The Physiological Toll of Arrests: An Examination of Arrest History on Midlife Allostatic Load

PURPOSE

To understand how allostatic load - cumulative physiologic burden of stress - varies by amount and timing of arrests stratified by race/ethnicity and by sex.

METHODS

Using The National Longitudinal Study of Adolescent to Adult Health, we calculated descriptive statistics and mean differences in bio-marker measured allostatic load by arrest history stratified by race/ethnicity and sex.

RESULTS

One-third of participants experienced at least one arrest, and most experienced arrests only as adults. Allostatic load scores were higher for those that had ever experienced an arrest compared to never (mean difference: 0.58 (0.33, 0.84)). Similar results held for men and women and across race/ethnicity, but Black non-Hispanic individuals had higher allostatic load at all levels compared to other individuals.

CONCLUSIONS

Experiencing both any arrest and multiple arrests were associated with higher allostatic load. The stress of arrests may contribute to physiological maladaptations and poor health. The public health and law enforcement fields must recognize the detrimental consequences of arrests on physiological stress and search for non-carceral solutions.

A Qualitative Exploration of Self-Advocacy Experiences of Black Women in the Perinatal Period: Who Is Listening?

INTRODUCTION

Black women face poor maternal health outcomes including being over 3 times more likely to die from pregnancy complications than White women. Yet the lived experience of how these women self-advocate has not been clearly explored. The goal of this cross-sectional qualitative study was to describe the lived experiences of Black women advocating for their needs and priorities during the perinatal period.

METHODS

Between January and October of 2022, we recruited Black women from obstetric clinics, research registries, and community advocacy groups who were either in their third trimester of pregnancy or within a year postpartum. Participants completed one-on-one interviews describing their experiences of self-advocacy. These data were analyzed using descriptive content analysis approaches that summarized women's experiences by iteratively creating major themes and subthemes that encapsulate their self-advocacy descriptions.

RESULTS

Fifteen Black women completed interviews. Major themes and subthemes describing women's experience of self-advocacy were the following: (1) carrying a burden with subthemes of having to be good and easy, not trusting health care information and providers, and being dismissed; (2) building comfort with health care providers with subthemes of trusting I have a good provider, comfort in knowing they understand, and wanting low-touch, high-concern care; and (3) advocating for my child and myself when I need to with subthemes of going with the flow, becoming informed, pushing to ask questions, and balancing being proactive and pushy.

DISCUSSION

Women reported self-advocating mainly due to experiences related to the burdens associated with not trusting providers and health care information. These findings provide clarity to how women carefully balance between ensuring their health is taken seriously while not jeopardizing their health or that of their newborn. This study offers promising directions to support Black women in advocating for their perinatal health care needs and values.

Isolating the Drivers of Racial Inequities in Prostate Cancer Treatment

BACKGROUND

Black individuals in the United States are less likely than White individuals to receive curative therapies despite a 2-fold higher risk of prostate cancer death. While research has described treatment inequities, few studies have investigated underlying causes.

METHODS

We analyzed a cohort of 40,137 Medicare beneficiaries (66 and older) linked to the Surveillance Epidemiology and End Results (SEER) cancer registry who had clinically significant, non-metastatic (cT1-4N0M0, grade group 2-5) prostate cancer (diagnosed 2010-2015). Using the Kitagawa-Oaxaca-Blinder decomposition, we assessed the contributions of patient health and health care delivery on the racial difference in localized prostate cancer treatments (radical prostatectomy or radiation). Patient health consisted of comorbid diagnoses, tumor characteristics, SEER site, diagnosis year, and age. Health care delivery was captured as a prediction model with these health variables as predictors of treatment, reflecting current treatment patterns.

RESULTS

A total of 72.1% and 78.6% of Black and White patients received definitive treatment, respectively, a difference of 6.5 percentage points. An estimated 15% [95% confidence interval (CI): 6-24] of this treatment difference was explained by measured differences in patient health, leaving the remaining estimated 85% (95% CI: 74-94) attributable to a potentially broad range of health care delivery factors. Limitations included insufficient data to explore how specific health care delivery factors, including structural racism and social determinants, impact differential treatment.

CONCLUSIONS

Our results show the inadequacy of patient health differences as an explanation of the treatment inequity.

IMPACT

Investing in studies and interventions that support equitable health care delivery for Black individuals with prostate cancer will contribute to improved outcomes.

Cancer-Related Financial Hardship Screening as Part of Practice Transformation

BACKGROUND

Data on financial hardship, an "adverse event" in individuals with cancer, are needed to inform policy and supportive care interventions and reduce adverse economic outcomes.

METHODS

Lay navigator-led financial hardship screening was piloted among University of Alabama at Birmingham oncology patients initiating treatment in October 2020. Financial hardship screening, including reported financial distress and difficulty, was added to a standard-of-care treatment planning survey. Screening feasibility and completion and proportions of reported financial distress and difficulty were calculated overall and by patient race and rurality. The risk of financial distress by patient sociodemographics was estimated.

RESULTS

Patients who completed a treatment planning survey (N=2741) were 18% Black, Indigenous, or persons of color (BIPOC) and 16% rural dwelling. The majority of patients completed financial hardship screening (90%), surpassing the target feasibility completion rate of 75%. The screening revealed 34% of patients were experiencing financial distress, including 49% of BIPOC and 30% of White patients. Adjusted models revealed BIPOC patients had a 48% higher risk of financial distress compared with those who were White (risk ratio 1.48, 95% CI, 1.31-1.66). Large differences in reported financial difficulties were seen comparing patients who were BIPOC and White (utilities: 33% vs. 10%, upfront medical payments: 44% vs. 23%, transportation: 28% vs. 12%, respectively).

CONCLUSIONS

The collection of patient-reported financial hardship data via routine clinical care was feasible and identified racial inequities at treatment initiation. Efforts to collect patient economic data should support the design, implementation, and evaluation of patient-centered interventions to improve equity and reduce the impact of financial hardship.

Clinical characteristics, racial inequities, and outcomes in patients with breast cancer and COVID-19: A COVID-19 and cancer consortium (CCC19) cohort study

Background

Limited information is available for patients with breast cancer (BC) and coronavirus disease 2019 (COVID-19), especially among underrepresented racial/ethnic populations.

Methods

This is a COVID-19 and Cancer Consortium (CCC19) registry-based retrospective cohort study of females with active or history of BC and laboratory-confirmed severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection diagnosed between March 2020 and June 2021 in the US. Primary outcome was COVID-19 severity measured on a five-level ordinal scale, including none of the following complications, hospitalization, intensive care unit admission, mechanical ventilation, and all-cause mortality. Multivariable ordinal logistic regression model identified characteristics associated with COVID-19 severity.

Results

1383 female patient records with BC and COVID-19 were included in the analysis, the median age was 61 years, and median follow-up was 90 days. Multivariable analysis revealed higher odds of COVID-19 severity for older age (aOR per decade, 1.48 [95% CI, 1.32-1.67]); Black patients (aOR 1.74; 95 CI 1.24-2.45), Asian Americans and Pacific Islander patients (aOR 3.40; 95 CI 1.70-6.79) and Other (aOR 2.97; 95 CI 1.71-5.17) racial/ethnic groups; worse ECOG performance status (ECOG PS ≥2: aOR, 7.78 [95% CI, 4.83-12.5]); pre-existing cardiovascular (aOR, 2.26 [95% CI, 1.63-3.15])/pulmonary comorbidities (aOR, 1.65 [95% CI, 1.20-2.29]); diabetes mellitus (aOR, 2.25 [95% CI, 1.66-3.04]); and active and progressing cancer (aOR, 12.5 [95% CI, 6.89-22.6]). Hispanic ethnicity, timing, and type of anti-cancer therapy modalities were not significantly associated with worse COVID-19 outcomes. The total all-cause mortality and hospitalization rate for the entire cohort was 9% and 37%, respectively however, it varied according to the BC disease status.

Conclusions

Using one of the largest registries on cancer and COVID-19, we identified patient and BC-related factors associated with worse COVID-19 outcomes. After adjusting for baseline characteristics, underrepresented racial/ethnic patients experienced worse outcomes compared to non-Hispanic White patients.

Funding

This study was partly supported by National Cancer Institute grant number P30 CA068485 to Tianyi Sun, Sanjay Mishra, Benjamin French, Jeremy L Warner; P30-CA046592 to Christopher R Friese; P30 CA023100 for Rana R McKay; P30-CA054174 for Pankil K Shah and Dimpy P Shah; KL2 TR002646 for Pankil Shah and the American Cancer Society and Hope Foundation for Cancer Research (MRSG-16-152-01-CCE) and P30-CA054174 for Dimpy P Shah. REDCap is developed and supported by Vanderbilt Institute for Clinical and Translational Research grant support (UL1 TR000445 from NCATS/NIH). The funding sources had no role in the writing of the manuscript or the decision to submit it for publication.

Clinical trial number

CCC19 registry is registered on ClinicalTrials.gov, NCT04354701.

Addressing racial disparities in cancer care: A collaborative grant initiative

A competitive grants program developed by the American Cancer Society and Pfizer Global Medical Grants funded 10 quality improvement projects aimed at reducing systemic barriers and addressing cancer disparities for Black men and women. This introduction details the purpose and scope of this program and addresses the potential for similar projects addressing disparities along the cancer care continuum.

Disparities in the provision of perinatal care based on patient race in the United States

BACKGROUND

In the United States, there are significant health inequities in perinatal care. This study examined differences in perinatal care provided to women based on the birthing person's designated race, within a large and diverse cohort of women.

METHODS

This retrospective electronic medical record review identified patients receiving perinatal care within a large hospital system between January 2012 and September 2018 and examined associations between maternal designated race/ethnicity (Hispanic or non-Hispanic [NH] Black, Asian or White) and various provider treatment decisions.

RESULTS

The study sample (N = 7056) was comprised of 36% Hispanic, 34% NH White, 21% NH Black, and 4% NH Asian women, aged 29.7 ± 6.3 years; 53% of the sample had private insurance, and 45% had Medicaid. Few differences by race were seen in perinatal care based on guidelines or expert recommendations (nondiscretionary care). Discretionary care, however, varied by race: Compared with NH White women, NH Black women were less likely to receive a prenatal depression screen (OR 0.8 [95% CI: 0.7, 0.9]) and more likely to have a urine drug test when denying drug use (OR 1.6 [95% CI 1.3, 2.0]), whereas Hispanic (OR 0.6 [95% CI: 0.5, 0.8]) and NH Asian (0.4 [95% CI 0.2, 0.9]) women were less likely to have a urine drug test completed when denying drug use.

DISCUSSION

Perinatal care differs by maternal race/ethnicity, particularly when guidelines or expert recommendations are absent. Greater efforts need to be made to identify and mitigate providers' implicit and explicit biases; expanded professional guidelines may offer some protections against inequitable, discretionary care.

Obstetrical health care inequities in a universally insured health care system

BACKGROUND

Racial and ethnic disparities in health care exist and are rooted in long-standing systemic inequities. These disparities result in significant excess health care expenditures and are due to complex interactions between patients, health care providers and systems, and social and environmental factors. In perinatal care, these inequities also exist, with Black patients being 3 to 4 times more likely to die of childbirth compared with White patients. Similar health care inequities may also exist in the Military Health System despite universal health care coverage, stable employment, and social programs that benefit military families.

OBJECTIVE

This study aimed to evaluate racial disparities in obstetrical outcomes in the Military Health System.

STUDY DESIGN

This is a retrospective cohort study of deliveries from 2019 to 2021 in the Military Health System, which provides obstetrical care for approximately 35,000 annual deliveries. The study was conducted using National Perinatal Information Center data on cesarean delivery, postpartum hemorrhage, and severe maternal morbidity by race and ethnicity from direct-care military hospitals representing tertiary care medical centers and community hospitals in the United States and abroad. Chi-square analyses and binary logistic regression were used to compare groups.

RESULTS

The cohort included 68,918 deliveries. Of these, 32,358 (47%) were White, 9594 (13.9%) Black, 3120 (4.5%) Asian Pacific Islander, 456 (0.7%) American Indian/Alaska Native, 19,543 (28.4%) other, 3976 (5.8%) unknown, 7096 (10.3%) Hispanic, 58,009 (84.2%) non-Hispanic, and 4399 (6.4%) other ethnicity. Rates of cesarean delivery were significantly higher for Black (30%; odds ratio, 1.44; 95% confidence interval, 1.37-1.52), Asian Pacific Islander (27%; odds ratio, 1.24; 95% confidence interval, 1.14-1.35), and other (26%; odds ratio, 1.20; 95% confidence interval, 1.15-1.25) compared with White race (23%) (P<.001). Postpartum hemorrhage rates were higher for Black (5.9%; odds ratio, 1.11; 95% confidence interval, 1.00-1.24) and Asian Pacific Islander (7.7%; odds ratio, 1.49; 95% confidence interval, 1.29-1.72) compared with White race (5.3%) (P<.001). Severe maternal morbidity was higher for Black (2.9%; odds ratio, 1.44; 95% confidence interval, 1.24-1.67), Asian Pacific Islander (2.9%; odds ratio, 1.45; 95% confidence interval, 1.15-1.82), and other (2.8%; odds ratio, 1.36; 95% confidence interval, 1.21-1.54) compared with White race (2.1%) (P<.001). For severe maternal morbidity excluding blood transfusions, rates were also significantly higher for Black (1%; odds ratio, 1.68; 95% confidence interval, 1.30-2.17) than for White race (0.6%) (P<.002). Hispanic ethnicity was associated with a lower rate of severe maternal morbidity excluding transfusions (0.5%; odds ratio, 0.68; 95% confidence interval, 0.48-0.98) compared with non-Hispanic ethnicity (0.7%) (P=.04).

CONCLUSION

Racial disparities in obstetrical outcomes exist in the Military Health System despite universal health care coverage, with significantly higher rates of cesarean delivery and severe maternal morbidity in Black, Asian Pacific Islander, and other races compared with White race. These findings suggest that these disparities are likely related to other factors or social determinants of health rather than availability of health care and insurance coverage. Further work should include investigation into such social determinants of health to address their causes, including systemic and structural barriers.

Addressing Barriers to Care in Hepatocellular Carcinoma: Promoting Equity and Access

Chronic hepatitis B virus (HBV) infection is the leading cause of hepatocellular carcinoma (HCC). Chronic viral hepatitis is projected to surpass the composite mortality rates of the human immunodeficiency virus (HIV), tuberculosis, and malaria by 2040. It can be attributed to several barriers to chronic HBV infection (CHBVI) surveillance that warrant urgent attention. Here, we report a case of a 40-year-old male with CHBVI who developed HCC and underwent partial hepatic resection. However, due to an interruption in insurance and medication regimen, the patient became the victim of healthcare disparity, which led to the progression of HCC and succumbed to widespread metastasis. This case highlights and discusses the healthcare disparity and critical value of continuity of care for patients with HBV infection to promote optimal patient outcomes.

Potentially More Out of Reach: Public Reporting Exacerbates Inequities in Home Health Access

Policy Points Public reporting is associated with both mitigating and exacerbating inequities in high-quality home health agency use for marginalized groups. Ensuring equitable access to home health requires taking a closer look at potentially inequitable policies to ensure that these policies are not inadvertently exacerbating disparities as home health public reporting potentially does. Targeted federal, state, and local interventions should focus on raising awareness about the five-star quality ratings among marginalized populations for whom inequities have been exacerbated.

CONTEXT

Literature suggests that public reporting of quality may have the unintended consequence of exacerbating disparities in access to high-quality, long-term care for older adults. The objective of this study is to evaluate the impact of the home health five-star ratings on changes in high-quality home health agency use by race, ethnicity, income status, and place-based factors.

METHODS

We use data from the Outcome and Assessment Information Set, Medicare Enrollment Files, Care Compare, and American Community Survey to estimate differential access to high-quality home health agencies between July 2014 and June 2017. To estimate the impact of the home health five-star rating introduction on the use of high-quality home health agencies, we use a longitudinal observational pretest-posttest design.

FINDINGS

After the introduction of the home health five-star ratings in 2016, we found that adjusted rates of high-quality home health agency use increased for all home health patients, except for Hispanic/Latine and Asian American/Pacific Islander patients. Additionally, we found that the disparity in high-quality home health agency use between low-income and higher-income home health patients was exacerbated after the introduction of the five-star quality ratings. We also observed that patients within predominantly Hispanic/Latine neighborhoods had a significant decrease in their use of high-quality home health agencies, whereas patients in predominantly White and integrated neighborhoods had a significant increase in high-quality home health agency use. Other neighborhoods experience a nonsignificant change in high-quality home health agency use.

CONCLUSIONS

Policymakers should be aware of the potential unintended consequences for implementing home health public reporting, specifically for Hispanic/Latine, Asian American/Pacific Islander, and low-income home health patients, as well as patients residing in predominantly Hispanic/Latine neighborhoods. Targeted interventions should focus on raising awareness around the five-star ratings.

Fruit and Vegetable Shopping Behavior and Intake among Low-Income Minority Households with Elementary-Aged Children

Low-income children and families do not meet the recommendations for fruit and vegetable (FV) intake. This study aimed to assess the association between FV shopping behavior and child FV intake through a cross-sectional study design analyzing self-reported surveys (n = 6074) from adult-child dyads of Hispanic/Latino and African American participants enrolled in the Brighter Bites co-op program. Through quantitative mixed effects linear regression models, accounting for school-level clustering and adjusting for covariates, child FV intake was positively associated with shopping for FV at large chain grocery stores (p < 0.001), natural/organic supermarkets (p < 0.001), warehouse club stores (p = 0.002), discount superstores (p < 0.001), small local stores/corner stores (p = 0.038), convenience stores (p = 0.022), ethnic markets (p = 0.002), farmers’ markets/co-op/school farm stands (p < 0.001), and gardens (p = 0.009) among Hispanic/Latinos participants. Among African American participants, there was significant positive association between child FV intake and shopping for FV at natural/organic supermarkets (p < 0.001), discount superstores (p = 0.005), and convenience stores (p = 0.031). The relationship between location and frequency of shopping for FV and child FV intake varied between races. Further research is needed to better understand the influence of cultural and physical environmental factors. Nutrition education programs are vital to encouraging families to make healthier food choices and purchases to improve child FV consumption.

The 5Ws of Racial Equity in Research: A Framework for Applying a Racial Equity Lens Throughout the Research Process

Ensuring equity in research is a critical step in advancing health equity. In this perspective, the authors introduce a guiding framework for advancing racial equity in research processes, environments, and among the research workforce, the 5Ws of Racial Equity in Research. Centering their discussion on the 5Ws: Who, What, When, Where, and Why, they use historical and contemporary examples of research inequities to demonstrate how these five simple questions can encourage open discussion and proactive planning for equity in research. They close with an acknowledgment of the framework's broad utility and a researcher-directed call to action.

Racial inequities in emergency department wait times for pregnancy-related concerns

Objective:

Emergency department care is common among US pregnant women. Given the increased likelihood of serious and life-threatening pregnancy-related health conditions among Black mothers, timeliness of emergency department care is vital. The objective of this study was to evaluate racial/ethnic variations in emergency department wait times for receiving obstetrical care among a nationally representative population.

Methods:

The study used pooled 2016–2018 data from the National Hospital Ambulatory Medical Care Survey, a nationally representative sample of emergency department visits. Regression models were estimated to determine whether emergency department wait time was associated with the race/ethnicity of the perinatal patient. Adjusted models controlled for age, obesity status, insurance type, whether the patient arrived by ambulance, triage status, presence of a patient dashboard, and region.

Results:

There were a total of 821 reported pregnancy-related visits in the National Hospital Ambulatory Medical Care Survey sample of emergency department visits. Of those 821 visits, 40.6% were among White women, 27.7% among Black women, and 27.5% among Hispanic women. Mean wait times differed substantially by race/ethnicity. After adjusting for potential confounders, Black women waited 46% longer than White women with emergency department visits for pregnancy problems (p < .05). Those reporting another race waited 95% longer for pregnancy problems in the emergency department than White women (p < .05).

Conclusion:

Findings from this study document significant racial/ethnic differences in wait times for perinatal emergency department care. Although inequities in wait times may emerge across the spectrum of care, documenting the factors influencing racial disparities in wait times are critical to promoting equitable perinatal health outcomes.

Infant Outcomes among Teenage and Young Mothers: Racial Inequities and the Role of Educational Attainment

OBJECTIVE

To examine the association of age-appropriate maternal educational attainment in teenage and young mothers on infant health outcomes across racial/ethnic groups.

STUDY DESIGN

In this retrospective, cross-sectional study using Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research Natality data (2016-2017), we included live births comparing 14- to 19- year-old mothers with 20- to 24-year-old mothers. To analyze the association of maternal age-appropriate education (≥8th grade for 15-18 years of age, 9th-12th grade/completed high school for 19-24 years of age), we conducted multivariable regression adjusting for mothers' demographics, reporting adjusted incidence rate ratios with 95% CI for infant mortality rate, and logistic regression for extreme prematurity and low birth weight, reporting aORs with 95% CI.

RESULTS

From 2016 to 2017, there were 1 976 334 live births among women 14-24 years of age; 407 576 (20.6%) were in 14- to 19-year-olds. In the multivariable model, increased term infant mortality rate was associated with age 14-19 years (adjusted incidence rate ratio 1.18, 95% 1.10, 1.27), age-inappropriate education (adjusted incidence rate ratio 1.38, 95% CI 1.28, 1.48), and non-Hispanic Black mothers (adjusted incidence rate ratio 1.21, 95% CI 1.12, 1.30). Extreme prematurity was associated with women age 14-19 years (aOR 1.35, 95% CI 1.30, 1.40), non-Hispanic Black (aOR 2.50, 95% CI 2.39, 2.61), and Hispanic mothers (aOR 1.09, 95% CI 1.04, 1.15). Term infant low birth weight was associated with age 14-19 years (aOR 1.14, 95% CI 1.12, 1.16), age-inappropriate education for non-Hispanic White (aOR 1.16, 95% CI 1.11, 1.21), and non-Hispanic Black (aOR 1.08, 1.04, 1.12) mothers.

CONCLUSIONS

Inadequate maternal educational attainment, which is influenced by modifiable social policies, is associated with increased adverse infant outcomes in mothers 14-24 years of age.

The Impact of Neighborhood Deprivation on Glycemic Control for Patients with Type 2 Diabetes During Pregnancy

Background: The impact of neighborhood level factors on glycemic control and pregnancy outcomes is understudied. The primary objective was to determine whether there is an association between glycemic control during pregnancy and level of neighborhood deprivation, defined by area deprivation index (ADI). Materials and Methods: We conducted a retrospective cohort study of women with type 2 diabetes who received care at a tertiary referral center from 2007 to 2017. Patients living in more deprived neighborhoods (ADI >85th national percentile) were compared to those living in less deprived neighborhoods (ADI ≤85th percentile). The primary outcome was change in hemoglobin A1c (HbA1c) over time. Demographic characteristics were compared between groups, and trends in mean A1c through each trimester were tested with repeated measures analysis. Results: Of 237 women meeting study criteria, 93 (39.2%) lived in less deprived (low ADI) and 144 (60.8%) lived in more deprived neighborhoods (high ADI). Women living in more deprived neighborhoods were more likely to be Black (86.8% vs. 53.8%, p < 0.01), less likely to be married (11.3% vs. 31.2%, p < 0.01), and had more severe diabetes (p = 0.05). Both groups achieved significant improvement in HbA1c across each trimester using repeated measures analysis. Those living in more deprived neighborhoods had significantly more improvement in HbA1c from their initial visit to the third trimester compared to those in less deprived neighborhoods, (p = 0.01) such that there was no longer a statistically significant disparity in HbA1c by the third trimester (6.69 ± 0.97 Less deprived vs. 6.95 ± 1.22 more deprived, p = 0.19). Conclusions: Low-income women living in more deprived neighborhoods enter pregnancy with significantly worse glycemic control than those living in less deprived neighborhoods, but the gap in glycemic control largely closes by the end of pregnancy with similar maternal and neonatal outcomes.

What Structural Racism Is (or Is Not) and How to Measure It: Clarity for Public Health and Medical Researchers

Interest in studying structural racism's impacts on health has grown exponentially in recent years. Across these studies, there is much heterogeneity in the definition and measurement of structural racism, leading to mixed interpretations of structural racism's impact on health. A precise definition of structural racism can offer conceptual clarity to inform what mechanisms to investigate and is imperative for conducting high-quality research on it and dismantling it. In this commentary, we trace the evolution of the definitions of structural racism and suggest ways in which the measurement of structural racism should move forward given these definitions.

A Race-Conscious Approach Toward Research on Racial Inequities in Palliative Care

Racial inequities in palliative and end-of-life care have been well-documented for many years. This inequity is long-standing and resistant to many intervention efforts. One reason for this may be that research in racial inequity in palliative care, and the interventions developed, do not account for the effects of race and the everyday racism that patients of color experience while navigating the healthcare system. Public Health Critical Race Praxis (PHCRP) offers researchers new routes of inquiry to broaden the scope of research priorities in palliative care and improving racial outcomes through a novel conceptual framework and methodology. PHCRP, based off critical race theory (CRT), contains 10 principles within four foci to guide researchers toward a more race conscious approach for the generation of research questions, research processes, and development of interventions targeting racial inequities.

Multidimensional structural racism predicts birth outcomes for Black and White Minnesotans

Objective

The objective of this study is to determine the linkage between multidimensional structural racism typologies and preterm birth (PTB), low birthweight (LBW), and small‐for‐gestational‐age (SGA) birth among infants of White, US‐born Black, and foreign‐born Black pregnant people in Minnesota.

Data Sources

The measures of structural racism were based on the 2017 American Community Survey 5‐year estimates and the 2017 jail incarceration data from the Vera Institute of Justice. Birth outcomes of infants born in 2018 were based on birth records from the Minnesota Department of Health.

Study Design

We conducted a latent class analysis to identify multidimensional structural racism typologies in 2017 and related these typologies to birth outcomes of pregnant people who gave birth in Minnesota in 2018 using Vermunt's 3‐step approach. Racial group‐specific age‐adjusted risks of PTB, LBW, and SGA by structural racism typologies were estimated.

Data Collection

Study data were from public sources.

Principal Findings

Our analysis identified three multidimensional structural racism typologies in Minnesota in 2017. These typologies can have high structural racism in some dimensions but low in others. The interactive patterns among various dimensions cannot simply be classified as “high” (i.e., high structural racism in all dimensions), “medium,” or “low.” The risks of PTB, LBW, and SGA for US‐born Black pregnant Minnesotans were always higher than for their White counterparts regardless of the typologies in which they lived during pregnancy. Furthermore, these excess risks among US‐born Black pregnant people did not vary significantly across the typologies. We did not find clear patterns when comparing the predicted risks for infants of US‐ and foreign‐born Black pregnant people.

Conclusion

Multidimensional structural racism increases the risks of adverse birth outcomes for US‐born Black Minnesotans. Policy interventions to dismantle structural racism and eliminate birth inequities must be multi‐sectoral as changes in one or a few dimensions, but not all, will unlikely reduce birth inequities.

Invited Commentary: Comparing Approaches to Measuring Structural Racism

In their article, Adkins-Jackson et al. (Am J Epidemiol. 2022;191(4):539-547) provide much needed insight on current approaches and challenges to epidemiologic research on structural racism. The authors encourage researchers to consider how structural racism is conceptualized in extant and future work, and whether existing measures accurately reflect the multidimensional nature of structural racism. In the spirit of continuing this conversation, I expand upon approaches to measuring structural racism. I compare the merits and challenges of scales, indexes, indicators, and policy-based measures of structural racism for use in epidemiologic research.

Evaluating racial disparities in healthcare system utilization and caregiver burden among older adults with dementia

OBJECTIVE

To evaluate racial differences in healthcare utilization and caregiver burden in a culturally diverse population of older adults with dementia.

METHOD

One hundred and thirty-three dyads (person with dementia, PWD and caregiver, CG), with at least one emergency department (ED) visit or hospitalization 12 months prior, were enrolled. Independent sample t-tests and chi-squared analyses were performed to compare racial groups on healthcare utilization and CG burden. Mann-Whitney U test was used for item-level analyses, principal component analysis was used to examine relationships among outcomes, and regressions were used to identify the relationship between race and potential covariates.

RESULTS

PWD sample mean age was 79 years, predominantly female, and with high school education. Racial distribution was 65% White and 35% Black. CG sample mean age was 64 years, predominantly female, with more than 12 years of education. No differences were found for age or dementia severity across racial groups. Black PWD experienced more ED and ambulance utilization when compared to White counterparts. Non-emergency hospitalization rates were higher for White PWD. No significant differences were found by race for CG burden total score; however, item-level analysis suggested more anger, reduced social life, uncertainty, and inadequacy in White CGs. Regressions demonstrated a positive relationship between Black race and adult-child CGs with increased ED visits, while dyad educational attainment was associated with hospitalizations independent of race.

CONCLUSIONS

Healthcare utilization disparities extend to older adults with dementia diagnoses. Our findings suggest that culturally tailored interventions may be appropriate. Future research is encouraged to explore the effect of other covariates.

Uterine Fibroids in Black Women: A Race-Stratified Subgroup Analysis of Treatment Outcomes After Laparoscopic Radiofrequency Ablation

Background: The disease and treatment burden of uterine fibroids (UF) in Black women is substantially greater compared with other racial groups, with higher rates of complications and poorer outcomes with both hysterectomy and myomectomy. The inequities in the access Black women have to minimally invasive routes of surgery contribute to their burden of illness. Laparoscopic radiofrequency ablation (LAP-RFA) is a minimally invasive, safe, and effective uterine-sparing treatment option. Methods: This subgroup analysis of the LAP-RFA Pivotal Trial stratified outcomes by race comparing White women (n = 28, 21%) versus Black women (n = 46, 34%). Results: At baseline, Black women had more fibroids on average (7.3 vs. 3.7; P ≤ 0.001), a greater symptom severity score (SSS) (P ≤ 0.001), and a lower health-related quality of life (HRQoL) score (P = 0.005) than White women. At 36 months post-treatment with LAP-RFA, the statistical differences that existed with baseline SSS and HRQoL score were eliminated between Black and White women. Menstrual blood loss (140.1 mL vs. 127.02 mL; P = 0.44) and mean fibroid volume reduction (47.5 cm³ vs. 36.0 cm³; P = 0.17) were similar between Black and White women at 12 months. Although not statistically significant, the intraoperative total blood loss and uterine blood loss was lower in Black women than White women, despite greater operative time (160 minutes vs. 137 minutes; P = 0.09). Conclusions: These results are promising in providing an alternative uterine-sparing option for Black women and may help to provide a minimally invasive option that can address some of the racial inequities in care for Black women with UF.

School Mental Health Providers’ Perspectives on the Impact of COVID-19 on Racial Inequities and School Disengagement

School disengagement is a critical factor that will likely exacerbate long-standing racial inequities in educational outcomes during the aftermath of the coronavirus disease (COVID-19) pandemic. Due to their training and contact with at-risk students, school social workers and other school-based mental health professionals (SMHP) are in an ideal position to understand the impact of COVID-19 and virtual learning on K–12 students. To that end, this study reports on findings from a survey of SMHP about the differential impact that the COVID-19 outbreak is having on students and their families. The findings suggest that COVID-19 has had a tremendous impact on families overall, especially among populations who were experiencing hardships before the current outbreak. In addition, several barriers were noted for student learning, with many students—particularly students of color—completely disengaging from school during spring 2020. However, SMHP reported several important insights on how to support students and their families—some requiring immediate action on the part of school districts and others requiring greater community-level investment into the economic, social, emotional, and overall health of families. Findings are discussed in light of addressing disengagement and educational inequities for students of color.

Psychosis and Rectal Bleeding as the Presenting Symptoms of AIDS in an Adolescent Male

Socioeconomic status, racial health disparities, and age are some of the many barriers that may confound and delay the diagnosis of human immunodeficiency virus (HIV). Despite the new and highly effective advancements in the treatment of HIV, in the United States, there is a disparity in the rate of timely diagnosis and treatment among Black/African Americans, men who have sex with men, those who suffer from homelessness, and transgendered youth. While there are existing recommendations in place to guide the testing of adolescents for HIV, the rate of testing is highly variable, which can lead to missed diagnoses. We present the case of a previously healthy 17-year-old African American male with psychosis who was initially diagnosed with a primary psychiatric disorder. Three weeks later, the patient presented with rectal bleeding. Further evaluation revealed that the patient was positive for HIV. The psychiatric symptoms were attributed to HIV dementia and rectal bleeding to HIV colitis. To our knowledge, this is the first case report of a patient with HIV dementia and rectal bleeding as the initial presenting symptoms of AIDS. This case demonstrated the potential consequences of variable testing practices for HIV and the devastating sequela that can follow the lack of timely diagnosis.

Maternal Depressive Symptoms, Sleep, and Odds of Spontaneous Early Birth: Implications for Racial Inequities in Birth Outcomes

STUDY OBJECTIVES

Delivery prior to full term affects 37% of US births, including ~400,000 preterm births (<37 weeks) and >1,000,000 early term births (37-38 weeks). Approximately 70% of cases of shortened gestation are spontaneous - without medically-indicated cause. Elucidation of modifiable behavioral factors would have considerable clinical impact.

METHODS

This study examined the role of depressive symptoms and sleep quality in predicting the odds of spontaneous shortened gestation among 317 women (135 Black, 182 White) who completed psychosocial assessment in mid-pregnancy.

RESULTS

Adjusting for key covariates, Black women had 1.89 times higher odds of spontaneous shortened gestation compared to White women (OR (95% CI) = 1.89 (1.01, 3.53), p=0.046). Women who reported only poor subjective sleep quality (PSQI > 6) or only elevated depressive symptoms (CES-D ≥ 16) exhibited no statistically significant differences in odds of spontaneous shortened gestation compared to those with neither risk factor. However, women with comorbid poor sleep and depressive symptoms exhibited markedly higher odds of spontaneous shortened gestation than those with neither risk factor [39.2% versus 15.7%, [OR (95% CI) = 2.69 (1.27, 5.70), p = 0.01]. A higher proportion of Black women met criteria for both risk factors (23% of Black women versus 11% of White women; p=0.004), with a lower proportion experiencing neither risk factor (40.7% of Black versus 64.3% of White women; p < 0.001).

CONCLUSIONS

Additive effects of poor subjective sleep quality and depressive symptoms were observed with markedly higher odds of spontaneous shortened gestation among women with both risk factors. Racial inequities in rates of comorbid exposure corresponded with inequities in shortened gestation. Future empirical studies and intervention efforts should consider the interactive effects of these commonly co-morbid exposures.

Clinical Characteristics and Outcomes Based on Race of Hospitalized Patients With COVID-19 in a New Orleans Cohort

Background

In Louisiana, deaths related to COVID-19 have disproportionately occurred in Black persons. Granular data are needed to better understand inequities and develop prevention strategies to mitigate further impact on Black communities.

Methods

We conducted a retrospective study of patients admitted to an urban safety net hospital in New Orleans, Louisiana, with reactive SARS-CoV-2 testing from March 9 to 31, 2020. Clinical characteristics of Black and other racial/ethnic group patients were compared using Wilcoxon rank-sum test and Fisher exact tests. The relationship between race and outcome was assessed using day 14 status on an ordinal scale.

Results

This study included 249 patients. The median age was 59, 44% were male, and 86% were age ≥65 years or had ≥1 comorbidity. Overall, 87% were Black, relative to 55% Black patients typically hospitalized at our center. Black patients had longer symptom duration at presentation (6.41 vs 5.88 days; P = .05) and were more likely to have asthma (P = .008) but less likely to have dementia (P = .002). There were no racial differences in initial respiratory status or laboratory values except for higher lactate dehydrogenase in Black patients. Patient age and initial oxygen requirement, but not race (adjusted proportional odds ratio, 0.92; 95% CI, 0.70–1.20), were associated with worse day 14 outcomes.

Conclusions

Our results demonstrate minor racial differences in comorbidities or disease severity at presentation, and day 14 outcomes were not different between groups. However, Black patients were disproportionately represented in hospitalizations, suggesting that prevention efforts should include strategies to limit SARS-CoV-2 exposures and transmission in Black communities as one step toward reducing COVID-19-related racial inequities.

Racism and Health: Evidence and Needed Research

In recent decades, there has been remarkable growth in scientific research examining the multiple ways in which racism can adversely affect health. This interest has been driven in part by the striking persistence of racial/ethnic inequities in health and the empirical evidence that indicates that socioeconomic factors alone do not account for racial/ethnic inequities in health. Racism is considered a fundamental cause of adverse health outcomes for racial/ethnic minorities and racial/ethnic inequities in health. This article provides an overview of the evidence linking the primary domains of racism-structural racism, cultural racism, and individual-level discrimination-to mental and physical health outcomes. For each mechanism, we describe key findings and identify priorities for future research. We also discuss evidence for interventions to reduce racism and describe research needed to advance knowledge in this area.

Racism and Health: Evidence and Needed Research

In recent decades, there has been remarkable growth in scientific research examining the multiple ways in which racism can adversely affect health. This interest has been driven in part by the striking persistence of racial/ethnic inequities in health and the empirical evidence that indicates that socioeconomic factors alone do not account for racial/ethnic inequities in health. Racism is considered a fundamental cause of adverse health outcomes for racial/ethnic minorities and racial/ethnic inequities in health. This article provides an overview of the evidence linking the primary domains of racism-structural racism, cultural racism, and individual-level discrimination-to mental and physical health outcomes. For each mechanism, we describe key findings and identify priorities for future research. We also discuss evidence for interventions to reduce racism and describe research needed to advance knowledge in this area.

Reducing racial and ethnic disparities in hypertension prevention and control: what will it take to translate research into practice and policy?

INTRODUCTION

Despite available, effective therapies, racial and ethnic disparities in care and outcomes of hypertension persist. Several interventions have been tested to reduce disparities; however, their translation into practice and policy is hampered by knowledge gaps and limited collaboration among stakeholders.

METHODS

We characterized factors influencing disparities in blood pressure (BP) control by levels of an ecological model. We then conducted a literature search using PubMed, Scopus, and CINAHL databases to identify interventions targeted toward reducing disparities in BP control, categorized them by the levels of the model at which they were primarily targeted, and summarized the evidence regarding their effectiveness.

RESULTS

We identified 39 interventions and several state and national policy initiatives targeted toward reducing racial and ethnic disparities in BP control, 5 of which are ongoing. Most had patient populations that were majority African-American. Of completed interventions, 27 demonstrated some improvement in BP control or related process measures, and 7 did not; of the 6 studies examining disparities, 3 reduced, 2 increased, and 1 had no effect on disparities.

CONCLUSIONS

Several effective interventions exist to improve BP in racial and ethnic minorities; however, evidence that they reduce disparities is limited, and many groups are understudied. To strengthen the evidence and translate it into practice and policy, we recommend rigorous evaluation of pragmatic, sustainable, multilevel interventions; institutional support for training implementation researchers and creating broad partnerships among payers, patients, providers, researchers, policymakers, and community-based organizations; and balance and alignment in the priorities and incentives of each stakeholder group.

Racial inequities in receipt of influenza vaccination among nursing home residents in the United States, 2008-2009: a pattern of low overall coverage in facilities in which most residents are black

OBJECTIVES

Nationwide among nursing home residents, receipt of the influenza vaccine is 8 to 9 percentage points lower among blacks than among whites. The objective of this study was to determine if the national inequity in vaccination is because of the characteristics of facilities and/or residents.

DESIGN

Cross-sectional study with multilevel modeling.

SETTING AND PARTICIPANTS

States in which 1% or more of nursing home residents were black and the difference in influenza vaccination coverage between white and black nursing home residents was 1 percentage point or higher (n = 39 states and the District of Columbia). Data on residents (n = 2,359,321) were obtained from the Centers for Medicare & Medicaid Service's Minimum Data Set for October 1, 2008, through March 31, 2009.

MEASUREMENTS

Residents' influenza vaccination status (vaccinated, refused vaccine, or not offered vaccination).

RESULTS

States with higher overall influenza vaccination coverage among nursing home residents had smaller racial inequities. In nursing homes with higher proportions of black residents, vaccination coverage was lower for both blacks and whites. The most dramatic inequities existed between whites in nursing homes with 0% blacks (L1) and blacks in nursing homes with 50% or more blacks (L5) in states with overall racial inequities of 10 percentage points or more. In these states, more black nursing home residents lived in nursing homes with 50% or more blacks (L5); in general, the same homes with low overall coverage.

CONCLUSION

Inequities in influenza vaccination coverage among nursing home residents are largely because of low vaccination coverage in nursing homes with a high proportion of black residents. Findings indicate that implementation of culturally appropriate interventions to increase vaccination in facilities with larger proportions of black residents may reduce the racial gap in influenza vaccination as well as increase overall state-level vaccination.