Pathways to maternal health inequities: Structural racism, sleep, and physiological stress.

Racial inequities in health are vast and well-documented, particularly regarding maternal and infant health. Sleep health, including but not limited to duration and quality, is central to overall health and well-being. However, research has not adequately addressed how racism embedded in structures and systems, in addition to individual experiences, may affect maternal health by impacting sleep. In this critical review, we aim to 1) synthesize findings, emphasizing collaborative studies within our group, 2) highlight gaps in knowledge, and 3) propose a theoretical framework and methodological approach for moving the field forward. Specifically, we focus on findings and future directions linking perinatal sleep, cardiovascular and immune function, and racial disparities in maternal health. Because too few studies look beyond individual-level determinants of sleep deficiencies among Black Americans, we assert a critical need for research that bridges multiple levels of analysis (e.g., individual, community, society) and provides recommendations for specific health parameters that researchers in this area can target. Although the need to understand and address perinatal health disparities is clear, the goal of identifying multilevel mechanisms underlying how racism in one's environment and daily life may interact to affect health extends far beyond pregnancy research.

Gender inequality in genitourinary malignancies clinical trials leadership.

BACKGROUND: Over the past 2 decades, there has been a growing interest in the significance of gender roles in healthcare and several efforts and initiatives have focused on increasing female representation in the medical field. Clinical trials play a very important role in shaping medical practice; moreover, the leaders of clinical trials often represent the upper echelon of researchers in any designated field. Presently, there is no data regarding women's representation in urological oncology clinical trials leadership. Therefore, the aim of this study is to examine the extent of female representation in leading urological clinical trials. METHODOLOGY: To thoroughly examine the representation of females as principal investigators (PIs) in urological cancer clinical trials between 2000 and 2020, we conducted a comprehensive search of completed trials focused on kidney, prostate, and bladder cancer on ClinicalTrials.gov. We extracted relevant information regarding the PIs and analyzed the data using univariate analyses to identify any significant differences between male and female PIs. RESULTS: A total of 9145 cancer clinical trials were conducted over the last 2 decades, and 11.3% (n = 1033) of them were urological cancer clinical trials. We were able to obtain detailed information about the principal investigators (PI) in 79.0% (n = 816) of the clinical trials, and we found that 16.8% (n = 137) of them were led by female investigators. Upon evaluating the characteristics of the PIs, female PIs had a significantly lower median age and median total citations as compared to male PIs (55.0 vs 59.0 and 5333 vs 7902; p-value < 0.001 and 0.006, respectively). However, there was no statistically significant difference between the termination rate, publication rate, funding source, cancer type, and the subject of conducting the clinical trials between male and female PIs. CONCLUSION: Between 2000 and 2020, only 16.8% of urological cancer clinical trials were led by a female PI, perhaps reflective of a low percentage of senior female researchers in the fields of urology, oncology and radiation oncology. Universities, research institutes and funding agencies should work to improve mentorship, representation and opportunities for female investigators to encourage more involvement for female researchers in these clinical trials.

Role of Insulin Use and Social Determinants of Health on Non-melanoma Skin Cancer: Results From the Behavioral Risk Factor Surveillance System.

BACKGROUND: Non-melanoma skin cancer (NMSC) is a frequent type of malignancy with a steadily increasing incidence rate worldwide. Although NMSC was shown to be associated with diabetes, no studies have addressed the extent to which insulin use influences the risk of NMSC in light of social determinants of health (SDOH). We conducted a quantitative study that examined the interplay between insulin use, SDOH, additional covariates, and NMSC among individuals with diabetes. METHODS: We based our analysis on the 2020 Behavioral Risk Factor Surveillance System (BRFSS), a national survey conducted yearly in the US. We performed weighted chi-squared test, logistic regression, and survival analyses on 8685 eligible participants with diabetes enrolled in the BRFSS. RESULTS: Kaplan Meier survival curves showed higher probability of NMSC event-free survival for participants with diabetes using insulin compared to participants with diabetes not using insulin (log-rank test P < .001). Significant associations were detected between insulin use and reduced odds of NMSC (OR .56; 95% CI: .38-.82), and decreased hazard (HR .36; 95% CI: .21-.62), along with indices of SDOH. CONCLUSIONS: Our findings suggest that socioeconomic differences related to the healthcare system and behavioral patterns are linked to discrepancies in the use of insulin and the development of NMSC.

Sociodemographic inequities in food allergy: Insights on food allergy from birth cohorts.

A large and growing corpus of epidemiologic studies suggests that the population-level burden of pediatric FA is not equitably distributed across major sociodemographic groups, including race, ethnicity, household income, parental educational attainment, and sex. As is the case for more extensively studied allergic disease states such as asthma and atopic dermatitis epidemiologic data suggest that FA may be more prevalent among certain populations experiencing lower socioeconomic status (SES), particularly those with specific racial and ethnic minority backgrounds living in highly urbanized regions. Emerging data also indicate that these patients may also experience more severe FA-related physical health, psychosocial, and economic outcomes relating to chronic disease management. However, many studies that have identified sociodemographic inequities in FA burden are limited by cross-sectional designs that are subject to numerous biases. Compared with cross-sectional study designs or cohorts established later in life, birth cohorts offer advantages relative to other study designs when investigators seek to understand causal relationships between exposures occurring during the prenatal or postnatal period and the atopic disease status of individuals later in life. Numerous birth cohorts have been established across recent decades, which include evaluation of food allergy-related outcomes, and a subset of these also have measured sociodemographic variables that, together, have the potential to shed light on the existence and possible etiology of sociodemographic inequities in food allergy. This manuscript reports the findings of a comprehensive survey of the current state of this birth cohort literature and draws insights into what is currently known, and what further information can potentially be gleaned from thoughtful examination and further follow-up of ongoing birth cohorts across the globe.

Assessment of disparities in timely diagnosis and comprehensive workup of cognitive impairment between English and Spanish speakers.

BACKGROUND: Previous studies have examined disparities in dementia care that affect the U.S. Hispanic/Latino population, including clinician bias, lack of cultural responsiveness, and less access to health care. However, there is limited research that specifically investigates the impact of language barriers to health disparities in dementia diagnosis. METHODS: In this retrospective cross-sectional study, 12,080 English- or Spanish- speaking patients who received an initial diagnosis of mild cognitive impairment (MCI) or dementia between July 2017 and June 2019 were identified in the Yale New Haven Health (YNHH) electronic medical record. To evaluate the timeliness of diagnosis, an initial diagnosis of MCI was classified as "timely", while an initial diagnosis of dementia was considered "delayed." Comprehensiveness of diagnosis was assessed by measuring the presence of laboratory studies, neuroimaging, specialist evaluation, and advanced diagnostics six months before or after diagnosis. Binomial logistic regressions were calculated with and without adjustment for age, legal sex, ethnicity, neighborhood disadvantage, and medical comorbidities. RESULTS: Spanish speakers were less likely to receive a timely diagnosis when compared with English speakers both before (unadjusted OR, 0.65; 95% CI, 0.53-0.80, p <0.0001) and after adjusting for covariates (adjusted OR, 0.55; 95% CI, 0.40-0.75, p = 0.0001). Diagnostic services were provided equally between groups, except for referrals to geriatrics, which were more frequent among Spanish-speaking patients. A subgroup analysis revealed that Spanish-speaking Hispanic/Latino patients were less likely to receive a timely diagnosis compared to English-speaking Hispanic/Latino patients (adjusted OR, 0.53; 95% CI, 0.38-0.73, p = 0.0001). CONCLUSIONS: Non-English language preference is likely to be a contributing factor to timely diagnosis of cognitive impairment. In this study, Spanish language preference rather than Hispanic/Latino ethnicity was a significant predictor of a less timely diagnosis of cognitive impairment. Policy changes are needed to reduce barriers in cognitive disorders care for Spanish-speaking patients.

Existing Health Inequities in the Treatment of Advanced and Metastatic Cancers.

PURPOSE OF REVIEW: This study aims to identify health inequities related to the medical treatment and supportive care of patients with advanced/metastatic cancer and recommend solutions to promote health equity. RECENT FINDINGS: Despite robust strides in the development of therapeutic strategies for advanced and metastatic cancer, significant disparities in treatment access and implementation exist. Race, socioeconomic status, gender, and geography represent just a few of the individual-level factors which contribute to challenges in treatment administration, thorough evaluation of germline genetics and tumor genomics, and quality palliative and end-of-life care. Given the increasing complexity of cancer treatments and our enhanced understanding of tumor biology, efforts to uniformly provide equitable and high-level care to all patients are needed. In this review we will discuss factors that contribute to health inequities in patients with advanced and metastatic cancer diagnoses, highlighting opportunities for intervention, ongoing challenges in change implementation, and national and international society recommendations to eliminate disparities. Acknowledging existing inequities and engaging in multilevel discourse with key stakeholders is needed to optimize care practices to the benefit of all patients.

Inequities in human papillomavirus vaccination among children aged 9-14 years old under constrained vaccine supply in China.

BACKGROUND: Inequities in access to human papillomavirus (HPV) vaccine are becoming a growing critical issue globally. Few studies investigate the factors determining HPV vaccine uptake disparities when vaccine supply is constrained, especially in low- and middle-income countries. The aim of this study was to investigate inequities of HPV vaccination and related factors under the constrained vaccine supply in China. METHODS: A cross-sectional survey was conducted in a developed eastern coastal province and a developing western one in China between November and December 2022. Employing multistage stratified cluster random sampling, the study collected data from parents of children aged 9-14. Mixed-effects logistic regression models with school units as random effects were used for analysis. RESULTS: From 4,127 eligible parents (as vaccine decision makers for girls), 1,346 (32.6%) intended to vaccinate their daughters against HPV, of which 836 (62.1%) attempted to schedule a vaccination appointment. Only 16.4% succeeded in booking an appointment. More than half of the intended parents expected the imported 9-valent HPV vaccine. There were significant disparities in HPV vaccine awareness, intention, and vaccination behavior across educational, income, geographic, ethnic, gender, and health literacy levels. Vaccine awareness and intentions were higher among parents with higher socioeconomic status; however, girls from lower socioeconomic families were more likely to receive the HPV vaccine and had a higher domestically produced vaccination rate. Significant disparities exist in vaccination intentions and actual vaccination behaviors, primarily due to large supply constraints of the HPV vaccine. CONCLUSIONS: Sustained health education campaigns are needed to raise awareness of the HPV vaccine, improve health literacy, and decrease over-preference for the 9-valent HPV vaccine. A mother's HPV vaccination behavior was positively associated with increased intention and actual vaccination behavior for her daughter. This study advocates for complementary cervical cancer prevention programs targeting both mothers and daughters.

Health inequity assessment in Brazil: is EQ-5D-3L sensible enough to detect differences among distinct socioeconomic groups?

BACKGROUND: Multidimensional health-related quality of life (HRQOL) instruments, such as the EQ-5D, are increasingly used to assess inequalities in health. However, it is necessary to explore the ability of these instruments to capture differences between population groups, especially in low/middle-income countries. This study aimed to investigate whether the EQ-5D-3L instrument can detect differences in HRQOL between groups of different socioeconomic status (SES) in Brazil. METHODS: Data collection occurred during the Brazilian EQ-5D-3L valuation study and included respondents aged 18 to 64 years enrolled in urban areas. SES was aggregated into three categories: "higher" (A and B), "intermediate" (C) and "lower" (D and E). EQ-5D-3L index was calculated considering the Brazilian value set. A mixed-effects regression model was estimated with random effects on individuals and marginal effects on SES, sex, and educational attainment. Odds ratios for the chance of reporting problems for each EQ-5D dimension were estimated by logistic regression. RESULTS: A total of 9,148 respondents were included in the study. Mean age was 37.80 ± 13.13 years, 47.4% were men and the majority was ranked as classes B or C (38.4% and 50.7%, respectively). Participants in lower SES classes reported increasingly poorer health compared to individuals in higher classes. The mean EQ-5D-3L index decreased as SES deteriorates being significantly higher for classes A and B (0.874 ± 0.14) compared to class C (0.842 ± 0.15) and classes D and E (0.804 ± 0.17) (p < 0.001). The same was observed for the mean EQ-VAS scores (84.0 ± 13.8 in classes A and B, 81.0 ± 17 in class C and 78.3 ± 18.7 in class C [p < 0.001]). The multivariate analysis confirmed that SES is an independent factor that effects EQ-5D-3L index measures. Participants in intermediate and lower SES classes have a statistically significant lower EQ-5D-3L index compared to participants in classes A and B, regardless of age, sex, and educational attainment. CONCLUSION: In a Brazilian population sample, the EQ-5D-3L instrument was able to detect important differences between groups with distinct socioeconomic statuses (SES). The EQ-5D-3L is useful for exploring inequities in health.

Developing and testing Advance Choice Document implementation resources for Black African and Caribbean people with experience of compulsory psychiatric admission.

BACKGROUND: Advance Choice Documents (ACDs) have been recommended for use in England and Wales based on evidence from trials that show that they can reduce involuntary hospitalisation, which disproportionately affects Black African and Caribbean people. Our aim was therefore to develop and test ACD implementation resources and processes for Black people who have previously been involuntarily hospitalised and the people that support them. METHODS: Resource co-production workshops were held to inform the development of the ACD template and two types of training for all stakeholders, comprising a Recovery College course and simulation training. An ACD facilitator then used the ACD template developed through the workshops to create personalised ACDs with service users and mental health staff over a series of meetings. Interviews were then conducted with service user and staff participants and analysed to document their experience of the process and opinions on ACDs. Other implementation strategies were also employed alongside to support and optimise the creation of ACDs. RESULTS: Nine ACDs were completed and were largely reported as appropriate, acceptable, and feasible to service users and staff. Both reported it being an empowering process that encouraged hope for better future treatment and therefore better wellbeing. Uncertainty was also expressed about the confidence people had that ACDs would be adhered to/honoured, primarily due to staff workload. The information provision training and the skills training were generally considered to be informative by trainees. CONCLUSIONS: The project has developed an ACD creation resource that was reported as agreeable to all stakeholders; however, the generalisability of the findings is limited due to the small sample size. The project also highlights the importance of staff and ACD facilitator capacity and good therapeutic relationships in ACD completion. Further research is needed to determine the adjustments needed for large scale use, including for those under age 18 and those under the care of forensic mental health services; and how to include carers/supporters more in the process.

Anti-oppression pedagogy in health professions: a scoping review.

Health professional learners are increasingly called to learn about health inequity to reduce inequities and improve patient care and health outcomes. Anti-oppression pedagogy (AOP) addresses the need for health professional learners to understand multiple health inequities and the structures and systems that produce inequities. However, the inclusion of AOP in health professions education varies and there is a lack of clarity in its conceptualization and integration. A scoping review was conducted to address this gap and to understand how AOP is conceptualized and integrated in health professions education. Thirty-six articles met the inclusion criteria. The articles demonstrated that AOP is not commonly utilized terminology within health professions education. When AOP is integrated, it is not consistently conceptualized but is generally viewed as a broad concept that focuses on antiracism; decoloniality; intersectionality; and supporting learners to understand, critically reflect on, and act against structural and systemic forms of oppressions. In addition, there is variation in the integration of AOP in health professions education with the most common methods consisting of discussions, cases, reflection, learning through lived experiences, and the incorporation of humanities within a longitudinal curriculum. The results of this scoping review highlight the need for health professions education to develop one clear concept that educators use when teaching about anti-oppression, which may reduce working in silos and allow educators to better collaborate with each other in advancing this work. In addition, this review suggests that health professional programs should consider incorporating AOP in curricula with a broad and longitudinal approach utilizing the common methods of delivery. To better support programs in including AOP in curricula, further research is required to emphasize the benefits, provide clarity on its conceptualization, and determine the most effective methods of integration.

Associations of latent patterns of parent‒child communication with communication quality and mental health outcomes among Chinese left-behind children.

BACKGROUND: Parent‒child communication in migrant families is essential to family bonds and the mental health of left-behind children (LBC). Little is known about the different patterns of communication between migrant parents and LBC and associated communication quality and mental health outcomes. METHODS: A sample of 2,183 Chinese children (mean age = 12.95 ± 1.29 years) from Anhui province, including LBC whose parents had both migrated (n = 1,025) and children whose parents had never migrated (never-LBC, n = 1,158), was analyzed. With the LBC sample, latent class analysis was applied to identify the patterns of parent‒child communication. Multinomial logistic regression analysis was conducted to assess the associations between the sociodemographic variables and class membership of LBC. Analysis of covariance and chi-square tests were used to compare communication quality and mental health outcome differences among the classes of LBC and between each of the classes and never-LBC. RESULTS: Five latent classes of communication formed through different media or channels between migrant parents and their LBC were identified. Higher household economic status (OR = 2.81, p < 0.05) was associated with adequate communication. LBC in Class 1, defined by frequent technologically-mediated and face-to-face communication, had a significantly higher quality of communication with their migrant parents (F = 8.92, p < 0.001) and better mental health than those in other latent classes; these children did not have significantly worse mental health outcomes compared to never -LBC. CONCLUSIONS: Facilitating multichannel parent‒child communication is a practical way of reducing mental health inequities between LBC and their peers.

The association of sociodemographic characteristics with work disability trajectories during and following long-term psychotherapy: a longitudinal register study.

PURPOSE: This register-based study examined the trajectories of depression or anxiety disorder-related work disability during and following long-term psychotherapy and identified sociodemographic factors that indicate membership in different trajectory groups. METHODS: Data were drawn from national registers (Statistics Finland, Social Insurance Institution of Finland). Participants included a random sample of Finnish working-age individuals (18-55 years) who started psychotherapy treatment between 2011 and 2014 and were followed for 5 years: 1 year before and 4 years after the onset of psychotherapy (N = 3 605 individuals; 18 025 person-observations across five time points). Group-based trajectory modeling was applied to assign individuals to work disability trajectories by the number of annual mental health-related work disability months. Multinomial logistic regression was used to examine the associations between trajectory group membership and baseline sociodemographic factors of age, gender, occupational status, and geographical area of residence. RESULTS: Four mental health-related work disability trajectories were identified: stable very low (72%), decrease (11%), persistent low (9%) and persistent high (7%). Those with older age, female gender, lower occupational status, and living in sparsely populated geographical areas were more likely to belong to the most unfavorable trajectory group of persistent high work disability. The presence of multiple risk characteristics substantially increased the probability of belonging to the most adverse trajectory group. CONCLUSIONS: Sociodemographic factors were associated with the course of mental health-related work disability in association with psychotherapy. Rehabilitative psychotherapy does not function as an equal support resource for work ability in all parts of the population.

Longitudinal associations between loneliness, social isolation, and healthcare utilisation trajectories: a latent growth curve analysis.

PURPOSE: To explore the longitudinal associations between eight-year trajectories of loneliness, social isolation and healthcare utilisation (i.e. inpatient, outpatient, and nursing home care) in US older adults. METHODS: The study used data from the Health and Retirement Study in 2006-2018, which included a nationally representative sample of American adults aged 50 and above (N = 6,832). We conducted latent growth curve models to assess the associations between trajectories of loneliness and isolation and healthcare utilisation over 8 years. RESULTS: Independent of sociodemographic and health-related confounders, social deficits were associated with a lower likelihood of baseline physician visits (loneliness ß= -0.15, SE = 0.08; social isolation ß= -0.19, SE = 0.08), but there was a positive association between loneliness and number of physician visits (ß = 0.06, SE = 0.03), while social isolation was associated with extended hospital (ß = 0.07, SE = 0.04) and nursing home stays (ß = 0.05, SE = 0.02). Longer nursing home stays also predicted better trajectories of loneliness and isolation over time. CONCLUSION: Loneliness and social isolation are cross-sectionally related to complex patterns of different types of healthcare. There was no clear evidence that social deficits led to specific trajectories of healthcare utilisation, but nursing home stays may over time help provide social contact, supporting trajectories of isolation and potentially loneliness. Non-clinical services such as social prescribing could have the potential to address unmet social needs and further promote patients' health-seeking profiles for improving healthcare equity.

Identifying barriers to outpatient appointment attendance in patient groups at risk of inequity: a mixed methods study in a London NHS trust.

BACKGROUND: There is significant health inequity in the United Kingdom (U.K.), with different populations facing challenges accessing health services, which can impact health outcomes. At one London National Health Service (NHS) Trust, data showed that patients from deprived areas and minority ethnic groups had a higher likelihood of missing their first outpatient appointment. This study's objectives were to understand barriers to specific patient populations attending first outpatient appointments, explore systemic factors and assess appointment awareness. METHODS: Five high-volume specialties identified as having inequitable access based on ethnicity and deprivation were selected as the study setting. Mixed methods were employed to understand barriers to outpatient attendance, including qualitative semi-structured interviews with patients and staff, observations of staff workflows and interrogation of quantitative data on appointment communication. To identify barriers, semi-structured interviews were conducted with patients who missed their appointment and were from a minority ethnic group or deprived area. Staff interviews and observations were carried out to further understand attendance barriers. Patient interview data were analysed using inductive thematic analysis to create a thematic framework and triangulated with staff data. Subthemes were mapped onto a behavioural science framework highlighting behaviours that could be targeted. Quantitative data from patient interviews were analysed to assess appointment awareness and communication. RESULTS: Twenty-six patients and 11 staff were interviewed, with four staff observed. Seven themes were identified as barriers - communication factors, communication methods, healthcare system, system errors, transport, appointment, and personal factors. Knowledge about appointments was an important identified behaviour, supported by eight out of 26 patients answering that they were unaware of their missed appointment. Environmental context and resources were other strongly represented behavioural factors, highlighting systemic barriers that prevent attendance. CONCLUSION: This study showed the barriers preventing patients from minority ethnic groups or living in deprived areas from attending their outpatient appointment. These barriers included communication factors, communication methods, healthcare the system, system errors, transport, appointment, and personal factors. Healthcare services should acknowledge this and work with public members from these communities to co-design solutions supporting attendance. Our work provides a basis for future intervention design, informed by behavioural science and community involvement.

'We are suffering. Nothing is changing.' Black mother's experiences, communication, and support in the neonatal intensive care unit in the United States: A Qualitative Study.

OBJECTIVES: Black mothers experience markedly disproportionate maternal morbidity and mortality in the United States, with racism often cited as the root cause manifesting through several pathways. The study examined Black mothers' perceived provider communication, support needs, and overall experiences in the neonatal intensive care unit (NICU). DESIGN: This study used grounded theory embedded in the Black feminist theoretical (BFT) framework to generate new ideas grounded in the data. Data was collected through semi-structured interviews using videoconferencing, with questions related to the mother's overall NICU experiences, communication within the NICU, and perceived support needs. Data were analyzed using thematic analysis. RESULTS: Twelve mothers participated in the study; most were married (n = 10), had a cesarean birth, had a previous pregnancy complication (e.g., diabetes, hypertension), had attained a graduate degree or more (n = 9), earned an annual household income of $75,000 or more, and were between 35-44 years of age (n = 7). Three broad domains with several accompanying themes and sub-themes were identified, explicating the mother's experiences in the NICU. Specifically, factors influencing NICU hospitalization for mothers included maternal care/nursing experiences, interactions in the NICU, and the perceived support need that might attenuate negative care and birthing experiences. . CONCLUSION: The study adds to the growing literature championing Black maternal health equity and multilevel quality improvement strategies to foster equitable maternal health. Our study reinforces the need for racially congruent interventions and policy reformations to protect Black birthing people regardless of socioeconomic factors and social class using life course, holistic approaches, and intersectionality mindset. Importantly, using the BFT, this study calls for culturally sensitive research to capture the nuances associated with the multiplicity of experiences of Black people.

Geographic inequities in neonatal survival in Nigeria: a cross-sectional evidence from spatial and artificial neural network analyses.

This study was conducted to provide empirical evidence of geographical variations of neonatal mortality and its associated social determinants with a view to improving neonatal survival at the subnational level in Nigeria. With a combination of spatial analysis and artificial intelligence techniques, this study analysed data from the 2016/2017 Nigeria Multiple Indicator Cluster Survey. The analysis focused on the neonatal period of a weighted national representative population of 30,924 live births delivered five years before the survey commencement. Global Moran's I index and local indicator of spatial autocorrelation cluster maps were used to determine hot and cold spots. A multilayer perceptron neural network was used to identify the key determinants of neonatal mortality across the states and geopolitical zones in Nigeria. The overall neonatal mortality rate was 38 deaths per 1000 live births. There is evidence of geographic clustering of neonatal mortality across Nigeria (worse in the North-Central and North-West zones), majorly driven by poor maternal access to mass media (which plays a critical role in promoting positive health behaviours), short birth interval, a higher position in a family birth order, and young maternal age at child's birth. This study highlights the need for a policy shift towards implementing state and region-specific strategies in Nigeria. Gender-responsive, culturally, and regionally appropriate reproductive, maternal, and child health-targeted interventions may address geographical inequity in neonatal survival.

Mortality due to cervical and breast cancer in health regions of Brazil: impact of public policies on cancer care.

OBJECTIVE: This analysis assessed the association between regional income, screening coverage for cervical and breast cancer, and temporal trends in mortality from these cancers in different Brazilian health regions. STUDY DESIGN: Spatiotemporal ecological study across 450 health regions of Brazil. METHODS: Data from 2010 Demographic Census were used to assess income. Variations in income distribution within health regions were measured using the Gini index. Data on screening coverage were obtained from the Ambulatory Information System (SIA/SUS). Mortality was assessed from the Global Burden of Disease Study 2019 data. The average annual percentage change (AAPC) in cervical and breast cancer mortality rates, 2010-2018, was calculated by health regions. Results were presented in regional maps. The associations between income, screening coverage and mortality changes were estimated by bivariate spatial correlation. RESULTS: Health regions located in the South and Southeast regions of Brazil had the greatest percentages of screening coverage and highest per capita incomes with the lowest Gini index values. From 2010 to 2018, mortality rates for cervical cancer were highest in the North and Northeast health regions. Breast cancer mortality rates were highest in the South and Southeast health regions. The AAPC in breast and cervical cancer mortality had a negative association with per capita income and screening coverage, and a positive association with the Gini index. CONCLUSIONS: There are large regional variations in income, screening coverage, and mortality rates for women with breast and cervical cancer. These inequities could be mitigated by policies to address income disparities and improved access to screening.

Racial and Ethnic Disparities in Predictive Accuracy of Machine Learning Algorithms Developed Using a National Database for 30-Day Complications Following Total Joint Arthroplasty.

BACKGROUND: While predictive capabilities of machine learning (ML) algorithms for hip and knee total joint arthroplasty (TJA) have been demonstrated in previous studies, their performance in racial and ethnic minority patients has not been investigated. This study aimed to assess the performance of ML algorithms in predicting 30-day complications following TJA in racial and ethnic minority patients. METHODS: A total of 267,194 patients undergoing primary TJA between 2013 and 2020 were identified from a national outcomes database. The patient cohort was stratified according to race, with further sub-stratification into Hispanic or non-Hispanic ethnicity. There were two ML algorithms, histogram-based gradient boosting (HGB), and random forest (RF), that were modeled to predict 30-day complications following primary TJA in the overall population. They were subsequently assessed in each racial and ethnic subcohort using discrimination, calibration, accuracy, and potential clinical usefulness. RESULTS: Both models achieved excellent (Area under the curve (AUC) > 0.8) discrimination (AUCHGB = AUCRF = 0.86), calibration, and accuracy (HGB: slope = 1.00, intercept = -0.03, Brier score = 0.12; RF: slope = 0.97, intercept = 0.02, Brier score = 0.12) in the non-Hispanic White population (N = 224,073). Discrimination decreased in the White Hispanic (N = 10,429; AUC = 0.75 to 0.76), Black (N = 25,116; AUC = 0.77), Black Hispanic (N = 240; AUC = 0.78), Asian non-Hispanic (N = 4,809; AUC = 0.78 to 0.79), and overall (N = 267,194; AUC = 0.75 to 0.76) cohorts, but remained well-calibrated. We noted the poorest model discrimination (N = 1,870; AUC = 0.67 to 0.68) and calibration in the American-Indian cohort. CONCLUSION: The ML algorithms demonstrate an inferior predictive ability for 30-day complications following primary TJA in racial and ethnic minorities when trained on existing healthcare big data. This may be attributed to the disproportionate underrepresentation of minority groups within these databases, as demonstrated by the smaller sample sizes available to train the machine learning models. The ML models developed using smaller datasets (e.g., in racial and ethnic minorities) may not be as accurate as larger datasets, highlighting the need for equity-conscious model development.

Introduction: Student Experiences of COVID-19 Around the Globe: Insights from the Pandemic Journaling Project.

The COVID-19 crisis has taken a significant toll on the mental health of many students around the globe. In addition to the traumatic effects of loss of life and livelihood within students' families, students have faced other challenges, including disruptions to learning and work; decreased access to health care services; emotional struggles associated with loneliness and social isolation; and difficulties exercising essential rights, such as rights to civic engagement, housing, and protection from violence. Such disruptions negatively impact students' developmental, emotional, and behavioral health and wellbeing and also become overlaid upon existing inequities to generate intersectional effects. With these findings in mind, this special issue investigates how COVID-19 has affected the mental health and wellbeing of high school and college students in diverse locations around the world, including the United States, Mexico, Brazil, China, and South Africa. The contributions collected here analyze data collected through the Pandemic Journaling Project, a combined research study and online journaling platform that ran on a weekly basis from May 2020 through May 2022, along with complementary projects and using additional research methods, such as semi-structured interviews and autobiographical writing by students. The collection offers a nuanced, comparative window onto the diverse struggles that students and educators experienced at the height of the pandemic and considers potential solutions for addressing the long-term impacts of COVID-19. It also suggests a potential role for journaling in promoting mental wellbeing among youth, particularly in the Global South.

An antiracism framework for educating nursing professionals.

BACKGROUND: A conceptual, methodological, and theoretical framework is needed in Nursing Education to center racism, in the curriculum, as a root cause of health inequity. PURPOSE: To provide Nursing and health professions' educators with a comprehensive unifying framework to fundamentally conceptualize and deliver a curriculum which positions racism's impact as a root cause of health inequities. METHODS: Critical race theory is the underpinning for a historical analysis of racism and a critique of scientific racism, whiteness, and white supremacy ideologies that perpetuate harmful and lethal outcomes for racialized individuals and communities. RESULTS: This framework conceptualizes learning, unlearning, relearning, and reflective practice as the fundamental process needed to transformative nursing education and advance health equity. DISCUSSION: Methodological application is given for 1) unlearning harmful white supremacy ideology 2) learning that racism as it is embedded in every sector of American life and racial inequities are inherent in the health care system 3) relearning the importance of counternarratives and building structural competency and 4) engaging in reflective practice to challenge deficit paradigms assigned to racialized people and their communities. CONCLUSION: The Antiracism Framework provides foundational principles, guiding steps, and rationale for curricula that acknowledges the critical role of racism as a barrier to achieving health equity.