Lessons Learned from Immigrant Health Cohorts: A Review of the Evidence and Implications for Policy and Practice in Addressing Health Inequities among Asian Americans, Native Hawaiians, and Pacific Islanders.

The health of Asian Americans, Native Hawaiians, and Pacific Islanders (AANHPI) is uniquely impacted by structural and social determinants of health (SSDH) shaped by immigration policies and colonization practices, patterns of settlement, and racism. These SSDH also create vast heterogeneity in disease risks across the AANHPI population, with some ethnic groups having high disease burden, often masked with aggregated data. Longitudinal cohort studies are an invaluable tool to identify risk factors of disease, and epidemiologic cohort studies among AANHPI populations have led to seminal discoveries of disease risk factors. This review summarizes the limited but growing literature, with a focus on SSDH factors, from seven longitudinal cohort studies with substantial AANHPI samples. We also discuss key information gaps and recommendations for the next generation of AANHPI cohorts, including oversampling AANHPI ethnic groups; measuring and innovating on measurements of SSDH; emphasizing the involvement of scholars from diverse disciplines; and, most critically, engaging community members to ensure relevancy for public health, policy, and clinical impact.

Potentially More Out of Reach: Public Reporting Exacerbates Inequities in Home Health Access.

Policy Points Public reporting is associated with both mitigating and exacerbating inequities in high-quality home health agency use for marginalized groups. Ensuring equitable access to home health requires taking a closer look at potentially inequitable policies to ensure that these policies are not inadvertently exacerbating disparities as home health public reporting potentially does. Targeted federal, state, and local interventions should focus on raising awareness about the five-star quality ratings among marginalized populations for whom inequities have been exacerbated. CONTEXT: Literature suggests that public reporting of quality may have the unintended consequence of exacerbating disparities in access to high-quality, long-term care for older adults. The objective of this study is to evaluate the impact of the home health five-star ratings on changes in high-quality home health agency use by race, ethnicity, income status, and place-based factors. METHODS: We use data from the Outcome and Assessment Information Set, Medicare Enrollment Files, Care Compare, and American Community Survey to estimate differential access to high-quality home health agencies between July 2014 and June 2017. To estimate the impact of the home health five-star rating introduction on the use of high-quality home health agencies, we use a longitudinal observational pretest-posttest design. FINDINGS: After the introduction of the home health five-star ratings in 2016, we found that adjusted rates of high-quality home health agency use increased for all home health patients, except for Hispanic/Latine and Asian American/Pacific Islander patients. Additionally, we found that the disparity in high-quality home health agency use between low-income and higher-income home health patients was exacerbated after the introduction of the five-star quality ratings. We also observed that patients within predominantly Hispanic/Latine neighborhoods had a significant decrease in their use of high-quality home health agencies, whereas patients in predominantly White and integrated neighborhoods had a significant increase in high-quality home health agency use. Other neighborhoods experience a nonsignificant change in high-quality home health agency use. CONCLUSIONS: Policymakers should be aware of the potential unintended consequences for implementing home health public reporting, specifically for Hispanic/Latine, Asian American/Pacific Islander, and low-income home health patients, as well as patients residing in predominantly Hispanic/Latine neighborhoods. Targeted interventions should focus on raising awareness around the five-star ratings.

Disparities in the provision of perinatal care based on patient race in the United States.

BACKGROUND: In the United States, there are significant health inequities in perinatal care. This study examined differences in perinatal care provided to women based on the birthing person's designated race, within a large and diverse cohort of women. METHODS: This retrospective electronic medical record review identified patients receiving perinatal care within a large hospital system between January 2012 and September 2018 and examined associations between maternal designated race/ethnicity (Hispanic or non-Hispanic [NH] Black, Asian or White) and various provider treatment decisions. RESULTS: The study sample (N = 7056) was comprised of 36% Hispanic, 34% NH White, 21% NH Black, and 4% NH Asian women, aged 29.7 ± 6.3 years; 53% of the sample had private insurance, and 45% had Medicaid. Few differences by race were seen in perinatal care based on guidelines or expert recommendations (nondiscretionary care). Discretionary care, however, varied by race: Compared with NH White women, NH Black women were less likely to receive a prenatal depression screen (OR 0.8 [95% CI: 0.7, 0.9]) and more likely to have a urine drug test when denying drug use (OR 1.6 [95% CI 1.3, 2.0]), whereas Hispanic (OR 0.6 [95% CI: 0.5, 0.8]) and NH Asian (0.4 [95% CI 0.2, 0.9]) women were less likely to have a urine drug test completed when denying drug use. DISCUSSION: Perinatal care differs by maternal race/ethnicity, particularly when guidelines or expert recommendations are absent. Greater efforts need to be made to identify and mitigate providers' implicit and explicit biases; expanded professional guidelines may offer some protections against inequitable, discretionary care.

An analysis of racial inequities in emergency department triage among patients with stroke-like symptoms in the United States.

BACKGROUND: Racial inequities exist in treatment and outcomes in patients with acute stroke. OBJECTIVES: Our objective was to determine if racial inequities exist in the time-lapse between patient presentation and provider assessment in patients with stroke-like symptoms in Emergency Departments (ED) across the U.S. METHODS: This study is a retrospective, observational study of the National Hospital Ambulatory Medical Care Survey (NHAMCS) 2014-2018. We identified visits with stroke-like symptoms and stratified the proportion of door-to-provider (DTP) times by racial groups. We used broad and narrow definitions of stroke-like symptoms. We performed bivariate and multivariate analyses using race and clinical and demographic characteristics as covariates. RESULTS: Between 2014-2018, there were an average of 138.58 million annual ED visits. Of the total ED visits, 0.36% to 7.39% of the ED visits presented with stroke-like symptoms, and the average DTP time ranged from 39 to 49 min. The proportion of the visits with a triage level of 1 (immediate) or 2 (emergent) ranged from 16.03% to 23.27% for stroke-like symptoms. We did not find statistically significant racial inequities in DTP or ED triage level. We found significantly longer DTP times in non-Hispanic blacks (15.88 min, 95% CI: 4.29-27.48) and Hispanics (by 14.77 min, 95% CI: 3.37-26.16) than non-Hispanic whites that presented with atypical stroke-like symptoms. We observed that non-Hispanic whites were significantly more diagnosed with a stroke/TIA than other racial minority groups (p = 0.045) for atypical stroke-like symptoms. CONCLUSION: In our population-based analysis, we did not identify systemic racial inequities in the DTP times or ED triage level at ED triage for stroke-like symptoms.

Unpacking Inequities in ADHD Diagnosis: Examining Individual-Level Race/Ethnicity and State-Level Online Information-Seeking Patterns.

Attention-deficit/hyperactivity disorder (ADHD) is a prevalent, persistent, and costly mental health condition. The internet is an increasingly popular source for information related to ADHD. With a nationally representative sample (2018 NSCH), we aimed to separate individual- and state-level effects to examine inequities in ADHD diagnoses. We extracted state-level relative search volumes using "ADHD," "ADHD treatment," "ADHD medication," and "ADHD therapy" from Google Trends, and sociodemographic and clinical variables from the 2018 National Survey of Children's Health (N = 26,835). We examined state variation in ADHD-related information-seeking and applied multilevel modeling to examine associations among individual-level race/ethnicity, state-level information-seeking patterns, and ADHD diagnoses. Online information seeking related to ADHD varies by state and search term. Individual-level racial/ethnic background and state-level information-seeking patterns were associated with ADHD diagnoses; however, their cross-level interaction was not significant. This study adds to the strong body of evidence documenting geographical variation and diagnostic disparity in mental health and the growing literature on the impact of the digital divide on population health, indicating an urgent need for addressing inequities in mental health care. Increasing public interest in and access to empirically supported online information may increase access to care, especially among people of color.

Invited Commentary: Comparing Approaches to Measuring Structural Racism.

In their article, Adkins-Jackson et al. (Am J Epidemiol. 2022;191(4):539-547) provide much needed insight on current approaches and challenges to epidemiologic research on structural racism. The authors encourage researchers to consider how structural racism is conceptualized in extant and future work, and whether existing measures accurately reflect the multidimensional nature of structural racism. In the spirit of continuing this conversation, I expand upon approaches to measuring structural racism. I compare the merits and challenges of scales, indexes, indicators, and policy-based measures of structural racism for use in epidemiologic research.

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.

Infant Outcomes among Teenage and Young Mothers: Racial Inequities and the Role of Educational Attainment.

OBJECTIVE: To examine the association of age-appropriate maternal educational attainment in teenage and young mothers on infant health outcomes across racial/ethnic groups. STUDY DESIGN: In this retrospective, cross-sectional study using Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research Natality data (2016-2017), we included live births comparing 14- to 19- year-old mothers with 20- to 24-year-old mothers. To analyze the association of maternal age-appropriate education (≥8th grade for 15-18 years of age, 9th-12th grade/completed high school for 19-24 years of age), we conducted multivariable regression adjusting for mothers' demographics, reporting adjusted incidence rate ratios with 95% CI for infant mortality rate, and logistic regression for extreme prematurity and low birth weight, reporting aORs with 95% CI. RESULTS: From 2016 to 2017, there were 1 976 334 live births among women 14-24 years of age; 407 576 (20.6%) were in 14- to 19-year-olds. In the multivariable model, increased term infant mortality rate was associated with age 14-19 years (adjusted incidence rate ratio 1.18, 95% 1.10, 1.27), age-inappropriate education (adjusted incidence rate ratio 1.38, 95% CI 1.28, 1.48), and non-Hispanic Black mothers (adjusted incidence rate ratio 1.21, 95% CI 1.12, 1.30). Extreme prematurity was associated with women age 14-19 years (aOR 1.35, 95% CI 1.30, 1.40), non-Hispanic Black (aOR 2.50, 95% CI 2.39, 2.61), and Hispanic mothers (aOR 1.09, 95% CI 1.04, 1.15). Term infant low birth weight was associated with age 14-19 years (aOR 1.14, 95% CI 1.12, 1.16), age-inappropriate education for non-Hispanic White (aOR 1.16, 95% CI 1.11, 1.21), and non-Hispanic Black (aOR 1.08, 1.04, 1.12) mothers. CONCLUSIONS: Inadequate maternal educational attainment, which is influenced by modifiable social policies, is associated with increased adverse infant outcomes in mothers 14-24 years of age.

A Conceptual Model of Help-Seeking by Black Americans After Violent Injury: Implications for Reducing Inequities in Access to Care.

Many inequities exist in serving and supporting Black survivors of violent crime. A key question in reducing inequities in care after victimization is whether police first responders and other formal system providers identify the victim as an "offender" and/or someone who is "undeserving" of supports. These labels and associated biases can directly reduce access to supports through a variety of mechanisms that include police withholding information about one's rights as a victim, among other direct and indirect barriers to social and health services. Unaddressed financial, mental, and physical health consequences of victimization contribute to poorer health outcomes later in life. This paper seeks to bring together the extant research on help-seeking, discrimination in criminal legal system functioning, and barriers to victim services by synthesizing these discrete threads into a theoretically and empirically informed conceptual model that captures the range of factors that shape Black Americans' decision to report their victimization to the police and subsequent help-seeking. Qualitative and quantitative data from a purposive sample of 91 Black victims of community violence is used to ground the developing model. The conceptual model can help lay the foundation for research that seeks to remedy the marked mismatch between the prevalence of violent victimization and help-seeking among Black Americans. Research findings can be applied to guide policies and programming to reduce inequities in care for victims of violence.

Self-Rated Health and Structural Racism Indicated by County-Level Racial Inequalities in Socioeconomic Status: The Role of Urban-Rural Classification.

Recent attention to the interrelationship between racism, socioeconomic status (SES) and health has led to a small, but growing literature of empirical work on the role of structural racism in population health. Area-level racial inequities in SES are an indicator of structural racism, and the associations between structural racism indicators and self-rated health are unknown. Further, because urban-rural differences have been observed in population health and are associated with different manifestations of structural racism, explicating the role of urban-rural classification is warranted. This study examined the associations between racial inequities in SES and self-rated health by county urban-rural classification. Using data from County Health Rankings and American Communities Surveys, black-white ratios of SES were regressed on rates of fair/poor health in U.S. counties. Racial inequities in homeownership were negatively associated with fair/poor health (ß = -0.87, s.e. = 0.18), but racial inequities in unemployment were positively associated with fair/poor health (ß = 0.03, s.e. = 0.01). The associations between structural racism and fair/poor health varied by county urban-rural classification. Potential mechanisms include the concentration of resources in racially segregated counties with high racial inequities that lead to better health outcomes, but are associated with extreme black SES disadvantage. Racial inequities in SES are a social justice imperative with implications for population health that can be targeted by urban-rural classification and other social contextual characteristics.

Racism and Health: Evidence and Needed Research.

In recent decades, there has been remarkable growth in scientific research examining the multiple ways in which racism can adversely affect health. This interest has been driven in part by the striking persistence of racial/ethnic inequities in health and the empirical evidence that indicates that socioeconomic factors alone do not account for racial/ethnic inequities in health. Racism is considered a fundamental cause of adverse health outcomes for racial/ethnic minorities and racial/ethnic inequities in health. This article provides an overview of the evidence linking the primary domains of racism-structural racism, cultural racism, and individual-level discrimination-to mental and physical health outcomes. For each mechanism, we describe key findings and identify priorities for future research. We also discuss evidence for interventions to reduce racism and describe research needed to advance knowledge in this area.

The physiological toll of arrests: An examination of arrest history on midlife allostatic load.

PURPOSE: To understand how allostatic load - cumulative physiologic burden of stress - varies by amount and timing of arrests stratified by race/ethnicity and by sex. METHODS: Using The National Longitudinal Study of Adolescent to Adult Health, we calculated descriptive statistics and mean differences in bio-marker measured allostatic load by arrest history stratified by race/ethnicity and sex. RESULTS: One-third of participants experienced at least one arrest, and most experienced arrests only as adults. Allostatic load scores were higher for those that had ever experienced an arrest compared to never (mean difference: 0.58 (0.33, 0.84)). Similar results held for men and women and across race/ethnicity, but Black non-Hispanic individuals had higher allostatic load at all levels compared to other individuals. CONCLUSIONS: Experiencing both any arrest and multiple arrests were associated with higher allostatic load. The stress of arrests may contribute to physiological maladaptations and poor health. The public health and law enforcement fields must recognize the detrimental consequences of arrests on physiological stress and search for non-carceral solutions.

A Qualitative Exploration of Self-Advocacy Experiences of Black Women in the Perinatal Period: Who Is Listening?

INTRODUCTION: Black women face poor maternal health outcomes including being over 3 times more likely to die from pregnancy complications than White women. Yet the lived experience of how these women self-advocate has not been clearly explored. The goal of this cross-sectional qualitative study was to describe the lived experiences of Black women advocating for their needs and priorities during the perinatal period. METHODS: Between January and October of 2022, we recruited Black women from obstetric clinics, research registries, and community advocacy groups who were either in their third trimester of pregnancy or within a year postpartum. Participants completed one-on-one interviews describing their experiences of self-advocacy. These data were analyzed using descriptive content analysis approaches that summarized women's experiences by iteratively creating major themes and subthemes that encapsulate their self-advocacy descriptions. RESULTS: Fifteen Black women completed interviews. Major themes and subthemes describing women's experience of self-advocacy were the following: (1) carrying a burden with subthemes of having to be good and easy, not trusting health care information and providers, and being dismissed; (2) building comfort with health care providers with subthemes of trusting I have a good provider, comfort in knowing they understand, and wanting low-touch, high-concern care; and (3) advocating for my child and myself when I need to with subthemes of going with the flow, becoming informed, pushing to ask questions, and balancing being proactive and pushy. DISCUSSION: Women reported self-advocating mainly due to experiences related to the burdens associated with not trusting providers and health care information. These findings provide clarity to how women carefully balance between ensuring their health is taken seriously while not jeopardizing their health or that of their newborn. This study offers promising directions to support Black women in advocating for their perinatal health care needs and values.

Racial Inequities in the Control of Hypertension and the Explanatory Role of Residential Segregation: a Decomposition Analysis in the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil).

The mechanisms underlying racial inequities in uncontrolled hypertension have been limited to individual factors. We investigated racial inequities in uncontrolled hypertension and the explanatory role of economic segregation in the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil). All 3897 baseline participants with hypertension (2008-2010) were included. Uncontrolled hypertension (SBP ≥ 140 mmHg or DBP ≥ 90 mmHg), self-reported race (White/Brown/Black people), and neighborhood economic segregation (low/medium/high) were analyzed cross-sectionally. We used decomposition analysis, which describes how much a disparity would change (disparity reduction; explained portion) and remain (disparity residual; unexplained portion) upon removing racial differences in economic segregation (i.e., if Black people had the distribution of segregation of White people, how much we would expect uncontrolled hypertension to decrease among Black people). Age- and gender-adjusted prevalence of uncontrolled hypertension (39.0%, 52.6%, and 54.2% for White, Brown, and Black participants, respectively) remained higher for Black and Brown vs White participants, regardless of economic segregation. Uncontrolled hypertension showed a dose-response pattern with increasing segregation levels for White but not for Black and Brown participants. After adjusting for age, gender, education, and study center, unexplained portion (disparity residual) of race on uncontrolled hypertension was 18.2% (95% CI 13.4%; 22.9%) for Black vs White participants and 12.6% (8.2%; 17.1%) for Brown vs White participants. However, explained portion (disparity reduction) through economic segregation was - 2.1% (- 5.1%; 1.3%) for Black vs White and 0.5% (- 1.7%; 2.8%) for Brown vs White participants. Although uncontrolled hypertension was greater for Black and Brown vs White people, racial inequities in uncontrolled hypertension were not explained by economic segregation.

The Impact of Structural Racism on Continuity of Care at Pediatric Academic Primary Care Clinics.

OBJECTIVE: Using a structural racism framework, we assessed racial inequities in continuity of care, using the Usual Provider Continuity Index (UPC - the proportion of visits with the provider the patient saw most frequently out of all visits), in a set of large pediatric academic clinics. METHODS: We conducted a retrospective cohort study. Patients 12-24 months seen at three pediatric academic primary care clinics for any visit during October 1-31, 2021 were included. We then reviewed continuity for these patients in the preceding 12 months. Outcomes included each patient's UPC for all visits, and a modified UPC for well child checks only (UPC Well). Covariates included race, ethnicity, insurance, clinic site, age, sex, care management, or seeing a social worker. We evaluated for differences in outcomes using bivariate analyses and multivariable regression models. RESULTS: Our cohort included 356 patients (74% Black, 5% Hispanic, 85% Medicaid, 52% female, median age 15.8 months). The median UPC was 0.33 and median UPC Well was 0.40. Black patients had significantly lower median values for UPC (0.33 Black vs 0.40 non-Black, P < .01) and UPC Well (0.33 Black vs 0.50 non-Black, P < .01). There were similar inequities in continuity rates by insurance and clinic site. In multivariable models, clinic site was the only variable significantly associated with continuity. CONCLUSIONS: Clinic sites serving higher percentages of Black patients had lower rates of continuity. The main driver of racial inequities in continuity rates was at the institutional level.

Healthcare disparities encountered by patients with headache disorders and potential mitigation strategies.

This chapter discusses the healthcare disparities in headache medicine and proposes solutions to mitigate them. Disparities exist in the diagnosis, treatment, and outcomes of underserved patients with migraine and other headache disorders. Systemic racism, provider bias and lack of cultural sensitivity, a history of mistrust and historical injustices, lack of research of underrepresented groups, lack of diversity in clinical and research realms as well as leadership positions within national institutions and organizations all contribute to the ongoing disparities in headache medicine. Making strides in increasing the diversity of the clinical and research workforce, training providers on cultural sensitivity, providing mentorship programs to underrepresented groups in headache medicine, increasing funding for headache medicine disparity research, and facilitating participation of underrepresented groups in research are all potential ways to address disparities.

Obstetrical health care inequities in a universally insured health care system.

BACKGROUND: Racial and ethnic disparities in health care exist and are rooted in long-standing systemic inequities. These disparities result in significant excess health care expenditures and are due to complex interactions between patients, health care providers and systems, and social and environmental factors. In perinatal care, these inequities also exist, with Black patients being 3 to 4 times more likely to die of childbirth compared with White patients. Similar health care inequities may also exist in the Military Health System despite universal health care coverage, stable employment, and social programs that benefit military families. OBJECTIVE: This study aimed to evaluate racial disparities in obstetrical outcomes in the Military Health System. STUDY DESIGN: This is a retrospective cohort study of deliveries from 2019 to 2021 in the Military Health System, which provides obstetrical care for approximately 35,000 annual deliveries. The study was conducted using National Perinatal Information Center data on cesarean delivery, postpartum hemorrhage, and severe maternal morbidity by race and ethnicity from direct-care military hospitals representing tertiary care medical centers and community hospitals in the United States and abroad. Chi-square analyses and binary logistic regression were used to compare groups. RESULTS: The cohort included 68,918 deliveries. Of these, 32,358 (47%) were White, 9594 (13.9%) Black, 3120 (4.5%) Asian Pacific Islander, 456 (0.7%) American Indian/Alaska Native, 19,543 (28.4%) other, 3976 (5.8%) unknown, 7096 (10.3%) Hispanic, 58,009 (84.2%) non-Hispanic, and 4399 (6.4%) other ethnicity. Rates of cesarean delivery were significantly higher for Black (30%; odds ratio, 1.44; 95% confidence interval, 1.37-1.52), Asian Pacific Islander (27%; odds ratio, 1.24; 95% confidence interval, 1.14-1.35), and other (26%; odds ratio, 1.20; 95% confidence interval, 1.15-1.25) compared with White race (23%) (P<.001). Postpartum hemorrhage rates were higher for Black (5.9%; odds ratio, 1.11; 95% confidence interval, 1.00-1.24) and Asian Pacific Islander (7.7%; odds ratio, 1.49; 95% confidence interval, 1.29-1.72) compared with White race (5.3%) (P<.001). Severe maternal morbidity was higher for Black (2.9%; odds ratio, 1.44; 95% confidence interval, 1.24-1.67), Asian Pacific Islander (2.9%; odds ratio, 1.45; 95% confidence interval, 1.15-1.82), and other (2.8%; odds ratio, 1.36; 95% confidence interval, 1.21-1.54) compared with White race (2.1%) (P<.001). For severe maternal morbidity excluding blood transfusions, rates were also significantly higher for Black (1%; odds ratio, 1.68; 95% confidence interval, 1.30-2.17) than for White race (0.6%) (P<.002). Hispanic ethnicity was associated with a lower rate of severe maternal morbidity excluding transfusions (0.5%; odds ratio, 0.68; 95% confidence interval, 0.48-0.98) compared with non-Hispanic ethnicity (0.7%) (P=.04). CONCLUSION: Racial disparities in obstetrical outcomes exist in the Military Health System despite universal health care coverage, with significantly higher rates of cesarean delivery and severe maternal morbidity in Black, Asian Pacific Islander, and other races compared with White race. These findings suggest that these disparities are likely related to other factors or social determinants of health rather than availability of health care and insurance coverage. Further work should include investigation into such social determinants of health to address their causes, including systemic and structural barriers.