Study designs, measures and indexes used in studying the structural racism as a social determinant of health in high income countries from 2000-2022: evidence from a scoping review.

BACKGROUND: Globally, structural racism has been well documented as an important social determinant of health (SODH) resulting in racial inequality related to health. Although studies on structural racism have increased over the years, the selection of appropriate designs, measures, and indexes of measurement that respond to SODH has not been comprehensively documented. Therefore, the lack of evidence seems to exist. This scoping review was conducted to map and summarize global evidence on the use of various designs, measures, and indexes of measurement when studying structural racism as a social determinant of health. METHODS: We performed a scoping review of global evidence from 2000 to 2022 published in 5 databases: PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycInfo, Web of Science, ProQuest, and relevant grey literature on structural racism. We conducted a systematic search using keywords and subject headings around 3 concepts. We included peer reviewed original research/review articles which conceived the framework of social determinants of health (SODH) and studied structural racism. RESULTS: Our review identified 1793 bibliographic citations for screening and 54 articles for final review. Articles reported 19 types of study design, 87 measures of exposure and 58 measures of health outcomes related to structural racism. 73 indexes or scales of measurement were used to assess health impacts of structural racism. Majority of articles were primary research (n = 43/54 articles; 79.6%), used quantitative research method (n = 32/54 articles; 59.3%) and predominantly conducted in the United States (n = 46/54 articles; 85.2.6%). Cross-sectional study design was the most used design (n = 17/54 articles; 31.5%) followed by systematic review (n = 7/54 articles; 13.0%) and narrative review (n = 6/54 articles; 11.1%). Housing and residential segregation was the largest cluster of exposure with the highest impact in infant health outcome. CONCLUSIONS: Our review found several key gaps and research priorities on structural racism such as lack of longitudinal studies and availability of structural or ecological data, lack of consensus on the use of consolidated appropriate measures, indexes of measurement and appropriate study designs that can capture complex interactions of exposure and outcomes related to structural racism holistically.

Refugee Births and the Migrant Health Effect in Syracuse NY.

OBJECTIVES: In Syracuse, NY among 5998 births in a 3-year period (2017-2019), 24% were to foreign-born women, among whom nearly 5% were refugees from the Democratic Republic of the Congo and Somalia. The impetus for the study was to identify potential risk factors and birth outcomes of refugee women, other foreign-born women, and US born women to inform care. METHODS: This study reviewed 3 years of births (2017-2019) in a secondary database of births in Syracuse, New York. Data reviewed included maternal demographics, natality, behavioral risk factors (e.g., drug use, tobacco use), employment, health insurance, and education. RESULTS: In a logistic regression model controlling for race, education, insurance status, employment status, tobacco use and illicit drug use, compared to US born mothers, refugees (OR 0.45, 95% CI 0.24-0.83) and other foreign born (OR 0.63, 95% CI 0.47-0.85) had significantly fewer low birth weight births. CONCLUSION: The results of this study supported the "healthy migrant effect," a concept that refugees have fewer low birth weight (LBW) births, premature births, and cesarean section deliveries than US born women. This study adds to the literature on refugee births and the healthy migrant effect.

Integrating the social determinants of health into two interprofessional courses: Findings from a pilot study.

Five colleges and universities in Upstate New York, United States, created the 'Route-90 Collaborative' to support faculty implementing the Institute of Medicine's (IOM) Framework for Educating Health Professionals to Address the Social Determinants of Health. The two courses described herein used a flipped classroom approach in which students from 14 different nations were responsible for facilitating individual classes. This descriptive study used an educational intervention in two interprofessional courses - reproductive health and global health - based on the IOM Framework into two courses. The evaluation used quantitative and open-ended text response data from students. Course evaluations indicated the students found the courses helped them to learn more about health issues and service delivery in various countries, expand their knowledge base on sociocultural and ecological influences on health care, and broaden their perspectives on various health topics so they will be able to provide higher quality healthcare. Although this is the first effort of our Collaborative to implement the Framework, given the student feedback, we believe implementing the Framework in various courses has the potential to enhance healthcare service delivery and reduce the negative impact of social determinants of health.

Community health agency administrators' access to public health data for program planning, evaluation, and grant preparation.

The Affordable Care Act mandates that public health data be made available for community agency use. Having access to such data allows community agencies to tailor interventions, evaluations, and funding requests more effectively. This study, jointly undertaken by Syracuse University faculty and students with the New York State Perinatal Association, sought to understand community agencies' access to requests for governmental data, as well as to identify areas for improving data access. Results from this survey of administrators from 43 agencies in New York State found that only one-half of their requests for data were successful. Difficulties in obtaining access to needed data included fiscal and staffing constraints of the state-level agencies that house the data, as well as possible overinterpretation of confidentiality policies. In addition, some of community agency respondents reported that their staff lacked skills in data analysis and would benefit from training in epidemiology and quantitative evaluation.

Filling out the forms: Health literacy among the uninsured.

This study addresses health literacy among patients at a free clinic in Syracuse, NY. Researchers conducted chart reviews of 600 patients and qualitative interviews with 22 patients and 7 providers. Most clinic patients had a high school, or higher, level education and no difficulty with reading comprehension. Nevertheless, a majority had at least some difficulty with comprehending and following through on health information. For many interviewees, the greatest difficulty was completing the required forms for entitlement programs. The findings demonstrate that low health literacy may occur even among well-educated patients and recommend that health literacy be assessed for all patients.

The Trauma Response Team: a Community Intervention for Gang Violence.

While violent crime has decreased in many cities in the USA, gang-related violence remains a serious problem in impoverished inner city neighborhoods. In Syracuse, New York, gang-related murders and gun shots have topped other New York state cities. Residents of the high-murder neighborhoods suffer trauma similar to those living in civil conflict zones. The Trauma Response Team was established in 2010, in collaboration with the Police Department, health care institutions, and emergency response teams and with the research support of Syracuse University faculty. Since its inception, gang-related homicides and gun shots have decreased in the most severely affected census tracts.

Horticultural therapy: a pilot study on modulating cortisol levels and indices of substance craving, posttraumatic stress disorder, depression, and quality of life in veterans.

CONTEXT: Horticultural therapy (HT) is a subgroup of occupational therapy (OT). Both HT and OT have been successful as adjunctive treatment modalities in substance abuse treatment. Studies have indicated that gardening promotes neuroendocrine and affective restoration from stress. OBJECTIVES: The study intended to assess the effect of HT versus nonhorticultural OT on cortisol levels, depression, symptoms of posttraumatic stress disorder (PTSD), alcohol cravings, and quality of life. METHODS: The research team designed a randomized pilot study. SETTING: The study was open for participation from July 2012-October 2012. It took place during multiple occurrences of a 28-d treatment programs for substance use disorder at a Veterans Affairs medical center. Participants • Participants were 49 veterans, averaging 46.4 y old (SD = 11.9); the dropout rate was 37%. INTERVENTION: Participants were randomly assigned to the HT or the OT group. They attended supervised HT and OT groups 5 h/d for 3 wk. Outcome Measures • Pre- and posttreatment, participants completed the Quality of Life Enjoyment and Satisfaction Questionnaire-Short Form (Q-LES-Q-SF), the Alcohol Craving Questionnaire (ACQ-NOW), the Posttraumatic Stress Disorder Checklist Civilian Version (PCLC), and the Center for Epidemiologic Studies Depression Scale (CES-D). Salivary cortisol samples were taken at wk 1, 2, and 3. RESULTS: A repeated measures analysis of variance (ANOVA) (F2,20 = 0.878) revealed that the HT performed was associated with a 12% reduction in salivary cortisol levels from wk 1 to wk 3, but the difference was not statistically significant (P = .43). Separate 1-way analyses of covariance (ANCOVAs) revealed no statistically significant differences in the self-administered tests, although both the Q-LES-Q-SF and CES-D showed a trend toward improving quality of life and depressive symptoms in the HT group compared with the OT group. Additional analysis of the nonbiologic tests suggests that most participants in the HT and OT had some benefit from the programmed activities. CONCLUSIONS: The trends suggest that HT may modulate stress in veterans, as evidenced by decreased cortisol levels and depressive symptoms, and may improve quality of life more than the programs in which the OT group participated. Further investigation with larger samples, including a nontreatment control group, is needed to determine whether the observed trends are treatment effects or due to abstinence.

Investigation of metronidazole use during pregnancy and adverse birth outcomes.

To assess whether treatment with metronidazole during pregnancy is associated with preterm birth, low birth weight, or major congenital anomalies, we conducted chart reviews and an analysis of electronic data from a cohort of women delivering at an urban New York State hospital. Of 2,829 singleton/mother pairs, 922 (32.6%) mothers were treated with metronidazole for clinical indications, 348 (12.3%) during the first trimester of pregnancy and 553 (19.5%) in the second or third trimester. There were 333 (11.8%) preterm births, 262 (9.3%) infants of low birth weight, and 52 infants (1.8%) with congenital anomalies. In multivariable analysis, no association was found between metronidazole treatment and preterm birth (odds ratio [OR], 1.02 [95% confidence interval [CI], 0.80 to 1.32]), low birth weight (OR, 1.05 [95% CI, 0.77 to 1.43]), or treatment in the first trimester and congenital anomalies (OR, 0.86 [0.30 to 2.45]). We found no association between metronidazole treatment during the first or later trimesters of pregnancy and preterm birth, low birth weight, or congenital anomalies.

Evaluation of Syracuse Healthy Start's program for abnormal flora management to reduce preterm birth among pregnant women.

UNLABELLED: Randomized trials of bacterial vaginosis (BV) treatment among pregnant women to reduce preterm birth have had mixed results. Among non-pregnant women, BV recurs frequently after treatment. Randomized trials of early BV treatment for pregnant women in which recurrence was retreated have shown promise in reducing preterm birth. Syracuse's Healthy Start (SHS) program began in 1997; in 1998 prenatal care providers for pregnant women living in high infant mortality zip codes were encouraged to screen for abnormal vaginal flora at the first prenatal visit. Vaginal swabs were sent to a referral hospital laboratory for Gram staining and interpretation. SHS encouraged providers to treat and rescreen women with bacterial vaginosis or abnormal flora (BV). We abstracted prenatal and hospital charts of live births between January 2000 and March 2002 for maternal conditions and treatments. We merged abstracted data with local electronic data. We evaluated the effect of BV screening before 22 weeks gestation, treatment, and rescreening using a retrospective cohort study design. Among 838 women first screened before 22 weeks, 346 (41%) had normal flora and 492 (59%) women had BV at a mean of 13 weeks gestation; 202 (24%) did not have treatment documented and 290 (35%) received treatment at a mean of 15 weeks gestation; 267 (92%) of those treated were re-screened. Among pregnant women with early BV, 42 (21%) untreated women and 28 (10%) treated women delivered preterm (Odds Ratio [OR] 0.4, 95% confidence interval [CI] 0.2-0.7)). After adjustment for age, race, prior preterm birth and other possible confounders, treatment remained associated with a reduced risk of preterm birth compared to no treatment (aOR = 0.5, 95% CI 0.3-0.9); the aOR for women with normal flora was not significantly different. CONCLUSION: Screening, treatment, and rescreening for BV/abnormal flora between the first prenatal visit and 22 weeks gestation showed promise in reducing preterm births and deserves further study.

The paternal component of the "healthy migrant" effect: fathers' natality and infants' low birth weight.

This study examines the predictors of birth outcomes among women of European and African ancestry and considers the birthplace of the babies' fathers (foreign born vs. native born) as a protective factor. This is a secondary data analysis of 146,431 singleton births among women of European and African ancestry, both native-born and foreign-born, in a 21 birth hospital region of Central New York State from 1996 to 2003. Foreign born fathers were found to have 15% fewer low birth weight infants than US-born fathers, after controlling for the race and birthplace of the mother, tobacco use and Medicaid. Although this secondary data analysis does not allow us to determine the social determinants of the better birth outcomes among infants of foreign born fathers, it does demonstrate that fathers matter and that foreign born fathers are associated with reduced low birth weight in their infants.

Routine deworming during antenatal care decreases risk of neonatal mortality and low birthweight: A retrospective cohort of survey data.

BACKGROUND: Soil transmitted helminths (STH) are a common infection among pregnant women in areas with poor access to sanitation. Deworming medications are cheap and safe; however, the health benefit of deworming during pregnancy is not clear. METHODS / PRINCIPAL FINDINGS: We created a retrospective cohort of more than 800,000 births from 95 Demographic and Health Survey datasets to estimate the impact of deworming medicine during routine antenatal care (ANC) on neonatal mortality and low birthweight. We first matched births on the probability of receiving deworming during ANC. We then modeled the birth outcomes with the matched group as a random intercept to estimate the effect of deworming during antenatal care after accounting for various risk factors. We also tested for effect modification of soil transmitted helminth prevalence on the impact of deworming during ANC. Receipt of deworming medication during ANC was associated with a 14% reduction in the risk of neonatal mortality (95% confidence interval = 10-17%, n = 797,772 births), with no difference between high and low transmission countries. In low transmission countries, we found an 11% reduction in the odds of low birth weight (95% confidence interval = 8-13%) for women receiving deworming medicine, and in high transmission countries, we found a 2% reduction in the odds of low birthweight (95% confidence interval = 0-5%). CONCLUSIONS / SIGNIFICANCE: These results suggest a substantial health benefit for deworming during ANC that may be even greater in countries with low STH transmission.

Lead Exposure in Newly Resettled Pediatric Refugees in Syracuse, NY.

Lead is a major environmental toxin that presents numerous health consequences for children. Refugee children are at a risk of lead poisoning post-resettlement due to urban housing and environmental inequalities stemming from lack of funding, legislation, and advocacy. This article addresses lead exposure upon arrival and post-resettlement in 705 refugee children (age 0-16 years) attending a university clinic in Syracuse, NY, a city with a large refugee population. 17% of the newly arrived children had elevated blood lead levels (BLLs) (≥ 5 µg/dL); 10% had elevated BLL upon follow-up; 8.3% of the children's follow-up elevated BLL were new exposures. 30% were found to have increased BLL at follow-up regardless of arrival status. An analysis of new exposures found a significant proportion of children would have been missed on routine screening that targets children < 2 years old. Primary prevention efforts are needed to prevent exposure and address risks to improve the health of all children locally, including newly resettled refugees.

Structural violence, urban retail food markets, and low birth weight.

This paper investigates urban retail food markets and health in Syracuse, New York. A structured observational analysis found that a majority of corner markets do not sell fresh produce or low fat dairy products, but conduct a lively business selling lottery tickets, cigarettes, and liquor. A comparison of census tracts with and without access to supermarkets that sell fresh produce and other healthy food found that pregnant women living in proximity to a supermarket had significantly fewer low birth weight births than other pregnant women regardless of income level.

Culturally congruent mentorship can reduce disruptive behavior among elementary school students: results from a pilot study.

BACKGROUND: Our study objective was to examine the feasibility of implementing a culturally congruent mentorship pilot program, Youth-First (YF), that targets behavior modification among elementary school-aged children with disruptive behavior and a history of school suspension. We hypothesize that it is feasible to implement the YF program to reduce disruptive behaviors and recidivism of level III/IV infractions in school settings among at-risk African American students. METHODS: We assessed program feasibility based on the success of program acceptance by parents/guardians, study enrollment, and intervention compliance by students. A pre/posttest study design was used to examine whether the YF program reduced recidivism of disruptive behavior among enrolled at-risk African American elementary school children between September 2016 and January 2017. Generalized linear mixed models examined whether student behavioral scores improved over time and varied by program mentor. A McNemar test examined the reduction in cumulative incidence of level III/IV infractions pre-post YF program intervention. RESULTS: Intervention acceptance, enrollment, and compliance were 100% (95% confidence interval [CI] 86 to 100%), 100% (95% CI 86 to 100%), and 67% (95% CI 45 to 84%), respectively (N = 24). Overall, student behavioral scores improved and plateaued over time (Time2 effect: b = - 0.01, 95% CI - 0.02, < 0.01); a two-week period was associated with a seven-point improvement (effect size: Cohen's d = 0.47, 95% CI 0.03, 0.94) in behavioral scores. Behavioral score improvements were class-specific, based on respectfulness behavior (b = 0.11, 95% CI < 0.01, 0.26). No recidivism of level III/IV infractions was reported during and post YF intervention. CONCLUSION: The integration of culturally congruent mentorship in elementary school-settings is feasible and can reduce risk of disruptive behaviors among at-risk African American students. Future studies should use randomized clinical trials to determine the effectiveness of culturally congruent mentorship interventions (void of potential selection and confounding biases) in reducing disruptive behavior, level III/IV infractions, and school suspensions among at-risk children.

Community Gun Violence as a Social Determinant of Elementary School Achievement.

The association of indirect exposure to firearm-related violence and standardized test scores among third grade elementary school children were analyzed using geospatial mapping of police department data for all gunshots in Syracuse, NY (n = 2, 127) and state standardized test scores from 2009-2015. Confirmed gunshots were geocoded and mapped across the city and neighborhood school catchment areas. Third grade standardized New York State test scores for English Language Arts (ELA) and math were coded as dichotomous variables of proficient and below proficient scores. State standardized test scores for ELA and math were found to be 50% lower in the elementary schools located within higher concentration gunshot areas, than in elementary schools in lower gunshot areas. Higher levels of gun violence within school catchment areas were significantly associated with higher rates of ELA and math failure (p ≤ .05). These findings suggest that community violence may be an important, though under recognized, social determinant of poor school performance.

Spatio-temporal patterns of gun violence in Syracuse, New York 2009-2015.

Gun violence in the United States of America is a large public health problem that disproportionately affects urban areas. The epidemiology of gun violence reflects various aspects of an infectious disease including spatial and temporal clustering. We examined the spatial and temporal trends of gun violence in Syracuse, New York, a city of 145,000. We used a spatial scan statistic to reveal spatio-temporal clusters of gunshots investigated and corroborated by Syracuse City Police Department for the years 2009-2015. We also examined predictors of areas with increased gun violence using a multi-level zero-inflated Poisson regression with data from the 2010 census. Two space-time clusters of gun violence were revealed in the city. Higher rates of segregation, poverty and the summer months were all associated with increased risk of gun violence. Previous gunshots in the area were associated with a 26.8% increase in the risk of gun violence. Gun violence in Syracuse, NY is both spatially and temporally stable, with some neighborhoods of the city greatly afflicted.

Neighborhood Trauma Due to Violence: A Multilevel Analysis.

In Syracuse, New York the social determinants of trauma from neighborhood violence are rooted in historical processes, including urban renewal, the Rockefeller drug laws, and de-industrialization. These contributed to destabilizing Syracuse communities of color, resulting in disproportionate incarceration, family disruption, and economic devastation. Community violence, clustering in densely populated neighborhoods, creates unmanageable stress for the families who live in them. A map of gunshots and gun fatalities (2009 to 2014) illustrates the continuing onslaught of bullets being fired, often in close proximity to elementary schools. A community survey indicated that over half of respondents personally knew more than 10 murder victims. Half the respondents scored positive on the Civilian PTSD Checklist; there thus is a great deal of unaddressed traumatic stress in the community. This analysis, conducted to prepare for planning future interventions to reduce the community trauma and violence, is part of an ongoing university-community collaboration.

Parental literacy and infant health: an evidence-based healthy start intervention.

Syracuse Healthy Start, a federally funded infant mortality prevention project in Onondaga County, New York, has undertaken a range of interventions to address parental low literacy as a risk factor for infant mortality. A growing number of studies advocate for health-related information that is easy to read, of a low literacy level, and culturally appropriate. Creation of an evidence-based public health intervention involves analyzing local data, reviewing published studies, assessing available materials, initiating programmatic interventions, and evaluating the outcomes. Preparing health educational materials that are clear, culturally sensitive, and at appropriate reading levels follows Paulo Freire's lead in empowering the disadvantaged to positively affect their health and the health of their infants toward the reduction of infant mortality.

Prenatal Depression: Screening and Referral for Women Who Are Low Income during Antenatal Care.

This study uses prenatal clinical chart reviews of 245 women who were screened for depression while receiving antenatal care services at an urban hospital-based clinic in Syracuse, New York. The results indicate that more than one half of the mothers who screened positive are not being adequately referred and followed-up on to ensure they are receiving proper treatment. Among the mothers who are not being successfully referred are women who are non-English speaking, facing multiple life stressors, and inadequately insured. Recommendations for colocating services that may ease the ongoing burdens of new motherhood are addressed.

Racial and ethnic disparity in low birth weight in Syracuse, New York.

This case-racial and ethnic disparity in low birth weight-is one of a series of teaching cases in the Case-Based Series in Population-Oriented Prevention (C-POP). It has been developed for use in medical school and residency prevention curricula. The complete set of cases is presented in this supplement to the American Journal of Preventive Medicine. Low birth weight is a leading cause of infant mortality. Unfortunately, despite declining rates of infant mortality, racial and ethnic disparities in both low birth weight and infant mortality rates persist. In this teaching case, a clinical vignette is used to draw attention to this public health priority in Syracuse, New York. Students learn essential epidemiology skills such as identifying limitations of sources of data and calculating relative risks, using the example of low birth weight. In performing these skills, students also identify etiologies for such disparity. Finally, students discuss interventions that, when implemented, may decrease infant mortality rates.