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1.
JDR Clin Trans Res ; : 2380084420939040, 2020 Jul 30.
Article in English | MEDLINE | ID: mdl-32731782

ABSTRACT

INTRODUCTION: Our ability to address child oral health inequalities would be greatly facilitated by a more nuanced understanding of whether underlying disease experience or treatment opportunities account for a larger share of differences between social groups. This is particularly relevant in the context of population subgroups who are socially marginalized, such as Australia's Indigenous population. The decayed, missing, and filled (dmf) surfaces index is at once a reflection of dental caries experience (d) and its management (m and f). OBJECTIVES: To 1) describe socioeconomic inequalities in dental caries experience and its management among Indigenous and non-Indigenous children and 2) compare these inequalities using absolute and relative measures. METHODS: Data were from the Australian National Child Oral Health Study 2012-2014. Absolute and relative income inequalities were assessed for overall dmfs and its individual components (ds, ms, fs) using adjusted means and health disparity indices (Slope Index of Inequality [SII] and Relative Index of Inequality [RII]). RESULTS: Mean dmfs among Indigenous children aged 5 to 10 y was 6.4 (95% confidence interval [CI], 5.4-7.4), ranging from 2.3 in the highest to 9.1 in the lowest income group. Mean dmfs among non-Indigenous children was 2.9 (95% CI, 2.8-3.1), ranging from 1.9 in the highest to 4.2 in the lowest income group. Age- and gender-adjusted social gradients for Indigenous children were evident across all dmfs components but were particularly notable for ds (SII = -4.6, RII = -1.7) and fs (SII = -3.2, RII = -1.5). The social gradients for non-Indigenous children were much lower in magnitude: ds (SII = -1.8, RII = -1.6) and fs (SII = -0.7, RII = -0.5). CONCLUSION: Our findings suggest that socioeconomic disadvantage may translate into both higher disease experience and increased use of dental services for both Indigenous and non-Indigenous groups, with the social gradients being much more amplified among Indigenous children. KNOWLEDGE TRANSFER STATEMENT: The findings of this study demonstrate the magnitude of disparities in dental caries among children by population groups in Australia. Our results suggest that the relationship between socioeconomic disadvantage and poor oral health is more deleterious among Indigenous than non-Indigenous children. Tackling upstream determinants of health might not only affect population patterns of health and disease but also mitigate the overwhelming racial inequalities in oral health between Indigenous and non-Indigenous Australians.

3.
Int J Equity Health ; 19(1): 114, 2020 07 06.
Article in English | MEDLINE | ID: mdl-32631328

ABSTRACT

Preliminary reports suggest that the Coronavirus Disease 2019 (COVID- 19) pandemic has led to disproportionate morbidity and mortality among historically disadvantaged populations. We investigate the racial and socioeconomic associations of COVID- 19 hospitalization among 418,794 participants of the UK Biobank, of whom 549 (0.13%) had been hospitalized. Both Black participants (odds ratio 3.7; 95%CI 2.5-5.3) and Asian participants (odds ratio 2.2; 95%CI 1.5-3.2) were at substantially increased risk as compared to White participants. We further observed a striking gradient in COVID- 19 hospitalization rates according to the Townsend Deprivation Index - a composite measure of socioeconomic deprivation - and household income. Adjusting for socioeconomic factors and cardiorespiratory comorbidities led to only modest attenuation of the increased risk in Black participants, adjusted odds ratio 2.4 (95%CI 1.5-3.7). These observations confirm and extend earlier preliminary and lay press reports of higher morbidity in non-White individuals in the context of a large population of participants in a national biobank. The extent to which this increased risk relates to variation in pre-existing comorbidities, differences in testing or hospitalization patterns, or additional disparities in social determinants of health warrants further study.


Subject(s)
Continental Population Groups/statistics & numerical data , Coronavirus Infections/ethnology , Coronavirus Infections/therapy , Health Status Disparities , Hospitalization/statistics & numerical data , Pneumonia, Viral/ethnology , Pneumonia, Viral/therapy , Adult , Aged , Biological Specimen Banks , Female , Humans , Male , Middle Aged , Pandemics , Prospective Studies , Socioeconomic Factors , United Kingdom/epidemiology
4.
Acad Pediatr ; 2020 Jul 08.
Article in English | MEDLINE | ID: mdl-32652121

ABSTRACT

Past research shows that high-quality public preschool may disproportionately support low-income children's school readiness, because low-income children tend to arrive at school with fewer of the academic skills needed for success. This suggests a compensatory process in human development in which the children who benefit most from a promotive factor are those who stand to gain the most. We propose that high-quality public preschool may similarly confer its greatest health rewards to low-income children, who are generally in poorer health than their peers. If that is true, preschool has the potential to narrow health disparities by income, which without intervention, persist into adulthood. To date, no one has articulated all the pathways through which high-quality public preschool may improve children's health, much less those that should disproportionately benefit those from low-income families. Drawing on the bioecological paradigm of human development, we propose a model identifying specific mechanisms likely to promote equity in child health. These mechanisms reflect core characteristics of high-quality public preschool that may disproportionately benefit low-income children's health. This model serves as a working template for a program of future research.

5.
J Sex Med ; 17(8): 1520-1528, 2020 Aug.
Article in English | MEDLINE | ID: mdl-32622764

ABSTRACT

BACKGROUND: In the United States, efforts to achieve health equity and reduce sexual health disparities remain a national priority; however, limited research has focused on understanding racial differences in patient/provider discussions about sexual health. AIM: To quantify racial differences between black and white women (aged 18-49 years) in the United States discussing sexual health with a healthcare provider in the past year. METHODS: Data were analyzed from a subset of 1,654 women aged 18-49 years who participated in the 2018 National Survey of Sexual Health and Behavior. Measures of interest included visiting a healthcare provider and discussing sexual health with the provider in the past year. Log binomial models were developed to estimate risk ratios for the likelihood of sexual health topics encountered by black women; models were adjusted for age, marital status, education level, and annual income. MAIN OUTCOME: Black women were significantly more likely to report having a healthcare visit in the past year compared to white women and were more likely to have discussed their sexual health activities. RESULTS: The adjusted risk ratio (ARR) for black women who reported discussing sex or sexual health with a healthcare provider was 1.16 (95% CI: 1.06-1.26). The ARR for black women who were asked if they were sexually active was 1.16 (95% CI: 1.06-1.26) and about their condom use was 1.49 (95% CI: 1.27-1.74). Black women were nearly 2 times more likely to be offered sexually transmitted disease testing (ARR: 1.72, 95% CI: 1.46-2.02) and to report that they were provided condoms for future use (ARR: 1.94, 95% CI: 1.12-3.36). CLINICAL TRANSLATION: Healthcare providers are encouraged to have routine sexual health discussions with all patients; however, we found that there are differences among black and white women in discussing their sexual health activities. STRENGTHS & LIMITATIONS: The present study utilized a nationally representative probability survey, including an oversample of black women. The study focused on sexual health discussions of black and white women with a healthcare provider, and therefore, women who did not have a healthcare visit in the past year were excluded from the analysis. CONCLUSION: Black women reported having conversations about their sexual activities (eg, condom use) and were offered sexually transmitted disease testing more often than white women. These data provide insights that will impact patient/provider communication and aid in improving the delivery of sexual healthcare for all women. Townes A, Rosenberg M, Guerra-Reyes L, et al. Inequitable Experiences Between Black and White Women Discussing Sexual Health With Healthcare Providers: Findings From a U.S. Probability Sample. J Sex Med 2020;17:1520-1528.

6.
Circ Cardiovasc Qual Outcomes ; : CIRCOUTCOMES119006438, 2020 Jul 24.
Article in English | MEDLINE | ID: mdl-32703013

ABSTRACT

Background Socially determined vulnerabilities (SDVs) to health disparities often cluster within the same individual. SDVs are separately associated with increased risk of heart failure (HF). The objective of this study was to determine the cumulative effect of SDVs to health disparities on incident HF hospitalization. Methods and Results Using the REGARDS (Reasons for Geographic and Racial Differences in Stroke) cohort study, we studied 25 790 participants without known HF and followed them for 10+ years. Our primary outcome was an incident HF hospitalization through December 31, 2016. Guided by the Healthy People 2020 framework for social determinants of health, we examined 10 potential SDVs. We retained SDVs associated with incident HF hospitalization (P<0.10) and created an SDV count (0, 1, 2, 3+). Using the count, we estimated Cox proportional hazard models to examine associations with incident HF hospitalization, adjusting for potential confounders. Models were stratified by age (45-64, 65-74, and 75+ years) because past reports suggest greater disparities in HF incidence at younger ages. Participants were followed for a median of 10.1 years (interquartile range, 6.5-11.9). Black race, low educational attainment, low annual household income, zip code poverty, poor public health infrastructure, and lack of health insurance were associated with incident HF hospitalization. In adjusted models, among those 45 to 64 years, compared with having no SDV, having 1 SDV (hazard ratio, 1.85 [95% CI, 1.12-3.05]), 2 SDVs (hazard ratio, 2.12 [95% CI, 1.28-3.50]), and 3+ SDVs (hazard ratio, 2.45 [95% CI, 1.48-4.04]) were significantly associated with incident HF hospitalization (P for trend, 0.001). We observed no significant associations for older individuals. Conclusions A greater number of SDVs significantly increased risk of incident HF hospitalization among adults <65 years, which persisted after adjustment for cardiovascular risk factors. Using a simple SDV count that could be obtained from a social history during clinical assessment may identify younger individuals at increased risk.

8.
Appl Clin Inform ; 11(3): 497-514, 2020 May.
Article in English | MEDLINE | ID: mdl-32726836

ABSTRACT

BACKGROUND: Health care disparity persists despite vigorous countermeasures. Clinician performance is paramount for equitable care processes and outcomes. However, precise and valid individual performance measures remain elusive. OBJECTIVES: We sought to develop a generalizable, rigorous, risk-adjusted metric for individual clinician performance (MIP) derived directly from the electronic medical record (EMR) to provide visual, personalized feedback. METHODS: We conceptualized MIP as risk responsiveness, i.e., administering an increasing number of interventions contingent on patient risk. We embedded MIP in a hierarchical statistical model, reflecting contemporary nested health care delivery. We tested MIP by investigating the adherence with prophylactic bundles to reduce the risk of postoperative nausea and vomiting (PONV), retrieving PONV risk factors and prophylactic antiemetic interventions from the EMR. We explored the impact of social determinants of health on MIP. RESULTS: We extracted data from the EMR on 25,980 elective anesthesia cases performed at Penn State Milton S. Hershey Medical Center between June 3, 2018 and March 31, 2019. Limiting the data by anesthesia Current Procedural Terminology code and to complete cases with PONV risk and antiemetic interventions, we evaluated the performance of 83 anesthesia clinicians on 2,211 anesthesia cases. Our metric demonstrated considerable variance between clinicians in the adherence to risk-adjusted utilization of antiemetic interventions. Risk seemed to drive utilization only in few clinicians. We demonstrated the impact of social determinants of health on MIP, illustrating its utility for health science and disparity research. CONCLUSION: The strength of our novel measure of individual clinician performance is its generalizability, as well as its intuitive graphical representation of risk-adjusted individual performance. However, accuracy, precision and validity, stability over time, sensitivity to system perturbations, and acceptance among clinicians remain to be evaluated.

9.
Semin Perinatol ; : 151267, 2020 Jun 19.
Article in English | MEDLINE | ID: mdl-32684310

ABSTRACT

Perinatal health outcomes in the United States continue to worsen, with the greatest burden of inequity falling on Black birthing communities. Despite transdisciplinary literature citing structural racism as a root cause of inequity, interventions continue to be mostly physician-centered models of perinatal and reproductive healthcare (PRH). These models prioritize individual, biomedical risk identification and stratification as solutions to achieving equity, without adequately addressing the social and structural determinants of health. The objective of this review is to: (1) examine the association between the impact of structural and obstetric racism and patient-centered access to PRH, (2) define and apply reproductive justice (RJ) as a framework to combat structural and obstetric racism in PRH, and (3) describe and demonstrate how to use an RJ lens to critically analyze physician-led and community-informed PRH models. We conclude with recommendations for building a PRH workforce whose capacity is aligned with racial equity. Institutional alignment with a RJ praxis creates opportunities for advancing PRH workforce diversification and development and improving PRH experiences and outcomes for our patients, communities, and workforce.

10.
Official Document;361
Monography in English | PAHO-IRIS | ID: phr-52473

ABSTRACT

The Pan American Health Organization (PAHO) Strategic Plan sets out the Organization’s strategic direction, based on the collective priorities of its Member States, and specifies the public health results to be achieved during the period 2020-2025. The Plan establishes the joint commitment of PAHO Member States and the Pan American Sanitary Bureau for the next six years. PAHO Member States have clearly stated that the Strategic Plan is a principal instrument for implementation of the Sustainable Health Agenda for the Americas 2018-2030 (SHAA2030) and thus for realizing the health-related Sustainable Development Goals (SDGs) in the Region of the Americas. The 11 SHAA2030 goals form the impact-level objectives of this Plan. Under the theme Equity at the Heart of Health, this Plan seeks to catalyze efforts in Member States to reduce inequities in health within and between countries and territories in order to improve health outcomes. The Plan identifies specific actions to tackle health inequality, including those recommended by the Commission on Equity and Health Inequalities in the Americas, with guidance from the High-level Commission for Universal Health. Four cross-cutting themes are central to this Plan’s approach to addressing the determinants of health: equity, gender, ethnicity, and human rights. In addition to highlighting an integrated multisectoral approach, this Plan applies evidence-based public health strategies, such as health promotion, the primary health care approach, and social protection in health, to address the social determinants. In addition to directly addressing the regional priorities established in the SHAA2030, this Plan aligns with the World Health Organization (WHO) 13th General Programme of Work (GPW13) and with other regional and global mandates in force during the planning period.


Subject(s)
Pan American Health Organization , Health Programs and Plans , Health Priorities , Universal Access to Health Care Services , Health Equity , Sustainable Development , Health Services , Health Priority Agenda , Communicable Diseases , Risk Factors , Environment and Public Health , Policies and Cooperation in Science, Technology and Innovation , Technical Cooperation , South-South Cooperation , Chronic Disease
11.
Article in English | MEDLINE | ID: mdl-32602040

ABSTRACT

This analysis develops indices of (1) modifiable social determinants of health and (2) social determinant inequity and applies the indices to the black population in US states. It uses state data available between 2013 and 2018 stratified by black and white race on six social determinants covering a range of topics (high school non-completion, incarceration, non-home ownership, poverty, unemployment, and voter non-registration). Determinants are ranked by state on (1) limited determinant access by blacks and (2) on black-white determinant differences, i.e., inequity. For each state, ranks are summed for each determinant and determinant differences. Greater determinant access and greater equity are found in southern states. More limited access is found in northeastern and western states; lowest ranked of access is found in some midwestern states. Greatest equity is found in southern states; greatest inequity is found in midwestern states. Indices are associated with state rates of black self-reported health. Indices of social determinant access and inequity can be developed and applied to states for US minority populations. The indices promote attention to the differential distribution of social determinants, suggest the consequences of structural racism, and indicate targets for the redress of inequity.

12.
Am J Epidemiol ; 2020 Jul 03.
Article in English | MEDLINE | ID: mdl-32619007

ABSTRACT

Epidemiology of the U.S. COVID-19 outbreak focuses on individuals' biology and behaviors, despite centrality of occupational environments in the viral spread. This demonstrates collusion between epidemiology and racial capitalism because it obscures structural influences, absolving industries of responsibility for worker safety. In an empirical example, we analyze economic implications of race-based metrics widely used in occupational epidemiology. In the U.S., White adults have better average lung function and worse hearing than Black adults. Both impaired lung function and hearing are criteria for Worker's compensation, which is ultimately paid by industry. Compensation for respiratory injury is determined using a race-specific algorithm. For hearing, there is no race adjustment. Selective use of race-specific algorithms for workers' compensation reduces industries' liability for worker health, illustrating racial capitalism operating within public health. Widespread and unexamined belief in inherent physiological inferiority of Black Americans perpetuates systems that limit industry payouts for workplace injuries. We see a parallel in the epidemiology of COVID-19 disparities. We tell stories of industries implicated in the outbreak and review how they exemplify racial capitalism. We call on public health professionals to: critically evaluate who is served and neglected by data analysis; and center structural determinants of health in etiological evaluation.

14.
Article in English | MEDLINE | ID: mdl-32635209

ABSTRACT

The aim of this study is to investigate the impact of social integration and socioeconomic status on immigrant health in China. Taking the framework of social determinants of health (SDH) as the theoretical starting point, this paper uses the Hangzhou sample of the 2018 Survey of Foreigners in China (SFRC2018) to explore two core factors affecting the health inequality of international migrants in China: the level of social integration following settlement, and socioeconomic status before and after coming to China. The results show that having a formal educational experience in China helped improve both the self-rated health status and self-assessed change in health of international migrants; that the socioeconomic status of an emigrant's home country affected self-rated health; and that the self-assessed change in health of immigrants from developing countries was significantly higher than those from developed countries. This study concludes that the health inequalities of immigrant populations in China must be understood in the context of China's specific healthcare system and treatment structure.

16.
Fam Process ; 2020 Jun 26.
Article in English | MEDLINE | ID: mdl-32589267

ABSTRACT

The COVID-19 pandemic brings to the forefront the complex interconnected dilemmas of globalization, health equity, economic security, environmental justice, and collective trauma, severely impacting the marginalized and people of color in the United States. This lack of access to and the quality of healthcare, affordable housing, and lack of financial resources also continue to have a more significant impact on documented and undocumented immigrants. This paper aims at examining these critical issues and developing a framework for family therapists to address these challenges by focusing on four interrelated dimensions: cultural values, social determinants of health, collective trauma, and the ethical and moral responsibility of family therapists. Given the fact that family therapists may unwittingly function as the best ally of an economic and political system that perpetuates institutionalized racism and class discrimination, we need to utilize a set of principles, values, and practices that are not just palliative or after the fact but bring forth into the psychotherapeutic and policy work a politics of care. Therefore, a strong call to promote and advocate for the broader continuum of health and critical thinking preparing professionals to meet the challenges of health equity, as well as economic and environmental justice, are needed. The issues discussed in this paper are specific to the United States despite their relevance to family therapy as a field. We are mindful not to generalize the United States' reality to the rest of the world, recognizing that issues discussed in this paper could potentially contribute to international discourse.

17.
Hastings Cent Rep ; 50(3): 58-60, 2020 May.
Article in English | MEDLINE | ID: mdl-32596896

ABSTRACT

In recent months, Covid-19 has devastated African American communities across the nation, and a Minneapolis police officer murdered George Floyd. The agents of death may be novel, but the phenomena of long-standing epidemics of premature black death and of police violence are not. This essay argues that racial health and health care disparities, rooted as they are in systemic injustice, ought to carry far more weight in clinical ethics than they generally do. In particular, this essay examines palliative and end-of-life care for African Americans, highlighting the ways in which American medicine, like American society, has breached trust. In the experience of many African American patients struggling against terminal illness, health care providers have denied them a say in their own medical decision-making. In the midst of the Covid-19 pandemic, African Americans have once again been denied a say with regard to the rationing of scarce medical resources such as ventilators, in that dominant and ostensibly race-neutral algorithms sacrifice black lives. Is there such thing as a "good" or "dignified" death when African Americans are dying not merely of Covid-19 but of structural racism?


Subject(s)
African Americans , Coronavirus Infections/epidemiology , Healthcare Disparities/ethnology , Palliative Care/organization & administration , Pneumonia, Viral/epidemiology , Terminal Care/organization & administration , Betacoronavirus , Health Care Rationing/ethics , Healthcare Disparities/ethics , Humans , Palliative Care/ethics , Pandemics , Racism , Social Determinants of Health/ethics , Social Determinants of Health/ethnology , Social Justice , Terminal Care/ethics , Trust , United States/epidemiology
18.
Am J Public Health ; 110(8): 1175-1181, 2020 Aug.
Article in English | MEDLINE | ID: mdl-32552022

ABSTRACT

Coronary heart disease (CHD) mortality rates in the United States have declined by up to two thirds in recent decades. Closer examination of these trends reveals substantial inequities in the distribution of mortality benefits. It is worrying that the uneven distribution of CHD that exists from lowest to highest social class-the social gradient-has become more pronounced in the United States since 1990 and is most pronounced for women.Here we consider ways in which this trend disproportionately affects premenopausal women aged 35 to 54 years. We apply a social determinants of health framework focusing on intersecting axes of inequalities-notably gender, class, ethnicity, geographical location, access to wealth, and class-among other power relations to which young and middle-aged women are especially vulnerable, and we argue that increasing inequalities may be driving these unprecedented deteriorations. We conclude by discussing interventions and policies to target and alleviate inequality axes that have potential to promote greater equity in the distribution of CHD mortality and morbidity gains.The application of this framework in the context of women's cardiovascular health can help shed light regarding why we are seeing persistently poorer outcomes for premenopausal US women.

19.
J Adolesc Health ; 2020 Jun 08.
Article in English | MEDLINE | ID: mdl-32527573

ABSTRACT

Adolescents and young adults, aged 13-24 years, are disproportionately affected by HIV in the United States. Youth with HIV (YHIV) face many psychosocial and structural challenges resulting in poor clinical outcomes including lower rates of medication adherence and higher rates of uncontrolled HIV. The Johns Hopkins Intensive Primary Care clinic, a longstanding HIV care program in Baltimore, Maryland, cares for 76 YHIV (aged 13-24 years). The multidisciplinary team provides accessible, evidenced-based, culturally sensitive, coordinated and comprehensive patient and family-centered HIV primary care. However, the ability to provide these intensive, in-person services was abruptly disrupted by the necessary institutional, state, and national coronavirus disease 2019 (COVID-19) mitigation strategies. As most of our YHIV are from marginalized communities (racial/ethnic, sexual, and gender minorities) with existing health and social inequities that impede successful clinical outcomes and increase HIV disparities, there was heightened concern that COVID-19 would exacerbate these inequities and amplify the known HIV disparities. We chronicle the structural and logistic approaches that our team has taken to proactively address the social determinants of health that will be negatively impacted by the COVID-19 pandemic, while supporting YHIV to maintain medication adherence and viral suppression.

20.
Rev Bras Epidemiol ; 23: e200038, 2020.
Article in English, Portuguese | MEDLINE | ID: mdl-32491050

ABSTRACT

INTRODUCTION: Sexual violence has emerged in the health field with changes in the epidemiological profiles of populations. METHODOLOGY: An ecological study with 5,565 Brazilian municipalities between 2010 and 2014. A descriptive analysis of the variables (Population rate of sexual violence reporting, household income per capita and HDI) and their stratification by quintile was performed. In order to explore the factors associated with changes in social inequalities regarding the rate of reporting of sexual violence, the Slope Index of Inequality and Relative Index of Inequality were adopted. An Equiplot was constructed for the outcome on each independent variable. RESULTS: The mean rate of reports of sexual violence in Brazil was 4.38 reports/100,000 inhabitants for the period. There was an increase in the rate of sexual violence and improvement in socioeconomic conditions. There was a higher rate of reporting in the quintile with better living conditions. An increase in the inequality of the rate of sexual violence as a function of household income and the HDI was observed. Several factors seem to influence the increase of reports of sexual violence in the country, among them the improvement in the living conditions of the population and greater moral sensitivity to violence. However, there is still a disparity in reporting among municipalities according to their socioeconomic status. CONCLUSION: The lack of public policies on social equity in health has interfered with reports of sexual violence in the country and has widened health inequities.


Subject(s)
Health Status Disparities , Sex Offenses/trends , Social Determinants of Health/trends , Socioeconomic Factors , Brazil/epidemiology , Cities/epidemiology , Female , Humans , Linear Models , Male , Mandatory Reporting , Sex Offenses/statistics & numerical data , Social Conditions/trends , Time Factors
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