomic insecurity shared a sense of stagnation in life, which co-occurred with stagnation in unhealthy routines and diminished well-being. Fourthly, participants expressed the need for someone to speak with. This support may help participants regain control over their lives, identify opportunities for more socioeconomic security, and focus on increased health and well-being.

CONCLUSIONS

This study sheds light on the challenges individuals face in dealing with socioeconomic insecurity, how it may affect their health, and their needs. Gaining perspective for improved socioeconomic security and having accessible professional support tailored to self-identified needs could have health-promoting effects for individuals living with socioeconomic insecurity. It is recommended to integrate professional support and assistance regarding social security into health policies and interventions. In future research, measures of financial strain should be adjusted to include the effort needed to get by.

Implementation of COVID-19 vaccination services in prison in six European countries: translating emergency intervention into routine life-course vaccination

BACKGROUND

Evidence has shown that the risk of transmission of SARS-CoV-2 is much higher in prisons than in the community. The release of the COVID-19 vaccine and the recommendation by WHO to include prisons among priority settings have led to the inclusion of prisons in national COVID-19 vaccination strategies. Evidence on prison health and healthcare services provision is limited and often focuses on a single country or institution due to the multiple challenges of conducting research in prison settings. The present study was done in the framework of the EU-founded project RISE-Vac. It aimed to analyse the best practices and challenges applied in implementing COVID-19 universal vaccination services during the pandemic to support future expansion of routine life course vaccination services for people living in prison (PLP).

METHODS

Two online cross-sectional surveys were designed and piloted: survey1 on prison characteristics and (non-COVID-19) immunisation practices; survey2 on the implementation and coverage of COVID-19 vaccination with open-ended questions for thematic analysis. Each RISE-Vac project partner distributed the questionnaire to one or two prisons in their country. Answers were collected from eight European prisons' directors or medical directors between November 2021-May 2022.

RESULTS

According to our findings, the implementation modalities of COVID-19 vaccination services in the surveyed prisons were effective in improving PLP vaccination coverage. Strategies for optimal management of the vaccination campaign included: periodic time slot for PLP vaccination; new staff recruitment and task shifting; distribution of informational material both to PLP and prison staff. Key challenges included continuity of care after release, immunisation information system, and vaccine hesitancy.

CONCLUSIONS

To the best of our knowledge, this is the first study describing the implementation of COVID-19 vaccination services in European prisons, suggesting that the expansion of vaccination provision in prison is possible. There is no unique solution that will fit every country but commonalities likely to be important in the design and implementation of future vaccination campaigns targeting PLP emerged. Increased availability of vaccination services in prison is not only possible, but feasible and highly desirable, and can contribute to the reduction of health inequalities.

Structural racism in primary schools and changes in epigenetic age acceleration among Black and White youth

Structural racism generates racial inequities in U.S. primary education, including segregated schools, inequitable funding and resources, racial disparities in discipline and achievement, and hostile racial climates, which are risk factors for adverse youth health and development. Black youth are disproportionately exposed to adverse school contexts that may become biologically embedded via stress-mediated epigenetic pathways. This study examined whether childhood exposure to adverse school contexts is associated with changes in epigenetic aging during adolescent development. DNA methylation-based epigenetic clocks were calculated from saliva samples at ages 9 and 15 among Black (n = 774) and White (n = 287) youth in the Future of Families and Child Wellbeing Study (2009-2015). We performed latent class analyses to identify race-specific primary school contexts using administrative data on segregation, discipline, achievement, resources, economic disadvantage, and racial harassment. We then estimated change in epigenetic age acceleration from childhood to adolescence across school typologies using GrimAge, PhenoAge, and DunedinPACE epigenetic clocks. Three distinct school contexts were identified for Black youth: segregated and highly-disadvantaged (17.0%), segregated and moderately-disadvantaged (52.1%), and integrated and moderately-disadvantaged (30.8%). Two school contexts emerged for White youth: integrated and unequal (46.5%) and predominantly White & advantaged (53.5%). At age 15, Black youth who attended segregated and highly-disadvantaged primary schools experienced increases in their speed of epigenetic aging with GrimAge and DunedinPACE. Slowed epigenetic aging with GrimAge was observed for Black youth who attended integrated and moderately-disadvantaged schools. School contexts were not associated with changes in epigenetic age acceleration for White youth. Our findings suggest that manifestations of structural racism in primary school contexts are associated with early-life epigenetic age acceleration and may forecast future health inequities.

Racial/Ethnic Discrimination and Cardiometabolic Diseases: A Systematic Review

INTRODUCTION

Racial discrimination has been identified as a risk factor for cardiometabolic diseases, the leading cause of morbidity and mortality among racial/ethnic minority groups; however, there is no synthesis of current knowledge on the association between discrimination and cardiometabolic diseases. The objective of this systematic review was to summarize evidence linking racial/ethnic discrimination and cardiometabolic diseases.

METHODS

The review was conducted based on studies identified via electronic searches of 5 databases (PubMed, Google Scholar, WorldWideScience.org, ResearchGate and Microsoft Academic) using terms related to discrimination and cardiometabolic disease.

RESULTS

Of the 123 eligible studies included in the review, 87 were cross-sectional, 25 longitudinal, 8 quasi-experimental, 2 randomized controlled trials and 1 case-control. Cardiometabolic disease outcomes discussed were hypertension (n = 46), cardiovascular disease (n = 40), obesity (n = 12), diabetes (n = 11), metabolic syndrome (n = 9), and chronic kidney disease (n = 5). Although a variety of discrimination measures was employed across the studies, the Everyday Discrimination Scale was used most often (32.5%). African Americans/Blacks were the most frequently studied racial/ethnic group (53.1%), and American Indians the least (0.02%). Significant associations between racial/ethnic discrimination and cardiometabolic disease were found in 73.2% of the studies.

DISCUSSION

Racial/ethnic discrimination is positively associated with increased risk of cardiometabolic disease and higher levels of cardiometabolic biomarkers. Identifying racial/ethnic discrimination as a potential key contributor to the health inequities associated with cardiometabolic diseases is important for addressing the significant burden borne by racial/ethnic minorities.

A Review of Community Health Worker Integration in Health Departments

Community health workers (CHWs) are frontline public health workers who bridge the gap between historically marginalized communities, healthcare, and social services. Increasingly, states are developing the CHW workforce by implementing training and certification policies. Health departments (HDs) are primarily responsible for community health through policy implementation and provision of public health services. The two objectives of this study are to explore: (1) state progress in establishing CHW training and certification policies, and (2) integration of CHWs in HD workforces. In this scoping review, we searched PubMed, CINAHL, and Google Scholar for articles published between 2012 and 2022. We looked for articles that discussed state-level certification and training for CHWs and those covering CHWs working with and for city, county, state, and federal HDs. We excluded studies set outside of the US or published in a language other than English. Twenty-nine studies were included for review, documenting CHWs working at all levels of HDs. Within the included studies, HDs often partner with organizations that employ CHWs. With HD-sponsored programs, CHWs increased preventative care, decreased healthcare costs, and decreased disease risk in their communities. Almost all states have begun developing CHW training and certification policies and are at various points in the implementation. HD-sponsored CHW programs improved the health of marginalized communities, whether CHWs were employed directly by HDs or by a partner organization. The success of HD-sponsored CHW programs and state efforts around CHW training and certification should encourage increased investment in CHW workforce development within public health.

[Impact of the COVID-19 pandemic on cardiovascular disease mortality trends in Mexico, 2000-2022]

OBJECTIVE

To estimate the impact of the COVID-19 pandemic on cardiovascular disease (CVD) mortality trends in Mexico.

METHODS

An ecological study was conducted where deaths from CVD reported in Mexico under the ICD-10 classification with codes I10 to I99 for the period 2000-2022 were analyzed. Age-standardized mortality rates were calculated at the national and state levels, then the annual percentage variation was estimated using joinpoint analysis to know the changes in the mortality trend in the period studied.

RESULTS

There was an increase of 27.96 deaths per 100,000 inhabitants from 2000 to 2022 in Mexico. The joinpoint analysis shows in the period 2019-2021 an annual percentage change at the national level of 17,398 and subsequently a negative trend is presented between the years 2021-2022. The states of Guanajuato, Tlaxcala and Querétaro showed the largest increases in CVD mortality trends during the COVID-19 pandemic.

CONCLUSIONS

The trend in CVD mortality in Mexico increased significantly during the COVID-19 pandemic.

Health Inequities in Cancer Incidence According to Economic Status and Regions Are Still Existed Even under Universal Health Coverage System in Korea: A Nationwide Population Based Study Using the National Health Insurance Database

PURPOSE

The purpose of this study is to determine the level of health equity in relation to cancer incidence.

MATERIALS AND METHODS

We used the National Health Insurance claims data of the National Health Insurance Service between 2005 and 2022 and annual health insurance and medical aid beneficiaries between 2011 and 2021 to investigate the disparities of cancer incidence. We calculated age-sex standardized cancer incidence rates by cancer and year according to the type of insurance and the trend over time using the annual percentage change. We also compared the hospital type of the first diagnosis by cancer type and year and cancer incidence rates by cancer type and region in 2021 according to the type of insurance.

RESULTS

The total cancer incidence increased from 255,971 in 2011 to 325,772 cases in 2021. The absolute difference of total cancer incidence rate between the NHI beneficiaries and the medical aid (MA) recipients increased from 510.1 cases per 100,000 population to 536.9 cases per 100,000 population. The odds ratio of total cancer incidence for the MA recipients increased from 1.79 (95% confidence interval [CI], 1.77 to 1.82) to 1.90 (95% CI, 1.88 to 1.93). Disparities in access to hospitals and regional cancer incidence were profound.

CONCLUSION

This study examined health inequities in relation to cancer incidence over the last decade. Cancer incidence was higher in the MA recipients, and the gap was widening. We also found that regional differences in cancer incidence still exist and are getting worse. Investigating these disparities between the NHI beneficiaries and the MA recipients is crucial for implementing of public health policies to reduce health inequities.

Socioeconomic Inequalities and Ethnic Discrimination in COVID-19 Outcomes: the Case of Mexico

In Mexico, Indigenous people were hospitalised and killed by COVID-19 at a disproportionate rate compared to the non-Indigenous population. The main factors contributing to this were poor health conditions and impoverished social and economic circumstances within the country. The objective of this study is to examine the extent to which ethnic disparities are attributable to processes of structural discrimination and further explore the factors that exacerbate or mitigate them. Using administrative public data on COVID-19 and Census information, this study uses the Oaxaca-Blinder decomposition method to examine the extent to which disparities are illegitimate and signal discrimination against Indigenous people. The results show that although ethnic disparities were mainly attributable to observable differences in individual and contextual characteristics, 22.8% (p < 0.001) of the ethnic gap in hospitalisations, 17.5% in early deaths and 16.4% in overall deaths remained unexplained and could potentially indicate systemic discrimination. These findings highlight that pre-existing and longstanding illegitimate disparities against Indigenous people jeopardise the capacity of multi-ethnic countries to achieve social justice in health.

Reaching the unheard: overcoming challenges in health research with hard-to-reach populations

PURPOSE

Addressing obstacles such as logistical complexities, social stigma, and the impact of historical traumas is essential for the successful inclusion of underrepresented groups in health research.

METHODS

This article reviews engagement and interview techniques used to ethically engage recently settled Afghan refugees in Oklahoma and rural Mexican-born women in Illinois in research. The paper concludes with a reflective discussion on the challenges and lessons learned.

RESULTS

Creative strategies to engage hard-to-reach populations in research included considering the participants' socioeconomic and cultural contexts in their interactions and developing community partnerships to establish trust and obtain reliable data. Other engagement strategies were communicating in the participants' preferred language, providing assistance with reading and responding to study questions for those with low literacy, employing research staff from the population of interest, and recruiting in specific locations where the populations of interest live.

CONCLUSIONS

Community engagement is essential at all stages of research for building trust in hard-to-reach populations, achieving inclusivity in health research, and ensuring that interventions are culturally sensitive and effective.

Women's experiences of seeking healthcare for abdominal pain in Ireland: a qualitative study

BACKGROUND

Evidence suggests that women's abdominal pain is more likely to be minimised or dismissed by healthcare professionals than men's. This can have a detrimental impact on health-related outcomes as well as quality of life. The aim of this study was to explore women's experiences of seeking healthcare for abdominal pain in Ireland.

METHOD

A qualitative design and opportunity sampling approach were employed in this study. Fourteen women living in Ireland with experience of seeking healthcare for abdominal pain took part in one-to-one semi-structured interviews via video-conferencing software. Data were analysed using reflexive thematic analysis.

RESULTS

Four themes were constructed from the data: [1] "Just Get on with It" - Normalisation and Invalidation; [2] "Bad Enough"? Costs of (Not) Seeking Help; [3] "Fight Your Case," Fight for Care; and [4] "Out of the Loop" - Systemic Barriers to Care. Perceived invalidation of pain by healthcare professionals was common, as was internalised normalisation of pain. This created challenges when negotiating pain management solutions. Despite functional interference, participants felt their pain needed to reach an extreme level of severity before seeking help. Costs of private healthcare were implicated in delayed help-seeking. Participants felt the onus was on them to fight for care. Social support and information-seeking facilitated participants in this fight while systemic issues were identified as barriers to adequate care. Despite their frustrations, participants expressed empathy for healthcare professionals operating in a flawed system.

CONCLUSIONS

Participants described mostly negative experiences of seeking healthcare for abdominal pain, characterised by dismissal of symptoms and internalisation of normative views of women's pain as less worthy of care. These experiences reinforced participants' views that self-advocacy is essential to access care for their pain. There are systemic issues at play within the Irish healthcare system that limit women's ability to access abdominal pain management support. Education and training for healthcare professionals on the Gender Pain Gap and its implications for patient care, as well as clear referral pathways for women presenting with abdominal pain, may help to ensure more equitable healthcare delivery for individuals with abdominal pain in Ireland.

Health equity in Somalia? An evaluation of the progress made from 2006 to 2019 in reducing inequities in maternal and newborn health

BACKGROUND

Every human being has the right to affordable, high-quality health services. However, mothers and children in wealthier households worldwide have better access to healthcare and lower mortality rates than those in lower-income ones. Despite Somalia's fragile health system and the under-5 mortality rate being among the highest worldwide, it has made progress in increasing reproductive, maternal, and child health care coverage. However, evidence suggests that not all groups have benefited equally. We analysed secondary 2006 and 2018-19 data to monitor disparities in reproductive, maternal, and child health care in Somalia.

METHODS

The study's variables of interest are the percentage of contraceptive prevalence through modern methods, adolescent fertility rate, prenatal care, the rate of births attended by midwives, the rate of births in a health care facility, the rate of early initiation of breastfeeding, stunting and wasting prevalence and care-seeking for children under-five. As the outcome variable, we analysed the under-five mortality rate. Using reliable data from secondary sources, we calculated the difference and ratio of the best and worst-performing groups for 2006 and 2018-19 in Somalia and measured the changes between the two.

RESULTS

Between 2006 and 2018-19, An increase in the difference between women with high and low incomes was noticed in terms of attended labours. Little change was noted regarding socioeconomic inequities in breastfeeding. The difference in the stunting prevalence between the highest and lowest income children decreased by 20.5 points, and the difference in the wasting prevalence of the highest and the lowest income children decreased by 9% points. Care-seeking increased by 31.1% points. Finally, although under-five mortality rates have decreased in the study period, a marked income slope remains.

CONCLUSIONS

The study's findings indicate that Somalia achieved significant progress in reducing malnutrition inequalities in children, a positive development that may have also contributed to the decrease in under-five mortality rate inequities also reported in this study. However, an increase in inequalities related to access to contraception and healthcare for mothers is shown, as well as for care-seeking for sick children under the age of five. To ensure that all mothers and children have equal access to healthcare, it is crucial to enhance efforts in providing essential quality healthcare services and distributing them fairly and equitably across Somalia.

Promoting Health Equity Among Marginalized and Vulnerable Populations

This article calls for a closer examination of health equity regarding the disparities and inequities in health care among marginalized and vulnerable populations. A review of strategies to improve culturally responsive care to these populations will be examined. This examination includes a discussion of the need for structural competence and the ongoing debate around the concepts of cultural competence and cultural humility. Cultural competemility, a new paradigm of thought regarding the relationship between cultural competence and cultural humility, will be proposed. This article culminates with downstream, midstream, and upstream approaches reducing the magnitude of inequity among marginalized and vulnerable populations.

Unveiling early childhood health inequities by age five through the national neighborhood equity index and the early development instrument

There is growing public urgency to close equity gaps in health and development by addressing inequities at multiple levels of children's developmental ecosystems. Current measurement strategies obscure the dynamic structural and relational patterns of oppression, adversity, and disadvantage that children can experience in their local intimate developmental ecosystem, as well as the leverage points that are necessary to change them. The purpose of this study is to examine the relationship between a universally available measure of neighborhood socio-economic context, the National Neighborhood Equity Index (NNEI), and a population measure of early child development and well-being, the Early Development Instrument (EDI). Data from a convenience sample of 144,957 kindergarteners in neighborhoods across the US demonstrate that children living in neighborhoods with more equity barriers are more likely to be on vulnerable developmental trajectories than those who reside in neighborhoods without any equity barriers. A multi-dimensional measurement approach that incorporates both the EDI and the NNEI can be used to quantify ethnoracialized patterns of structural disadvantage during critical periods of health development. These measures can inform community action to intervene early in the lifecourse to optimize children's health development trajectories at a population level.

The role of Doctor of Nursing Practice programs' mission, vision, and values statements in the development of students' professional identity: A qualitative study

OBJECTIVES

The effectiveness of university and program mission, vision, and values statements in shaping Doctor in Nursing Practice (DNP) programs' curricula and their students' professional identity is insufficiently understood.

DESIGN

This qualitative research project explored how these statements inform DNP program curricula and contribute to the development of the professional identity of students SETTING: Three DNP programs in the U.S. American Midwest participated in this research.

PARTICIPANTS

Participants included students, alumni, and faculty from these three programs.

METHODS

33 semi-structured interviews were conducted. The transcriptions were analyzed, using the Grounded Theory approach, and the results were interpreted in light of the statements of participating programs.

RESULTS

While a wide range of themes related to interviewees' professional identity was identified, it became apparent that students' professional identity is centered on (1) being citizens engaged in social, democratic, and political processes, (2) building caring relationships and communities, and (3) addressing health inequities. Such priorities are explicitly aligned with the statements of participating programs.

CONCLUSIONS

The results (1) highlight the potential of statements to foster students' development of a professional identity as DNPs and (2) underscore that this identity is aligned with nursing programs' specific mission and values.

Association between patient ethnicity and prostate cancer diagnosis following a prostate-specific antigen test: a cohort study of 730,000 men in primary care in the UK

BACKGROUND

Black men have higher prostate-specific antigen (PSA) levels and higher prostate cancer incidence and mortality than White men, while Asian men tend to have lower prostate cancer incidence and mortality than White men. Much of the evidence comes from the USA, and information from UK populations is limited.

METHODS

This retrospective cohort study used data on patients registered at general practices in England contributing to the Clinical Practice Research Datalink (CPRD) Aurum dataset. Those eligible were men aged 40 and over with a record of ethnicity and a PSA test result recorded between 2010 and 2017 with no prior cancer diagnosis. The aim was to assess the incidence of prostate cancer following a raised PSA test result in men from different ethnic groups. Additionally, incidence of advanced prostate cancer was investigated. Cancer incidence was estimated from multi-level logistic regression models adjusting for potential confounding factors.

RESULTS

730,515 men with a PSA test were included (88.9% White). Black men and men with mixed ethnicity had higher PSA values, particularly for those aged above 60 years. In the year following a raised PSA result (using age-specific thresholds), Black men had the highest prostate cancer incidence at 24.7% (95% CI 23.3%, 26.2%); Asian men had the lowest at 13.4% (12.2%, 14.7%); incidence for White men was 19.8% (19.4%, 20.2%). The peak incidence of prostate cancer for all groups was in men aged 70-79. Incidence of prostate cancer diagnosed at an advanced stage was similar between Black and White men.

CONCLUSIONS

More prostate cancer was diagnosed in Black men with a raised PSA result, but rates of advanced prostate cancer were not higher in this group. In this large primary care-based cohort, the incidence of prostate cancer in men with elevated PSA levels increases with increasing age, even when using age-adjusted thresholds, with Black men significantly more likely to be diagnosed compared to White or Asian men. The incidence of advanced stage prostate cancer at diagnosis was similar for Black and White men with a raised PSA result, but lower for Asian men.

Health equity in pediatrics: Current concepts for the care of children in the 21st century (Dis Mon)

This is an analysis of important aspects of health equity in caring for children and adolescents written by a multidisciplinary team from different medical centers. In this discussion for clinicians, we look at definitions of pediatric health equity and the enormous impact of social determinants of health in this area. Factors involved with pediatric healthcare disparities that are considered include race, ethnicity, gender, age, poverty, socioeconomic status, LGBT status, living in rural communities, housing instability, food insecurity, access to transportation, availability of healthcare professionals, the status of education, and employment as well as immigration. Additional issues involved with health equity in pediatrics that are reviewed will include the impact of the COVID-19 pandemic, behavioral health concepts, and the negative health effects of climate change. Recommendations that are presented include reflection of one's own attitudes on as well as an understanding of these topics, consideration of the role of various healthcare providers (i.e., community health workers, peer health navigators, others), the impact of behavioral health integration, and the need for well-conceived curricula as well as multi-faceted training programs in pediatric health equity at the undergraduate and postgraduate medical education levels. Furthermore, ongoing research in pediatric health equity is needed to scrutinize current concepts and stimulate the development of ideas with an ever-greater positive influence on the health of our beloved children. Clinicians caring for children can serve as champions for the optimal health of children and their families; in addition, these healthcare professionals are uniquely positioned in their daily work to understand the drivers of health inequities and to be advocates for optimal health equity in the 21st century for all children and adolescents.

Evaluating the effects of the 2017 National Health Insurance coverage expansion on amenable mortality and its disparities between areas in South Korea using Bayesian structural time-series models

To improve the low coverage rate of the National Health Insurance (NHI), South Korea implemented the NHI coverage expansion plan in 2017 to cover medically essential non-covered services and reduce copayment rates. This study aimed to estimate the effects of the 2017 NHI coverage expansion on amenable mortality and its disparities between areas in South Korea under a controlled interrupted time-series design using Bayesian structural time-series models. Age-standardized amenable mortality rates and rate differences (RDs) and rate ratios (RRs) between areas for amenable mortality were calculated monthly between July 2012 and December 2021 and used as the response series. The non-equivalent control series were monthly non-avoidable mortality rates and their regional disparities. After the coverage expansion, amenable mortality rates decreased for both males (-8.8%, 95% credible interval [CrI] -13.4% to -3.9%) and females (-8.3%, 95% CrI -13.4% to -2.4%), with the largest decline in the non-Seoul-Capital metropolitan area (-11.6%, 95% CrI -16.5% to -6.3%) rather than the Seoul Capital Area (-7.5%, 95% CrI -11.9% to -2.5%) and a non-significant reduction in the non-Seoul-Capital non-metropolitan area in females. RDs and RRs between areas for amenable mortality decreased non-significantly (-16.2%, 95% CrI -31.3% to 2.6% for RD and -1.2%, 95% CrI -3.7% to 1.5% for RR), except for a significant decrease in RD in males (-21.8%, 95% CrI -38.0% to -1.5%), and decreased less in females than in males. The coverage expansion was generally effective in reducing amenable mortality rates by area, but had limited effects in closing amenable mortality disparities between areas, favoring males and the non-Seoul-Capital metropolitan area. These results implied that additional measures are necessary to improve access to quality health care for females and underserved areas to enhance the effectiveness of the coverage expansion.

Intersecting Inequities in COVID-19 Vaccination: A Discourse Analysis of Information Use and Decision-Making Among Ethnically Diverse Parents in Canada

BACKGROUND

Little is known about how intersecting social privilege and disadvantage contribute to inequities in COVID-19 information use and vaccine access. This study explored how social inequities intersect to shape access to and use of COVID-19 information and vaccines among parents in Canada.

METHODS

We conducted semi-structured interviews on COVID-19 vaccination information use with ethnically diverse parents of children ages 11 to 18 years from April to August 2022. We purposefully invited parents from respondents to a national online survey to ensure representation across diverse intersecting social identities. Five researchers coded transcripts in NVivo using a discourse analysis approach informed by intersectionality. Our analysis focused on use of vaccine information and intersecting privileges and oppressions, including identifying with equity-denied group(s).

RESULTS

Interview participants (N = 48) identified as ethnically diverse non-Indigenous (n = 40) and Indigenous (n = 8) Peoples from seven Canadian provinces. Racialized minority or Indigenous participants reflected on historical and contemporary events of racism from government and medical institutions as barriers to trust and access to COVID-19 information, vaccines, and the Canadian healthcare system. Participants with privileged social locations showed greater comfort in resisting public health measures. Despite the urgency to receive COVID-19 vaccines, information gaps and transportation barriers delayed vaccination among some participants living with chronic medical conditions.

CONCLUSION

Historicization of colonialism and ongoing events of racism are a major barrier to trusting public health information. Fostering partnerships with trusted leaders and/or healthcare workers from racialized communities may help rebuild trust. Healthcare systems need to continuously implement strategies to restore trust with Indigenous and racialized populations.

Cross-country health inequalities of four common nutritional deficiencies among children, 1990 to 2019: data from the Global Burden of Disease Study 2019

BACKGROUND

Nutritional deficiencies remain serious medical and public health issues worldwide, especially in children. This study aims to analyze cross-country inequality in four common nutritional deficiencies (protein-energy malnutrition, dietary iron deficiency, vitamin A deficiency and iodine deficiency) among children from 1990 to 2019 based on Global Burden of Disease (GBD) 2019 data.

METHODS

Prevalence and disability-adjusted life years (DALYs) data as measures of four nutritional deficiency burdens in people aged 0 to 14 years were extracted from the GBD Results Tool. We analyzed temporal trends in prevalence by calculating the average annual percent change (AAPC) and quantified cross-country inequalities in disease burden using the slope index.

RESULTS

Globally, the age-standardized prevalence rates of dietary iron deficiency, vitamin A deficiency and iodine deficiency decreased, with AAPCs of -0.14 (-0.15 to -0.12), -2.77 (-2.96 to -2.58), and -2.17 (-2.3 to -2.03) from 1999 to 2019, respectively. Significant reductions in socio-demographic index (SDI)-related inequality occurred in protein-energy malnutrition and vitamin A deficiency, while the health inequality for dietary iron deficiency and iodine deficiency remained basically unchanged. The age-standardized prevalence and DALY rates of the four nutritional deficiencies decreased as the SDI and healthcare access and quality index increased.

CONCLUSIONS

The global burden of nutritional deficiency has decreased since 1990, but cross-country health inequalities still exist. More efficient public health measures are needed to reduce disease burdens, particularly in low-SDI countries/territories.

What makes a good general practice consultation: an exploratory pilot study with people from a low socioeconomic background

BACKGROUND

Whilst patients from low socioeconomic (SES) backgrounds are at increased risk of developing chronic health conditions, typically managed within general practice, they report less positive consultation experiences with general practitioners (GP). To our knowledge, existing research does not provide an in-depth understanding of GP conducts contribute to positive consultations.

AIM

To identify the factors that patients from low SES backgrounds perceive as essential for creating good consultation experiences.

DESIGN & SETTING

This qualitative research was performed in Melbourne GP clinics.

METHOD

We used an appreciative inquiry approach, focused on positive consultation experiences, previously shown to be helpful for researching sensitive topics. Nine patients with low SES backgrounds who reported positive consultation experiences, undertook a semi-structured qualitative interview whilst watching the video-recording of their GP consultation. Four different GPs were captured in the recordings. Inductive thematic coding was performed by two researchers.

RESULTS

Four categories were developed relating to: (1) the doctor's demeanour and the patient's feelings, (2) the therapeutic relationship, (3) the doctor's therapeutic skill set and (4) communication techniques. In each interview, the discussion about the video-recorded consultation often triggered reflections about previous consultations with the respective GP.

CONCLUSION

For patients from low SES groups, positive consultation experiences were underpinned by perceived continuity of care with a specific GP who consistently showed good communication skills and key interpersonal characteristics. This research is a small step towards increasing our understanding of the experience of individuals with low SES backgrounds in primary care and the existing health inequities within this.

Enhancing Diabetes Care through a Mobile Application: A Randomized Clinical Trial on Integrating Physical and Mental Health among Disadvantaged Individuals

Background

This study examines integrating physical and mental healthcare for disadvantaged persons with type 2 diabetes mellitus and mild-to-moderate depression in the community, using a mobile application within a public-private-academic partnership.

Methods

The Korean Diabetes Association has developed a mobile application combining behavioral activation for psychological well-being and diabetes self-management, with conventional medical therapy. Participants were randomly assigned to receive the application with usual care or only usual care. Primary outcomes measured changes in psychological status and diabetes selfmanagement through questionnaires at week 12 from the baseline. Secondary outcomes assessed glycemic and lipid control, with psychological assessments at week 16.

Results

Thirty-nine of 73 participants completed the study (20 and 19 in the intervention and control groups, respectively) and were included in the analysis. At week 12, the intervention group showed significant reductions in depression severity and perceived stress compared to the control group. Additionally, they reported increased perceived social support and demonstrated improved diabetes self-care behavior. These positive effects persisted through week 16, with the added benefit of reduced anxiety. While fasting glucose levels in the intervention group tended to improve, no other significant differences were observed in laboratory assessments between the groups.

Conclusion

This study provides compelling evidence for the potential efficacy of a mobile application that integrates physical and mental health components to address depressive symptoms and enhance diabetes self-management in disadvantaged individuals with type 2 diabetes mellitus and depression. Further research involving larger and more diverse populations is warranted to validate these findings and solidify their implications.

A novel application of interrupted time series analysis to identify the impact of a primary health care reform on intersectional inequities in avoidable hospitalizations in the adult Swedish population

Primary health care (PHC) systems are a crucial instrument for achieving equitable population health, but there is little evidence of how PHC reforms impact equities in population health. In 2010, Sweden implemented a reform that promoted marketization and privatization of PHC. The present study uses a novel integration of intersectionality-informed and evaluative epidemiological analytical frameworks to disentangle the impact of the 2010 Swedish PHC reform on intersectional inequities in avoidable hospitalizations. The study population comprised the total Swedish population aged 18-85 years across 2001-2017, in total 129 million annual observations, for whom register data on sociodemographics and hospitalizations due to ambulatory care sensitive conditions were retrieved. Multilevel Analysis of Individual Heterogeneity and Discriminatory Analyses (MAIHDA) were run for the pre-reform (2001-2009) and post-reform (2010-2017) periods to provide a mapping of inequities. In addition, random effects estimates reflecting the discriminatory accuracy of intersectional strata were extracted from a series MAIHDAs run per year 2001-2017. The estimates were re-analyzed by Interrupted Time Series Analysis (ITSA), in order to identify the impact of the reform on measures of intersectional inequity in avoidable hospitalizations. The results point to a complex reconfiguration of social inequities following the reform. While the post-reform period showed a reduction in overall rates of avoidable hospitalizations and in age disparities, socioeconomic inequities in avoidable hospitalizations, as well as the importance of interactions between complex social positions, both increased. Socioeconomically disadvantaged groups born in the Nordic countries seem to have benefited the least from the reform. The study supports a greater attention to the potentially complex consequences that health reforms can have on inequities in health and health care, which may not be immediate apparent in conventional evaluations of either population-average outcomes, or by simple evaluations of equity impacts. Methodological approaches for evaluation of complex inequity impacts need further development.

Corporate Social Responsibility Framework: An Innovative Solution to Social Determinants of Health in the USA

PURPOSE

Expand firms' corporate social responsibility (CSR) framework to systematically address social determinants of health (SDOH) in their communities and improve firms' performance (FP). GAP: The U.S. healthcare system has struggled to improve population health outcomes while enhancing delivery performance. An oft-overlooked contributor to this deficit is SDOH inequities, accounting for 25-60% of deaths in the USA annually. Ironically, most healthcare firms do not view investment in SDOH, a neglected phenomenon, to develop sustainable healthy communities as their direct responsibility due to the "wrong pocket problem." Although extant literature theorizes the CSR construct, there is a paucity of research on SDOH integration with the CSR framework.

DESIGN

We integrate a quantitative and qualitative study with supplementary literature on CSR and SDOH using the grounded theory method by researching fourteen health plan firms across the USA.

FINDINGS

Research reveals early efforts undertaken by top-performing healthcare insurers to address SDOH and provides evidence that such measures can be integrated profitably under CSR as a competitive advantage.

ORIGINALITY

Contributes to CSR theory and practice by providing an empirical model and expanding its framework to address SDOH systematically. Key implications are as follows: (1) healthcare firms to link with unconventional partners, such as housing authorities, food banks, employment agencies, and schools; (2) the entire healthcare supply chain to collaborate with social enterprises and regulators to develop sustainable communities; (3) policymakers must incentivize firms to align social equity and corporate goals; and (4) long-term view on CSR, SDOH, and healthy living (HL) will in-turn eliminate social inequities while enhancing FP.

Persistent Disparities: Trends in Rates of Sheltered Homelessness Across Demographic Subgroups in the USA

CONTEXT

Homelessness is a public health crisis affecting millions of Americans every year, with severe consequences for health ranging from infectious diseases to adverse behavioral health outcomes to significantly higher all-cause mortality. A primary constraint of addressing homelessness is a lack of effective and comprehensive data on rates of homelessness and who experiences homelessness. While other types of health services research and policy are based around comprehensive health datasets to successfully evaluate outcomes and link individuals with services and policies, there are few such datasets that report homelessness.

METHODS

Gathering archived data from the US Department of Housing and Urban Development, we created a unique dataset of annual rates of homelessness, nationally, as measured by persons accessing homeless shelter systems, for 11 years (2007-2017, including the Great Recession and prior to the start of the 2020 pandemic). Responding to the need to measure and address racial and ethnic disparities in homelessness, the dataset reports annual rates of homelessness across HUD selected, Census-based racial and ethnic categories.

FINDINGS

Between 2007 and 2017, across all types of sheltered homelessness, whether individual, family, or total, Black, American Indian or Alaska Native, and Native Hawaiian and Pacific Islander individuals and families were far more likely to experience homelessness than non-Hispanic White individuals and families. Particularly concerning about the rates of homelessness among these populations is the persistent and increasing nature of these disparities across the entire study period.

CONCLUSIONS

While homelessness is a public health problem, the hazard of experiencing homelessness is not uniformly distributed across different populations. Because homelessness is such a strong social determinant of health and risk factor across multiple health domains, it deserves the same careful annual tracking and evaluation by public health stakeholders as other areas of health and health care.

Determinants of unhealthy living by gender, age group, and chronic health conditions across districts in Korea using the 2010-2017 Community Health Surveys

OBJECTIVES

We investigated the prevalence and determinants of unhealthy living by gender, age, and comorbidities across Korean districts.

METHODS

For 806,246 men and 923,260 women from 245 districts who participated in the 2010-2017 Korean Community Health Surveys, risk scores were calculated based on obesity, physical inactivity, smoking, and high-risk alcohol consumption, each scored from 0 (lowest risk) to 2 (highest risk). A risk score ≥4 was defined as indicating unhealthy living, and weighted proportions were calculated for each district. Using multivariate regression, an ecological model including community socioeconomic, interpersonal, and neighborhood factors was examined by gender, age, and comorbidities.

RESULTS

The mean age-standardized rate of unhealthy living was 24.05% for men and 4.91% for women (coefficients of variation, 13.94% and 29.51%, respectively). Individuals with chronic diseases more frequently exhibited unhealthy lifestyles. Unhealthy lifestyles were associated with educational attainment (β-coefficients: men, -0.21; women, -0.15), high household income (β=0.08 and 0.03, respectively), pub density (β=0.52 and 0.22, respectively), and fast-food outlet density (β=2.81 and 1.63, respectively). Negative associations were observed with manual labor, social activity participation, and hospital bed density. Unhealthy living was positively associated with living alone among women and with being unemployed among middle-aged men. Access to parks was negatively associated with unhealthy living among young men and women. The ecological model explained 32% of regional variation in men and 41% in women.

CONCLUSIONS

Improving the neighborhood built and socioeconomic environment may reduce regional disparities in lifestyle behaviors; however, the impacts may vary according to socio-demographic traits and comorbidities.

Multimorbidity patterns and disability and healthcare use in Europe: do the associations change with the regional socioeconomic status?

Multimorbidity, the concurrence of several chronic conditions, is a rising concern that increases the years lived with disability and poses a burden on healthcare systems. Little is known on how it interacts with socioeconomic deprivation, previously associated with poor health-related outcomes. We aimed to characterize the association between multimorbidity and these outcomes and how this relationship may change with socioeconomic development of regions. 55,915 individuals interviewed in 2017 were drawn from the Survey of Health, Ageing and Retirement in Europe, a population-based study. A Latent Class Analysis was conducted to fit multimorbidity patterns based on 16 self-reported conditions. Physical limitation, quality-of-life and healthcare utilization outcomes were regressed on those patterns adjusting for additional covariates. Those analyses were then extended to assess whether such associations varied with the region socioeconomic status. We identified six different patterns, labelled according to their more predominant chronic conditions. After the "healthy" class, the "metabolic" and the "osteoarticular" classes had the best outcomes involving limitations and the lowest healthcare utilization. The "neuro-affective-ulcer" and the "several conditions" classes yielded the highest probabilities of physical limitation, whereas the "cardiovascular" group had the highest probability of hospitalization. The association of multimorbidity over physical limitations appeared to be stronger when living in a deprived region, especially for metabolic and osteoarticular conditions, whereas no major effect differences were found for healthcare use. Multimorbidity groups do differentiate in terms of limitation and healthcare utilization. Such differences are exacerbated with socioeconomic inequities between regions even within Europe.

WaSH insecurity and anxiety among people who inject drugs in the Tijuana-San Diego border region

BACKGROUND

Water, sanitation, and hygiene (WaSH) insecurity increases the risk of water-related diseases. However, limited research has been conducted on psychosocial distress as it relates to WaSH insecurity, especially among people who inject drugs (PWID). We examined the relationship between WaSH insecurity and related anxiety among PWID living in different housing conditions along the US-Mexico border region.

METHODS

From 2020-2021, a cross-sectional study was conducted among 585 people who injected drugs within the last month in Tijuana (N = 202), San Diego (N = 182), and in both Tijuana and San Diego (N = 201). Participants underwent interviewer-administered surveys related to WaSH access, substance use, and generalized anxiety disorder (GAD-7). Quasi-Poisson regressions were used to assess associations between WaSH insecurity and anxiety in the prior 6-months.

RESULTS

Participants were 75% male, 42% were unhoused and 91% experienced WaSH insecurity in the prior 6-months. After adjusting for housing status, gender, and age, lack of access to basic drinking water (Adj RR: 1.28; 95% CI: 1.02-1.58), sanitation (Adj RR:1.28; 95% CI: 1.07-1.55), and a daily bath/shower (Adj RR: 1.38; 95% CI: 1.15-1.66) were associated with mild-severe anxiety. The number of WaSH insecurities was independently associated with a 20% increased risk of experiencing anxiety per every additional insecurity experienced (Adj RR: 1.20; CI: 1.12-1.27). We also found a significant interaction between gender and housing status (p = 0.003), indicating that among people experiencing sheltered/unsheltered homelessness, women had a higher risk of mild-severe anxiety compared to men (Adj RR: 1.55; 95% CI: 1.27-1.89). At the same time, among women, those who are unhoused have 37% increased risk of anxiety than those who live in stable housing conditions (Adj RR: 1.37; 95% CI: 1.01-1.89).

CONCLUSION

The lack of specific WaSH services, particularly lack of drinking water, toilets, and daily showers were associated with higher levels of anxiety among PWID in the Tijuana-San Diego border region. Women experiencing homelessness were especially vulnerable. WaSH interventions that provide safe, 24-h access may help to reduce anxiety and health risks associated with WaSH insecurity.

Quantitative approaches to measuring structural cisgenderism

There is rapidly growing interest in understanding the impacts of structural cisgenderism on health and health inequities for transgender and nonbinary populations. This growing interest has led to an influx of novel measures of structural cisgenderism. In this commentary, we discuss and identify gaps in existing measures and offer considerations for the development of future measures. Developing and utilizing valid measures of structural cisgenderism is crucial to quantify its impacts on health and health inequities, and to inform public health interventions, laws, and policies to eliminate gender identity and modality-based health inequities.

"We have to lie low … that sort of poisons me more and more": A qualitative study of violent political rhetoric and health implications for Spanish and Chinese speaking immigrants

BACKGROUND

In recent years, the historical legacy of anti-immigrant sentiment in the US has resurfaced, fueled by a new wave of anti-immigrant political rhetoric. Violent political rhetoric, defined as either explicit or metaphorically targeted language to dehumanize targeted groups, can incite discriminatory treatment of immigrants at both interpersonal and institutional levels, shaping their health and healthcare experiences. This qualitative study explores and compares how Spanish- and Chinese-speaking immigrant populations in Chicago make sense of violent political rhetoric against their racial and ethnic identities, utilize coping strategies to maintain their sense of belonging, and experience downstream health consequences.

METHODS

In 2019, 14 semi-structured focus groups were conducted among immigrants to the U.S. (n = 79). Participants were recruited from four community sites in either Hispanic/Latino or Chinese neighborhoods in Chicago. Focus groups were conducted by racially- and linguistically concordant interviewers in Spanish, Mandarin, or Cantonese. The research team developed a codebook iteratively and analyzed transcripts using grounded theory and the constant comparison method.

RESULTS

Participants included Chinese (61%) and Spanish-speaking immigrants (39%), with an average age of 61.4 years (sd = 13); the majority were female (62%), unemployed (68%), and attained less than a high school diploma (53%). Self-reported stress due to political rhetoric was more pronounced among Spanish-speaking participants (93%) than Chinese participants (39.6%). Immigrants responded to manifestations of violent political rhetoric in numerous ways including mobilizing the model minority myth with internalized racism, anticipatory stress, and "high effort" coping mechanisms (John Henryism), all with downstream health effects.

CONCLUSION

Violent political rhetoric is one of the mechanisms by which racism and xenophobia exacerbate a toll on the health of racialized immigrant groups. These processes have implications for both interpersonal and institutional experiences, as well as health and healthcare interactions. We propose a conceptual model that outlines these mechanisms and points to potential areas of intervention to ameliorate immigrant health inequities.

Gender differences in trajectories of health-related quality of life from childhood to adolescence in a 7-year follow-up study in a urban socially disadvantaged sample from Argentina

PURPOSE

The transition from childhood to adolescence is a period of developmental changes, with social influences. Few previous studies have analyzed changes in health-related quality of life (HRQoL) during childhood and adolescence based on longitudinal studies in high-income countries. This study aimed to describe the evolution of HRQoL scores by gender in a school sample over a 7-year period in Argentina.

METHODS

Prospective cohort of children attending fourth grade in public schools. HRQoL was measured using the KIDSCREEN-52 questionnaire. Trajectories of HRQoL were estimated for girls and boys through multilevel models, adjusted by socioeconomic status (SES).

RESULTS

The study began in 2014 with a sample of 494 school children, reaching an 85.6% response rate in 2016, 31.4% in 2018, and 41.9% in 2021. Most of the predicted scores are negatively associated with linear age or/and quadratic age, suggesting a decrease in scores over the 7-year follow-up. Interactions between gender and age denote an increase in the differences in scores between girls and boys over time in favor of the latter. For the Index, Physical Well-being, Psychological Well-being, Autonomy, Parent relations, Social support and peers and Financial resources, individuals with medium or high SES have significantly higher scores than those with low SES.

CONCLUSIONS

HRQoL scores decrease during the transition period from childhood to adolescence, with girls showing the greatest decrease. There were also socioeconomic inequalities in the evolution of HRQoL in a context characterized by social segregation and economic crisis, possibly aggravated by the COVID-19 pandemic.

Racial Disparities in Breast Cancer: from Detection to Treatment

PURPOSE OF REVIEW

Update on current racial disparities in the detection and treatment of breast cancer.

RECENT FINDINGS

Breast cancer remains the leading cause of cancer death among Black and Hispanic women. Mammography rates among Black and Hispanic women have surpassed those among White women, with studies now advocating for earlier initiation of breast cancer screening in Black women. Black, Hispanic, Asian, and American Indian and Alaskan Native women continue to experience delays in diagnosis and time to treatment. Further, racial discrepancies in receipt of guideline-concordant care, access to genetic testing and surgical reconstruction persist. Disparities in the initiation, completion, toxicity, and efficacy of chemotherapy, endocrine therapy, and targeted drug therapy remain for racially marginalized women. Efforts to evaluate the impact of race and ethnicity across the breast cancer spectrum are increasing, but knowledge gaps remain and further research is necessary to reduce the disparity gap.

Regional disparities in the availability of cancer clinical trials in Korea

OBJECTIVES

Unequal access to cancer clinical trials is an important issue, given the potential benefits of participation for cancer patients. We evaluated regional disparities in access to cancer clinical trials in Korea.

METHODS

From the Ministry of Food and Drug Safety database, we extracted 2,465 records of all cancer clinical trials approved between January 2012 and April 2023. To measure disparities in cancer clinical trial access, we calculated the ratio of clinical trials open to non-capital areas relative to those open to capital areas. We then analyzed temporal trends in this ratio, which we termed the trial geographical equity index (TGEI).

RESULTS

Disparities in access to cancer clinical trials, as indicated by the TGEI, did not significantly improve during the study period (regression coefficient, 0.002; p=0.59). However, for phase II/III trials sponsored by global pharmaceutical companies, the TGEI improved significantly (regression coefficient, 0.021; p<0.01). In contrast, the TGEI deteriorated for trials initiated by investigators or those testing domestically developed therapeutics (regression coefficient, -0.015; p=0.05). Furthermore, the increasing trend of TGEI for phase II/III trials sponsored by global companies began to reverse after 2019, coinciding with the outbreak of coronavirus disease 2019 (COVID-19).

CONCLUSIONS

Over the past decade, access to cancer clinical trials has improved in Korea, particularly for phase II/III trials evaluating therapeutics from global companies. However, this increase in accessibility has not extended to trials initiated by investigators or those assessing domestically developed therapeutics. Additionally, the impact of COVID-19 on disparities in clinical trial access should be closely monitored.

Demographic and Geographic Inequities in Antimicrobial Use and Prescribing

Little is known about how social determinants of health may impact antimicrobial prescribing among racial and ethnic minority populations, different age groups and genders, and across geographic regions. The factors that influence antimicrobial prescribing are complex, but evidence suggests that demographic and socioeconomic factors do influence prescribing patterns. This review describes the inequities observed in antimicrobial use and prescribing that have been heretofore published, with a focus on differences observed by race and ethnicity, age, gender, and geographic region of the United States.

How is equity captured for colorectal, breast and cervical cancer incidence and screening in the Republic of Ireland: A review

Introduction

Organised screening reduces the incidence and late-stage diagnosis of cancer. However, participation in screening is not consistent across populations. Variations can be measured using demographic factors on place of residence, race/ethnicity, occupation, gender/sex, religion, education, socio-economic position (SEP), and social capital (PROGRESS-Plus stratifiers). The Republic of Ireland has screening programmes for colorectal, breast, and cervical cancer but assessment of screening participation and cancer incidence is inconsistent. The review aimed to evaluate the use of stratifiers in breast, cervical and colorectal cancer incidence and screening literature, and assess variations in incidence and screening participation across subgroups in Ireland.

Methods

PubMed was searched systematically and grey literature was identified via Google, Google Scholar, Lenus (Irish Health Research repository), and The Irish Longitudinal Study of Aging (TILDA) in June 2022. Studies were included if they captured stratifiers alongside incidence or screening participation data of the three cancers.

Results

Thirty-six studies and reports were included. Place of residence, SEP, sex, and age were most frequently captured. Incidence and screening participation varied by age, place of residence, SEP, and sex.

Discussion

PROGRESS-Plus is a useful equity lens to review health literature. Cancer incidence and screening participation studies lacked a comprehensive equity lens resulting in difficulties in identifying inequities and non-attenders. Place of residence, SEP and ethnicity should be prioritised in monitoring inequities. Integrating unique health identifiers should improve monitoring and enable evidence-based population-specific interventions to promote screening. Collaboration with community organisations would support engagement with vulnerable populations when data is limited.

Barriers to Type 2 Diabetes Mellitus Management for Older Hmong Patients with Minimal English Language Skills: Accounts from Caregivers, Case Managers, and Clinicians

Type 2 diabetes mellitus prevalence rates for Hmong Americans in Wisconsin are more than double that of non-Hispanic Whites. The Hmong's history, lifestyle (dietary and behavioral patterns), and reliance on traditional medicine contribute to their increased risk of diabetes. This qualitative study aimed to better understand the barriers challenging older Hmong patients' ability to manage diabetes. Asian Americans have long been overlooked in health-related research, but recent disaggregated data of specific ethnic groups reveal significant health inequities. Among the different ethnic groups, there is a significant lack of research on the Hmong Americans. Three participant groups (Hmong American family caregivers, Hmong American case managers, and clinicians from different racial backgrounds who provide care for Hmong patients) were recruited from the community and interviewed to understand the barriers experienced by older Hmong patients with minimal English language skills in managing their diabetes. Directed content analysis of the data resulted in three major themes: adherence to culture, health inequity, and managing diabetes. Subthemes included Hmong herbs and shamans, lack of trust in Western medicine, the significance of rice, language barriers, lack of cultural sensitivity, health literacy, monitoring glucose, medicine compliance, and nutrition. Minimal English language skills and low literacy rates (health and education) contribute to their strong adherence to cultural practices which challenges Western medicine, creating difficulty for older Hmong patients to manage their diabetes. Recognizing cultural differences and barriers will enable healthcare providers to improve and cater the treatment options, bridging the gap between older Hmong patients and Western medicine.