Assessing Mental Health Treatment Receipt Among Asian Adults with Limited English Proficiency Using an Intersectional Approach.

U.S. Asian adults and people with limited English proficiency (LEP) confront mental health treatment receipt disparities. At the intersection of racial and language injustice, Asian adults with LEP may face even greater disparity, but studies have not assessed this through explicitly intersectional approaches. Using 2019 and 2020 National Survey of Drug Use and Health data, we computed disparities in mental health treatment among those with mental illness comparing: Non-Hispanic (NH) Asian adults with LEP to NH White adults without LEP (joint disparity), NH Asian adults without LEP to NH White adults without LEP (referent race disparity), NH Asian adults with LEP to those without LEP (referent LEP disparity), and the joint disparity versus the sum of referent disparities (excess intersectional disparity). In age- and gender-adjusted analyses, excess intersectional disparity was 26.8% (95% CI=-29.8%-83.4%) of the joint disparity in 2019 and 63.0% (95% CI=29.1%-96.8%) in 2020. The 2019 joint disparity was 1.37 (95% CI=0.31-2.42) times that if the race-related disparity did not vary by LEP, and if LEP-related disparity did not vary by race; this figure was 2.70 (95% CI=0.23-5.17) in 2020. These findings highlight the necessity of considering the intersection of race and LEP in addressing mental health treatment disparities.

Getting Precise about Gender and Sex Measurement: A Primer for Epidemiologists.

Accurately measuring gender and sex is crucial in public health and epidemiology. Iteratively reexamining how variables-including gender and sex-are conceptualized and operationalized is necessary to achieve impactful research. Reexamining gender and sex advances epidemiology toward its goals of health promotion and disease elimination. While we cannot reduce the complexities of sex and gender to simply an issue of measurement, striving to capture these concepts and experiences accurately must be an ongoing dialogue and practice-to the benefit of the field and population health. We assert that epidemiology must counteract misconceptions and accurately measure gender and sex in epidemiology. We aim to summarize existing critiques and guiding principles in measuring gender and sex that can be applied in practice.

The Association of Oncology Provider Density With Black-White Disparities in Cancer Mortality in US Counties.

BACKGROUND: Black-White racial disparities in cancer mortality are well-documented in the US. Given the estimated shortage of oncologists over the next decade, understanding how access to oncology care might influence cancer disparities is of considerable importance. We aim to examine the association between oncology provider density in a county and Black-White cancer mortality disparities. METHODS: An ecological study of 1048 US counties was performed. Oncology provider density was estimated using the 2013 National Plan and Provider Enumeration System data. Black:White cancer mortality ratio was calculated using 2014-2018 age-standardized cancer mortality rates from State Cancer Profiles. Linear regression with covariate adjustment was constructed to assess the association of provider density with (1) Black:White cancer mortality ratio, and (2) cancer mortality rates overall, and separately among Black and White persons. RESULTS: The mean Black:White cancer mortality ratio was 1.12, indicating that cancer mortality rate among Black persons was on average 12% higher than that among White persons. Oncology provider density was significantly associated with greater cancer mortality disparities: every 5 additional oncology providers per 100 000 in a county was associated with a .02 increase in the Black:White cancer mortality ratio (95% CI: .007 to .03); however, the unexpected finding may be explained by further analysis showing that the relationship between oncology provider density and cancer mortality was different by race group. Every 5 additional oncologists per 100 000 was associated with a 1.6 decrease per 100 000 in cancer mortality rates among White persons (95% CI: -3.0 to -.2), whereas oncology provider density was not associated with cancer mortality among Black persons. CONCLUSION: Greater oncology provider density was associated with significantly lower cancer mortality among White persons, but not among Black persons. Higher oncology provider density alone may not resolve cancer mortality disparities, thus attention to ensuring equitable care is critical.

Our study provides timely information to address the growing concern about the need to increase oncology supply and the impact it might have on racial disparities in cancer outcomes. This analysis of counties across the US is the first study to estimate the association of oncology provider density with Black-White racial disparities in cancer mortality. We show that having more oncology providers in a county is associated with significantly lower cancer mortality among the White population, but is not associated with cancer mortality among the Black population, thereby leading to a disparity. Our findings suggest that having more oncology providers alone may be insufficient to overcome existing disadvantages for Black patients to access and use high-quality cancer care. These findings have important implications for addressing racial disparities in cancer outcomes that are persistent and well-documented in the US.

Identifying HIV PrEP Attributes to Increase PrEP Use Among Different Groups of Gay, Bisexual, and Other Men Who Have Sex with Men: A Latent Class Analysis of a Discrete Choice Experiment.

Daily pre-exposure prophylaxis (PrEP) is highly effective at preventing HIV among gay, bisexual, and other men who have sex with men (GBMSM), although uptake remains suboptimal. By identifying the features of PrEP that appeal to various subgroups of GBMSM, this study aimed to improve PrEP uptake by examining preferences for PrEP use. Adults ≥ 18 years old in six New England states completed an online discrete choice experiment survey. A latent class analysis (LCA) was conducted to identify groups of GBMSM based on four attributes of choices for PrEP (cost, time, side effects, and mode of administration). Multinominal logistic regression was conducted to compare the association between sociodemographic and behavioral characteristics and class memberships. Data from 675 GBMSM were analyzed. A 3-Class model was selected as the best fit model. Class 1 (47.7% of individuals) was identified as having "no specific preferences". Class 2 (18.5% of individuals) were "Cost- and time-conscious" and were significantly more likely to be older, have prior sexually transmitted infection (STI) testing, have low household income, private insurance, and have extreme concerns about HIV risk than those with no specific preference (Class 1). Finally, Class 3 (34.1% of individuals) were "Side effects-conscious" and were more likely to have low income, private insurance, and have moderate and extreme concerns about HIV risk than those with no specific preference (Class 1). Findings indicate that outreach to GBMSM who have never used PrEP should emphasize low cost and short travel times to increase potential PrEP use.

Correcting the Narrative Toward More Diverse & Inclusive Institutions.

As the first anniversary of the inaugural Sherman A. James Diverse and Inclusive Epidemiology Award from the Society of Epidemiologic Research approaches, I present a transcript of that session.

Different Responses to Social Capital Among Black People and White People: What Racial Differential Item Functioning Reveals for Racial Health Equity.

Social capital has been conceptualized as features of social organization, such as networks, and norms that facilitate coordination and cooperation for mutual benefit. Because of long-standing anti-Black structural oppression in the United States, social capital may be associated with health differently for Black people than for other racial/ethnic groups. Our aim was to examine the psychometric properties of social capital indicators, comparing responses from Black and White people to identify whether there is differential item functioning (DIF) in social capital according to race. DIF examines how items are related to a latent construct and whether this relationship differs across groups such as different racial groups. We used data from respondents to the Southeastern Pennsylvania Household Health Survey in 2004, who lived in Philadelphia (n = 2,048), a city with a large Black population. We used item response theory analysis to test for racial DIF. We found DIF across the items, indicating measurement error, which could be related to the way these items were developed (i.e., based on cultural assumptions tested in mainstream White America). Hence, our findings underscore the need to interrogate the assumptions that underly existing social capital items through an equity-based lens, and to take corrective action when developing new items to ensure that they are racially and culturally congruent.

Engaging Black sexual minority women in breast cancer research: Lessons in community partnerships.

BACKGROUND: Black sexual minority women (BSMW) face significant breast cancer health inequities and are underrepresented in health research because of historical and present-day exclusion. However, there exists no peer-reviewed literature on best practices for the inclusion of BSMW in cancer research. "Our Breast Health: The Access Project" was a national primary data collection study in June 2018 through October 2019 that aimed to identify facilitators and barriers to breast cancer care among BSMW, and that successfully recruited the highest number of BSMW for any national breast cancer screening study at the time of its publication. METHODS: The present analysis highlights best practices for reaching BSMW by examining by how effective various recruitment sources were at recruiting BSMW. Recruitment partners were grouped into several categories: (1) cancer focused, (2) Black women or sexual minority women focused, (3) BSMW focused, (4) social media, and (5) other. Then logistic regression was used to estimate the odds that a particular recruitment source category could recruit BSMW compared with other categories. RESULTS: Partnerships with community-based organizations led by and intended for BSMW were the most successful at recruiting BSMW, demonstrating the importance of an intersectional approach to recruitment. Community-based organizations focused on BSMW specifically were 26 times more successful in recruiting BSMW to the study compared with recruiting Black women who were not sexual minorities (odds ratio, 26.43 [95% CI, 7.50-93.10]). CONCLUSIONS: Successful recruitment enables breast cancer research grounded in the perspectives of BSMW, which can generate key findings that have the potential to remedy longstanding health inequities for this population.

Sexually Transmitted Infections Risk and Interstate Sexual Networks Among Men Who Have Sex With Men in New England.

ABSTRACT: By investigating relationships between sexual mobility and sexual transmitted infection (STI) risk factors among men who have sex with men, we found that STI history, number of sexual partners, and substance use are associated with increased odds of interstate sexual encounters, suggesting that interjurisdictional approaches to STI prevention are needed.

Critical interactions between race and the highly granular area deprivation index in liver transplant evaluation.

Neighborhood socioeconomic deprivation may have important implications on disparities in liver transplant (LT) evaluation. In this retrospective cohort study, we constructed a novel dataset by linking individual patient-level data with the highly granular Area Deprivation Index (ADI), which is advantageous over other neighborhood measures due to: specificity of Census Block-Group (versus Census Tract, Zip code), scoring, and robust variables. Our cohort included 1377 adults referred to our center for LT evaluation 8/1/2016-12/31/2019. Using modified Poisson regression, we tested for effect measure modification of the association between neighborhood socioeconomic status (nSES) and LT evaluation outcomes (listing, initiating evaluation, and death) by race and ethnicity. Compared to patients with high nSES, those with low nSES were at higher risk of not being listed (aRR = 1.14; 95%CI 1.05-1.22; p < .001), of not initiating evaluation post-referral (aRR = 1.20; 95%CI 1.01-1.42; p = .03) and of dying without initiating evaluation (aRR = 1.55; 95%CI 1.09-2.2; p = .01). While White patients with low nSES had similar rates of listing compared to White patients with high nSES (aRR = 1.06; 95%CI .96-1.17; p = .25), Underrepresented patients from neighborhoods with low nSES incurred 31% higher risk of not being listed compared to Underrepresented patients from neighborhoods with high nSES (aRR = 1.31; 95%CI 1.12-1.5; p < .001). Interventions addressing neighborhood deprivation may not only benefit patients with low nSES but may address racial and ethnic inequities.

Optimizing Uptake of Long-Acting Injectable Pre-exposure Prophylaxis for HIV Prevention for Men Who Have Sex with Men.

Pre-exposure prophylaxis (PrEP) is a highly effective HIV prevention tool. Long-acting injectable PrEP (LAI-PrEP) offers another opportunity to reduce HIV. However, how at-risk individuals will consider LAI-PrEP over other modes of administration is unclear. We conducted a discrete choice experiment on preferences for PrEP among a sample of N = 688 gay, bisexual, and other men who have sex with men (GBMSM). We analyzed preferences for mode of administration, side-effects, monetary cost, and time cost using a conditional logit model and predicted preference for PrEP options. LAI-PrEP was preferred, despite mode of administration being the least important PrEP attribute. Side-effects were the most important attribute influencing preferences for PrEP (44% of decision); costs were second-most-important (35% of decision). PrEP with no side-effects was the most important preference, followed by monthly out-of-pocket costs of $0. Practitioners and policymakers looking to increase PrEP uptake should keep costs low, communicate clearly about PrEP side-effects, and allow the use of patient-preferred modes of PrEP administration, including LAI-PrEP.

RESUMEN: La profilaxis prexposición (PrEP) es una herramienta de prevención del VIH muy eficaz. La PrEP inyectable de acción prolongada (LAI-PrEP) ofrece otra oportunidad para reducir el VIH. Sin embargo, no está claro cómo las personas en riesgo considerarán LAI-PrEP sobre otros modos de administración. Realizamos un experimento de elección discreta sobre las preferencias por la PrEP entre una muestra de N = 688 hombres homosexuales, bisexuales y otros hombres que tienen sexo con hombres (GBMSM). Analizamos las preferencias por el modo de administración, los efectos secundarios, el costo monetario y el costo del tiempo mediante un modelo logit condicional y la preferencia prevista por las opciones de PrEP. Se prefirió LAI-PrEP, a pesar de que el modo de administración es el atributo de PrEP menos importante. Los efectos secundarios fueron el atributo más importante que influyó en las preferencias por la PrEP (44% de la decisión); los costos fueron los segundos más importantes (35% de la decisión). La PrEP sin efectos secundarios fue la preferencia más importante, seguida de costos de bolsillo mensuales de $0. Los médicos y legisladores que buscan aumentar la aceptación de la PrEP deben mantener los costos bajos, comunicar claramente los efectos secundarios de la PrEP y permitir el uso de los modos de administración de la PrEP preferidos por los pacientes, incluido LAI-PrEP.

Same-Sex Marriage Laws, Provider-Patient Communication, and PrEP Awareness and Use Among Gay, Bisexual, and Other Men Who have Sex with Men in the United States.

State-level structural stigma and its consequences in healthcare settings shape access to pre-exposure prophylaxis (PrEP) for HIV prevention among gay, bisexual, and other men who have sex with men (GBMSM). Our objective was to assess the relationships between same-sex marriage laws, a measure of structural stigma at the state level, provider-patient communication about sex, and GBMSM awareness and use of PrEP. Using data from the Fenway Institute's MSM Internet Survey collected in 2013 (N = 3296), we conducted modified Poisson regression analyses to evaluate associations between same-sex marriage legality, measures of provider-patient communication, and PrEP awareness and use. Living in a state where same-sex marriage was legal was associated with PrEP awareness (aPR 1.27; 95% CI 1.14, 1.41), as were feeling comfortable discussing with primary care providers that they have had sex with a man (aPR 1.63; 95% CI 1.46, 1.82), discussing with their primary care provider having had condomless sex with a man (aPR 1.65; 95% CI 1.49, 1.82), and discussing with their primary care provider ways to prevent sexual transmission of HIV (aPR 1.39; 95% CI 1.26, 1.54). Each of these three measures of provider-patient communication were additionally associated with PrEP awareness and use. In sum, structural stigma was associated with reduced PrEP awareness and use. Policies that reduce stigma against GBMSM may help to promote PrEP and prevent HIV transmission.

An intersectional analysis of historical and contemporary structural racism on non-fatal shootings in Baltimore, Maryland.

Introduction Non-fatal shooting rates vary tremendously within cities in the USA. Factors related to structural racism (both historical and contemporary) could help explain differences in non-fatal shooting rates at the neighbourhood level. Most research assessing the relationship between structural racism and firearm violence only includes one dimension of structural racism. Our study uses an intersectional approach to examine how the interaction of two forms of structural racism is associated with spatial non-fatal shooting disparities in Baltimore, Maryland. Methods We present three additive interaction measures to describe the relationship between historical redlining and contemporary racialized economic segregation on neighbourhood-level non-fatal shootings. Results Our findings revealed that sustained disadvantage census tracts (tracts that experience contemporary socioeconomic disadvantage and were historically redlined) have the highest burden of non-fatal shootings. Sustained disadvantage tracts had on average 24 more non-fatal shootings a year per 10 000 residents compared with similarly populated sustained advantage tracts (tracts that experience contemporary socioeconomic advantage and were not historically redlined). Moreover, we found that between 2015 and 2019, the interaction between redlining and racialized economic segregation explained over one-third of non-fatal shootings (approximately 650 shootings) in sustained disadvantage tracts. Conclusion These findings suggest that the intersection of historical and contemporary structural racism is a fundamental cause of firearm violence inequities in Baltimore. Intersectionality can advance injury prevention research and practice by (1) serving as an analytical tool to expose inequities in injury-related outcomes and (2) informing the development and implementation of injury prevention interventions and policies that prioritise health equity and racial justice.

What Structural Racism Is (or Is Not) and How to Measure It: Clarity for Public Health and Medical Researchers.

Interest in studying structural racism's impacts on health has grown exponentially in recent years. Across these studies, there is much heterogeneity in the definition and measurement of structural racism, leading to mixed interpretations of structural racism's impact on health. A precise definition of structural racism can offer conceptual clarity to inform what mechanisms to investigate and is imperative for conducting high-quality research on it and dismantling it. In this commentary, we trace the evolution of the definitions of structural racism and suggest ways in which the measurement of structural racism should move forward given these definitions.

Advancing the Social Epidemiology Mission of the American Journal of Epidemiology.

Social epidemiology is concerned with how social forces influence population health. Rather than focusing on a single disease (as in cancer or cardiovascular epidemiology) or a single type of exposure (e.g., nutritional epidemiology), social epidemiology encompasses all the social and economic determinants of health, both historical and contemporary. These include features of social and physical environments, the network of relationships in a society, and the institutions, politics, policies, norms and cultures that shape all of these forces. This commentary presents the perspective of several editors at the Journal with expertise in social epidemiology. We articulate our thinking to encourage submissions to the Journal that: 1) expand knowledge of emerging and underresearched social determinants of population health; 2) advance new empirical evidence on the determinants of health inequities and solutions to advance health equity; 3) generate evidence to inform the translation of research on social determinants of health into public health impact; 4) contribute to innovation in methods to improve the rigor and relevance of social epidemiology; and 5) encourage critical self-reflection on the direction, challenges, successes, and failures of the field.

Social Capital, Black Social Mobility, and Health Disparities.

This review aims to delineate the role of structural racism in the formation and accumulation of social capital and to describe how social capital is leveraged and used differently between Black and White people as a response to the conditions created by structural racism. We draw on critical race theory in public health praxis and restorative justice concepts to reimagine a race-conscious social capital agenda. We document how American capitalism has injured Black people and Black communities' unique construction of forms of social capital to combat systemic oppression. The article proposes an agenda that includes communal restoration that recognizes forms of social capital appreciated and deployed by Black people in the United States that can advance health equity and eliminate health disparities. Developing a race-conscious social capital framing that is inclusive of and guided by Black community members and academics is critical to the implementation of solutions that achieve racial and health equity and socioeconomic mobility.

Pharmacy-Based Interventions to Increase Use of HIV Pre-exposure Prophylaxis in the United States: A Scoping Review.

HIV pre-exposure prophylaxis (PrEP) remains underutilized in the U.S. Since greater than 85% of PrEP prescriptions are filled at commercial pharmacies, pharmacists are uniquely positioned to increase PrEP use. This scoping review explores pharmacy-based initiatives to increase PrEP use. We searched PubMed, PsycINFO, CINAHL, and Scopus for peer-reviewed studies on pharmacist-led interventions to increase PrEP use or pharmacy-based PrEP initiatives. Forty-nine articles were included in this review. Overall, studies demonstrated that patients expressed strong support for pharmacist prescription of PrEP. Three intervention designs compared changes in PrEP initiation or knowledge pre- and post-intervention. Commentary/review studies recommended PrEP training for pharmacists, policy changes to support pharmacist screening for HIV and PrEP prescription, and telemedicine to increase prescriptions. Pharmacists could play key roles in improving PrEP use in the U.S. Studies that assess improvements in PrEP use after interventions such as PrEP prescription, PrEP-specific training, and adherence monitoring by pharmacists are needed.

Foundational Approaches to Advancing Hearing Health Equity: A Primer in Social Epidemiology.

Hearing health is inextricably linked to factors beyond biology. Social, demographic, environmental, geographic, and historical influences affect hearing health, but these factors are often unmeasured within traditional biological, clinical, and epidemiological studies of hearing health. With increasing recognition of hearing health over the life course as a public health priority, there is also a growing understanding of existing hearing health inequities at the individual, community, national, and global levels. To make progress in addressing these inequities, public health disciplines, such as social epidemiology, can provide valuable frameworks. With a focus on integrating the biological and functional with social and structural factors influencing health, social epidemiology provides key concepts and approaches for filling existing research and practice gaps. In this review, we introduce the discipline of social epidemiology and its associated concepts to inspire greater cross-disciplinary collaboration for the ultimate goal of advancing hearing health equity.

A database of US state policies to mitigate COVID-19 and its economic consequences.

BACKGROUND: Since COVID-19 first appeared in the United States (US) in January 2020, US states have pursued a wide range of policies to mitigate the spread of the virus and its economic ramifications. Without unified federal guidance, states have been the front lines of the policy response. MAIN TEXT: We created the COVID-19 US State Policy (CUSP) database ( https://statepolicies.com/ ) to document the dates and components of economic relief and public health measures issued at the state level in response to the COVID-19 pandemic. Documented interventions included school and business closures, face mask mandates, directives on vaccine eligibility, eviction moratoria, and expanded unemployment insurance benefits. By providing continually updated information, CUSP was designed to inform rapid-response, policy-relevant research in the context of the COVID-19 pandemic and has been widely used to investigate the impact of state policies on population health and health equity. This paper introduces the CUSP database and highlights how it is already informing the COVID-19 pandemic response in the US. CONCLUSION: CUSP is the most comprehensive publicly available policy database of health, social, and economic policies in response to the COVID-19 pandemic in the US. CUSP documents widespread variation in state policy decisions and implementation dates across the US and serves as a freely available and valuable resource to policymakers and researchers.

Racial/Ethnic Inequities in Adverse Childhood Experiences and Selected Health-Related Behaviors and Problems Among Maryland Adolescents.

We examined racial/ethnic inequities in the prevalence of adverse childhood experiences (ACEs) and examined the association between ACEs and selected health-related behaviors and problems. Data for this cross-sectional study come from the 2018 Maryland Youth Risk Behavior Survey/Youth Tobacco Survey, a statewide survey of high school students (n = 40,188). ACEs included caregiver verbal abuse and household food insecurity, substance use or gambling, mental illness, and involvement with the criminal justice system. We estimated the prevalence of ACEs overall and by race/ethnicity, and then used multiple logistic regression to determine associations between ACEs and emotional/behavioral problems, adjusting for race/ethnicity. Outcome variables included emotional distress, poor school performance, suicidal ideation, fighting, alcohol use, and marijuana use. More than one fifth of students reported each individual ACE. Differences in the prevalence of ACEs by race/ethnicity were statistically significant (p < .001). More than one fourth (25.8%) reported one of the five ACEs, 15.1% reported two, and 15.4% reported three or more. For each ACE, reporting having experienced it (vs. not) was associated with a >30% higher prevalence for each of the outcome variables. Among students who reported three or more ACEs (relative to none), the odds of emotional distress and suicidal ideation were more than 8 times greater. Among Maryland adolescents, ACEs are common, are inequitably distributed by race/ethnicity, and are strongly linked to behavioral health. Findings suggest the need to monitor ACEs as a routine component of adolescent health surveillance and to refocus assessment and intervention toward "upstream" factors that shape adolescent health.

"This is some mess right here": Exploring interactions between Black sexual minority women and health care providers for breast cancer screening and care.

BACKGROUND: Few studies have explored how the intersection of race and sexual identity contribute to breast cancer disparities for Black sexual minority women (SMW). Issues within patient-provider relationships, including bias, contribute to health disparities for minority groups. The authors used constructs from self-determination theory (SDT) to explore the nature of health care provider interactions in breast cancer screening and care among Black SMW. METHODS: Participants were sampled nationally through social media, targeted emails, and referrals. Qualitative, in-depth interviews were conducted with 15 Black cisgender SMW, ages 38 to 64 years, who had a breast cancer diagnosis or recent abnormal mammogram. Interviews were conducted face-to-face or online, audio-recorded, and transcribed verbatim. Two analysts coded the interviews. Codes were analyzed across interviews to identify themes salient to SDT. RESULTS: Themes aligned with the SDT constructs of relatedness and autonomy. Some participants discussed feeling most understood by Black and/or female providers who shared at least 1 of their identities. Feeling understood through shared identity contributed to participants feeling seen and heard by their providers. Participants who discussed negative experiences with providers believed that the provider made negative assumptions about them based on their race and/or sexual orientation. CONCLUSIONS: When interacting with health care providers for breast cancer screening and care, Black SMW face specific challenges related to their multiply marginalized social position. Reducing health care provider bias toward Black SMW may improve patients' desires to continue in care. Providing equitable care while acknowledging and respecting women with multiply marginalized identities may improve the nature of these interactions.