Does everyday discrimination account for the increased risk of vasomotor symptoms in Black women?: the Study of Women's Health Across the Nation (SWAN).

OBJECTIVES: Vasomotor symptoms (VMS), including hot flashes and night sweats, are hallmark symptoms of the menopause transition. Previous research has documented greater frequency, duration, and severity of VMS in Black women compared with women from other racial/ethnic groups, even after accounting for other factors. This analysis examined the association between discrimination and VMS and the extent to which discrimination accounts for the disproportionate burden of VMS in Black women. METHODS: Using available discrimination and VMS data from the SWAN cohort study (n = 2,377, 48% White, 32% Black, 6% Japanese, 4% Chinese, and 9% Hispanic women) followed approximately yearly in midlife from premenopause (42-52 y) through postmenopause (~20 y), we assessed concurrent associations between discrimination and VMS frequency in the past 2 weeks using weighted generalized mixed models. We also assessed associations between chronic discrimination across first four visits and VMS trajectories from premenopause to postmenopause using weighted multinomial logistic regression. Models were adjusted for known risk factors for VMS. RESULTS: Higher levels of discrimination were associated with concurrent reporting of any (odds ratio [OR], 1.57 [1.31-1.89]) and frequent (≥6 d) VMS (OR, 1.55 [1.21-1.99]). After adjustment, associations remained significant for any (OR, 1.30 [1.09-1.54]) but not frequent VMS. For any VMS trajectories, chronic discrimination was associated with "continuously high" (OR, 1.69 [1.03-2.77]) and "high pre-FMP-decline post-FMP" (OR, 1.70 [1.01-2.88]) versus "FMP-onset low" trajectories. After adjusting for discrimination, odds of reporting any, frequent, and of being in the "continuously high" any VMS trajectory remained elevated for Black versus White women. CONCLUSIONS: Discrimination is associated with greater concurrent risk of any (but not frequent) VMS, and chronic discrimination is associated with a continuously high reporting of any VMS over time, independent of known risk factors. Adjusting for discrimination attenuates but does not eliminate the increased risk of VMS for Black women.

Effects of intimate partner violence and homophobic bullying on ART adherence among young Thai men who have sex with men: a causal mediation analysis.

Background: Adherence to antiretroviral therapy is crucial in determining health outcomes and secondary HIV transmission for people living with HIV/AIDS. Young men who have sex with men (YMSM) living with HIV are often challenged by the prevailing experiences of psychosocial stressors, such as intimate partner violence and homophobic bullying, which may negatively affect their HIV care engagement. Methods: This study is the first to utilize a prospective cohort design (N= 185) involving YMSM living with HIV in Thailand. We examined the effects of intimate partner violence and homophobic bullying on ART adherence. We also tested the mediating effect of depression on the relationship between intimate partner violence and homophobic bullying on ART adherence. Results: We found that intimate partner violence (AOR: 2.58, 95% CI: 1.13, 5.42) and homophobic bullying (AOR: 2.40, 95% CI: 1.26, 4.48) were associated with subsequent ART nonadherence. Moreover, depression partially mediated 17.4% (95% CI: 0.75%, 56%) of the effect of homophobic bullying on ART nonadherence. Conclusions: The results suggest that tailored interventions to optimize ART adherence should address the impacts of intimate partner violence and homophobic bullying for HIV+ YMSM. The screening and subsequent treatment of depression alone may not be sufficient to address the effects of intimate partner violence, homophobic bullying, and possibly other MSM-specific psychosocial stressors on ART adherence.

Stress is a Latent Construct: Exploring the Differential Experience of Stress and Discrimination on Depressive Symptoms Among Black Older Adults.

Objectives: While evidence highlights the detrimental mental health consequences of chronic stress exposure, the impact of this stress exposure on older Black Americans' mental health varies by exposure to other types of stressors like discrimination as well as subjective evaluations of stress like chronic stress appraisal. Methods: Using data from the 2010/2012 Health and Retirement Study, we use latent profile analysis (LPA) to describe 2,415 Black older adults experience with chronic stress exposure, appraisal, and discrimination and examine which stress contexts are associated with depressive symptomology. Results: Analyses revealed five stress clusters-demonstrating the diversity in the stress experience for older Black adults. Black older adults with stress profiles that include lower stress appraisal report fewer depressive symptoms regardless of number of stress exposures. Discussion: LPA is as an alternative approach to examining the stress-mental health link that can define stress profiles by both exposure and appraisal-based measures.

Disparities in Reproductive Aging and Midlife Health between Black and White women: The Study of Women's Health Across the Nation (SWAN).

This paper reviews differences in the experience of the menopause transition and midlife health outcomes between Black and White women who participated in the Study of Women's Health Across the Nation (SWAN), a 25-year, longitudinal, multi-racial/ethnic cohort study. We identify health disparities, i.e., instances in which Black women's outcomes are less favorable than those of White women, and consider whether structural racism may underlie these disparities. Although SWAN did not explicitly assess structural racism, Black women in SWAN grew up during the Jim Crow era in the United States, during which time racism was legally sanctioned. We consider how we might gain insight into structural racism by examining proxy exposures such as socioeconomic characteristics, reports of everyday discrimination, and a range of life stressors, which likely reflect the longstanding, pervasive and persistent inequities that have roots in systemic racism in the US. Thus, this paper reviews the presence, magnitude, and longitudinal patterns of racial disparities observed in SWAN in six areas of women's health - menopause symptoms, sleep, mental health, health related quality of life, cardio-metabolic health, and physical function -and elucidates the contextual factors that are likely influencing these disparities. We review the strengths and weaknesses of SWAN's design and approach to analysis of racial disparities and use this as a springboard to offer recommendations for future cohort studies.

Capnometric feedback training decreases 24-h blood pressure in hypertensive postmenopausal women.

BACKGROUND: High normal resting pCO2 is a risk factor for salt sensitivity of blood pressure (BP) in normotensive humans and has been associated with higher resting systolic BP in postmenopausal women. To date, however, no known studies have investigated the effects of regular practice of voluntary mild hypocapnic breathing on BP in hypertensive patients. The objective of the present research was to test the hypothesis that capnometric feedback training can decrease both resting pCO2 and 24-h BP in a series of mildly hypertensive postmenopausal women. METHODS: A small portable end tidal CO2 (etCO2) monitor was constructed and equipped with software that determined the difference between the momentary etCO2 and a pre-programmed criterion range. The monitor enabled auditory feedback for variations in CO2 outside the criterion range. 16 mildly hypertensive postmenopausal women were individually trained to sustain small decreases in etCO2 during six weekly sessions in the clinic and daily sessions at home. 24-h BP monitoring was conducted before and after the intervention, and in 16 prehypertensive postmenopausal women in a control group who did not engage in the capnometric training. RESULTS: Following the intervention, all 16 capnometric training participants showed decreases in resting etCO2 (- 4.3 ± 0.4 mmHg; p < .01) while 15 showed decreases in 24-h systolic BP (- 7.6 ± 2.0 mmHg; p < .01). No significant changes in either measure was observed in the control group. In addition, nighttime (- 9.5 ± 2.6; p < .01) and daytime (- 6.7 ± 0.2 mmHg) systolic BP were both decreased following capnometric training, while no significant changes in nighttime (- 2.8 ± 2.2 mmHg; p = .11) or daytime (- 0.7 ± 1.0 mmHg; p ≤ .247) systolic BP were observed in the control group. CONCLUSIONS: These findings support the hypothesis that regular practice of mild hypocapnic breathing that decreases resting etCO2 reliably decreases 24-h blood pressure in hypertensive postmenopausal women. The extent to which these effects persist beyond the training period or can be observed in other hypertensive subgroups remains to be investigated.

US law enforcement policy predictors of race-specific police fatalities during 2015-16.

Mounting evidence suggests that law enforcement organizational factors contribute to higher incidence and racial disparities in police killings. To determine whether agency policies contribute to race-specific civilian fatalities, this exploratory study compared fatality rates among agencies with and without selected policies expected to reduce killings. A cross-section of 1085 fatalities in the 2015-2016 The Counted public-use database were matched to 481 agencies in the 2013 Law Enforcement Management and Administrative Statistics (LEMAS) database. Negative binomial regression estimated incidence rate ratios (IRR) adjusted for agency type, number of officers, percent female personnel, median income, percent with a bachelor's degree, violent crime rate, and population size, with inference using robust standard errors. Agencies with greater proportions of full-time personnel (range 43-100%) had lower rates of all (IRR = 0.85; 95% confidence interval [CI] = 0.77-0.93) and non-White civilian killings (IRR = 0.85; CI = 0.73-0.99). Mission statements predicted lower rates of all (IRR = 0.70; CI = 0.58-0.84) and White killings (IRR = 0.60; CI = 0.40-0.90). Community evaluation and more types of personnel incentives predicted lower rates of White (IRR = 0.82; CI = 0.68-0.99) and non-White killings (IRR = 0.94; CI = 0.89-1.00), respectively. Increasing video use predicted higher rates of White killings (IRR = 1.13; CI = 1.01-1.28). No policies were significantly associated with Black civilian killings. Law enforcement policies that help reduce police killings may vary across racial groups with the least benefit for Black civilians. Impact evaluations and meta-analyses of initiatives aimed to mitigate fatalities should be explored, particularly policies to address anti-Black bias. A national registry tracking all police killings and agency policies is urgently needed to inform law enforcement policies aimed to mitigate civilian fatalities.

Symptom clusters predict risk of metabolic-syndrome and diabetes in midlife: the Study of Women's Health Across the Nation.

PURPOSE: Women's cardio-metabolic risk increases in midlife. Previous work relating menopause symptoms to diabetes/Metabolic Syndrome (MetS) does not consider the adverse impact of multiple concurrent physical and psychological symptoms in midlife. METHODS: Data are from 3097 participants in the Study of Women's Health Across the Nation, a cohort of midlife women followed for over 20 years. Baseline latent symptom classes (LSC) were derived from 58 questions assessing physical, psychological and menopausal symptoms. Six identified LSCs ranged from 1 (most symptoms present at high severity) to 6 (few symptoms present at low severity). Accelerated failure time models estimated time to onset of type 2 diabetes and MetS for each LSC. RESULTS: Women with multiple high/moderate severity symptoms had an earlier onset of diabetes (13.2%, 14.1% and 20.8% earlier onset in LSCs 1, 2, 3, respectively) and MetS (15.5%, 13.0% and 19.7% earlier onset in LSCs 1, 2, 3, respectively) than women with few/low severity symptoms. CONCLUSIONS: Having multiple concurrent moderate to high intensity physical and psychological symptoms in midlife are associated with early onset of diabetes and MetS. Monitoring and subsequent intervention on a broad range of symptoms in midlife may significantly mitigate cardio-metabolic risk during this critical life stage.

Everyday Racial Discrimination and Hypertension among Midlife African American Women: Disentangling the Role of Active Coping Dispositions versus Active Coping Behaviors.

Racial discrimination, a psychosocial stressor, may contribute to disproportionate rates of hypertension among African American women. Coping moderates the effects of psychosocial stress on health. Coping dispositions describe stable personality characteristics, whereas contextual frameworks emphasize flexible coping behaviors in response to specific stressful encounters. Using data from the African American Women's Heart and Health Study-a non-probability cross-section of 208 midlife African American women in Northern California-we estimated the association between everyday racial discrimination (Everyday Discrimination Scale, EDS) and prevalence of hypertension (HTN), and evaluated moderation by coping disposition (John Henryism Active Coping scale, JH) versus context-specific active coping behavior (Active Coping with Racism scale, ACR). There were no main associations between EDS, JH, or ACR on HTN prevalence. There was evidence of statistical interaction between EDS and ACR (p-int = 0.05), but not JH (p-int = 0.90). Among those with high levels of ACR, reporting monthly (prevalence ratio (PR) = 2.35, 95% confidence interval (CI) = 1.13, 4.87), weekly (PR = 2.15, 95% CI = 1.01, 4.61), or daily (PR = 2.36, 95% CI = 1.14, 4.88) EDS was associated with higher HTN prevalence, versus reporting racial discrimination yearly or less. In contrast, among those with low levels of ACR, reporting more chronic racial discrimination was associated with lower hypertension prevalence, although results were less precise. Findings suggest that ongoing active coping with chronic racial discrimination may contribute to hypertension risk among African American women.

The association between perceived discrimination in midlife and peripheral neuropathy in a population-based cohort of women: the Study of Women's Health Across the Nation.

PURPOSE: Peripheral neuropathy (PN) is a highly prevalent condition with serious sequelae. Many studies of the condition have been restricted to populations with diabetes, limiting evidence of potential contributing risk factors including salient psychosocial risk factors such as discrimination. METHODS: The longitudinal Study of Women's Health Across the Nation was used to assess the relationship between perceived discrimination and prevalent PN in 1718 ethnically diverse midlife women. We used multivariable logistic regression to determine the association between perceived discrimination (Detroit Area Study Everyday Discrimination Scale) and PN (symptom questionnaire and monofilament testing) and conducted an assessment of the mediating effects of body mass index (BMI). RESULTS: The prevalence of PN was 26.1% in the total sample and 40.9% among women with diabetes. Women who reported perceived discrimination had 29% higher odds of PN compared with women who did not report perceived discrimination (95% confidence interval, 1.01-1.66). Approximately 30% of the total effect of discrimination on PN was mediated indirectly by BMI. CONCLUSIONS: More research is needed to determine the contributing factors to nondiabetic PN. Our findings reaffirm the impact of financial strain, BMI, and diabetes as significant correlates of PN and highlight discrimination as an important risk factor.

Differential associations between everyday versus institution-specific racial discrimination, self-reported health, and allostatic load among black women: implications for clinical assessment and epidemiologic studies.

PURPOSE: Black women have the highest estimated allostatic load (AL). AL and self-perceived health are strong health predictors and have been linked to racial discrimination. Research suggests that everyday and institution-specific racial discrimination may predict different AL and self-reported health (SRH) outcomes. Furthermore, discrepancies between AL and self-perceived health could widen disparities. We estimated associations between everyday versus institution-specific racial discrimination with AL and SRH. METHODS: Data are from a San Francisco Bay Area community sample of 208 black women aged 30-50 years. Participation involved a questionnaire, self-interview, blood draw, and anthropometric measurements. Adjusted generalized linear regression models estimated associations of racial discrimination with AL and SRH. RESULTS: After adjusting for age, socioeconomic position, and medication use, institution-specific discrimination was negatively associated with AL (i.e., better health), whereas everyday experiences showed no association. Those reporting very-high (vs. moderate) institution-specific discrimination had lower AL (ß = -1.31 [95% CI: -2.41, -0.20]; AL range: 0-15). No racial discrimination-SRH association was found. CONCLUSIONS: For black women, (1) institution-specific racial discrimination may be differentially embodied compared with everyday experiences and (2) institutional racism may contribute to physiologic stress-regulation regardless of self-perceived health status. Potential factors that may contribute to an inverse racial discrimination-AL association, and future research, are discussed.

Racial discrimination, educational attainment, and biological dysregulation among midlife African American women.

OBJECTIVE: To examine the association between self-reported racial discrimination and allostatic load, and whether the association differs by socioeconomic position. METHODS: We recruited a purposive cross-section of midlife (ages 30-50) African American women residing in four San Francisco Bay area counties (n = 208). Racial discrimination was measured using the Experience of Discrimination scale. Allostatic load was measured as a composite of 15 biomarkers assessing cardiometabolic, neuroendocrine, and inflammatory activity. We calculated four composite measures of allostatic load and three system-specific measures of biological dysregulation. Multivariable regression was used to examine associations, while adjusting for relevant confounders. RESULTS: In the high education group, reporting low (b = -1.09, P = .02, 95% CI = -1.99, -0.18) and very high (b = -1.88, P = .003, 95% CI = -3.11, -0.65) discrimination was associated with lower allostatic load (reference=moderate). Among those with lower education, reporting low (b = 2.05, P = .008, 95% CI = 0.55,3.56) discrimination was associated with higher allostatic load. Similar but less consistent associations were found for poverty status. Associations were similar for cardiometabolic functioning, but not for neuroendocrine or inflammatory activity. CONCLUSIONS: Racial discrimination may be an important predictor of cumulative physiologic dysregulation. Factors associated with educational attainment may mitigate this association for African American women and other groups experiencing chronic social stress.

Relative Roles of Race Versus Socioeconomic Position in Studies of Health Inequalities: A Matter of Interpretation.

An abundance of research has documented health inequalities by race and socioeconomic position (SEP) in the United States. However, conceptual and methodological challenges complicate the interpretation of study findings, thereby limiting progress in understanding health inequalities and in achieving health equity. Fundamental to these challenges is a lack of clarity about what race is and the implications of that ambiguity for scientific inquiry. Additionally, there is wide variability in how SEP is conceptualized and measured, resulting in a lack of comparability across studies and significant misclassification of risk. The objectives of this review are to synthesize the literature regarding common approaches to examining race and SEP health inequalities and to discuss the conceptual and methodological challenges associated with how race and SEP have been employed in public health research. Addressing health inequalities has become increasingly important as the United States trends toward becoming a majority-minority nation. Recommendations for future research are presented.