Perceptions of Racial-Ethnic Inequities in COVID-19 Healthcare and Willingness to Receive the COVID-19 Vaccine.

BACKGROUND: Perceptions of the US healthcare system can impact individuals' healthcare utilization, including vaccination intentions. This study examined the association between perceived racial-ethnic inequities in COVID-19 healthcare and willingness to receive the COVID-19 vaccine. METHODS: This study used data from REACH-US, a nationally representative online survey of a large, diverse sample of U.S. adults (N=5145 January 26, 2021-March 3, 2021). Confirmatory factor and regression analyses examined a latent factor of perceived racial-ethnic inequities in COVID-19 healthcare, whether the factor was associated with willingness to receive the COVID-19 vaccine, and whether associations varied across racial-ethnic groups reported as probit estimates (B) and 95% confidence intervals (CIs). RESULTS: Perceived racial-ethnic inequities in COVID-19 healthcare were highest among Black/African American adults (mean latent factor score: 0.65 ± 0.43) and lowest among White adults (mean latent factor score: 0.04 ± 0.67). Black/African American (B = -0.08; 95% CI = -0.19, 0.03) and Native Hawaiian/Pacific Islander (B = -0.08; 95% CI = -0.23, 0.07) adults who perceived greater racial-ethnic inequities in COVID-19 healthcare were less willing than participants who perceived lower inequities. In contrast, American Indian/Alaska Native (B = 0.15; 95% CI = -0.01, 0.30), Asian (B = 0.20; 95% CI = 0.08, 0.31), Hispanic/Latino (English language preference) (B = 0.22; 95% CI = 0.01, 0.43), Multiracial (B = 0.23; 95% CI = 0.09, 0.36), and White (B = 0.31; 95% CI = 0.19, 0.43) adults who perceived greater racial-ethnic inequities in COVID-19 healthcare were more willing to receive the COVID-19 vaccine than participants perceiving higher inequities. CONCLUSIONS: Greater perceived racial-ethnic inequities in COVID-19 healthcare were associated with less willingness to receive the COVID-19 vaccine among Black/African American and Native Hawaiian/Pacific Islander adults.

Multimorbidity trajectories in early adulthood and middle age: Findings from the CARDIA prospective cohort study.

Background: Multimorbidity research has focused on the prevalence and consequences of multimorbidity in older populations. Less is known about the accumulation of chronic conditions earlier in the life course. Methods: We identified patterns of longitudinal multimorbidity accumulation using 30 years of data from in-person exams, annual follow-ups, and adjudicated end-points among 4,945 participants of the Coronary Artery Risk Development in Young Adults (CARDIA) study. Chronic conditions included arthritis, asthma, atrial fibrillation, cancer, end stage renal disease, chronic obstructive pulmonary disease, coronary heart disease, diabetes, heart failure, hyperlipidemia, hypertension, and stroke. Trajectory patterns were identified using latent class growth curve models. Results: Mean age (SD) at baseline (1985-6) was 24.9 (3.6), 55% were female, and 51% were Black. The median follow-up was 30 years (interquartile range 25-30). We identified six trajectory classes characterized by when conditions began to accumulate and the rapidity of accumulation: (1) early-fifties, slow, (2) mid-forties, fast, (3) mid-thirties, fast, (4) late-twenties, slow, (5) mid-twenties, slow, and (6) mid-twenties, fast. Compared with participants in the early-fifties, slow trajectory class, participants in mid-twenties, fast were more likely to be female, Black, and currently smoking and had a higher baseline mean waist circumference (83.6 vs. 75.6 cm) and BMI (27.0 vs. 23.4 kg/m2) and lower baseline physical activity (414.1 vs. 442.4 exercise units). Conclusions: A life course approach that recognizes the heterogeneity in patterns of accumulation of chronic conditions from early adulthood into middle age could be helpful for identifying high risk subgroups and developing approaches to delay multimorbidity progression.

Structural Racism and Health Stratification: Connecting Theory to Measurement.

Less than 1% of studies on racialized health inequities have empirically examined their root cause: structural racism. Moreover, there has been a disconnect between the conceptualization and measurement of structural racism. This study advances the field by (1) distilling central tenets of theories of structural racism to inform measurement approaches, (2) conceptualizing U.S. states as racializing institutional actors shaping health, (3) developing a novel latent measure of structural racism in states, (4) using multilevel models to quantify the association between structural racism and five individual-level health outcomes among respondents from the Health and Retirement Study (N = 9,020) and the Behavioral Risk Factor Surveillance System (N = 308,029), and (5) making our measure of structural racism publicly available to catalyze research. Results show that structural racism is consistently associated with worse health for Black people but not White people. We conclude by highlighting this study's contributions (theoretical, methodological, and substantive) and important avenues for future research on the topic.

Association of educational attainment with cancer mortality in a national cohort study of black and white adults: A mediation analysis.

Background: Low educational attainment is associated with excess cancer mortality. However, the mechanisms driving this association remain unknown. Methods: Using data from the REasons for Geographic and Racial Differences in Stroke (REGARDS) study, we evaluated the associations of participant and parental/caregiver education with cancer mortality using Cox proportional hazards models, adjusting for socio-demographic characteristics and health conditions. We used principal components analysis to generate indices of measures representing the social determinants of health (SDOH) and health behaviors. We used structural equation modeling to determine if the association between educational attainment and cancer mortality was mediated by these domains. Results: Among 30,177 REGARDS participants included in this analysis, 3798 (12.6%) had less than a high school degree. In fully adjusted models, those without a high school education experienced about 50% greater risk of death than high school graduates and higher (White participants HR: 1.47; 95% CI: 1.23, 1.76 and Black HR: 1.54; 95% CI: 1.33, 1.79). There was evidence of a modest mediation effect for the association between education and cancer mortality by the SDOH domain score (White total effect HR: 1.25; 95% CI: 1.18, 1.33, indirect effect HR: 1.04; 95% CI: 1.03, 1.05, direct effect HR: 1.21; 95% CI: 1.14, 1.28 and Black total effect HR: 1.24; 95% CI: 1.18, 1.29, indirect effect HR: 1.04; 95% CI: 1.03, 1.05, direct effect HR: 1.19; 95% CI: 1.14, 1.24). There was no evidence of mediation by the health behaviors score. No significant associations were found for female caregiver/mother's or male caregiver/father's education (N = 13,209). Conclusions: In conclusion, participant education was strongly associated with cancer mortality, and this association was partially mediated by the SDOH domain score.

Racialized Health Inequities: Quantifying Socioeconomic and Stress Pathways Using Moderated Mediation.

Racism drives population health inequities by shaping the unequal distribution of key social determinants of health, such as socioeconomic resources and exposure to stressors. Research on interrelationships among race, socioeconomic resources, stressors, and health has proceeded along two lines that have largely remained separate: one examining differential effects of socioeconomic resources and stressors on health across racialized groups (moderation processes), and the other examining the role of socioeconomic resources and stressors in contributing to racial inequities in health (mediation processes). We conceptually and analytically integrate these areas using race theory and a novel moderated mediation approach to path analysis to formally quantify the extent to which an array of socioeconomic resources and stressors-collectively and individually-mediate racialized health inequities among a sample of older adults from the Health and Retirement Study. Our results yield theoretical contributions by showing how the socioeconomic status-health gradient and stress processes are racialized (24% of associations examined varied by race), substantive contributions by quantifying the extent of moderated mediation of racial inequities (approximately 70%) and the relative importance of various social factors, and methodological contributions by showing how commonly used simple mediation approaches that ignore racialized moderation processes overestimate-by between 5% and 30%-the collective roles of socioeconomic status and stressors in accounting for racial inequities in health.

How Social Roles Affect Sleep Health during Midlife.

This study draws on role theory and the life course perspective to examine how sleep health (duration, quality, and latency) is shaped by social role accumulation (number of roles), role repertoires (role combinations), and role contexts among middle-aged adults. We also examine how the relationships between social roles and sleep health are gendered. We use data from the National Longitudinal Survey of Youth 1979 Cohort (N = 7,628). Results show that role accumulation is associated with less sleep and decreased insomnia symptoms, and that role repertoires also impact sleep (e.g., parenthood leads to diminished sleep quantity and quality). There is also evidence that contextual factors related to employment history, marital quality, and parenthood affect sleep health. Furthermore, results reveal that several of the relationships between social roles and sleep are gendered. Taken together, findings demonstrate the utility of examining links between multiple dimensions of social roles and sleep health.

The Future of Social Determinants of Health: Looking Upstream to Structural Drivers.

Policy Points Policies that redress oppressive social, economic, and political conditions are essential for improving population health and achieving health equity. Efforts to remedy structural oppression and its deleterious effects should account for its multilevel, multifaceted, interconnected, systemic, and intersectional nature. The U.S. Department of Health and Human Services should facilitate the creation and maintenance of a national publicly available, user-friendly data infrastructure on contextual measures of structural oppression. Publicly funded research on social determinants of health should be mandated to (a) analyze health inequities in relation to relevant data on structural conditions and (b) deposit the data in the publicly available data repository.

Racial inequality in functional trajectories between Black and White U.S. veterans.

BACKGROUND: Racial inequality in functional trajectories has been well documented in the U.S. civilian population but has not been explored among Veterans. Our objectives were to: (1) assess how functional trajectories differed for Black and White Veterans aged ≥50 and (2) explore how socioeconomic, psychosocial, and health-related factors altered the relationship between race and function. METHODS: We conducted a prospective, longitudinal analysis using the 2006-2016 Health and Retirement Study. The study cohort included 3700 Veterans who self-identified as Black or White, responded to baseline psychosocial questionnaires, and were community-dwelling on first observation. We used stepwise and stratified linear mixed effects models of biannually assessed functional limitations. The outcome measure was as a count of functional limitations. Race was measured as respondent self-identification as Black or White. Demographic measures included gender and age. Socioeconomic resources included partnership status, education, income, and wealth. Psychosocial stressors included exposure to day-to-day and major discrimination, traumatic life events, stressful life events, and financial strain. Health measures included chronic and mental health diagnoses, smoking, rurality, and use of Veterans Affairs services. RESULTS: Black Veterans developed functional limitations at earlier ages and experienced faster functional decline than White Veterans between the ages of 50 and 70, with convergence occurring at age 85. Once we accounted for economic resources and psychosocial stressors in multivariable analyses, the association between race and the number of functional limitations was no longer statistically significant. Lower wealth, greater financial strain, and traumatic life events were significantly associated with functional decline. CONCLUSIONS: Health systems should consider how to track Veterans' function earlier in the life course to ensure that Black Veterans are able to get timely access to services that may slow premature functional decline. Providers may benefit from training about the role of economic resources and psychosocial stressors in physical health outcomes.

Attribution for everyday discrimination typologies and mortality risk among older black adults: Evidence from the health and retirement study?

BACKGROUND: The present study assessed how attributions of everyday discrimination typologies relate to all-cause mortality risk among older Black adults. METHODS: This study utilized data from a subsample of older Black adults from the 2006/2008 Health and Retirement Study (HRS). Attributions for everyday discrimination (i.e., ancestry, age, gender, race, physical appearance, physical disability, sexual orientation, weight, and other factors) were based on self-reports, while their vital statuses were obtained from the National Death Index and reports from key informants (spanning 2006-2019). We applied latent class analysis (LCA) to identify subgroups of older Black adults based on their attributions to everyday discrimination. Cox proportional hazards models were used to analyze time to death as a function of LCA group membership and other covariates. RESULTS: Based on fit statistics, we selected a four-class model that places respondents into one of the following classes: Class One (7%) attributed everyday discrimination to age, race, and physical disability; Class Two (72%) attributed everyday discrimination to few/no sources, Class Three (19%) attributed everyday discrimination to race and national origin; and Class Four (2%) attributed everyday discrimination to almost every reason. After adjusting for sociodemographic, behavioral, multisystem physiological dysregulation, and socioeconomic characteristics, we found that the relative risk of death remained higher for the respondents in Class One (Hazard Ratio [H.R.]: 1.80, 95% Confidence Interval [C.I.]: (1.09-2.98) and Class Four (H.R.: 3.92, 95% C.I.: 1.62-9.49) compared to respondents in Class Two. CONCLUSIONS: Our findings illustrate the utility of using attribution for everyday discrimination typologies in research on the psychosocial dimensions of mortality risk among older Black adults. Future research should assess the mechanisms that undergird the link between everyday discrimination classes and all-cause mortality risk among older Black adults.

Corrigendum to "Overcrowding and COVID-19 mortality across U.S. counties: Are disparities growing over time?" [SSM-Population Health 15 (2021) 100845].

[This corrects the article DOI: 10.1016/j.ssmph.2021.100845.].

Empirical evidence on structural racism as a driver of racial inequities in COVID-19 mortality.

Objective: This study contributes to the literature by empirically testing the extent to which place-based structural racism is a driver of state-level racial inequalities in COVID-19 mortality using theoretically-informed, innovative approaches. Methods: CDC data are used to measure cumulative COVID-19 death rates between January 2020 and August 2022. The outcome measure is a state-level Black-White (B/W) ratio of age-adjusted death rates. We use state-level 2019 administrative data on previously validated indicators of structural racism spanning educational, economic, political, criminal-legal and housing to identify a novel, multi-sectoral latent measure of structural racism (CFI = 0.982, TLI = 0.968, and RMSEA = 0.044). We map B/W inequalities in COVID-19 mortality as well as the latent measure of structural racism in order to understand their geographic distribution across U.S. states. Finally, we use regression analyses to estimate the extent to which structural racism contributes to Black-White inequalities in COVID-19 mortality, net of potential confounders. Results: Results reveal substantial state-level variation in the B/W ratio of COVID-19 death rates and structural racism. Notably, regression estimates indicate that the relationship between the structural racism and B/W inequality in COVID-19 mortality is positive and statistically significant (p < 0.001), both in the bivariate model (adjusted R2 = 0.37) and net of the covariates (adjusted R2 = 0.54). For example, whereas states with a structural racism value 2 standard deviation below the mean have a B/W ratio of approximately 1.12, states with a structural racism value 2 standard deviation above the mean have a ratio of just above 2.0. Discussion: Findings suggest that efficacious health equity solutions will require bold policies that dismantle structural racism across numerous societal domains.

A Ru(II)-arene-ferrocene complex with promising antibacterial activity.

The evolution of high virulence bacterial strains has necessitated the development of novel therapeutic agents to treat resistant infections. Metal-based therapeutics represent a promising avenue for advancement, given their structural variability and unique modes of action relative to classical organic molecules. One strategy that has seen marked success is the incorporation of ferrocene into the framework of established antibacterial agents, while ruthenium-based complexes have also shown promise as bioactive compounds. This work focused on the preparation of novel ruthenium(II)-arene complexes containing Schiff base ligands with an attached ferrocene, and evaluation of their antibacterial activity. Structure-activity relationships identified the importance of having a phenyl group between the Schiff base imine and the appended ferrocene. This complex, C2, showed prominent activity against several clinically relevant bacterial strains, including a minimum inhibitory concentration of 16 µg mL-1 for methicillin-resistant Staphylococcus aureus (MSRA). Overall, the results of this study represent a promising new lead for future development of novel antibacterial agents.

Work-Related Stress, Psychosocial Resources, and Insomnia Symptoms Among Older Black Workers.

Objectives: To examine the association between work-related stress (job lock and job stress appraisal) and insomnia symptoms among older Black workers, as well as the extent to which psychosocial resources (mastery, social support, and religious involvement) mediate or moderate this association. Methods: This study uses Ordinary Least Squares regression analysis and data from the Health and Retirement Study (HRS) on Black workers aged 51 and older (N = 924). Results: Job lock due to financial reasons and job stress appraisal are associated with increased insomnia symptoms among older Black workers. Religious attendance buffers the harmful effects of financial job lock on sleep quality, while religiosity exacerbates the effects of job stress on insomnia symptoms. Discussion: Taken together, findings underscore the utility of the Stress Process Model for understanding diverse stress and sleep experiences in later life. Furthermore, findings have the potential to inform efficacious policies for reducing work-related stress and mitigating its harmful consequences.

Improving The Measurement Of Structural Racism To Achieve Antiracist Health Policy.

Antiracist health policy research requires methodological innovation that creates equity-centered and antiracist solutions to health inequities by centering the complexities and insidiousness of structural racism. The development of effective health policy and health equity interventions requires sound empirical characterization of the nature of structural racism and its impact on public health. However, there is a disconnect between the conceptualization and measurement of structural racism in the public health literature. Given that structural racism is a system of interconnected institutions that operates with a set of racialized rules that maintain White supremacy, how can anyone accurately measure its insidiousness? This article highlights methodological approaches that will move the field forward in its ability to validly measure structural racism for the purposes of achieving health equity. We identify three key areas that require scholarly attention to advance antiracist health policy research: historical context, geographical context, and theory-based novel quantitative and qualitative methods that capture the multifaceted and systemic properties of structural racism as well as other systems of oppression.

Sick And Tired Of Being Excluded: Structural Racism In Disenfranchisement As A Threat To Population Health Equity.

Theoretical research suggests that racialized felony disenfranchisement-a form of structural racism-is likely to undermine the health of Black people, yet empirical studies on the topic are scant. We used administrative data on disproportionate felony disenfranchisement of Black residents across US states, linked to geocoded individual-level health data from the 2016 Health and Retirement Study, to estimate race-specific regression models describing the relationship between racialized disenfranchisement and health among middle-aged and older adults, adjusting for other individual- and state-level factors. Results show that living in states with higher levels of racialized disenfranchisement is associated with more depressive symptoms, more functional limitations, more difficulty performing instrumental activities of daily living, and more difficulty performing activities of daily living among Black people. However, there are no statistically significant relationships between racialized disenfranchisement and health among White people. These findings suggest that policies aiming to mitigate disproportionate Black felony disenfranchisement not only are essential for political inclusion but also may be valuable tools for improving population health equity.

Kinome Analysis of Cattle Peripheral Lymph Nodes to Elucidate Differential Response to Salmonella spp.

Salmonella spp., contained within the peripheral lymph nodes (PLNs) of cattle, represents a significant source of contamination of ground beef. Herein is the first report where species-specific kinome peptide arrays designed for bovine biology were used to further the understanding of Salmonella spp. within these PLNs. For the purpose of this research, multiple comparisons of sub-iliac lymph nodes were made to include nodes from feedlot cattle that were infected with Salmonella spp. to those that were non-infected; seasonal differences in feedlot cattle harvested in either August or January; cull dairy cows compared to feedlot cattle; and PLNs from cattle experimentally inoculated with Salmonella spp. versus naturally infected animals. The first comparison of Salmonella-positive and -negative PLNs found that considering the kinotypes for these animals, the major distinguishing difference was not the presence or absence of Salmonella spp. in the PLNs but the concentration. Further, the majority of pathways activated were directly related to immune responses including innate immunity, thus Salmonella spp. within the PLNs activates the immune system in that node. Results from the comparison of feedlot cattle and cull dairy cows suggests that a Salmonella spp.-negative animal, regardless of type, has a more consistent kinome profile than that of a Salmonella spp.-positive animal and that the differences between feedlot and cull dairy cattle are only pronounced when the PLNs are Salmonella spp. positive. PLNs collected in the winter showed a much more consistent kinome profile, regardless of Salmonella status, suggesting that in the winter these cattle are similar, and this is not affected by the presence of Salmonella spp., whereas significant variability among kinotypes was observed for PLNs collected in the summer. The most distinct clustering of kinotypes observed in this study was related to how the animal was infected with Salmonella spp. There were significant differences in the phosphorylation state of the immune response peptides between experimentally and naturally infected animals, suggesting that the immune system is activated in a significantly different manner when comparing these routes of infection. Increasing our understanding of Salmonella spp. within cattle, and specifically within the PLNs, will ultimately help design effective pre-harvest intervention strategies as well as appropriate experimentation to validate those technologies.

Prevalence, severity and distribution of depression and anxiety symptoms using observational data collected before and nine months into the COVID-19 pandemic.

BACKGROUND: The COVID-19 pandemic has been accompanied by substantial increases in adverse mental health, particularly among the young. However, it remains unclear to what extent increases in population scores on mental health assessments are due to changes in prevalence, rather than severity of symptoms. Further, it is not obvious that widely used assessments of aggregate symptoms retain their typical interpretation during an event that directly disrupts behavior. METHODS: Pre-pandemic data on workers age 18-69y in the 2019 National Health Interview Survey are reweighted to match distributions of demographic characteristics of Duke University employees surveyed nine months into the pandemic. The latter population was at low risk of infection or economic insecurity. Prevalence, severity, and scores for each of nine symptoms are compared overall and by age group. OUTCOMES: Elevated psychological distress is primarily driven by increases in prevalence of particular symptoms. Prevalence of trouble concentrating increased six-fold from 9.6% to 72.5%. Other symptoms increased by over one-third; feeling anxious, having little interest, feeling depressed, sleep problems and being irritable, while some symptoms rose only 10% or less. Severity also increased but magnitudes are small relative to prevalence changes. Escalation in prevalence and severity are greatest for the youngest. INTERPRETATION: Some of the least prevalent symptoms pre-pandemic became the most prevalent during the pandemic, affecting interpretation of indices validated pre-pandemic. Clinical and policy interventions should focus on specific symptoms that increased including trouble concentrating and anxiety. FUNDING: Trinity College of Arts & Sciences and Social Science Research Institute at Duke University.

Structural Intersectionality as a New Direction for Health Disparities Research.

This article advances the field by integrating insights from intersectionality perspectives with the emerging literatures on structural racism and structural sexism-which point to promising new ways to measure systems of inequality at a macro level-to introduce a structural intersectionality approach to population health. We demonstrate an application of structural intersectionality using administrative data representing macrolevel structural racism, structural sexism, and income inequality in U.S. states linked to individual data from the Behavioral Risk Factor Surveillance System to estimate multilevel models (N = 420,644 individuals nested in 76 state-years) investigating how intersecting dimensions of structural oppression shape health. Analyses show that these structural inequalities: (1) vary considerably across U.S. states, (2) intersect in numerous ways but do not strongly or positively covary, (3) individually and jointly shape health, and (4) are most consistently associated with poor health for black women. We conclude by outlining an agenda for future research on structural intersectionality and health.

Overcrowding and COVID-19 mortality across U.S. counties: Are disparities growing over time?

A growing line of research underscores that sociodemographic factors may contribute to disparities in the impact of COVID-19. Further, stages of disease theory suggests that disparities may grow as the pandemic unfolds and more advantaged areas are better able to apply growing knowledge and mitigation strategies. In this paper, we focus on the role of county-level household overcrowding on disparities in COVID-19 mortality in U.S. counties. We examine this relationship across three theoretically important periods of the pandemic from April-October 2020, that mark both separate stages of community knowledge and national mortality levels. We find evidence that the percentage of overcrowded households is a stronger predictor of COVID-19 mortality during later periods of the pandemic. Moreover, despite a relationship between overcrowding and poverty at the county-level, overcrowding plays an independent role in predicting COVID-19 mortality. Our findings underscore that areas disadvantaged by overcrowding may be more vulnerable to the effects of COVID-19 and that this vulnerability may lead to changing disparities over time.