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Social Determinants of Health in Neurology
Abstract
Neurologic health disparities are created and perpetuated by structural and social determinants of health. These factors include, but are not limited to, interpersonal bias, institutional factors that lead to disparate access to care, and neighborhood-level factors, such as socioeconomic status, segregation, and access to healthy food. Effects of these determinants of health can be seen throughout neurology, including in stroke, epilepsy, headache, amyotrophic lateral sclerosis, multiple sclerosis, and dementia. Interventions to improve neurologic health equity require multilayered approaches to address these interdependent factors that create and perpetuate disparate neurologic health access and outcomes.
... [29][30][31][32][33] Within the field of pediatrics, the role of SD in health care outcomes has been well established among disorders such as asthma, diabetes, COVID-19, sleep health, and autism. [34][35][36][37][38][39][40][41] In the field of epilepsy, there has been growing awareness of the impact of socioeconomic and neighborhood disadvantage on health and health-related factors in epilepsy. [42][43][44][45][46][47] In addition, SD may play a role in psychiatric outcomes of children with epilepsy, as children from poor families and from single-parent homes have a significantly higher risk of developing a psychiatric disorder compared to their less disadvantaged peers with epilepsy, 48 suggesting that lower socioeconomic status may be an independent factor associated with poor behavioral outcomes in youths with epilepsy. ...
... Based on past literature, each SD variable chosen is a relevant social determinant of health. [29][30][31][32][33][34][35][36][42][43][44][45][46][47][48] For caregiver education level and household income, those families below the mean for the sample were assigned a score of 1, whereas those families at or above the mean were assigned a score of 0. The distribution of income for this sample was nearly identical to national income statistics at the time of recruitment. 52 For race and caregiver marital status, non-White race and nonmarried status were each assigned a score of 1, whereas White race and married status received a score of 0. The SD score is the sum of all four disadvantage variables, ranging 0-4. ...
... Our findings presented here extend our understanding of the impact and role of disadvantage in the epilepsy literature, which is consistent with health care outcome findings in multiple other disorders including asthma, autism, COVID-19, diabetes, and sleep health. [29][30][31][32][33][34][35][36][37][38][39][40][41][42][43][44][45][46][47][48] Examining the influence of disadvantage at the time of diagnosis as well as at 18 and 36 months later, we find that behavior problems, as rated by parents, the child's teacher, and the child with seizures him-/herself, all indicate that behavioral risk increases with greater social disadvantage. This unanimity of effect, across all informants, with the consistency of relationship over time, points to the robustness and reliability of the effect of disadvantage. ...
Objective
This study was undertaken to determine the short‐term and longer term impact of sociodemographic disadvantage on the emotional–behavioral status of youths with new onset epilepsy and their unaffected siblings at the time of diagnosis and the subsequent 3 years.
Methods
Three hundred twelve youths with newly diagnosed epilepsies and 223 unaffected siblings, aged 6–16 years, were independently assessed regarding their emotional and behavioral status by their parents and teachers at baseline, and at 18 at 36 months later; youths with seizures also completed self‐report measures of depression, anxiety, and hostility at those three time points. A sociodemographic disadvantage score was computed for each family (children with newly diagnosed seizures and their siblings), and families were separated into four categories from most disadvantaged to least disadvantaged.
Results
In both children and siblings, the least disadvantaged group exhibited the lowest level of neurobehavioral problems, whereas the most disadvantaged group showed a higher level of neurobehavioral problems across all the same behavior metrics. Findings remained stable and significant across all informants (parent, teacher, child) and across all time periods (throughout the 3‐year period). Furthermore, both corrected and uncorrected linear regression analyses indicated that disadvantage was a more constant and stable predictor of behavioral and emotional problems over time compared to clinical seizure characteristics and abnormalities in magnetic resonance imaging and electroencephalographic testing.
Significance
Sociodemographic disadvantage bears a strong relationship to youths with emotional and behavioral problems both at the time of diagnosis as well as prospectively. The relationship is robust and reflected in reports from multiple informants (parent, teacher, child self‐report), evident in siblings as well, and possibly more explanatory than traditional clinical seizure variables. Future studies will be needed to determine whether this disadvantage factor is modifiable with early intervention.
... Social ecological models of disparities relating to access to stroke care and functional outcomes from stroke are particularly demonstrative of the ways that gender, ethnoracial minoritization and class/socioeconomic status are mutually constitutive of increased barriers and worsened outcomes (27). Epidemiological data relating to inequity and health disparities in stroke are welldocumented, but understanding underlying causes has been more lacking, often due to the complex and multi-level nature of the phenomena: intra-and interpersonal factors including implicit bias and stereotype threat; institutional and organizational factors such as the number of care transitions that take place in stroke pathways; multidirectional neighborhood and community factors that influence predisposing factors in addition to accessibility of care, referral pathways, and functional supports; and larger policies and practices that can embed structural forms of racism amongst other discriminatory practices in health settings (27). ...
... Social ecological models of disparities relating to access to stroke care and functional outcomes from stroke are particularly demonstrative of the ways that gender, ethnoracial minoritization and class/socioeconomic status are mutually constitutive of increased barriers and worsened outcomes (27). Epidemiological data relating to inequity and health disparities in stroke are welldocumented, but understanding underlying causes has been more lacking, often due to the complex and multi-level nature of the phenomena: intra-and interpersonal factors including implicit bias and stereotype threat; institutional and organizational factors such as the number of care transitions that take place in stroke pathways; multidirectional neighborhood and community factors that influence predisposing factors in addition to accessibility of care, referral pathways, and functional supports; and larger policies and practices that can embed structural forms of racism amongst other discriminatory practices in health settings (27). While the interpersonal factors that Ms. G cogently described are notable within this particular case, we also have to consider how larger systems and structures facilitate (or alternatively can correct) implicit biases. ...
Recent attention into sex and gender-based inequities surrounding outcomes for brain health disorders has generated momentum toward addressing what has been called the “brain health gap.” Importantly though, “women” are not uniform demographic group. In this perspective piece, we discuss misdiagnosis in stroke as an aspect of access and quality of care within brain health. Drawing on narrative data from a mixed methods study of young stroke survivors we suggest that while missed stroke isn't only an issue of gender, if we are going to understand gender-based gaps in access and navigation through stroke care, we have to understand how intersections of gender with age, ethnoracial identity, nationality, language, (dis)ability, and other aspects of social identity come together to create affordances as well as biases that contribute to stroke outcomes.
... Factors such as economic stability (employment, income, expenses, debt, medical bills, support), habitability, biological, territory, neighborhood and physical environment (housing, transportation, safety, parks, playgrounds, walkability, zip code/geography), education (literacy, language, early childhood education, vocational training, higher education), food security (hunger, access to healthy options), community and social context (social integration, support systems, community engagement, discrimination, stress), access to health care system (health coverage, provider availability, provider linguistic and cultural competency, quality of care) are the major determinants. 2,3,4 Social determinants of health are connected to health disparities, being a significant target of the World Health Organization's health policy as they result in mortality, morbidity, life expectancy, health expenses, health status and functional limitations. 2 Many initiatives are available to address the social determinants of health, focusing on both health and non-health sectors (e.g., schools, workplaces, religious temples, community areas). ...
... 2 Many initiatives are available to address the social determinants of health, focusing on both health and non-health sectors (e.g., schools, workplaces, religious temples, community areas). 3 Promoting health equity is a key factor in public policies, considering that life and work conditions of the population are closely linked to social and cultural factors as well as psychological, emotional and health conditions, which influence the occurrence of disease and mortality. Therefore, promotion, prevention, cure and rehabilitation are primary measures based on health education and guidelines of universal health systems. ...
... Strengthen parental commitment to parenting goals by enhancing negative emotion tolerance and stress-coping capacities (e.g., calmness and decisiveness) [46]. (2) Policy-Level Interventions: Adopting the lens of Social Determinants of Health (SDOH) Resilience [47,48], policymakers should prioritize implementing means-tested medical subsidies to redress systemic healthcare allocation disparities, thereby addressing structural inequities in medical resource distribution through social policy reforms. Concurrently, integrate SDOH resilience view into public health agendas and foster cross-sectoral collaboration (e.g., healthcare, social security and housing departments) to support preterm infant care. ...
Background
High levels of parental infant care competence could facilitate the transition of preterm infants from hospital to home and reduce their readmission rate and emergency visits after discharge. Researchers have confirmed psychological resilience and family resilience were excellent psychological resources that played important roles in the development of parental infant care competence. However, the interaction between these three variables in the parents of preterm infants remains unclear and requires further validation. This study aimed to explore the association between parental psychological resilience and premature infant care competence and the mediating role of family resilience on this relationship.
Methods
A multi-center cross-sectional study recruited a convenience sample of 381 parents of premature infants across four public hospitals in East China between November 2022 and December 2023. Research instruments included Connor-Davidson Resilience Scale, Family Hardiness Index, and Premature Infant Care Competency Scale. Structure equation modeling (SEM) were used to detect mediating effect of family resilience, while controlling for covariates.
Results
The average score of parental premature infant care competence was 134.02 points. Differences in levels of premature infant care competence were found across parental gender, education levels and pre-existing diseases. The results of SEM showed a direct relationship between the mentioned three covariates and transitional parental premature infant care competence, but not with family resilience. SEM also revealed psychological resilience as a significant predictor of transitional parental care competence, exerting both direct effects (β = 0.318, P < 0.001, 95%CI: [0.166, 0.464]) and indirect effects (β = 0.111, P = 0.001, 95%CI: [0.049, 0.183]) mediated through family resilience.
Conclusions
The findings suggested higher psychological resilience related to better family resilience which can provide supportive environment, thus contributing to increased parental premature infant care competence. Future researchers could pay more attention to the early resilience assessment of parents and family resilience improvements based on the formation of therapeutic alliance with the entire family system of preterm babies.
... As the global population ages, the number of older individuals continues to rise, leading to an upward trend in age-related cognitive impairment [1]. In China, the prevalence of dementia has reached figures comparable to those observed in high-income nations and is anticipated to escalate further [2]. ...
Background: As the global population ages, there is an increasing prevalence of mild cognitive impairment and dementia. Protecting and preserving cognitive function in older adults has become a critical public health concern. Methods: This study utilized data from four phases of the Chinese Longitudinal Healthy Longevity Survey conducted from 2008 to 2018, encompassing a total of 2454 participants. Latent growth curve modeling was employed to analyze the trajectory and role of protein intake frequency and cognitive function. Results: The frequency of protein intake among older adults tends to rise, with individuals exhibiting higher initial levels experiencing smaller subsequent increases. Conversely, cognitive function generally declines, with those starting at higher levels experiencing more pronounced decreases. Notably, the initial frequency of protein intake is positively correlated with the initial level of cognitive function (β = 0.227, 95% CI: 0.156 to 0.299, p < 0.001), but does not significantly influence the rate of change in cognitive function (β = −0.030, 95% CI: −0.068 to 0.009, p = 0.128). The rate of change in protein intake frequency is positively associated with the rate of change in cognitive function (β = 0.152, 95% CI: 0.023 to 0.280, p = 0.020). Conclusions: The alterations in protein intake frequency are linked to alterations in cognitive function among older adults. Maintaining a stable high frequency of protein intake or increasing the frequency of protein intake may contribute to stabilizing cognitive function as well as reducing the risk of cognitive impairment and dementia in older adults.
... For example, the adverse neurodevelopmental effects of brain injury in preterm infants was attenuated by higher maternal education level [11]. Access to healthcare is a further key determinant of disability among adults with neurological disability [12,13], and thus we can expect that socioeconomic status not only influences the risk of adverse perinatal outcomes but will continue to adversely influence neurodevelopmental outcomes throughout a person's life. All these factors are likely to be even more important in low-and middle-income countries. ...
... 1,2 Social determinants of health (SDoH) encompass environmental and social factors that impact health outcomes and are an area of increasing interest in healthcare research. 3,4 Research into the impact of SDoH on MS has been robust, but few studies have investigated the relationship of SDoH to outcomes in individuals with NMOSD. Some evidence suggests racial difference in clinical NMOSD outcomes, [5][6][7][8] including a retrospective study conducted at two US referral centers that found Black patients made up 41% of the NMOSD population but accounted for 90% of the disease mortality. ...
Background
Little is known about the relationship between neighborhood disadvantage and neuromyelitis optica spectrum disorder (NMOSD) outcomes.
Objective
The objective is to determine the impact of neighborhood disadvantage on time from symptom onset to diagnosis and annualized relapse rate (ARR).
Methods
Neighborhood disadvantage were captured with the Area Deprivation Index (ADI), a validated measure of neighborhood-level disadvantage. Negative binomial regression models assessed the impact of ADI on diagnostic delay (⩾3 months between symptom onset and diagnosis) and ARR.
Results
A total of 158 NMOSD patients were identified, a majority of whom were White (56.3%) and female (89.9%) with a mean age of 46 years at diagnosis. The ADI did not significantly affect odds of diagnostic delay (odds ratio (OR) = 0.99, p = 0.26). In univariable models, the ADI was not significantly associated with ARR (OR = 1.004, p = 0.29), but non-White race (OR = 1.541, p = 0.02) and time on immunosuppressive therapies (ISTs; OR = 0.994, p = 0.03) were. White patients used IST for an average of 81% of the follow-up period, compared to an average of 65% for non-White patients (p < 0.01).
Conclusion
No significant relationship between neighborhood-level disadvantage and diagnostic delay or ARR in NMOSD patients was observed. Non-White patients had a higher ARR, which may be related to less IST use.
... Individual characteristics included in the regression model were age (�60,* >60), sex (Female, Male*), race (Black, White*), ethnicity (Hispanic, Non-Hispanic*), region of residence (Northeast,* North Central/Midwest, South, West), family size (1 to 9), income (<$30,000, �$30,000*), insurance status (insured,* uninsured), education (less than college graduation, college graduate or above*), time post aphasia onset, and aphasia type (Anomic,* Broca's, Global). Since literature outlining social determinants of aphasia is sparse, these covariates were selected based on a review of recently published studies outlining the determinants of stroke [11,[39][40][41]. ...
Introduction
Traditionally, the study of aphasia focused on brain trauma, clinical biomarkers, and cognitive processes, rarely considering the social determinants of health. This study evaluates the relationship between aphasia impairment and demographic, socioeconomic, and contextual determinants among people with aphasia (PWA).
Methods
PWA indexed within AphasiaBank—a database populated by multiple clinical aphasiology centers with standardized protocols characterizing language, neuropsychological functioning, and demographic information—were matched with respondents in the Medical Expenditure Panel Survey based on response year, age, sex, race, ethnicity, time post stroke, and mental health status. Generalized log-linear regression models with bootstrapped standard errors evaluated the association between scores on the Western Aphasia Battery-Revised Aphasia Quotient (WAB-R AQ) and demographic, economic, and contextual characteristics accounting for clustering of respondents and the stratification of data collection. Region, age, and income specific models tested the sensitivity of results.
Results
PWA over age 60 had 2.4% (SE = 0.020) lower WAB-R AQ scores compared with younger PWA. Compared to White PWA, Black and Hispanic PWA had 4.7% (SE = 0.03) and 0.81% (SE = 0.06) lower WAB-R AQ scores, respectively, as did those and living in the Southern US (-2.2%, SE = 0.03) even after controlling for age, family size, and aphasia type. Those living in larger families (β = 0.005, SE = 0.008), with income over $30,000 (β = 0.017, SE = 0.022), and a college degree (β = 0.030, SE = 0.035) had higher WAB-R AQ relative to their counterparts. Region-specific models showed that racial differences were only significant in the South and Midwest, while ethnic differences are only significant in the West. Sex differences only appeared in age-specific models. Racial and ethnic differences were not significant in the high-income group regression.
Conclusion
These findings support evidence that circumstances in which individuals live, work, and age are significantly associated with their health outcomes including aphasia impairment.
... In recent years, a growing attention has been made to the social determinants (SD) of health i.e., the conditions in which people are born, live, grow up, and function, and which affect their access to health and outcome [73]. As early as 1848 Rudolph Virchow noted that "if medicine is to accomplish its great task, it must intervene in political and social life" [74]. ...
Current definitions of migraine that are based mainly on clinical characteristics do not account for other patient’s features such as those related to an impaired quality of life, due to loss of social life and productivity, and the differences related to the geographical distribution of the disease and cultural misconceptions which tend to underestimate migraine as a psychosocial rather than neurobiological disorder.
Global differences definition, care access, and health equity for headache disorders, especially migraine are reported in this paper from a collaborative group of the editorial board members of the Journal of Headache and Pain. Other components that affect patients with migraine, in addition to the impact promoted by the migraine symptoms such as stigma and social determinants, are also reported.
... These disparities are linked to social determinants of health (SDOH) including education, income, insurance, occupation, racism, stigma, neighborhood, and the built environment. 3,4 In stroke, one of the most common neurologic diseases, disparities are attributable to SDOH factors rooted in race and ethnic and socioeconomic differences that lead to inequitable access and delivery of health care. [5][6][7][8] Nationally, a greater prevalence of White individuals is living with ADRD compared with any other race or ethnic group. ...
Background and Objectives
Evidence suggests a significant prevalence of race and ethnic disparities in the United States among people with neurologic conditions including stroke, Alzheimer disease and related dementia (ADRD), Parkinson disease (PD), epilepsy, spinal cord injury (SCI), and traumatic brain injury (TBI). Recent neurologic research has begun the paradigm shift from observational health disparities research to intervention research in an effort to narrow the disparities gap. There is an evidence base that suggests that community engagement is a necessary component of health equity. While the increase in disparities focused neurologic interventions is encouraging, it remains unclear whether and how community-engaged practices are integrated into intervention design and implementation. The purpose of this scoping review was to identify and synthesize intervention studies that have actively engaged with the community in the design and implementation of interventions to reduce disparities in neurologic conditions and to describe the common community engagement processes used.
Methods
Two databases, PubMed and CINAHL, were searched to identify eligible empirical studies within the United States whose focus was on neurologic interventions addressing disparities and using community engagement practices.
Results
We identified 392 disparity-focused interventions in stroke, ADRD, PD, epilepsy, SCI, and TBI, of which 53 studies incorporated community engagement practices: 32 stroke studies, 15 ADRD, 2 epilepsy studies, 2 PD studies, 1 SCI study, and 1 TBI study. Most of the interventions were designed as randomized controlled trials and were programmatic in nature. The interventions used a variety of community engagement practices: community partners (42%), culturally tailored materials and mobile health (40%), community health workers (32%), faith-based organizations and local businesses (28%), focus groups/health need assessments (25%), community advisory boards (19%), personnel recruited from the community/champions (19%), and caregiver/social support (15%).
Discussion
Our scoping review reports that the proportion of neurologic intervention studies incorporating community engagement practices is limited and that the practices used within those studies are varied. The major practices used included collaboration with community partners and utilization of culturally tailored materials. We also found inconsistent reporting and dissemination of results from studies that implemented community engagement measures in their interventions. Future directions include involving the community in research early and continuously, building curricula that address challenges to community engagement, prioritizing the inclusion of community engagement reporting in peer-reviewed journals, and prioritizing and incentivizing research of subpopulations that experience disparities in neurologic conditions.
Advocacy is an important part of the practice of neurology integral to optimal patient care and research. Opportunities exist for neurologists to further their engagement in advocacy outside of the office, and neurologists are well-positioned to share their knowledge and expertise as advocates. Many barriers to care, such as the cost of and access to prescription drugs, have an outsized impact on patients with neurological conditions, which underscores the importance of neurological advocacy. Advocacy opportunities span many different forms and range from local to global in scale. The benefits to a neurology career can be vast, from improved knowledge of health care systems to leadership opportunities, to networking among colleagues and community leaders, and enhanced academic profiles. Numerous resources are available for neurologists seeking further engagement in advocacy for their patients and profession.
Background and objectives
Dystonia is the third most common movement disorder. Motor and non-motor manifestations of dystonia may impact Health Related Quality of Life (HRQoL), with lower HRQoL scores compared to the healthy population. People with generalized dystonia report worse HRQoL scores (vs. people with focal distributions). Social determinants of health (SDOH) may play a role in HRQoL outcomes in dystonia, but scant data exists. We aimed to examine differences in HRQoL scores in people with focal vs. non-focal (e.g., segmental, multifocal, generalized) dystonia and the association with SDOH.
Methods
129 participants with isolated dystonia, who were recruited through Mass General Brigham movement disorders clinic and enrolled in the Dystonia Partners Research Bank, completed a follow-up survey on SDOH and HRQoL: Quality of Life in Neurological Disorders Version 2.0 Short Form (Neuro- QoL-SF) and the EuroGroup 5-level (Euro-QoL). Linear regression analyses were performed.
Results
Participants with isolated dystonia were predominantly female (72.1%), non-Hispanic white (79.8%), and highly educated (79.8%; ≥ bachelor’s degree). 71.3% of the participants had focal dystonia and 28.7% of the participants had non-focal dystonia. Participants with focal dystonia (vs. non-focal dystonia) reported older age at diagnosis (49.2 ± 11.7 vs. 40.6 ± 19.2, p = 0.004). Participants with focal dystonia (vs. non-focal dystonia) reported higher (i.e., better) overall health scores (80.4 ± 13.9 vs. 72.8 ± 13.5, p = 0.005), higher ability to participate in social activities (51.3 ± 7.7 vs. 47.2 ± 6.0, p = 0.003), lower fatigue (44.7 ± 8.4 vs. 49.8 ± 7.2, p = 0.001), and lower sleep disturbance (48.0 ± 8.2 vs. 53.0 ± 7.9, p = 0.002). Independent predictors of higher overall health ratings included focal distribution of dystonia (b = 7.5; p = 0.01), a higher level of education (b = 9.2; p = 0.04) and not having a mental health diagnosis (b = 7.5; p = 0.01).
Conclusion
Participants with focal dystonia were diagnosed later and had higher (i.e., better) HRQoL measures vs. participants with non-focal dystonia. Predictors of better HRQoL were having focal dystonia and higher level of education, whereas the presence of a mental health diagnosis was associated with lower HRQoL (i.e., worse) scores. SDOH such as employment status, medical literacy, and ability to afford basic needs may influence HRQoL ratings for participants with isolated dystonia. Our findings may not be generalizable to the general population of patients with isolated dystonia. We highlight areas for further research and development.
Objectives
Survivors of intracerebral haemorrhage (ICH) are at high risk of incident depression, which is modified by social determinants of health (SDOH) and associated with worse functional outcomes. We sought to determine the role of prestroke SDOH in depression incidence after ICH to better characterise post-ICH outcomes.
Study design
We analysed data from a cohort study of ICH survivors without prestroke depression, presenting at Massachusetts General Hospital between 2006 and 2017. We collected information from electronic health records (EHR), follow-up interviews and CT/MRI. The relationship between social vulnerability, air quality and post-ICH depression incidence within 12 months of acute haemorrhage was investigated using logistic regression models that also included EHR and CT/MRI information as predictors.
Results
Participants were 576 survivors, median age of 72 (IQR=61–81), 317 (55%) self-reported as male and 482 (84%) as white. 204 (35%) were diagnosed with depression within 12 months of ICH. Hospital admission longer than 1 week (OR 1.80, 95% CI 1.08 to 3.00), cerebral amyloid angiopathy (CAA) burden (OR 1.45, 95% CI 1.25 to 1.68) and social vulnerability (OR 3.03, 95% CI 1.49 to 6.19) were associated with depression incidence post-ICH.
Conclusions
In addition to CAA burden and patient location 1-week post-ICH, social vulnerability was independently associated with depression among ICH survivors. Our findings suggest that social vulnerability influences ICH outcomes. Future studies should investigate how poststroke clinical care interventions can address SDOH effects to reduce incident depression and improve outcomes among ICH survivors.
This chapter highlights the evidence of disparities in neuromuscular diseases, focusing on conditions where there is more published evidence such as hereditary transthyretin amyloidosis, amyotrophic lateral sclerosis (ALS), muscular dystrophies, and peripheral neuropathy. The analysis underscores racial and ethnic disparities in disease prevalence, access to care, and treatment outcomes. The impact of cultural factors on pain perception, healthcare seeking behavior, and communication is explored. Additionally, the chapter emphasizes the importance of culturally sensitive patient education materials to improve health literacy. The potential of telehealth to address access issues is discussed, with attention to the challenges related to technology accessibility and reimbursement models. The COVID-19 pandemic’s exacerbation of existing healthcare disparities is also acknowledged.
Underserved and underrepresented populations have historically been excluded from neurological research. This lack of representation has implications for translation of research findings into clinical practice given the impact of social determinants of health on neurological disease risk, progression, and outcomes. Lack of inclusion in research is driven by individual-, investigator-, and study-level barriers as well as larger systemic injustices (e.g., structural racism, discriminatory practices). Although strategies to increase inclusion of underserved and underrepresented populations have been put forth, numerous questions remain about the most effective methodology. In this article, we highlight inclusivity patterns and gaps among the most common neurological conditions and propose best practices informed by our own experiences in engagement of local community organizations and collaboration efforts to increase underserved and underrepresented population participation in neurological research.
Background and Objectives
Mortality after intracerebral hemorrhage (ICH) is common. Neighborhood socioeconomic status (nSES) is an important social determinant of health (SDoH) that can affect clinical outcome. We hypothesize that SDoH, including nSES, contribute to differences in withdrawal of life-sustaining therapies (WLSTs) and mortality in patients with ICH.
Methods
We performed a retrospective study of patients with ICH at 3 tertiary care hospitals between January 2017 and December 2022 identified through the Get with the Guidelines Database. We collected data on age, clinical severity, race/ethnicity, median household income, insurance, marital status, religion, mortality before discharge, and WLST from the electronic medical record. We assessed for associations between SDoH and WLST, mortality, and poor discharge mRS using Mann-Whitney U tests and χ ² tests. We performed multivariable analysis using backward stepwise logistic regression.
Results
We identified 868 patients (median age 67 [interquartile range (IQR) 55–78] years; 43% female) with ICH. Of them, 16% were Black non-Hispanic, 17% were Asian, and 15% were of Hispanic ethnicity; 50% were on Medicare and 22% on Medicaid, and the median (IQR) household income was 58,669–$122,078). Mortality occurred in 17% of patients, and of them, 84% of patients had WLST. Patients from zip codes with higher median household incomes had higher incidence of WLST and mortality ( p < 0.01). Black non-Hispanic race was associated with lower WLST and discharge mortality ( p ≤ 0.01 for both). In multivariable analysis adjusting for age and clinical severity scores, patients who lived in zip codes with high-income levels were more likely to have WLST (adjusted odds ratio [aOR] 1.88; 95% CI 1.29–2.74) and mortality before discharge (aOR 1.5; 95% CI 1.06–2.13).
Discussion
SDoH, including nSES, are associated with WLST after ICH. This has important implications for the care and management of patients with ICH.
Background:
DBS is an effective surgical treatment for ET, PD, and dystonia. Racial disparities in DBS utilization in PD have been documented demonstrating that Black patients receive DBS at lower rates than White patients. To our knowledge, no studies have investigated if this pattern of non-use persists in other movement disorders with FDA-approval.
Objective:
To identify racial and ethnic disparities in DBS utilization in those hospitalized for ET, PD, and dystonia.
Methods:
The NIS database was queried for US hospitalizations from 2012 to 2018 with a primary diagnosis of ET, PD, or dystonia, and a total of 3,363, 21,963, and 1,835 discharges were recorded, respectively. Within that sample, treatment with DBS was identified. Sex, race, age, payment method, income quartile, year, mortality risk, hospital size, urban/rural setting, teaching status, and geographic region were extracted. A multivariate logistic regression was performed to identify predictors for use and non-use of DBS.
Results:
Between 2012 and 2018, Black patients with PD, ET, and dystonia were less likely to receive DBS than White patients. Black patients with PD were 7 times less likely to receive DBS (OR = 0.145, CI = 0.111-0.189), and Black patients with ET and dystonia were 5 times less likely to receive DBS than White patients (OR = 0.188, CI = 0.124-0.285; OR = 0.186, CI = 0.084-0.414). Compared to White patients, Hispanic patients with PD (OR = 0.631, OR = 0.539-0.740) and ET (OR = 0.438, CI = 0.277-0.695) were less likely to undergo DBS. When controlling for patient and hospital level characteristics, racial and ethnic disparities remained.
Conclusions:
Our data suggest that Black patients with a diagnosis of ET, PD, or dystonia and Hispanic patients with a diagnosis of ET or PD were less likely to be treated with DBS than White patients between 2012 and 2018.
Background and objectives:
Temporal lobe epilepsy (TLE) is the most common adult form of epilepsy and is associated with high risk for cognitive deficits and depressed mood. However, little is known about the role of environmental factors on cognition and mood in TLE. This cross-sectional study examined the relationship between neighborhood deprivation and neuropsychological function in adults with TLE.
Methods:
Neuropsychological data were obtained from a clinical registry of patients with TLE and included measures of intelligence, attention, processing speed, language, executive function, visuospatial skills, verbal/visual memory, depression, and anxiety. Home addresses were used to calculate the Area Deprivation Index (ADI) for each individual, which were separated into quintiles (i.e., Quintile 1=least disadvantaged, Quintile 5=most disadvantaged). Kruskal-Wallis tests compared quintile groups on cognitive domain scores as well as mood and anxiety scores. Multivariable regression models, with and without ADI, were estimated for overall cognitive phenotype as well as for mood and anxiety scores.
Results:
800 patients (median age 38 years-old; 58% female) met all inclusion criteria.Effects of disadvantage (increasing ADI) were observed across nearly all measured cognitive domains as well as with significant increases in symptoms of depression and anxiety. Further, patients in more disadvantaged ADI quintiles had increased odds of a worse cognitive phenotype (P=0.013). Patients who self-identified as members of minoritized groups were over-represented in the most disadvantaged ADI quintiles and were 2.91 (95% confidence interval, CI: 1.87-4.54) times more likely to be in a severe cognitive phenotype than non-Hispanic Whites (P < 0.001). However, accounting for ADI attenuated this relationship, suggesting neighborhood deprivation may account for some of the relationship between race/ethnicity and cognitive phenotype (ADI-adjusted proportional odds ratio [95% CI]: 1.82 [1.37 - 2.42]).
Discussion:
These findings highlight the importance of environmental factors and regional characteristics in neuropsychological studies of epilepsy. There are many potential mechanisms by which neighborhood disadvantage can adversely impact cognition (e.g., fewer educational opportunities, limited access to health care, food insecurity/poor nutrition, greater medical comorbidities). Future research will seek to investigate these potential mechanisms and to determine whether structural and functional alterations in the brain moderate the relationship between ADI and cognition.
Background and Objectives
Chronic health conditions are influenced by social determinants of health (SDH) including neighborhood-linked markers of affluence. We explored whether neighborhood socioeconomic factors differ in people with different types of clinical movement disorders (MDs).
Methods
We conducted a retrospective study of patients seen in MD clinics at our center in 2021. Patient data were linked to the US National Neighborhood Data Archive linked to US census tract data. We evaluated variations in neighborhood socioeconomic factors across 8 different categories of MDs.
Results
Compared with the neighborhoods of patients with Parkinson disease, neighborhoods of patients with cerebellar ataxias, functional movement disorders, and Huntington disease were characterized by higher proportions of people earning less than 15,000 US dollars/year, people receiving public assistance, and people with less than a high school diploma.
Discussion
Neighborhood-linked SDH vary among different MDs. These findings have implications for public health interventions aimed at improving the care of people affected by MDs.
The functional medicine matrix provides us with an opportunity to understand how social determinants of health (SDOH) and health related social needs may be root causes and contributors to current health and illness among patients. The matrix also allows us to map and recognize the intersectionality of SDOH on exposures and behaviors that influence antecedents, triggers, mediators, lifestyle factors, and clinical imbalances. Incorporating SDOH into clinical evaluations helps uncover and address the complex factors that lead to health disparities in order to provide more optimal patient-centered care.
BACKGROUND
Information on cerebrovascular consequences of high social risk, as determined by the social determinants of health, is limited. We sought to evaluate the impact of high social risk on the progression of white matter hyperintensities (WMHs) of presumed vascular origin.
METHODS
Following a longitudinal prospective study design, participants of the Atahualpa Project Cohort received baseline social risk determinations by means of social determinants of health components included in the Gijon’s Social-Familial Evaluation Scale together with clinical interviews and brain magnetic resonance imagings. Those who also received follow-up brain magnetic resonance imaging at the end of the study were included. We used Poisson regression models adjusted for demographics, education levels and traditional cardiovascular risk factors to assess the incidence rate ratio of WMH progression according to the Gijon’s Social-Familial Evaluation Scale score.
RESULTS
The study included 263 individuals aged ≥60 years (mean age, 65.7±6.2 years; 57% women). The Gijon’s Social-Familial Evaluation Scale mean score was 8.9±2.2 points. Follow-up magnetic resonance imagings revealed WMH progression in 103 (39%) individuals after a mean follow-up of 6.5 years (SD±1.4 years). Poisson regression models showed increased WMH progression rate among individuals in the third tertile of the Gijon’s Social-Familial Evaluation Scale score compared with those in the first tertile (incidence rate ratio, 1.65 [95% CI, 1.05–2.61]; P =0.032). Separate Poisson regression models using individual social determinants of health components showed that poor social relationships (incidence rate ratio, 1.39 [95% CI, 1.10–1.77]; P =0.006) and deficient support networks (incidence rate ratio, 1.79 [95% CI, 1.19–2.69]; P =0.005) were independently associated with WMH progression, whereas family situation, economic status, and housing did not.
CONCLUSIONS
Poor social relationships and deficient support networks were significantly associated with WMH progression in community-dwelling older adults living in a rural setting. Our findings may help planning cost-effective preventive policies to reduce progression of cerebral small vessel disease among vulnerable populations.
This year, the COVID-19 pandemic has altered neurological care in many ways. However, evidence indicates that people from marginalized ethnic and socioeconomic groups have been affected by these changes more than others, highlighting and amplifying existing health-care disparities. Black patients with acute ischaemic stroke and COVID-19 have faced higher morbidity and mortality than white, Asian or Latino patients2.Patients hospitalized with COVID-19 at non-academic medical centres had worse outcomes than those at academic medical centres; gaps in access to critical and specialty care might influence these disparities3.Black patients with acute ischaemic stroke were less likely than white patients to receive telestroke services during the pandemic; gaps in access to acute stroke care have also been observed among Latino patients5.Among patients with Parkinson disease, those with lower incomes have had worse access to health care during the pandemic than patients with higher incomes9. Black patients with acute ischaemic stroke and COVID-19 have faced higher morbidity and mortality than white, Asian or Latino patients2. Patients hospitalized with COVID-19 at non-academic medical centres had worse outcomes than those at academic medical centres; gaps in access to critical and specialty care might influence these disparities3. Black patients with acute ischaemic stroke were less likely than white patients to receive telestroke services during the pandemic; gaps in access to acute stroke care have also been observed among Latino patients5. Among patients with Parkinson disease, those with lower incomes have had worse access to health care during the pandemic than patients with higher incomes9.
Importance
While current reports suggest that a disproportionate share of US coronavirus disease 2019 (COVID-19) cases and deaths are among Black residents, little information is available regarding how race is associated with in-hospital mortality.
Objective
To evaluate the association of race, adjusting for sociodemographic and clinical factors, on all-cause, in-hospital mortality for patients with COVID-19.
Design, Setting, and Participants
This cohort study included 11 210 adult patients (age ≥18 years) hospitalized with confirmed severe acute respiratory coronavirus 2 (SARS-CoV-2) between February 19, 2020, and May 31, 2020, in 92 hospitals in 12 states: Alabama (6 hospitals), Maryland (1 hospital), Florida (5 hospitals), Illinois (8 hospitals), Indiana (14 hospitals), Kansas (4 hospitals), Michigan (13 hospitals), New York (2 hospitals), Oklahoma (6 hospitals), Tennessee (4 hospitals), Texas (11 hospitals), and Wisconsin (18 hospitals).
Exposures
Confirmed SARS-CoV-2 infection by positive result on polymerase chain reaction testing of a nasopharyngeal sample.
Main Outcomes and Measures
Death during hospitalization was examined overall and by race. Race was self-reported and categorized as Black, White, and other or missing. Cox proportional hazards regression with mixed effects was used to evaluate associations between all-cause in-hospital mortality and patient characteristics while accounting for the random effects of hospital on the outcome.
Results
Of 11 210 patients with confirmed COVID-19 presenting to hospitals, 4180 (37.3%) were Black patients and 5583 (49.8%) were men. The median (interquartile range) age was 61 (46 to 74) years. Compared with White patients, Black patients were younger (median [interquartile range] age, 66 [50 to 80] years vs 61 [46 to 72] years), were more likely to be women (2259 [49.0%] vs 2293 [54.9%]), were more likely to have Medicaid insurance (611 [13.3%] vs 1031 [24.7%]), and had higher median (interquartile range) scores on the Neighborhood Deprivation Index (−0.11 [−0.70 to 0.56] vs 0.82 [0.08 to 1.76]) and the Elixhauser Comorbidity Index (21 [0 to 44] vs 22 [0 to 46]). All-cause in-hospital mortality among hospitalized White and Black patients was 23.1% (724 of 3218) and 19.2% (540 of 2812), respectively. After adjustment for age, sex, insurance, comorbidities, neighborhood deprivation, and site of care, there was no statistically significant difference in risk of mortality between Black and White patients (hazard ratio, 0.93; 95% CI, 0.80 to 1.09).
Conclusions and Relevance
Although current reports suggest that Black patients represent a disproportionate share of COVID-19 infections and death in the United States, in this study, mortality for those able to access hospital care did not differ between Black and White patients after adjusting for sociodemographic factors and comorbidities.
Internalized racism represents a critical component of the system of racial oppression wherein People of Color adopt the negative beliefs about their race held by members of the White majority group. In this meta-analysis, the authors reviewed 29 studies (32 effect sizes) on the relationships between internalized racism and negative physical and mental health outcomes published between 1999 and 2015 and tested for literature-driven moderator effects using subgroup analyses. Results suggested that the direct overall relation between internalized racism and health was strongest for negative mental health outcomes ( r = .26), followed by negative physical health outcomes ( r = .11). Significant moderator effects were found for scale of measurement, country of sample (United States vs. international), and sampling method. Moderator effects of gender, publication type, year, and sample setting were not statistically significant. These findings are discussed and their implications for practice, advocacy, education/training, and research are described.
Statements about building walls, deportation and denying services to undocumented immigrants made during President Trump’s presidential campaign and presidency may induce fear in Latino populations and create barriers to their health care access. To assess how these statements relate to undocumented Latino immigrants’ (UDLI) and Latino legal residents/citizens’ (LLRC) perceptions of safety and their presentations for emergency care, we conducted surveys of adult patients at three county emergency departments (EDs) in California from June 2017 to December 2018. Of 1,684 patients approached, 1,337 (79.4%) agreed to participate: 34.3% UDLI, 36.9% LLRC, and 29.8% non-Latino legal residents/citizens (NLRC). The vast majority of UDLI (95%), LLRC (94%) and NLRC (85%) had heard statements about immigrants. Most UDLI (89%), LLRC (88%) and NLRC (87%) either thought that these measures were being enacted now or will be enacted in the future. Most UDLI and half of LLRC reported that these statements made them feel unsafe living in the US, 75% (95% CI 70–80%) and 51% (95% CI 47–56%), respectively. More UDLI reported that these statements made them afraid to come to the ED (24%, 95% CI 20–28%) vs LLRC (4.4%, 95% CI 3–7%) and NLRC (3.5%, 95% CI 2–6%); 55% of UDLI with this fear stated it caused them to delay coming to the ED (median delay 2–3 days). The vast majority of patients in our California EDs have heard statements during the 2016 presidential campaign or from President Trump about measures against undocumented immigrants, which have induced worry and safety concerns in both UDLI and LLRC patients. Exposure to these statements was also associated with fear of accessing emergency care in some UDLIs. Given California’s sanctuary state status, these safety concerns and ED access fears may be greater in a nationwide population of Latinos.
Stigma is a well-documented barrier to health seeking behavior, engagement in care and adherence to treatment across a range of health conditions globally. In order to halt the stigmatization process and mitigate the harmful consequences of health-related stigma (i.e. stigma associated with health conditions), it is critical to have an explicit theoretical framework to guide intervention development, measurement, research, and policy. Existing stigma frameworks typically focus on one health condition in isolation and often concentrate on the psychological pathways occurring among individuals. This tendency has encouraged a siloed approach to research on health-related stigmas, focusing on individuals, impeding both comparisons across stigmatized conditions and research on innovations to reduce health-related stigma and improve health outcomes. We propose the Health Stigma and Discrimination Framework, which is a global, crosscutting framework based on theory, research, and practice, and demonstrate its application to a range of health conditions, including leprosy, epilepsy, mental health, cancer, HIV, and obesity/overweight. We also discuss how stigma related to race, gender, sexual orientation, class, and occupation intersects with health-related stigmas, and examine how the framework can be used to enhance research, programming, and policy efforts. Research and interventions inspired by a common framework will enable the field to identify similarities and differences in stigma processes across diseases and will amplify our collective ability to respond effectively and at-scale to a major driver of poor health outcomes globally.
Obesity is a major public health issue, affecting both developed and developing societies. Obesity increases the risk for heart disease, stroke, some cancers, and type II diabetes. While individual behaviours are important risk factors, impacts on obesity and overweight of the urban physical and social environment have figured large in the recent epidemiological literature, though evidence is incomplete and from a limited range of countries. Prominent among identified environmental influences are urban layout and sprawl, healthy food access, exercise access, and the neighbourhood social environment. This paper reviews the literature and highlights the special issue contributions within that literature.
As a result of a large and compelling body of evidence documenting the impacts of social determinants, such as income and education, on health outcomes, health care systems are beginning to incorporate social and economic risk data into health care delivery decisions. But there is a risk that some of these efforts could worsen health and widen health inequities. We highlight 3 examples- including recent policy changes in Medicaid, social needs, informed risk prediction models, and advances in precision medicine-where the inclusion of social risk information threatens to reduce care quality or health care access for some groups of patients. A new dialog is needed about both the opportunities and potential consequences of bringing information about patients' social circumstances into a market-based health care system.
While the prevalence of cardiovascular risk factors has decreased in the United States in recent years, cardiovascular disparities by sex and race persist. Among the factors contributing to these disparities is the physical environment in which individuals live. Neighborhood characteristics, ranging from air pollution exposure to residential segregation, have been found to be related to cardiovascular health and stroke risk. Through the use of cross‐sectional, longitudinal, and analytic regression modeling, we are gaining clarity about the relationship between an individual’s external environment and cardiovascular health. Moreover, differences in cardiovascular health vary by sex and/or race within the same neighborhood. The mechanism by which these disparities exist is still being explored. In this review, we examine the literature that has accumulated regarding how external environments and community factors affect individuals and populations by race and sex.
Purpose of Review
Despite recognition of rising prevalence and significant burden, migraine remains underestimated, underdiagnosed, and undertreated. This is especially true among groups who have been historically, socially, and economically marginalized such as communities of color, women, people experiencing poverty, people with lower levels of education, and people who hold more than one of these marginalized identities. While there is growing public and professional interest in disparities in migraine prevalence, there is a paucity of research focusing on racial/ethnic and socioeconomic disparities, and the social and structural determinants of health and equity that perpetuate these disparities. From a health equity perspective, migraine research and treatment require an examination not only of biological and behavioral factors, but of these identities and underlying, intersecting social and structural determinants of health.
Recent Findings
Significant disparities in migraine incidence, prevalence, migraine-related pain and disability, access to care, and quality of care persist among marginalized and underserved groups: African Americans, Hispanics, people experiencing poverty, un- or under-employment, the un- and under-insured, people who have been exposed to stressful and traumatic events across the lifespan, and people experiencing multiple, overlapping marginalized identities. These same groups are largely underrepresented in migraine research, despite bearing disproportionate burden. Current approaches to understanding health disparities in migraine largely assume an essentializing approach, i.e., documenting differences between single identity groups—e.g., race or income or education level—rather than considering the mechanisms of disparities: the social and structural determinants of health.
Summary
While disparities in migraine are becoming more widely acknowledged, we assert that migraine is more aptly understood as a health equity issue, that is, a condition in which many of the health disparities are avoidable. It is important in research and clinical practice to consider perspectives that incorporate a cultural understanding of racial, ethnic, and socioeconomic identity within and across all levels of society. Incorporating perspectives of intersectionality provides a strong foundation for understanding the role of these complex combination of factors on migraine pain and treatment. We urge the adoption of intersectional and systems perspectives in research, clinical practice, and policy to examine (1) interplay of race, gender, and social location as key factors in understanding, diagnosing, and treating migraine, and (2) the complex configurations of social and structural determinants of health that interact to produce health inequities in migraine care. An intentional research and clinical focus on these factors stands to improve how migraine is identified, documented, and treated among marginalized populations.
Background
Research has shown that sexual minorities (SMs) (e.g. lesbian, gay, and bisexual individuals), compared to their heterosexual counterparts, may engage in riskier health behaviors, are at higher risk of some adverse health outcomes, and are more likely to experience reduced health care access and utilization. However, few studies have examined how the interplay between race and sexual orientation impacts a range of health measures in a nationally representative sample of the U.S. population. Methods
To address these gaps in the literature, we sought to investigate associations between sexual orientation identity and health/healthcare outcomes among U.S. women and men within and across racial/ethnic groups. Using 2013–2015 National Health Interview Survey data (N = 91,913) we employed Poisson regression with robust variance to directly estimate prevalence ratios (PR) comparing health and healthcare outcomes among SMs of color to heterosexuals of color and white heterosexuals, stratified by gender and adjusting for potential confounders. ResultsThe sample consisted of 52% women, with approximately 2% of each sex identifying as SMs. Compared to their heterosexual counterparts, white (PR = 1.25 [95% confidence interval (CI): 1.08–1.45]) and black (1.54 [1.07, 2.20]) SM women were more likely to report heavy drinking. Hispanic/Latino SM women and men were more likely to experience short sleep duration compared to white heterosexual women (1.33 [1.06, 1.66]) and men (1.51 [1.21, 1.90). Black SM women had a much higher prevalence of stroke compared to black heterosexual women (3.25 [1.63, 6.49]) and white heterosexual women (4.51 [2.16, 9.39]). White SM women were more likely than white heterosexual women to be obese (1.31 [1.15, 1.48]), report cancer (1.40 [1.07, 1.82]) and report stroke (1.91 [1.16, 3.15]. White (2.41 [2.24, 2.59]), black (1.40[1.20, 1.63]), and Hispanic/Latino SM (2.17 [1.98, 2.37]) men were more likely to have been tested for HIV than their heterosexual counterparts. Conclusions
Sexual minorities had a higher prevalence of some poor health behaviors, health outcomes, and healthcare access issues, and these disparities differed across racial groups. Further research is needed to investigate potential pathways, such as discrimination, in the social environment that may help explain the relationship between sexual orientation and health.
About 3.5% Americans identify themselves as lesbian, gay, or bisexual while 0.3% identify themselves as transgender. The LGBT (lesbian, gay, bisexual, and transgender) community belongs to almost every race, ethnicity, religion, age, and socioeconomic group. The LGBT youth are at a higher risk for substance use, sexually transmitted diseases (STDs), cancers, cardiovascular diseases, obesity, bullying, isolation, rejection, anxiety, depression, and suicide as compared to the general population. LGBT youth receive poor quality of care due to stigma, lack of healthcare providers’ awareness, and insensitivity to the unique needs of this community. The main objective of this literature review is to highlight the challenges faced by the LGBT youth and to enhance the awareness among physicians about the existing disparities in order to provide a more comprehensive, evidence-based, and humane medical care to this community.
Disability is an emerging field within public health; people with significant disabilities account for more than 12% of the US population. Disparity status for this group would allow federal and state governments to actively work to reduce inequities. We summarize the evidence and recommend that observed differences are sufficient to meet the criteria for health disparities: population-level differences in health outcomes that are related to a history of wide-ranging disadvantages, which are avoidable and not primarily caused by the underlying disability. We recommend future research and policy directions to address health inequities for individuals with disabilities; these include improved access to health care and human services, increased data to support decision-making, strengthened health and human services workforce capacity, explicit inclusion of disability in public health programs, and increased emergency preparedness. (Am J Public Health. Published online ahead of print February 17, 2015: e1-e9. doi:10.2105/AJPH.2014.302182).
Abstract Ethnic minority groups across the world face a complex set of adverse social and psychological challenges linked to their minority status, often involving racial discrimination. Racial Discrimination is increasingly recognised as an important contributing factor to health disparities among non-dominant ethnic minorities. A growing body of literature has recognised these health disparities and has investigated the relationship between racial discrimination and poor health outcomes. Chronically elevated cortisol levels and a dysregulated hypothalamic-pituitary-adrenal (HPA) axis appear to mediate effects of racial discrimination on allostatic load and disease. Racial discrimination seems to converge on the anterior cingulate cortex (ACC) and may impair the function of the prefrontal cortex (PFC), hence showing substantial similarities to chronic social stress. This review provides a summary of recent literature on hormonal and neural effects of racial discrimination and a synthesis of potential neurobiological pathways by which discrimination affects mental health.
This paper describes a shift in medical education away from pedagogic approaches to stigma and inequalities that emphasize cross-cultural understandings of individual patients, toward attention to forces that influence health outcomes at levels above individual interactions. It reviews existing structural approaches to stigma and health inequalities developed outside of medicine, and proposes changes to U.S. medical education that will infuse clinical training with a structural focus. The approach, termed "structural competency," consists of training in five core competencies: 1) recognizing the structures that shape clinical interactions; 2) developing an extra-clinical language of structure; 3) rearticulating "cultural" formulations in structural terms; 4) observing and imagining structural interventions; and 5) developing structural humility. Examples are provided of structural health scholarship that should be adopted into medical didactic curricula, and of structural interventions that can provide participant-observation opportunities for clinical trainees. The paper ultimately argues that increasing recognition of the ways in which social and economic forces produce symptoms or methylate genes then needs to be better coupled with medical models for structural change.
Objective
To examine associations between neighborhood socioeconomic status (nSES) and 90-day post-stroke outcomes.
Methods
The Brain Attack Surveillance in Corpus Christi Project is a population-based surveillance study in Nueces County, Texas. Stroke patients were identified between 2010 and 2016 via active and passive surveillance and enrolled in the study. nSES index is a standardized composite of 2010 census-tract level income, wealth, education, and employment (median -4.56; IQR: -7.48 to -0.46). 90-day outcomes were ascertained via interview: functional status measured by the average of 22 activities of daily living/instrumental activities of daily living (range 1-4), biopsychosocial health by the Stroke-Specific Quality of Life scale (range 0-5), and depressive symptoms by the 8-item Patient Health Questionnaire (range 0-24). Associations between nSES and outcomes were estimated using confounder-adjusted generalized estimating equations with an nSES*National Institute of Health Stroke Scale interaction term.
Results
776 survivors composed the analytic sample (52.96% male, 62.24% Mexican-American, 52.96% ≥ 64 years-old). Higher compared to lower nSES (mean difference comparing 75 th to 25 th percentile of nSES ) was associated with better function (-0.27, 95% CI: -0.49, -0.05), better biopsychosocial health (0.26, 95% CI: 0.06, 0.47), and less depressive symptoms (-1.77, 95% CI: -3.306, -0.48) among those with moderate-to-severe strokes. Among those with minor strokes, higher nSES was associated with better function (-0.13; 95% CI: -0.24, -0.02).
Conclusions: nSES may influence post-stroke recovery. Studies should identify neighborhood characteristics that contribute to post-stroke outcomes, particularly in moderate-to-severe stroke survivors.
Introduction
Although evidence indicates that Black gay, bisexual, and other sexual minority men experience vast psychological and behavioral health inequities, most research has focused on individual rather than structural drivers of these inequities. This study examines the associations between structural racism and anti–lesbian, gay, bisexual, transgender, and queer policies and the psychological and behavioral health of Black and White sexual minority men.
Methods
Participants were an Internet-based U.S. national sample of 1,379 Black and 5,537 White sexual minority men during 2017–2018. Analysis occurred in 2019–2020. Structural equation modeling tested the associations from indicators of structural racism, anti‒lesbian, gay, bisexual, transgender, and queer policies, and their interaction to anxiety symptoms, depressive symptoms, perceived burdensomeness, heavy drinking, and HIV testing frequency. Separate models for Black and White sexual minority men adjusted for contextual and individual covariates.
Results
For Black participants, structural racism was positively associated with anxiety symptoms (β=0.20, SE=0.10, p=0.04), perceived burdensomeness (β=0.42, SE=0.09, p<0.001), and heavy drinking (β=0.23, SE=0.10, p=0.01). Anti‒lesbian, gay, bisexual, transgender, and queer policies were positively associated with anxiety symptoms (β=0.08, SE=0.04, p=0.03), perceived burdensomeness (β=0.20, SE=0.04, p<0.001), and heavy drinking (β=0.10, SE=0.04, p=0.01) and were negatively associated with HIV testing frequency (β= −0.14, SE=0.07, p=0.04). Results showed significant interaction effects, such that the positive associations between structural racism and both perceived burdensomeness (β=0.38, SE=0.08, p≤0.001) and heavy drinking (β=0.22, SE=0.07, p=0.003) were stronger for individuals living in states with high levels of anti‒lesbian, gay, bisexual, transgender, and queer policies. Neither of the oppression variables nor their interaction was significantly associated with outcomes for White sexual minority men.
Conclusions
Results highlight the intersectional nature of structural oppression and suggest that racist and anti–lesbian, gay, bisexual, transgender, and queer policies must be repealed to rectify health inequities facing Black sexual minority men.
Background:
Hospitalized patients with comorbid substance use disorders (SUDs) are at high risk for poor outcomes, including readmission and emergency department (ED) use.
Objective:
To determine whether patient navigation services reduce hospital readmissions.
Design:
Randomized controlled trial comparing Navigation Services to Avoid Rehospitalization (NavSTAR) versus treatment as usual (TAU). (ClinicalTrials.gov: NCT02599818).
Setting:
Urban academic hospital in Baltimore, Maryland, with an SUD consultation service.
Participants:
400 hospitalized adults with comorbid SUD (opioid, cocaine, or alcohol).
Intervention:
NavSTAR used proactive case management, advocacy, service linkage, and motivational support to resolve internal and external barriers to care and address SUD, medical, and basic needs for 3 months after discharge.
Measurements:
Data on inpatient readmissions (primary outcome) and ED visits for 12 months were obtained for all participants via the regional health information exchange. Entry into SUD treatment, substance use, and related outcomes were assessed at 3-, 6-, and 12-month follow-up.
Results:
Participants had high levels of acute care use: 69% had an inpatient readmission and 79% visited the ED over the 12-month observation period. Event rates per 1000 person-days were 6.05 (NavSTAR) versus 8.13 (TAU) for inpatient admissions (hazard ratio, 0.74 [95% CI, 0.58 to 0.96]; P= 0.020) and 17.66 (NavSTAR) versus 27.85 (TAU) for ED visits (hazard ratio, 0.66 [CI, 0.49 to 0.89]; P= 0.006). Participants in the NavSTAR group were less likely to have an inpatient readmission within 30 days than those receiving TAU (15.5% vs. 30.0%; P< 0.001) and were more likely to enter community SUD treatment after discharge (P= 0.014; treatment entry within 3 months, 50.3% NavSTAR vs. 35.3% TAU).
Limitation:
Single-site trial, which limits generalizability.
Conclusion:
Patient navigation reduced inpatient readmissions and ED visits in this clinically challenging sample of hospitalized patients with comorbid SUDs.
Primary funding source:
National Institute on Drug Abuse.
This study assessed the impact of individual social risk factor variables and social determinants of health (SDOH) measures on hospital readmission rates and penalties used in the Centers for Medicare and Medicaid Services (CMS) Hospital Readmissions Reduction Program (HRRP). Using 2012-16 hospital discharge data from New York City, we projected HRRP penalties by augmenting CMS's readmission model for heart attack, heart failure, and pneumonia with SDOH scores constructed at each of four geographic levels and a measure of individual-level social risk. Including additional SDOH scores in the model, especially those constructed with the most granular geographic data, along with social risk factor variables substantially affects projected penalties for hospitals treating the highest proportion of patients with high SDOH scores. Improved performance occurred even after we included peer-group stratification in the HRRP model pursuant to the 21st Century Cures Act. Small improvements in model accuracy were associated with substantial shifts in projected performance. Our results suggest that CMS's continued omission of relevant patient and geographic data from the HRRP readmission model misallocates penalties attributable to SDOH and social risk factor effects to hospitals with the largest share of high-risk patients.
Objective:
Population segmentation has been recognized as a foundational step to help tailor interventions. Prior studies have predominantly identified subgroups based on diagnoses. In this study, we identify clinically coherent subgroups using social determinants of health (SDH) measures collected from Veterans at high risk of hospitalization or death.
Study design and setting:
SDH measures were obtained for 4684 Veterans at high risk of hospitalization through mail survey. Eleven self-report measures known to impact hospitalization and amenable to intervention were chosen a priori by the study team to identify subgroups through latent class analysis. Associations between subgroups and demographic and comorbidity characteristics were calculated through multinomial logistic regression. Odds of 180-day hospitalization were compared across subgroups through logistic regression.
Results:
Five subgroups of high-risk patients emerged-those with: minimal SDH vulnerabilities (8% hospitalized), poor/fair health with few SDH vulnerabilities (12% hospitalized), social isolation (10% hospitalized), multiple SDH vulnerabilities (12% hospitalized), and multiple SDH vulnerabilities without food or medication insecurity (10% hospitalized). In logistic regression, the "multiple SDH vulnerabilities" subgroup had greater odds of 180-day hospitalization than did the "minimal SDH vulnerabilities" reference subgroup (odds ratio: 1.53, 95% confidence interval: 1.09-2.14).
Conclusion:
Self-reported SDH measures can identify meaningful subgroups that may be used to offer tailored interventions to reduce their risk of hospitalization and other adverse events.
Background:
While health-related social needs (HRSN) are known to compromise health, work to date has not clearly demonstrated the relationship between clinically acknowledged social needs, via ICD-10 Z-codes, and readmission.
Objective:
Assess the rate of 30-, 60-, and 90-day readmission by the level of ICD-10-identified social need. In addition, we examined the associations between demographics, social need, hospital characteristics, and comorbidities on 30-day readmission.
Design:
Retrospective study using the 2017 Nationwide Readmission Database PARTICIPANTS: We identified 5 domains of HRSN from ICD-10 diagnosis codes including employment, family, housing, psychosocial, and socioeconomic status (SES) and identified how many and which an individual was coded with during the year.
Main measures:
The proportion of patients with 30-, 60-, and 90-day readmission stratified by the number of HRSN domains with a multivariable logistic regression to examine the relationship between the number/type of and readmission adjusting for sex, age, payer, hospital characteristics, functional limitations, and comorbidities.
Key results:
From 13,217,506 patients, only 2.4% had at least one HRSN diagnosis. Among patients without HRSN, 11.5% had a 30-day readmission, compared to 27.0% of those with 1 domain, increasing to 63.5% for patients with codes in 5 domains. Similar trends were observed for 60- and 90-day readmission; 78.7% of patients with documented HRSN in all 5 domains were hospitalized again within 90 days. The adjusted odds ratio for readmission for individuals with all 5 domains was 12.55 (95% CI: 9.04, 17.43). Housing and employment emerged as two of the most commonly documented HRSN, as well as having the largest adjusted odds ratio.
Conclusions:
There is a dose-response relationship between the number of HRSN diagnoses and hospital readmission. This work calls attention to the need to develop interventions to reduce readmissions for those at social risk and demonstrates the significance of ICD-10 Z-codes in health outcomes studies.
Importance
Little is known about the neurologic health needs of sexual and gender minority (SGM) individuals, and existing research indicates health care disparities for this group.
Objective
To describe the current state of science in SGM neurology and highlight areas of knowledge and gaps to guide future research.
Evidence Review
All articles published before April 12, 2020, in PubMed, Embase, Web of Science, PsycInfo, CINAHL, and BIOSIS Previews were searched using a search string encompassing SGM descriptors and neurologic disorders. A total of 8359 items were found and entered into EndNote, and 2921 duplicates were removed. A blind title and abstract review was performed followed by full-text review in duplicate, with conflicts settled through consensus, to identify 348 articles eligible for data abstraction. Articles presenting primary data about an identified adult SGM population addressing a clinical neurology topic were included. Descriptive statistics were used for abstracted variables.
Findings
Of 348 studies, 205 (58.9%) were case reports or series, 252 (72.4%) included sexual minority cisgender men, and 247 (70.9%) focused on HIV. An association was found between autism spectrum disorder and gender dysphoria in 9 of 16 studies (56.3%), and a higher risk of ischemic stroke in transgender women was shown in other studies. Literature in neuroinfectious disease, the most common topic, largely focused on HIV (173 of 200 studies [86.5%]). Findings in other neurologic topics were limited by lack of data.
Conclusions and Relevance
In this rigorous compendium of SGM neurology literature, several deficiencies were found: most studies focused on a limited breadth of neurologic pathology, included only a portion of the overall SGM community, and did not assess other aspects of sociodemographic diversity that may contribute to disparities in health care access and outcomes among SGM individuals. Expanding neurologic research to include broader representation of SGM individuals and incorporating sociodemographic factors, like race/ethnicity and socioeconomic status, are essential steps toward providing equitable neurologic care for this community.
Objective
The goal of this paper is to give a narrative review of the racial/ethnic disparities in African-Americans (AA) found in headache medicine and provide plausible responses to the National Institute of Neurological Disorders and Stroke (NINDS) issued Request for information (RFI); “Soliciting Input on Areas of Health Disparities and Inequities in Neurological Disease and/or Care in the United States (US)” as it relates to AA and headache medicine.
Background
On March 31, 2020 the NINDS issued a RFI “Soliciting Input on Areas of Health Disparities and Inequities in Neurological Disease and/or Care in the US Across the Lifespan”, RFI-NOT–NS–20-026, with response date ending June 15, 2020.¹ However as of June 13, 2020, a PubMed search with key terms “African American Headache disparities” yielded few results.
Methods
Multi-database search and literature review.
Results/Discussion
As of June 13, 2020, a PubMed search with key terms “African American (or Black) Headache disparities” yielded 13 results. Searches of “Migraine Disparities Race” and “Migraine disparities African American” both yielded three results with one non-specific for migraine. In, “Headache disparities race” yielded one result in the PsycINFO database and 23 results in Web of Science database. Key areas of adult headache disparity and/or inequity were health care services for migraine treatment are less utilized, follow-up appointments are terminated more regularly, inaccurate diagnoses are more common, acute migraine attack medications are prescribed less frequently, mistrust and lower quality communication with physicians is reported, mistrust, increased migraine burden, frequency, and severity and risk for progression more associated depression and lower quality of life in AAs compared to non-Hispanic Whites. Literature on race-based disparities is even more scarce in pediatric populations, however it has been shown that white children are significantly more likely to receive neuroimaging than others which may indicate biases in pediatric populations. Potential determinants of these race-based disparities, research strategies and approaches vary and are discussed.
Conclusions
Race-based disparities exist in headache medicine in the US. Research is needed. Research strategies and approaches currently with limited use in neurology and headache medicine may be warranted and appropriate to address race-based headache disparities. Funding is paramount.
Migraine affects 1 in 6 adults and represents the fifth leading cause of emergency department visits in the US. Despite an increasing recognition of disparities in migraine prevalence by race/ethnicity, sex, and socioeconomic status, there is a paucity of research on disparities by sexual orientation. Sexual minority groups (eg, lesbian, gay, bisexual, and other nonheterosexual people) may experience unique discrimination, stigma, and barriers to health care access, thus leading to disparities in physical and mental health. The objective of this study was to determine the association between sexual orientation and migraine in a nationally representative sample of US adults.
Previous work has not examined how the association of sexual orientation and severe headache/migraine may be explained by differences between sexual minorities and heterosexuals in sociodemographic and health-related characteristics. Using data from the 2013-2018 National Health Interview Survey, regression decomposition was used to identify determinants of disparities in headache/migraine between sexual minorities collectively and heterosexuals, as well as between bisexual men and gay men, and bisexual women and lesbians. The prevalence of headache/migraine was the highest among bisexual women (36.8%), followed by lesbians (24.7%), bisexual men (22.8%), heterosexual women (19.7%), gay men (14.8%), and heterosexual men (9.8%). Across all models, the largest percentage of the disparity between sexual orientation/gender groups was attributable to age (range, 18.3%-42.2%), serious psychological distress (range, 6.6%-14.0%), and hours of regular sleep (range, 1.7%-8.2%). Although age accounted for the largest part of the disparity in headache/migraine by sexual orientation, several modifiable risk factors also played a role.
Introduction:
Allostatic load refers to the cumulative burden of chronic stress and life events. It involves the interaction of different physiological systems at varying degrees of activity. When environmental challenges exceed the individual ability to cope, then allostatic overload ensues. Allostatic load is identified by the use of biomarkers and clinical criteria.
Objective:
To summarize the current knowledge on allostatic load and overload and its clinical implications based on a systematic review of the literature.
Methods:
PubMed, PsycINFO, Web of Science, and the Cochrane Library were searched from inception to December 2019. A manual search of the literature was also performed, and reference lists of the retrieved articles were examined.We considered only studies in which allostatic load or overload were adequately described and assessed in either clinical or non-clinical adult populations.
Results:
A total of 267 original investigations were included. They encompassed general population studies, as well as clinical studies on consequences of allostatic load/overload on both physical and mental health across a variety of settings.
Conclusions:
The findings indicate that allostatic load and overload are associated with poorer health outcomes. Assessment of allostatic load provides support to the understanding of psychosocial determinants of health and lifestyle medicine. An integrated approach that includes both biological markers and clinimetric criteria is recommended.
The USA is one of the few countries in the world in which maternal and infant morbidity and mortality continue to increase, with the greatest disparities observed among non-Hispanic Black women and their infants. Traditional explanations for disparate outcomes, such as personal health behaviors, socioeconomic status, health literacy, and access to healthcare, do not sufficiently explain why non-Hispanic Black women continue to die at three to four times the rate of White women during pregnancy, childbirth, or postpartum. One theory gaining prominence to explain the magnitude of this disparity is allostatic load or the cumulative physiological effects of stress over the life course. People of color disproportionally experience social, structural, and environmental stressors that are frequently the product of historic and present-day racism. In this essay, we present the growing body of evidence implicating the role of elevated allostatic load in adverse pregnancy outcomes among women of color. We argue that there is a moral imperative to assign additional resources to reduce the effects of elevated allostatic load before, during, and after pregnancy to improve the health of women and their children.
Background and Purpose—
An excess incidence of strokes among blacks versus whites has been shown, but data on disparities related to Hispanic ethnicity remain limited. This study examines race/ethnic differences in stroke incidence in the multiethnic, largely Caribbean Hispanic, NOMAS (Northern Manhattan Study), and whether disparities vary by age.
Methods—
The study population included participants in the prospective population-based NOMAS, followed for a mean of 14±7 years. Multivariable-adjusted Cox proportional hazards models were constructed to estimate the association between race/ethnicity and incident stroke of any subtype and ischemic stroke, stratified by age.
Results—
Among 3298 participants (mean baseline age 69±10 years, 37% men, 24% black, 21% white, 52% Hispanic), 460 incident strokes accrued (400 ischemic, 43 intracerebral hemorrhage, 9 subarachnoid hemorrhage). The most common ischemic subtype was cardioembolic, followed by lacunar infarcts, then cryptogenic. The greatest incidence rate was observed in blacks (13/1000 person-years), followed by Hispanics (10/1000 person-years), and lowest in whites (9/1000 person-years), and this order was observed for crude incidence rates until age 75. By age 85, the greatest incidence rate was in Hispanics. Blacks had an increased risk of stroke versus whites overall in multivariable models that included sociodemographics (hazard ratio, 1.51 [95% CI, 1.13–2.02]), and stratified analyses showed that this disparity was driven by women of age ≥70. The increased rate of stroke among Hispanics (age/sex-adjusted hazard ratio, 1.48 [95% CI, 1.13–1.93]) was largely explained by education and insurance status (a proxy for socieoeconomic status; hazard ratio after further adjusting for these variables, 1.17 [95% CI, 0.85–1.62]) but remained significant for women age ≥70.
Conclusions—
This study provides novel data regarding the increased stroke risk among Caribbean Hispanics in this elderly population. Results highlight the need to create culturally tailored campaigns to reach black and Hispanic populations to reduce race/ethnic stroke disparities and support the important role of low socioeconomic status in driving an elevated risk among Caribbean Hispanics.
Objective:
Income volatility presents a growing public health threat. To our knowledge, no previous study examined the relationship among income volatility, cognitive function, and brain integrity.
Methods:
We studied 3,287 participants aged 23-35 years in 1990 from the Coronary Artery Risk Development in Young Adults prospective cohort study. Income volatility data were created using income data collected from 1990 to 2010 and defined as SD of percent change in income and number of income drops ≥25% (categorized as 0, 1, or 2+). In 2010, cognitive tests (n = 3,287) and brain scans (n = 716) were obtained.
Results:
After covariate adjustment, higher income volatility was associated with worse performance on processing speed (β = -1.09, 95% confidence interval [CI] -1.73 to -0.44) and executive functioning (β = 2.53, 95% CI 0.60-4.50) but not on verbal memory (β = -0.02, 95% CI -0.16 to 0.11). Similarly, additional income drops were associated with worse performance on processing speed and executive functioning. Higher income volatility and more income drops were also associated with worse microstructural integrity of total brain and total white matter. All findings were similar when restricted to those with high education, suggesting reverse causation may not explain these findings.
Conclusion:
Income volatility over a 20-year period of formative earning years was associated with worse cognitive function and brain integrity in midlife.
Background:
Social determinants of health are well linked to adverse health outcomes, but less is known about how they relate to migraine. While much attention has been given to the role of modifiable lifestyle factors which may mitigate risk of migraine, the role of physical activity in headache management is not yet understood.
Objectives:
The purpose of this study was to explore the relationship between social determinants of health, health behaviors, and migraine prevalence in a sample of the Canadian population aged 45-85 years.
Methods:
In this cross-sectional analysis of baseline data from the Canadian Longitudinal Study on Aging, respondents were between 45 and 85 years of age and migraine was self-report of physician diagnosis. Analyses were stratified by sex/gender (nwomen = 22,176, nmen = 21,549).
Results:
The weighted prevalence of migraine for men and women was 7.5% and 19.6%, respectively. There were relationships between social determinants of health and migraine for both men and women. Notably, higher perceived social status was associated with a 3% reduced odds of migraine among women (OR = 0.97, 95% CI: 0.95, 0.98, P < .001). Gay and bisexual men had 50% higher odds of migraine compared to heterosexual men (OR = 1.50, 95% CI: 1.13, 1.99, P = .005). Some forms of physical activity were associated with reduced odds of migraine for women: walking for 30 minutes but less than 1 hour (OR = 0.87, 95% CI: 0.78, 0.96, P = .005), light sports for less than 30 minutes (OR = 0.86, 95% CI: 0.73, 1.00, P = .048), and 1 hour but less than 2 hours (OR = 0.85, 95% CI: 0.74, 0.97, P = .018), strenuous sports for 30 minutes but less than 1 hour (OR = 0.79, 95% CI: 0.71, 0.89, P < .001), and 1 hour but less than 2 hours (OR = 0.82, 95% CI: 0.73, 0.92, P = .001). Men who engaged in daily walking as a form of leisure time physical activity had higher odds of migraine: walking less than 30 minutes (OR = 1.21, 95% CI: 1.01, 1.45, P = .042), 2 hours but less than 4 hours (OR = 1.42, 95% CI: 1.11, 1.80, P = .005), and 4 hours or more (OR = 1.65, 95% CI: 1.18, 2.31, P = .004).
Conclusions:
Social determinants of health are associated with migraine prevalence for both men and women. Physical activity is a modifiable lifestyle factor which merits further exploration as an intervention option for migraine headaches in aging samples, especially among older women. Greater odds of migraine among older men who walked for exercise may be explained by reverse causality.
Objective:
To determine whether lower socioeconomic status (SES) and longer home to hospital driving time are associated with reductions in tissue plasminogen activator (tPA) administration and timeliness of the treatment.
Methods:
We conducted a retrospective observational study using data from the Get With The Guidelines-Stroke Registry (GWTG-Stroke) between January 2015 and March 2017. The study included 118,683 ischemic stroke patients age ≥18 who were transported by emergency medical services to one of 1,489 US hospitals. We defined each patient's SES based on zip code median household income. We calculated the driving time between each patient's home zip code and the hospital where he or she was treated using the Google Maps Directions Application Programing Interface. The primary outcomes were tPA administration and onset-to-arrival time (OTA). Outcomes were analyzed using hierarchical multivariable logistic regression models.
Results:
SES was not associated with OTA (p = 0.31) or tPA administration (p = 0.47), but was associated with the secondary outcomes of onset-to-treatment time (OTT) (p = 0.0160) and in-hospital mortality (p = 0.0037), with higher SES associated with shorter OTT and lower in-hospital mortality. Driving time was associated with tPA administration (p < 0.001) and OTA (p < 0.0001), with lower odds of tPA (0.83, 0.79-0.88) and longer OTA (1.30, 1.24-1.35) in patients with the longest vs shortest driving time quartiles. Lower SES quintiles were associated with slightly longer driving time quartiles (p = 0.0029), but there was no interaction between the SES and driving time for either OTA (p = 0.1145) or tPA (p = 0.6103).
Conclusions:
Longer driving times were associated with lower odds of tPA administration and longer OTA; however, SES did not modify these associations.
Introduction:
This study aims to assess the effect of individual and geographic-level social determinants of health on risk of hospitalization in the Veterans Health Administration primary care clinics known as the Patient Aligned Care Team.
Methods:
For a population of Veterans enrolled in the primary care clinics, the study team extracted patient-level characteristics and healthcare utilization records from 2015 Veterans Health Administration electronic health record data. They also collected census data on social determinants of health factors for all U.S. census tracts. They used generalized estimating equation modeling and a spatial-based GIS analysis to assess the role of key social determinants of health on hospitalization. Data analysis was completed in 2018.
Results:
A total of 6.63% of the Veterans Health Administration population was hospitalized during 2015. Most of the hospitalized patients were male (93.40%) and white (68.80%); the mean age was 64.5 years. In the generalized estimating equation model, white Veterans had a 15% decreased odds of hospitalization compared with non-white Veterans. After controlling for patient-level characteristics, Veterans residing in census tracts with the higher neighborhood SES index experienced decreased odds of hospitalization. A spatial-based analysis presented variations in the hospitalization rate across the Veterans Health Administration primary care clinics and identified the clinic sites with an elevated risk of hospitalization (hotspots) compared with other clinics across the country.
Conclusions:
By linking patient and population-level data at a geographic level, social determinants of health assessments can help with designing population health interventions and identifying features leading to potentially unnecessary hospitalization in selected geographic areas that appear to be outliers.
Aging with Pride: National Health, Aging, and Sexuality/Gender Study is the first federally funded study addressing aging among LGBTQ older adults throughout the United States. This article examines the evolution of this landmark study and explores the well-being of LGBTQ adults aged 80 years and older (n = 200), the most underrepresented group in the field. Based on the Iridescent Life Course, we examined the diverse, intersectional nature of LGBTQ older adults’ lives, finding high levels of education and poverty. Microaggressions were negatively associated with quality-of-life and positively associated with poor physical and mental health; the inverse relationship was found with mastery. When the oldest encountered risks, it resulted in greater vulnerability. This longitudinal study is assessing trajectories in aging over time using qualitative, quantitative, and biological data and testing evidence-based culturally responsive interventions for LGBTQ older adults. Research with LGBTQ oldest adults is much needed before their stories are lost to time.
Objective:
This study was conducted to determine whether longer lifespans in African Americans with amyotrophic lateral sclerosis (ALS), compared to white non-Hispanics, are secondary to higher rates of tracheostomy and invasive ventilation (TIV) in African Americans.
Methods:
A retrospective case-control study was conducted with 49 African Americans with ALS matched by age, gender, and site of onset to 137 white persons with ALS.
Results:
African Americans had longer survival than whites when the outcome was death (p = 0.016), but this was no longer significant when the outcome was death or TIV (p = 0.100). African Americans also had a lower rate of noninvasive ventilation use compared to whites (27 [55%] vs 96 [70%], p = 0.015) and a higher rate of TIV (8 [16%] vs 7 [5%], p = 0.016), but after controlling for baseline severity, only the noninvasive ventilation difference (p = 0.036), and not the TIV difference (p = 0.115), remained significant.
Conclusion:
African Americans with ALS live longer than white persons with ALS, and this may be secondary to higher rates of TIV use among African Americans.
Many advances in prevention, diagnosis, and treatment of neurologic disease have emerged in the last few decades, resulting in reduced mortality and decreased disability. However, these advances have not benefitted all populations equally. A growing body of evidence indicates that barriers to care fall along racial and ethnic lines, with persons from minority groups frequently having lower rates of evaluation, diagnosis, and intervention, and consequently experiencing worse neurologic outcomes than their white counterparts. The American Academy of Neurology (AAN) challenged its 2017 Diversity Leadership Program cohort to determine what the AAN can do to improve quality of care for racially and ethnically diverse patients with neurologic disorders. Developing a fuller understanding of the effect of disparities in neurologic care (neurodisparity) on patients is an important prerequisite for creating meaningful change. Clear insight into how bias and trust affect the doctor-patient relationship is also crucial to grasp the complexity of this issue. We propose that the AAN take a vital step toward achieving equity in neurologic care by enhancing health literacy, patient education, and shared decision-making with a focus on internet and social media. Moreover, by further strengthening its focus on health disparities research and training, the AAN can continue to inform the field and aid in the development of current and future leaders who will address neurodisparity. Ultimately, the goal of tackling neurodisparity is perfectly aligned with the mission of the AAN: to promote the highest-quality patient-centered neurologic care and enhance member career satisfaction.
Purpose of review:
Disparities in treatment and outcomes of patients with epilepsy have been identified in several distinct patient populations. The purpose of this review is to organize the literature and establish clear pathways as to why certain patient populations are not receiving epilepsy surgery. By establishing the acronym FACETS (fear of treatment, access to care, communication barriers, education, trust between patient and physician, and social support), we set up a pathway to further study this area in an organized fashion, hopefully leading to objective solutions.
Recent findings:
Studies revealed that African American, Hispanic, and non-English-speaking patients underwent surgical treatment for epilepsy at rates significantly lower compared to white patients.
Summary:
This article explains possible reasons outlined by FACETS for the health disparities in epilepsy surgery that exist in patients of a certain race, socioeconomic status, and language proficiency.
Objectives:
While sleep is critical for good health, it remains a major public health concern because millions of individuals do not obtain a sufficient amount of sleep at night to reap proper health benefits. When examining factors that contribute to deleterious sleep outcomes, few researchers to date have examined the physical and social environments together.
Study design:
This article is an analytical essay.
Methods:
In the present study, 18 empirical articles on environmental factors that promote sleep loss were analyzed and synthesized according to the study type, exposure measures, outcome measures, methodology, and findings.
Results:
Data from the literature demonstrate that neighborhood airplane, roadway, and rail noise pollution; air pollution from ozone and particulate matter (PM10); and, to some extent, ambient light, interfere with residents' ability to fall asleep, stay asleep, and wake feeling rested. There is also some evidence that neighborhood green space, walkability, safety, built environment, and other social characteristics, such as neighborhood disorder and ability to trust one's neighbors, dramatically impact residents' sleep.
Conclusions:
This article provides a critical assessment of the multidimensional relationship between neighborhood physical and social characteristics and sleep, addresses major methodological concerns that limit current empirical knowledge, and suggests steps to shape future research.
Sexual minority (i.e., non-heterosexual) individuals experience poorer mental and physical health, accounted for in part by the additional burden of sexual minority stress occurring from being situated in a culture favoring heteronormativity. Informed by previous research, the purpose of this study was to identify the relationship between sexual minority stress and leukocyte gene expression related to inflammation, cancer, immune function, and cardiovascular function. Sexual minority men living with HIV who were on anti-retroviral medication, had viral load <200 copies/mL, and had biologically confirmed, recent methamphetamine use completed minority stress measures and submitted blood samples for RNA sequencing on leukocytes. Differential gene expression and pathway analyses were conducted comparing those with clinically elevated minority stress (n=18) and those who did not meet the clinical cutoff (n=20), covarying reactive urine toxicology results for very recent stimulant use. In total, 90 differentially expressed genes and 138 gene set pathways evidencing 2-directional perturbation were observed at false discovery rate (FDR) < 0.10. Of these, 41 of the differentially expressed genes and 35 of the 2-directionally perturbed pathways were identified as functionally related to hypothesized mechanisms of inflammation, cancer, immune function, and cardiovascular function. The neuroactive-ligand receptor pathway (implicated in cancer development) was identified using signaling pathway impact analysis. Our results suggest several potential biological pathways for future work investigating the relationship between sexual minority stress and health.
Background and purpose:
The evidence supporting the deleterious cardiovascular health effects of living near a major roadway is growing, although this association is not universal. In primary analyses, we hypothesized that residential proximity to a major roadway would be associated with incident ischemic stroke and that cardiovascular risk factors would modify that association.
Methods:
NOMAS (The Northern Manhattan Study) is an ongoing, population-based cohort study designed to measure cardiovascular risk factors, stroke incidence, and other outcomes in a multiethnic urban population. Recruitment occurred from 1993 to 2001 and participants are followed-up annually by telephone. Residential addresses at baseline were geocoded and Euclidean distance to nearest major roadway was estimated and categorized as in prior studies. We used Cox proportional hazard models to calculate hazard ratios and 95% confidence intervals for the association of this distance to incidence of stroke and other outcomes, adjusting for sociodemographic and cardiovascular risk factors, year at baseline, and neighborhood socioeconomic status. We assessed whether these associations varied by age, sex, smoking status, diabetes mellitus, and hypertension.
Results:
During a median follow-up period of 15 years (n=3287), 11% of participants were diagnosed with ischemic stroke. Participants living <100 m from a roadway had a 42% (95% confidence interval, 1.01-2.02) higher rate of ischemic stroke versus those living >400 m away. This association was more pronounced among noncurrent smokers (hazard ratio, 1.54; 95% confidence interval, 1.05-2.26) and not evident among smokers (hazard ratio, 0.69; 95% confidence interval, 0.23-2.06). There was no clear pattern of association between proximity to major roadways and other cardiovascular events including myocardial infarction, all-cause death, or vascular death.
Conclusions:
In this urban multiethnic cohort, we found evidence supporting that within-city variation in residential proximity to major roadway is associated with higher risk of ischemic stroke. An individual's smoking history modified this association, with the association remaining only among participants not currently smokers.
Objective:
To evaluate race differences in tissue plasminogen activator (tPA) refusal among eligible patients with acute ischemic stroke (AIS) in Chicago.
Methods:
Using the Get With The Guidelines-Stroke registry data from 15 primary stroke centers between January 2013 and June 2015, we performed a retrospective analysis of patients with AIS presenting to the emergency department within 4.5 hours from symptom onset. Patient or proxy refusal was captured as a reason for nonadministration of tPA to eligible patients in the registry. We assessed whether tPA refusal differed by race using logistic regression.
Results:
Among 704 tPA-eligible patients with AIS, tPA was administered to 86.2% (black race, 82.5% vs nonblack race, 89.5%; p < 0.001). Fifty-three (7.5%) tPA refusals were documented. Refusal was more common in black vs nonblack patients (10.6% vs 4.8%; p = 0.004). In multivariable analysis, the following were associated with tPA refusal: black race (adjusted odds ratio [OR] 2.5, 95% confidence interval [CI] 1.3-4.6), self-pay status (adjusted OR 3.23, 95% CI 1.2-8.71), prior stroke (adjusted OR 2.11, 95% CI 1.14-3.90), age (adjusted OR 1.04, 95% CI 1.02-1.07), and NIH Stroke Scale score (adjusted OR 0.94, 95% CI 0.90-0.99).
Conclusions:
Among tPA-eligible patients with AIS in Chicago, over 7% refused tPA. Refusal was more common in black patients and accounted for the apparent lower rates of tPA use in black vs nonblack patients. Further research is needed to understand barriers to consent and overcome race-ethnic disparities in tPA treatment for AIS.
Aims/hypothesisOur aim was to assess the association of perceived racism with type 2 diabetes, and the possible mediating influence of diet and BMI. Methods
The Black Women’s Health Study, a follow-up of 59,000 African-American women, began in 1995. Over 16 years 5344 incident cases of diabetes occurred during 576,577 person-years. Cox proportional hazards models were used to estimated HRs and 95% CIs for categories of ‘everyday racism’ (interpersonal racism in daily life) and ‘lifetime racism’ (reporting ever treated unfairly due to race with respect to police, housing or work) and incident type 2 diabetes. Models were adjusted for age, questionnaire cycle, marital status, socioeconomic status, education, family history of diabetes, physical activity, alcohol use and smoking status, with and without inclusion of terms for dietary patterns and adult BMI. ResultsCompared with women in the lowest quartile of exposure, women in the highest quartile of exposure to everyday racism had a 31% increased risk of diabetes (HR 1.31; 95% CI 1.20, 1.42) and women with the highest exposure to lifetime racism had a 16% increased risk (HR 1.16; 95% CI 1.05, 1.27). Mediation analysis estimated that BMI accounted for half of the association between either the everyday or lifetime racism measure and incident diabetes. Conclusions/interpretationPerceived everyday and lifetime racism were associated with increased risk of type 2 diabetes in this cohort of African-American women and appear to be at least partly mediated by BMI.
Objective:
To evaluate racial and ethnic differences in the utilization of neurologic care across a wide range of neurologic conditions in the United States.
Methods:
We analyzed nationally representative data from the 2006-2013 Medical Expenditure Panel Survey (MEPS), including information on demographics, patient-reported health conditions, neurology visit rates, and costs. Using diagnostic codes, we identified persons with any self-identified neurologic disorder except back pain, as well as 5 subgroups (Parkinson disease, multiple sclerosis, headache, cerebrovascular disease, and epilepsy). To assess disparities in neurologic care utilization, we performed logistic regression analyses of outpatient department neurologic care visit rates and expenditures for each racial ethnic group controlling for age, sex, health status, socioeconomic characteristics, and geographic region of care.
Results:
Of the 279,103 MEPS respondents, 16,936 (6%) self-reported a neurologic condition; 5,890 (2%) received a total of 13,685 outpatient neurology visits. Black participants were nearly 30% less likely to see an outpatient neurologist (odds ratio [OR] 0.72, confidence interval [CI] 0.64-0.81) relative to their white counterparts, even after adjustment for demographic, insurance, and health status differences. Hispanic participants were 40% less likely to see an outpatient neurologist (OR 0.61, CI 0.54-0.69). Among participants with known neurologic conditions, blacks were more likely to be cared for in the emergency department, to have more hospital stays, and to have higher per capita inpatient expenditures than their white counterparts.
Conclusions:
Our findings highlight racial and ethnic inequalities in the utilization of neurologic care in the United States.
Objective:
To explore the influence of several estimates of family socioeconomic status on the long-term clinical course and social outcomes of children with epilepsy.
Methods:
The Nova Scotia childhood epilepsy cohort is population based and includes all children in this Canadian province who developed epilepsy between 1977 and 1985. Eligible patients had ≥10 years of follow-up. Children with childhood absence epilepsy were excluded. Total family income at seizure onset was assessed at seizure onset and classified as "poor" (first quintile), "adequate" (second to third quintiles), and "well-off" (fourth to fifth quintiles). We also assessed parental education and home ownership. Social outcome was assessed in those with normal intelligence who were ≥18 years of age at the end of follow-up using a semistructured interview that explored eight adverse effects.
Results:
Of 584 patients, 421 (72%) were included. Average follow-up was 26 ± 5.6 years. Overall 137 families (33%) had "poor" income, 159 (38%) had "adequate income," and 125 (30%) were "well-off." Terminal remission of epilepsy occurred in 65% of the poor, 61% of the adequate, and 61% of the well-off (p = ns). Intractable epilepsy, status epilepticus, number of antiepileptic drugs (AEDs) used, and the number of generalized tonic-clonic or focal with secondary generalization seizures through the clinical course was the same in all groups. Home ownership did not predict remission. Neither paternal nor maternal education was associated with remission. Poor children had significantly more adverse social outcomes including failure to graduate from high school, unemployment, personal poverty, inadvertent pregnancy, and psychiatric diagnoses.
Significance:
In Nova Scotia with universal health care, coming from a poor or more affluent family does not seem to affect the clinical course or long-term seizure outcome of childhood epilepsy. Unfortunately children from poor families are less likely to have a good social outcome.
Methods:
Data from the Indiana Black Men's Health Study, a community-based sample of adult Black men, was used to conduct multivariate logistic regression to examine the relationship between the physical and emotional effects of discrimination and smoking, net of healthcare and workplace discrimination, age, education, household income, and being married.
Results:
After adjusting for having an emotional response to discrimination, health care and workplace discrimination, age, education, household income, and being married, males who had a physical response to discrimination (e.g., upset stomach or headache) had higher odds of cigarette use (odds ratio (OR): 1.95, 95% confidence interval (CI): 1.15-3.30) than men who did not have a physical response to discrimination.
Conclusion:
Findings from the study suggest that Black males may use cigarette smoking as a means to mitigate the stress associated with experiences of discrimination. Future research is needed further to explore if and how Black males use cigarette smoking to cope with unfair treatment.
Objectives:
We provide the first known examination of differences in nonurgent and urgent emergency department (ED) usage between Hispanic and non-Hispanic white individuals, with varying levels of acculturation.
Materials and methods:
We pooled cross-sectional data for Hispanic and non-Hispanic white adults (ages 18-64) from the 2011 to 2013 National Health Interview Surveys. Using logistic regression models, we examined differences in past-year ED use, urgent ED use, and nonurgent ED use by acculturation level, which we measure by combining information on respondents' citizenship status, birthplace, and length of stay (immigrants <5, 5-10, >10 y in the United States; naturalized citizens; US born).
Results:
Overall, 17.8% of Hispanic individuals and 18.5% of non-Hispanic white individuals use the ED annually. Compared with US-born non-Hispanic white individuals, the least acculturated Hispanic individuals are 14.4% points (P<0.001) less likely to use the ED for any reason, 9.8% points (P<0.001) less likely to use it for a nonurgent reason, and 5.3% points (P<0.01) less likely to use it for an urgent reason.
Conclusions:
Contrary to popular perception, the least acculturated Hispanic individuals are the least likely to use the ED. As acculturation level rises, so does one's likelihood of using the ED, particularly for nonurgent visits.
An increasing body of literature indicates that discrimination has a negative impact on health; poor sleep may be an underlying mechanism. The primary objective of this review was to examine existing studies on the relationship between discrimination and sleep to clarify (a) the potential role of discrimination in shaping population patterns of sleep and sleep disparities, and (b) the research needed to develop interventions at individual and institutional levels. We identified articles from English-language publications in PubMed and EBSCO databases from inception through July 2014. We employed a broad definition of discrimination to include any form of unfair treatment and all self-reported and objectively assessed sleep outcomes, including duration, difficulties, and sleep architecture. Seventeen studies were identified: four prospective, 12 cross-sectional, and one that utilized a daily-diary design. Fifteen of the 17 studies evaluated interpersonal discrimination as the exposure and the majority of studies included self-reported sleep as the outcome. Only four studies incorporated objective sleep assessments. All 17 studies identified at least one association between discrimination and a measure of poorer sleep, although studies with more detailed consideration of either discrimination or sleep architecture revealed some inconsistencies. Taken together, existing studies demonstrate consistent evidence that discrimination is associated with poorer sleep outcomes. This evidence base can be strengthened with additional prospective studies that incorporate objectively measured aspects of sleep. We outline important extensions for this field of inquiry that can inform the development of interventions to improve sleep outcomes, and consequently promote well-being and reduce health inequities across the life course.
Copyright © 2015 Elsevier B.V. All rights reserved.
Background: African-American patients who visit physicians of the same race rate their medical visits as more satisfying and participatory than do those who see physicians of other races. Little research has investigated the communication process in race-concordant and race-discordant medical visits. Objectives: To compare patient-physician communication in race-concordant and race-discordant visits and examine whether communication behaviors explain differences in patient ratings of satisfaction and participatory decision making. Design: Cohort study with follow-up using previsit and postvisit surveys and audiotape analysis. Setting: 16 urban primary care practices. Patients: 252 adults (142 African-American patients and 110 white patients) receiving care from 31 physicians (of whom 18 were African-American and 13 were white). Measurements: Audiotape measures of patient-centeredness, patient ratings of physicians' participatory decision-making styles, and overall satisfaction. Results: Race-concordant visits were longer (2.15 minutes [95% Cl, 0.60 to 3.71]) and had higher ratings of patient positive affect (0.55 point, [95% Cl, 0.04 to 1.05]) compared with race-discordant visits. Patients in race-concordant visits were more satisfied and rated their physicians as more participatory (8.42 points [95% Cl, 3.23 to 13.60]). Audiotape measures of patient-centered communication behaviors did not explain differences in participatory decision making or satisfaction between race-concordant and race-discordant visits. Conclusions: Race-concordant visits are longer and characterized by more patient positive affect. Previous studies link similar communication findings to continuity of care. The association between race concordance and higher patient ratings of care is independent of patient-centered communication, suggesting that other factors, such as patient and physician attitudes, may mediate the relationship. Until more evidence is available regarding the mechanisms of this relationship and the effectiveness of intercultural communication skills programs, increasing ethnic diversity among physicians may be the most direct strategy to improve health care experiences for members of ethnic minority groups.
Social factors have been identified as key drivers of epilepsy care, outcomes, and disparities, but there is a limited understanding of what these factors are and how they translate into disparities. This targeted review provides an overview of the social determinants of health framework and applies this perspective to the literature about social and psychosocial factors in epilepsy; a social determinants of health - epilepsy model is proposed. The key social determinants of health in epilepsy include socioeconomic status, race/ethnicity, age, and gender. For example, low socioeconomic status and minority status have been associated with a higher risk of epilepsy, more hospitalizations and emergency room visits (versus neurology services), antiepileptic drug nonadherence, and a lower rate of epilepsy surgery. Such differences in care/treatment and outcomes translate into health disparities, many of which are considered unjust (inequitable) and modifiable through social action. Other social determinants of health include structural and sociocultural contextual conditions (e.g., health economy, policy, and social stigma/discrimination) and mediating mechanisms including material (e.g., housing), behavioral/biological (e.g., adherence), psychosocial (e.g., perceived stigma), and health system (e.g., access) factors. There are complex relationships among social determinants of health in epilepsy, which remain poorly understood and hamper efforts to address and eliminate disparities in epilepsy care and outcomes. Further empirical work grounded in sound theory and robust methodologies is needed to identify points of intervention and design effective and socially acceptable solutions to any pervasive disparities in epilepsy.