Systematic review of how racialized health inequities are addressed in Epidemiologic Reviews articles (1979-2021): a critical conceptual and empirical content analysis and recommendations for best practices.

Critical analysis of the determinants of current and changing racialized health inequities, including the central role of racism, is an urgent priority for epidemiology, for both original research studies and epidemiologic review articles. Motivating our systematic overview review of Epidemiologic Reviews articles is the critical role of epidemiologic reviews in shaping discourse, research priorities, and policy relevant to the social patterning of population health. Our approach was first to document the number of articles published in Epidemiologic Reviews (1979-2021; n = 685) that either: (1) focused the review on racism and health, racial discrimination and health, or racialized health inequities (n = 27; 4%); (2) mentioned racialized groups but did not focus on racism or racialized health inequities (n = 399; 59%); or (3) included no mention of racialized groups or racialized health inequities (n = 250; 37%). We then conducted a critical content analysis of the 27 review articles that focused on racialized health inequities and assessed key characteristics, including (1) concepts, terms, and metrics used regarding racism and racialized groups (notably only 26% addressed the use or nonuse of measures explicitly linked to racism; 15% provided explicit definitions of racialized groups); (2) theories of disease distribution guiding (explicitly or implicitly) the review's approach; (3) interpretation of findings; and (4) recommendations offered. Guided by our results, we offer recommendations for best practices for epidemiologic review articles for addressing how epidemiologic research does or does not address ubiquitous racialized health inequities.

The association of posttraumatic stress disorder, depression, and head injury with mid-life cognitive function in civilian women.

BACKGROUND: Despite evidence linking posttraumatic stress disorder (PTSD), depression, and head injury, separately, with worse cognitive performance, investigations of their combined effects on cognition are limited in civilian women. METHODS: The Cogstate Brief Battery assessment was administered in 10,681 women from the Nurses' Health Study II cohort, mean age 64.9 years (SD = 4.6). Psychological trauma, PTSD, depression, and head injury were assessed using online questionnaires. In this cross-sectional analysis, we used linear regression models to estimate mean differences in cognition by PTSD/depression status and stratified by history of head injury. RESULTS: History of head injury was prevalent (36%), and significantly more prevalent among women with PTSD and depression (57% of women with PTSD and depression, 21% of women with no psychological trauma or depression). Compared to having no psychological trauma or depression, having combined PTSD and depression was associated with worse performance on psychomotor speed/attention ( ß = -.15, p = .001) and learning/working memory ( ß = -.15, p < .001). The joint association of PTSD and depression on worse cognitive function was strongest among women with past head injury, particularly among those with multiple head injuries. CONCLUSIONS: Head injury, like PTSD and depression, was highly prevalent in this sample of civilian women. In combination, these factors were associated with poorer performance on cognitive tasks, a possible marker of future cognitive health. Head injury should be further explored in future studies of PTSD, depression and cognition in women.

Cervical cancer knowledge and barriers and facilitators to screening among women in two rural communities in Guatemala: a qualitative study.

BACKGROUND: Approximately 80% of deaths due to cervical cancer occur in low- and middle-income countries. In Guatemala, limited access to effective screening and treatment has resulted in alarmingly high cervical cancer incidence and mortality rates. Despite access to free-of-cost screening, women continue to face significant barriers in obtaining screening for cervical cancer. METHODS: In-depth interviews (N = 21) were conducted among women in two rural communities in Guatemala. Interviews followed a semi-structured guide to explore knowledge related to cervical cancer and barriers and facilitators to cervical cancer screening. RESULTS: Cervical cancer knowledge was variable across sites and across women. Women reported barriers to screening including ancillary costs, control by male partners, poor provider communication and systems-level resource constraints. Facilitators to screening included a desire to know one's own health status, conversations with other women, including community health workers, and extra-governmental health campaigns. CONCLUSIONS: Findings speak to the many challenges women face in obtaining screening for cervical cancer in their communities as well as existing facilitators. Future interventions must focus on improving cervical cancer-related knowledge as well as mitigating barriers and leveraging facilitators to promote screening.

Quantifying Lifecourse Drivers of International Migration: A Cross-national Analysis of Mexico and the United States.

BACKGROUND: Evaluating the long-term health consequences of migration requires longitudinal data on migrants and non-migrants to facilitate adjustment for time-varying confounder-mediators of the effect of migration on health. METHODS: We merged harmonized data on subjects aged 50+ from the US-based Health and Retirement Study (HRS) and the Mexican Health and Aging Study (MHAS). Our exposed group includes MHAS-return migrants (n = 1555) and HRS Mexican-born migrants (n = 924). Our unexposed group includes MHAS-never migrants (n = 16,954). We constructed a lifecourse data set from birth (age 0) until either age at migration to the United States or age at study entry. To account for confounding via inverse probability of treatment weights (IPTW), we modeled the probability of migration at each year of life using time-varying pre-migration characteristics. We then evaluated the effect of migration on mortality hazard estimated with and without IPTW. RESULTS: Mexico to the United States migration was predicted by time-varying factors that occurred before migration. Using measured covariates at time of enrollment to account for selective migration, we estimated that, for women, migrating reduces mortality risk by 13%, although this estimate was imprecise and results were compatible with either large protective or deleterious associations (hazard ratio [HR] =0.87, 95% confidence interval [CI]: 0.60, 1.27). When instead using IPTWs, the estimated effect on mortality was similarly imprecise (HR = 0.98, 95% CI: 0.77, 1.25). The relationship among men was similarly uncertain in both models. CONCLUSIONS: Although time-varying social factors predicted migration, IPTW weighting did not affect our estimates. Larger samples are needed to precisely estimate the health effects of migration.

State School Policies as Predictors of Physical and Mental Health: A Natural Experiment in the REGARDS Cohort.

We used differences in state school policies as natural experiments to evaluate the joint influence of educational quantity and quality on late-life physical and mental health. Using US Census microsample data, historical measures of state compulsory schooling and school quality (term length, student-teacher ratio, and attendance rates) were combined via regression modeling on a scale corresponding to years of education (policy-predicted years of education (PPYEd)). PPYEd values were linked to individual-level records for 8,920 black and 14,605 white participants aged ≥45 years in the Reasons for Geographic and Racial Differences in Stroke study (2003-2007). Linear and quantile regression models estimated the association between PPYEd and Physical Component Summary (PCS) and Mental Component Summary (MCS) from the Short Form Health Survey. We examined interactions by race and adjusted for sex, birth year, state of residence at age 6 years, and year of study enrollment. Higher PPYEd was associated with better median PCS (ß = 1.28, 95% confidence interval (CI): 0.40, 1.49) and possibly better median MCS (ß = 0.46, 95% CI: -0.01, 0.94). Effect estimates were higher among black (vs. white) persons (PCS × race interaction, ß = 0.22, 95% CI: -0.62, 1.05, and MCS × race interaction, ß = 0.18; 95% CI: -0.08, 0.44). When incorporating both school quality and duration, this quasiexperimental analysis found mixed evidence for a causal effect of education on health decades later.

Using self-collection HPV testing to increase engagement in cervical cancer screening programs in rural Guatemala: a longitudinal analysis.

BACKGROUND: Cervical cancer is a leading cause of death in low- and middle-income countries. Self-collection testing for human papillomavirus (HPV) is an alternative form of cervical cancer screening that can be completed privately and at home. Understanding how the use of HPV testing influences follow-up care in low-resourced settings is crucial before broad implementation. This study aimed to identify if access to self-collection HPV testing impacts participation in established cervical cancer screening programs among women in two rural communities in Guatemala. METHODS: A cohort of 956 women was recruited in 2016 and followed for 2 years for the HPV Multiethnic Study (HPV MES). At baseline, women answered a questionnaire assessing cervical cancer screening history and were offered self-collection HPV testing. Women were re-contacted yearly to determine receipt of additional screening. Statistical changes in screening behavior before and throughout study participation, stratified by self-collection status, were assessed using McNemar pair tests for proportions. Alluvial plots were constructed to depict changes in individual screening behavior. The odds of changes in Pap-compliance (screened in past 3 years), given collection status, were assessed using multivariate logistic regressions. RESULTS: Reported screening rates increased 2 years after enrollment compared to rates reported for the 3 years before study entry among women who collected a sample (19.1% increase, p < 0.05), received results of their test (22.1% increase, p < 0.05), and received positive (24.2% increase, p < 0.1) or negative results (21.7% increase, p < 0.05). However, most increases came from one community, with minimal changes in the other. The adjusted odds of becoming Pap compliant were higher for women who collected a sample vs. did not (OR: 1.48, 95% CI: 0.64, 3.40), received their result vs. did not (OR: 1.29, 95% CI: 0.52, 3.02), and received a positive result vs. negative (OR: 2.43, 95% CI: 0.63, 16.10). CONCLUSIONS: Participation in self-collection HPV testing campaigns may increase likelihood of involvement in screening programs. However, results varied between communities, and reporting of screening histories was inconsistent. Future work should identify what community-specific factors promote success in HPV testing programs and focus on improving education on existing cervical cancer interventions.

Inequalities in elevated depressive symptoms in middle-aged and older adults by rural childhood residence: The important role of education.

OBJECTIVES: To quantify inequalities in the prevalence of elevated depressive symptoms by rural childhood residence and the extent to which childhood socioeconomic conditions and educational attainment contribute to this disparity. METHODS: We identified the prevalence of depressive symptoms among US-born adults ages 50 years and older in the 1998 to 2014 waves of the Health and Retirement Study (n = 16 022). We compared prevalence of elevated depressive symptoms (>4/8 symptoms) by rural versus nonrural childhood residence (self-report) and the extent to which own education mediated this disparity. We used generalized estimating equations and marginal standardization to calculate predicted probabilities of elevated depressive symptoms. RESULTS: In age, race/ethnicity, and sex-adjusted models, rural childhood residence was associated with elevated depressive symptoms (OR = 1.20; 95% CI, 1.12-1.29; marginal predicted probability 10.5% for rural and 8.9% for nonrural childhood residence). Adjusting for US Census birth region and parental education attenuated this association (OR = 1.07; 95% CI, 0.99-1.15; marginal predicted probability 9.9% for rural and 9.3% for nonrural). After additional adjustment for own education, rural childhood residence was not associated with elevated depressive symptoms (OR = 0.94; 95% CI, 0.87-1.01; marginal predicted probability 9.2% for rural and 9.8% for nonrural). CONCLUSIONS: Rural childhood residence was associated with elevated depressive symptoms in middle-aged and older adults; birth region, parental education, and own education appear to contribute to this disparity.

Intimate Partner Violence, Mental Health Symptoms, and Modifiable Health Factors in Women During the COVID-19 Pandemic in the US.

Importance: During the COVID-19 pandemic, the prevalence and severity of intimate partner violence (IPV) increased. Associations between IPV and mental health symptoms and modifiable health factors early in the pandemic have yet to be explored. Objective: To prospectively investigate the association of IPV with greater risk of mental health symptoms and adverse health factors during the COVID-19 pandemic in 3 cohorts of female participants. Design, Setting, and Participants: This cohort study used observational data from 3 prospective, population-based, longitudinal cohorts in the US: the Nurses' Health Study II, Growing Up Today Study, and Nurses' Health Study 3. Data analyzed included baseline and follow-up survey responses about IPV experiences early in the pandemic (March-September 2020); mental health domains of depression, anxiety, and posttraumatic stress symptoms (PTSS); and modifiable health factors (May 2020-October 2021). Female participants (both health care professionals and non-health care workers) aged 21 to 60 years from the 3 cohorts were included in the full analytic sample. Exposures: Experience of IPV measured by the Relationship Assessment Tool and fear of partner. Main Outcomes and Measures: Mental health symptoms, including depression, anxiety, and PTSS, and modifiable health factors, including sleep duration, sleep quality, physical activity, alcohol use, and use of alcohol or other substances to cope with stress. Results: The full analytic sample included 13 597 female participants with a mean (SD) age of 44 (10.6) years. Accounting for sociodemographic factors and prepandemic mental health symptoms and correcting for multiple testing, experiencing IPV was associated with higher endorsement of depression (odds ratio [OR], 1.44; 95% CI, 1.38-1.50), anxiety (OR, 1.31; 95% CI, 1.26-1.36), and PTSS (OR, 1.22; 95% CI, 1.15-1.29) in random-effects meta-analyses across the 3 cohorts. The IPV experience was also associated with poorer sleep quality (OR, 1.21; 95% CI, 1.16-1.26), shorter sleep duration (OR, 1.13; 95% CI, 1.08-1.19), increased use of alcohol (OR, 1.10; 95% CI, 1.06-1.14), and use of alcohol or other substances to cope with stress (OR, 1.13; 95% CI, 1.08-1.18) across all cohorts as well as decreased physical activity (OR, 1.17; 95% CI, 1.09-1.26) in the Nurses' Health Study II only. Conclusions and Relevance: Results of the study showed that IPV experiences at the start of the pandemic were associated with worse mental health symptoms and modifiable health factors for female participants younger than 60 years. Screening and interventions for IPV and related health factors are needed to prevent severe, long-term health consequences.

Eliminating racial disparities in dementia risk by equalizing education quality: A sensitivity analysis.

BACKGROUND: Higher risk of dementia among racial/ethnic minorities compared to White populations in the U.S. has been attributed to life-course exposures to adverse conditions such as lower educational attainment, but most studies have not considered additional disparities in education quality. We sought to determine the extent to which disparities in dementia would be reduced had different racial groups received the same quality of education, with no change to present disparities in educational attainment. METHODS: We conducted a literature review to assess whether and how measures of educational attainment and quality are utilized in the development of norms for standard cognitive screening measures. In a separate search of the literature, we identified estimates of relationships between race, education quality and dementia; and calculated the adjusted association between race and dementia had education quality been equalized between Black and White participants. RESULTS: Most norms for cognitive measures included educational attainment, but few addressed quality. Our search identified relevant parameter estimates: 44.3% of Black participants and 10.5% of White participants had "limited literacy" (<9th grade reading level, a potential marker of poor education quality), which was associated with a 53% greater hazard of dementia compared with "adequate literacy" (≥ 9th grade reading level) after adjusting for educational attainment. Applying these parameters to a hazard ratio of 1.37 (95%CI: 1.12,1.67) for the risk of dementia comparing Black to White participants, we obtained an adjusted hazard ratio of 1.17 (0.96,1.43), a 54% reduction. DISCUSSION: Present studies are limited in their consideration of education quality. Our work using available measures from the literature suggests that if education quality were equalized across groups by race, without changing disparities in attainment, racial disparities in dementia would be reduced by about half. Future work should seek to consistently incorporate education quality in order to better understand the sources of disparities.

Trauma, psychological distress and markers of systemic inflammation among US women: A longitudinal study.

BACKGROUND: Prior evidence links posttraumatic stress disorder (PTSD) and depression, separately, with chronic inflammation. However, whether effects are similar across each independently or potentiated when both are present is understudied. We evaluated combined measures of PTSD and depression in relation to inflammatory biomarker concentrations. METHODS: Data are from women (n's ranging 628-2797) in the Nurses' Health Study II. Trauma exposure, PTSD, and depression symptoms were ascertained using validated questionnaires. We examined (a) a continuous combined psychological distress score summing symptoms for PTSD and depression, and (b) a categorical cross-classified measure of trauma/PTSD symptoms/depressed mood status (reference group: no trauma or depressed mood). Three inflammatory biomarkers (C-reactive protein [CRP], interleukin-6 [IL-6], tumor necrosis factor alpha receptor 2 [TNFR2]) were assayed from at least one of two blood samples collected 10-16 years apart. We examined associations of our exposures with levels of each biomarker concentration (log-transformed and batch-corrected) as available across the two time points (cross-sectional analyses; CRP, IL-6 and TNFR2) and with rate of change in biomarkers across time (longitudinal analyses; CRP and IL-6) using separate linear mixed effects models. RESULTS: In sociodemographic-adjusted models accounting for trauma exposure, a one standard deviation increase in the continuous combined psychological distress score was associated with 10.2% (95% confidence interval (CI): 5.2-15.4%) higher CRP and 1.5% (95% CI: 0.5-2.5%) higher TNFR2 concentrations cross-sectionally. For the categorical exposure, women with trauma/PTSD symptoms/ depressed mood versus those with no trauma or depressed mood had 29.5% (95% CI: 13.3-47.9%) higher CRP and 13.1% (95% CI: 5.1-21.7%) higher IL-6 cross-sectionally. In longitudinal analysis, trauma/PTSD symptoms/depressed mood was associated with increasing CRP levels over time. CONCLUSIONS: High psychological distress levels with trauma exposure is associated with elevated inflammation and is a potential biologic pathway by which distress can impact development of inflammatory-related chronic diseases, such as cardiovascular disease. Considering multiple forms of distress in relation to these pathways may provide greater insight into who is at risk for biologic dysregulation and later susceptibility to chronic diseases.

Estimating the effects of Mexico to U.S. migration on elevated depressive symptoms: evidence from pooled cross-national cohorts.

PURPOSE: Migrating from Mexico to the U.S. is a major, stressful life event with potentially profound influences on mental health. However, estimating the health effects of migration is challenging because of differential selection into migration and time-varying confounder mediators of migration effects on health. METHODS: We pooled data from the Mexican Health and Aging Study (N = 17,771) and Mexican-born U.S. Health and Retirement Study (N = 898) participants to evaluate the effects of migration to the U.S. (at any age and in models for migration in childhood or adulthood) on depressive symptom-count, measured with a modified Centers for Epidemiologic Studies-Depression scale. We modeled probability of migrating in each year of life from birth to either age at initial migration to the U.S. or enrollment and used these models to calculate inverse probability of migration weights. We applied the weights to covariate-adjusted negative binomial GEE models, estimating the ratio of average symptom-count associated with migration. RESULTS: Mexico to U.S. migration was unrelated to depressive symptoms among men (ratio of average symptom-count= 0.98 [95% CI: 0.89, 1.08]) and women (ratio of average symptom-count = 1.00 [95% CI: 0.92, 1.09]). Results were similar for migration in childhood, early adulthood, or later adulthood. CONCLUSIONS: In this sample of older Mexican-born adults, migration to the U.S. was unrelated to depressive symptoms.

Prevalence and Correlates of Mental Health Outcomes During the SARS-Cov-2 Epidemic in Mexico City and Their Association With Non-adherence to Stay-At-Home Directives, June 2020.

Objectives: To describe the prevalence and correlates of depressive symptoms, generalized anxiety disorder (GAD), and perceived negative mental health impact during the SARS-Cov-2 pandemic in Mexico City and evaluate their association with adherence to stay-at-home directives. Methods: Baseline data from a cohort study of 2,016 Mexico City government employees were analyzed using multivariable logistic regression models. Results: Among participants, 17.2% had clinically significant depressive symptoms, 21.6% had probable GAD, and 15.2% reported that the pandemic has had a major impact on their mental health. Factors including the presence of COVID-19 symptoms, self-isolation, and economic difficulties were associated with poor mental health. The presence of depressive symptoms and general anxiety were associated with non-adherence to public health directives, particularly among those who might have experienced these symptoms for the first time during the pandemic. Conclusion: Our study is one of the first to document the population mental health burden during the SARS-CoV-2 pandemic in Mexico and to provide evidence of the potential role of mental health in the adherence to public health measures.

Association of work-family experience with mid- and late-life memory decline in US women.

OBJECTIVE: To test the hypothesis that life course patterns of employment, marriage, and childrearing influence later-life rate of memory decline among women, we examined the relationship of work-family experiences between ages 16 and 50 years and memory decline after age 55 years among US women. METHODS: Participants were women ages ≥55 years in the Health and Retirement Study. Participants reported employment, marital, and parenthood statuses between ages 16 and 50 years. Sequence analysis was used to group women with similar work-family life histories; we identified 5 profiles characterized by similar timing and transitions of combined work, marital, and parenthood statuses. Memory performance was assessed biennially from 1995 to 2016. We estimated associations between work-family profiles and later-life memory decline with linear mixed-effects models adjusted for practice effects, baseline age, race/ethnicity, birth region, childhood socioeconomic status, and educational attainment. RESULTS: There were 6,189 study participants (n = 488 working nonmothers, n = 4,326 working married mothers, n = 530 working single mothers, n = 319 nonworking single mothers, n = 526 nonworking married mothers). Mean baseline age was 57.2 years; average follow-up was 12.3 years. Between ages 55 and 60, memory scores were similar across work-family profiles. After age 60, average rate of memory decline was more than 50% greater among women whose work-family profiles did not include working for pay after childbearing, compared with those who were working mothers. CONCLUSIONS: Women who worked for pay in early adulthood and midlife experienced slower rates of later-life memory decline, regardless of marital and parenthood status, suggesting participation in the paid labor force may protect against later-life memory decline.

Life course biopsychosocial effects of retrospective childhood social support and later-life cognition.

Social support during childhood lays the foundation for social relationships throughout the life course and has been shown to predict a wide range of mental and physical health outcomes. Social support measured in late life is prospectively associated with better cognitive aging, but few studies have evaluated social support received earlier in the life course. We quantified the effects of childhood social support, reported retrospectively, on later-life cognitive trajectories and investigated biopsychosocial mechanisms underlying these associations. Latent growth curve models estimated 10-year cognitive trajectories in 8,538 participants (baseline ages 45-93; Mage = 63) in the REasons for Geographic And Racial Differences in Stroke (REGARDS) project. Independent of sociodemographics, childhood socioeconomic status, and household size, greater retrospective childhood social support was associated with better initial episodic memory, but not verbal fluency or cognitive change, in later adulthood. Associations with initial memory level were mediated by sociodemographic and psychosocial variables; specifically, those who reported greater childhood social support reported higher educational attainment and had better physical and emotional health in adulthood, which were each associated with better memory. These results provide support for broad and enduring effects of childhood social support on mental, physical, and cognitive health decades later. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

HPV self-sampling acceptability in rural and indigenous communities in Guatemala: a cross-sectional study.

INTRODUCTION: Cervical cancer disproportionately burdens low-income and middle-income countries (LMICs) such as Guatemala. Self-collection testing for human papillomavirus (HPV) has been suggested as a form of cervical cancer screening to facilitate access in LMICs. This study assessed and compared the acceptability of self-collection HPV testing in two rural, indigenous and ethnically distinct communities in Guatemala: Santiago Atitlán, Sololá and Livingston, Izabal. METHODS: All participants, women between the ages of 18 and 60, completed a questionnaire. Eligible participants were also asked to self-collect a vaginal sample and complete a questionnaire regarding comfort and acceptability. Self-collected samples were tested for high-risk HPV using the real-time PCR Hybribio kit. RESULTS: In the indigenous community of Santiago Atitlán, of 438 age-eligible participants, 94% completed self-collection. Of those, 81% found it comfortable and 98% were willing to use it as a form of screening. In the multiethnic (Afro-Caribbean, indigenous) community of Livingston, of 322 age-eligible participants, 53% chose to self-collect. Among those who took the test, 83% found it comfortable and 95% were willing to use it as a form of screening. In Livingston, literacy (can read and/or write vs cannot read or write) was higher in women who chose to self-collect (prevalence ratio 2.25; 95% CI 1.38 to 3.68). Ethnicity, history of screening and reproductive history were not associated with willingness to self-collect in Livingston. Women in Santiago reported less prior use of healthcare than women in Livingston. Overall, 19% (106/549) of samples tested positive for high-risk HPV. CONCLUSION: Among women willing to self-collect in rural and indigenous communities in Guatemala, self-collection for HPV testing is highly acceptable. However, willingness to try self-collection might vary across communities and settings. Women from a community that used less healthcare were more likely to choose self-collection. Further research is necessary to determine what factors influence a woman's choice to self-collect.