The C2DREAM framework: Investigating the structural mechanisms undergirding racial health inequities.

Racism shapes the distribution of the social determinants of health (SDoH) along racial lines. Racism determines the environments in which people live, the quality of housing, and access to healthcare. Extensive research shows racism in its various forms negatively impacts health status, yet few studies and interventions seriously interrogate the role of racism in impacting health. The C2DREAM framework illuminates how exposure to racism, in multiple forms, connects to cardiovascular disease, hypertension, and obesity. The goal of the C2DREAM framework is to guide researchers to critically think about and measure the role of racism across its many levels of influence to better elucidate the ways it contributes to persistent health inequities. The conceptual framework highlights the interconnectedness between forms of racism, SDoH, and the lifecourse to provide a greater context to individual health outcomes. Utilizing this framework and critically contending with the effects of racism in its multiple and cumulative forms will lead to better research and interventions.

Instruments for racial health equity: a scoping review of structural racism measurement, 2019-2021.

Progress toward racial health equity cannot be made if we cannot measure its fundamental driver - structural racism. As in other epidemiological studies, the first step is to measure the exposure. But how to measure structural racism is an ongoing debate. To characterize the approaches epidemiologists and other health researchers use to quantitatively measure structural racism, highlight methodological innovations, and identify gaps in the literature, we conducted a scoping review of the peer-reviewed and grey literature published during 2019-2021 to accompany the work of Groos et al. (J Health Dispar Res Pract. 2018;11(2):Article 13), which surveys the scope of structural racism measurement up to 2017. We identified several themes from the recent literature: the current predominant focus on measuring anti-Black racism, using residential segregation as well as other segregation-driven measures as proxies of structural racism, measuring structural racism as spatial exposures, an increasing call by epidemiologists and other health researchers to measure structural racism as a multidimensional, multi-level determinant of health and related innovations, the development of policy databases, the utility of simulated counterfactual approaches in the understanding of how structural racism drive racial health inequities, and the lack of measures of antiracism and limited work on later life effects. Our findings sketch out several future steps to improve the science around structural racism measurements, which is the key to advancing antiracism policies.

Racial Arrest Disparities in the USA by Rural-Urban Location and Region.

BACKGROUND: Urban racial arrest disparities are well known. Emerging evidence suggests that rural policing shares similar patterns as urban policing in the USA, but without receiving the same public scrutiny, raising the risk of biased rural policing going unnoticed. METHODS: We estimated adult and adolescent arrest rates and rate ratios (RR) by race, rural-urban status, and US region based on 2016 Uniform Crime Reporting Program arrest and US Census population counts using general estimating equation Poisson regression models with a 4-way interaction between race, region, age group, and urbanicity. RESULTS: With few exceptions, arrest rates were highest in small towns and rural areas, especially among Black and American Indian populations. Arrest rates differed between US regions with highest rates and racial disparities in the Midwest. For example, arrest rates among Black adults in the rural Midwest were 148.6 arrests [per 1000 population], 95% CI 131.4-168.0, versus 94.4 arrests, 95% CI 77.2-115.4 in the urban Midwest; and versus corresponding rural Midwest arrests among white adults, 32.7 arrests, 95% CI 30.8-34.8, Black versus white rural RR 4.54, 95% CI 4.09-5.04. Racial arrest disparities in the South were lower but still high, e.g., rural South, Black versus White adults, RR 1.86, 95% CI 1.71-2.03. CONCLUSIONS: Rural areas and small towns are potential hotspots of racial arrest disparities across the USA, especially in the Midwest. Approaches to overcoming structural racism in policing must include strategies targeted at rural/small town communities. Our findings underscore the importance of dismantling racist policing in all US communities.

Retracted: Transactional and transformative diversity, equity, and inclusion activities in health services research departments.

The above article, published online on 08 January 2023 in Wiley Online Library (wileyonlinelibrary.com), has been retracted by agreement between the authors, the journal's Editor-in-Chief, Austin B. Frakt, the Health Research and Education Trust, and John Wiley & Sons Ltd. The retraction has been agreed following concerns raised by the authors following publication that their characterisation of specific data (personal narratives and experiences) was either inaccurate, misleading, or false. The final submitted manuscript unintentionally contained content that mischaracterised the authenticity of experiences represented, and the authors have requested retraction.

Perceptions of workplace climate and diversity, equity, and inclusion within health services and policy research.

OBJECTIVE: To describe the perception of professional climate in health services and policy research (HSPR) and efforts to advance diversity, equity, and inclusion (DEI) in the HSPR workforce and workplaces. DATA SOURCE: We administered the HSPR Workplace Culture Survey online to health services and policy researchers. STUDY DESIGN: Our survey examined participants' sociodemographic, educational, and professional backgrounds, their perception on DEI in HSPR, experience with DEI initiatives, feeling of inclusion, and direct and witnessed experiences of discrimination at their institutions/organizations. We calculated sample proportions of responses by gender identity, sexual orientation, race/ethnicity, and disability status and compared them with Fisher's exact test. DATA COLLECTION: We administered the survey online from July 28 to September 4, 2020. HSPR professionals and trainees aged 18 and older were eligible to participate. Analyses used complete cases only (n = 906; 70.6% completion rate). PRINCIPAL FINDINGS: 53.4% of the participants did not believe that the current workforce reflects the diversity of communities impacted by HSPR. Although most participants have witnessed various DEI initiatives at their institutions/organizations, nearly 40% characterized these initiatives as "tokenistic." Larger proportions of participants who identified as female, LGBQI+, underrepresented racial/ethnic groups, and those with a disability held this perception than their male, heterosexual, White, and non-disabled counterparts. Current DEI initiatives focused on "planning" activities (e.g., convening task forces) rather than "implementation" activities (e.g., establishing mentoring or network programs). 43.7% of the participants felt supported on their career development, while female, Black, Hispanic/Latino, LGBQI+ participants and those with a disability experienced discrimination at their workplace. CONCLUSIONS: Despite an increasing commitment to increasing the diversity of the HSPR workforce and improving equity and inclusion in the HSPR workplace, our results suggest that there is more work to be done to achieve such goals.

Predicting the onset of hypertension for workers: does including work characteristics improve risk predictive accuracy?

Despite extensive evidence of work as a key social determinant of hypertension, risk prediction equations incorporating this information are lacking. Such limitations hinder clinicians' ability to tailor patient care and comprehensively address hypertension risk factors. This study examined whether including work characteristics in hypertension risk equations improves their predictive accuracy. Using occupation ratings from the Occupational Information Network database, we measured job demand, job control, and supportiveness of supervisors and coworkers for occupations in the United States economy. We linked these occupation-based measures with the employment status and health data of participants in the Coronary Artery Risk Development in Young Adults (CARDIA) study. We fit logistic regression equations to estimate the probability of hypertension onset in five years among CARDIA participants with and without variables reflecting work characteristics. Based on the Harrell's c- and Hosmer-Lemeshow's goodness-of-fit statistics, we found that our logistic regression models that include work characteristics predict hypertension onset more accurately than those that do not incorporate these variables. We also found that the models that rely on occupation-based measures predict hypertension onset more accurately for White than Black participants, even after accounting for a sample size difference. Including other aspects of work, such as workers' experience in the workplace, and other social determinants of health in risk equations may eliminate this discrepancy. Overall, our study showed that clinicians should examine workers' work-related characteristics to tailor hypertension care plans appropriately.

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.

Occupational Segregation And Hypertension Inequity: The Implication Of The Inverse Hazard Law Among Healthcare Workers.

In the United States (US), Black-particularly Black female-healthcare workers are more likely to hold occupations with high job demand, low job control with limited support from supervisors or coworkers and are more vulnerable to job loss than their white counterparts. These work-related factors increase the risk of hypertension. This study examines the extent to which occupational segregation explains the persistent racial inequity in hypertension in the healthcare workforce and the potential health impact of workforce desegregation policies. We simulated a US healthcare workforce with four occupational classes: health diagnosing professionals (i.e., highest status), health treating professionals, healthcare technicians, and healthcare aides (i.e., lowest status). We simulated occupational segregation by allocating 25-year-old workers to occupational classes with the race- and gender-specific probabilities estimated from the American Community Survey data. Our model used occupational class attributes and workers' health behaviors to predict hypertension over a 40-year career. We tracked the hypertension prevalence and the Black-white prevalence gap among the simulated workers under the staus quo condition (occupational segregation) and the experimental conditions in which occupational segregation was eliminated. We found that the Black-white hypertension prevalence gap became approximately one percentage point smaller in the experimental than in the status quo conditions. These findings suggest that policies designed to desegregate the healthcare workforce may reduce racial health inequities in this population. Our microsimulation may be used in future research to compare various desegregation policies as they may affect workers' health differently. Supplementary Information: The online version contains supplementary material available at 10.1007/s41996-022-00098-5.

Improving The Measurement Of Structural Racism To Achieve Antiracist Health Policy.

Antiracist health policy research requires methodological innovation that creates equity-centered and antiracist solutions to health inequities by centering the complexities and insidiousness of structural racism. The development of effective health policy and health equity interventions requires sound empirical characterization of the nature of structural racism and its impact on public health. However, there is a disconnect between the conceptualization and measurement of structural racism in the public health literature. Given that structural racism is a system of interconnected institutions that operates with a set of racialized rules that maintain White supremacy, how can anyone accurately measure its insidiousness? This article highlights methodological approaches that will move the field forward in its ability to validly measure structural racism for the purposes of achieving health equity. We identify three key areas that require scholarly attention to advance antiracist health policy research: historical context, geographical context, and theory-based novel quantitative and qualitative methods that capture the multifaceted and systemic properties of structural racism as well as other systems of oppression.

Where are the labor markets?: Examining the association between structural racism in labor markets and infant birth weight.

Racist policies and practices that restrict Black, as compared to white workers, from employment may drive racial inequities in birth outcomes among workers. This study examined the association between structural racism in labor markets, measured at a commuting zone where workers live and commute to work, and low-birthweight birth. We found the deleterious effect of structural racism in labor markets among US-born Southern Black pregnant people of working age, but not among African- or Caribbean-born counterparts in any US region. Our analysis highlights the intersections of structural racism, culture, migration, and history of racial oppression that vary across regions and birth outcomes of Black workers.

Measuring Structural Racism: A Guide for Epidemiologists and Other Health Researchers.

There have been over 100 years of literature discussing the deleterious influence of racism on health. Much of the literature describes racism as a driver of social determinants of health, such as housing, employment, income, and education. More recently, increased attention has been given to measuring the structural nature of a system that advantages one racialized group over others rather than solely relying on individual acknowledgement of racism. Despite these advances, there is still a need for methodological and analytical approaches to complement the aforementioned. This commentary calls on epidemiologists and other health researchers at large to engage the discourse on measuring structural racism. First, we address the conflation between race and racism in epidemiologic research. Next, we offer methodological recommendations (linking of interdisciplinary variables and data sets and leveraging mixed-method and life-course approaches) and analytical recommendations (integration of mixed data, use of multidimensional models) that epidemiologists and other health researchers may consider in health equity research. The goal of this commentary is to inspire the use of up-to-date and theoretically driven approaches to increase discourse among public health researchers on capturing racism as well as to improve evidence of its role as the fundamental cause of racial health inequities.

Association of Residence in High-Police Contact Neighborhoods With Preterm Birth Among Black and White Individuals in Minneapolis.

Importance: Police contact may have negative psychological effects on pregnant people, and psychological stress has been linked to preterm birth (ie, birth at <37 weeks' gestation). Existing knowledge of racial disparities in policing patterns and their associations with health suggest redesigning public safety policies could contribute to racial health equity. Objective: To examine the association between community-level police contact and the risk of preterm birth among White pregnant people, US-born Black pregnant people, and Black pregnant people who were born outside the US. Design, Setting, and Participants: This cross-sectional study used medical record data of 745 White individuals, 121 US-born Black individuals, and 193 Black individuals born outside the US who were Minneapolis residents and gave birth to a live singleton at a large health system between January 1 and December 31, 2016. Data were analyzed from March 2019 to October 2020. Exposures: Police contact was measured at the level of the census tract where the pregnant people lived. Police incidents per capita (ie, the number of police incidents divided by the census tract population estimate) were dichotomized into high if the value was in the fourth quartile and low for the remaining three quartiles. Main Outcomes and Measures: Preterm birth status was based on the International Statistical Classification of Diseases and Related Health Problems, 10th revision, Clinical Modification (ICD-10-CM) code. Preterm infants were those with ICD-10-CM codes P07.2 and P07.3 documented in their charts. Results: Of 1059 pregnant people (745 [70.3%] White, 121 [11.4%] US-born Black, 193 [18.2%] Black born outside the US) in the sample, 336 White individuals (45.1%) and 62 Black individuals who were born outside the US (32.1%) gave birth between the ages of 30 and 34 years, while US-born Black individuals gave birth at younger ages, with 49 (40.5%) aged 25 years or younger. The incidence of preterm birth was 6.7% for White individuals (50 pregnant people), 14.0% for US-born Black individuals (17 pregnant people), and 5.7% for Black individuals born outside the US (11 pregnant people). In areas with high police contact vs low police contact, the odds of preterm birth were 90% higher for White individuals (odds ratio [OR], 1.9; 95% CI, 1.9-2.0), 100% higher for US-born Black individuals (OR, 2.0; 95% CI, 1.8-2.2), and 10% higher for Black individuals born outside the US (OR, 1.1; 95% CI, 1.0-1.2). Secondary geospatial analysis further revealed that the proportion of Black residents in Minneapolis census tracts was correlated with the number of police incidents reported between 2012 and 2016 (P = .001). Conclusions and Relevance: In this study, police contact was associated with preterm birth for both Black and White pregnant people. Predominantly Black neighborhoods had greater police contact than predominantly White neighborhoods, indicating that Black pregnant people were more likely to be exposed to police than White pregnant people. These findings suggest that racialized police patterns borne from a history of racism in the United States may contribute to racial disparity in preterm birth.

The intricacy of structural racism measurement: A pilot development of a latent-class multidimensional measure.

BACKGROUND: Structural racism is a complex system of inequities working in tandem to cause poor health for communities of color, especially for Black people. However, the multidimensional nature of structural racism is not captured by existing measures used by population health scholars to study health inequities. Multidimensional measures can be made using complex analytical techniques. Whether or not the multidimensional measure of structural racism provides more insight than the existing unidimensional measures is unknown. METHODS: We derived measures of Black-White residential segregation, inequities in education, employment, income, and homeownership, evaluated for 2,338 Public Use Microdata Areas (PUMAs) in the United States (US), and consolidated them into a multidimensional measure of structural racism using a latent class model. We compared the median COVID-19 vaccination rates observed across 54 New York City (NYC) PUMAs by levels (high/low) of structural racism and the multidimensional class using the Kruskal-Wallis test. This study was conducted in March 2021. FINDINGS: Our latent class model identified three structural racism classes in the US, all of which can be found in NYC. We observed intricate interactions between the five dimensions of structural racism of interest that cannot be simply classified as "high" (i.e., high on all dimensions of structural racism), "medium," or "low." Compared to Class A PUMAs with the median rate of two-dose completion of 6·9%, significantly lower rates were observed for Class B PUMAs (5·5%, p = 0·04) and Class C PUMAs (5·2%, p = 0·01). When the vaccination rates were evaluated based on each dimension of structural racism, significant differences were observed between PUMAs with high and low Black-White income inequity only (7·2% vs. 5·3%, p = 0·001). INTERPRETATION: Our analysis suggests that measuring structural racism as a multidimensional determinant of health provides additional insight into the mechanisms underlying population health inequity vis-à-vis using multiple unidimensional measures without capturing their joint effects. FUNDING: This project is funded by the Robert J. Jones Urban Research and Outreach-Engagement Center, University of Minnesota. Additional support is provided by the Minnesota Population Center, which is funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development (Grant P2C HD041023).

Assessing the Impact of Language Access Regulations on the Provision of Pharmacy Services.

Approximately 25 million people in the United States are limited English proficient (LEP). Appropriate language services can improve care for LEP individuals, and health care facilities receiving federal funds are required to provide such services. Recognizing the risk of inadequate comprehension of prescription medication instructions, between 2008 and 2012, New York City and State passed a series of regulations that require chain pharmacies to provide translated prescription labels and other language services to LEP patients. We surveyed pharmacists before (2006) and after (2015) implementation of the regulations to assess their impact in chain pharmacies. Our findings demonstrate a significant improvement in capacity of chains to assist LEP patients. A higher proportion of chain pharmacies surveyed in 2015 reported printing translated labels, access and use of telephone interpreter services, multilingual signage, and documentation of language needs in patient records. These findings illustrate the potential impact of policy changes on institutional practices that impact large and vulnerable portions of the population.

Maternal Opioid Use Disorder and Neonatal Abstinence Syndrome Among Rural US Residents, 2007-2014.

PURPOSE: Opioid use disorder (OUD) during pregnancy is associated with poor maternal and infant outcomes, including neonatal abstinence syndrome (NAS), and both maternal OUD and NAS are increasing disproportionately among rural residents. This study describes the trajectory and characteristics associated with diagnosis of maternal OUD or NAS among rural residents who gave birth at different types of hospitals based on rural/urban location and teaching status. METHODS: Hospital discharge data from the all-payer National Inpatient Sample were used to describe maternal OUD and infant NAS among rural residents from 2007-2014. Hospitals were categorized as rural, urban teaching, and urban nonteaching. We estimated incidence trends by hospital categories, followed by multivariable logistic regression analyses to identify correlates of OUD and NAS among rural residents, stratified by hospital category. FINDINGS: Incidence of maternal OUD increased in all hospital categories, with higher rates (8.9/1,000 deliveries) among rural residents who gave birth at urban teaching hospitals compared with those who gave birth at rural hospitals (4.3/1,000 deliveries) or urban nonteaching hospitals (3.6/1,000 deliveries; P < .001). A similar pattern was observed for infant NAS. In multivariable models, the association between maternal OUD and infant NAS diagnoses and hospital category differed by rurality (micropolitan vs. noncore.) CONCLUSIONS: There has been a sustained increase in both maternal OUD and NAS diagnoses among rural residents. Measured sociodemographic and clinical correlates of maternal OUD and NAS differ by hospital category, indicating variability across hospital locations in patient populations and clinical needs for rural residents with these conditions.

The impact of buprenorphine/naloxone treatment on HIV risk behaviors among HIV-infected, opioid-dependent patients.

BACKGROUND: Opioid dependence is a major risk factor for HIV infection, however, the impact of buprenorphine/naloxone treatment on HIV risk behaviors among HIV-infected opioid-dependent patients is unknown. METHODS: We conducted a longitudinal analysis of 303 HIV-infected opioid-dependent patients initiating buprenorphine/naloxone treatment. Outcomes included self-reported past 90-day needle-sharing and non-condom use. We assessed trends over the 12 months using the Cochran-Armitage trend test. Using generalized estimating equations, after multiple imputation, we determined factors independently associated with needle-sharing and non-condom use, including time-updated variables. We then conducted a mediation analysis to determine whether substance use explained the relationship between time since treatment initiation and needle-sharing. RESULTS: Needle-sharing decreased from baseline to the fourth quarter following initiation of buprenorphine/naloxone (9% vs. 3%, p<0.001), while non-condom use did not (23% vs. 21%, p=0.10). HIV risk behaviors did not vary based on the presence of a detectable HIV-1 RNA viral load. Patients who were homeless and used heroin, cocaine/amphetamines or marijuana were more likely to report needle-sharing. Heroin use fully mediated the relationship between time since treatment initiation and needle-sharing. Women, patients who identified as being gay/lesbian/bisexual, those married or living with a partner and who reported heroin or alcohol use were more likely to report non-condom use. Older patients were less likely to report non-condom use. CONCLUSIONS: While buprenorphine/naloxone is associated with decreased needle-sharing among HIV-infected opioid-dependent patients, sexual risk behaviors persist regardless of viral load. Targeted interventions to address HIV risk behaviors among HIV-infected opioid-dependent populations receiving buprenorphine/naloxone are needed.

Health, community, and spirituality: evaluation of a multicultural faith-based diabetes prevention program.

PURPOSE: The purpose of this study was to evaluate Fine, Fit, and Fabulous (FFF), a faith-based diabetes prevention program for black and Latino congregants at churches in low-income New York City neighborhoods. FFF includes nutrition education and fitness activities while incorporating Bible-based teachings that encourage healthy lifestyles. METHODS: FFF is a 12-week, bilingual program developed by the Bronx Health REACH coalition, a Centers for Disease Control and Prevention-funded Center of Excellence for the Elimination of Disparities. This program has been implemented in 15 Bronx and Harlem churches, engaging a primarily black and Latino overweight and obese urban population. Pre-post surveys, nutrition tests, and weight logs were collected to assess knowledge, attitudes, and behaviors regarding healthy eating and physical activity. RESULTS: Participants (n = 183) reported statistically significant improvements in knowledge and healthy behaviors from baseline. Increased numbers of participants reported exercising in the past 30 days, eating fruit daily, being able to judge portion sizes, and reading food labels. Statistically significant numbers reported that they ate less fast food and were less likely to overeat at follow-up. The average weight loss across churches was 4.38 lbs or 2% of participants' initial body weight. Significant differences were observed when stratifying by race/ethnicity. CONCLUSION: Evaluation results show FFF's success at engaging overweight adults in behavior changes related to healthy eating and exercise. FFF demonstrates the potential of faith-based health interventions to address obesity and diabetes risk in high-need communities of color.

Becoming a patient-centered medical home: a 9-year transition for a network of Federally Qualified Health Centers.

PURPOSE: The patient-centered medical home (PCMH) model has great potential for optimizing the care of chronically ill patients, yet there is much to be learned about various implementations of this model and their impact on patient care processes and outcomes. METHODS: We examined changes in patterns of health care use in a network of Federally Qualified Health Centers throughout a 9-year period of practice transformation that included recognition of all centers by the National Committee for Quality Assurance (NCQA) as Level 3 PCMH practices. We analyzed deidentified data from electronic health records for the period 2003 to 2011 to identify patterns of service use for all 4,595 patients with diabetes. We also examined a subsample of 545 patients who were in care throughout the study period to track improvement in glycated hemoglobin levels as a clinical measure over time. RESULTS: Through the transition to a PCMH, the mean number of encounters with outreach, diabetes educators, and psychosocial services increased for all diabetic patients; virtually all patients had visits with a primary care clinician, but the mean number of visits decreased slightly. Among patients in the subsample, mean annual levels of glycated hemoglobin decreased steadily during the 9-year study period, mainly driven by a reduction in patients having baseline levels exceeding 9%. CONCLUSIONS: This retrospective study conducted in a real-world setting using electronic health record data demonstrates a shift in resource use by diabetic patients from the primary care clinician to other members of the care team. The findings suggest that PCMH implementation has the potential to alter processes of care and improve outcomes of care, especially among those with higher disease burden.