Neighborhoods and racial/ethnic differences in ideal cardiovascular health (the Multi-Ethnic Study of Atherosclerosis)

Using data from the Multi-Ethnic Study of Atherosclerosis baseline sample from 2000 to 2002 (N=5263; mean age=62) we examined cross-sectional racial/ethnic differences in ideal CVH, defined by the American Heart Association 2020 Impact Goals as a summary measure of ideal levels of blood pressure, fasting glucose, cholesterol, body mass index, diet, physical activity, and smoking. Using three different analytical approaches, we examined differences before and after adjustment for neighborhood socioeconomic, physical, and social environments. Significant racial/ethnic differences were present for all indicators of ideal CVH (excluding physical activity). Additional adjustments for neighborhood factors produced modest reductions in racial/ethnic differences. Future research is necessary to better understand the impact of neighborhood context on health disparities using longitudinal study designs.     

The dynamics of income and neighborhood context for population health: Do long-term measures of socioeconomic status explain more of the black/white health disparity than single-point-in-time measures?

Socioeconomic status, though a robust and strong predictor of health, has generally been unable to fully explain the health gap between blacks and whites in the United States. However, at both the individual and neighborhood levels, socioeconomic status is often treated as a static factor with only single-point-in-time measurements. These cross-sectional measures fail to account for possible heterogeneous histories within groups who may share similar characteristics at a given point in time. As such, ignoring the dynamic nature of socioeconomic status may lead to the underestimation of its importance in explaining health and racial health disparities.     

Concentrated affluence,concentrated disadvantage,and children's readiness for school: A population-based,multi-level investigation

A number of studies demonstrates a relationship between neighbourhood concentration of affluence and disadvantage and the health and development of its residents. We contribute to this literature by testing hypotheses about the relationship between neighbourhood-level concentrated affluence/disadvantage and child-level developmental outcomes in a study population of 37,798 Kindergarten children residing in 433 neighbourhoods throughout the province of British Columbia, Canada. We utilise a previously-validated measure of neighbourhood socioeconomic composition—the Index of Concentration at the Extremes (ICE)—which not only allows for more precise estimation of the competing influences of concentrated affluence and disadvantage, but also facilitates examination of the potential impact of neighbourhood-level income inequality. Our findings show that increases in neighbourhood affluence are associated with increases in children's scores on the Early Development Instrument (EDI), a holistic measure of Kindergarteners' readiness for school. Particularly noteworthy is that, for four of the five EDI scales (physical, social, emotional, and communication) and the total score, results indicate a significant curvilinear relationship – whereby the highest average child-level outcomes are not found in locations with the highest concentrations of affluence, but rather in locations with relatively equal proportions of affluent and disadvantaged families. This finding suggests, first, that concentrated affluence may have diminishing rates of return on contributing to enhanced child development, and, second, that children residing in mixed-income neighbourhoods may benefit both from the presence of affluent residents and from the presence of services and institutions aimed at assisting lower-income residents. Implications and future directions are discussed.     

Disparities in Quality of Care among Publicly Insured Adults with Schizophrenia in Four Large U.S. States, 2002–2008

Objective

To examine racial/ethnic disparities in quality of schizophrenia care and assess the size of observed disparities across states and over time.

Data Sources

Medicaid claims data from CA, FL, NY, and NC.

Study Design

Observational repeated cross-sectional panel cohort study of white, black, and Latino fee-for-service adult beneficiaries with schizophrenia. Main outcome was the relationship of race/ethnicity and year with a composite measure of quality of schizophrenia care derived from 14 evidence-based quality indicators.

Principal Findings

Quality was assessed for 325,373 twelve-month person-episodes between 2002 and 2008, corresponding to 123,496 Medicaid beneficiaries. In 2002, quality was lowest for blacks in all states. With the exception of FL, quality was lower for Latinos than whites. In CA, blacks had about 43 percent of the individual indicators met compared to 58 percent for whites. Quality improved annually for all groups in CA, NY, and NC. While in CA the improvement was slightly larger for Latinos, in FL quality improved for blacks but declined for Latinos and whites.

Conclusions

Quality of schizophrenia care is poor and racial/ethnic disparities exist among Medicaid beneficiaries from four states. The size of the disparities varied across the states, and most of the initial disparities were unchanged by 2008.     

Evidence of Social and Structural COVID-19 Disparities by Sexual Orientation,Gender Identity,and Race/Ethnicity in an Urban Environment

The ongoing COVID-19 pandemic has had widespread social, psychological, and economic impacts. However, these impacts are not distributed equally: already marginalized populations, specifically racial/ethnic minority groups and sexual and gender minority populations, may be more likely to suffer the effects of COVID-19. The COVID-19 Resiliency Survey was conducted by the city of Chicago to assess the impact of COVID-19 on city residents in the wake of Chicago’s initial lockdown, with particular focus on the experiences of minority populations. Chi-square tests of independence were performed to compare COVID-19-related outcomes and impacts on heterosexual vs. sexual minority populations, cisgender vs. gender minority populations, and White vs. racial/ethnic minority subgroups. Marginalized populations experienced significant disparities in COVID-19 exposure, susceptibility, and treatment access, as well as in psychosocial effects of the pandemic. Notably, Black and Latinx populations reported significant difficulties accessing food and supplies (p = 0.002). Healthcare access disparities were also visible, with Black and Latinx respondents reporting significantly lower levels of access to a provider to see if COVID-19 testing would be appropriate (p = 0.013), medical services (p = 0.001), and use of telehealth for mental health services (p = 0.001). Sexual minority respondents reported significantly lower rates of using telehealth for mental health services (p = 0.011), and gender minority respondents reported significantly lower levels of primary care provider access (p = 0.016). There are evident COVID-19 disparities experienced in Chicago especially for Black, Latinx, sexual minority, and gender minority groups. A greater focus must be paid to health equity, including providing increased resources and supplies for affected groups, adapting to inequities in the built environment, and ensuring adequate access to healthcare services to ameliorate the burden of COVID-19 on these marginalized populations.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11524-020-00497-9.     

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

Objective

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

Data sources

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

Study design

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

Principal findings

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

Conclusions

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

     

Neighborhood built environment and income: Examining multiple health outcomes

There is growing interest in the relation of built environments to physical activity, obesity, and other health outcomes. The purpose of the present study was to test associations of neighborhood built environment and median income to multiple health outcomes and examine whether associations are similar for low- and high-income groups. This was a cross-sectional study of 32 neighborhoods in Seattle, WA and Baltimore, MD regions, stratified by income and walkability, and conducted between 2001 and 2005. Participants were adults aged 20–65 years (n = 2199; 26% ethnic minority). The main outcomes were daily minutes of moderate-to-vigorous physical activity (MVPA) from accelerometer monitoring, body mass index (BMI) based on self-report, and mental and physical quality of life (QoL) assessed with the SF-12.     

Assessing Racial/Ethnic Disparities in Treatment across Episodes of Mental Health Care

ObjectiveTo investigate disparities in mental health care episodes, aligning our analyses with decisions to start or drop treatment, and choices made during treatment.Study DesignWe analyzed whites, blacks, and Latinos with probable mental illness from Panels 9–13 of the Medical Expenditure Panel Survey, assessing disparities at the beginning, middle, and end of episodes of care (initiation, adequate care, having an episode with only psychotropic drug fills, intensity of care, the mixture of primary care provider (PCP) and specialist visits, use of acute psychiatric care, and termination).FindingsCompared with whites, blacks and Latinos had less initiation and adequacy of care. Black and Latino episodes were shorter and had fewer psychotropic drug fills. Black episodes had a greater proportion of specialist visits and Latino episodes had a greater proportion of PCP visits. Blacks were more likely to have an episode with acute psychiatric care.ConclusionsDisparities in adequate care were driven by initiation disparities, reinforcing the need for policies that improve access. Many episodes were characterized only by psychotropic drug fills, suggesting inadequate medication guidance. Blacks’ higher rate of specialist use contradicts previous studies and deserves future investigation. Blacks’ greater acute mental health care use raises concerns over monitoring of their treatment.     

现金卫生支出贫困影响的分析方法研究

现金卫生支出的贫困影响方法研究是卫生领域公平性系列研究的重要组成部分。在借鉴国际研究成果的基础上，结合我国实际情况对其分析方法进行探索性研究，旨在从卫生筹资公平性角度，详细阐述现金卫生支出对贫困影响研究的分析方法和政策意义。     

Adjusting distributions of the Health Utilities Index Mark 3 utility scores of health-related quality of life

The Health Utilities Index Mark 3 (HUI3) is a multi-dimensional, preference-based measure of health status and health-related quality of life (HRQoL). HUI3 scores correlate strongly with self-ratings of health status and functional disability and vary according to age, gender and occupation. In comparative studies relating to HRQoL, it is necessary to carry out adjusted comparison of the health status of the different groups, taking into account unbalanced distribution of confounding variables. This paper describes a stratification method to adjust the distributions of HUI3 scores. This method provides a graphical representation of adjusted distribution of HUI3, which can also be used to adjust other HRQoL scores. Cross-sectional data from the 1998/1999 National Population Health Survey (NPHS) in Canada were used to verify the proposed method. Male agriculture workers and male construction workers in Canada had quite different age distributions but similar HUI3 distributions. After adjusting the age distribution of the construction group to match the distribution of agriculture group, the mean HUI3 score of the former significantly decreased.     

A meta-analysis of the hepatitis C virus distribution in diverse racial/ethnic drug injector groups

Hepatitis C virus (HCV) is mostly transmitted through blood-to-blood contact during injection drug use via shared contaminated syringes/needles or injection paraphernalia. This paper used meta-analytic methods to assess whether HCV prevalence and incidence varied across different racial/ethnic groups of injection drug users (IDUs) sampled internationally. The 29 prevalence and 11 incidence studies identified as part of the HCV Synthesis Project were categorized into subgroups based on similar racial/ethnic comparisons. The effect estimate used was the odds or risk ratio comparing HCV prevalence or incidence rates in racial/ethnic minority groups versus those of majority status. For prevalence studies, the clearest disparity in HCV status was observed in the Canadian and Australian Aboriginal versus White comparison, followed by the US non-White versus White categories. Overall, Hispanic IDUs had greater HCV prevalence, and HCV prevalence in African-Americans was not significantly greater than that of Whites in the US. Aboriginal groups showed higher HCV seroconversion rates when compared to others, and African-Americans had lower seroconversion rates compared to other IDUs in the US. The findings suggest that certain minority groups have elevated HCV rates in comparison to other IDUs, which may be a consequence of stigma, discrimination, different risk behaviors or decreased access to health care, services and preventive education. Future research should seek to explicitly explore and explain racial/ethnic variations in HCV prevalence and incidence, and define the groups more precisely to allow for more accurate detection of possible racial/ethnic differences in HCV rates.     

“Which Box Should I Check?”: Examining Standard Check Box Approaches to Measuring Race and Ethnicity

ObjectiveThis study examined methodological concerns with standard approaches to measuring race and ethnicity using the federally defined race and ethnicity categories, as utilized in National Institutes of Health (NIH) funded research.ConclusionsThe NIH''s current race and ethnicity measure demonstrated poor differentiation of race and ethnicity, restricted response options, and lack of an inclusive ethnicity question. Separating race and ethnicity and providing respondents with adequate flexibility to identify themselves both racially and ethnically may improve valid operationalization.     

Proxy ratings of health related quality of life in patients with hepatocellular carcinoma

The present study prospectively assessed consistency of ratings of health-related quality of life between patients with hepatocellular carcinoma and two types of proxy raters, family caregivers and oncologist care providers. Patients and proxies completed the Functional Assessment of Cancer Therapy-Hepatobiliary (FACT-Hep) at baseline prior to treatment (82 patients plus proxies), at 3-months (32 patients plus proxies), and 6-months follow up (16 patients plus proxies) after diagnosis. Patient and proxy demographic data and patient medical data were also collected. At baseline, significant intra-class correlations (ICC) were found for patient–caregiver ratings of physical, social/family, and functional well-being, additional concerns (symptoms, side effects), and overall health related quality of life (HRQL); for patient–care provider ratings of physical well-being; and for caregiver–care provider ratings of physical and emotional well-being. At 3-months follow-up, the most significant number of ICCs were recorded across all three rater pairs. Significant consistencies were found for overall HRQL, and all subscale scores except for social and family well-being. The fewest significant ICCs were found at the 6-month follow-up, and were for patient–caregiver ratings of physical and functional well-being, and additional concerns; and for caregiver–care provider ratings on overall HRQL. These results suggest that family caregivers are adequate proxies of patient physical and functional well-being and additional concerns throughout the patients illness, more so than oncologist care providers. Further research is warranted with larger samples.     

Comparative community outreach to increase cervical cancer screening in the Mississippi Delta

Objective

The aim of the study was to increase participation in cervical cancer screening of under-screened women living in the Mississippi Delta, a U.S. population at high risk for cervical cancer.

Methods

We conducted a door-to-door feasibility study of women living in the Mississippi Delta to increase participation in cervical cancer screening in 2009-10. Women (n = 119) aged 26-65 years who had not been screened in last 3 years or more, were not pregnant, and had a cervix were offered a cost-free choice: clinic-based Pap testing or home self-collection with HPV DNA testing.

Results

Seventy-seven women (64.7%) chose self-collection with HPV testing, of which sixty-two (80.5%) returned their self-collected specimen. By comparison, 42 women (35.3%) chose Pap testing, of which 17 (40.5%) attended their clinic appointment. Thus there was an almost 4-fold greater participation of under-screened women in self-collection with HPV testing than in free Pap testing (78.4% vs. 21.5%).

Conclusions

We found that offering self-collection will increase participation in cervical cancer screening among under-screened populations living in the Mississippi Delta. Based on these preliminary results, we suggest that self-collection with HPV DNA testing might complement current Pap testing programs to reach under-screened populations of women, such as those living in the Mississippi Delta.     

Collecting Patient Race/Ethnicity and Primary Language Data in Ambulatory Care Settings: A Case Study in Methodology

Objective. To collect patient race/ethnicity and language (r/e/l) in an ambulatory care setting.
Data Sources/Study Setting. The Palo Alto Medical Foundation (PAMF), December 2006–May 2008.
Study Design. Three pilot studies: (1) Comparing mail versus telephone versus clinic visit questionnaire distribution; (2) comparing the front desk method (FDM) versus exam room method (ERM) in the clinic visit; and (3) determining resource allocation necessary for data entry.
Data Collection/Extraction Methods. Studies were planned and executed by PAMF's Quality and Planning division.
Principal Findings. Collecting r/e/l data during clinic visits elicited the highest response rate. The FDM yielded higher response rate than the ERM. One full-time equivalent is initially necessary for data entry.
Conclusions. Conducting sequential studies can help guide r/e/l collection in a short time frame.     

Areas of decrement in health-related quality of life (HRQL): Comparing the SF-12, EQ-5D,and HUI 3

Background: Different measures of health status and health-related quality of life (HRQL) have been advocated for different purposes at the clinical and population level. Relatively little is known about how these measures function in relationship to one another. We examined the relationship between the Short-Form 12 (SF-12), EQ-5D, and Health Utilities Index (HUI) Mark 3 for overall scores and in analogous domains of health. A convenience sample was obtained through surveying patients at an inner-city community health center. Measurements and main results: The sample was comprised primarily of low-income racial/ethnic minorities; 393 patients were approached and 301 patients (77%) participated. The three measures had correlations between overall scores that ranged from 0.41 to 0.69 and correlations between similar domains from different measures that ranged from 0.42 to 0.59. For the HUI 3, any impairment most frequently was noted with pain, vision, cognition, and emotion. For the EQ-5D, pain/discomfort and anxiety/depression were reported as impaired most often. Compared to published population scores, participants reported impairments with increased frequency and at a greater level. Conclusions: Participants demonstrated consistency with responses to similar types of items and correlations between related aspects of health were moderate to strong. Domains of health most often reported as impaired resembled those noted in national surveys. Despite differences in the structure of the measures, all three instruments capture information about decrements in broadly analogous domains of health.