Development of a Multicomponent Intervention to Decrease Racial Bias Among Healthcare Staff.

BACKGROUND: Real or perceived discrimination contributes to lower quality of care for Black compared to white patients. Some forms of discrimination come from non-physician and non-nursing (non-MD/RN) staff members (e.g., receptionists). METHODS: Utilizing the Burgess Model as a framework for racial bias intervention development, we developed an online intervention with five, 30-min modules: (1) history and effects of discrimination and racial disparities in healthcare, (2) implicit bias and how it may influence interactions with patients, (3) strategies to handle stress at work, (4) strategies to improve communication and interactions with patients, and (5) personal biases. Modules were designed to increase understanding of bias, enhance internal motivation to overcome bias, enhance emotional regulation skills, and increase empathy in patient interactions. Participants were non-MD/RN staff in nine primary care clinics. Effectiveness of the intervention was assessed using Implicit Association Test and Symbolic Racism Scale, to measure implicit and explicit racial bias, respectively, before and after the intervention. Acceptability was assessed through quantitative and qualitative feedback. RESULTS: Fifty-eight non-MD/RN staff enrolled. Out of these, 24 completed pre- and post-intervention assessments and were included. Among participants who reported characteristics, most were Black, with less than college education and average age of 43.2 years. The baseline implicit bias d-score was 0.22, indicating slight pro-white bias. After the intervention, the implicit bias score decreased to -0.06 (p=0.01), a neutral score indicating no pro-white or Black bias. Participant rating of the intervention, scored from 1 (strongly disagree) to 5 (strongly agree), for questions including whether "it was made clear how to apply the presented content in practice" and "this module was worth the time spent" was ≥4.1 for all modules. CONCLUSIONS: There was a decrease in implicit pro-white bias after, compared with before, the intervention. Intervention materials were highly rated.

Prenatal psychosocial stress and children's sleep problems: Evidence from the ELSPAC-CZ study.

Prenatal exposure to maternal stress may increase the risk of developing sleep problems in childhood. This study examined the association between prenatal stressful life events (PSLE) and children's sleep problems, taking into consideration their trajectory over time. Data were obtained from the Czech portion of the European Longitudinal Cohort Study of Pregnancy and Childhood (ELSPAC-CZ; N = 4,371 children). Mothers reported PSLE using an inventory of 42 life events and child sleep problems at five time-points (child age of 1.5, 3, 5, 7, and 11 years). The association was tested by a Poisson latent growth model, controlling for maternal and family demographics, birth characteristics, maternal depression, and alcohol use in pregnancy. The average rate of sleep problems was 2.06 (p < 0.001) at the age of 1.5 years and the rate of sleep problems decreased in a linear fashion over time (estimate = -0.118; p < 0.001). A higher number of PSLE was associated with a higher rate of sleep problems at the age of 1.5 years (incidence rate ratio [IRR] per interquartile range = 1.08, 95% confidence interval [CI] 1.05-1.12, p < 0.001) and with a reduced rate of decrease in sleep problems between the ages of 1.5 and 11 years (p < 0.001). Thus, PSLE were associated with chronicity of sleep problems in addition to their amount during early childhood. Prenatal exposure to stress may predispose individuals to the development of sleep problems in later life.

Assessing Stress in Pregnancy and Postpartum: Comparing Measures.

INTRODUCTION: Measuring early-life psychosocial stress is complicated by methodological challenges. This paper compares three survey instruments for the assessment of life in pregnancy/postpartum and investigates the effects of the timing of early-life stress for emotional/behavioral difficulties (EBD) of offspring during mid/late childhood and adolescence. METHODS: Observational data were obtained from the European Longitudinal Cohort Study of Pregnancy and Childhood (ELSPAC-CZ), which included 4811 pregnancies in two Czech metropolitan areas. We used data collected between 1991 and 2010 at 20 weeks of pregnancy (T1), after delivery (T2), at 6 months postpartum (T3), and at child's age of 7 years (T4), 11 years (T5), 15 years (T6), and 18 years (T7). Life stress was assessed with (1) the Edinburgh Postnatal Depression Scale (EPDS), (2) a stressful life events (SLE) count based on 42-item inventory, and (3) the SLE measure weighted by perceived stressfulness (PS). Each stress measure was administered at T1, T2, and T3. Child's EBD were assessed with the Strengths and Difficulties Questionnaire at T4, T5, T6, and T7. RESULTS: Each stress measure independently predicted long-term EBD. The best data fit was obtained in a model combining EPDS and SLE. Effect sizes for SLEs decreased between the first half of pregnancy and postpartum, while the effect of EPDS increased. DISCUSSION: SLE-based methods capture an aspect of perinatal stress not adequately assessed by EPDS. Combination of psychological distress measures and SLE-based measures is optimal in predicting EBD of the child. Stress measures based on SLE are suitable for early pregnancy, while self-reports of depressive symptoms may perform better in postpartum.

Long-term implications of autologous HCT for caregiver quality of life: how does the survivor's health matter?

INTRODUCTION: This study examines caregiver quality of life (CQOL) 3-26 years after autologous hematopoietic cell transplantation (HCT) for patients with lymphoma. Using a framework that views the patient-caregiver dyad as a system of mutual influence, we argue that CQOL is associated with survivor functional health status and sense of personal control. METHODS: Ninety-nine autologous HCT survivor-caregiver dyads participated. CQOL was measured using the Caregiver Quality of Life Scale-Cancer. Survivor functional health status was assessed using the Functional Assessment of Cancer Therapy-General. Sense of control was examined using an instrument from the MIDUS II study. Clinical measures were collected from medical records. RESULTS: After controlling for sociodemographic and clinical covariates, caregivers with higher sense of control had higher CQOL. Poorer survivor functional health was associated with lower CQOL but only when the survivor reported low personal control. When the survivor reported high personal control, functional health was not a factor. Lower CQOL was observed for younger and more educated caregivers. In contrast, more education among survivors was linked to higher CQOL. CONCLUSION: These results (1) support using a mutuality framework for the study of long-term outcomes of caregivers, (2) suggest the importance of ongoing support for caregivers, and (3) help identify caregivers at risk for poorer adaptation. Poorer survivor functional health is a risk factor, but its adverse implications can be offset by higher caregiver and survivor sense of control, a psychological resource aiding caregiver adaptation. These findings can inform the development of support programs for long-term caregivers.

Exploring the Association of Healthcare Worker Race and Occupation with Implicit and Explicit Racial Bias.

BACKGROUND: Racial bias is associated with suboptimal healthcare treatment for minorities. Research focuses on bias among physicians rather than non-physician healthcare staff (e.g., receptionists). Patients spend considerable amounts of time with non-physician staff. Therefore, we investigate differences in implicit and explicit racial bias by healthcare staff race and occupation using the Implicit Association Test and Modern Racism Scale, respectively. METHODS: Staff (n = 107) were recruited using the Alabama based Primary Care Research Coalition. Occupation was categorized into "medical doctors/registered nurses" (MD/RN) and "non-MD/RN" (e.g., receptionists). RESULTS: Implicit bias scores were higher among whites compared with blacks (0.62, -0.04, respectively; p < 0.01). Among whites, non-MD/RNs demonstrated more pro-white implicit bias compared with MD/RNs (0.67, 0.44, respectively; p < 0.01). Whites had higher explicit bias scores than blacks (17.7, 12.3, respectively; p < 0.01). CONCLUSION: Non-MD/RNs should not be overlooked for cultural competency training, and efforts are needed to reduce racial bias among healthcare workers identified as having higher levels of bias.

Does one size fit all? The role of body mass index and waist circumference in systemic inflammation in midlife by race and gender.

OBJECTIVE: This study investigates the associations of body mass index (BMI) and waist circumference (WC) with markers of systemic inflammation in midlife by race and gender. DESIGN: Data were obtained from the Survey of Midlife in the United States, a cross-sectional, observational study of Americans 35 years old or older (White men: N = 410; White women: N = 490; Black men: N = 58; Black women: N = 117). Inflammation was measured by concentrations of fibrinogen and C-reactive protein (CRP) in fasting plasma and concentrations of E-selectin and interleukin-6 (IL-6) in fasting serum. Anthropometric data were used to obtain BMI and WC. Socio-demographic and health-related factors were assessed with a survey. Multivariate models by race and gender were estimated to test the roles of BMI and WC for each inflammation marker. RESULTS: Compared to White men, Black women have higher BMI and higher levels of all four inflammation markers; White women have lower BMI, lower WC, and lower E-selectin and fibrinogen but higher CRP; and Black men have higher fibrinogen. After adjusting for socio-demographic and health-related covariates as well as perceived discrimination, WC is associated with all four markers of inflammation among White men and women; with three markers (fibrinogen, CRP, and IL-6) of inflammation among Black women; and with CRP (and marginally with fibrinogen and E-selectin) among Black men. BMI is associated with higher CRP and fibrinogen among Black men (marginally so for White men) but not for women of either race. CONCLUSIONS: WC shows more consistent associations with inflammation markers than BMI, although the relationships vary by inflammation marker and population group. Our findings suggest that WC is a risk factor for systemic inflammation among White and Black men and women, and BMI is an additional risk factor for Black men.

Is Perceived Discrimination in Pregnancy Prospectively Linked to Postpartum Depression? Exploring the Role of Education.

Objectives The role of perceived discrimination in postpartum depression is largely unknown. We investigate whether perceived discrimination reported in pregnancy contributes to postpartum depression, and whether its impact varies by education level. Methods Prospective data are a part of European Longitudinal Study of Pregnancy and Childhood, the Czech Republic. Surveys were collected in mid-pregnancy and at 6 months after delivery. Depression was measured using Edinburgh Postnatal Depression Scale. Generalized linear models were estimated to test the effects of perceived discrimination on postpartum depression. Results Multivariate models revealed that among women with low education, discrimination in pregnancy was prospectively associated with 2.43 times higher odds of postpartum depression (p < .01), after adjusting for antenatal depression, history of earlier depression, and socio-demographic background. In contrast, perceived discrimination was not linked to postpartum depression among women with high education. Conclusions Perceived discrimination is a risk factor for postpartum depression among women with low education. Screening for discrimination and socio-economic disadvantage during pregnancy could benefit women who are at risk for mental health problems.

Social Determinants of Adherence to Pulmonary Rehabilitation for Chronic Obstructive Pulmonary Disease.

Adherence to pulmonary rehabilitation (PR) is low. Previous studies have focused on clinical predictors of PR completion. We aimed to identify social determinants of adherence to PR. A cross-sectional analysis of a database of COPD patients (N = 455) in an outpatient PR program was performed. Adherence, a ratio of attended-to-prescribed sessions, was coded as low (<35%), moderate (35-85%), and high (>85%). Individual-level measures included age, sex, race, BMI, smoking status, pack-years, baseline 6-minute walk distance (6MWD: <150, 150-249, ≥250), co-morbidities, depression, and prescribed PR sessions (≤20, 21-30, >30). Fifteen area-level measures aggregated to Census tracts were obtained from the U.S. Census after geocoding patients' addresses. Using exploratory factor analysis, a neighborhood socioeconomic disadvantage index was constructed, which included variables with factor loading >0.5: poverty, public assistance, households without vehicles, cost burden, unemployment, and minority population. Multivariate regression models were adjusted for clustering on Census tracts. Twenty-six percent of patients had low adherence, 23% were moderately adherent, 51% were highly adherent. In the best fitted full model, each decile increase in neighborhood socioeconomic disadvantage increased the risk of moderate vs high adherence by 14% (p < 0.01). Smoking tripled the relative risk of low adherence (p < 0.01), while each increase in 6MWD category decreased that risk by 72% (p < 0.01) and 84% (p < 0.001), respectively. These findings show that, relative to high adherence, low adherence is associated with limited functional capacity and current smoking, while moderate adherence is associated with socioeconomic disadvantage. The distinction highlights different pathways to suboptimal adherence and calls for tailored intervention approaches.

Dimensions of Racial Identity and Perceived Discrimination in Health Care.

OBJECTIVE: Perceived discrimination is an important risk factor for minority health. Drawing from the scholarship on multidimensionality of race, this study examines the relationships between perceived discrimination in health care and two dimensions of racial identity: self-identified race/ethnicity and perceived attributed race/ethnicity (respondents' perceptions of how they are racially classified by others). METHODS: We used Behavioral Risk Factor Surveillance System data collected in 2004-2013 and we specifically examined the data on perceived racial discrimination in health care during the past 12 months, perceived attributed race/ethnicity, and self-identified race/ethnicity. RESULTS: In models adjusting for sociodemographic and other factors, both dimensions of racial/ethnic identity contributed independently to perceived discrimination in health care. After controlling for self-identified race/ethnicity, respondents who reported being classified as Black, Asian, Hispanic, and Native American had higher likelihood of perceived discrimination than respondents who reported being classified as White. Similarly, after taking perceived attributed race/ethnicity into account, self-identified Blacks, Native Americans, and multiracial respondents were more likely to report perceived discrimination than counterparts who self-identified as White. The model using only perceived attributed race/ethnicity to predict perceived discrimination showed a superior fit with the data than the model using only self-identified race/ethnicity. CONCLUSION: Perceived attributed race/ethnicity captures an aspect of racial/ethnic identity that is correlated, but not interchangeable, with self-identified race/ethnicity and contributes uniquely to perceived discrimination in health care. Applying the concept of multidimensionality of race/ethnicity to health disparities research may reveal understudied mechanisms linking race/ethnicity to health risks.

Exploring long-term cancer survivors' experiences in the career and financial domains: Interviews with hematopoietic stem cell transplantation recipients.

Using semi-structured interviews with 50 hematopoietic stem cell transplantation (HSCT) recipients who were 2 to 22 years post-transplant, this study investigates cancer survivors' interpretations of their economic and work-related experiences during and after treatment. Survivors described a variety of challenges in these areas, including job insecurity, discrimination, career derailment, the lack of career direction, delayed goals, financial losses, insurance difficulties, constraints on job mobility, and physical/mental limitations. Survivors described the ways these challenges were offset by external factors that helped them to navigate these difficulties and buffered the negative financial and career-related impacts. Good health insurance, favorable job characteristics, job accommodations, and financial buffers were prominent offsetting factors. Most survivors, however, were also forced to rely on individual behavioral and interpretative strategies to cope with challenges. Behavioral strategies included purposeful job moves, retraining, striving harder, and retiring. Some strategies were potentially problematic, such as acquiring large debt. Interpretive strategies included reprioritizing and value shifts, downplaying the magnitude of cancer impact on one's life, denying the causal role of cancer in negative events, making favorable social comparisons, and benefit finding. Post-treatment counseling and support services may assist survivors in identifying available resources and useful strategies to improve long-term adaptation in the career and financial realms.

Perceived discrimination in primary care: Does Payer mix matter?

INTRODUCTION: Previous literature has explored patient perceptions of discrimination by race and insurance status, but little is known about whether the payer mix of the primary care clinic (i.e., that is majority public insurance vs. majority private insurance clinics) influences patient perceptions of race- or insurance-based discrimination. METHODS: Between 2015-2017, we assessed patient satisfaction and perceived race- and insurance-based discrimination using a brief, anonymous post-clinic visit survey. RESULTS: Participants included 3,721 patients from seven primary care clinics-three public clinics and four private clinics. Results from unadjusted logistic regression models suggest higher overall reports of race- and insurance-based discrimination in public clinics compared with private clinics. In mulvariate analyses, increasing age, Black race, lower education and Medicaid insurance were associated with higher odds of reporting race- and insurance-based discrimination in both public and private settings. CONCLUSION: Reports of race and insurance discrimination are higher in public clinics than private clinics. Sociodemographic variables, such as age, Black race, education level, and type of insurance also influence reports of race- and insurance-based discrimination in primary care.

Non-verbal communication between primary care physicians and older patients: how does race matter?

BACKGROUND: Non-verbal communication is an important aspect of the diagnostic and therapeutic process, especially with older patients. It is unknown how non-verbal communication varies with physician and patient race. OBJECTIVE: To examine the joint influence of physician race and patient race on non-verbal communication displayed by primary care physicians during medical interviews with patients 65 years or older. DESIGN, SETTING, AND PARTICIPANTS: Video-recordings of visits of 209 patients 65 years old or older to 30 primary care physicians at three clinics located in the Midwest and Southwest. MAIN MEASURES: Duration of physicians' open body position, eye contact, smile, and non-task touch, coded using an adaption of the Nonverbal Communication in Doctor-Elderly Patient Transactions form. KEY RESULTS: African American physicians with African American patients used more open body position, smile, and touch, compared to the average across other dyads (adjusted mean difference for open body position = 16.55, p < 0.001; smile = 2.35, p = 0.048; touch = 1.33, p < 0.001). African American physicians with white patients spent less time in open body position compared to the average across other dyads, but they also used more smile and eye gaze (adjusted mean difference for open body position = 27.25, p < 0.001; smile = 3.16, p = 0.005; eye gaze = 17.05, p < 0.001). There were no differences between white physicians' behavior toward African American vs. white patients. CONCLUSION: Race plays a role in physicians' non-verbal communication with older patients. Its influence is best understood when physician race and patient race are considered jointly.

Maternal gender discrimination and child emotional and behavioural problems: A population-based, longitudinal cohort study in the Czech Republic.

Background: Gender discrimination may be a novel mechanism through which gender inequality negatively affects the health of women and girls. We investigated whether children's mental health varied with maternal exposure to perceived gender discrimination. Methods: Complete longitudinal data was available on 2,567 mother-child dyads who were enrolled between March 1, 1991 and June 30, 1992 in the European Longitudinal Cohort Study of Pregnancy and Childhood-Czech cohort and were surveyed at multiple time points between pregnancy and child age up to 15 years. The Strengths and Difficulties Questionnaire (SDQ) was administered at child age 7, 11, and 15 years to assess child emotional/behavioural difficulties. Perceived gender discrimination was self-reported in mid-pregnancy and child age 7 and 11 years. Multilevel mixed-effects linear regression of SDQ scores were estimated. Mediation was tested using structural equation models. Findings: Perceived gender discrimination, reported by 11.2% of mothers in mid-pregnancy, was related to increased emotional/behavioural difficulties among children in bivariate analysis (slope = 0.24 [95% confidence interval (CI): 0.15, 0.32], p<0.0001) and in the fully adjusted model (slope = 0.18 [95% CI: 0.09, 0.27], p<0.0001). Increased difficulties were evident among children of mothers with more depressive symptoms (slope = 0.04 [95% CI: 0.03, 0.05], p<0.0001), boys (slope = 0.26 [95% CI: 0.19, 0.34], p<0.0001), first children (slope = 0.16 [95% CI: 0.09, 0.23], p<0.0001), and families under financial hardship (slope = 0.09 [95% CI: 0.04, 0.14], p<0.0001). Effects were attenuated for married mothers (slope-0.12 [95% CI: -0.22, -0.01], p<0.05]. Maternal depressive symptoms and financial hardship mediated about 37% and 13%, respectively, of the total effect of perceived gender discrimination on SDQ scores. Interpretation: Perceived gender discrimination among child-bearing women in family contexts was associated with more mental health problems among their children and adolescents, extending prior research showing associations with maternal mental health problems. Maternal depressive symptoms and, to a lesser extent, financial hardship both partially mediated the positive relationship between perceived gender discrimination and child emotional/behavioural problems. This should be taken into consideration when measuring the societal burden of gender inequality and gender-based discrimination. Moreover, gender-based discrimination affects more than one gender and more than one generation, extending to boys in the household even moreso than girls, highlighting that gender discrimination is everyone's issue. Further research is required on the intergenerational mechanisms whereby gender discrimination may lead to maternal and child mental health consequences. Funding: Bill and Melinda Gates Foundation; Ministry of Education, Youth and Sports, Czech Republic and European Structural and Investment Funds.

A model of perinatal stress and childhood wheezing: ELSPAC-CZ cohort.

BACKGROUND: Prenatal origins of wheezing are not fully understood. This study develops a model of mechanisms linking perinatal stress exposure to wheeze phenotypes in children. METHODS: Data were obtained from 1880 mother-child dyads participating in ELSPAC-CZ birth cohort. Wheeze phenotypes assessed between birth and age 7 years included "never wheeze," "early-onset transient (EOT) wheeze," "early-onset persistent (EOP) wheeze," and "late-onset (LO) wheeze." Prenatal and postnatal stress exposures were assessed in mid-pregnancy and 6 months after delivery, respectively, using an inventory of 42 life events. RESULTS: In adjusted models, children in the highest tercile (high) versus lowest tercile (low) for prenatal life events had a 38% higher risk of EOT wheeze (relative risk ratio [RRR] = 1.38; 95% confidence interval [CI] = 1.01-1.88; p = .041) and 50% higher risk of LO wheeze (RRR = 1.50; 95% CI = 1.00-2.25; p = .047). High versus low exposure to postnatal life events predicted a 60% increase in relative risk of EOT wheeze (RRR = 1.60; 95% CI = 1.17-2.19; p = .003) and medium versus low exposure was related to an 85% increase in relative risk of EOP wheeze (RRR = 1.85; 95% CI = 1.16-2.95; p = .010). Lower respiratory tract infections and postpartum depression partially mediated between postnatal life events and any wheeze (indirect effects 1.06, 95% CI = 1.02-1.09, p = .003 and odds ratio [OR] = 1.08, 95% CI = 1.02-1.15, p = .012, respectively), while postnatal events mediate for prenatal events (indirect effect OR = 1.11; 95% CI = 1.03-1.18; p = .005). CONCLUSIONS: Exposures to prenatal and postnatal life events are risk factors for the development of wheezing. Prenatal stress contributes to wheeze directly and also through postnatal life events, respiratory infections, and maternal depression.

Gender discrimination and depressive symptoms among child-bearing women: ELSPAC-CZ cohort study.

BACKGROUND: Depression is approximately two-fold more prevalent among women than men. Social theories suggest that discrimination is a pathway through which gender inequalities affect women's lives, but data are lacking. This cohort study evaluates whether perceived gender discrimination is linked to depressive symptoms among child-bearing women. METHODS: Data were obtained from 4,688 participants enrolled in pregnancy in 1991-92 in the European Longitudinal Cohort Study of Pregnancy and Childhood, Czech Republic. Perceived gender discrimination was assessed in mid-pregnancy, year seven, and year eleven. Depressive symptoms were assessed using the Edinburgh Postnatal Depression Scale at eight time-points between mid-pregnancy and year eleven post-delivery. Linear mixed error-component models of depressive symptoms were estimated. FINDINGS: Perceived gender discrimination, reported by 10.7% of women, was related to higher depressive symptoms, both in the unadjusted analysis (b = 0.15 [95% confidence interval (CI): 0.12, 0.19], p < 0.001) and in the fully adjusted model (b = 0.12 [95% CI: 0.09, 0.16], p < 0.001). Covariates linked to higher depressive symptoms included financial hardship (b = 0.12 [95% CI: 0.10, 0.14], p < 0.001), childhood emotional/physical neglect (b = 0.18 [95% CI: 0.14, 0.22], p < 0.001), and childhood sexual abuse (b = 0.04 [95% CI: 0.03, 0.06], p < 0.001); an inverse relationship was evident for social support (-0.05 [95% CI: -0.07, -0.04], p < 0.001) and having a partner who performs female-stereotypical household tasks (b=-0.03 [95% CI: -0.05, -0.01], p = 0.001). INTERPRETATION: The findings provide the first evidence that perceived gender discrimination is associated with depressive symptoms among child-bearing women. Social intervention programs aimed at reducing gender discrimination can potentially contribute to better mental health of women. FUNDING: Bill and Melinda Gates Foundation.

Perinatal Maternal Stress and Susceptibility to Infectious Diseases in Later Childhood: An Early Life Programming Perspective.

There is evidence of transmission of stress-related dysregulation from parents to offspring during early developmental stages, leading to adverse health outcomes. This study investigates whether perinatal stress is linked to the risk of infectious diseases in children aged 7-11 years. We hypothesize that stress exposure during pregnancy and the first 6 months after birth independently predict common infectious diseases. Data are obtained from ELSPAC-CZ, a prospective birth cohort. Maternal stress, operationalized as the number of life events, is examined for pregnancy and the first 6 months postpartum. Children's diseases include eye infection, ear infection, bronchitis/lung infection, laryngitis, strep throat, cold sores, and flu/flu-like infection. More prenatal and postnatal life events are both independently linked to a higher number of infectious diseases between the ages of 7-11 years. The effect is larger for postnatal vs. prenatal events, and the effect of prenatal events is attenuated after maternal health in pregnancy is controlled. The results suggest that perinatal stress is linked to susceptibility to infectious diseases in school-age children. Interventions to address stress in pregnant and postpartum women may benefit long-term children's health.

Objective Versus Self-Reported Adherence to Airway Clearance Therapy in Cystic Fibrosis.

BACKGROUND: Historically, studies of adherence to airway clearance therapy in cystic fibrosis (CF) have relied on self-reporting. We compared self-reported airway clearance therapy adherence to actual usage data from home high-frequency chest wall compressions (HFCWC) vests and identified factors associated with overestimation of adherence in self-reports. METHODS: Pediatric patients who perform airway clearance therapy with a HFCWC vest were eligible to participate. Objective adherence data were obtained from the HFCWC device, which records cumulative utilization time. Two readings at least 5 weeks apart were collected. Objective adherence was recorded as a ratio of mean-to-prescribed daily use (%). Self-reported adherence data were collected with a caregiver survey at enrollment. Adherence rates were categorized as low (< 35% of prescribed), moderate (36-79% of prescribed), and high (≥ 80% of prescribed). An overestimation was present when self-reported adherence was at least one category higher than objective adherence. RESULTS: In the final sample (N = 110), mean adherence by usage data was 61%. Only 35% of subjects (n = 38) were highly adherent, and 28% (n = 31) were low adherent. In contrast, 65% of subjects (n = 72) reported high adherence and only 8% (n = 9) reported low adherence (P < .001). Nearly half of self-reports (46%) overestimated adherence. In a multiple regression analysis, overestimation was associated with multiple airway clearance therapy locations (odds ratio 7.13, 95% CI 1.16-43.72, P = .034) and prescribed daily use ≥ 60 min (odds ratio 3.85, 95% CI 1.08-13.76, P < .038). Among subjects with prescribed daily airway clearance therapy ≥ 60 min, the odds of overestimating adherence increased 3-fold (odds ratio 3.04, 95% CI 1.17-7.87, P = .02) in a lower-income (< $50,000/y) environment. CONCLUSIONS: Self-reports overestimated actual adherence to airway clearance therapy, and the overestimation increased with treatment occurring in multiple households and prescribed therapy duration. Among participants with prescribed airway clearance therapy ≥ 60 min, overestimation increased with lower income. Objective measures of adherence are needed, particularly for lower-income children and those receiving treatments in multiple locations.

Substance Use Stigma and Antiretroviral Therapy Adherence Among a Drug-Using Population Living with HIV.

Among people living with HIV (PLWH), HIV-related stigma predicts nonadherence to antiretroviral therapy (ART); however, the role of stigma associated with drug use is largely unknown. We examined the association between substance use (SU) stigma and optimal ART adherence in a sample of 172 self-reported HIV-infected drug users. Participants completed surveys on SU, stigma, and ART adherence. The three substance classes with the greatest number of participants exhibiting moderate/high-risk scores were for cocaine/crack cocaine (66.28%), cannabis (64.53%), and hazardous alcohol consumption (65.70%). Multivariable logistic regression was conducted to investigate associations between levels of SU stigma and optimal ART adherence, adjusting for sociodemographic characteristics, severity of illicit drug use (alcohol, smoking and substance involvement screening test) and alcohol use severity (Alcohol Use Disorders Identification Test-C), HIV-related stigma, and social support. The odds of optimal adherence among participants experiencing moderate [Adjusted Odds Ratio (AOR) = 0.36, p = 0.039] and very high (AOR = 0.25, p = 0.010) levels of anticipated SU stigma were significantly lower than participants experiencing low levels of anticipated SU stigma. No other stigma subscales were significant predictors of ART adherence. Interventions aiming to improve ART adherence among drug-using PLWH need to address anticipated SU stigma.

Effects of poverty and lack of insurance on perceptions of racial and ethnic bias in health care.

OBJECTIVE: To investigate whether poverty and lack of insurance are associated with perceived racial and ethnic bias in health care. DATA SOURCE: 2001 Survey on Disparities in Quality of Health Care, a nationally representative telephone survey. We use data on black, Hispanic, and white adults who have a regular physician (N=4,556). STUDY DESIGN: We estimate multivariate logistic regression models to examine the effects of poverty and lack of health insurance on perceived racial and ethnic bias in health care for all respondents and by racial, ethnic, and language groups. PRINCIPAL FINDINGS: Controlling for sociodemographic and other factors, uninsured blacks and Hispanics interviewed in English are more likely to report racial and ethnic bias in health care compared with their privately insured counterparts. Poor whites are more likely to report racial and ethnic bias in health care compared with other whites. Good physician-patient communication is negatively associated with perceived racial and ethnic bias. CONCLUSIONS: Compared with their more socioeconomically advantaged counterparts, poor whites, uninsured blacks, and some uninsured Hispanics are more likely to perceive that racial and ethnic bias operates in the health care they receive. Providing health insurance for the uninsured may help reduce this perceived bias among some minority groups.

Perceived Discrimination and Privilege in Health Care: The Role of Socioeconomic Status and Race.

INTRODUCTION: This study examined how perceived racial privilege and perceived racial discrimination in health care varied with race and socioeconomic status (SES). METHODS: The sample consisted of white, black, and Native American respondents to the Behavioral Risk Factor Surveillance System (2005-2013) who had sought health care in the past 12 months. Multiple logistic regression models of perceived racial privilege and perceived discrimination were estimated. Analyses were performed in 2016. RESULTS: Perceptions of racial privilege were less common among blacks and Native Americans compared with whites, while perceptions of racial discrimination were more common among these minorities. In whites, higher income and education contributed to increased perceptions of privileged treatment and decreased perceptions of discrimination. The pattern was reversed in blacks, who reported more discrimination and less privilege at higher income and education levels. Across racial groups, respondents who reported foregone medical care due to cost had higher risk of perceived racial discrimination. Health insurance contributed to less perceived racial discrimination and more perceived privilege only among whites. CONCLUSIONS: SES is an important social determinant of perceived privilege and perceived discrimination in health care, but its role varies by indicator and racial group. Whites with low education or no health insurance, well-educated blacks, and individuals who face cost-related barriers to care are at increased risk of perceived discrimination. Policies and interventions to reduce these perceptions should target structural and systemic factors, including society-wide inequalities in income, education, and healthcare access, and should be tailored to account for racially specific healthcare experiences.