Examining the Relationship between Social Determinants of Health and Adverse Pregnancy Outcomes in Black Women.

OBJECTIVE: Our objective was to examine associations between social determinants of health (cultural, neighborhood, and psychosocial factors) and adverse pregnancy outcomes (gestational age at birth [GAB], preterm birth [PTB], and preeclampsia) in Black women. STUDY DESIGN: Cross-sectional data (n = 204) comprised adult Black women aged ≥18 years who delivered between 2013 and 2022 in Milwaukee,Wisconsin. Sequential unadjusted linear and logistic regression models were run to evaluate associations between social determinants of health and pregnancy outcomes. Stepwise regressions with forward selection were run to test the contribution of the social determinants of health to adverse pregnancy outcomes, independent of the contribution of established risk factors. RESULTS: Mean GAB was 37.9 weeks, 19.6% had a PTB and 17.7% had preeclampsia. In all fully adjusted models, education (ß0.15, 95% confidence interval [CI]: 0.005, 0.29), nulliparity (ß -1.26, 95%CI: -2.08, -0.44), multifetal gestation (ß -2.67, 95% CI: -4.29, -1.05), and exposure to neighborhood violence (ß -0.13, 95%CI: -0.25, -0.005) were associated with shortened GAB. Education (adjusted odds ratio [aOR]: 0.83, 95%CI: 0.69, 0.99), provider trust (aOR: 0.94, 95%CI: 0.88, 0.99), chance health locus of control (aOR: 0.88, 95%CI: 0.78, 0.99), and anxiety (aOR: 0.81, 95%CI: 0.69, 0.95) were associated with reduced odds of PTB. Powerful others health locus of control (aOR: 1.16, 95%CI: 1.03, 1.32), depression (aOR: 1.17, 95%CI: 1.01, 1.34), nulliparity (aOR: 4.73, 95%CI: 1.79, 12.55), multifetal gestation (aOR: 17.78, 95%CI: 3.49, 90.50), diabetes (aOR: 4.71, 95%CI: 1.17, 19.00), and obstructive sleep apnea (aOR: 44.28, 95%CI: 2.50, 783.12) were associated with increased odds of PTB. Internal health locus of control (aOR: 1.13, 95%CI: 1.01, 1.25), depression (aOR: 1.09, 95%CI: 1.01, 1.17), preeclampsia in a previous pregnancy (aOR: 5.96, 95% CI: 2.22, 16.01), and kidney disease (aOR: 34.27, 95% CI: 1.54, 763.75) were associated with preeclampsia. CONCLUSION: Provider trust, health locus of control, neighborhood violence, depression, and anxiety were associated with adverse pregnancy outcomes in Black women, independent of demographic and clinical risk factors. KEY POINTS: · We identified associations between exposure to neighborhood violence and gestational age at birth.. · Trust, locus of control, depression, and anxiety were associated with preterm birth and preeclampsia.. · Future research should focus on interventions that address social and clinical factors..

Contraception utilization in women with pregestational diabetes.

OBJECTIVE: To compare contraception use between women with and without pregestational diabetes. METHODS: Cross-sectional data on women aged 18-44 years from 2011 to 2017 National Survey of Family Growth (NSFG) was analysed. Maternal diabetes was defined as the presence of pre-gestational type 1 or type 2 diabetes. Bivariate and multiple logistic regression analyses were run to evaluate the association between the use of contraception and by contraception type: permanent, long-acting reversible contraception (LARC), other hormonal method, other non-hormonal method, and none, and maternal diabetes status, controlling for relevant covariates. RESULTS: Among the total study sample of 28,454, 1344 (4.7%) had pregestational diabetes. Unadjusted analysis showed women with a history of pregestational diabetes were more likely to use permanent contraception following pregnancy (58.0% vs. 38.7%, p < 0.001) or no contraception (27.2% vs. 24.5%, p < 0.001), but less likely to use LARC (3.4% vs. 11.7%, p < 0.001), other hormonal contraception (4.1% vs. 8.9%, p < 0.001), or other non-hormonal contraception (7.2% vs. 16.4%, p < 0.001). In adjusted analyses, permanent (aOR 1.62, 95% CI 0.72-2.26) remained significant, however the differences were no longer statistically significant: LARC (aOR 0.34, 95% CI 0.12-1.00); other hormonal (aOR 0.61, 95% CI 0.27-1.35); other non-hormonal (aOR 0.59, 95% CI 0.25-1.43); and None (aOR 1.11, 95% CI 0.65-1.89). CONCLUSION: In this analysis, we found that women with pregestational diabetes were more likely to use permanent contraception methods compared to women without pregestational diabetes; however over a quarter of women with pregestational diabetes did not use contraception between pregnancies.

Trends in Healthcare Expenditures among Adults in the United States by Cancer Diagnosis Status, 2008-2016: A Cross-Sectional Study.

BACKGROUND: This study aims to assess trends in direct medical expenditures and indirect costs between adults with and without a prior cancer diagnosis from 2008 to 2016. METHODS: Nine years of data (2008-2016) from the Medical Expenditure Panel Survey (weighted N = 236,811,875) were used. The outcomes included medical expenditures (total expenditure, inpatient, office-based, medications, outpatient, dental, emergency room visits, home health, other) and health-related missed workdays. The predictor was prior cancer diagnosis. Covariates included demographic characteristics, comorbidities, and calendar year at time of survey completion. Two-part statistical modeling with a combination of binomial and positive distributions was used to estimate medical expenditures and missed workdays. Data were clustered into five timepoints: 2008 to 2009, 2010 to 2011, 2012 to 2013, 2014 to 2015, and 2016. RESULTS: Eleven percent of the sample (n = 25,005,230) had a prior cancer diagnosis. Compared with those without a prior cancer diagnosis, those with a prior cancer diagnosis had higher mean incremental total expenditures across all years. Between 2008 and 2016, the adjusted annual incremental total expenditures were $3,522 [95% confidence interval (CI), $3,072-$3,972]; office-based visits ($1,085; 95% CI, $990-$1180); inpatient hospitalizations ($810; 95% CI, $627-$992); outpatient appointments ($517; 95% CI, $434-$600); and medications ($409; 95% CI, $295-$523); and health-related missed workdays (0.75; 95% CI, 0.45-1.04) compared with adults without a prior cancer diagnosis. CONCLUSIONS: Adults with a prior cancer diagnosis had significantly increased healthcare expenditures and health-related missed workdays compared with those with no cancer diagnosis. IMPACT: Our findings highlight the need for increasing strategies to remedy the impact of increasing direct and indirect costs associated with cancer survivorship as the population grows and ages.

Pathways between neighbourhood factors, stress and glycaemic control in individuals with type 2 diabetes in Southeastern United States: a cross-sectional pathway analysis.

OBJECTIVES: Understanding the pathway by which neighbourhood factors influence glycaemic control may be crucial to addressing health disparities in diabetes. This study aimed to examine if the pathway between neighbourhood factors and glycaemic control is mediated by stress. DESIGN: Structured equation modelling (SEM) was used to investigate direct and indirect effects in the relationship between neighbourhood factors, stress and glycaemic control, with standardised estimates to allow comparison of paths. PARTICIPANTS: Data was obtained from 615 adults with type 2 diabetes in the Southeastern United States. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome variable was glycaemic control determined by glycated haemoglobin (HbA1c) within the prior 6 months. Neighbourhood factors included neighbourhood violence, aesthetic quality of the neighbourhood, access to healthy food, and social cohesion. Stress was measured using the perceived stress scale. RESULTS: In the final model (χ2(158)=406.97, p<0.001, root mean square error of approximation=0.05, p-close 0.38, Comparative Fit Index=0.97, Tucker-Lewis index=0.96, the coefficient of determination=1.0), violence (r=0.79, p=0.006), neighbourhood aesthetics (r=0.74, p=0.02) and social cohesion (r=0.57, p=0.04) were significantly associated with higher perceived stress. Stress (r=0.06, p=0.004) was directly associated with higher glycaemic control. Significant indirect effects existed between violence and higher HbA1c (r=0.05, p=0.04). After controlling for other neighbourhood factors, there was no significant relationship between access to healthy food and either stress or glycaemic control. CONCLUSIONS: While a number of neighbourhood factors were directly associated with stress, only neighbourhood violence had a significant indirect effect on glycaemic control via stress within the tested pathway. Future studies should examine individual-level stress management interventions and should consider community-level interventions targeting neighbourhood violence as strategies for addressing disparities in diabetes.

Residential proximity to tree canopy and preterm birth in Black women.

BACKGROUND: There are marked racial disparities in obstetrical outcomes, with the incidence of preterm birth being the highest among non-Hispanic Black women. The presence of green space, such as forests and parks, is now widely viewed as a health-promoting characteristic of residential environments. OBJECTIVE: This study aimed to examine the association between the proximity of tree canopies to a prenatal residential address and the rates of preterm birth among non-Hispanic Black women in Milwaukee, Wisconsin. STUDY DESIGN: This was a retrospective, case-control study utilizing hospital pregnancy records of self-identified non-Hispanic Black women. The addresses of the women, who delivered from 2011 to 2019, were geocoded to characterize the percentage of tree canopy surrounding the prenatal address using the National Land Cover Database. Circular residential buffers of 100, 150, 250, and 500 m were used to assess the exposure to tree canopy coverage in proximity to a prenatal address. Univariable and multivariable analyses were conducted to determine whether tree canopy percentage at 4 different proximity buffers, examined both in means and quartiles, was associated with preterm birth (birth at <37 weeks' gestation). RESULTS: Of the 2771 non-Hispanic Black women included in the study, 333 (12.0%) experienced preterm births. Less tree canopy coverage was significantly (P < .05) associated with preterm birth, irrespective of whether the coverage was quantified as a mean or by quartile. In the unadjusted and adjusted models, which adjusted for sociodemographic and clinical risk factors for preterm birth, a 10% increase in tree canopy coverage was associated with lower odds of preterm birth at all 4 buffers examined. When examining the green space by quartile, higher quartiles were associated with lower odds of preterm birth at the 100-, 150-, and 250 m buffers, but not at the 500 m buffer. CONCLUSION: A higher percentage of tree canopy coverage in close proximity to the prenatal residential address is associated with lower odds of preterm birth among non-Hispanic Black women. These findings suggest that access to neighborhood green space is an important factor associated with preterm birth.

Canadian practice assessment in chronic obstructive pulmonary disease: respiratory specialist physician perception versus patient reality.

INTRODUCTION: Chronic obstructive pulmonary disease (COPD) is a common respiratory condition and the fourth leading cause of death in Canada. Optimal COPD management requires patients to participate in their care and physician knowledge of patients' perceptions of their disease. METHODS: A prospective study in which respiratory specialist physicians completed a practice assessment questionnaire and patient assessments for 15 to 20 consecutive patients with COPD. Patients also completed a questionnaire regarding their perceptions of COPD and its management. RESULTS: A total of 58 respiratory specialist physicians from across Canada completed practice assessments and 931 patient assessments. A total of 640 patients with COPD (96% with moderate, severe or very severe disease) completed questionnaires. Symptom burden was high and most patients had experienced a recent exacerbation. Potential COPD care gaps were identified with respect to appropriate medication prescription, lack of an action plan, and access to COPD educators and pulmonary rehabilitation. Perceived knowledge needs and gaps differed between physicians and patients. CONCLUSIONS: Despite the dissemination of Canadian and international COPD clinical practice guidelines for more than a decade, potential care gaps remain among patients seen by respiratory specialist physicians. Differing perceptions regarding many aspects of COPD among physicians and patients may contribute to these care gaps.

Awareness of risk factors among persons at risk for lung cancer, chronic obstructive pulmonary disease and sleep apnea: a Canadian population-based study.

OBJECTIVE: To assess awareness among persons at risk for lung cancer, chronic obstructive pulmonary disease (COPD) and sleep apnea regarding symptoms and risk factors of the disease, and their attitudes regarding the disease and toward those who are affected. METHODS: A quantitative hybrid telephone and Internet survey of a representative population of Canadian adults at risk for at least one of the three diseases was conducted. To measure the awareness and attitudes of First Nations, Inuit and Métis people to these diseases, a proportionate number were also surveyed.  RESULTS: A total of 3626 individuals were contacted. Of these, 3036 (84%) were eligible to participate. Of those at risk for lung cancer and COPD, 65% and 69%, respectively, were due to tobacco smoke exposure. Among those at risk, 72% believed that they were informed about lung cancer compared with 36% for COPD and 56% for sleep apnea. Most respondents were knowledgeable about the common symptoms of lung cancer, COPD and sleep apnea, but were less aware of the impact lifestyle choices could have on the development of these disorders and the availability of treatment. Most of the participants (77%) believed that smoking was an addiction rather than a habit (19%). There were no significant differences in the awareness of risk factors, symptoms and attitudes toward all three lung diseases between First Nations, Inuit and Métis people and the general population. CONCLUSIONS: Canadians are reasonably aware of risk factors and symptoms for lung cancer and sleep apnea. However, there is poor awareness of COPD as a disease entity. There is a lack of appreciation for the impact lifestyle choices and changes can have on lung diseases.

Optimizing pulmonary rehabilitation in chronic obstructive pulmonary disease--practical issues: a Canadian Thoracic Society Clinical Practice Guideline.

Pulmonary rehabilitation (PR) participation is the standard of care for patients with chronic obstructive pulmonary disease (COPD) who remain symptomatic despite bronchodilator therapies. However, there are questions about specific aspects of PR programming including optimal site of rehabilitation delivery, components of rehabilitation programming, duration of rehabilitation, target populations and timing of rehabilitation. The present document was compiled to specifically address these important clinical issues, using an evidence-based, systematic review process led by a representative interprofessional panel of experts. The evidence reveals there are no differences in major patient-related outcomes of PR between nonhospital- (community or home sites) or hospital-based sites. There is strong support to recommend that COPD patients initiate PR within one month following an acute exacerbation due to benefits of improved dyspnea, exercise tolerance and health-related quality of life relative to usual care. Moreover, the benefits of PR are evident in both men and women, and in patients with moderate, severe and very severe COPD. The current review also suggests that longer PR programs, beyond six to eight weeks duration, be provided for COPD patients, and that while aerobic training is the foundation of PR, endurance and functional ability may be further improved with both aerobic and resistance training.