"Hang Ups, Let Downs, Bad Breaks, Setbacks": Impact of Structural Socioeconomic Racism and Resilience on Cognitive Change Over Time for Persons Racialized as Black.

Introduction: Older adults racialized as Black experience higher rates of dementia than those racialized as White. Structural racism produces socioeconomic challenges, described by artist Marvin Gaye as "hang ups, let downs, bad breaks, setbacks" that likely contribute to dementia disparities. Robust dementia literature suggests socioeconomic factors may also be key resiliencies. Methods: We linked state-level data reflecting the racialized landscape of economic opportunity across the 20th Century from the U.S. Census (1930-2010) with individual-level data on cognitive outcomes from the U.S. Health and Retirement Study participants racialized as Black. A purposive sample of participants born after the Brown v. Board ruling (born 1954-59) were selected who completed the modified Telephone Interview for Cognitive Status between 2010 and 2020 (N=1381). We tested associations of exposure to structural racism and resilience before birth, and during childhood, young-adulthood, and midlife with cognitive trajectories in mid-late life using mixed-effects regression models. Results: Older adults born in places with higher state-level structural socioeconomic racism experienced a more rapid cognitive decline in later life compared to those with lower levels of exposure. In addition, participants born in places with higher levels of state-level structural socioeconomic resilience experienced slower cognitive change over time than their counterparts. Discussion: These findings reveal the impact of racist U.S. policies enacted in the past that influence cognitive health over time and dementia risk later in life.

Does Neighborhood Social Cohesion Influence Participation in Routine Cancer Screening? Findings From a Representative Sample of Adults in South Florida.

BACKGROUND AND OBJECTIVES: Neighborhood social cohesion (NSC) has been associated with a variety of health outcomes, but limited research has examined its impact on behaviors that support cancer control. The purpose of this study was to examine associations between NSC and guideline-concordant breast, cervical and colorectal cancer screening. METHODS: Data are from a cross-sectional survey administered to 716 adults in South Florida from 2019 to 2020. The analytic samples included adults eligible for breast (n = 134), cervical (n = 195), and colorectal cancer (n = 265) screening. NSC was measured using a validated 5-item instrument. Associations between NSC and guideline-concordant screening were examined using multivariable logistic regression. RESULTS: In fully adjusted analyses, the odds of guideline-concordant breast cancer screening increased by 86% for every unit increase in NSC (aOR = 1.86; 95% CI, 1.03-3.36). NSC was not statistically significantly associated with guideline-concordant cervical cancer screening (aOR = 0.86; 95% CI, 0.54-1.38) or colorectal cancer screening (aOR = 1.29; 95% CI, 0.81-2.04). CONCLUSIONS: These findings suggest that NSC supports some screening behaviors, namely, mammography use. To better understand heterogeneous relationships between NSC and utilization of preventive care services such as cancer screening, more research is needed that disaggregates effects by sex, age, race/ethnicity, and socioeconomic status.

Government Housing Assistance and Cancer Screening Among Adults With Low Income.

INTRODUCTION: Access to affordable housing may support cancer control for adults with low income by alleviating financial barriers to preventive care. This study examines relationships between cancer screening and receipt of government housing assistance among adults with low income. METHODS: Data are from the 2019 and 2021 National Health Interview Survey. Eligible respondents were classified as up-to-date or not with breast cancer (BC), cervical cancer (CVC) and colorectal cancer (CRC) screening guidelines. Multivariable logistic regression was used to model guideline-concordant screening by receipt of government housing assistance, overall and stratified by urban-rural status, race/ethnicity, and age. Analyses were performed in 2023. RESULTS: Analyses for BC, CVC and CRC screening included 2,258, 3,132, and 3,233 respondents, respectively. There was no difference in CVC screening by housing assistance status, but screening for BC and CRC was higher among those who received assistance compared to those who did not (59.7% vs. 50.8%, p<0.01 for BC; 57.1% vs. 44.1%, p<0.01 for CRC). In models adjusted for sociodemographic characteristics, health status and insurance, these differences were not statistically significant for either BC or CRC screening. In stratified adjusted models, housing assistance was statistically significantly associated with increased BC screening in urban areas (aOR=1.35, 95% CI=1.00-1.82) and among Hispanic women (aOR=2.20, 95% CI=1.01-4.78) and women 45-54 years of age (aOR=2.10, 95% CI=1.17-3.75). CONCLUSIONS: Policies that address housing affordability may enhance access to BC screening for some subgroups, including women in urban areas, Hispanic women, and younger women. More research on the mechanisms that link housing assistance to BC screening is needed.

Hyperlocal disparities in breast, cervical, and colorectal cancer screening: An ecological study of social vulnerability in Miami-Dade county.

Neighborhoods have been identified as important determinants of health-related outcomes, but limited research has assessed the influence of neighborhood context along the cancer continuum. This study used census tract-level data from the United States Census Bureau and Centers for Disease Control and Prevention to characterize Miami-Dade County census tracts (n = 492) into social vulnerability clusters and assess their associated breast, cervical, and colorectal cancer screening participation rates. We identified disparities by social vulnerability cluster in cancer screening participation rates. Further investigation of geographic disparities in social vulnerability and cancer screening participation could inform equity-focused cancer control efforts.

Intersectional disparities in climate vulnerability and cancer risk.

Despite significant progress in the early detection, treatment, and survivorship of cancer in recent decades, cancer disparities continue to plague segments of the US population. Many of these cancer disparities, especially those among historically marginalized racial and ethnic groups and those with lower socioeconomic resources, are caused and perpetuated by social and structural barriers to health. These social and structural barriers, which operate beyond the framework of cancer control, also systematically increase vulnerability to and decrease adaptive capacity for the deleterious effects of anthropogenic climate change. The established and emerging overlap between climate vulnerability and cancer risk presents complex challenges to cancer control, specifically among populations who suffer compounding hazards and intersectional vulnerabilities. By embracing these intersections, we may be able to conceptualize promising new research frameworks and programmatic opportunities that decrease vulnerability to a wide range of climate and health threats to advance health equity.

Partially Recursively Induced Structured Moderation (PRISM) for modeling racial differences in endometrial cancer survival.

PURPOSE: Health disparities are driven by a complex interplay of determinants operating across multiple levels of influence. However, while recognized conceptually, much disparities research fails to capture this inherent complexity in study focus and/or design; little of such work accounts for the interplay across the multiple levels of influence from structural (contextual) to biological or clinical. We developed a novel modeling framework that addresses these challenges and provides new insights. METHODS: We used data from the Florida Cancer Data System on endometrial cancer patients and geocoded-derived social determinants of health to demonstrate the applicability of a new modeling paradigm we term PRISM regression. PRISM is a new highly interpretable tree-based modeling framework that allows for automatic discovery of potentially non-linear hierarchical interactions between health determinants at multiple levels and differences in survival outcomes between groups of interest, including through a new specific area-level disparity estimate (SPADE) incorporating these multilevel influences. RESULTS: PRISM demonstrates that hierarchical influences on racial disparity in endometrial cancer survival appear to be statistically relevant and that these better predict survival differences than only using individual level determinants. The interpretability of the models allows more careful inspection of the nature of these hierarchical effects on disparity. Additionally, SPADE estimates show distinct geographical patterns across census tracts in Florida. CONCLUSION: PRISM can provide a powerful new modeling framework with which to better understand racial disparities in cancer survival.

"We're playing on the same team": Communication (dis)connections between trauma patients and surgical residents.

BACKGROUND: Patient-physician communication is key to better clinical outcomes and patient well-being. Communication between trauma patients and their physicians remains relatively unexplored. We aimed to identify and characterize the range of strengths and challenges in patient-physician communication in the setting of trauma care. METHODS: A qualitative, grounded theory approach was used to explore communication strengths and challenges for patients and residents. Patients previously admitted to the trauma service for violent injuries were recruited and interviewed in-person during their trauma clinic appointments. Surgical residents were recruited via email and interviewed virtually via Zoom. Anonymous, semistructured interviews were conducted until thematic saturation was reached. RESULTS: Twenty-nine interviews with patients and 14 interviews with residents were conducted. Patients reported feeling ignored and misunderstood and having inadequate communication with physicians. Residents cited lack of time, patients' lack of health literacy, differences in background, and emotional responses to trauma as barriers to effective communication with patients. Patients and residents reported an understanding of each other's stressors, similar emotional experiences regarding traumatic stress, and a desire to communicate with each other in greater depth both inside and outside of the hospital. CONCLUSION: Trauma patients and residents can feel disconnected due to the lack of time for thorough communication and differences in background; however, they understand each other's stressors and share similar emotional responses regarding trauma and a desire for increased communication, connection, and solidarity. Leveraging these shared values to guide interventions, such as a resident curriculum, may help bridge disconnects and improve their communication. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Food Insecurity Disparities and Mental Health Impacts Among Cancer Survivors During the COVID-19 Pandemic.

Introduction: Food insecurity can negatively impact adherence and receipt of high-quality cancer care. The purpose of the study was to (1) compare the prevalence of COVID-19-associated food insecurity by cancer history and (2) examine determinants associated with COVID-19-related food insecurity among cancer survivors. Methods: We used nationally representative data from the 2020 COVID-19 Household Impact Survey (n=10,760). Our primary exposure was participants' self-report of a cancer diagnosis (n=854, 7.1%). Primary outcomes of food insecurity were categorized by the following questions: "We worried our food would run out before we got money to buy more" or "The food that we bought just didn't last, and we didn't have money to get more"; respondents were categorized as food insecure if they chose often true or sometimes true. Multivariable Poisson regression was used to identify demographic determinants of food insecurity among cancer survivors. Results: Thirty-two percent of cancer survivors were food insecure. Cancer survivors 30-44 years of age and those ≥60 years of age were more likely to report being food insecure compared to respondents without a history of cancer, respectively (30-44 years, 59.9% vs. 41.2% p=0.01, ≥60 years 27.2% vs. 20.2%, p=0.01). Cancer survivors without a high school diploma were more likely to report food insecurity compared to adults with no history of cancer (87.0% vs. 64.1%, p=0.001). In multivariable models, uninsured cancer survivors (adjusted prevalence ratio [aPR] aPR: 2.39, 95% CI: 1.46-3.92) and those on Medicaid (aPR: 2.10, 95% CI: 1.40-3.17) were also more likely to report being food insecure. Conclusion: Food insecurity during the COVID-19 pandemic is vast, but disparities persist. Among cancer survivors, differences in food insecurity were observed by age and socio economic status. Cancer survivors experiencing food insecurity more frequently reported mental health symptoms of depression, loneliness, and hopelessness compared to those who were food secure.

Moving from Policy to Practice for Early Childhood Obesity Prevention: A Nationwide Evaluation of State Implementation Strategies in Childcare.

Policies requiring childcare settings to promote healthy eating, physical activity, and limited screentime have the potential to improve young children's health. However, policies may have limited impact without effective implementation strategies to promote policy adoption. In this mixed-methods study, we evaluated the type, quality, and dose of implementation strategies for state-level childcare licensing regulations focused on healthy eating, physical activity, or screentime using: (1) a survey of state licensing staff and technical assistance providers (n = 89) in 32 states; (2) a structured review of each state's childcare licensing and training websites for childcare providers; and (3) in-depth, semi-structured interviews with 31 childcare licensing administrators and technical assistance providers across 17 states. Implementation strategies for supporting childcare providers in adopting healthy eating, physical activity, and screentime regulations vary substantially by state, in quantity and structure. Childcare programs' financial challenges, staff turnover, and lack of adequate facilities were identified as key barriers to adoption. Access to federal food programs was seen as critical to implementing nutrition regulations. Implementation resources such as training and informational materials were rarely available in multiple languages or targeted to providers serving low-income or racially/ethnically diverse families. There is a substantial need for implementation supports for ensuring policies are successfully and equitably implemented in childcare.

Recommendations for Using Causal Diagrams to Study Racial Health Disparities.

There have been calls for race to be denounced as a biological variable and for a greater focus on racism, instead of solely race, when studying racial health disparities in the United States. These calls are grounded in extensive scholarship and the rationale that race is not a biological variable, but instead socially constructed, and that structural/institutional racism is a root cause of race-related health disparities. However, there remains a lack of clear guidance for how best to incorporate these assertions about race and racism into tools, such as causal diagrams, that are commonly used by epidemiologists to study population health. We provide clear recommendations for using causal diagrams to study racial health disparities that were informed by these calls. These recommendations consider a health disparity to be a difference in a health outcome that is related to social, environmental, or economic disadvantage. We present simplified causal diagrams to illustrate how to implement our recommendations. These diagrams can be modified based on the health outcome and hypotheses, or for other group-based differences in health also rooted in disadvantage (e.g., gender). Implementing our recommendations may lead to the publication of more rigorous and informative studies of racial health disparities.

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.

Developing the Florida Academic Cancer Center Alliance Health Disparities Common Measure: The Florida Health and Ancestry Survey.

PURPOSE: Our specific aim was to develop and assess the consensus-based validity of common measures for understanding health behaviors and ancestry in Florida's population subgroups and establish the feasibility of wide-scale implementation of the measures and biospecimen collection within three cancer centers' catchment areas. METHODS: Using the National Cancer Institute's Grid-Enabled Measures web-based platform and an iterative process, we developed the Florida Health and Ancestry Survey (FHAS). We then used three sampling approaches to implement the FHAS: community-engaged, panel respondent, and random digit dialing (RDD). We asked a subset of participants to provide a saliva sample for future validation of subjective ancestry report with DNA-derived ancestry markers. RESULTS: This process supported the FHAS content validity. As an indicator of feasibility, the goals for completed surveys by sampling approach were met for two of the three cancer centers, yielding a total of 1438 completed surveys. The RDD approach produced the most representative sample. The panel sampling approach produced inadequate representation of older individuals and males. The community-engaged approach along with social media recruitment produced extreme underrepresentation only for males. Two of the cancer centers mailed biospecimen kits, whereas one did not due to resource constraints. On average, the community engaged approach was more productive in obtaining returned biospecimen samples (80%) than the panel approach (48%). CONCLUSIONS: We successfully developed and implemented the FHAS as a common measure to show its feasibility for understanding cancer health disparities in Florida. We identified sampling approach successes and challenges to obtaining biospecimens for ancestry research.

Carceral epidemiology: mass incarceration and structural racism during the COVID-19 pandemic.

The COVID-19 pandemic and the ongoing epidemic of mass incarceration are closely intertwined, as COVID-19 entered US prisons and jails at astounding rates. Although observers warned of the swiftness with which COVID-19 could devastate people who are held and work in prisons and jails, their warnings were not heeded quickly enough. Incarcerated populations were deprioritised, and COVID-19 infected and killed those in jails and prisons at rates that outpaced the rates among the general population. The COVID-19 pandemic highlighted what has been long-known: mass incarceration is a key component of structural racism that creates and exacerbates health inequities. It is imperative that the public health, particularly epidemiology, public policy, advocacy, and medical communities, are catalysed by the COVID-19 pandemic to drastically rethink the USA's criminal legal system and the public health emergency that it has created and to push for progressive reform.

Resident Experiences With a Place-Based Collaboration to Address Health and Social Inequities: A Survey of Visitors to the East Harlem Neighborhood Health Action Center.

In 2016 and 2017, the New York City Department of Health and Mental Hygiene established Neighborhood Health Action Centers (Action Centers) in disinvested communities of color as part of a place-based model to advance health equity. This model includes co-located partners, a referral and linkage system, and community space and programming. In 2018, we surveyed visitors to the East Harlem Action Center to provide a more comprehensive understanding of visitors' experiences. The survey was administered in English, Spanish, and Mandarin. Respondents were racially diverse and predominantly residents of East Harlem. The majority had been to the East Harlem Action Center previously. Most agreed that the main service provider for their visit made them feel comfortable, treated them with respect, spoke in a way that was easy to understand, and that they received the highest quality of service. A little more than half of returning visitors reported engaging with more than one Action Center program in the last 6 months. Twenty-one percent of respondents reported receiving at least one referral at the Action Center. Two thirds were aware that the Action Center offered a number of programs and services and half were aware that referrals were available. Additional visits to the Action Center were associated with increased likelihood of engaging with more than one program and awareness of the availability of programs and referral services. Findings suggest that most visitors surveyed had positive experiences, and more can be done to promote the Action Center and the variety of services it offers.

Structural Racism and Breast Cancer-specific Survival: Impact of Economic and Racial Residential Segregation.

OBJECTIVE: To analyze the effect of economic and racial/ethnic residential segregation on breast cancer-specific survival (BCSS) in South Florida, a diverse metropolitan area that mirrors the projected demographics of many United States regions. SUMMARY BACKGROUND DATA: Despite advances in diagnosis and treatment, racial and economic disparities in BCSS. This study evaluates these disparities through the lens of racial and economic residential segregation, which approximate the impact of structural racism. METHODS: Retrospective cohort study of stage I to IV breast cancer patients treated at our institution from 2005 to 2017. Our exposures include index of concentration at the extremes, a measurement of economic and racial neighborhood segregation, which was computed at the census-tract level using American Community Survey data. The primary outcome was BCSS. RESULTS: Random effects frailty models predicted that patients living in low-income neighborhoods had higher mortality compared to those living in high-income neighborhoods [hazard ratios (HR): 1.56, 95% confidence interval (CI): 1.23-2.00]. Patients living in low-income non-Hispanic Black and Hispanic neighborhoods had higher mortality compared to those living in high-income non-Hispanic White (NHW) neighborhoods (HR: 2.43, 95%CI: 1.72, 3.43) and (HR: 1.99, 95%CI: 1.39, 2.84), after controlling for patient characteristics, respectively. In adjusted race-stratified analysis, NHWs living in low-income non-Hispanic Black neighborhoods had higher mortality compared to NHWs living in high-income NHW neighborhoods (HR: 4.09, 95%CI: 2.34-7.06). CONCLUSIONS: Extreme racial/ethnic and economic segregation were associated with lower BCSS. We add novel insight regarding NHW and Hispanics to a growing body of literature that demonstrate how the ecological effects of structural racism-expressed through poverty and residential segregation-shape cancer survival.

Measuring Structural Racism: A Guide for Epidemiologists and Other Health Researchers.

There have been over 100 years of literature discussing the deleterious influence of racism on health. Much of the literature describes racism as a driver of social determinants of health, such as housing, employment, income, and education. More recently, increased attention has been given to measuring the structural nature of a system that advantages one racialized group over others rather than solely relying on individual acknowledgement of racism. Despite these advances, there is still a need for methodological and analytical approaches to complement the aforementioned. This commentary calls on epidemiologists and other health researchers at large to engage the discourse on measuring structural racism. First, we address the conflation between race and racism in epidemiologic research. Next, we offer methodological recommendations (linking of interdisciplinary variables and data sets and leveraging mixed-method and life-course approaches) and analytical recommendations (integration of mixed data, use of multidimensional models) that epidemiologists and other health researchers may consider in health equity research. The goal of this commentary is to inspire the use of up-to-date and theoretically driven approaches to increase discourse among public health researchers on capturing racism as well as to improve evidence of its role as the fundamental cause of racial health inequities.