Long term mortality trends in people with severe mental illnesses and how COVID-19, ethnicity and other chronic mental health comorbidities contributed: a retrospective cohort study.

BACKGROUND: People with schizophrenia-spectrum and bipolar disorders (severe mental illnesses; 'SMI') experience excess mortality. Our aim was to explore longer-term trends in mortality, including the COVID-19 pandemic period, with a focus on additional vulnerabilities (psychiatric comorbidities and race/ ethnicity) in SMI. METHODS: Retrospective cohort study using electronic health records from secondary mental healthcare, covering a UK region of 1.3 million people. Mortality trends spanning fourteen years, including the COVID-19 pandemic, were assessed in adults with clinician-ascribed ICD-10 diagnoses for schizophrenia-spectrum and bipolar disorders. RESULTS: The sample comprised 22 361 people with SMI with median follow-up of 10.6 years. Standardized mortality ratios were more than double the population average pre-pandemic, increasing further during the pandemic, particularly in those with SMI and psychiatric comorbidities. Mortality risk increased steadily among people with SMI and comorbid depression, dementia, substance use disorders and anxiety over 13-years, increasing further during the pandemic. COVID-19 mortality was elevated in people with SMI and comorbid depression (sub-Hazard Ratio: 1.48 [95% CI 1.03-2.13]), dementia (sHR:1.96, 1.26-3.04) and learning disabilities (sHR:2.30, 1.30-4.06), compared to people with only SMI. COVID-19 mortality risk was similar for minority ethnic groups and White British people with SMI. Elevated all-cause mortality was evident in Black Caribbean (adjusted Rate Ratio: 1.40, 1.11-1.77) and Black African people with SMI (aRR: 1.59, 1.07-2.37) during the pandemic relative to earlier years. CONCLUSIONS: Mortality has increased over time in people with SMI. The pandemic exacerbated pre-existing trends. Actionable solutions are needed which address wider social determinants and address disease silos.

Quality of ethnicity data within Scottish health records and implications of misclassification for ethnic inequalities in severe COVID-19: a national linked data study.

BACKGROUND: We compared the quality of ethnicity coding within the Public Health Scotland Ethnicity Look-up (PHS-EL) dataset, and other National Health Service datasets, with the 2011 Scottish Census. METHODS: Measures of quality included the level of missingness and misclassification. We examined the impact of misclassification using Cox proportional hazards to compare the risk of severe coronavirus disease (COVID-19) (hospitalization & death) by ethnic group. RESULTS: Misclassification within PHS-EL was higher for all minority ethnic groups [12.5 to 69.1%] compared with the White Scottish majority [5.1%] and highest in the White Gypsy/Traveller group [69.1%]. Missingness in PHS-EL was highest among the White Other British group [39%] and lowest among the Pakistani group [17%]. PHS-EL data often underestimated severe COVID-19 risk compared with Census data. e.g. in the White Gypsy/Traveller group the Hazard Ratio (HR) was 1.68 [95% Confidence Intervals (CI): 1.03, 2.74] compared with the White Scottish majority using Census ethnicity data and 0.73 [95% CI: 0.10, 5.15] using PHS-EL data; and HR was 2.03 [95% CI: 1.20, 3.44] in the Census for the Bangladeshi group versus 1.45 [95% CI: 0.75, 2.78] in PHS-EL. CONCLUSIONS: Poor quality ethnicity coding in health records can bias estimates, thereby threatening monitoring and understanding ethnic inequalities in health.

The influence of a hostile environment on a syndemic of depression, stress and chronic limiting illness among LGBTQ+ people during the COVID-19 pandemic.

Lesbian, Gay, Bisexual, Transgender, Queer, Questioning (LGBTQ+) are at greater risk of poorer COVID-19 prognosis due to higher levels of chronic disease and a greater impact on mental health from pandemic mitigation strategies due to worse pre-pandemic mental health. We examine how a hostile social system contributes to LGBTQ+ people's negative health experiences during the pandemic through adopting a syndemic framework and using data from The Queerantine Study, a cross-sectional, web-based survey (n = 515). Identification of a health syndemic is based on depressive symptoms, perceived stress and limiting long-term illness. We used Latent Class Analysis to identify latent classes based on experiences of a hostile social system. A syndemic was identified among a third of respondents (33.2%), with transgender/gender-diverse and younger participants at higher risk. Latent Class Analysis identified five groups based on experiences of hostile social systems using psychosocial and socioeconomic indicators. Classes reflecting psychosocial hostility were predictive of a health syndemic and worsening health. This study emphasises (i) mental and physical health issues are intertwined among LGBTQ+ people; (ii) experiences of hostile social systems can account for part of variation in health across LGBTQ+ groups; (iii) that psychosocial hostility continued and was exacerbated throughout the pandemic, and (iv) experiences of psychosocial hostility in particular were associated with a greater likelihood of experiencing a syndemic.

Ethnic inequalities in primary care experiences for people with multiple long-term conditions: Evidence from the general practice patient survey.

OBJECTIVES: To examine the relationship between ethnicity and experiences of primary care for people with multiple long-term conditions (MLTCs) and assess the relative importance of demographic, practice, and area-level factors as influences on primary care experiences across ethnic groups. STUDY DESIGN: A retrospective study using 2018-19 GP Patient Survey data linked to General Practice Workforce data and small area data published by the Office for National Statistics. METHODS: We conducted multilevel regression analysis to assess the relationship between ethnicity and experience of accessing primary care and interacting with healthcare professionals. We built separate regression models for each outcome and included (i) each covariate separately, (ii) demographic factors and (iii) demographic, practice, and area-level factors. RESULTS: Upon full adjustment Arab, Bangladeshi, Chinese, Indian, Pakistani, other Asian, mixed white and Asian, and other white people with MLTCs have lower levels of satisfaction with primary care access and interacting with healthcare professionals compared with white British people. The influence of demographic, practice and area-level factors is not uniform across ethnic groups; demographic factors account for the inequalities in levels of satisfaction with access to primary care between white British people and Black other, mixed other, mixed white & Black Caribbean and Gypsy & Irish Travellers. However, practice and area-level factors strengthen inequalities in the experience of accessing primary care for Bangladeshi, Indian and Pakistani people. CONCLUSIONS: Given the link between patient satisfaction and patient-related health outcomes, the lower levels of satisfaction with accessing primary care and interacting with healthcare professionals among the aforementioned minoritised ethnic groups are concerning and require further scrutiny. Qualitative studies are required to understand and address the sources of poor experiences in primary care for minoritised people with MLTCs to improve patient-centred healthcare and outcomes.

Confronting the consequences of racism, xenophobia, and discrimination on health and health-care systems.

Racism, xenophobia, and discrimination are key determinants of health and equity and must be addressed for improved health outcomes. We conclude that far broader, deeper, transformative action is needed compared with current measures to tackle adverse effects of racism on health. To challenge the structural drivers of racism and xenophobia, anti-racist action and other wider measures that target determinants should implement an intersectional approach to effectively address the causes and consequences of racism within a population. Structurally, legal instruments and human rights law provide a robust framework to challenge the pervasive drivers of disadvantage linked to caste, ethnicity, Indigeneity, migratory status, race, religion, and skin colour. Actions need to consider the historical, economic, and political contexts in which the effects of racism, xenophobia, and discrimination affect health. We propose several specific actions: a commission that explores how we action the approaches laid out in this paper; building a conversation and a series of events with international multilateral agency stakeholders to raise the issue and profile of racism, xenophobia, and discrimination within health; and using our multiple platforms to build coalitions, expand knowledge, highlight inequities, and advocate for change across the world.

Severe mental illness, race/ethnicity, multimorbidity and mortality following COVID-19 infection: nationally representative cohort study.

BACKGROUND: The association of COVID-19 with death in people with severe mental illness (SMI), and associations with multimorbidity and ethnicity, are unclear. AIMS: To determine all-cause mortality in people with SMI following COVID-19 infection, and assess whether excess mortality is affected by multimorbidity or ethnicity. METHOD: This was a retrospective cohort study using primary care data from the Clinical Practice Research Database, from February 2020 to April 2021. Cox proportional hazards regression was used to estimate the effect of SMI on all-cause mortality during the first two waves of the COVID-19 pandemic. RESULTS: Among 7146 people with SMI (56% female), there was a higher prevalence of multimorbidity compared with the non-SMI control group (n = 653 024, 55% female). Following COVID-19 infection, the SMI group experienced a greater risk of death compared with controls (adjusted hazard ratio (aHR) 1.53, 95% CI 1.39-1.68). Black Caribbean/Black African people were more likely to die from COVID-19 compared with White people (aHR = 1.22, 95% CI 1.12-1.34), with similar associations in the SMI group and non-SMI group (P for interaction = 0.73). Following infection with COVID-19, for every additional multimorbidity condition, the aHR for death was 1.06 (95% CI 1.01-1.10) in the SMI stratum and 1.16 (95% CI 1.15-1.17) in the non-SMI stratum (P for interaction = 0.001). CONCLUSIONS: Following COVID-19 infection, patients with SMI were at an elevated risk of death, further magnified by multimorbidity. Black Caribbean/Black African people had a higher risk of death from COVID-19 than White people, and this inequity was similar for the SMI group and the control group.

Ethnic inequities in the patterns of personalized care adjustments for 'informed dissent' and 'patient unsuitable': a retrospective study using Clinical Practice Research Datalink.

BACKGROUND: In England, general practitioners voluntarily take part in the Quality and Outcomes Framework, which is a program that seeks to improve care by rewarding good practice. They can make personalized care adjustments (PCAs), e.g. if patients choose not to have the treatment/intervention offered ('informed dissent') or because they are considered to be clinically 'unsuitable'. METHODS: Using data from the Clinical Practice Research Datalink (Aurum), this study examined patterns of PCA reporting for 'informed dissent' and 'patient unsuitable', how they vary across ethnic groups and whether ethnic inequities were explained by sociodemographic factors or co-morbidities. RESULTS: The odds of having a PCA record for 'informed dissent' were lower for 7 of the 10 minoritized ethnic groups studied. Indian patients were less likely than white patients to have a PCA record for 'patient unsuitable'. The higher likelihood of reporting for 'patient unsuitable' among people from Black Caribbean, Black Other, Pakistani and other ethnic groups was explained by co-morbidities and/or area-level deprivation. CONCLUSIONS: The findings counter narratives that suggest that people from minoritized ethnic groups often refuse medical intervention/treatment. The findings also illustrate ethnic inequities in PCA reporting for 'patient unsuitable', which are linked to clinical and social complexity and should be tackled to improve health outcomes for all.

Ethnic inequalities in multiple long-term health conditions in the United Kingdom: a systematic review and narrative synthesis.

Indicative evidence suggests that minoritised ethnic groups have higher risk of developing multiple long-term conditions (MLTCs), and do so earlier than the majority white population. While there is evidence on ethnic inequalities in single health conditions and comorbidities, no review has attempted to look across these from a MLTCs perspective. As such, we currently have an incomplete understanding of the extent of ethnic inequalities in the prevalence of MLTCs. Further, concerns have been raised about variations in the way ethnicity is operationalised and how this impedes our understanding of health inequalities. In this systematic review we aimed to 1) describe the literature that provides evidence of ethnicity and prevalence of MLTCs amongst people living in the UK, 2) summarise the prevalence estimates of MLTCs across ethnic groups and 3) to assess the ways in which ethnicity is conceptualised and operationalised. We focus on the state of the evidence prior to, and during the very early stages of the pandemic. We registered the protocol on PROSPERO (CRD42020218061). Between October and December 2020, we searched ASSIA, Cochrane Library, EMBASE, MEDLINE, PsycINFO, PubMed, ScienceDirect, Scopus, Web of Science, OpenGrey, and reference lists of key studies/reviews. The main outcome was prevalence estimates for MLTCs for at least one minoritised ethnic group, compared to the majority white population. We included studies conducted in the UK reporting on ethnicity and prevalence of MLTCs. To summarise the prevalence estimates of MLTCs across ethnic groups we included only studies of MLTCs that provided estimates adjusted at least for age. Two reviewers screened and extracted data from a random sample of studies (10%). Data were synthesised using narrative synthesis. Of the 7949 studies identified, 84 met criteria for inclusion. Of these, seven contributed to the evidence of ethnic inequalities in MLTCs. Five of the seven studies point to higher prevalence of MLTCs in at least one minoritised ethnic group compared to their white counterparts. Because the number/types of health conditions varied between studies and some ethnic populations were aggregated or omitted, the findings may not accurately reflect the true level of ethnic inequality. Future research should consider key explanatory factors, including those at the macrolevel (e.g. racism, discrimination), as they may play a role in the development and severity of MLTCs in different ethnic groups. Research is also needed to ascertain the extent to which the COVID19 pandemic has exacerbated these inequalities.

Ethnic inequalities in age-related patterns of multiple long-term conditions in England: Analysis of primary care and nationally representative survey data.

Little is known about the patterning of multiple long-term conditions (MLTCs) by age, ethnicity and across conceptualisations of MLTCs (e.g. MLTCs with/without mental health conditions [MHCs]). We examined ethnic inequalities in age-related patterns of MLTCs, and combinations of physical and MHCs using the English GP Patient Survey and Clinical Practice Research Datalink. We described the association between MLTCs and age using multilevel regression models adjusting for sex and area-level deprivation with patients nested within GP practices. Similar analyses were repeated for MLTCs that include MHCs. We observed ethnic inequalities from middle-age onwards such as older Pakistani, Indian, Black Caribbean and Other ethnic people had increased risk of MLTCs compared to white British people, even after adjusting for area-level deprivation. Compared to white British people, Gypsy and Irish Travellers had higher levels of MLTCs across the age groups, and Chinese people had lower levels. Pakistani and Bangladeshi people aged 50-74 years were more likely than white people to report MLTCs that included MHCs. We find clear evidence of ethnic inequalities in MLTCs. The lower prevalence of MLTCs that include MHCs among some minoritised ethnic groups may be an underestimation due to underdiagnosis and/or inadequate primary care and requires further scrutiny.

Inequalities in mental health, self-rated health, and social support among sexual minority young adults during the COVID-19 pandemic: analyses from the UK Millennium Cohort Study.

PURPOSE: Young adults who self-identify as a sexual minority may have been particularly harmed by the consequences of lockdown, closure of educational institutions, and social distancing measures as they are likely to have been confined in households that may not be supportive of their sexual orientation. We examine inequalities in the mental health and self-rated health of sexual minority young adults, compared to their heterosexual peers, at the height of lockdown restrictions in the UK. METHODS: We analysed data from singletons who participated in waves 6, 7, and the wave 1 COVID-19 survey (n = 2211) of the Millennium Cohort Study, a nationally representative longitudinal study of infants born in the UK between September 2000 and January 2002. Regression models compared the mental health, self-rated health, and social support of sexual minority young adults to that of their heterosexual peers. RESULTS: One in four young adults self-identified with a sexual orientation or attraction other than completely heterosexual. Sexual minority young adults had significantly lower levels of social support (ß = - 0.38, SE 0.08), poorer self-rated health (OR 3.91, 95% CI 2.41-6.34), and higher levels of psychological distress (ß = 2.26, SE 0.34), anxiety (ß = 0.40, SE 0.15), and loneliness (ß = 0.66, SE 0.18) when compared to heterosexual young adults. CONCLUSIONS: Sexual minority young adults in the UK have been detrimentally impacted by the coronavirus pandemic, experiencing inequalities in mental health, self-rated health, and social support when compared to heterosexual young adults. Implications for policy and practice include a stronger provision of safe spaces in the community and in institutions, and policies that address marginalisation and harassment.

Explaining ethnic variations in adolescent mental health: a secondary analysis of the Millennium Cohort Study.

PURPOSE: The relationship between ethnicity and adolescent mental health was investigated using cross-sectional data from the nationally representative UK Millennium Cohort Study. METHODS: Parental Strengths and Difficulties Questionnaire reports identified mental health problems in 10,357 young people aged 14 (n = 2042 from ethnic minority backgrounds: Mixed n = 492, Indian n = 275, Pakistani n = 496, Bangladeshi n = 221, Black Caribbean n = 102, Black African n = 187, Other Ethnic Group n = 269). Univariable logistic regression models investigated associations between each factor and outcome; a bivariable model investigated whether household income explained differences by ethnicity, and a multivariable model additionally adjusted for factors of social support (self-assessed support, parental relationship), participation (socialising, organised activities, religious attendance), and adversity (bullying, victimisation, substance use). Results were stratified by sex as evidence of a sex/ethnicity interaction was found (P = 0.0002). RESULTS: There were lower unadjusted odds for mental health problems in boys from Black African (OR 0.15, 95% CI 0.04-0.61) and Indian backgrounds (OR 0.42, 95% CI 0.21-0.86) compared to White peers. After adjustment for income, odds were lower in boys from Black African (OR 0.10, 95% CI 0.02-0.38), Indian (OR 0.40, 95% CI 0.21-0.77), and Pakistani (OR 0.49, 95% CI 0.27-0.89) backgrounds, and girls from Bangladeshi (OR 0.18, 95% CI 0.05-0.65) and Pakistani (OR 0.63, 95% CI 0.41-0.99) backgrounds. After further adjustment for social support, participation, and adversity factors, only boys from a Black African background had lower odds (OR 0.16, 95% CI 0.03-0.71) of mental health problems. CONCLUSIONS: Household income confounded lower prevalence of mental health problems in some young people from Pakistani and Bangladeshi backgrounds; findings suggest ethnic differences are partly but not fully accounted for by income, social support, participation, and adversity. Addressing income inequalities and socially focused interventions may protect against mental health problems irrespective of ethnicity.

Armed conflict as a determinant of children malnourishment: a cross-sectional study in The Sudan.

BACKGROUND: Children's nutritional status influences their physical, socioemotional and cognitive development throughout the life course. We aimed to determine the role of armed conflict on the prevalence of childhood malnourishment in The Sudan, and understand the underlying mechanisms using a framework based on the social determinants of health. METHODS: We analysed cross-sectional data from the 2014-Sudan Multiple Indicator Cluster Survey (n = 14,081) to compare the prevalence of malnourishment in states undergoing armed conflict and states free of conflict. Four-level multilevel multivariate modelling was conducted to identify the contribution of the social determinants of malnourishment in explaining the role of armed conflict in child health, with conflict status as the central predictor and progressive adjustments for child-, household- and cluster- and state-level predictors. RESULTS: Armed conflict is strongly associated with greater risk of severe and moderate underweight among children under-5. Adjusting for key social determinants of health reduced the strength of the association between armed conflict and risk of underweight, but there is statistical evidence of association between armed conflict and risk of severe underweight (OR: 1.60, 95%CI: 1.03-2.49 for the low intensity group). CONCLUSION: Conflict-exposed children are particularly vulnerable to malnourishment, and this association is mostly explained by key socio-demographic factors. With the prolonged political instability in The Sudan, sustainable nutritional interventions are necessary to ease hard conditions in conflict-exposed states, and also among disadvantaged families in conflict-free regions.

Maternal experiences of ethnic discrimination and subsequent birth outcomes in Aotearoa New Zealand.

BACKGROUND: Interpersonal discrimination experience has been associated with adverse birth outcomes. Limited research has evaluated this relationship within multicultural contexts outside the United States where the nature and salience of discrimination experiences may differ. Such research is important in order to help identify protective and risk factors that may mediate the relationship between discrimination experience and adverse birth outcomes. METHODS: Evaluated the relationship between perceived discrimination, as measured in pregnancy, with birth weight and gestation length among Maori, Pacific, and Asian women from Aotearoa New Zealand (N = 1653). RESULTS: Thirty percent of the sample reported some type of unfair treatment that they attributed to their ethnicity. For Maori women specifically, unfair treatment at work (ß = - 243 g) and in acquiring housing (ß = - 146 g) were associated with lower birth weight when compared to Maori women not experiencing these types of discrimination, while an ethnically motivated physical attack (ß = - 1.06 week), and unfair treatment in the workplace (ß = - 0.95 week), in the criminal justice system (ß = - 0.55 week), or in banking (ß = - 0.73 week) were associated with significantly shorter gestation. CONCLUSIONS: Despite a high prevalence of discrimination experience among women from all ethnic groups, discrimination experience was a strong predictor of lower birth weight and shorter gestation length among indigenous Maori women only. Additional research is needed to better understand the risk and protective factors that may moderate the relationship between discrimination experience and adverse birth outcomes among women from different ethnic groups.

Race/ethnic inequalities in early adolescent development in the United Kingdom and United States.

BACKGROUND: Comparative literature investigating race/ethnic patterning of children's health has found racial/ethnic minority status to be linked to health disadvantages. Less is known about differences during early adolescence, a period during which health outcomes are linked to later life health. OBJECTIVE: Using the UK Millennium Cohort Study (n = 10,188) and the US Early Childhood Longitudinal Survey-Kindergarten Cohort (n ~ 6,950), we examine differences in socioemotional and cognitive development among 11-year-old adolescents and the contribution of family resources in explaining any observed differences, including socioeconomic, cultural traditions, and psychosocial resources. RESULTS: Adverse socioemotional health and cognitive development were associated with race/ethnic minority status in both countries. In the United States, we found that cultural resources and family socioeconomic capital played a large role in attenuating differences in problem behaviors between Asian American, Black, and Latino adolescents and their White peers. In the United Kingdom, the explanatory factors explaining differences in problem behaviors varied by racial/ethnic group. In both contexts, family resources cannot explain the sizable cross-country differences in verbal skills. In the United Kingdom, Indian adolescents had nearly one-third of a standard deviation increase in their verbal scores whereas in the United States, Black and Latino adolescents had scores nearly two-fifths and one-fifth of a standard deviation below the mean, respectively. CONTRIBUTION: We use a detailed race/ethnic classification in the investigation of racial/ethnic inequalities across the United States and United Kingdom. There are strong family resource effects, suggesting that relative family advantages and disadvantages do have meaningful associations with adolescent socioemotional and cognitive development. Although levels of resources do explain some cross-national differences, there appears to be a broader range of family background variables in the United Kingdom that influence adolescent development. Our findings point to the critical role of both the extent and nature of family social capital in affecting adolescent development.

Perceived Interpersonal Discrimination and Older Women's Mental Health: Accumulation Across Domains, Attributions, and Time.

Experiencing discrimination is associated with poor mental health, but how cumulative experiences of perceived interpersonal discrimination across attributes, domains, and time are associated with mental disorders is still unknown. Using data from the Study of Women's Health Across the Nation (1996-2008), we applied latent class analysis and generalized linear models to estimate the association between cumulative exposure to perceived interpersonal discrimination and older women's mental health. We found 4 classes of perceived interpersonal discrimination, ranging from cumulative exposure to discrimination over attributes, domains, and time to none or minimal reports of discrimination. Women who experienced cumulative perceived interpersonal discrimination over time and across attributes and domains had the highest risk of depression (Center for Epidemiologic Studies Depression Scale score ≥16) compared with women in all other classes. This was true for all women regardless of race/ethnicity, although the type and severity of perceived discrimination differed across racial/ethnic groups. Cumulative exposure to perceived interpersonal discrimination across attributes, domains, and time has an incremental negative long-term association with mental health. Studies that examine exposure to perceived discrimination due to a single attribute in 1 domain or at 1 point in time underestimate the magnitude and complexity of discrimination and its association with health.

Ethnic density effects for adult mental health: systematic review and meta-analysis of international studies.

BACKGROUND: Despite increased ethnic diversity in more economically developed countries it is unclear whether residential concentration of ethnic minority people (ethnic density) is detrimental or protective for mental health. This is the first systematic review and meta-analysis covering the international literature, assessing ethnic density associations with mental health outcomes. METHODS: We systematically searched Medline, PsychINFO, Sociological Abstracts, Web of Science from inception to 31 March 2016. We obtained additional data from study authors. We conducted random-effects meta-analysis taking into account clustering of estimates within datasets. Meta-regression assessed heterogeneity in studies due to ethnicity, country, generation, and area-level deprivation. Our main exposure was ethnic density, defined as the residential concentration of own racial/ethnic minority group. Outcomes included depression, anxiety and the common mental disorders (CMD), suicide, suicidality, psychotic experiences, and psychosis. RESULTS: We included 41 studies in the review, with meta-analysis of 12 studies. In the meta-analyses, we found a large reduction in relative odds of psychotic experiences [odds ratio (OR) 0.82 (95% confidence interval (CI) 0.76-0.89)] and suicidal ideation [OR 0.88 (95% CI 0.79-0.98)] for each 10 percentage-point increase in own ethnic density. For CMD, depression, and anxiety, associations were indicative of protective effects of own ethnic density; however, results were not statistically significant. Findings from narrative review were consistent with those of the meta-analysis. CONCLUSIONS: The findings support consistent protective ethnic density associations across countries and racial/ethnic minority populations as well as mental health outcomes. This may suggest the importance of the social environment in patterning detrimental mental health outcomes in marginalized and excluded population groups.

Racial/Ethnic Inequities in Low Birth Weight and Preterm Birth: The Role of Multiple Forms of Stress.

Introduction Racial/ethnic inequities in low birth weight (LBW) and preterm birth (PTB) persist in the United States. Research has identified numerous risk factors for adverse birth outcomes; however, they do not fully explain the occurrence of, or inequalities in PTB/LBW. Stress has been proposed as one explanation for differences in LBW and PTB by race/ethnicity. Methods Using the Pregnancy Risk Assessment Monitoring System (PRAMS) data from 2012 to 2013 for 21 states and one city (n = 15,915) we used Poisson regression to estimate the association between acute, financial and relationship stressors and LBW and PTB, and to examine the contribution of these stressors individually and simultaneously to racial/ethnic differences in LBW and PTB. Results Adjusting for age and race/ethnicity, acute (p < 0.001), financial (p < 0.001) and relationship (p < 0.05) stressors were associated with increased risk of LBW, but only acute (p < 0.05) and financial (p < 0.01) stress increased risk of PTB. Across all models, non-Hispanic blacks had higher risk of LBW and PTB relative to non-Hispanic whites (IRR 1.87, 95% CI 1.55, 2.27 and IRR 1.46, 95% CI 1.18, 1.79). Accounting for the effects of stressors attenuated the risk of LBW and PTB by 17 and 22% respectively, but did not fully explain the increased likelihood of LBW and PTB among non-Hispanic blacks. Discussion Results of this study demonstrate that stress may increase the risk of LBW and PTB. While stressors may contribute to racial/ethnic differences in LBW and PTB, they do not fully explain them. Mitigating stress during pregnancy may help promote healthier birth outcomes and reduce racial/ethnic inequities in LBW and PTB.

Cumulative Effect of Racial Discrimination on the Mental Health of Ethnic Minorities in the United Kingdom.

OBJECTIVES: To examine the longitudinal association between cumulative exposure to racial discrimination and changes in the mental health of ethnic minority people. METHODS: We used data from 4 waves (2009-2013) of the UK Household Longitudinal Study, a longitudinal household panel survey of approximately 40 000 households, including an ethnic minority boost sample of approximately 4000 households. RESULTS: Ethnic minority people who reported exposure to racial discrimination at 1 time point had 12-Item Short Form Health Survey (SF-12) mental component scores 1.93 (95% confidence interval [CI] = -3.31, -0.56) points lower than did those who reported no exposure to racial discrimination, whereas those who had been exposed to 2 or more domains of racial discrimination, at 2 different time points, had SF-12 mental component scores 8.26 (95% CI = -13.33, -3.18) points lower than did those who reported no experiences of racial discrimination. Controlling for racial discrimination and other socioeconomic factors reduced ethnic inequalities in mental health. CONCLUSIONS: Cumulative exposure to racial discrimination has incremental negative long-term effects on the mental health of ethnic minority people in the United Kingdom. Studies that examine exposure to racial discrimination at 1 point in time may underestimate the contribution of racism to poor health.

Bullying Victimization and Racial Discrimination Among Australian Children.

OBJECTIVES: To compare the prevalence of bullying victimization and racial discrimination by ethnicity. METHODS: We completed a cross-sectional analysis of 3956 children aged 12 to 13 years from wave 5 (2011-2012) of the nationally representative Longitudinal Study of Australian Children. RESULTS: Bullying victimization and racial discrimination were weakly associated and differently patterned by ethnicity. Children from visible minorities reported less bullying victimization but more racial discrimination than did their peers with Australian-born parents. Indigenous children reported the highest risk of bullying victimization and racial discrimination. CONCLUSIONS: Peer victimization and racial discrimination each require specific attention as unique childhood stressors. A focus on general bullying victimization alone may miss unique stress exposures experienced by children from stigmatized ethnic backgrounds.