Digital Redlining-The Invisible Structural Determinant of Health.

This Viewpoint describes digital redlining as racialized inequities in access to technology infrastructure, including access to health care, education, employment, and social services.

Job Flexibility, Job Security, and Mental Health Among US Working Adults.

Importance: Understanding the association between job characteristics and mental health can inform policies and practices to promote employee well-being. Objective: To investigate associations between job characteristics and mental health, work absenteeism, and mental health care use among US adults. Design, Setting, and Participants: This cross-sectional study analyzed data from the 2021 National Health Interview Survey and included adults aged 18 years or older who reported employment during the past 12 months. Data were analyzed from May 2023 to January 2024. Exposures: Job flexibility was assessed as a summative variable to 3 questions: perceived ease of changing one's work schedule to do things important to oneself or their family, regularity of work schedule changes, and advance notice of work hours. Job security was measured as perceived likelihood of losing one's job. Main Outcomes and Measures: Mental health outcomes included self-reported serious psychological distress and frequency of anxiety. Work absenteeism was assessed using the number of missed workdays due to illness. Mental health care use was examined for both current and past year use. Multivariable logistic and binomial regression analyses were used to examine associations of interest. Results: The analytic sample consisted of 18 144 adults (52.3% [95% CI, 51.5%-53.2%] male; mean age, 42.2 [95% CI, 41.9-42.6] years). Greater job flexibility was associated with decreased odds of serious psychological distress (odds ratio [OR], 0.74 [95% CI, 0.63-0.86]; P < .001) and lower odds of weekly anxiety (OR, 0.89 [95% CI, 0.81-0.97]; P = .008) or daily anxiety (OR, 0.87 [95% CI, 0.79-0.96]; P = .005). Greater job security was associated with decreased odds of serious psychological distress (OR, 0.75 [95% CI, 0.65-0.87]; P < .001) and lower odds of anxiety weekly (OR, 0.79 [95% CI, 0.71-0.88]; P < .001) or daily (OR, 0.73 [95% CI, 0.66-0.81]; P < .001). Greater job flexibility (incidence rate ratio [IRR], 0.84 [95% CI, 0.74-0.96]; P = .008) and job security (IRR, 0.75 [95% CI, 0.65-0.87]; P < .001) were each associated with decreased number of days worked despite feeling ill over the past 3 months. Greater job security was associated with decreased absenteeism in the past year (IRR, 0.89 [95% CI, 0.82-0.98]; P < .014). Conclusions and Relevance: Organizational policies that enhance job flexibility and security may facilitate a healthier work environment, mitigate work-related stress, and ultimately promote better mental health.

Shifts in Child Health Behaviors and Obesity After COVID-19.

This Viewpoint examines recent COVID-19­related behavioral shifts in children's diet, physical activity, sleep, and screen time from a health equity perspective and provides upstream interventions to support overall child health.

Aligning Employee Health and Diversity, Equity, and Inclusion Initiatives in the Workplace: A Call for Synchronization.

Reports of burnout and poor mental health are at all-time highs among working U.S. adults.  Simultaneously, failure to promote diversity, equity, and inclusion (DEI) is among the top characteristics of an unhealthy work culture and has contributed to high rates of employee attrition. Though many organizations across multiple sectors have made pledges to prioritize employee health and invest in DEI in recent years, few have explicitly addressed these two issues as interconnected. The link between the workplace as a determinant of mental and physical health is well-established. Several studies demonstrate that experiencing discrimination in the workplace is associated with detrimental physical and mental health outcomes. Additionally, the way work is structured directly and indirectly contributes to employee health inequities. In this commentary, we make the connection between employee health and organizational DEI and propose guiding principles to synchronize DEI and employee health initiatives in the workplace. These include: investing in DEI as a cornerstone for developing a healthy workforce for all; recognizing differences in employee experiences, needs, and their connection to health; prioritizing systemic approaches to promote employee health and organizational DEI. Embedding employee health and DEI efforts into broader organizational strategy is a crucial step towards fostering equitable practices that promote inclusive work environments andpositive employee well-being.

Health Misinformation on Social Media and Adolescent Health.

This Viewpoint discusses strategies for dealing with health misinformation on social media.

A systematic review of diversity, equity, and inclusion and antiracism training studies: Findings and future directions.

A growing number of organizations are prioritizing diversity, equity, and inclusion (DEI) and antiracism in the workplace, including investing resources in DEI or antiracism training. However, such trainings vary widely in curriculum, objectives, delivery, and evaluation, with little known about the efficacy of existing trainings. The aim of this systematic review is to evaluate training characteristics, measures, and results of peer-reviewed studies (published between 2000 and 2022) testing DEI or antiracism trainings. Studies were identified using Google Scholar, JSTOR, and a university library database. Key search terms included "diversity, equity, and inclusion training"; "antiracism training"; and "effect," "impact," "outcome," or "evaluation." The search yielded N = 15 DEI training studies and N = 8 antiracism training studies. The majority of studies (75% of antiracism training; 66.6% of DEI training) utilized a one-time training session. Content, objectives, measures, and impact varied widely across studies. Randomized designs were uncommon (13%), and over 70% of studies had majority female participants. Findings highlight several strategies to advance the field of DEI and antiracism training, such as shifting curriculum from targeting individual knowledge to supporting behavioral and organizational change, providing longitudinal training, standardizing outcomes of interest, and implementing rigorous evaluation methods.

Despite the increased number of organizations dedicating resources to diversity, equity, and inclusion training and/or antiracism training, little is known about which strategies yield successful results. This systematic review synthesizes research findings on diversity, equity, and inclusion and antiracism training studies over the past two decades and presents research and practice-based recommendations for how to move the field forward.

From Awareness to Action: Pathways to Equity in Pain Management.

This commentary calls for a shift in the identification, analysis, and treatment of disparities in pain management. We provide context and research that summarize social and structural determinants that contribute to disparities across multiple levels of the pain management continuum. Informed by the evidence, we provide guideposts for mitigating disparities in the assessment, diagnosis, and care provided to those experiencing pain, with a focus on highlighting the specific needs of marginalized communities and the importance of culturally appropriate and context-specific approaches to pain management. This commentary informs efforts to promote equity by identifying areas of concern, guiding interventions, and advocating for policies that aim to eliminate disparities in pain treatment. Researchers, health care providers, and organizations can collectively work to provide equitable culturally sensitive pain management and improve overall patient outcomes.

Weight-based discrimination and disordered eating behaviors in a cohort of U.S. sexual minority young adults.

OBJECTIVE: Though prevalent, weight-based discrimination is understudied and has been linked to disordered eating behaviors (DEB) among adolescents and adults. Sexual minority populations experience elevated risk of DEB, but little is known about the role of weight discrimination in this elevated risk. METHODS: Participants were 1257 sexual minority women and men (ages 18-31 years) in the US Growing Up Today Study cohort. We examined cross-sectional associations between weight discrimination victimization and three DEB in the past year: unhealthy weight control behaviors, overeating, and binge eating. Generalized estimating equations, adjusted for potential confounders, were used to estimate prevalence ratios (PRs) and 95% confidence intervals (CIs). RESULTS: Three in 10 participants (31%) reported weight-based discrimination victimization. Sexual minority young adults who reported weight-based discrimination had greater relative prevalence of unhealthy weight control behaviors (PR [95% CI]: 1.92 [1.35, 2.74]), overeating (3.15 [2.24, 4.44]), and binge eating (3.92 [2.51, 6.13]), compared with those who reported no weight-based discrimination. Associations with overeating and binge eating remained significant after adjusting for BMI. DISCUSSION: The role of weight-based discrimination, and its intersections with other forms of stressors for sexual minority young adults, must be included in efforts to advance eating disorder prevention for this underserved population. PUBLIC SIGNIFICANCE: Three in 10 sexual minority young adults in this study had experienced weight-based discrimination, a common but understudied form of discrimination. Sexual minority young adults who experienced weight-based discrimination were at greater risk of disordered eating behaviors than those who had not experienced weight-based discrimination. These findings suggest that weight-based discrimination may be an important-and preventable-risk factor for disordered eating behaviors among sexual minority young adults.

Exploring Social Media Preferences for Healthy Weight Management Interventions Among Adolescents of Color: Mixed Methods Study.

BACKGROUND: Social media holds promise as an intervention platform to engage youths in healthy weight management and target racial inequities in obesity. OBJECTIVE: This mixed methods study aimed to examine social media habits, preferences, and obesity-related behaviors (eg, diet and physical activity) among adolescents of color and understand preferences for healthy weight management interventions delivered via social media. METHODS: This mixed methods study is comprised of a cross-sectional web-based survey and a series of digital focus groups. Study participants (English-speaking youths of color ages 14-18 years) were recruited from high schools and youth-based community settings in Massachusetts and California. For surveys, participants were invited to complete an anonymous web-based survey assessing self-reported sociodemographics, social media habits and preferences, health behaviors (diet, physical activity, sleep, and screen time), and height and weight. For focus groups, participants were invited to participate in 45- to 60-minute web-based group discussions assessing social media habits, preferred social media platforms, and preferences for physical activity and nutrition intervention content and delivery. Survey data were analyzed descriptively; focus group transcripts were analyzed using a directed content analysis approach. RESULTS: A total of 101 adolescents completed the survey and 20 adolescents participated in a total of 3 focus groups. Participants reported most frequently using TikTok, followed by Instagram, Snapchat, and Twitter; preference for platform varied by purpose of use (eg, content consumption, connection, or communication). TikTok emerged as the platform of choice as an engaging way to learn about various topics, including desired health information on physical fitness and diet. CONCLUSIONS: Findings from this study suggest that social media platforms can be an engaging way to reach adolescents of color. Data will inform future social media-based interventions to engage adolescents of color in healthy weight management content.

Factors impacting implementation of nutrition and physical activity policies in rural schools.

BACKGROUND: Rural Latino children have higher rates of obesity compared to non-Latino Whites. Schools are in a unique position to address rural childhood obesity through policies. While evidence exists on factors that promote or impede school-based physical activity (PA) and nutrition policies, only a fraction has been in rural communities. This study seeks to understand 1) the knowledge and perceptions of school nutrition and PA policies and 2) barriers and facilitators to their implementation among rural school stakeholders from Washington State. METHODS: We conducted 20 semi-structured, in-depth interviews with school stakeholders (e.g., principals and school nutrition directors) from four K-12 school districts in the Lower Yakima Valley of Eastern Washington State. Thematic analysis was conducted using inductive, constant comparison approach to identify themes around knowledge and perceptions of policies and barriers and facilitators of policy implementation. RESULTS: Three main themes were identified: perceptions and knowledge of school PA and nutrition policies, barriers to policy implementation, and facilitators of policy implementation. The majority of stakeholders were supportive of school-based policies promoting PA and a healthy diet, even when lacking a specific understanding of these policies. Four subthemes were identified as barriers to policy implementation: viewing PA as a low priority, misuse of recess time, funding constraints, and lack of strong leadership. Facilitators of implementation included strong leadership at the district level, creating healthy norms through school-community linkages and pooling community resources to improve nutrition and PA among children. CONCLUSIONS: Schools provide a unique setting to promote healthy diet and PA behaviors among children and their families. Study findings show that while knowledge of specific nutrition and PA policies may vary, support for such policies were high among rural stakeholders. Study findings can inform policy development and support strategies for policy implementation in rural settings. Future studies may want to examine whether implementation of strategies addressing the barriers and enhancing facilitators lead to success in rural school settings.

Higher walkability associated with increased physical activity and reduced obesity among United States adults.

OBJECTIVE: This study examined associations among perceived neighborhood walkability, physical activity (PA), and obesity among United States adults. METHODS: Data from the 2020 National Health Interview Survey were analyzed. Walkability was assessed using a summative scale and was categorized as low, medium, or high. PA was categorized as insufficient (0-149 min/wk) or sufficient (150+ min/wk). Multivariable regressions estimated an association between obesity and BMI and PA/walkability. Mediation analysis was used to partition contribution of PA as a mediator. Effect modification by race and ethnicity in the association between walkability and BMI was explored. RESULTS: The sample included N = 31,568 adults. Compared with those in low-walkability neighborhoods, participants in high-walkability neighborhoods had increased odds of sufficient PA (odds ratio [OR] = 1.48; 95% CI: 1.30-1.69) and decreased obesity odds (OR = 0.76; 95% CI: 0.66-0.87). PA partially mediated the association between walkability and BMI (23.4%; 95% CI: 14.6%-62.7%). The association between walkability and BMI was modified by race and ethnicity (F[5,567]  = 2.75; p = 0.018). Among White, Black, Hispanic, and Asian adults, BMI decreased with increasing walkability; among American Indian/Alaska Native and multiracial/other adults, BMI increased with increasing walkability. CONCLUSIONS: The findings highlight the importance of investing in the built environment to improve perceptions of walkability and promote PA and healthy weight, as well as developing interventions to target racial and ethnic disparities in these outcomes.

The call for science communication and public scholarship.

This commentary calls for a collective shift in the sciences and academia to prioritize and invest in communicating research in ways that are engaging, relevant, and accessible to public audiences. We provide the context and rationale for increasing and enhancing science communication, and identify barriers that prevent health researchers, educators, and practitioners from engaging with the public. Academic institutions need to develop and implement policies that encourage and support science communication and public scholarship initiatives that are sustainable and scalable.

Racial and Socioeconomic Disparities in Breast Cancer Outcomes within the AJCC Pathologic Prognostic Staging System.

BACKGROUND: Non-Hispanic black (NHB) women and those of lower socioeconomic status (SES) have inferior breast cancer outcomes compared with non-Hispanic white (NHW) women and those of higher SES. We examined racial and SES disparities in breast cancer survival within the AJCC 8th edition pathologic prognostic staging system. METHODS: Using the Surveillance, Epidemiology and End Results Program, we identified patients diagnosed with invasive breast cancer from 2010 to 2015, with follow-up through 2016. Census tract-level SES (cSES) data were available as a composite index and analyzed in quintiles. Cox proportional-hazards survival analyses adjusted for age, race, cSES, insurance, marital status, histology, pathologic prognostic stage, and treatment were used to estimate disease-specific survival (DSS). RESULTS: A total of 259,852 patients were included: 176,369 (67.9%) NHW; 28,510 (11.0%) NHB; 29,737 (11.4%) Hispanic; and 22,887 (8.8%) Asian. NHB race and lower cSES were associated with increased incidence of triple-negative disease compared with NHW (p < 0.01). NHB race, lower cSES, public insurance, lower education, and increased poverty were associated with lower DSS. Survival analyses adjusting for cSES, tumor, and treatment characteristics demonstrated that NHB patients had inferior DSS within each AJCC pathologic prognostic stage (hazard ratio [HR] 1.25, 95% confidence interval [CI] 1.20-1.30) compared with NHW patients. Fully adjusted models also showed patients residing in lower SES counties had inferior DSS. CONCLUSIONS: Racial and cSES disparities in breast cancer-specific mortality were evident across all stages, even within the pathologic prognostic staging system which incorporates tumor biology. Future efforts should assess the biological, behavioral, social, and environmental determinants that underlie racial and SES inequities in outcomes.

Neighborhood social cohesion and physical activity and obesity outcomes among Native Hawaiian and Pacific Islander individuals.

OBJECTIVE: Native Hawaiian and Pacific Islander (NHPI) individuals report high obesity rates and low physical activity (PA) levels. This study examined associations between neighborhood social cohesion, obesity, and PA among NHPI adults. METHODS: Cross-sectional data from the 2014 NHPI National Health Interview Survey were analyzed. Social cohesion was assessed using a summative scale and categorized as low, medium, and high. PA was measured via self-report and categorized as insufficiently active (0-149 min/wk) or sufficiently active (150+ min/wk). Obesity status was based on self-reported height and weight measures converted into standard BMI categories. Multivariable logistic regression models estimated odds of obesity and sufficient PA associated with social cohesion level. RESULTS: The study sample included n = 2,590 NHPI adults. Compared with those in low social cohesion neighborhoods, participants in high social cohesion neighborhoods had increased sufficient PA odds (odds ratio [OR] = 1.59, 95% CI: 1.19-2.12; p = 0.003) and decreased obesity odds (OR = 0.57, 95% CI: 0.40-0.83; p = 0.005). No associations were observed between social cohesion and obesity and PA outcomes comparing individuals in medium versus low social cohesion neighborhoods. CONCLUSIONS: High social cohesion was associated with reduced obesity odds and increased sufficient PA odds. Findings highlight the importance of enhancing social connectivity as a potential strategy to promote PA and healthy weight among NHPI individuals.

Pilot Intervention Targeting Sugary Drink Intake Associated With Improvements in Adolescent Sleep Duration.

OBJECTIVE: To examine temporal associations between participation in a community-based intervention targeting sugary drink intake and sleep outcomes among children. METHODS: Data are from an ethnically diverse sample of 100 children aged 9-12 years from 2 Massachusetts Boys and Girls Club (BGC) sites who participated in a pilot-site randomized trial (usual BGC programming plus H2GO! intervention vs usual BGC programming). Secondary outcomes of the trial (sleep duration and adequate sleep duration [≥ 9 h/night] were assessed via a self-report survey at baseline, 2 months, and 6 months. Generalized linear and logistic regression models estimated intervention effects associated with outcomes. RESULTS: The intervention was associated with increased sleep duration (ß = 0.74; 95% confidence interval, 0.03-1.45) and higher odds of adequate sleep (odds ratio, 2.47; 95% confidence interval, 1.06-5.74) at 2 months. Sleep did not differ by treatment condition at 6 months. CONCLUSIONS AND IMPLICATIONS: This community-based sugary drink intake intervention may be a potential avenue to improve child sleep outcomes in the short term.

A youth empowerment intervention to prevent childhood obesity: design and methods for a cluster randomized trial of the H2GO! program.

BACKGROUND: Reducing sugar-sweetened beverage (SSB) consumption is a promising dietary target for childhood obesity prevention. This paper describes the design and methods of a cluster randomized trial of H2GO!, a youth empowerment intervention to prevent childhood obesity through reducing SSB consumption among a low-income, ethnically diverse sample of youth. METHODS: This cluster randomized controlled trial is an academic-community partnership with the Massachusetts Alliance of Boys and Girls Clubs (BGC). Ten BGC sites will be randomly assigned to the H2GO! intervention or a wait-list, usual care control. Eligible study participants will be N = 450 parent-child pairs (youth ages 9-12 years and their parents/caregivers) recruited from participating BGCs. The 6-week in-person H2GO! intervention consists of 12 group-based sessions delivered by BGC staff and youth-led activities. An innovative feature of the intervention is the development of youth-produced narratives as a strategy to facilitate youth empowerment and parental engagement. Child outcomes include measured body mass index z scores (zBMI), beverage intake, and youth empowerment. Parent outcomes include beverage intake and availability of SSBs at home. Outcomes will be measured at baseline and at 2, 6, and 12 months. With a 75% retention rate, the study is powered to detect a minimum group difference of 0.1 zBMI units over 12 months. DISCUSSION: Empowering youth may be a promising intervention approach to prevent childhood obesity through reducing SSB consumption. This intervention was designed to be delivered through BGCs and is hypothesized to be efficacious, relevant, and acceptable for the target population of low-income and ethnically diverse youth. TRIAL REGISTRATION: ClinicalTrials.gov NCT04265794 . Registered 11 February 2020.

Sugar-Sweetened Beverage Consumption and Sleep Duration and Quality Among Pregnant Women.

OBJECTIVE: To examine sugar-sweetened beverage (SSB) consumption, sleep duration, and quality during pregnancy. METHODS: Pregnant women completed 3 24-hour dietary recalls and the Pittsburgh Sleep Quality Index. Logistic regression models estimated odds of short sleep duration (< 7 h/night) and poor sleep quality (Pittsburgh Sleep Quality Index score > 5) by SSB consumption (servings/d averaged across 3 days). RESULTS: Participants (n = 108) were a median age of 30 years old (interquartile range [IQR], 26-33) and at 23.9 weeks gestation (IQR, 18.9-30.6). Participants consumed a median of 0.4 servings of SSBs per day on average (IQR, 0-1.1; range, 0-4.6). Fifty-two percent reported poor quality sleep and 38% short sleep. Each additional serving of SSB was associated with higher odds of short sleep (adjusted odds ratio, 1.6; 95% confidence interval, 1.1-2.5) and poor sleep quality (adjusted odds ratio, 2.1; 95% confidence interval, 1.2-3.6). CONCLUSIONS AND IMPLICATIONS: SSB consumption may be a modifiable risk factor for short/poor sleep during pregnancy. Longitudinal research is needed to explore the interplay between SSB consumption and sleep.

Community-based sugar-sweetened beverage intervention associated with short-term improvements in self-rated oral health.

OBJECTIVES: To assess the efficacy of a community-based childhood obesity prevention intervention targeting Sugar-sweetened beverage (SSB) consumption on self-rated oral health among children and their parents/caregivers. METHODS: This study is a secondary analysis of data from a pilot site-randomized intervention (H2 GO!) targeting SSB consumption and obesity risk among children. The 6-week SSB behavioural intervention was implemented in two Massachusetts Boys and Girls Club sites that were matched for size and racial/ethnic composition. Children ages 9-12 years and their parents/caregivers were eligible to participate. Data on self-rated oral health and sociodemographics were obtained via self-report surveys at baseline, 2 and 6 months. Generalized linear mixed regression models were used to estimate 2- and 6-month change in oral health associated with the intervention. RESULTS: Data are from 100 child participants (46% female; 38% Black, 20% Hispanic, 13% White, 12% Multiracial, 11% Asian) and 87 parent participants (78.2% female; 37.9% Hispanic, 29.9% Black, 14.9% Asian, 10.3% White). At baseline, 47% of child participants rated their oral health as good, followed by very good (32%), fair (11%) and excellent (10%). Among parents, 46.3% rated their oral health as good, followed by very good (29.3%), excellent (9.8%), fair (9.7%) and poor (4.9%). The intervention was associated with 2- and 6-month improvements in child participants' mean self-rated oral health scores (ß = 0.78; 95% CI: 0.48, 1.087; P < .001; ß = 0.98; 95% CI: 0.61, 1.34; P < .001, respectively) and with 2-month improvements in parent participants' mean self-rated oral health (ß = 0.42; 95% CI: 0.016, 0.82; P = .042). CONCLUSION: Short-term improvements in oral health among children and their parents/caregivers were observed among those participating in a SSB behavioural intervention. Community-based behavioural programmes targeting SSB consumption may be a promising approach to promote oral health as well as prevent childhood obesity.

BMI and related risk factors among U.S. Marshallese with diabetes and their families.

Objective: Examine cross-sectional associations between body mass index (BMI) and related health behaviors, barriers and facilitators to health care, and perceived health status among a sample of U.S. Marshallese adults with Type 2 diabetes and evaluate associations of interest between participants and their family members.Design: Cross-sectional baseline data were analyzed from participants in a diabetes self-management education intervention trial.Setting: Data collection took place in home or community settings through a community-academic partnership in Arkansas.Participants: Study participants consisted of U.S. Marshallese adults with Type 2 diabetes (N = 221) and their family members (N = 211) recruited through community settings.Intervention(s): N/A.Main Outcome Measure(s): Participants' height and weight were measured using standard protocols to calculate BMI (kg/m2). Diet, physical activity, health care access, financial strain related to health care, perceived health status, and health care satisfaction were measured using self-report surveys.Results: Participants' mean BMI was 31.0 (95% CI: 30.2-31.7), with over half of study participants and their family members' BMI falling in the obese category. Participants' BMI was positively associated with spreading health care bill payments over time (ß = 1.75 (SE = 0.87); p = 0.045). Positive associations between participants and their family members were observed for self-reported health status conditions, health care coverage, health care utilization, and health care satisfaction.Conclusion: Study findings highlight the high prevalence of obesity and related risk factors among U.S. Marshallese adults with Type 2 diabetes and emphasize the need for intervention strategies that build upon cultural strengths and target community, policy, systems, and environmental changes to address obesity and chronic disease in this marginalized community.