A Matter of Time: Racialized Time and the Production of Health Disparities.

An expansive and methodologically varied literature designed to investigate racial disparities in health now exists. Empirical evidence points to an overlapping, complex web of social conditions that accelerate the pace of aging and erodes long-term health outcomes among people of color, especially Black Americans. However, a social exposure-or lack thereof-that is rarely mentioned is time use. The current paper was specifically designed to address this shortcoming. First, we draw on extant research to illustrate how and why time is a critical source of racial disparities in health. Second, we employ fundamental causes theory to explain the specific mechanisms through which the differential distribution of time across race is likely to give rise to unequal health outcomes. Finally, we introduce a novel conceptual framework that identifies and distinguishes between four distinct forms of time use likely to play an outsized role in contributing to racial disparities in health.

Racial and Economic Segregation Over the Life Course and Incident Hypertensive Disorders of Pregnancy Among Black Women in California.

Black women in the United States have the highest incidence of hypertensive disorders of pregnancy (HDP) and are disproportionately burdened by its adverse sequalae, compared with women of all racial and ethnic groups. Segregation, a key driver of structural racism for Black families, can provide information critical to understanding these disparities. We examined the association between racial and economic segregation at 2 points and incident HDP using intergenerationally linked birth records of 45,204 Black California-born primiparous mothers (born 1982-1997) and their infants (born 1997-2011), with HDP ascertained from hospital discharge records. Women's early childhood and adulthood neighborhoods were categorized as deprived, mixed, or privileged based on the Index of Concentration at the Extremes (a measure of concentrated racial and economic segregation), yielding 9 life-course trajectories. Women living in deprived neighborhoods at both time points experienced the highest odds of HDP (from mixed effect logistic regression, unadjusted odds ratio = 1.26, 95% confidence interval: 1.13, 1.40) compared with women living in privileged neighborhoods at both time points. All trajectories involving residence in a deprived neighborhood in early childhood or adulthood were associated with increased odds of HDP, whereas mixed-privileged and privileged-mixed trajectories were not. Future studies should assess the causal nature of these associations.

A Framework for Interfacing and Partnering with Environmental Justice Communities as a Prelude to Human Health and Hazard Identification in the Vulnerable Census Tracts of Columbus, Ohio.

Columbus, Ohio is one of the more prosperous, well-educated, and progressive cities in the United States. However, it ranks as the second worst life expectancy at birth, has a census tract wealth gap (27-year disparity), and one of the higher infant mortality rates in the country. These data suggest that there are likely several high-risk, vulnerable neighborhoods in Columbus with residents experiencing disparate and adverse outcomes. Illustrative of this fact are studies that have examined the social processes and mechanisms through which neighborhood contexts are at the forefront, including exposures to chemical stressors such as particulate matter (PM2.5) as well as non-chemical stressors including violence, social determinants of health, zoning, and land use policies. It is documented that disparate and adverse outcomes are magnified in the vulnerable neighborhoods on the Near East Side as compared to Columbus city proper, Franklin County and/or the state of Ohio. As such, we developed a nuanced community engagement framework to identify potential environmental hazards associated with adverse pregnancy outcomes in those census tracts. The refined framework uses a blended version of traditional community-based participatory research (CBPR) models and is referred to as E6, Enhancing Environmental Endeavors via e-Equity, Education, and Empowerment.

Shades of health: Skin color, ethnicity, and mental health among Black Americans.

Skin color is an important predictor of health outcomes among Black Americans. Black Americans with darker complexions experience worse physical and psychological functioning than those with lighter complexions. However, most research on the health effects of colorism focuses solely on African Americans, omitting the experiences of other Black subpopulations. Using data from the National Survey of American Life (NSAL), we investigate the relationship between skin color and mental health among African Americans (N = 3393) and Caribbean Blacks (N = 1378). Findings from multivariate logistic regressions reveal that Black Americans with the lightest complexions-regardless of ethnicity-report worse psychological functioning. However, the shape of the association between skin tone and mental health varies significantly based on ethnicity and the specific psychiatric outcome under study. For Caribbean Blacks, the association between skin color and any mental disorders and mood disorders is linear, while the relationship for anxiety disorders is curvilinear. For African Americans, the relationship between skin color and mental health shows an elevated risk among only those with the lightest skin tones. These results illustrate the heterogeneity within the Black community and highlight the importance of recognizing ethnicity in health disparities research.

Structural and Social Determinants of Health Factors Associated with County-Level Variation in Non-Adherence to Antihypertensive Medication Treatment.

BACKGROUND: Non-adherence to antihypertensive medication treatment (AHM) is a complex health behavior with determinants that extend beyond the individual patient. The structural and social determinants of health (SDH) that predispose populations to ill health and unhealthy behaviors could be potential barriers to long-term adherence to AHM. However, the role of SDH in AHM non-adherence has been understudied. Therefore, we aimed to define and identify the SDH factors associated with non-adherence to AHM and to quantify the variation in county-level non-adherence to AHM explained by these factors. METHODS: Two cross-sectional datasets, the Centers for Disease Control and Prevention (CDC) Atlas of Heart Disease and Stroke (2014-2016 cycle) and the 2016 County Health Rankings (CHR), were linked to create an analytic dataset. Contextual SDH variables were extracted from the CDC-CHR linked dataset. County-level prevalence of AHM non-adherence, based on Medicare fee-for-service beneficiaries' claims data, was extracted from the CDC Atlas dataset. The CDC measured AHM non-adherence as the proportion of days covered (PDC) with AHM during a 365 day period for Medicare Part D beneficiaries and aggregated these measures at the county level. We applied confirmatory factor analysis (CFA) to identify the constructs of social determinants of AHM non-adherence. AHM non-adherence variation and its social determinants were measured with structural equation models. RESULTS: Among 3000 counties in the U.S., the weighted mean prevalence of AHM non-adherence (PDC < 80%) in 2015 was 25.0%, with a standard deviation (SD) of 18.8%. AHM non-adherence was directly associated with poverty/food insecurity (ß = 0.31, P-value < 0.001) and weak social supports (ß = 0.27, P-value < 0.001), but inversely with healthy built environment (ß = -0.10, P-value = 0.02). These three constructs explained one-third (R2 = 30.0%) of the variation in county-level AHM non-adherence. CONCLUSION: AHM non-adherence varies by geographical location, one-third of which is explained by contextual SDH factors including poverty/food insecurity, weak social supports and healthy built environments.

The Effects of Social, Personal, and Behavioral Risk Factors and PM2.5 on Cardio-Metabolic Disparities in a Cohort of Community Health Center Patients.

(1) Background: Cardio-metabolic diseases (CMD), including cardiovascular disease, stroke, and diabetes, have numerous common individual and environmental risk factors. Yet, few studies to date have considered how these multiple risk factors together affect CMD disparities between Blacks and Whites. (2) Methods: We linked daily fine particulate matter (PM2.5) measures with survey responses of participants in the Southern Community Cohort Study (SCCS). Generalized linear mixed modeling (GLMM) was used to estimate the relationship between CMD risk and social-demographic characteristics, behavioral and personal risk factors, and exposure levels of PM2.5. (3) Results: The study resulted in four key findings: (1) PM2.5 concentration level was significantly associated with reported CMD, with risk rising by 2.6% for each µg/m3 increase in PM2.5; (2) race did not predict CMD risk when clinical, lifestyle, and environmental risk factors were accounted for; (3) a significant variation of CMD risk was found among participants across states; and (4) multiple personal, clinical, and social-demographic and environmental risk factors played a role in predicting CMD occurrence. (4) Conclusions: Disparities in CMD risk among low social status populations reflect the complex interactions of exposures and cumulative risks for CMD contributed by different personal and environmental factors from natural, built, and social environments.

The Intergenerational Transmission of Discrimination: Children's Experiences of Unfair Treatment and Their Mothers' Health at Midlife.

A growing body of research suggests that maternal exposure to discrimination helps to explain racial disparities in children's health. However, no study has considered if the intergenerational health effects of unfair treatment operate in the opposite direction-from child to mother. To this end, we use data from mother-child pairs in the National Longitudinal Survey of Youth 1979 to determine whether adolescent and young adult children's experiences of discrimination influence their mother's health across midlife. We find that children who report more frequent instances of discrimination have mothers whose self-rated health declines more rapidly between ages 40 and 50 years. Furthermore, racial disparities in exposure to discrimination among children explains almost 10% of the black-white gap but little of the Hispanic-white gap in self-rated health among these mothers. We conclude that the negative health impacts of discrimination are likely to operate in a bidirectional fashion across key family relationships.

Do rising tides lift all boats? Racial disparities in health across the lifecourse among middle-class African-Americans and Whites.

Although racial inequalities in health are well documented, much less is known about the underlying mechanisms that create and sustain these population patterns, especially among nonpoor subgroups. Using 20 waves of data from the Panel Study of Income Dynamics (PSID), we estimate the magnitude of the Black/White gap in self-rated health among middle-income, working-age (18-65) adults and explore potential sources of this disparity. Findings from multilevel regression models suggest that intragenerational gains in family income result in significantly smaller improvements in self-rated health for middle-class African-Americans than similarly situated Whites. We also note that childhood disadvantage predicts subsequent health trajectories in adulthood, but does little to explain the Black/White gap in the association between family income and self-rated health. We conclude that middle-class status provides restricted health returns to upward mobility for African-Americans and this differential relationship cannot be accounted for by greater exposure to early life disadvantage.

Racial disparities in health among nonpoor African Americans and Hispanics: The role of acute and chronic discrimination.

Racial disparities in health tend to be more pronounced at the upper ends of the socioeconomic (SES) spectrum. Despite having access to above average social and economic resources, nonpoor African Americans and Latinos report significantly worse health compared to nonpoor Whites. We combine data from the parents and children of the 1979 National Longitudinal Survey of Youth (NLSY79) to address two specific research aims. First, we generate longitudinal SES trajectories over a 33-year period to estimate the extent to which socioeconomic mobility is associated with exposure to discrimination (acute and chronic) across different racial/ethnic groups (nonHispanic Whites, nonHispanic Blacks, and Hispanics). Then we determine if the disparate relationship between SES and self-rated health across these groups can be accounted for by more frequent exposure to unfair treatment. For Whites, moderate income gains over time result in significantly less exposure to both acute and chronic discrimination. Upwardly mobile African Americans and Hispanics, however, were significantly more likely to experience acute and chronic discrimination, respectively, than their socioeconomically stable counterparts. We also find that differential exposure to unfair treatment explains a substantial proportion of the Black/White, but not the Hispanic/White, gap in self-rated health among this nationally representative sample of upwardly mobile young adults. The current study adds to the debate that the shape of the SES/health gradient differs, in important ways, across race and provides empirical support for the diminishing health returns hypothesis for racial/ethnic minorities.

Two Mechanisms: The Role of Social Capital and Industrial Pollution Exposure in Explaining Racial Disparities in Self-Rated Health.

This study provides an empirical test of two mechanisms (social capital and exposure to air pollution) that are theorized to mediate the effect of neighborhood on health and contribute to racial disparities in health outcomes. To this end, we utilize the Social Capital Benchmark Study, a national survey of individuals nested within communities in the United States, to estimate how multiple dimensions of social capital and exposure to air pollution, explain racial disparities in self-rated health. Our main findings show that when controlling for individual-confounders, and nesting within communities, our indicator of cognitive bridging, generalized trust, decreases the gap in self-rated health between African Americans and Whites by 84%, and the gap between Hispanics and Whites by 54%. Our other indicator of cognitive social capital, cognitive linking as represented by engagement in politics, decreases the gap in health between Hispanics and Whites by 32%, but has little impact on African Americans. We also assessed whether the gap in health was explained by respondents' estimated exposure to toxicity-weighted air pollutants from large industrial facilities over the previous year. Our results show that accounting for exposure to these toxins has no effect on the racial gap in self-rated health in these data. This paper contributes to the neighborhood effects literature by examining the impact that estimated annual industrial air pollution, and multiple measures of social capital, have on explaining the racial gap in health in a sample of individuals nested within communities across the United States.

Social inequalities in suicide: the role of selective serotonin reuptake inhibitors.

We aimed to examine the relationship between socioeconomic status (SES) and suicide associated with the introduction and diffusion of selective serotonin reuptake inhibitors (SSRIs). Negative binomial regression was used to estimate county-level suicide rates among persons aged 25 years or older using death certificate data collated by the National Center for Health Statistics from 1968 to 2009; SES was measured using the decennial US Census. The National Health and Nutrition Examination Survey and the Medical Expenditure Panel Survey were used to measure SSRI use. Once SSRIs became available in 1988, a 1% increase in SSRI usage was associated with a 0.5% lower suicide rate. Prior to the introduction of SSRIs, SES was not related to suicide. However, with each 1% increase in SSRI use, a 1-standard deviation (SD) higher SES was associated with a 0.6% lower suicide rate. In 2009, persons living in counties with SES 1 SD above the national average were 13.6% less likely to commit suicide than those living in counties with SES 1 SD below the national average--a difference of 1.9/100,000 adults aged ≥25 years. Higher SSRI use was associated with lower suicide rates among US residents aged ≥25 years; however, SES inequalities modified the association between SSRI use and suicide.

Is breast truly best? Estimating the effects of breastfeeding on long-term child health and wellbeing in the United States using sibling comparisons.

Breastfeeding rates in the U.S. are socially patterned. Previous research has documented startling racial and socioeconomic disparities in infant feeding practices. However, much of the empirical evidence regarding the effects of breastfeeding on long-term child health and wellbeing does not adequately address the high degree of selection into breastfeeding. To address this important shortcoming, we employ sibling comparisons in conjunction with 25 years of panel data from the National Longitudinal Survey of Youth (NLSY) to approximate a natural experiment and more accurately estimate what a particular child's outcome would be if he/she had been differently fed during infancy. Results from standard multiple regression models suggest that children aged 4 to 14 who were breast- as opposed to bottle-fed did significantly better on 10 of the 11 outcomes studied. Once we restrict analyses to siblings and incorporate within-family fixed effects, estimates of the association between breastfeeding and all but one indicator of child health and wellbeing dramatically decrease and fail to maintain statistical significance. Our results suggest that much of the beneficial long-term effects typically attributed to breastfeeding, per se, may primarily be due to selection pressures into infant feeding practices along key demographic characteristics such as race and socioeconomic status.

Fundamental causes of colorectal cancer mortality in the United States: understanding the importance of socioeconomic status in creating inequality in mortality.

OBJECTIVES: We used the fundamental cause hypothesis as a framework for understanding the creation of health disparities in colorectal cancer mortality in the United States from 1968 to 2005. METHODS: We used negative binomial regression to analyze trends in county-level gender-, race-, and age-adjusted colorectal cancer mortality rates among individuals aged 35 years or older. RESULTS: Prior to 1980, there was a stable gradient in colorectal cancer mortality, with people living in counties of higher socioeconomic status (SES) being at greater risk than people living in lower SES counties. Beginning in 1980, this gradient began to narrow and then reversed as people living in higher SES counties experienced greater reductions in colorectal cancer mortality than those in lower SES counties. CONCLUSIONS: Our findings support the fundamental cause hypothesis: once knowledge about prevention and treatment of colorectal cancer became available, social and economic resources became increasingly important in influencing mortality rates.

Fundamental causes of colorectal cancer mortality: the implications of informational diffusion.

CONTEXT: Colorectal cancer is a major cause of mortality in the United States, with 52,857 deaths estimated in 2012. To explore further the social inequalities in colorectal cancer mortality, we used fundamental cause theory to consider the role of societal diffusion of information and socioeconomic status. METHODS: We used the number of deaths from colorectal cancer in U.S. counties between 1968 and 2008. Through geographical mapping, we examined disparities in colorectal cancer mortality as a function of socioeconomic status and the rate of diffusion of information. In addition to providing year-specific trends in colorectal cancer mortality rates, we analyzed these data using negative binomial regression. FINDINGS: The impact of socioeconomic status (SES) on colorectal cancer mortality is substantial, and its protective impact increases over time. Equally important is the impact of informational diffusion on colorectal cancer mortality over time. However, while the impact of SES remains significant when concurrently considering the role of diffusion of information, the propensity for faster diffusion moderates its effect on colorectal cancer mortality. CONCLUSIONS: The faster diffusion of information reduces both colorectal cancer mortality and inequalities in colorectal cancer mortality, although it was not sufficient to eliminate SES inequalities. These findings have important long-term implications for policymakers looking to reduce social inequalities in colorectal cancer mortality and other, related, preventable diseases.

Excess black mortality in the United States and in selected black and white high-poverty areas, 1980-2000.

OBJECTIVES: Black working-aged residents of urban high-poverty areas suffered severe excess mortality in 1980 and 1990. Our goal in this study was to determine whether this trend persisted in 2000. METHODS: We analyzed death certificate and census data to estimate age-standardized all-cause and cause-specific mortality among 16- to 64-year-old Blacks and Whites nationwide and in selected urban and rural high-poverty areas. RESULTS: Urban men's mortality rate estimates peaked in 1990 and declined between 1990 and 2000 back to or below 1980 levels. Evidence of excess mortality declines among urban or rural women and among rural men was modest, with some increases. Between 1980 and 2000, there was little decline in chronic disease mortality among men and women in most areas, and in some instances there were increases. CONCLUSIONS: In 2000, despite improved economic conditions, working-age residents of the study areas still died disproportionately of early onset of chronic disease, suggesting an entrenched burden of disease and unmet health care needs. The lack of consistent improvement in death rates among working-age residents of high-poverty areas since 1980 necessitates reflection and concerted action given that sustainable progress has been elusive for this age group.

Examination of inequalities in HIV/AIDS mortality in the United States from a fundamental cause perspective.

OBJECTIVES: We examined changes in socioeconomic status (SES) and Black to White inequalities in HIV/AIDS mortality in the United States before and after the introduction of highly active antiretroviral therapy (HAART). METHODS: Taking a fundamental cause perspective, we used negative binomial regression to analyze trends in county-level gender-, race-, and age-specific HIV/AIDS mortality rates among those aged 15 to 64 years during the period 1987-2005. RESULTS: Although HIV/AIDS mortality rates decreased once HAART became available, the declines were not uniformly distributed among population groups. The associations between SES and HIV/AIDS mortality and between race and HIV/AIDS mortality, although present in the pre-HAART period, were significantly greater in the peri- and post-HAART periods, with higher SES and White race associated with the greatest declines in mortality during the post-HAART period. CONCLUSIONS: Our findings support the fundamental cause hypothesis, as the introduction of a life-extending treatment exacerbated inequalities in HIV/AIDS mortality by SES and by race. In addition to a strong focus on factors that improve overall population health, more effective public health interventions and policies would facilitate an equitable distribution of health-enhancing innovations.

Maternal upward socioeconomic mobility and black-white disparities in infant birthweight.

OBJECTIVES: We estimate the extent to which upward socioeconomic mobility limits the probability that Black and White women who spent their childhoods in or near poverty will give birth to a low-birthweight baby. METHODS: Data from the National Longitudinal Survey of Youth 1979 and the 1970 US Census were used to complete a series of logistic regression models. We restricted multivariate analyses to female survey respondents who, at 14 years of age, were living in households in which the income-to-needs ratio did not exceed 200% of poverty. RESULTS: For White women, the probability of giving birth to a low-birthweight baby decreases by 48% for every 1 unit increase in the natural logarithm of adult family income, once the effects of all other covariates are taken into account. For Black women, the relation between adult family income and the probability of low birthweight is also negative; however, this association fails to reach statistical significance. CONCLUSIONS: Upward socioeconomic mobility contributes to improved birth outcomes among infants born to White women who were poor as children, but the same does not hold true for their Black counterparts.

Urban-rural differences in excess mortality among high-poverty populations: evidence from the Harlem Household Survey and the Pitt County, North Carolina Study of African American Health.

Black youth residing in high-poverty areas have dramatically lower probabilities of surviving to age 65 if they are urban than if they are rural. Chronic disease deaths contribute heavily. We begin to probe the reasons using the Harlem Household Survey (HHS) and the Pitt County, North Carolina Study of African American Health (PCS). We compare HHS and PCS respondents on chronic disease rates, health behaviors, social support, employment, indicators of health care access, and health insurance. Chronic disease profiles do not favor Pitt County. Smoking uptake is similar across samples, but PCS respondents are more likely to quit. Indicators of access to health care and private health insurance are more favorable in Pitt County. Findings suggest rural mortality is averted through secondary or tertiary prevention, not primary. Macroeconomic and health system changes of the past 20 years may have left poor urban Blacks as medically underserved as poor rural Blacks.

Getting a piece of the pie? The economic boom of the 1990s and declining teen birth rates in the United States.

In the United States, the 1990s was a decade of dramatic economic growth as well as a period characterized by substantial declines in teenage childbearing. This study examines whether falling teen fertility rates during the 1990s were responsive to expanding employment opportunities and whether the implementation of the Personal Responsibility and Work Opportunities Act (PRWORA), increasing rates of incarceration, or restrictive abortion policies may have affected this association. Fixed-effects Poisson regression models were estimated to assess the relationship between age-specific birth rates and state-specific unemployment rates from 1990 to 1999 for Black and White females aged 10-29. Falling unemployment rates in the 1990s were associated with decreased childbearing among African-American women aged 15-24, but were largely unrelated to declines in fertility for Whites. For 18-19 year-old African-Americans, the group for whom teen childbearing is most normative, our model accounted for 85% of the decrease in rates of first births. Young Black women, especially older teens, may have adjusted their reproductive behavior to take advantage of expanded labor market opportunities.