Browsing by Subject "Health disparities"

Introduction: In the fourth decade of the HIV epidemic, African American women continue to be disproportionately affected by HIV across all age ranges in the U.S. African American women make up only 13% of the female population in the U.S. yet account for 64% of HIV infections among women (Aitcheson et al., 2014). African American women face multiple challenges that intersect to influence how they effectively age into older adulthood and manage their health. Due to the increased challenges experienced by older African American women across the life course, it is imperative to identify factors that may mitigate the challenges of aging with the disease. Scant research exists focusing specifically on older African American women with HIV and thus our understanding of their experiences is still quite limited. Examining the personal strengths and social resources utilized to curb the deleterious effects of aging is necessary to improve health and well-being in this population.

Purpose and Methods: The purpose of this dissertation was to advance our understanding of the experiences of African American women with HIV aging across the life course with particular attention paid to the influence of the role of social relationships on health and well-being. The purpose was achieved through exploring the challenges of aging with HIV as an African American woman and the importance of utilizing the life course perspective (Elder & Giele, 2009) to explore their experiences over time; examining the literature on the relationship between social relationships and health; and presenting two papers from the findings of a qualitative descriptive study conducted with older African American women that explored their experiences over the life course. Eighteen African American women over the age of 50 participated in this qualitative study that utilized in-depth life history interviews and timelines as the primary means of data elicitation. In the first paper, we analyzed the data for experiences with social relationships across the life course. In the second paper, we analyzed trajectories and turning points across the life course.

Results: Findings from the first paper highlight that developing and maintaining relationships over time was influenced by a variety of life course themes at the personal, relational, and structural level presented over three developmental time periods (childhood/adolescence, young/middle adulthood, and older adulthood). Women described tremendous barriers to relationship development and maintenance in both childhood/adolescence and young/middle adulthood including child sexual abuse, crack cocaine addiction, intimate partner violence, and HIV-related stigma. Women also reported having large social networks in younger years but not many important relationships. In contrast, older adulthood was described as a time with more positive social relationships, especially for those who were addicted to crack cocaine in their youth. As women aged, they built supportive networks with people they valued.

Findings from the trajectories and turning points paper show that while trajectories across participants were diverse, they were categorized into three main patterns: anchored; early struggling and upward progression; and continuously struggling. Life experiences were most dissimilar between women who experienced crack cocaine addiction compared to women who never used to drugs. The syndemic impact of substance abuse, violence, and HIV (Singer, 2009) was also important as was the cyclical nature of these co-occurring epidemics over time. Our study provides evidence that a traumatic event in early life may be the first step in the syndemic cycle.

In this dissertation, I conduct three studies focusing on differences in social groups and their health outcomes or opinions related to medical practices. In Chapter 1, I outline each study and its findings.

Chapter 2 focuses on the Great Recession in the United States (2007–2009) and how this crisis is associated with health disparities. In this chapter, I use nine waves spanning 16 years (1998-2014) of the RAND version of the Health and Retirement Study (HRS) to examine disparities in cardiovascular disease, stroke, or related death (e.g., circulatory disease) among Americans ages 50 and older to determine whether these health disparities among different educational groups narrowed, widened, or remained constant during and after the Great Recession. In general, findings from discrete-time hazard analyses suggest that the disparities remained relatively constant with some (nonsignificant) evidence of some narrowing between the most educated and least educated groups.

Chapter 3 examines whether there is symmetry in the effects of certain health behaviors—smoking, drinking, weight management—on cardiovascular disease, stroke, or related death between socioeconomic groups. This chapter also uses nine waves (1998–2014) of the RAND HRS. Discrete-time hazard regression analyses indicate that while those with higher socioeconomic status maintain better health outcomes regardless of health behaviors, the effects of health behaviors are not equally distributed. Poor weight management and higher numbers of daily cigarettes are associated with a greater increased risk for those with more education than for those with less. The effects of heavy drinking, however, are less severe for the those with the most education compared to those with the least education.

Chapter 4 studies the role of social change by investigating trends in approval for euthanasia among cohorts in the United States and how those trends are influenced by cohort replacement and religious attitudes. This chapter uses 16 waves of the General Social Survey (1985–2014) and estimates differences in approval ratings between cohorts using logistic regression models. Results show that baby boomers are significantly more likely to approve of euthanasia than either their predecessors or successors, suggesting a cohort effect. Individuals belonging to more conservative religious groups and displaying higher levels of religiosity are less likely to approve. With the meaningful effect of cohorts on approval for euthanasia, findings suggest that as baby boomers age and as the population becomes less religious, approval for euthanasia might increase again.

Background: While nationwide health surveys commonly assess the prevalence of mental health conditions and disability status at the population level, they often fail to elucidate the relationship between mental health and disability. The aim of this study is to estimate the association between past-month poor mental health days and two indicators of disability (difficulty doing errands alone and difficulty making decisions) among sexual and gender minority (SGM) respondents to the 2021 BRFSS survey. Methods: A secondary analysis was conducted on the publicly accessible 2021 BRFSS data to estimate the association between past-month poor mental health days and indicators of disability among SGM. Logistic regression models were used to report odds ratios and 95% confidence intervals. We then examined potential effect modification by gender, sexual orientation, race, and SES factors, and present stratified estimates as indicated. Results: We observed increasing difficulty of completing errands alone with increasing past-month poor mental health days (OR 2.64, 95% CI 2.194, 3.178 at moderately poor mental health; OR 5.025, 95% CI 4.289, 5.889 at severely poor mental health). This association is modified by gender and SES. We also observed increasing difficulty of making decisions alone with increasing past-month poor mental health days (OR 3.298, 95% CI 2.871, 3.787 at moderately poor mental health; OR 6.792, 95% CI 5.979, 7.716 at severely poor mental health). This association is modified by sexual orientation, gender and race. Conclusions: There are clear dose response relationships between mental health and the two disability outcomes that are modified by socioeconomic status, gender and sexual identity.

Studies of human health have recently expanded to focus on the exposome paradigm, encompassing allexposures humans encounter from conception onward. The central theme of this work is to develop and test novel statistical methodologies that can address the challenges of the complex relationships between environmental exposures, socioeconomic distress, and health outcomes. However, source, measurement, and volume intricacies inherent to these data have constrained progression of statistical methods for key research questions.

In this work, we explore three approaches to characterizing community health and its potential impact on several types of disease outcomes. In the first approach, we implement a latent class model to socioeconomic and comorbidities data and explore these classifications as fixed effects in an ecological spatial model of COVID-19 cases and deaths in NYC during two time periods of the pandemic. In the second, we use a non-parametric Bayesian approach to form socio-economic and pollution cluster profiles across US counties. We then use these profiles to inform a Bayesian spatial model on breast cancer mortality for data from 2014. In the final approach, we utilize a latent network model traditionally used in psychometrics research to explore structural racism. Using information from five domains (employment, education, housing, health, and criminal justice), we identify new variable complexes to illustrate the complex the manifestations of structural racism at the census tract level in Pennsylvania.

In 2010, approximately 84% of the American population lives in a metropolitan area. Different metropolitan areas are characterized by distinct labor markets and economies, housing markets and residential patterns, socioeconomic and demographic factors, and according to some, even distinct 'spirits.' The nature and influence of such structural factors lie at the heart of urban sociology, and have particularly profound effects on patterns of racial and ethnic stratification. This dissertation examines new urban structural changes arising within recent decades, and their implications for racial/ethnic stratification. Specifically, I study the transition to the 'new economy' and racial/ethnic wage inequality; increases in the level and inequality of housing prices and racial/ethnic stratification in homeownership; and increased income inequality, combined with population aging, and racial/ethnic disparities in disability and poor health. I measure metropolitan-level structural factors and racial/ethnic inequalities with data from 5% samples of the 1980, 1990, and 2000 Censuses; the 2010 American Community Survey (ACS); and the 1999-2001 and 2009-2011 Current Population Surveys (CPS). Cross-sectional multilevel regression models examine the spatial distributions of structural factors and racial/ethnic inequality, and the fixed-effects regression models identify the impact of changes in structural factors over time on observed trends in racial stratification. Additionally, I distinguish between effects on minority-white gaps in resource access, and minorities' levels of resource access. This dissertation also makes novel contributions to the field by empirically documenting complex patterns of inequalities among the country's four largest racial and ethnic groups. Perhaps most relevant to theories of racial stratification, this dissertation demonstrates seemingly race-neutral structural changes can have racially stratified effects.

Chapter 1 describes the foundational literature in urban sociology and racial/ethnic stratification, and provides an overview of the subsequent chapters. Chapter 2 measures the transition to the `new economy' with six structural factors of labor markets: skill-biased technological change, financialization, the rise of the creative class, employment casualization, immigration, and deunionization. Overall, the results indicate the observed Latino-white wage gap may be up to 40% larger in 2010 than in the theoretical absence of the new economy, and the black-white wage gap may be up to 31% larger. Chapter 3 focuses on the long-term trend toward higher and more unequally distributed home prices within local housing markets, epitomized by the housing crisis of the late 2000s. Increases in housing market inequality worsen the Asian-white homeownership gap, but narrow the black-white and Latino-white gaps. However, the level of homeownership is reduced for all groups. Chapter 4 empirically tests the frequently-debated Income Inequality Hypothesis, that macro-level income inequality undermines population health, and hypothesizes any negative effect on health is stronger in areas with greater population aging. The results provide no support for the Income Inequality Hypothesis or any of its proposed extensions, but the chapter's analytic approach may be fruitfully applied to future examinations of structural determinants of health. The theoretical and substantive conclusion of the dissertation is that metropolitan areas represent salient, and changing structural contexts that significantly shape patterns racial/ethnic stratification in America.

Black females experience disparate rates of hypertension and earlier decline in cardiovascular health (CVH) than other females in the U.S. To date, much of research has focused on health behaviors, but more research is needed to understand how adversities early in life and in the social environment may contribute to premature decline in CVH among young Black women. Studies show that early life stress in the form of adverse childhood experiences (ACEs), like family dysfunction and child maltreatment, are reported in higher numbers by women, and historically minoritized populations, and experiencing four or more adversities in childhood may independently double the odds of CVD. In addition, social adversities like racial discrimination, housing insecurity, and social isolation in young adulthood may also contribute to inequities in CVH. Many health behaviors, such as cigarette use and dietary intake, are used as a stress coping measure, further highlighting the importance of understanding the stressors and adversities that are commonly experienced by young adult Black women. However, much of research has focused on CVD as a disease of middle and older adults, but less is known about the CVH of young adult Black women.

Young adulthood is an important developmental period when women are busy launching careers, and establishing social roles such as intimate partnerships and parenting, and forming new health behavior patterns to accommodate these changes. Per the developmental origins of health and disease hypothesis, stress, adversity, and health behaviors in young adulthood not only affect the individual, but also that of future generations. Improving the CVH of young adult Black women is essential to reducing and eliminating health inequities, and requires an appreciation of the heterogeneity among Black women, and the use of innovative approaches to identify subgroups of women who are doing well.

This dissertation includes a systematic review of the published literature on ACEs and blood pressure among women in the United States, and a secondary analysis of The National Longitudinal Study of Adolescent to Adult Health (Add Health) to examine how adverse childhood and social experiences relate to the cardiovascular health (CVH) health of young adult Black women. The systematic search of three databases identified 1,640 articles, and ten met all established inclusion criteria. In our review ACEs were positively associated with blood pressure in six of the ten articles reviewed. The inconsistency in results may be related to self-report vs objective assessment of blood pressure. Racial and ethnic diversity was limited, with half of the articles consisting of samples that were majority White. Future research should incorporate diverse, population representative samples, with consideration for sex-or-race specific stressors, such as racism, and its potential impact on blood pressure and CVH.

Data presented in the remaining three chapters of the dissertation study are an observational, cross-sectional analysis of data from Black females, ages 24-32 who participated in the Add Health study at wave four. The first data based chapter examines if social adversities and sleep characteristics are indicators of increased risk of hypertension among young adult Black women. Of the five social adversities (social isolation, discrimination, high perceived stress, low subjective social status, child abuse) and four sleep characteristics examined (delayed sleep onset, poor sleep continuity, short sleep, long sleep, and snoring), only discrimination and poor sleep continuity were positively associated with higher odds of hypertension, adjusting for age and BMI. Since social adversities often co-exist, the next chapter examined patterns or latent classes of social adversity. Three latent classes were identified: (1) low stress, (2) high violence, and (3) high stress. In analyses adjusted for age, income, education and depression, the subclasses of social adversity were related to diet, and physical activity, but were not related to overall ideal CVH. Whereas chapters 3 and 4 both focused on stressors in young adulthood as predictors of CVH, chapter 5 added an additional life course perspective by considering the impact of adverse childhood experiences on CVH. This chapter also sought to advance the literature by examining the maternal relationship and religion and spirituality in adolescence and young adulthood as potential protective factors that may buffer the stress of childhood adversity. The results in chapter five suggest that a strong religious and spiritual connection in adolescence or young adulthood may promote CVH among young Black women, but it’s impact on CVH is diminished after taking into account other factors such as severity of ACEs, socioeconomic status, and mental health. The second proposed protective factor, maternal relationship, did not have a significant direct influence on CVH.

This study may be the first to explore CVH in a within-group, population-representative sample of young adult Black women in the United States. The present findings suggest there are critical differences in how social contributors influence health, and in fact, many of the social constructs measured had little influence on health. This suggests that the factors measured may not accurately reflect the underlying construct for different subpopulations. Moreover, there may be other social factors that are not well captured in existing scientific research that likely are impacting the health of Black women and need to be explored, to advance the American Heart Association’s goal of equitable improvements in CVH.

Frailty is a common geriatric syndrome in older adults associated with a host of adverse outcomes. Frailty disproportionately affects women, older adults who identify as Hispanic, non-Hispanic Black, and those with less income in the US. The underlying mechanism contributing to frailty disparities across structural social determinants of health (gender, race, ethnicity, and education) is poorly understood. This study aimed to elucidate whether these structural social determinants operate through intermediary biological factors (cardiometabolic) and psychosocial stressors and influence frailty in community-dwelling older adults in the US. The World Health Organization’s conceptual framework of action on social determinants of health (CSDH) underpins this study. The CSDH framework claims that structural social determinants of health shape social hierarchy contingent on individuals’ gender, race, ethnicity, and education, which may offer structural advantages and disadvantages. Individuals’ ranking in the social hierarchy may differentially expose them to intermediary health-promoting or damaging factors leading to disparate health outcomes. This study hypothesized that structural social determinants (gender, race, ethnicity, and education) are associated with disproportionate exposure to intermediary biological cardiometabolic factors and psychosocial stressors, which may be related to the differential frailty risk. This cross-sectional, descriptive, correlational study is the secondary analysis of the existing data from the Health and Retirement Study (HRS). This study involved approximately 8000 older adults (65 years and above) who met the eligibility criteria for the examination of physical, cardiometabolic biomarker measurements, and psychosocial information in 2006 or 2008. We used the Fried phenotype to classify frailty on the basis of the presence of at least three features, such as poor grip strength, slow gait speed, fatigue, weight loss, and low physical activity. We used clinical cutoffs to dichotomize the presence and absence of seven cardiometabolic factors (elevated blood pressure, sugar, C-reactive protein, total cholesterol; obesity, abdominal obesity, and low high-density lipoprotein). Based on empirical studies, we dichotomized six psychosocial factors (loneliness, financial strain, perceived everyday discrimination, subjective social status, poor neighborhood, and experience of traumatic life events) originating from multiple life domains into high and low psychosocial stressors. We used latent class analysis to identify subgroups of older adults with distinct combinations of cardiometabolic (typologies). Path analysis (a series of logistic regressions) was used to examine the structural determinants and cardiometabolic relationships with frailty and explore whether cardiometabolic typologies mediate the relationship between structural determinants and frailty. Our results further confirm that frailty disparities persist. Female, older adults who identify as Hispanic, non-Hispanic Black, and those with less education had a higher frailty risk relative to male, non-Hispanic White older adults, and those with high education. Structural social determinants were significantly related to latent subgroups of older adults with distinct cardiometabolic typologies. The members of the insulin resistance subgroup were more likely to be female, they were more likely identify as non-Hispanic Black, and were college non-graduates. The members of the hypertensive dyslipidemia were more likely to identify as non-Hispanic other minorities and were high school graduates, and the members in the hypertensive subgroup were more likely to be male and college graduates. The frailty risk differed among these latent subgroups of older adults, and the insulin resistance subgroup had a higher frailty risk than hypertensive dyslipidemia and hypertensive subgroups. In contrast, the frailty risk did not differ in the latter two subgroups. However, cardiometabolic typologies did not mediate the relationship between structural social determinants and frailty. Cumulative psychosocial stress was used to assess co-occurring psychosocial stress stemming from multiple life domains. We measured cumulative psychosocial stress by counting six dichotomized psychosocial stressors originating from multiple life domains. Path analysis (a series of multivariable regression models) was used to examine structural social determinants and cumulative psychosocial stress relationships with frailty and determine the mediating role of cumulative psychosocial stress between structural social determinants and frailty. Older adults who identified as Hispanic, non-Hispanic Black, non-Hispanic other ethnic minorities, and those with less education were more likely to experience greater cumulative psychosocial stress. Greater cumulative psychosocial stress was associated with higher frailty risk; however, it did not mediate the relationship between structural social determinants and frailty. Our results solidify the multifactorial nature of frailty. Structural social determinants, cardiometabolic typologies, and cumulative psychosocial stress independently contributed to frailty. Surprisingly, cardiometabolic typologies and cumulative psychosocial stress did not mediate the relationships between structural social determinants and frailty. Our study sets the foundation for exploring other biological and psychosocial stressors contributing to frailty and examining their mediating roles.

Mental health issues are prevalent in childhood, but the majority of problems go untreated. Black children and girls are less likely than their White male peers to receive mental health treatment when needed. As a primary gatekeeper, teachers may be partially responsible for these disparities. The goal of the current study was to measure implicit race and gender bias at several steps in the decision-making process leading up to, and including, referral for services. Participants were 1,106 public middle school teachers in the state of North Carolina. Teachers were presented a series of vignettes that described complex behavior, including both internalizing and externalizing problems. Perceived child race and gender was manipulated via normed given names; vignettes were otherwise identical within each condition. Controlling for teacher demographics and randomized condition, vignettes with a male name were attributed more externalizing problems, rated marginally more severe, and more likely to be referred for academic and behavioral interventions than those with female names. Vignettes with Black names were less likely to be referred for mental health treatment and marginally more likely to be referred for academic services. Results of this analysis suggest that implicit racial and gender bias may play an important role in teacher assessments of problematic child behavior and referral for services. Future research is needed to further explicate these processes and how they correlate with in vivo decision-making.

Background: Globally, hypertension affects one billion people and disproportionately impacts the developing world. Sub-Saharan Africa has a high prevalence of hypertension with a low rate of awareness and compliance with treatment. The current model of community-based screening does not always ensure follow-up for treatment initiation. In high-income countries, emergency department (ED)-based screening has been successful at capturing undiagnosed/uncontrolled hypertension cases.

Methods: Between July 2017 and March 2018 we conducted a prospective cohort study of hypertensive patients in the emergency department of Kilimanjaro Christian Medical Center (KCMC) in Moshi, Tanzania. Adults patients with a triage blood pressure > 140/90 were recruited, completed a demographic and knowledge, attitudes and practices (KAP) survey and were followed for one month. Hypertension was defined as a single blood pressure ≥ 160/100 mmHg or a three-time average of ≥ 140/90 mmHg. Successful follow-up was defined as seeing a medical doctor within one month of the ED visit. Basic demographics were performed and to investigate relationships with potential risk factors and failure to follow-up, generalized linear models were used.

Results: We enrolled 595 adults (mean age 59.6) including 175 men (39.2%) and 271 women (60.7%). Of the 600 patients enrolled, 590 (99%) meet our definition for hypertension. Overall, the prevalence of hypertension was 10.3 % (95% CI 9.5,11.0) and 303 (56.2%) of participants failed to follow-up with a primary care physician within 1 month of the ED visit. Successful follow-up was independently associated with understanding that hypertension requires lifelong treatment (RR 1.11; 95% CI 1.03,1.21) and inversely associated with being worried about a future with hypertension (RR 0.80; 95% CI .64,1.00). The majority (78.6%) of the participants were aware of their disease, but many 223 (37.2%) had uncontrolled hypertension and 265 (44%) had evidence of end-organ damage.

Conclusion: The emergency department in Moshi Tanzania experiences a high burden of hypertensive patients, the majority of which fail to follow-up within one month of the ED visit. Multi-disciplinary strategies should be employed to improve linkage to care for high-risk patients from the emergency department.