Health Implications of Housing Assignments for Incarcerated Transgender Women.

Transgender women (i.e., persons who were assigned male sex at birth but who live and identify as female) experience forms of discrimination that limit their access to stable housing and contribute to high rates of incarceration; once incarcerated, the approaches used to assign them housing within the jail or prison place them at risk for abuse, rape, and other outcomes. Yet, a paucity of studies explores the implications of carceral housing assignments for transgender women.Whether the approaches used to assign housing in jails and prisons violate the rights of incarcerated transgender persons has been argued before the US federal courts under Section 1983 of the US Constitution, which allows persons who were raped while incarcerated to claim a violation of their Eighth Amendment rights.Reforms and policy recommendations have been attempted; however, the results have been mixed and the public health implications have received limited attention.

Endometrial cancer disparities: a race-conscious critique of the literature.

Racial disparities in endometrial cancer are stark and have increased over the past decade. While the disparities are well documented, intervention work to address the mortality gap is nonexistent. This review critiques how race has been conceptualized to explain the causes of endometrial cancer disparities, assesses gaps in knowledge production, and proposes new research priorities. Using public health critical race praxis, a research approach for examining racial disparities and knowledge production processes, we reviewed the endometrial cancer disparities literature from 1995 through 2016. Using systematic search methods, 133 unique records were identified and 48 studies critiqued. We found that a narrow definition of race as a purely biological construct is common throughout the literature. This appears to result in an underemphasis on the role of modifiable, nonbiological contributors to racial disparities and a lack of follow-up work to address these contributors. Key knowledge gaps identified were the role of health care systems in early diagnosis, a lack of intervention studies to address persistent treatment inequity by race, and the near absence of qualitative work to understand the perspectives of Black women diagnosed with endometrial cancer. We conclude with an iterative demonstration of the public health critical race praxis and suggest new routes of inquiry to broaden the scope of research priorities to understand and improve the outcomes of Black women with endometrial cancer.

Commentary: Just What is Critical Race Theory and What's it Doing in a Progressive Field like Public Health?

Gloria Ladson-Billings cautiously promotes the use of Critical Race Theory (CRT) to address racism's contribution to educational disparities. Nearly a decade ago, we issued a similar call to the multidisciplinary field of public health. Public health touts its progressive roots and focus on equity, but do those efforts draw on CRT? To answer this question, we define CRT, describe its origin in the field of law, and review the ways its use has grown in the field of public health. Public health interventions and policies rely heavily on evidence; therefore, we re-introduce the semi-structured research method we developed to facilitate empirical application of CRT, ie, the Public Health Critical Race Praxis (PHCRP).

Editorial: Critical Race Theory - We Are all Others.

Over the past two years, the persistence of racism in the United States has been particularly pronounced in the policies and actions of the administration of President Donald J. Trump; however, the structure of the United States has been racialized since its inception. This supplement of Ethnicity & Disease uses Critical Race Theory (CRT) to explore several implications for public health and public health research. We intend for it to spark conversations in the classroom and among researchers on how racial phenomena operate and how we as a field can address racism.

Anti-Racism Methods for Big Data Research: Lessons Learned from the HIV Testing, Linkage, & Retention in Care (HIV TLR) Study.

Public Health Critical Race Praxis (PHCRP) contributes three functional elements to health equity studies: a race conscious orientation; an antiracism lexicon based on Critical Race Theory (CRT); and an integrated, reflexive approach. Few big data studies employ all three functional elements. Therefore, this article describes the application of PHCRP to the Human Immunodeficiency Virus Testing, Linkage and Retention in care (HIV TLR) study (N=3,476,741), which connects multiple large datasets to electronic medical records to examine contextual determinants of racial/ethnic disparities in HIV care continuum outcomes in southern California. As HIV TLR demonstrates, PHCRP's innovative tools and strategies help big data research maintain fidelity to CRT.

Intersection of Living in a Rural Versus Urban Area and Race/Ethnicity in Explaining Access to Health Care in the United States.

OBJECTIVES: To examine whether living in a rural versus urban area differentially exposes populations to social conditions associated with disparities in access to health care. METHODS: We linked Medical Expenditure Panel Survey (2005-2010) data to geographic data from the American Community Survey (2005-2009) and Area Health Resource File (2010). We categorized census tracts as rural and urban by using the Rural-Urban Commuting Area Codes. Respondent sample sizes ranged from 49 839 to 105 306. Outcomes were access to a usual source of health care, cholesterol screening, cervical screening, dental visit within recommended intervals, and health care needs met. RESULTS: African Americans in rural areas had lower odds of cholesterol screening (odds ratio[OR] = 0.37; 95% confidence interval[CI] = 0.25, 0.57) and cervical screening (OR = 0.48; 95% CI = 0.29, 0.80) than African Americans in urban areas. Whites had fewer screenings and dental visits in rural versus urban areas. There were mixed results for which racial/ethnic group had better access. CONCLUSIONS: Rural status confers additional disadvantage for most of the health care use measures, independently of poverty and health care supply.

Sexual Risk Behaviors and Substance Use Among Men Sexually Victimized by Women.

OBJECTIVES: To investigate whether forced sex of men by women was associated with sexual risk behaviors, and whether this association was mediated by substance use. METHODS: Data from US men aged 18 years or older at interview in the National Survey of Family Growth 2006-2010 (n = 8108) who reported sexual behavior history. Outcome variables were condom use at most recent sex and number of lifetime sexual partners. Sexual activity covariates included age at first consensual sex and treatment of sexually transmitted infections. Alcohol and drug use were the mediating factors. RESULTS: Six percent of men reported forced sex by a woman at a mean age of 18 years. On average, victimized men had 3 more lifetime sexual partners than nonvictimized men (P < .01). Furthermore, victimized men who reported drug use had, on average, 4 more female sexual partners (P < .01) than nonvictimized men. Marijuana (P < .05) and crack cocaine use (P < .05) partially mediated the association between forced sex and number of female partners. Neither condom use nor number of male partners differed between victimized and nonvictimized men. CONCLUSIONS: A nontrivial fraction of men experience forced sex by women; some of them have elevated sexual risk behaviors.

Relationship between a Centers for Disease Control and Prevention expanded HIV testing initiative and past-year testing by race/ethnicity: a multilevel analysis of the Behavioral Risk Factor Surveillance System.

The Centers for Disease Control and Prevention's (CDC) expanded testing initiative (ETI) aims to bolster HIV testing among populations disproportionately affected by the HIV epidemic by providing additional funding to health departments serving these communities. ETI prioritizes testing in clinical settings; therefore, we examined the relationship between state-level ETI participation and past-year HIV testing among a racially/ethnically diverse sample of adult respondents to the 2012 Behavioral Risk Factor Surveillance System who accessed health services within the 12 months prior to being interviewed. Controlling for individual- and state-level characteristics in a multilevel logistic regression model, ETI participation was independently and positively associated with past-year testing, but this association varied by race/ethnicity. Hispanics had higher odds (adjusted odds ratio [AOR]: 1.49; 95% CI: 1.11-2.02) and American Indian/Alaska Natives had lower odds (AOR: 0.66; 95% CI: 0.43-0.99) of testing if they resided in states with (vs. without) ETI participation. State-level ETI participation did not significantly alter past-year testing among other racial/ethnic groups. Prioritizing public health resources in states most affected by HIV can improve testing patterns, but other mechanisms likely influence which racial/ethnic groups undergo testing.

Recent HIV Testing Prevalence, Determinants, and Disparities Among U.S. Older Adult Respondents to the Behavioral Risk Factor Surveillance System.

BACKGROUND: Although routine human immune deficiency virus (HIV) testing during health care visits is recommended for most adults, many older adults (i.e., ages 50-64 years) do not receive it. This study identified factors associated with HIV testing in the past 12 months (i.e., recent HIV testing) among US adults in the 3 categories of older adulthood (50-54, 55-59, and 60-64 years) for which routine HIV testing is recommended. METHOD: This was a cross-sectional analysis of data from US older adult respondents to the 2010 Behavioral Risk Factor Surveillance System. We calculated prevalence (proportions) of HIV testing by age category and race/ethnicity. Using multiple logistic regression, we identified predisposing, enabling, and need factors associated with recent HIV testing within and across age categories, by race/ethnicity and controlling for covariates. RESULTS: HIV testing prevalence was low (<5%), varied by race/ethnicity, and decreased with age. Within and across age categories, the odds of testing were highest among blacks (odds ratio [OR], 3.47; 95% confidence interval [CI], 2.82-4.25) and higher among Latinos (OR, 2.06; 95% CI, 1.50-2.84) and the oldest and youngest categories of American Indians/Alaska Natives (OR, 2.48; 95% CI, 1.11-5.55; OR, 2.98; 95% CI, 1.49-5.95) than among whites. Those reporting a recent doctor visit (OR, 2.32; 95% CI, 1.92-2.74) or HIV risk behaviors (OR, 3.50; 95% CI, 2.67-4.59) had higher odds of HIV testing. CONCLUSION: Regardless of risk, the oldest older adults, whites, and older women may forego HIV testing. Doctor visits may facilitate HIV testing. Additional research is needed to understand why eligible older adults seen by providers may not be screened for HIV infection.

HIV testing among clients in high HIV prevalence venues: disparities between older and younger adults.

The Centers for Disease Control and Prevention recommends routine human immunodeficiency virus (HIV) testing of every client presenting for services in venues where HIV prevalence is high. Because older adults (aged ≥50 years) have particularly poor prognosis if they receive their diagnosis late in the course of HIV disease, any screening provided to younger adults in these venues should also be provided to older adults. We examined aging-related disparities in recent (past 12 months) and ever HIV testing in a probability sample of at-risk adults (N = 1238) seeking services in needle exchange sites, sexually transmitted disease clinics, and Latino community clinics that provide HIV testing. Using multiple logistic regression with generalized estimating equations, we estimated associations between age category (<50 years vs. ≥50 years) and each HIV testing outcome. Even after controlling for covariates such as recent injection drug use, older adults had 40% lower odds than younger adults did of having tested in the past 12 months (odds ratio [OR] = 0.6; 95% confidence interval [CI] = 0.40-0.90) or ever (OR = 0.6; 95% CI = 0.40-0.90). Aging-related disparities in HIV testing exist among clients of these high HIV prevalence venues and may contribute to known aging-related disparities in late diagnosis of HIV infection and poor long-term prognosis.

The relationship between discrimination and high-risk social ties by race/ethnicity: examining social pathways of HIV risk.

High-risk social ties portend differences in opportunity for HIV exposures and may contribute to racial/ethnic disparities in HIV transmission. Discrimination may affect the formation of high-risk social ties and has not been explored as a possible explanation for these persistent disparities. Using data from injection and non-injection drug users, we examined the association between the number of high-risk sex and drug ties with discrimination due to race, drug use, and incarceration stratified by race/ethnicity. Negative binomial regression models were used. While blacks had significantly fewer injecting ties than Latinos and whites, blacks who reported racial discrimination compared to blacks who did not, had more sex and injecting ties. Latinos who reported drug use discrimination compared to Latinos who did not also had more sex ties. Latinos and whites who reported drug use discrimination had more injecting ties than Latinos and whites who did not. Discrimination is associated with high-risk social ties among all racial/ethnic groups. But, these data highlight different forms of discrimination within racial/ethnic group are associated with risky social ties. More research is needed to confirm these findings and further explore the association between various forms of discrimination and social ties that may help explain racial/ethnic disparities in HIV.

Racial discrimination, gender discrimination, and substance abuse among Latina/os nationwide.

This study investigates the relationship between discrimination and substance abuse among Latina/os, and further examines whether this relationship differs by gender and type of discrimination. Analyses focus on the Latina/o respondents (n = 1,039 men; n = 1,273 women) from the National Latino and Asian American Study carried out from 2002-2003. Outcomes were alcohol abuse and drug abuse measured using DSM-IV definitions and criteria. Additional covariates included immigrant characteristics and demographics. Analyses were completed using gender-stratified multinomial logistic regression. Men reported more discrimination (39.6% vs. 30.3%) and had higher prevalence of alcohol abuse (16.5% vs. 4.5%) and drug abuse (9.5% vs. 2.3%) than women. Discrimination was significantly associated with increased risk of alcohol abuse for women and increased risk of drug abuse for men. Men and women also varied in the types of discrimination (e.g., racial vs. gender) reported, and in the associations between these types of discrimination and substance abuse. These data indicate that discrimination is associated with different substance abuse outcomes between genders. Future research should consider the mechanisms that explain these differences.

Contextualizing Inequities in COVID Vaccination Trends Among Project REFOCUS Pilot Sites: Racism-Related Determinants of Health.

Introduction: Coronavirus disease (COVID) dashboards rarely provide insights about the racialized contexts in which vaccination inequities occur. Objective: The purpose of this study was to use the emerging Project REFOCUS dashboard to contextualize COVID vaccination patterns among 6 diverse communities. Methods: We queried the dashboard to generate descriptive statistics on vaccination trends and racism-related contextual factors among the 6 Project REFOCUS pilot sites (Albany, Georgia, Bronx, New York, Detroit, Michigan, Helena-West Helena, Arkansas, San Antonio, Texas, and Wake County, North Carolina). Results: Vaccination rates, demographic indicators, and contextual factors differed across sites. As of October 17, 2022, the proportion of people who had received at least 1 COVID vaccine dose ranged from 58.4% (Wayne County, Michigan) to 95.0% (Wake County, North Carolina). The pilot sites with the greatest percentage of Black residents (Dougherty County, Georgia, Wayne County, Michigan, and Phillips County, Arkansas) had lower proportions of fully vaccinated people. Wayne County, Michigan, had the highest level of residential segregation between Black and White residents (78.5%) and non-White and White residents (68.8%), whereas Phillips County, Arkansas, had the highest overall mortgage denial rates (38.9%). Both counties represent settings where over 75.0% of residents report Black race and over 30.0% of the population live in poverty. Discussion: The dashboard integrates racism-related factors with COVID vaccination visualizations and provides a fuller picture of the context in which COVID trends are occurring. Conclusions: Community organizers, researchers, policymakers, and practitioners can track racism-related factors and other social determinants of health as part of the contexts in which COVID-related inequities occur.

Intimate partner violence prevention services and resources in Los Angeles: issues, needs, and challenges for assisting lesbian, gay, bisexual, and transgender clients.

Intimate partner violence (IPV) is as prevalent in lesbian, gay, bisexual, and transgender (LGBT) relationships as it is in heterosexual ones; however, the issues, needs, and challenges associated with assisting or advocating on behalf of LGBT persons are poorly understood. Using community-based participatory approaches, we conducted a brief survey of professionals (e.g., shelter staff, domestic violence prevention and intervention programs, law enforcement) affiliated with one or more domestic violence prevention and/or intervention networks in Los Angeles, California. The sample, which included professionals (N = 54) from diverse programs/agencies, was obtained using purposive and snowball sampling. Participants self-administered a 33-item, online questionnaire. Analyses primarily involved descriptive statistics (frequencies, proportions). Most respondents had little or no training in LGBT IPV; nevertheless, nearly 50% of them reported having assisted LGBTs "sometimes" or "often" in the past year. Nearly all (92%) reported that their agencies/programs lack staff with dedicated responsibilities to LGBT IPV. The most frequent requests for assistance respondents reported receiving from LGBTs were for counseling, safe housing, legal assistance, and assistance navigating the medical system. The findings suggest that staff believe their agencies/programs inadequately address LGBT IPV but that many of the inadequacies (e.g., lack of staff training on LGBT IPV) are remediable.

An Equity-Based Scoring System for Evaluating Surveillance-Related Harm in Public Health Crises.

Background: Although surveillance systems used to mitigate disasters serve essential public health functions, communities of color have experienced disproportionate harms (eg, criminalization) as a result of historic and enhanced surveillance. Methods: To address this, we developed and piloted a novel, equity-based scoring system to evaluate surveillance systems regarding their potential and actual risk of adverse effects on communities made vulnerable through increased exposure to policing, detention/incarceration, deportation, and disruption of access to social services or public resources. To develop the scoring system, we reviewed the literature and surveyed an expert panel on surveillance to identify specific harms (eg, increased policing) that occur through surveillance approaches. Results: Scores were based on type of information collected (individual and/or neighborhood level) and evidence of sharing information with law enforcement. Scores were 0 (no risk of harm identified), 1 (potential for risk), 2 (evidence of risk), and U (data not publicly accessible). To pilot the scoring system, 44 surveillance systems were identified between June 2020 and October 2020 through an environmental scan of systems directly related to COVID-19 (n=21), behavioral and health-related services (n=11), and racism and racism-related factors (n=12). A score of 0-2 was assigned to 91% (n=40) of the systems; 9% were scored U; 30% (n=13) scored a 0. Half scored a 1 (n=22), indicating a "potential for the types of harm of concern in this analysis." "Evidence of harm," a score of 2, was found for 12% (n=5). Conclusions: The potential for surveillance systems to compromise the health and well-being of racialized and/or vulnerable populations has been understudied. This project developed and piloted a scoring system to accomplish this equity-based imperative. The nobler pursuits of public health to improve the health for all must be reconciled with these potential harms.

Race, ancestry, and genetic risk for kidney failure.

In a retrospective analysis of over 62,000 Black and non-Black participants from eight United States cohorts, Gutiérrez et al.1 examined estimated glomerular filtration rate (eGFR) equations to assess racial differences in kidney failure requiring replacement therapy and in mortality across different equations.

Using COVID-19 Surveillance Systems to Identify and Monitor Disparities: Best Practices and Recommendations.

Inadequate attention to racial health equity is a common challenge to effective, reliable monitoring and mitigation of COVID-19 disparities. Efforts to monitor and mitigate COVID-19 disparities continue to be hampered by inadequacies in how surveillance systems collect, tabulate, and report COVID-19-related outcomes. We conducted environmental scans of existing public health surveillance systems and reporting standards, literature reviews, focus groups with surveillance experts, and consultations with the Centers for Disease Control and Prevention (CDC) and an expert panel on surveillance to identify and explore strengths, weaknesses, and gaps in how existing systems monitor COVID-19 and their implications for addressing disparities in related outcomes. We present recommendations based on these reviews and propose a core minimum set of health indicators and best-practice standards for reporting these indicators by COVID-19 surveillance systems to monitor racial/ethnic and other disparities in the pandemic. These recommendations are relevant to monitoring disparities in the ongoing COVID-19 pandemic and may inform monitoring of future epidemics. This discussion is part of an effort by Project REFOCUS to develop syndemic surveillance systems for monitoring the intersecting pandemics of COVID-19 and racism.

Use of Race in Kidney Research and Medicine: Concepts, Principles, and Practice.

Black Americans and other racially and ethnically minoritized individuals are disproportionately burdened by higher morbidity and mortality from kidney disease when compared with their White peers. Yet, kidney researchers and clinicians have struggled to fully explain or rectify causes of these inequalities. Many studies have sought to identify hypothesized genetic and/or ancestral origins of biologic or behavioral deficits as singular explanations for racial and ethnic inequalities in kidney health. However, these approaches reinforce essentialist beliefs that racial groups are inherently biologically and behaviorally different. These approaches also often conflate the complex interactions of individual-level biologic differences with aggregated population-level disparities that are due to structural racism (i.e., sociopolitical policies and practices that created and perpetuate harmful health outcomes through inequities of opportunities and resources). We review foundational misconceptions about race, racism, genetics, and ancestry that shape research and clinical practice with a focus on kidney disease and related health outcomes. We also provide recommendations on how to embed key equity-enhancing concepts, terms, and principles into research, clinical practice, and medical publishing standards.