Latino-White Disparities in Identification and Control of Elevated Blood Pressure Among Adults With Hypertension.

BACKGROUND: Studies analyzing blood pressure (BP) management using the hypertension control cascade have consistently shown disparities in hypertension awareness, treatment, and BP control between Latino patients and non-Latino White patients. We analyze this cascade using electronic health record data from a multistate network of community health centers. METHODS AND RESULTS: Data from 790 clinics in 23 US states from 2012 to 2020, including 1 270 174 patients, were analyzed to compare BP documentation in the electronic health record, clinician acknowledgment (diagnosis or treatment) of incident hypertension (BP ≥140/90), medication prescription, and BP control between non-Latino White patients, English-preferring Latino patients, and Spanish-preferring Latino patients, adjusted for patient-level covariates, and clustered on patients' primary clinics. Among the 429 182 patients with elevated BP (≥140/90) during ambulatory visits from 2012 to 2020, we found that clinician acknowledgment of hypertension was more likely in Spanish-preferring and English-preferring Latino patients versus non-Latino White patients (adjusted odds ratio [aOR], 1.17 [95% CI, 1.11-1.24]; aOR, 1.07 [95% CI, 1.02-1.12], respectively). In addition, Spanish-preferring Latino patients were more likely to receive a medication versus non-Latino White patients (aOR, 1.21 [95% CI, 1.16-1.28]). Among those receiving medication, Latino patients were as likely as non-Latino White patients to have their BP controlled (<140/90). CONCLUSIONS: In a large retrospective study of community health center patients with incident hypertension, the expected disparities in hypertension management between Spanish-preferring Latino, English-preferring Latino, and non-Latino White patients were not identified. These findings add to the hypertension control cascade by examining robust electronic health record data from community health centers and may provide clues to reducing disparities in hypertension management.

Policy solutions to eliminate racial and ethnic child health disparities in the USA.

Societal systems act individually and in combination to create and perpetuate structural racism through both policies and practices at the local, state, and federal levels, which, in turn, generate racial and ethnic health disparities. Both current and historical policy approaches across multiple sectors-including housing, employment, health insurance, immigration, and criminal legal-have the potential to affect child health equity. Such policies must be considered with a focus on structural racism to understand which have the potential to eliminate or at least attenuate disparities. Policy efforts that do not directly address structural racism will not achieve equity and instead worsen gaps and existing disparities in access and quality-thereby continuing to perpetuate a two-tier system dictated by racism. In Paper 2 of this Series, we build on Paper 1's summary of existing disparities in health-care delivery and highlight policies within multiple sectors that can be modified and supported to improve health equity, and, in so doing, improve the health of racially and ethnically minoritised children.

Region of origin and cervical cancer stage in multiethnic Hispanic/Latinx patients living in the United States.

BACKGROUND: Hispanic/Latinx people have the second highest cervical cancer incidence rates in the U.S. However, there is a lack of disaggregated data on clinical outcomes for this diverse and populous group, which is critical to direct resources and funding where they are most needed. This study assessed differences in stage at diagnosis of cervical cancer among Hispanic/Latinx subpopulations and associated factors. METHODS: We analyzed patients with primary cervical cancer from 2004 to 2019 in the National Cancer Database. Hispanic/Latinx patients were further categorized into Mexican, Puerto Rican (PR), Cuban, Dominican, and Central/South American, as per standard NCDB categories, and evaluated based on stage at diagnosis and sociodemographic characteristics. Multinomial logistic regression quantified the odds of advanced stage at presentation. Regression models were adjusted for age, education, neighborhood income, insurance status, and additional factors. RESULTS: Hispanic/Latinx cervical cancer patients were more likely to be uninsured (18.9% vs. 6.0%, p < 0.001) and more likely to live in low-income neighborhoods (28.6% vs. 16.9%, p < 0.001) when compared to non-Hispanic White populations. Uninsured Hispanic/Latinx patients had 37.0% higher odds of presenting with regional versus localized disease (OR 1.37; 95% CI, 1.19-1.58) and 47.0% higher odds of presenting with distant versus. Localized disease than insured patients (OR 1.47; 95% CI, 1.33-1.62). When adjusting for age, education, neighborhood income, and insurance status, PR patients were 48% more likely than Mexican patients to present with stage IV versus stage I disease (OR 1.48; 95% CI, 1.34-1.64). CONCLUSION: Disaggregating health data revealed differences in stage at cervical cancer presentation among Hispanic/Latinx subpopulations, with insurance status as a major predictor. Further work targeting structural factors, such as insurance status, within specific Hispanic/Latinx subpopulations is needed.

Facing a dual threat: Pandemic stress and immigration policy vulnerability on mental health among Latinx immigrant parents.

BACKGROUND: Exclusionary immigration policies rooted in structural racism threaten the wellbeing of Latinx families, increasing stress, anxiety, depression, and distress among immigrant parents. The COVID-19 pandemic has had devastating and disproportionate impacts on communities of color with unique impacts on Latinx immigrant parents in mixed-status families. AIMS: From a syndemic theory lens, we explored the convergence of structural racism and the COVID-19 pandemic to explore if the stress of the COVID-19 pandemic may compound harmful immigration-related policies. METHODS: Our community-based participatory research cross-sectional study administered 145 surveys among Latinx immigrant parents in mixed-status families in Georgia. We examined the relationship of pandemic stress and perceived statewide immigration policy vulnerability to depressive, anxiety, and PTSD symptoms. We conducted multiple linear regression analyses to test these relationships and their interaction. RESULTS: We found that that greater perceived policy immigration vulnerability and reported pandemic stress were associated with higher symptoms of depression. Increased PTSD symptoms were also associated with immigration policy vulnerability, but not pandemic stress. Tests to assess if pandemic stress strengthened the relationship between policy vulnerability on depressive, anxiety, and PTSD symptoms revealed no statistically significant interactions. CONCLUSION: Our findings suggest that stress of the COVID-19 pandemic and longstanding anti-immigrant policies in Georgia were salient for and related to the mental health of these Latinx immigrant parents.

Inequities in referrals to a breast cancer risk assessment and prevention clinic: a mixed methods study.

BACKGROUND: Inequitable access to personalized breast cancer screening and prevention may compound racial and ethnic disparities in outcomes. The Breast Cancer Personalized Risk Assessment, Education and Prevention (B-PREP) program, located within the Brigham and Women's Hospital (BWH) Comprehensive Breast Health Center (BHC), provides care to patients at high risk for developing breast cancer. We sought to characterize the differences between BWH primary care patients referred specifically to B-PREP for risk evaluation and those referred to the BHC for benign breast conditions. Through interviews with primary care clinicians, we sought to explore contributors to potentially inequitable B-PREP referral patterns. METHODS: We used electronic health record data and the B-PREP clinical database to identify patients referred by primary care clinicians to the BHC or B-PREP between 2017 and 2020. We examined associations with likelihood of referral to B-PREP for risk assessment. Semi-structured interviews were conducted with nine primary care clinicians from six clinics to explore referral patterns. RESULTS: Of 1789 patients, 78.0% were referred for benign breast conditions, and 21.5% for risk assessment. In multivariable analyses, Black individuals were less likely to be referred for risk than for benign conditions (OR 0.38, 95% CI:0.23-0.63) as were those with Medicaid/Medicare (OR 0.72, 95% CI:0.53-0.98; OR 0.52, 95% CI:0.27-0.99) and those whose preferred language was not English (OR 0.26, 95% CI:0.12-0.57). Interviewed clinicians described inconsistent approaches to risk assessment and variable B-PREP awareness. CONCLUSIONS: In this single-site evaluation, among individuals referred by primary care clinicians for specialized breast care, Black, publicly-insured patients, and those whose preferred language was not English were less likely to be referred for risk assessment. Larger studies are needed to confirm these findings. Interventions to standardize breast cancer risk assessment in primary care may improve equity.

Immigration Enforcement Climate in Georgia and the Mental Health of Latinx Immigrants.

INTRODUCTION: Immigrant-related social policies and immigration enforcement contribute to a sociopolitical environment that affects immigrants' health. This exploratory study in six metro-Atlanta counties examined associations among immigrants' perceived vulnerability to harmful immigrant-related social policies and county-level 287(g) agreements (which facilitate cooperation between local law enforcement and federal immigration authorities), county-level immigration enforcement levels (arrests, community arrests, detainers, and removals), and immigrants' mental health. METHODS: Using data from a 2020 study among Latinx parents who were undocumented or members of mixed-status families (N = 140), we merged data on individuals' perceived policy vulnerability and depressive and anxiety symptoms with county 287(g) status and immigration enforcement levels. RESULTS: Perceived policy vulnerability was not associated with county-level 287(g) status or immigration enforcement levels. Greater policy vulnerability and Immigration and Customs Enforcement arrests were associated with higher depressive and anxiety symptoms, but 287(g) status was associated with lower depressive and anxiety symptoms. CONCLUSION: Perceived policy vulnerability, 287(g) status, and immigration enforcement levels do not always align and can have different associations with mental health.

Answering calls for rigorous health equity research: a cross-sectional study leveraging electronic health records for data disaggregation in Latinos.

INTRODUCTION: Country of birth/nativity information may be crucial to understanding health equity in Latino populations and is routinely called for in health services literature assessing cardiovascular disease and risk, but is not thought to co-occur with longitudinal, objective health information such as that found in electronic health records (EHRs). METHODS: We used a multistate network of community health centres to describe the extent to which country of birth is recorded in EHRs in Latinos, and to describe demographic features and cardiovascular risk profiles by country of birth. We compared geographical/demographic/clinical characteristics, from 2012 to 2020 (9 years of data), of 914 495 Latinos recorded as US-born, non-US-born and without a country of birth recorded. We also described the state in which these data were collected. RESULTS: Country of birth was collected for 127 138 Latinos in 782 clinics in 22 states. Compared with those with a country of birth recorded, Latinos without this record were more often uninsured and less often preferred Spanish. While covariate adjusted prevalence of heart disease and risk factors were similar between the three groups, when results were disaggregated to five specific Latin countries (Mexico, Guatemala, Dominican Republic, Cuba, El Salvador), significant variation was observed, especially in diabetes, hypertension and hyperlipidaemia. CONCLUSIONS: In a multistate network, thousands of non-US-born, US-born and patients without a country of birth recorded had differing demographic characteristics, but clinical variation was not observed until data was disaggregated into specific country of origin. State policies that enhance the safety of immigrant populations may enhance the collection of health equity related data. Rigorous and effective health equity research using Latino country of birth information paired with longitudinal healthcare information found in EHRs might have significant potential for aiding clinical and public health practice, but it depends on increased, widespread and accurate availability of this information, co-occurring with other robust demographic and clinical data nativity.

Involvement in Chemotherapy Decision Making among Patients with Stage II and III Colon Cancer.

Background. To explore preferred and actual involvement in chemotherapy decision making among stage II and III colon cancer (CC) patients by sociodemographic, interpersonal, and intrapersonal communication factors. Methods. Cross-sectional exploratory study collecting self-reported survey data from stage II and III CC patients from 2 cancer centers located in northern Manhattan. Results. Of 88 patients approached, 56 completed the survey. Only 19.3% reported shared involvement in their chemotherapy decisions. We observed significant differences in preferred involvement by gender, with women preferring more physician-controlled decisions. CC patients with higher levels of decisional self-efficacy significantly preferred shared decisions (F = 4.4 [2], P = 0.02). Actual involvement in decisions differed by race (physician controlled 33% for White v. 67% for Other, P < 0.01), age (shared control 18% for ≤55 y, 55% for 55-64 y, and 27% for 65+ y, P = 0.04), and perception of choice (shared control 73% "yes" v. 27% "no,"P = 0.02). Actual or preferred involvement did not differ by stage. Significantly higher levels of medical mistrust (discrimination t = 2.8 [50], P = 0.01; lack of support t = 3.6 [49], P < 0.01), and lower levels of decisional self-efficacy (t = 2.5 [49], P = 0.01) were reported among women. Discussion. Reports of shared involvement around chemotherapy decisions is limited among CC patients. Factors influencing preferred versus actual chemotherapy decision making are complex and may differ; hence, more research is needed to understand and address factors contributing to discordance between preferred and actual involvement in chemotherapy decision making for CC patients. Highlights: Shared involvement around chemotherapy decisions remains limited for patients diagnosed with colon cancer.Sociodemographic (age, race, gender), interpersonal (medical mistrust), and intrapersonal (decisional self-efficacy, perception of choice) factors that influence preferred involvement in chemotherapy decision making may differ from those influencing actual involvement in chemotherapy decision making.Shared involvement in chemotherapy decisions may look different than currently conceptualized, notably when uncertainty around the benefits exists.

Disaggregating Latino nativity in equity research using electronic health records.

OBJECTIVE: To develop and validate prediction models for inference of Latino nativity to advance health equity research. DATA SOURCES/STUDY SETTING: This study used electronic health records (EHRs) from 19,985 Latino children with self-reported country of birth seeking care from January 1, 2012 to December 31, 2018 at 456 community health centers (CHCs) across 15 states along with census-tract geocoded neighborhood composition and surname data. STUDY DESIGN: We constructed and evaluated the performance of prediction models within a broad machine learning framework (Super Learner) for the estimation of Latino nativity. Outcomes included binary indicators denoting nativity (US vs. foreign-born) and Latino country of birth (Mexican, Cuban, Guatemalan). The performance of these models was compared using the area under the receiver operating characteristics curve (AUC) from an externally withheld patient sample. DATA COLLECTION/EXTRACTION METHODS: Census surname lists, census neighborhood composition, and Forebears administrative data were linked to EHR data. PRINCIPAL FINDINGS: Of the 19,985 Latino patients, 10.7% reported a non-US country of birth (5.1% Mexican, 4.7% Guatemalan, 0.8% Cuban). Overall, prediction models for nativity showed outstanding performance with external validation (US-born vs. foreign: AUC = 0.90; Mexican vs. non-Mexican: AUC = 0.89; Guatemalan vs. non-Guatemalan: AUC = 0.95; Cuban vs. non-Cuban: AUC = 0.99). CONCLUSIONS: Among challenges facing health equity researchers in health services is the absence of methods for data disaggregation, and the specific ability to determine Latino country of birth (nativity) to inform disparities. Recent interest in more robust health equity research has called attention to the importance of data disaggregation. In a multistate network of CHCs using multilevel inputs from EHR data linked to surname and community data, we developed and validated novel prediction models for the use of available EHR data to infer Latino nativity for health disparities research in primary care and health services research, which is a significant potential methodologic advance in studying this population.

Current Family Functioning and Youth Cardiometabolic Health in the SOL Youth Study.

BACKGROUND: Family functioning may impact children's cardiometabolic health; however, few studies have examined multiple cardiometabolic markers among a diverse racial/ethnic cohort. The relationship between child- and caregiver-reported family functioning and the cardiometabolic health of Hispanic/Latino youth was examined. METHOD: Data were from the Hispanic Community Children's Health Study/Study of Latino Youth (SOL Youth) (2012-2014), a population-based cohort study of children and adolescents whose parents participated in the HCHS/SOL (2008-2011). The relationship between youth- and caregiver-rated family functioning, and concordance of ratings is modeled, utilizing the general functioning subscale of the McMaster Family Assessment Device with youth objective cardiometabolic health markers (obesity, central adiposity, prediabetes/diabetes, prehypertension/hypertension, triglycerides, HDL cholesterol) adjusting for sociodemographic factors. RESULTS: Among boys, child/caregiver concordant ineffective family functioning rating was associated with higher cumulative cardiometabolic risk (adjusted B (95% CI): 0.30 (0.04, 0.56)), but no association was observed among girls (adjusted B (95% CI): 0.04 (-0.13, 0.21)). Among girls, ineffective child rating/effective caregiver rating was associated with higher cumulative cardiometabolic risk (adjusted B (95% CI): 0.27 (0.06, 0.48)), but no association was observed among boys (adjusted B (95% CI): 0.02 (-0.23, 0.27). CONCLUSION: Findings suggest that family functioning among this Hispanic/Latino population may influence cardiometabolic risk among youth. Observed differences in the associations by youth sex and concordant/discordant reports of family functioning suggest interventions at the family level, targeting both caregivers and youth, that consider differential sex effects are warranted.

Self-rated health of both US citizens and noncitizens is associated with state-level immigrant criminalization policies.

Evidence shows that state-level restrictive immigrant policies are associated with health disparities between noncitizens and citizens. Most research has focused on Latinos and there is limited knowledge of the relationship between restrictive policies and citizenship status among other groups, particularly Asian and Pacific Islanders (API). We examined whether state-level criminalization policy contexts (e.g., law enforcement collaboration with immigration authorities, E-Verify employment authorization) were associated with self-rated health (SRH) by citizenship, with a focus on Latinos and APIs. We expected that criminalization policies would be associated with worse health for noncitizens and citizens, but with a more negative influence for noncitizens; and that this pattern would be the same for Latinos and APIs. We merged a state-level immigrant criminalization policy database with a multi-racial/ethnic sample from 2014 to 2015 National Health Interview Survey (NHIS, n = 70,335). We tested the association between SRH and the number of state-level criminalization policies and generated predicted probabilities of noncitizens and citizens reporting excellent health in states with the most and fewest criminalization policies for the full sample, Latino, and API respondents. In states with the most criminalization policies, all noncitizens had a higher and all US-born citizens had a lower probability of excellent health. In states with the fewest criminalization policies there were no differences by citizenship status. Findings provide new evidence that state-level immigrant policies may harm the health of US-born citizens. As immigrant policymaking at the state level continues, understanding the relationship between state-level immigrant policies and health inequities across citizenship statuses will continue to be critical to improving population health.

Immigrant-Related Policies and the Health Outcomes of Latinx Adults in the United States: A Systematic Review.

BACKGROUND: US federal and subfederal immigrant-related policy activity has increased in recent years. We hypothesize that these policies are structural determinants of health for Latinx communities, operating through access to resources, discriminatory enforcement, and stress. METHODS: We searched seven databases for quantitative studies, published as of September 2021, examining the association between the presence of federal, state, or local immigrant-related policy(ies), over time or cross-sectionally, and mental or physical health outcomes among immigrant or US-born Latinx adults. We rated studies on methodologic quality. RESULTS: Eleven studies were included. Policies included federal and state policies. Health outcomes included mental health (seven studies), self-rated health (n = 6), and physical disability (n = 1). Among immigrant, noncitizen, or Spanish-preferring Latinx adults, exclusionary policies were associated with poor self-rated health, physical disability, and poor mental health. Inclusive policies were associated with better health, although null findings were more common than among studies of exclusionary policies. Only three studies separately examined policy effects on US-born or citizen Latinx adults and these findings were often null. All studies received a weak overall study quality rating; among quality domains, studies were strongest in confounding control and weakest in outcome information bias and reporting missing data approaches. CONCLUSIONS: These results support the hypothesis that immigrant-related policies, especially exclusionary policies, are structural drivers of health for immigrant or noncitizen Latinx adults. However, evidence is scant among US-born or citizen Latinx adults. Studies of policies and physical health outcomes besides disability are lacking, as are results disaggregated by nativity and/or citizenship status.

Examining the impact of the Cultural Gap Narrative on Family Functioning and Youth Substance Use among the Health Study/Study of latino Youth (HCHS/SOL Youth) population.

The acculturation gap theory provides a complex illustration of how cultural orientations affect health behaviors among adolescents, by assuming that familial cultural orientation gaps lead to compromised family functioning and children adopting negative health behaviors. This analysis used three methods to conceptualize cultural gaps to examine the relationships between familial cultural orientation gaps and family functioning and substance use susceptibility among the Hispanic Community Children's Health Study/Study of Hispanic/Latino Youth population. Results did not support the assumptions behind the acculturation gap theory. The methods used to conceptualize cultural gaps did not illustrate consistent underlying trends when measuring the relationship between cultural gaps and substance use susceptibility. There was no evidence of mediation on substance use susceptibility by perceived family functioning for either cultural domains using each method. This analysis underscores the need to refine the framework behind the acculturation gap theory and how cultural gaps are measured among Hispanic/Latino youth.

Federal, State, and Local Immigrant-Related Policies and Child Health Outcomes: a Systematic Review.

The passage of US immigrant-related policies at the federal, state, and local level is on the rise. These policies may affect child health through several mechanisms. We performed a systematic review of English-language, peer-reviewed, quantitative studies examining US immigrant-related policies and the mental and physical health of youth in immigrant families. We searched PubMed and five social science databases for studies published between 1986 and 2019. Two independent reviewers screened the studies and appraised study quality. Of the final 17 studies, ten studies examined birth outcomes and seven studies examined other outcomes in childhood and adolescence (e.g., self-rated health). Generally, exclusionary policies were associated with worse health outcomes and inclusive policies were associated with better health outcomes. Several studies did not observe an association, but only one study found an association of the opposite direction. In that study, similar trends in different policy environments and across foreign-born and US-born women suggest alternative causes for the observed association. Overall, we find that exclusionary policies are, at best, neutral, but likely harmful towards child wellbeing, while inclusive policies can be beneficial.

Patient perspectives on treatment decision-making under clinical uncertainty: chemotherapy treatment decisions among stage II colon cancer patients.

The decision to use adjuvant chemotherapy (ACT) after surgical resection for stage II colon cancer remains an area of clinical uncertainty. Many patients diagnosed with stage II colon cancer receive ACT, despite inconclusive evidence of long-term clinical benefit. This study investigates patient experiences and perceptions of treatment decision-making and shared decision making (SDM) for ACT among patients diagnosed with stage II colon cancer. Stage II colon cancer patients engaged in treatment or follow-up care aged >18 years were recruited from two large NYC health systems. Patients participated in 30-60-min semi-structured interviews. All interviews were transcribed, translated, coded, and analyzed using a thematic analysis approach. We interviewed 31 patients, of which 42% received ACT. Overall, patient perspectives indicate provider inconsistency in communicating ACT harms, benefits, and uncertainties, and poor elicitation of patient preferences and values. Patients reported varying perceptions and understanding of personal risk and clinical benefits of ACT. For many patients, receiving a clear treatment recommendation from the provider limited their participation in the decision-making process, whether it aligned with their decisional support preferences or not. Findings advance understanding of perceived roles and preferences of patients in SDM processes for cancer treatment under heightened clinical uncertainty, and indicate a notable gap in understanding for decisions made using SDM models in the context of clinical uncertainty. Educational and communication strategies and training are needed to support providers in communicating uncertainty, risk, treatment options, and implementing clinical guidelines to support patient awareness and informed decisions.

Association of Maternal Nativity Status and Race/Ethnicity on Emergency Department Utilization Among Children in Vulnerable Families.

OBJECTIVES: We aimed to determine the role of mothers' nativity and race/ethnicity on their children's emergency department utilization. METHODS: Data from the Fragile Families and Child Wellbeing Study was used for the analyses. Descriptive and regression analyses were conducted to compare use of ED services between children of foreign-born versus US-born mothers within different racial groups. RESULTS: The sample in this analysis contained 3426 mother-child pairs, of which 14.2% were foreign-born mothers. Adjusting for mother's race, education, and marital status, child's insurance coverage, and caregiver's perception of child's health, children of foreign-born mothers were less likely to use ED services compared with those born to US-born mothers (risk ratio [RR], 0.71 [0.54-0.94]). Emergency department utilization was lower among children of Hispanic, foreign-born mothers (RR, 0.67 [0.46-0.96]) and among children of non-Hispanic Asian or other race, foreign-born mothers (RR, 0.32 [0.14-0.74]) when compared with children of their US-born counterparts in the respective race. CONCLUSIONS: Maternal nativity status and race influence child's use of emergency department services. Future research should explore the intersection of parental nativity, immigrant documentation status, and citizenship status and how that may influence children's health care usage.