Ethnic discrimination, asking for fair treatment, and poor self-rated health: a gender stratified analysis of 13,443 Korean Chinese waged workers in South Korea.

BACKGROUND: In South Korea, Korean Chinese workers experience ethnic discrimination although they share physical similarities and ethnic heritage with native-born Koreans. This study aimed to examine whether perceived ethnic discrimination is associated with poor self-rated health and whether the association differs by gender among Korean Chinese waged workers in South Korea. METHODS: We conducted a pooled cross-sectional analysis using data of 13,443 Korean Chinese waged workers from the Survey on Immigrants' Living Conditions and Labor Force conducted in 2018, 2020, and 2022. Based on perceived ethnic discrimination, asking for fair treatment, and subsequent situational improvement, respondents were classified into the following four groups: "Not experienced," "Experienced, not asked for fair treatment," "Experienced, asked for fair treatment, not improved," and "Experienced, asked for fair treatment, improved." Poor self-rated health was assessed using a single question "How is your current overall health?" We applied logistic regression to examine the association between perceived ethnic discrimination and poor self-rated health, with gender-stratified analyses. RESULTS: We found an association between ethnic discrimination and poor self-rated health among Korean Chinese waged workers. In the gender-stratified analysis, the "Experienced, not asked for fair treatment" group was more likely to report poor self-rated health compared to the "Not experienced" group, regardless of gender. However, gender differences were observed in the group stratified by situational improvements. For male workers, no statistically significant association was found in the "Experienced, asked for fair treatment, improved" group with poor self-rated health (odd ratios: 0.87, 95% confidence intervals: 0.30-2.53). Conversely, among female workers, a statistically significant association was observed (odd ratios: 2.63, 95% confidence intervals: 1.29-5.38). CONCLUSIONS: This study is the first to find an association between perceived ethnic discrimination and poor self-rated health, along with gender differences in the association between situational improvements after asking for fair treatment and poor self-rated health among Korean Chinese waged workers in South Korea.

Change in employment status and its causal effect on suicidal ideation and depressive symptoms: A marginal structural model with machine learning algorithms.

OBJECTIVE: This study aimed to assess the causal effect of a change in employment status on suicidal ideation and depressive symptoms by applying marginal structural models (MSM) with machine-learning (ML) algorithms. METHODS: We analyzed data from the 8-15th waves (2013-2020) of the Korean Welfare Panel Study, a nationally representative longitudinal dataset. Our analysis included 13 294 observations from 3621 participants who had standard employment at baseline (2013-2019). Based on employment status at follow-up year (2014-2020), respondents were classified into two groups: (i) maintained standard employment (reference group), (ii) changed to non-standard employment. Suicidal ideation during the past year and depressive symptoms during the past week were assessed through self-report questionnaire. To apply the ML algorithms to the MSM, we conducted eight ML algorithms to build the propensity score indicating a change in employment status. Then, we applied the MSM to examine the causal effect by using inverse probability weights calculated based on the propensity score from ML algorithms. RESULTS: The random forest algorithm performed best among all algorithms, showing the highest area under the curve 0.702, 95% confidence interval (CI) 0.686-0.718. In the MSM with the random forest algorithm, workers who changed from standard to non-standard employment were 2.07 times more likely to report suicidal ideation compared to those who maintained standard employment (95% CI 1.16-3.70). A similar trend was observed in the analysis of depressive symptoms. CONCLUSIONS: This study found that a change in employment status could lead to a higher risk of suicidal ideation and depressive symptoms.

Female workers with long working hours are more likely to have depressive symptoms when having family-to-work conflict.

PURPOSE: Workers' health can be influenced by risk factors from their family environments as well as their work environments. This paper sought to examine how the association between long working hours and depressive symptoms differs based on the level of FWC after being stratified by worker's gender. METHODS: We used the dataset of 20,384 full-time wage workers from the sixth Korean Working Conditions Survey (2020). Long working hours were defined as working 52 h or more per week. FWC was measured using a 2-item questionnaire, and depressive symptoms were measured using the WHO-5 well-being index. Applying modified Poisson regression, we evaluated how the association between long working hours and depressive symptoms differs by the level of FWC male and female workers separately. RESULTS: In the analysis of the female workers, long working hours were associated with depressive symptoms in the high FWC group (PR 1.35, 95% CI 1.17, 1.55) after adjusting for potential confounders whereas no association was observed in the low FWC group. Among the male workers, a statistically significant association was observed in both high FWC (PR 1.22, 95% CI 1.07, 1.38) and low FWC (PR 1.28, 95% CI 1.12, 1.47) groups. CONCLUSION: FWC may act as a workplace stressor that potentially amplifies the health impact of long working hours among female workers.

Situational Avoidance and Its Association with Mental Health Among Transgender Adults in South Korea: A Nationwide Cohort Study.

Purpose: In fear of discrimination or unwanted disclosure of their transgender identity, transgender and nonbinary (TGNB) people may commonly avoid daily activities. We assessed the prevalence of situational avoidance among TGNB people and examined its associations with mental health outcomes. Methods: We analyzed data from a longitudinal survey conducted at baseline (2020) and follow-up (2021) among 268 TGNB people in South Korea. Situational avoidance due to transgender identity within the past 12 months was assessed based on 12 kinds of daily activities (e.g., public bathroom use, job applications, and hospital visits). Past-week depressive symptoms and past 2-week anxiety symptoms were measured with the Center for Epidemiologic Studies-Depression Scale and General Anxiety Disorder Scale, respectively. Results: Of 268 participants, 135 (50.4%) have ever avoided daily activities. The most frequently reported situational avoidance was public bathroom use (32.1%), followed by job applications (24.3%) and hospital visits (12.3%). After adjusting for confounders including baseline depressive symptoms and experience of anti-transgender discrimination, participants with any situational avoidance experience were 1.30 times (95% confidence intervals [CI] = 1.01-1.69) more likely to have anxiety symptoms compared with those without situational avoidance experience. In particular, participants who avoided three or more kinds of daily activities were 1.40 times (95% CI = 1.02-1.93) more likely to have anxiety symptoms than those without any experience of situational avoidance. No association was observed with depressive symptoms. Conclusion: Multilateral interventions including anti-discrimination law enactment are necessary to reduce transphobia and provide support for TGNB people in Korea, thus reducing their fear of participating in daily activities and promoting their mental well-being.

Associations between discrimination experiences and symptoms of depression and anxiety among transgender adults: a nationwide cohort study of 269 transgender adults in South Korea.

PURPOSE: Recently, there has been an increase in awareness of social stigma and mental health issues experienced by transgender individuals in South Korea. To provide quantitative evidence, we conducted a nationwide cohort study of transgender adults, first of its kind in Asia. The aim of the study is to assess the prevalence of depressive and anxiety symptoms and examine their associations with discrimination experiences among transgender adults. METHODS: We conducted a two-wave longitudinal survey of 269 Korean transgender adults, where the baseline was collected in October 2020 and the follow-up in October 2021. Experiences of discrimination in the past 12 months at follow-up were categorized accordingly: those who experienced (1) none, (2) only anti-transgender discrimination, (3) only other types of discrimination, and (4) both anti-transgender and other types of discrimination. Depressive symptoms were measured using the Center for Epidemiologic Studies Depression scale at both waves and anxiety symptoms were measured using the Generalized Anxiety Disorder 7 only at follow-up. We used modified Poisson regression to examine the association between experiences of discrimination and mental health outcomes at follow-up and adjusted for sociodemographic characteristics and baseline depressive symptoms. RESULTS: A total of 63.9% had depressive symptoms and 47.2% had anxiety symptoms. Participants who experienced both anti-transgender and other types of discrimination had 1.38-times (95% CI 1.06-1.81) and 1.77-times (95% CI 1.16-2.70) higher prevalence of depressive and anxiety symptoms, respectively, compared to those without any experiences of discrimination. CONCLUSIONS: Interventions to lessen discrimination towards transgender individuals are needed for the promotion of mental health among transgender individuals.

Transgender-specific COVID-19-related stressors and their association with depressive symptoms among transgender adults: A nationwide cross-sectional survey in South Korea.

Introduction: COVID-19 has disproportionately impacted marginalized groups, including transgender populations, reproducing and exacerbating inequalities and vulnerabilities that existed in those groups prior to the pandemic. This study aimed to assess the prevalence of transgender-specific COVID-19-related stressors and their association with depressive symptoms among South Korean transgender adults. Methods: We conducted a nationwide cross-sectional study of 564 South Korean transgender adults (trans women, trans men, and nonbinary people) from October 7 to October 31, 2020. We measured four transgender-specific COVID-19-related stressors as follows: (A) had difficulty receiving gender-affirming healthcare due to economic hardship related to COVID-19, (B) had difficulty receiving gender-affirming healthcare due to limited access to hospitals under the COVID-19 situation, (C) had difficulty purchasing a public face mask due to gender information on an identification card, and (D) avoided getting a COVID-19 test in fear of unfair treatment and dirty looks due to gender identity, despite having COVID-19 symptoms. Past-week depressive symptoms were assessed using the Center for Epidemiologic Studies-Depression Scale. Results: Of the total participants, 30.7% experienced any of the four transgender-specific COVID-19-related stressors, and 70.2% were classified as having depressive symptoms during the past week. We found statistically significant associations with depressive symptoms among participants who reported that they had difficulty receiving gender-affirming healthcare due to either economic hardship (adjusted prevalence ratio [aPR] = 1.20, 95% Confidence Interval [CI] = 1.05-1.37) or limited access to hospitals (aPR = 1.15, 95% CI = 1.00-1.32), respectively. Furthermore, those who had two or more of the four transgender-specific COVID-19-related stressors were 1.21 times (95% CI = 1.05-1.40) more likely to report depressive symptoms, compared to those who did not report any stressor. Conclusion: Transgender-specific COVID-19-related stressors may negatively influence depressive symptoms among South Korean transgender adults. Given these findings, transgender-inclusive interventions should be implemented at the policy level during the COVID-19 pandemic in South Korea.

Gender Identity Change Efforts Are Associated with Depression, Panic Disorder, and Suicide Attempts in South Korean Transgender Adults.

Purpose: Gender identity change efforts (GICEs), sometimes referred to as "conversion therapy," are considered pseudoscientific and unethical practices that are not supported by the existing scientific literature. However, a substantial portion of transgender people face such practices during their lives. We assessed lifetime exposure to GICEs and its associations with mental health indicators among transgender adults in South Korea. Methods: We analyzed a nationwide cross-sectional survey of 566 Korean transgender adults conducted in October 2020. Lifetime exposure to GICEs was classified as follows: "never had GICE-related experiences," "received a referral, but did not undergo GICEs," and "undergone GICEs." We assessed mental health indicators, including past-week depressive symptoms; medical diagnosis or treatment of depression and panic disorder; and past 12-month suicidal ideation, suicide attempts, and self-harm. Results: Of the total participants, 12.2% had "received a referral, but did not undergo GICEs," and 11.5% had "undergone GICEs." Compared with those who had "never had GICE-related experiences," participants who had "undergone GICEs" showed significantly higher prevalence of depression (adjusted prevalence ratio [aPR]=1.34, 95% confidence interval [CI]=1.11-1.61), panic disorder (aPR=2.52, 95% CI=1.75-3.64), and suicide attempts (aPR=1.73, 95% CI=1.10-2.72). However, we did not find significant associations between having "received a referral, but did not undergo GICEs" and mental health indicators. Conclusion: Given our findings suggest that lifetime exposure to GICEs may harm transgender adults' mental health, legal restrictions should be imposed to ban GICEs in South Korea.

Lack of compensation for COVID-19-related overtime work and its association with burnout among EMS providers in Korea.

OBJECTIVES: This study examined the association between lack of compensation for COVID-19-related overtime work (LCCOW) and burnout among emergency medical service (EMS) providers in Seoul, Korea. METHODS: We conducted a cross-sectional survey of 693 EMS providers in Seoul, Korea. Participants were classified into 3 groups according to their experience of coronavirus disease 2019 (COVID-19)-related overtime work and LCCOW: (1) "did not experience," (2) "experienced and was compensated," and (3) "experienced and was not compensated." Burnout was measured using the Korean version of the Copenhagen Burnout Inventory, which has 3 subdomains: personal burnout (PB), work-related burnout (WRB), and citizen-related burnout (CRB). Multiple linear regression was applied to examine whether LCCOW was associated with burnout after adjusting for potential confounders. RESULTS: In total, 74.2% of participants experienced COVID-19-related overtime work, and 14.6% of those who worked overtime experienced LCCOW. COVID-19-related overtime work showed a statistically non-significant association with burnout. However, the association differed by LCCOW. Compared to the "did not experience" group, the "experienced and was not compensated" group was associated with PB (ß=10.519; 95% confidence interval [CI], 3.455 to 17.584), WRB (ß=10.339; 95% CI, 3.398 to 17.280), and CRB (ß=12.290; 95% CI, 6.900 to 17.680), whereas no association was observed for the "experienced and was compensated" group. Furthermore, an analysis restricted to EMS providers who worked overtime due to COVID-19 showed that LCCOW was associated with PB (ß=7.970; 95% CI, 1.064 to 14.876), WRB (ß=7.276; 95% CI, 0.270 to 14.283), and CRB (ß=10.000; 95% CI, 3.435 to 16.565). CONCLUSIONS: This study suggests that LCCOW could be critical in worsening burnout among EMS providers who worked overtime due to COVID-19.

Internalized homophobia and HIV testing among Korean gay and bisexual men: a study in a high-income country with pervasive HIV/AIDS stigma.

Limited research has been conducted on factors contributing to HIV testing among sexual minority populations in South Korea (hereafter, Korea), where stigma against homosexuality and HIV/AIDS is pervasive. We used a nationwide cross-sectional survey of 907 Korean cisgender gay and bisexual (GB) men who were HIV-negative or HIV-unknown in 2016. Regarding internalized homophobia (IHP), participants were categorized into tertiles (low, moderate, and high). Past 12-month HIV testing was assessed via a single yes/no question. Using a modified Poisson regression model, we examined the association between IHP and HIV testing among cisgender GB men in Korea. The overall prevalence of obtaining an HIV test was 41.8% among Korean cisgender GB men. We also found a statistically significant association between IHP and past 12-month HIV testing in this population. Specifically, participants with low IHP had a higher prevalence of HIV testing (adjusted PR = 1.37, 95% CI = 1.14-1.65) compared to those with high IHP. Given these findings, more efforts are needed in Korea to enhance GB men's access to HIV testing, such as improving social circumstances to lower IHP of GB men and creating an environment that enables and facilitates GB men to receive HIV testing without stigma against their sexual identity.

Racism, xenophobia, discrimination, and the determination of health.

This Series shows how racism, xenophobia, discrimination, and the structures that support them are detrimental to health. In this first Series paper, we describe the conceptual model used throughout the Series and the underlying principles and definitions. We explore concepts of epistemic injustice, biological experimentation, and misconceptions about race using a historical lens. We focus on the core structural factors of separation and hierarchical power that permeate society and result in the negative health consequences we see. We are at a crucial moment in history, as populist leaders pushing the politics of hate have become more powerful in several countries. These leaders exploit racism, xenophobia, and other forms of discrimination to divide and control populations, with immediate and long-term consequences for both individual and population health. The COVID-19 pandemic and transnational racial justice movements have brought renewed attention to persisting structural racial injustice.

Racism, xenophobia, and discrimination: mapping pathways to health outcomes.

Despite being globally pervasive, racism, xenophobia, and discrimination are not universally recognised determinants of health. We challenge widespread beliefs related to the inevitability of increased mortality and morbidity associated with particular ethnicities and minoritised groups. In refuting that racial categories have a genetic basis and acknowledging that socioeconomic factors offer incomplete explanations in understanding these health disparities, we examine the pathways by which discrimination based on caste, ethnicity, Indigeneity, migratory status, race, religion, and skin colour affect health. Discrimination based on these categories, although having many unique historical and cultural contexts, operates in the same way, with overlapping pathways and health effects. We synthesise how such discrimination affects health systems, spatial determination, and communities, and how these processes manifest at the individual level, across the life course, and intergenerationally. We explore how individuals respond to and internalise these complex mechanisms psychologically, behaviourally, and physiologically. The evidence shows that racism, xenophobia, and discrimination affect a range of health outcomes across all ages around the world, and remain embedded within the universal challenges we face, from COVID-19 to the climate emergency.

Association between discrimination and poor sleep health outcomes among 2192 South Korean gay, lesbian, and bisexual adults: A nationwide cross-sectional survey.

OBJECTIVE: The study aimed to assess the prevalence of poor sleep health outcomes and examine the associations between experiences of discrimination and the sleep health outcomes among lesbian, gay, and bisexual (LGB) adults in Korea. DESIGN & SETTING: The study used data from Rainbow Connection Project I, a nationwide cross-sectional survey of Korean LGB adults, conducted via online in 2016. MEASUREMENTS: Participants were asked about experiences of anti-LGB discrimination and discrimination based on other characteristics (ie, gender, age, place of origin, nationality/race, religion, appearance including height and weight, disability status, and other) in the past 12 months. Using the responses, the participants were categorized into 4 groups: those who experienced (1) none, (2) only anti-LGB discrimination, (3) only other types of discrimination, and (4) both anti-LGB and other types of discrimination. Past-week sleep quality, unrestful sleep, and long sleep latency were included as sleep health outcomes. RESULTS: Of the 2192 participants, 740 (33.8%) had poor sleep quality, 1211 (55.2%) had unrestful sleep, and 681 (31.1%) had long sleep latency in the past week. Participants who experienced both anti-LGB and other types of discrimination had 1.65 times (95% confidence interval [CI] = 1.38-1.98), 1.30 times (95% CI = 1.16-1.45), and 1.58 times (95% CI = 1.31-1.90) higher prevalence of poor sleep quality, unrestful sleep, and long sleep latency, respectively, compared to those without any experiences of discrimination. CONCLUSIONS: Experiencing discrimination may deprive Korean LGB adults of good quality sleep. Interventions that seek to prevent discrimination are needed to promote sleep health among Korean LGB individuals.

Discrimination keeps transgender people awake at night: A nationwide cross-sectional survey of 583 transgender adults in South Korea.

OBJECTIVES: We sought to investigate the association between transgender identity discrimination and sleep problems among transgender people in South Korea (hereafter, Korea), and whether family support for transgender identity plays a protective role in the association. DESIGN & SETTING: We analyzed a nationwide cross-sectional survey of 583 Korean transgender adults which was anonymously conducted through an online platform. MEASUREMENTS: Transgender identity discrimination was assessed using a single-item question. Sleep problems were defined as having any of the following problems: poor sleep quality, short sleep duration, and use of alcohol or sleep medications to fall asleep. Family support for transgender identity was classified into 3 groups as follows: not supportive, supportive, and unaware of participants' transgender identity. RESULTS: Of 583 participants, 383 (65.7%) experienced transgender identity discrimination over the past 12 months. Participants who experienced transgender identity discrimination were 1.48 times (95% confidence intervals [95% CI] = 1.19-1.83) more likely to have any sleep problems, compared to those who never experienced transgender identity discrimination. When stratified by family support level, the associations between transgender identity discrimination and sleep problems remained statistically significant only among those with a family unsupportive (adjusted prevalence ratio [aPR] = 1.64; 95% CI = 1.16-2.31) or unaware (aPR = 1.60; 95% CI = 1.01-2.52) of participants' transgender identity. However, the association was not statistically significant among those with a supportive family (aPR = 1.41; 95% CI = 0.96-2.07). CONCLUSION: Given transphobic environments in Korea, legal and institutional efforts are required to reduce transgender identity discrimination (eg, anti-discrimination laws) as well as to build trans-specific family resources.

Association Between Intimate Partner Violence and Suicidal Ideation Among Female and Male Adults in South Korea: A Nationally Representative Longitudinal Study.

This study sought to assess the prevalence of intimate partner violence (IPV) victimization and to examine the sex-stratified associations between IPV and suicidal ideation in South Korea. This study used nationally representative longitudinal survey data from 2011 to 2020 of the Korean Welfare Panel Study of 9732 married adults at baseline. Participants were annually asked about IPV experiences of verbal abuse, physical threat, or physical assault over the past year in 2011-2019. Suicidal ideation in the past year was assessed in the following year 2012-2020 of IPV experiences. Using multilevel logistic regression models, we examined the associations between IPV and suicidal ideation among married adults. The prevalence of verbal abuse, physical threat, and physical assault was respectively 19.8%, 3.0%, and 1.4% in females (n = 5056); and 18.8%, 2.7%, and 1.0% in males (n = 4676). After adjusting for potential confounders (e.g., lifetime suicidal ideation and random effects of individuals and households) in the same year when participants had IPV experiences, all types of IPV experiences were statistically associated with suicidal ideation in the following year among both females and males, except for physical threat among males. We found a statistically significant association between physical threat and suicidal ideation among females (adjusted odds ratio: 2.22, 95% confidence interval: 1.62, 3.04), whereas no association was observed among males. Our findings suggest that public health interventions related to suicidal behaviors that can be attributable to experiencing IPV are necessary among both females and males in South Korea.

Expectation of Rejection and Its Association with Health Care Avoidance and Delay Among 2175 Korean Lesbian, Gay, and Bisexual Adults: A Nationwide Cross-Sectional Survey.

Purpose: The study examined an association between expectation of rejection and health care avoidance and delay (HAD) among lesbian, gay, and bisexual (LGB) adults in South Korea. Methods: We analyzed data from a nationwide cross-sectional survey of 2175 South Korean LGB adults, which was approved by the Korea University Institutional Review Board. We categorized expectation of rejection into tertiles ("low," "medium," and "high" levels) and investigated its association with past 12-month HAD using multivariate modified Poisson regression. Results: After adjusting for covariates, including experiences of discrimination, participants with high levels of expectation of rejection had 1.38-times (95% confidence interval: 1.16-1.65) higher prevalence of HAD compared with those with low levels. Conclusion: Living in anticipation of rejection can negatively impact LGB adults' health care utilization.

Working Alone, Limited Restroom Accessibility, and Poor Menstrual Health Among Cosmetics Saleswomen in South Korea.

Menstrual hygiene management (MHM) at work has been neglected in occupational health research despite its importance for female workers' health. This study investigated the association between hours of working alone and poor menstrual health among 740 cosmetics saleswomen in South Korea. Hours of working alone in a day were classified into 4 categories. MHM was measured by asking "Over the past six months, have you ever experienced that you could not change your sanitary pad when you need to change it at work?" We also measured the experience of dermatopathy due to unchanged sanitary pads. Cosmetics saleswomen who worked alone for 3 h or more in a day reported a higher prevalence of ever being unable to change the sanitary pads (prevalence ratio [PR] 1.84, 95% confidence interval [CI]: 1.37-2.46) and dermatopathy due to unchanged sanitary pads (PR 2.06, 95% CI: 1.18-3.59) than those who worked alone less than 1 h in a day.

Adolescent Bullying Victimization at Secondary School and Adult Suicidality and Depressive Symptoms Among 2152 Lesbian, Gay, and Bisexual Adults in South Korea.

This study examined the association between adolescent bullying victimization (ABV) and adult mental health among lesbian, gay, and bisexual (LGB) individuals in South Korea (hereafter Korea). We conducted a cross-sectional survey of 2152 Korean LGB adults in 2016. Based on experiences of and reasons for ABV, participants were categorized into four groups: "never bullied," "bullied due to sexual orientation and gender expression (SOGE)," "bullied due to other reasons," and "bullied, reason unspecified." Compared with participants who have never been bullied during adolescence, those who have been "bullied due to SOGE" were 1.56 times, 1.53 times, and 3.59 times more likely to report depressive symptoms, suicidal ideation, and suicide attempts, respectively. Statistically significant associations with all three mental health indicators were also observed among those who have been "bullied due to other reasons": depressive symptoms (adjusted prevalence ratio [aPR] = 1.72), suicidal ideation (aPR = 1.48), and suicide attempts (aPR = 3.15). This study suggests that ABV may increase depressive symptoms and suicidality in adulthood among LGB individuals.

Validity evaluation of indirect adjustment method for multiple unmeasured confounders: A simulation and empirical study.

BACKGROUND: An indirect adjustment method was developed to control for unmeasured confounders in a large administrative cohort study. A previous study that proposed the indirect adjustment method assessed the validity of the method by simulations but did not consider the direction of bias and scenarios with multiple missing confounders. In this study, we evaluated the direction and the magnitude of bias of the indirect adjustment method with multiple correlated unmeasured confounders using simulation and empirical datasets. METHODS: A simulation study was conducted to compare the bias of the indirect adjustment by varying the number of confounders, magnitude of correlation between confounders, and the number of adjustment variables. An empirical study was conducted by applying the indirect adjustment method to the association between PM10 and mortality using the Korea National Health and Nutrition Examination Survey linked Cause of Death data for 2007-2016. RESULTS: The simulations of the present study demonstrated that 1) when a confounder is positively associated with both exposure and outcome, indirect adjustment might bias the effect size downward; 2) the magnitude of bias might depend on the correlation between unmeasured confounders; and 3) indirect adjustment for multiple missing confounders at once could result in a higher bias than that for some of the missing confounders. Empirical analyses also showed consistent results, but the bias of indirectly adjusted effect estimates was sometimes larger than that of unadjusted effect estimates. CONCLUSIONS: The indirect adjustment method is a promising technique to reduce the bias from unmeasured confounding; however, it should be implemented carefully, particularly when there are multiple correlated unmeasured confounders of the same direction.

Does Discrimination Affect Whether Transgender People Avoid or Delay Healthcare?: A Nationwide Cross-sectional Survey in South Korea.

This study examined the association between perceived discrimination and healthcare avoidance and delay (HAD) among transgender adults in South Korea (hereafter Korea). We conducted a nationwide cross-sectional survey of 244 Korean transgender adults in 2017. Discrimination within the last 12 months was categorized into four groups based on the reason(s) of discrimination experienced: (1) 'never experienced' discrimination, (2) 'only due to transgender identity,' (3) 'due to reason(s) other than transgender identity,' and (4) 'due to both transgender identity and other reason(s).' Korean transgender adults who experienced discrimination 'only due to transgender identity' and 'due to both transgender identity and other reason(s)' reported 1.91-times (95% CI 1.02-3.55) and 1.96-times (95% CI 1.32-2.92) higher prevalence of past 12-month HAD, respectively, than those who had no such experiences. Our findings suggest that institutional efforts are needed to protect transgender people from discrimination, which can contribute to improved access to healthcare among transgender populations in Korea.

Health Disparities Among Workers With Standing Position and Limited Restroom Access: A Cosmetics Saleswomen Study in South Korea.

Korean cosmetics sales workers in department stores face harmful working environments, including limited restroom access, working long hours in a standing position, and customer violence. This study investigated health disparities between cosmetics saleswomen and the general population of working women in South Korea. We assessed the prevalence of health indicators, including physician-diagnosed disease, using a cross-sectional survey of 860 Korean cosmetics saleswomen in September 2018. Health indicators of cosmetics saleswomen were compared to those of general working women from the nationally representative datasets (e.g., National Health Insurance Service-National Sample Cohort). We estimated age-standardized prevalence ratios (SPRs) for health outcomes, including physical, mental, and health-related behavioral conditions. Cosmetics saleswomen were more likely to be diagnosed or treated for physical and mental conditions (e.g., cystitis SPR: 4.03, 95% confidence interval [CI]: 3.48-4.65; plantar fasciitis SPR: 23.48, 95% CI: 18.12-29.93; varicose vein SPR: 38.41, 95% CI: 32.18-45.49; and depression SPR: 11.18, 95% CI: 8.53-14.40) compared to general working women. Prevalence of smoking and hazardous alcohol consumption was also higher among cosmetics saleswomen than those of general women workers. Given our findings, further research is needed to identify work-related risk factors that could deteriorate cosmetic sales workers' health in South Korea.