Racial disparities in stroke incidence in the Women's Health Initiative: Exploring biological, behavioral, psychosocial, and social risk factors.

Background: - Disparities in incident stroke risk among women by race and ethnicity persist. Few studies report the distribution and association of stroke risk factors by age group among a diverse sample of women. Methods: - Data from the Women's Health Initiative (WHI) Observational Study collected between 1993 and 2010 were used to calculate cumulative stroke incidence and incidence rates among non-Hispanic African American (NHAA), non-Hispanic white (NHW), and Hispanic white or African American (HWAA) women by age group in participants aged ≥50 years at baseline (N = 77,247). Hazard ratios (HRs) and 95% CIs for biological, behavioral, psychosocial, and socioeconomic factors overall and by race or ethnicity were estimated using sequential Cox proportional hazard regression models. Results: - Average follow-up time was 11.52 (SD, 3.48) years. The incident stroke rate was higher among NHAA (306 per 100,000 person-years) compared to NHW (279/100,000py) and HWAA women (147/100,000py) overall and in each age group. The disparity was largest at ages >75 years. The association between stroke risk factors (e.g., smoking, BMI, physical activity) and incident stroke varied across race and ethnicity groups. Higher social support was significantly associated with decreased stroke risk overall (HR:0.84, 95% CI, 0.76, 0.93); the degree of protection varied across race and ethnicity groups. Socioeconomic factors did not contribute additional stroke risk beyond risk conferred by traditional and psychosocial factors. Conclusions: - The distribution and association of stroke risk factors differed between NHAA and NHW women. There is a clear need for stroke prevention strategies that address factors driving racial disparities in stroke risk.

A Quantitative Framework for Medication Non-Adherence: Integrating Patient Treatment Expectations and Preferences.

Introduction: Medication non-adherence remains a significant challenge in healthcare, impacting treatment outcomes and the overall effectiveness of medical interventions. This article introduces a novel approach to understanding and predicting medication non-adherence by integrating patient beliefs, efficacy expectations, and perceived costs. Existing theoretical models often fall short in quantifying the impact of barrier removal on medication adherence and struggle to address cases where patients consciously choose not to follow prescribed medication regimens. In response to these limitations, this study presents an empirical framework that seeks to provide a quantifiable model for both individual and population-level prediction of non-adherence under different scenarios. Methods: We present an empirical framework that includes a health production function, specifically applied to antihypertensive medications nonadherence. Data collection involved a pilot study that utilized a double-bound contingent-belief (DBCB) questionnaire. Through this questionnaire, participants could express how efficacy and side effects were affected by controlled levels of non-adherence, allowing for the estimation of sensitivity in health outcomes and costs. Results: Parameters derived from the DBCB questionnaire revealed that on average, patients with hypertension anticipated that treatment efficacy was less sensitive to non-adherence than side effects. Our derived health production function suggests that patients may strategically manage adherence to minimize side effects, without compromising efficacy. Patients' inclination to manage medication intake is closely linked to the relative importance they assign to treatment efficacy and side effects. Model outcomes indicate that patients opt for full adherence when efficacy outweighs side effects. Our findings also indicated an association between income and patient expectations regarding the health of antihypertensive medications. Conclusion: Our framework represents a pioneering effort to quantitatively link non-adherence to patient preferences. Preliminary results from our pilot study of patients with hypertension suggest that the framework offers a viable alternative for evaluating the potential impact of interventions on treatment adherence.

Advancing health equity through social care interventions.

OBJECTIVE: To use evidence on addressing racism in social care intervention research to create a framework for advancing health equity for all populations with marginalized social identities (e.g., race, gender, and sexual orientation). Such groups have disproportionate social needs (e.g., food insecurity) and negative social determinants of health (SDOH; e.g., poverty). We recommend how the Agency for Healthcare Research and Quality (AHRQ) could advance health equity for marginalized populations through social care research and care delivery. DATA SOURCES AND STUDY SETTING: This commentary is informed by a literature review of social care interventions that were affiliated with healthcare systems; input from health equity researchers, policymakers, and community leaders attending the AHRQ Health Equity Summit; and consensus of the authors. PRINCIPAL FINDINGS: We recommend that AHRQ: (1) create an ecosystem that values research on SDOH and the effectiveness and implementation of social care interventions in the healthcare sector; (2) work with other federal agencies to (a) develop position statements with actionable recommendations about racism and other systems that perpetuate marginalization based on social identity and (b) develop aligned, complementary approaches to research and care delivery that address social marginalization; (3) advance both inclusive care delivery and inclusive research teams; (4) advance understanding of racism as a social determinant of health and effective strategies to mitigate its adverse impact on health; (5) advance the creation and scaling of effective strategies for addressing SDOH in healthcare systems, particularly in co-creation with community partners; and (6) require social care intervention researchers to use methods that advance our understanding of social health equity. CONCLUSIONS: AHRQ, as a federal agency, could help advance health equity using a range of strategies, including using the agency's levers to ensure AHRQ stakeholders examine and address the unique experiences of socially marginalized populations in SDOH and social care intervention research.

Racial and Ethnic Differences in Self-Reported COVID-19 Exposure Risks, Concerns, and Behaviors Among Diverse Participants in the Women's Health Initiative Study.

BACKGROUND: Racial and ethnic disparities in coronavirus disease 2019 (COVID-19) risk are well-documented; however, few studies in older adults have examined multiple factors related to COVID-19 exposure, concerns, and behaviors or conducted race- and ethnicity-stratified analyses. The Women's Health Initiative (WHI) provides a unique opportunity to address those gaps. METHODS: We conducted a secondary analysis of WHI data from a supplemental survey of 48 492 older adults (mean age 84 years). In multivariable-adjusted modified Poisson regression analyses, we examined predisposing factors and COVID-19 exposure risk, concerns, and behaviors. We hypothesized that women from minoritized racial or ethnic groups, compared to non-Hispanic White women, would be more likely to report: exposure to COVID-19, a family or friend dying from COVID-19, difficulty getting routine medical care or deciding to forego care to avoid COVID-19 exposure, and having concerns about the COVID-19 pandemic. RESULTS: Asian women and non-Hispanic Black/African American women had a higher risk of being somewhat/very concerned about risk of getting COVID-19 compared to non-Hispanic White women and each was significantly more likely than non-Hispanic White women to report forgoing medical care to avoid COVID-19 exposure. However, Asian women were 35% less likely than non-Hispanic White women to report difficulty getting routine medical care since March 2020 (adjusted relative risk 0.65; 95% confidence interval 0.57, 0.75). CONCLUSIONS: We documented COVID-related racial and ethnic disparities in COVID-19 exposure risk, concerns, and care-related behaviors that disfavored minoritized racial and ethnic groups, particularly non-Hispanic Black/African American women.

Quantifying structural racism in cohort studies to advance prospective evidence.

Calls-to-action in health research have described a need to improve research on race, ethnicity, and structural racism. Well-established cohort studies typically lack access to novel structural and social determinants of health (SSDOH) or precise race and ethnicity categorization, contributing to a loss of rigor to conduct informative analyses and a gap in prospective evidence on the role of structural racism in health outcomes. We propose and implement methods that prospective cohort studies can use to begin to rectify this, using the Women's Health Initiative (WHI) cohort as a case study. To do so, we evaluated the quality, precision, and representativeness of race, ethnicity, and SSDOH data compared with the target US population and operationalized methods to quantify structural determinants in cohort studies. Harmonizing racial and ethnic categorization to the current standards set by the Office of Management and Budget improved measurement precision, aligned with published recommendations, disaggregated groups, decreased missing data, and decreased participants reporting "some other race". Disaggregation revealed sub-group disparities in SSDOH, including a greater proportion of Black-Latina (35.2%) and AIAN-Latina (33.3%) WHI participants with income below the US median compared with White-Latina (42.5%) participants. We found similarities in the racial and ethnic patterning of SSDOH disparities between WHI and US women but less disparity overall in WHI. Despite higher individual-level advantage in WHI, racial disparities in neighborhood resources were similar to the US, reflecting structural racism. Median neighborhood income was comparable between Black WHI ($39,000) and US ($34,700) women. WHI SSDOH-associated outcomes may be generalizable on the basis of comparing across race and ethnicity but may quantitatively (but not qualitatively) underestimate US effect sizes. This paper takes steps towards data justice by implementing methods to make visible hidden health disparity groups and operationalizing structural-level determinants in prospective cohort studies, a first step to establishing causality in health disparities research.

Black Smokers' Preferences for Features of a Smoking Cessation App: Qualitative Study.

BACKGROUND: Mobile health (mHealth) interventions for smoking cessation have grown extensively over the last few years. Although these interventions improve cessation rates, studies of these interventions consistently lack sufficient Black smokers; hence knowledge of features that make mHealth interventions attractive to Black smokers is limited. Identifying features of mHealth interventions for smoking cessation preferred by Black smokers is critical to developing an intervention that they are likely to use. This may in turn address smoking cessation challenges and barriers to care, which may reduce smoking-related disparities that currently exist. OBJECTIVE: This study aims to identify features of mHealth interventions that appeal to Black smokers using an evidence-based app developed by the National Cancer Institute, QuitGuide, as a reference. METHODS: We recruited Black adult smokers from national web-based research panels with a focus on the Southeastern United States. Participants were asked to download and use QuitGuide for at least a week before participation in remote individual interviews. Participants gave their opinions about features of the QuitGuide app and other mHealth apps they may have used in the past and suggestions for future apps. RESULTS: Of the 18 participants, 78% (n=14) were women, with age ranging from 32 to 65 years. Themes within five major areas relevant for developing a future mHealth smoking cessation app emerged from the individual interviews: (1) content needs including health and financial benefits of quitting, testimonials from individuals who were successful in quitting, and strategies for quitting; (2) format needs such as images, ability to interact with and respond to elements within the app, and links to other helpful resources; (3) functionality including tracking of smoking behavior and symptoms, provision of tailored feedback and reminders to users, and an app that allows for personalization of functions; (4) social network, such as connecting with friends and family through the app, connecting with other users on social media, and connecting with a smoking cessation coach or therapist; and (5) the need for inclusivity for Black individuals, which may be accomplished through the inclusion of smoking-related information and health statistics specific for Black individuals, the inclusion of testimonials from Black celebrities who successfully quit, and the inclusion of cultural relevance in messages contained in the app. CONCLUSIONS: Certain features of mHealth interventions for smoking cessation were highly preferred by Black smokers based on their use of a preexisting mHealth app, QuitGuide. Some of these preferences are similar to those already identified by the general population, whereas preferences for increasing the inclusivity of the app are more specific to Black smokers. These findings can serve as the groundwork for a large-scale experiment to evaluate preferences with a larger sample size and can be applied in developing mHealth apps that Black smokers may be more likely to use.

Resiliency Among Women's Health Initiative Women Aged 80 and Older by Race, Ethnicity, and Neighborhood Socioeconomic Status.

OBJECTIVES: A comprehensive examination of resilience by race, ethnicity, and neighborhood socioeconomic status (NSES) among women aged ≥80 is needed, given the aging of the U.S. population, increasing longevity, and growing racial and ethnic diversity. METHODS: Participants were women aged ≥80 enrolled in the Women's Health Initiative. Resilience was assessed with a modified version of the Brief Resilience Scale. Descriptive statistics and multiple linear regression examined the association of demographic, health, and psychosocial variables with resilience by race, ethnicity, and NSES. RESULTS: Participants (n = 29,367, median age = 84.3) were White (91.4%), Black (3.7%), Hispanic (1.9%), and Asian (1.7%) women. There were no significant differences by race and ethnicity on mean resiliency scores (p = .06). Significant differences by NSES were observed regarding mean resiliency scores between those with low NSES (3.94 ± 0.83, out of 5) and high NSES (4.00 ± 0.81). Older age, higher education, higher self-rated health, lower stress, and living alone were significant positive correlates of resilience in the sample. Social support was correlated with resilience among White, Black, and Asian women, but not for Hispanic women. Depression was a significant correlate of lower resilience, except among Asian women. Living alone, smoking, and spirituality were significantly associated with higher resilience among women with moderate NSES. DISCUSSION: Multiple factors were associated with resilience among women aged ≥80 in the Women's Health Initiative. Despite some differing correlates of resilience by race, ethnicity, and NSES, there were many similarities. These results may aid in the design of resilience interventions for the growing, increasingly diverse population of older women.

Time trends in infectious and chronic disease consultations in Dakar, Senegal: Impact of COVID-19 sanitary measures.

Background: The impact of COVID-19 sanitary measures on the time trends in infectious and chronic disease consultations in Sub-Saharan Africa remains unknown. Methods: We conducted a cohort study on all emergency medical consultations from January 2016 to July 2020, from SOS Medecins in Dakar, Senegal. The consultation records provided basic demographic information such as age, ethnicity (Senegalese or Caucasian), and sex as well as the principal diagnosis using an ICD-10 classification ("infectious", "chronic", and "other"). We first investigated how the pattern in emergency consultation differed from March to July 2020 compared to previous years. Then, we examined any potential racial/ethnic disparities in COVID-19 consultation. Results: We obtained data on emergency medical consultations from 53 583 patients of all ethnic origins. The mean age of patients was 37.0 (standard deviation (SD) = 25.2) and 30.3 (SD = 21.7) in 2016-2019 and 45.5 (SD = 24.7) and 39.5 (SD = 23.3) in 2020 for Senegalese and Caucasian patients, respectively. The type of consultations between January and July were similar from 2016 to 2019; however, in 2020, there was a drop in the number of infectious disease consultations, particularly from April to May 2020, when sanitary measures for COVID-19 were applied (average of 366.5 and 358.2 in 2016-1019 and 133.0 and 125.0 in 2020). The prevalence of chronic conditions remained steady during the same period (average of 381.0 and 394.7 in 2016-2019 and 373.0 and 367.0 in 2020). In a multivariate analysis adjusted for age and sex, infectious disease consultations were significantly more likely to occur in 2016-2019 compared to 2020 (2016 odds ratio (OR) = 2.39, 2017 OR = 2.74, 2018 OR = 2.39, 2019 OR = 2.01). Furthermore, the trend in the number of infectious and chronic consultations was similar among Senegalese and Caucasian groups, indicating no disparities among those seeking treatment. Conclusions: During the implementation of COVID-19 sanitary measures, infectious disease rates dropped as chronic disease rates remained stagnant in Dakar. We observed no racial/ethnic disparities among the infectious and chronic consultations.

Racial Health Equity and Social Needs Interventions: A Review of a Scoping Review.

Importance: Social needs interventions aim to improve health outcomes and mitigate inequities by addressing health-related social needs, such as lack of transportation or food insecurity. However, it is not clear whether these studies are reducing racial or ethnic inequities. Objective: To understand how studies of interventions addressing social needs among multiracial or multiethnic populations conceptualize and analyze differential intervention outcomes by race or ethnicity. Evidence Review: Sources included a scoping review of systematic searches of PubMed and the Cochrane Library from January 1, 1995, through November 29, 2021, expert suggestions, and hand searches of key citations. Eligible studies evaluated interventions addressing social needs; reported behavioral, health, or utilization outcomes or harms; and were conducted in multiracial or multiethnic populations. Two reviewers independently assessed titles, abstracts, and full text for inclusion. The team developed a framework to assess whether the study was "conceptually thoughtful" for understanding root causes of racial health inequities (ie, noted that race or ethnicity are markers of exposure to racism) and whether analyses were "analytically informative" for advancing racial health equity research (ie, examined differential intervention impacts by race or ethnicity). Findings: Of 152 studies conducted in multiracial or multiethnic populations, 44 studies included race or ethnicity in their analyses; of these, only 4 (9%) were conceptually thoughtful. Twenty-one studies (14%) were analytically informative. Seven of 21 analytically informative studies reported differences in outcomes by race or ethnicity, whereas 14 found no differences. Among the 7 that found differential outcomes, 4 found the interventions were associated with improved outcomes for minoritized racial or ethnic populations or reduced inequities between minoritized and White populations. No studies were powered to detect differences. Conclusions and Relevance: In this review of a scoping review, studies of social needs interventions in multiracial or multiethnic populations were rarely conceptually thoughtful for understanding root causes of racial health inequities and infrequently conducted informative analyses on intervention effectiveness by race or ethnicity. Future work should use a theoretically sound conceptualization of how race (as a proxy for racism) affects social drivers of health and use this understanding to ensure social needs interventions benefit minoritized racial and ethnic groups facing social and structural barriers to health.

Leveraging Implementation Science for Cardiovascular Health Equity: A Scientific Statement From the American Heart Association.

Reducing cardiovascular disease disparities will require a concerted, focused effort to better adopt evidence-based interventions, in particular, those that address social determinants of health, in historically marginalized populations (ie, communities excluded on the basis of social identifiers like race, ethnicity, and social class and subject to inequitable distribution of social, economic, physical, and psychological resources). Implementation science is centered around stakeholder engagement and, by virtue of its reliance on theoretical frameworks, is custom built for addressing research-to-practice gaps. However, little guidance exists for how best to leverage implementation science to promote cardiovascular health equity. This American Heart Association scientific statement was commissioned to define implementation science with a cardiovascular health equity lens and to evaluate implementation research that targets cardiovascular inequities. We provide a 4-step roadmap and checklist with critical equity considerations for selecting/adapting evidence-based practices, assessing barriers and facilitators to implementation, selecting/using/adapting implementation strategies, and evaluating implementation success. Informed by our roadmap, we examine several organizational, community, policy, and multisetting interventions and implementation strategies developed to reduce cardiovascular disparities. We highlight gaps in implementation science research to date aimed at achieving cardiovascular health equity, including lack of stakeholder engagement, rigorous mixed methods, and equity-informed theoretical frameworks. We provide several key suggestions, including the need for improved conceptualization and inclusion of social and structural determinants of health in implementation science, and the use of adaptive, hybrid effectiveness designs. In addition, we call for more rigorous examination of multilevel interventions and implementation strategies with the greatest potential for reducing both primary and secondary cardiovascular disparities.

Listening to patients: Opportunities to improve reproductive wellness for women with chronic conditions.

OBJECTIVE: To understand how Black and Native American women with chronic conditions experience reproductive health care and identify patient-centered strategies to improve care. STUDY SETTING AND PARTICIPANTS: We held a series of virtual focus groups between February 2021 and December 2021 with 34 women who self-identified as Black or Native American, were of childbearing age, had one or more chronic conditions, and lived in North Carolina. STUDY DESIGN AND ANALYSIS: This qualitative, community-engaged study reviewed notes, video recordings, and graphic illustrations from the focus group sessions. Content analysis was used to iteratively identify themes. Emerging themes were reviewed by community and patient partners. PRINCIPAL FINDINGS: There were six thematic areas that emerged on the current state of reproductive health care for people with chronic conditions: (1) lack of trust in health care providers and institutions, (2) lack of health care provider knowledge, (3) uncoordinated care, (4) need for self-advocacy, (5) provider bias, and (6) mental health strain from coping. Six approaches for care improvement emerged: (1) build on models of coordinated health care services from other conditions to design more comprehensive care clinics, (2) involve care coordinators or navigators, (3) improve educational materials for patients, (4) train clinicians to increase their capacity to be trustworthy and provide quality, equitable, person-focused care, (5) design scripts to improve clinicians' ability to talk with women about infertility, miscarriage, infant loss, and (6) all interventions and research should be co-designed to address patient priorities. CONCLUSIONS: Engaging Black and Native American patient partners with chronic conditions in research planning is feasible, necessary, and beneficial using methods that support connection, respect, and bi-directional learning. Patient partners defined actionable strategies to improve reproductive care and wellness including comprehensive care clinics with patient navigators, trust-enhancing interventions, and better provision of reproductive health related education.

Effects of Objective and Perceived Social Isolation on Cardiovascular and Brain Health: A Scientific Statement From the American Heart Association.

Background Social isolation, the relative absence of or infrequency of contact with different types of social relationships, and loneliness (perceived isolation) are associated with adverse health outcomes. Objective To review observational and intervention research that examines the impact of social isolation and loneliness on cardiovascular and brain health and discuss proposed mechanisms for observed associations. Methods We conducted a systematic scoping review of available research. We searched 4 databases, PubMed, PsycInfo, Cumulative Index of Nursing and Allied Health, and Scopus. Findings Evidence is most consistent for a direct association between social isolation, loneliness, and coronary heart disease and stroke mortality. However, data on the association between social isolation and loneliness with heart failure, dementia, and cognitive impairment are sparse and less robust. Few studies have empirically tested mediating pathways between social isolation, loneliness, and cardiovascular and brain health outcomes using appropriate methods for explanatory analyses. Notably, the effect estimates are small, and there may be unmeasured confounders of the associations. Research in groups that may be at higher risk or more vulnerable to the effects of social isolation is limited. We did not find any intervention studies that sought to reduce the adverse impact of social isolation or loneliness on cardiovascular or brain health outcomes. Conclusions Social isolation and loneliness are common and appear to be independent risk factors for worse cardiovascular and brain health; however, consistency of the associations varies by outcome. There is a need to develop, implement, and test interventions to improve cardiovascular and brain health for individuals who are socially isolated or lonely.

Relationship of Social Connectedness With Decreasing Physical Activity During the COVID-19 Pandemic Among Older Women Participating in the Women's Health Initiative Study.

BACKGROUND: Aging is generally accompanied by decreasing physical activity (PA), which is associated with a decline in many health parameters, leading to recommendations for older adults to increase or at least maintain PA. METHODS: We determined relationships between social connectedness and decreasing or increasing PA levels during the coronavirus disease 2019 pandemic among 41 443 participants of the Women's Health Initiative Extension Study. Outcomes of logistic regression models were decreasing PA activity (reference: maintaining or increasing) and increasing PA activity (reference: maintaining or decreasing). The main predictor was social connectedness as a combined variable: not living alone (reference: living alone) and communicating with others outside the home more than once/week (reference: once/week or less). We adjusted for age, race, ethnicity, body mass index, physical function level, and education. RESULTS: Compared with participants who were not socially connected, socially connected participants had lower odds of decreasing PA (adjusted odds ratio 0.91, 95% confidence interval 0.87-0.95). Odds of increasing PA (vs decreasing or maintaining PA) were not significantly different among socially connected and not socially connected participants. Associations between social connectedness and decreasing PA did not significantly differ by age (<85 vs ≥85 years), race/ethnicity (non-Hispanic White vs other races/ethnicity), education (college vs 75). CONCLUSION: Social connectedness was associated with lower odds of decreasing PA among older women during the pandemic. These findings could inform the development of future interventions to help older women avoid decreasing PA.

Rural-urban differences in family and paid caregiving utilization in the United States: Findings from the Cornell National Social Survey.

PURPOSE: While rates of family caregiving and paid caregiving are increasing, how often they occur together ("shared care") and whether utilization varies geographically are unknown. We examined differences in family and paid caregiving utilization by rurality and region in the United States. METHODS: The 2020 Cornell National Social Survey is an annual cross-sectional telephone-based survey of a random sample of 1,000 US adults. Participants were asked if they have been a family caregiver, including if they provided care alongside a paid caregiver. Rural-Urban Commuting Area Codes and Census areas classified rurality and region. The association between residence and the prevalence of caregiving was determined with multivariable Poisson regression. FINDINGS: Among 857 participants with geographic and caregiving data, 11.8% (n = 101) were rural dwellers and 34.2% were family caregivers. Rural residence (vs urban) was associated with a higher prevalence of family caregiving (PR: 1.59 [1.22, 2.06]), and Western residence (vs Northeast) was associated with a lower prevalence of family caregiving (PR: 0.63 [0.46, 0.87], P = .01). Forty percent of family caregivers shared care with a paid caregiver. There was no significant difference in shared care by rural residence in unadjusted (31.8% rural vs 43.1% urban, P = .22) or adjusted models (PR: 0.85 [0.51, 1.41], P = .53). CONCLUSIONS: Although family caregiving was more prevalent in rural areas and certain regions, shared care did not differ by rurality or region. Studies are needed to understand why rural residents do more family caregiving without additional support from paid caregivers, and what the implications are for caregivers and care recipients.

Greater Social Functioning Associated With Lower Depressive Symptomatology Among Black Belt African Americans Enrolled in the Southeastern Collaboration to Improve Blood Pressure Control Study.

Objective: In many populations, higher social functioning is associated with lower depressive symptomatology, which in turn is associated with improved cardiovascular health. This study aimed to establish an association between social functioning and depressive symptomatology, which has not yet been demonstrated in the African American Black Belt. This would be an important finding in a region with high cardiovascular morbidity.Methods: This observational study used baseline data from 1,225 African American Black Belt residents with uncontrolled hypertension in the Southeastern Collaboration to Improve Blood Pressure Control (SEC) trial. Three Patient Reported Outcomes Measurement Information System (PROMIS) questionnaires-the emotional support, instrumental support, and social isolation questionnaires-and marital status assessed social functioning. The 8-item Patient Health Questionnaire assessed depressive symptomatology. Multivariable logistic regression models examined associations between social functioning and depressive symptomatology separately and then simultaneously. Data were collected from May 2017 to April 2021.Results: Social functioning was higher than US-reported averages, and the prevalence of moderate to severe depressive symptomatology was low (20.8%) among primary care populations. In a separate model, lower emotional support, lower instrumental support, and increased social isolation were significantly associated with greater depressive symptomatology (odds ratio [OR] = 1.56, 95% CI, 1.20-2.02; OR = 1.33, 95% CI, 1.01-1.77; and OR = 2.39, 95% CI, 1.81-3.16, respectively). In a simultaneous model, only increased perceived social isolation remained significantly associated with greater depressive symptomatology (OR = 2.24, 95% CI, 1.67-3.00).Conclusions: Greater social functioning is associated with lower depressive symptom burden in the Black Belt region. Future research into the directionality of this association could assist in the development of interventions to improve regional mental and cardiovascular health.Trial Registration: ClinicalTrials.gov identifier: NCT02866669.

Sociodemographic determinants of change in cardiovascular health in middle adulthood in a bi-racial cohort.

BACKGROUND AND AIMS: Cardiovascular health (CVH), as many other aspects of health, is socially patterned. However, little is known about the socioeconomic determinants of following a more or less favourable pattern of CVH change at midlife. METHODS: We used data on 11,049 participants in the Atherosclerosis Risk in Communities (ARIC) study, a prospective, population-based, bi-racial cohort that included participants aged 44-66 years in 1987-1989, who attended a second visit 6 years later. At both visits, CVH was assessed with the American Heart Association's Life's Simple 7 (LS7) score ranging 0-14, based on 7 metrics: cholesterol, blood glucose, blood pressure, smoking, body mass index, physical activity, and diet. An LS7 score ≥8 was considered ideal, <8 was considered poor. Multivariable logistic regression models were used. In a first sample (N = 4416) of participants who started with a poor CVH, we modelled odds of improvement (Poor-Ideal vs. Poor-Poor). In a second sample (N = 6633) with baseline ideal CVH, we modelled odds of deterioration (Ideal-Poor vs. Ideal-Ideal). The determinants considered were baseline age, sex, race, educational level, income and working status. RESULTS: The majority (8,347, 75.5%) of participants remained in the same CVH category at both waves: 28.7% poor-poor, and 46.8% ideal-ideal. The remaining 24.5% were evenly split between improving (11.2%) and deteriorating (13.2%). Compared to poor-poor CVH, older participants displayed higher odds of improving to ideal CVH (OR>58yvs < 50y = 1.41; 95% CI:1.17, 1.69), whereas Black race (vs White, OR = 0.68; 0.57, 0.80), low education (vs high, OR = 0.65; 0.53, 0.79) and low income (vs high, OR = 0.71; 0.57, 0.87)) were associated with lower odds of improvement. Compared to ideal-ideal CVH, Black participants (OR = 1.59; 1.33, 1.89), with low education (OR = 1.98; 1.64, 2.39), low income (OR = 1.57; 1.30, 1.88), and non-working (vs currently working, OR = 1.27; 1.06, 1.51) had greater odds of deterioration to poor CVH. CONCLUSIONS: We identified vulnerable groups at higher risk of worsening their CVH over time: Black people, with low income, low education, and who are unemployed. Efforts to reduce income and educational gaps and address structural racism, which shapes the distribution of health-promoting and health-harming resources, are paramount to reduce inequities in CVH.

Social Isolation and Incident Heart Failure Hospitalization in Older Women: Women's Health Initiative Study Findings.

Background The association of social isolation or lack of social network ties in older adults is unknown. This knowledge gap is important since the risk of heart failure (HF) and social isolation increase with age. The study examines whether social isolation is associated with incident HF in older women, and examines depressive symptoms as a potential mediator and age and race and ethnicity as effect modifiers. Methods and Results This study included 44 174 postmenopausal women of diverse race and ethnicity from the WHI (Women's Health Initiative) study who underwent annual assessment for HF adjudication from baseline enrollment (1993-1998) through 2018. We conducted a mediation analysis to examine depressive symptoms as a potential mediator and further examined effect modification by age and race and ethnicity. Incident HF requiring hospitalization was the main outcome. Social isolation was a composite variable based on marital/partner status, religious ties, and community ties. Depressive symptoms were assessed using CES-D (Center for Epidemiology Studies-Depression). Over a median follow-up of 15.0 years, we analyzed data from 36 457 women, and 2364 (6.5%) incident HF cases occurred; 2510 (6.9%) participants were socially isolated. In multivariable analyses adjusted for sociodemographic, behavioral, clinical, and general health/functioning; socially isolated women had a higher risk of incident HF than nonisolated women (HR, 1.23; 95% CI, 1.08-1.41). Adding depressive symptoms in the model did not change this association (HR, 1.22; 95% CI, 1.07-1.40). Neither race and ethnicity nor age moderated the association between social isolation and incident HF. Conclusions Socially isolated older women are at increased risk for developing HF, independent of traditional HF risk factors. Registration URL: http://www.clinicaltrials.gov; Unique identifier: NCT00000611.

Association between race/ethnicity and income on the likelihood of coronary revascularization among postmenopausal women with acute myocardial infarction: Women's health initiative study.

BACKGROUND: Historically, race, income, and gender were associated with likelihood of receipt of coronary revascularization for acute myocardial infarction (AMI). Given public health initiatives such as Healthy People 2010, it is unclear whether race and income remain associated with the likelihood of coronary revascularization among women with AMI. METHODS: Using the Women's Health Initiative Study, hazards ratio (HR) of revascularization for AMI was compared for Black and Hispanic women vs White women and among women with annual income <$20,000/year vs ≥$20,000/year over median 9.5 years follow-up(1993-2019). Proportional hazards models were adjusted for demographics, comorbidities, and AMI type. Results were stratified by revascularization type: percutaneous coronary intervention and coronary artery bypass grafting(CABG). Trends by race and income were compared pre- and post-2010 using time-varying analysis. RESULTS: Among 5,284 individuals with AMI (9.5% Black, 2.8% Hispanic, and 87.7% White; 23.2% <$20,000/year), Black race was associated with lower likelihood of receiving revascularization for AMI compared to White race in fully adjusted analyses [HR:0.79(95% Confidence Interval:[CI]0.66,0.95)]. When further stratified by type of revascularization, Black race was associated with lower likelihood of percutaneous coronary intervention for AMI compared to White race [HR:0.72(95% CI:0.59,0.90)] but not for CABG [HR:0.97(95%CI:0.72,1.32)]. Income was associated with lower likelihood of revascularization [HR:0.90(95%CI:0.82,0.99)] for AMI. No differences were observed for other racial/ethnic groups. Time periods (pre/post-2010) were not associated with change in revascularization rates. CONCLUSION: Black race and income remain associated with lower likelihood of revascularization among patients presenting with AMI. There is a substantial need to disrupt the mechanisms contributing to race, sex, and income disparities in AMI management.