Structural racism and racial health disparities at the state level: A latent variable approach

Introduction Structural racism is increasingly being recognized as a fundamental cause of racial health disparities. We used a novel measure of structural racism at the state level to examine the relationship between structural racism and disparities in death rates from firearm homicide, infant mortality, HIV, diabetes, stroke, hypertension, asthma, and kidney disease between non-Hispanic Black and non-Hispanic White people in the United States.Methods We used confirmatory factor analysis to measure the latent construct of structural racism for all 50 states. The model included seven indicators across the structural racism domains of residential segregation, economic status/employment, education, incarceration, political participation and representation, environmental racism, and racial equity inclusion. Weights for each of the indicators were determined by examining alternative models and selecting the model with the best fit statistics. The resulting factor scores, representing the level of structural racism in each state across the seven domains, were then used as predictor variables in a series of linear regressions with the ratio of Black to White death rates for each health outcome as the dependent variables.Results We found significant relationships between higher levels of the latent structural racism measure and greater disparities between non-Hispanic Black and non-Hispanic White people in age-adjusted death rates for firearm homicide, infant mortality, HIV, asthma, and obesity. The magnitude of this relationship was greatest for firearm homicide, with each one standard deviation increase in a state's structural racism factor score being associated with an increase of 4.54 (95% CI, 2.91-6.17) in that state's Black-White firearm homicide rate ratio.Conclusions This research provides further evidence that structural racism is a fundamental cause of racial health disparities and that to repair these inequities, macro-level changes in societal structures, institutions, resource allocation, representation, and power will be necessary.     

Closing the gap in representation of racial and ethnic minorities in pain medicine: A 2018–2019 status report

Racial health disparities persist despite increased public awareness of systemic racism. Due to the inherent subjectivity of pain perception, assessment and management, physician-patient bias in pain medicine remains widespread. It is broadly accepted that increasing racial diversity in the field of medicine is a critical step towards addressing persistent inequities in patient care. To assess the current racial demographics of the pain medicine pipeline, we conducted a cross-sectional analysis of medical school matriculants and graduates, residents, and pain fellows in 2018. Our results show that the 2018 anesthesiology residency ERAS applicant pool consisted of 46.2% non-Hispanic White, 7.0% non-Hispanic Black and 5.8% Hispanic students. The population of 2018 anesthesiology residents included 63% non-Hispanic White, 6.8% non-Hispanic Black and 5.4% Hispanic persons. Of the total eligible resident pool for pain fellowships (n = 30,415) drawn from core specialties, 44% were non-Hispanic White, 4.9% non-Hispanic Black and 5.1% Hispanic. Similar proportions were observed for pain medicine and regional anesthesia fellows. We briefly discuss the implications of the shortage of non-Hispanic Black and Hispanic representation in pain medicine as it relates to the COVID-19 pandemic and suggest approaches to improving these disparities.     

Racial differences in self-reports of sleep duration in a population-based study

STUDY OBJECTIVES: Racial and ethnic differences in sleep duration are not well understood. Research shows that short (< or =6 hours) and long (> or =9 hours) sleepers have higher mortality risks than mid-range sleepers. We investigated whether sleep duration varies by racial and ethnic characteristics and if some of these associations may be explained by residential context. DESIGN: Cross-sectional National Health Interview Survey. SETTING: Non-institutionalized adults living in the United States in 1990. PARTICIPANTS: 32,749 people aged 18 years or older. MEASUREMENT AND RESULTS: We estimate a multinomial logistic regression that predicts short, mid-range, and long sleep duration; including covariates for race/ethnicity, among other demographic, health, and neighborhood characteristics. Black respondents had an increased risk of being short and long sleepers (OR=1.41, 95% CI=1.27-1.57 and OR=1.62, 95% CI=1.40-1.88, respectively) relative to white respondents. Hispanics (excluding Mexican Americans) and non-Hispanic "Others" were also associated with increased risk of short sleeping (OR=1.26, 95% CI= 1.07-1.49 and OR=1.35, 95% CI= 1.11-1.64, respectively). Living in an inner city was associated with increased risk of short sleeping and reduced risk of long sleeping, compared to non-urban areas. Some of the higher risk of short sleeping among blacks can be explained by higher prevalence of blacks living in the inner city. CONCLUSIONS: Blacks and other racial minorities are more likely to have sleep durations that are associated with increased mortality. The results are consistent with the hypothesis that unhealthy sleep patterns among minorities may contribute to health differentials.     

Past racial discrimination exacerbates the effects of racial exclusion on negative affect,perceived control,and alcohol-risk cognitions among Black young adults

Racial discrimination is associated with alcohol use and risky sex cognitions and behaviors, which are risk factors for negative health outcomes, including human immunodeficiency virus infection. The current study investigated the causal impact of racial discrimination on alcohol and sexual-risk cognitions while exploring potential mediators that might help explain this relation: negative affect, perceived control, and meaningful existence. We also examined if past discrimination impacts the strength of (moderates) these effects. Participants were 287 Black/African American young adults aged 18–25. They were randomly assigned to be excluded or included by White peers via the game Cyberball. Racial exclusion (vs. inclusion) predicted greater: perceived racial discrimination, negative affect, alcohol use willingness, and reduced perceived control and meaningful existence. Furthermore, excluded participants who experienced more past racial discrimination reported the lowest perceived control, and greatest negative affect and alcohol-risk cognitions. The findings suggest that past racial discrimination exacerbates the harmful health effects of immediate experiences of discrimination.     

Perceived discrimination and youths' adjustment: sleep as a moderator

Adolescents' sleep duration was examined as a moderator of the association between perceived discrimination and internalizing (anxiety, depression) and externalizing symptoms. Participants were 252 adolescents (mean: 15.79 years; 66% European American, 34% African American) who reported on their perceived discrimination (racial and general) and adjustment. Sleep duration was measured using actigraphy. Moderation effects were evident. The lowest levels of internalizing symptoms were observed for adolescents with longer sleep duration in conjunction with lower levels of perceived racial discrimination. Further, general perceived discrimination was associated more strongly with externalizing behaviours for youth with shorter versus longer sleep. Findings highlight the importance of sleep as a bioregulatory system that can ameliorate or exacerbate the effects of discrimination on youths' adjustment.     

Anticipatory racism stress,smoking and disease activity: the Black women’s experiences living with lupus (BeWELL) study

African American women with systemic lupus erythematosus (SLE) have worse disease outcomes compared to their White counterparts. Stressors associated with race may contribute to poorer health in this population through maladaptive behavioral pathways. This study investigated relationships between stress associated with anticipating racism, smoking, and SLE disease activity. Data were from 432 African American women with SLE in the Black Women’s Experiences Living with Lupus (BeWELL) Study. Controlling for sociodemographic and health-related covariates, multivariable regression analyses revealed a significant association between anticipatory racism stress (ARS) and disease activity (p?=?0.00, b?=?1.13, 95% CI [0.43, 1.82]). A significant interaction between ARS and smoking also indicated that smoking exacerbated the effect of ARS on disease activity (p?=?0.04, b?=?1.95, CI?=?0.04, 3.96). Test for evidence of smoking mediating the effect of ARS on disease activity were not statistically significant (z?=?1.77, p?=?0.08). Findings have implications for future SLE disparities research among African American women with SLE.

     

Racial identity and autonomic responses to racial discrimination

Several studies identify racial identity—the significance and meaning that individuals attribute to race—as a mitigating factor in the association between racial discrimination and adjustment. In this study, we employed a visual imagery paradigm to examine whether racial identity would moderate autonomic responses to blatant and subtle racial discrimination analogues with Black and White perpetrators. We recruited 105 African American young adults from a public, southeastern university in the United States. The personal significance of race as well as personal feelings about African Americans and feelings about how others view African Americans moderated autonomic responses to the vignettes. We use polyvagal theory and a stress, appraisal, and coping framework to interpret our results with an eye toward elucidating the ways in which racial identity may inform individual differences in physiological responses to racial discrimination.     

The relationship between state-level structural racism and disparities between the non-hispanic black and non-hispanic white populations in multiple health outcomes

AimsWhile several studies have examined the impact of individual indicators of structural racism on single health outcomes, few have explicitly modeled racial disparities in a wide range of health outcomes using a multidimensional, composite structural racism index. This paper builds on the previous research by examining the relationship between state-level structural racism and a wider array of health outcomes, focusing on racial disparities in mortality from firearm homicide, infant mortality, stroke, diabetes, hypertension, asthma, HIV, obesity, and kidney disease.MethodsWe used a previously developed state structural racism index that consists of a composite score derived by averaging eight indicators across five domains: (1) residential segregation; (2) incarceration; (3) employment; (4) economic status/wealth; and (5) education. Indicators were obtained for each of the 50 states using Census data from 2020. We estimated the Black-White disparity in each health outcome in each state by dividing the age-adjusted mortality rate for the non-Hispanic Black population by the age-adjusted mortality rate for the non-Hispanic White population. These rates were obtained from the CDC WONDER Multiple Cause of Death database for the combined years 1999-2020. We conducted linear regression analyses to examine the relationship between the state structural racism index and the Black-White disparity in each health outcome across the states. In multiple regression analyses, we controlled for a wide range of potential confounding variables.ResultsOur calculations revealed striking geographic differences in the magnitude of structural racism, with the highest values generally being observed in the Midwest and Northeast. Higher levels of structural racism were significantly associated with greater racial disparities in mortality for all but two of the health outcomes.ConclusionsThere is a robust relationship between structural racism and Black-White disparities in multiple health outcomes across states. Programs and policies to reduce racial heath disparities must include strategies to help dismantle structural racism and its consequences.     

Racial (vs. self) affirmation as a protective mechanism against the effects of racial exclusion on negative affect and substance use vulnerability among black young adults

Affirming one’s racial identity may help protect against the harmful effects of racial exclusion on substance use cognitions. This study examined whether racial versus self-affirmation (vs. no affirmation) buffers against the effects of racial exclusion on substance use willingness and substance use word associations in Black young adults. It also examined anger as a potential mediator of these effects. After being included, or racially excluded by White peers, participants were assigned to a writing task: self-affirmation, racial-affirmation, or describing their sleep routine (neutral). Racial exclusion predicted greater perceived discrimination and anger. Excluded participants who engaged in racial-affirmation reported reduced perceived discrimination, anger, and fewer substance use cognitions compared to the neutral writing group. This relation between racial-affirmation and lower substance use willingness was mediated by reduced perceived discrimination and anger. Findings suggest racial-affirmation is protective against racial exclusion and, more generally, that ethnic based approaches to minority substance use prevention may have particular potential.     

Examining How Racial Discrimination Impacts Sleep Quality in African Americans: Is Perseveration the Answer?

Background: African Americans experience more problematic and disordered sleep than White Americans. Racial discrimination has been implicated in this disparity. However, the mechanisms by which discrimination disrupts sleep are unclear. It has been theorized that Perseverative Cognition (PC), characterized by recurrent patterns of reflective (i.e., rumination) and anticipatory (i.e., worry) negative thinking about personally relevant stressors, may reflect the functional mechanism linking discrimination to sleep. The present study is the first to empirically examine the dual components of PC as a candidate functional mechanism in the association between racial discrimination and subjective sleep quality. Participants: Sixty-eight self-identified African American college students (55.9% female; M_age = 20.18, SD = 2.93) were recruited at a large predominantly white public university in the Midwest. Methods: The participants completed the Perceived Ethnic Discrimination Questionnaire (PEDQ), Pittsburgh Sleep Quality Index (PSQI), Penn State Worry Questionnaire (PSWQ), and Ruminative Responses Scale (RRS). Results: After adjusting for age, gender, and social class, results revealed a significant indirect effect of racial discrimination (RD) on subjective sleep quality through rumination, 95% CI [.008, .125], but not worry. RD was positively associated with rumination, b =.50, SE =.16, p = .003, and rumination, in turn, was positively associated with poorer sleep quality, b = .09, SE = .04, p = .012. Conclusions: As both RD and poor sleep quality have been directly linked to heart disease, diabetes, depression, and a number of other maladies, our findings suggest that RD, sleep, and coping strategies (e.g., rumination) employed to manage RD experiences may be important targets for addressing racial disparities in health.     

Racial differences in beliefs about genetic screening among patients at inner-city neighborhood health centers

BACKGROUND: Genetic testing has the potential to identify persons at high risk for disease. Given the history of racial disparities in screening, early detection and accessing treatment, understanding racial differences in beliefs about genetics is essential to preventing disparities in some conditions. METHODS: In 2004, a sample of older adult patients from four inner-city health centers was surveyed to assess beliefs about genetic determinants of disease, genetic testing and religion. Logistic regression determined which beliefs were associated with race. RESULTS: Of the 314 respondents, 50% were African Americans. Most respondents thought that sickle cell disease, cystic fibrosis and diabetes are primarily genetic. African Americans were more likely than Caucasians to believe that genetic testing will lead to racial discrimination (Odds ratio (OR): 3.02, 95% confidence interval (CI): 1.5-6.0) and to think that all pregnant women should have genetic tests (OR=3.8, 95% CI: 1.7-8.6). African Americans were more likely to believe that God's Word is the most important source for moral decisions (OR: 3.6, 95% CI :1.5-8.7). CONCLUSION: African Americans and Caucasians differ in beliefs about genetic testing and the basis for moral decision-making. Acknowledging and understanding these differences may lead to better medical care.     

Psychological adjustment of women with HIV/AIDS: Racial and ethnic comparisons

The relationship of race and ethnicity with standardized measures of depressive symptomatology and mental health was examined in a sample of HIV-infected African American (n = 48), Puerto Rican (n = 50), and White non-Hispanic (n = 48) women in New York City. Mean scores of women from all three racial and ethnic groups were higher than those reported for normative samples on measures of depressive symptomatology and psychological distress, and mean scores on measures of psychological well-being were lower. Puerto Rican women reported significantly higher levels of depressive symptomatology than either African American or White women. Puerto Rican women also reported significantly higher levels of psychological distress and lower levels of psychological well-being than African American women. The findings suggest that while all HIV-infected women are at risk of poor adjustment, Puerto Rican women may be especially vulnerable. They also point to the need for future research to determine what factors in these women's lives are predictive of adjustment, especially those factors amenable to intervention. © 1998 John Wiley & Sons, Inc.     

Risk factors for missed HIV primary care visits among men who have sex with men

Benefits of anti-retroviral therapy (ART) depend on consistent HIV care attendance. However, appointment non-adherence (i.e. missed appointments) is common even in programs that reduce financial barriers. Demographic, health/treatment, and psychosocial contributors to appointment non-adherence were examined among men who have sex with men (MSM) attending HIV primary care. Participants (n = 503) completed questionnaires, and HIV biomarker data were extracted from medical records. At 12 months, records were reviewed to assess HIV primary care appointment non-adherence. Among MSM, 31.2% missed without cancellation at least one appointment during 12-month study period. Independent predictors (P < 0.05) were: low income (OR = 1.87); African American (OR = 3.00) and Hispanic/Latino (OR = 4.31) relative to non-Hispanic White; depression (OR = 2.01); and low expectancy for appointments to prevent/treat infection (OR = 2.38), whereas private insurance (OR = 0.48) and older age (OR = 0.94) predicted lower risk. Low self-efficacy predicted marginal risk (OR = 2.74, P = 0.10). The following did not independently predict risk for non-adherence: education, relationship status, general health, time since HIV diagnosis, ART history, post-traumatic stress disorder, HIV stigma, or supportive clinic staff. Appointment non-adherence is prevalent, particularly among younger and racial/ethnic minority MSM. Socioeconomic barriers, depression and low appointment expectancy and self-efficacy may be targets to increase care engagement.     

Ethnic differences in allopregnanolone concentrations in women during rest and following mental stress

The neuroactive steroid allopregnanolone (ALLO) is stress sensitive, negatively modulates the HPA axis, and has been implicated in mood disorders. We examined ethnic differences in plasma ALLO at rest and following mental stress in African American (AA) men (n = 21) and women (n = 24) and non-Hispanic White men (n = 24) and women (n = 25). Overall, AA women had lower ALLO concentrations than non-Hispanic White women (p < .05), especially following mental stress (p < .01). Only 20% of AA women showed the expected stress-induced increase in ALLO compared with 59% of non-Hispanic White women (p < .01). No ethnic differences were seen in men. For both ethnic groups, poststress ALLO was negatively correlated with poststress cortisol (p < .05). Results are interpreted to reflect dysregulation in ALLO mechanisms in AA women and may have implications for ethnic differences in mood disorders.     

Birth Control Conspiracy Beliefs, Perceived Discrimination, and Contraception among African Americans: An Exploratory Study

We conducted a cross-sectional telephone survey to explore the relationship of birth control conspiracy beliefs and perceived discrimination to contraceptive attitudes and behavior among a sample of African Americans (aged 18-45) in the USA (N = 71). Results indicated that a large percentage of respondents perceived discrimination targeted at African American women and endorsed birth control conspiracy beliefs, and that a significant proportion of female respondents perceived discrimination when getting family planning or contraceptive services. Stronger conspiracy beliefs and greater perceived discrimination were associated with negative attitudes toward contraceptive methods, particularly birth control pills, and with contraceptive behavior and intentions. Our findings suggest that conspiracy beliefs and perceived discrimination may play an important role in African Americans' attitudes toward and use of contraceptive methods.     

RACE,PERCEIVED DISCRIMINATION,AND EMOTION‐FOCUSED COPING

This study examined the associations among race, perceived discrimination, and emotion‐focused coping. Participants were 3,688 respondents (160 Blacks and 3,533 non‐Hispanic Whites) to the National Survey of Midlife Development in the United States. We tested our hypotheses with analyses of covariance and multiple regression, and we confirmed mediation with bias‐corrected bootstrap confidence intervals. All analyses controlled for age and gender; educational attainment and household income were included as covariates in additional analyses. Consistent with previous research, Blacks engaged in more emotion‐focused coping than did Whites. However, as predicted, perceived discrimination explained the association between race and emotion‐focused coping. Being Black compared with White predicted more perceived discrimination; in turn, perceived discrimination predicted more emotion‐focused coping. Perceived discrimination fully mediated the association between race and emotion‐focused coping. Findings demonstrate that relying on emotion‐focused coping is a function of facing daily discrimination rather than racial status.     

Periodic limb movements during sleep: population prevalence, clinical correlates, and racial differences

STUDY OBJECTIVE: There is growing interest in the study of periodic limb movements during sleep and their potential clinical correlates. The aim of the present analysis is to address the lack of population-based studies using polysomnographic (PSG) measures to determine the prevalence of period limb movements during sleep in specific racial groups as well as the general population. SETTINGS AND PARTICIPANTS: A community-based sample of 592 participants drawn from the general population of tricounty Detroit (mean age = 41.9 +/- 12.6 years; 52.9% F; 31.5% African American). All individuals were assessed using objective and subjective measures in the sleep laboratory. MEASUREMENTS: Participants were evaluated during a 24-h laboratory assessment, including a polysomnogram and multiple sleep latency test. Periodic leg movements were scored using standard criteria. Reports of sleep disturbance and daytime sleepiness were also assessed using standardized measures including the Global Sleep Assessment Questionnaire (GSAQ) and the Epworth Sleepiness Scale (ESS). RESULTS: The overall prevalence of periodic limb movements during sleep (PLMSI >15) was 7.6%. African Americans had a lower prevalence of PLMSI >15 than Caucasians (4.3% vs. 9.3%; chi2= 4.5, P < 0.05). Regardless of race, symptoms of insomnia were significantly higher in individuals with PLMSI >15 than in those with PLMSI < or =15 (45% vs. 25%; chi2= 6.84, P < 0.01). CONCLUSION: This is the first study to determine the prevalence of PLMS in a population-based sample using standardized objective criteria. A key finding of the present study is that racial differences in this PSG parameter do exist, with African Americans being less likely to have elevated PLMS.     

Caregiving-Related Sleep Problems and Their Relationship to Mental Health and Daytime Function in Female Veterans

Objective/Background: To identify caregiving-related sleep problems and their relationship to mental health and daytime function in female Veterans. Participants: Female Veterans (N = 1,477) from cross-sectional, nationwide, postal survey data. Methods: The survey respondent characteristics included demographics, comorbidity, physical activity, health, use of sleep medications, and history of sleep apnea. They self-identified caregiving- related sleep problems (i.e., those who had trouble sleeping because of caring for a sick adult, an infant/child, or other respondents). Patient Health Questionnaire (PHQ-4) was used to assess mental health, and daytime function was measured using 11 items of International Classification of Sleep Disorders-2 (ICSD-2). Results: Female Veterans with self-identified sleep problems due to caring for a sick adult (n = 59) experienced significantly more symptoms of depression and anxiety (p < 0.001) and impairment in daytime function (e.g., fatigue, daytime sleepiness, loss of concentration, p < 0.001) than those with self-identified sleep problems due to caring for an infant or child (n = 95) or all other respondents (n = 1,323) after controlling for the respondent characteristics. Conclusions: Healthcare providers should pay attention to assessing sleep characteristics of female Veterans with caregiving responsibilities, particularly those caregiving for a sick adult.