Designing and Implementing a Curriculum to Support Health Equity Research Leaders: The Interdisciplinary Research Leaders Experience.

Health inequities in the United States are well-documented. However, research that is focused on solutions, rather than just describing the problem, and research that is designed explicitly to inform needed policy and practice change, is still too rare. The Robert Wood Johnson Foundation Interdisciplinary Research Leaders (IRL) program launched in 2016 with the goal of filling this gap: to generate community-engaged research to catalyze policy action in communities, while promoting leadership among researchers and community partners. In this paper, we describe the creation and implementation of a curriculum for IRL program participants over the first 5 years of the program. The curriculum-spanning domains of leadership, policy, communication, community engagement, and research methodologies-was designed to cultivate leaders who use research evidence in their efforts to promote change to advance health equity in their communities. The curriculum components implemented by IRL might be applied to other educational programs or fellowships to amplify and accelerate the growth of leaders nationwide who can use research and action to respond to grave and ongoing threats to community health.

Mobility restrictions were associated with reductions in COVID-19 incidence early in the pandemic: evidence from a real-time evaluation in 34 countries.

Most countries have implemented restrictions on mobility to prevent the spread of Coronavirus disease-19 (COVID-19), entailing considerable societal costs but, at least initially, based on limited evidence of effectiveness. We asked whether mobility restrictions were associated with changes in the occurrence of COVID-19 in 34 OECD countries plus Singapore and Taiwan. Our data sources were the Google Global Mobility Data Source, which reports different types of mobility, and COVID-19 cases retrieved from the dataset curated by Our World in Data. Beginning at each country's 100th case, and incorporating a 14-day lag to account for the delay between exposure and illness, we examined the association between changes in mobility (with January 3 to February 6, 2020 as baseline) and the ratio of the number of newly confirmed cases on a given day to the total number of cases over the past 14 days from the index day (the potentially infective 'pool' in that population), per million population, using LOESS regression and logit regression. In two-thirds of examined countries, reductions of up to 40% in commuting mobility (to workplaces, transit stations, retailers, and recreation) were associated with decreased cases, especially early in the pandemic. Once both mobility and incidence had been brought down, further restrictions provided little additional benefit. These findings point to the importance of acting early and decisively in a pandemic.

Racism and the Political Economy of COVID-19: Will We Continue to Resurrect the Past?

COVID-19 is not spreading over a level playing field; structural racism is embedded within the fabric of American culture, infrastructure investments, and public policy and fundamentally drives inequities. The same racism that has driven the systematic dismantling of the American social safety net has also created the policy recipe for American structural vulnerability to the impacts of this and other pandemics. The Bronx provides an important case study for investigating the historical roots of structural inequities showcased by this pandemic; current lived experiences of Bronx residents are rooted in the racialized dismantling of New York City's public infrastructure and systematic disinvestment. The story of the Bronx is repeating itself, only this time with a novel virus. To address the root causes of inequities in cases and deaths due to COVID-19, we need to focus not just on restarting the economy but also on reimagining the economy, divesting of systems rooted in racism, and the devaluation of Black and Brown lives.

Are "Obstetrically Underserved Areas" really underserved? Role of a government support program in the context of changing landscape of maternal service utilization in South Korea: A sequential mixed method approach.

OBJECTIVES: The Korean government has been providing financial support to open and operate the maternal hospital in Obstetrically Underserved Areas (OUAs) since 2011. Our study aims to assess the effectiveness of the government-support program for OUAs and to suggest future directions for it. METHODS: We performed sequential-mixed method approach. Descriptive analyses and multi-level logistic regression were performed based on the 2015 Korean National Health Insurance claim data. Data for the qualitative analysis were obtained from in-depth interviews with health providers and mothers in OUAs. RESULTS: Descriptive analyses indicated that the share of babies born in the hospitals located in the area among total babies ever born from mothers residing in the area (Delivery concentration Index: DCI) was lower in government-supported OUAs than other areas. Qualitative analyses revealed that physical distance is no longer a barrier in current OUAs. Mothers travel to neighboring big cities to seek elective preferences only available at specialized maternal hospitals rather than true medical need. Increasing one-child families changed the mother's perception of pregnancy and childbirth, making them willing to pay for more expensive services. Concern about an emergency for mothers or infants, especially of high-risk mothers was also an important factor to make mothers avoid local government-supported hospitals. Adjusted multi-level logistic regression indicated that DCIs of government-supported OUAs were higher than the ones of their counterpart areas. CONCLUSION: Our results suggest that current OUAs do not reflect reality. Identification of true OUAs where physical distance is a real barrier to the use of obstetric service and focused investment on them is necessary. In addition, more sophisticated performance indicator other than DCI needs to be developed.

Use of high-level health facilities and catastrophic expenditure in Vietnam: can health insurance moderate this relationship?

BACKGROUND: Overcrowding of high-level health facilities is a major concern in a Vietnamese health system. This may increase an economic burden to the households since health insurance is still insufficient in providing financial risk protection. This paper sought to examine the association between the use of high-level health facilities and household-level expenditure status such as out-of-pocket (OOP), and catastrophic expenditure on health, as well as a moderating effect of health insurances in rural and urban districts of Vietnam. METHODS: Data utilized a health system community survey collected between 2015 and 2017 in two districts of Vietnam (one from rural area in northern part, and the other one from urban area in sourthern part). The world Health Organization's definition of catastrophic expenditure was used. Multivariate tobit and logistic regression were employed for catastrophic expenditure and OOP respectively. Interaction term between health insurance status and visit frequency in high-level facilities was included to investigate the moderating effect of health insurance. RESULTS: Health insurance status was associated with neither OOP health expenditure nor catastrophic expenditure occurrence, whereas visit frequency of high-level health facilities was strongly associated with both outcomes in both districts(e.g., for catastrophic expenditure, ORs are 1.77 and 1.30 in northern and southern district respecitvely. P values are < 0.001). Significant interaction between health insurance status and use of high-level facilities on catastrophic expenditure occurrence was found in Quoc Oai district (OR = 0.68, p < 0.05). CONCLUSIONS: The present study demonstrated negative financial impact of utilizing high-level facility on household financial status and weak role of health insurance in decreasing this impact. Multi-faceted approach is called for to mitigate the patient's financial burden.

Neighborhood Differences in Post-Stroke Mortality.

BACKGROUND: Post-stroke mortality is higher among residents of disadvantaged neighborhoods, but it is not known whether neighborhood inequalities are specific to stroke survival or similar to mortality patterns in the general population. We hypothesized that neighborhood disadvantage would predict higher poststroke mortality, and neighborhood effects would be relatively larger for stroke patients than for individuals with no history of stroke. METHODS AND RESULTS: Health and Retirement Study participants aged ≥50 years without stroke at baseline (n=15 560) were followed ≤12 years for incident stroke (1715 events over 159 286 person-years) and mortality (5325 deaths). Baseline neighborhood characteristics included objective measures based on census tracts (family income, poverty, deprivation, residential stability, and percent white, black, or foreign-born) and self-reported neighborhood social ties. Using Cox proportional hazard models, we compared neighborhood mortality effects for people with versus people without a history of stroke. Most neighborhood variables predicted mortality for both stroke patients and the general population in demographic-adjusted models. Neighborhood percent white predicted lower mortality for stroke survivors (hazard ratio, 0.75 for neighborhoods in highest 25th percentile versus below, 95% confidence interval, 0.62-0.91) more strongly than for stroke-free adults (hazard ratio, 0.92; 95% confidence interval, 0.83-1.02; P=0.04 for stroke-by-neighborhood interaction). No other neighborhood characteristic had different effects for people with versus without stroke. Neighborhood-mortality associations emerged within 3 months after stroke, when associations were often stronger than among stroke-free individuals. CONCLUSIONS: Neighborhood characteristics predict mortality, but most effects are similar for individuals without stroke. Eliminating disparities in stroke survival may require addressing pathways that are not specific to traditional poststroke care.

Changes in Depressive Symptoms and Incidence of First Stroke Among Middle-Aged and Older US Adults.

BACKGROUND: Although research has demonstrated that depressive symptoms predict stroke incidence, depressive symptoms are dynamic. It is unclear whether stroke risk persists if depressive symptoms remit. METHODS AND RESULTS: Health and Retirement Study participants (n=16 178, stroke free and noninstitutionalized at baseline) were interviewed biennially from 1998 to 2010. Stroke and depressive symptoms were assessed through self-report of doctors' diagnoses and a modified Center for Epidemiologic Studies - Depression scale (high was ≥3 symptoms), respectively. We examined whether depressive symptom patterns, characterized across 2 successive interviews (stable low/no, onset, remitted, or stable high depressive symptoms) predicted incident stroke (1192 events) during the subsequent 2 years. We used marginal structural Cox proportional hazards models adjusted for demographics, health behaviors, chronic conditions, and attrition. We also estimated effects stratified by age (≥65 years), race or ethnicity (non-Hispanic white, non-Hispanic black, Hispanic), and sex. Stroke hazard was elevated among participants with stable high (adjusted hazard ratio 2.14, 95% CI 1.69 to 2.71) or remitted (adjusted hazard ratio 1.66, 95% CI 1.22 to 2.26) depressive symptoms compared with participants with stable low/no depressive symptoms. Stable high depressive symptom predicted stroke among all subgroups. Remitted depressive symptoms predicted increased stroke hazard among women (adjusted hazard ratio 1.86, 95% CI 1.30 to 2.66) and non-Hispanic white participants (adjusted hazard ratio 1.66, 95% CI 1.18 to 2.33) and was marginally associated among Hispanics (adjusted hazard ratio 2.36, 95% CI 0.98 to 5.67). CONCLUSIONS: In this cohort, persistently high depressive symptoms were associated with increased stroke risk. Risk remained elevated even if depressive symptoms remitted over a 2-year period, suggesting cumulative etiologic mechanisms linking depression and stroke.

Short- and long-term associations between widowhood and mortality in the United States: longitudinal analyses.

BACKGROUND: Past research shows that spousal death results in elevated mortality risk for the surviving spouse. However, most prior studies have inadequately controlled for socioeconomic status (SES), and it is unclear whether this 'widowhood effect' persists over time. METHODS: Health and Retirement Study participants aged 50+ years and married in 1998 (n = 12 316) were followed through 2008 for widowhood status and mortality (2912 deaths). Discrete-time survival analysis was used to compare mortality for the widowed versus the married. RESULTS: Odds of mortality during the first 3 months post-widowhood were significantly higher than in the continuously married (odds ratio (OR) for men = 1.87, 95% CI: 1.27, 2.75; OR for women = 1.47, 95% CI: 0.96, 2.24) in models adjusted for age, gender, race and baseline SES (education, household wealth and household income), behavioral risk factors and co-morbidities. Twelve months following bereavement, men experienced borderline elevated mortality (OR = 1.16, 95% CI: 1.00, 1.35), whereas women did not (OR = 1.07, 95% CI: 0.90, 1.28), though the gender difference was non-significant. CONCLUSION: The 'widowhood effect' was not fully explained by adjusting for pre-widowhood SES and particularly elevated within the first few months after widowhood. These associations did not differ by sex.

Does the association between depressive symptoms and cardiovascular mortality risk vary by race? Evidence from the Health and Retirement Study.

OBJECTIVE: To test whether the association between depressive symptoms and cardiovascular disease (CVD) mortality is stronger among Blacks than Whites. DESIGN, SETTING AND PARTICIPANTS: 2,638 Black and 15,132 White participants from a prospective, observational study of community-dwelling Health and Retirement Study participants (a nationally representative sample of U.S. adults aged > or = 50). Average follow-up was 9.2 years. OUTCOME MEASURE: Cause of death (per ICD codes) and month of death were identified from National Death Index linkages. METHODS: The associations between elevated depressive symptoms and mortality from stroke, ischemic heart disease (IHD), or total CVD were assessed using Cox proportional hazards models to estimate adjusted hazard ratios (HRs). We used interaction terms for race by depressive symptoms to assess effect modification (multiplicative scale). RESULTS: For both Whites and Blacks, depressive symptoms were associated with a significantly elevated hazard of total CVD mortality (Whites: HR=1.46; 95% CI: 1.33, 1.61; Blacks: HR=1.42, 95% CI: 1.10, 1.83). Adjusting for health and socioeconomic covariates, Whites with elevated depressive symptoms had a 13% excess hazard of CVD mortality (HR=1.13, 95% CI: 1.03, 1.25) compared to Whites without elevated depressive symptoms. The HR in Blacks was similar, although the confidence interval included the null (HR=1.12, 95% CI: .86, 1.46). The hazard associated with elevated depressive symptoms did not differ significantly by race (P>.15 for all comparisons). Patterns were similar in analyses restricted to respondents age > or =65. CONCLUSION: Clinicians should consider the depressive state of either Black or White patients as a potential CVD mortality risk factor.

Transition to retirement and risk of cardiovascular disease: prospective analysis of the US health and retirement study.

Transitioning from work to retirement could be either beneficial or harmful for health. We investigated the association between transition to retirement and risk of stroke and myocardial infarction (MI). We followed US Health and Retirement Study participants age 50+ working full-time for pay and free of major cardiovascular disease (n = 5422) in 1998 up to 10 years for transition to full retirement and self- or proxy-report of either stroke or MI (CVD; 665 events). We used discrete-time survival analysis to compare the CVD incidence for the fully retired versus the full-time working population. To distinguish short-term from long-term risks, we compared the association in the first year after retirement to estimates 2+ years after retirement. In the full model adjusting for age, sex, childhood and adult SES, behavior, and co-morbidities, being retired was associated with elevated odds of CVD onset (OR = 1.40, 95% CI: 1.04, 1.90) compared to those remaining in the full-time labor force. The odds ratio for CVD incidence within the first year of retirement was 1.55 (95% CI: 1.03, 2.33). From the second year post-retirement and thereafter, the retired had marginally elevated risk of CVD compared to those still working (OR = 1.35; 95% CI: 0.96, 1.91). Although confidence intervals were wide for some sub-groups, there were no significant interactions by sex or socioeconomic status. Results suggest that CVD risk is increased after retirement.

Stroke incidence in older US Hispanics: is foreign birth protective?

BACKGROUND AND PURPOSE: Although Hispanics are the fastest growing ethnic group in the United States, relatively little is known about stroke risk in US Hispanics. We compare stroke incidence and socioeconomic predictors in US- and foreign-born Hispanics with patterns among non-Hispanic whites. METHODS: Health and Retirement Study participants aged 50+ years free of stroke in 1998 (mean baseline age, 66.3 years) were followed through 2008 for self- or proxy-reported first stroke (n=15 784; 1388 events). We used discrete-time survival analysis to compare stroke incidence among US-born (including those who immigrated before age 7 years) and foreign-born Hispanics with incidence in non-Hispanic whites. We also examined childhood and adult socioeconomic characteristics as predictors of stroke among Hispanics, comparing effect estimates with those for non-Hispanic whites. RESULTS: In age- and sex-adjusted models, US-born Hispanics had higher odds of stroke onset than non-Hispanic whites (OR, 1.44; 95% CI, 1.08-1.90), but these differences were attenuated and nonsignificant in models that controlled for childhood and adulthood socioeconomic factors (OR, 1.07; 95% CI, 0.80-1.42). In contrast, in models adjusted for all demographic and socioeconomic factors, foreign-born Hispanics had significantly lower stroke risk than non-Hispanic whites (OR, 0.58; 95% CI, 0.41-0.81). The impact of socioeconomic predictors on stroke did not differ between Hispanics and whites. CONCLUSIONS: In this longitudinal national cohort, foreign-born Hispanics had lower incidence of stroke incidence than non-Hispanic whites and US-born Hispanics. Findings suggest that foreign-born Hispanics may have a risk factor profile that protects them from stroke as compared with other Americans.

Elevated depressive symptoms and incident stroke in Hispanic, African-American, and White older Americans.

Although depressive symptoms have been linked to stroke, most research has been in relatively ethnically homogeneous, predominantly white, samples. Using the United States based Health and Retirement Study, we compared the relationships between elevated depressive symptoms and incident first stroke for Hispanic, black, or white/other participants (N = 18,648) and estimated the corresponding Population Attributable Fractions. The prevalence of elevated depressive symptoms was higher in blacks (27%) and Hispanics (33%) than whites/others (18%). Elevated depressive symptoms prospectively predicted stroke risk in the whites/other group (HR = 1.53; 95% CI: 1.36-1.73) and among blacks (HR = 1.31; 95% CI: 1.05-1.65). The HR was similar but only marginally statistically significant among Hispanics (HR = 1.33; 95% CI: 0.92-1.91). The Population Attributable Fraction, indicating the percent of first strokes that would be prevented if the incident stroke rate in those with elevated depressive symptoms was the same as the rate for those without depressive symptoms, was 8.3% for whites/others, 7.8% for blacks, and 10.3% for Hispanics.

Current and long-term spousal caregiving and onset of cardiovascular disease.

BACKGROUND: Prior evidence suggests that caregiving may increase risk of cardiovascular disease (CVD) onset. This association has never been examined in a nationally (USA) representative sample, and prior studies could not fully control for socioeconomic confounders. This paper seeks to estimate the association between spousal caregiving and incident CVD in older Americans. METHODS: Married, CVD-free Health and Retirement Study respondents aged 50+ years (n=8472) were followed up to 8 years (1669 new stroke or heart disease diagnoses). Current caregiving exposure was defined as assisting a spouse with basic or instrumental activities of daily living ≥14 h/week according to the care recipients' report in the most recent prior biennial survey; we define providing ≥14 h/week of care at two consecutive biennial surveys as 'long-term caregiving'. Inverse probability weighted discrete-time hazard models with time-updated exposure and covariate information (including socioeconomic and cardiovascular risk factors) were used to estimate the effect of caregiving on incident CVD. RESULTS: Caregiving significantly predicted CVD incidence (HR=1.35, 95% CI 1.06 to 1.68) in the population overall. Long-term caregiving was associated with double the risk of CVD onset (HR=1.95, 95% CI 1.19 to 3.18). This association for long-term care givers varied significantly by race (p<0.01): caregiving predicted CVD onset for white (HR=2.37, 95% CI 1.43 to 3.92) but not for non-white (HR=0.28, 95% CI 0.06 to 1.28). CONCLUSIONS: Spousal caregiving independently predicted risk of CVD in a large sample of US adults. There was significant evidence that the effect for long-term care givers differs for non-whites and white.

Spousal caregiving and incident hypertension.

BACKGROUND: Caring for one's spouse has been associated with poor health, including risk of cardiovascular disease (CVD) onset and mortality. However, few studies have assessed the risk of incident hypertension associated with spousal caregiving. This paper investigates this association in a large, nationally representative sample of American older adults. METHODS: Married, hypertension-free, Health and Retirement Study (HRS) respondents aged 50+ in 2000, (n = 5,708) were followed up to 8 years (1,708 new self-reported hypertension diagnoses). Current caregiving exposure was defined as assisting a spouse with instrumental or basic activities of daily living (IADLs) 14+ h/week; we define providing ≥14 h/week of care at two consecutive biennial surveys as "long-term caregiving." We used inverse probability weighted discrete-time hazard models with time-updated exposure and covariates to estimate effects of current and long-term caregiving on incident hypertension. We tested for effect modification by race, gender, and recipient memory illness. Sensitivity analyses restricted to respondents whose spouses had care needs. RESULTS: After adjusting for demographic, socioeconomic, and health factors, (including risk behaviors, comorbid conditions, and self-rated health), current caregiving significantly predicted hypertension incidence (risk ratio (RR) = 1.36, 95% confidence interval (CI): 1.01, 1.83). For long-term caregivers, there was significant evidence of risk of hypertension onset associated with caregiving (RR = 2.29, 95% CI: 1.17, 4.49). The risk of hypertension onset associated with both current and long-term caregiving did not vary by race, gender, or recipient memory illness diagnosis. Sensitivity analyses supported the primary findings. CONCLUSIONS: Providing IADL care to a spouse significantly predicted hypertension onset in a nationally representative sample of US adults.

Widowhood and mortality: a meta-analysis.

BACKGROUND: While the "widowhood effect" is well known, there is substantial heterogeneity in the magnitude of effects reported in different studies. We conducted a meta-analysis of widowhood and mortality, focusing on longitudinal studies with follow-up from the time of bereavement. METHODS AND FINDINGS: A random-effects meta-analysis was conducted to calculate the overall relative risk (RR) for subsequent mortality among 2,263,888 subjects from 15 prospective cohort studies. We found a statistically significant positive association between widowhood and mortality, but the widowhood effect was stronger in the period earlier than six months since bereavement (overall RR = 1.41, 95% CI: 1.26, 1.57) compared to the effect after six months (overall RR = 1.14, 95% CI: 1.10, 1.18). Meta-regression showed that the widowhood effect was not different for those aged younger than 65 years compared to those older than 65 (P = 0.25). There was, however, a difference in the magnitude of the widowhood effect by gender; for women the RR was not statistically significantly different from the null (overall RR = 1.04, 95% CI: 1.00, 1.08), while it was for men (overall RR = 1.23, 95% CI: 1.18, 1.28). CONCLUSIONS: The results suggest that further studies should focus more on the mechanisms that generate this association especially among men.