Long-standing Inequalities Research Articles

Patterns of Demand and Provision in English Adult Social Care Services

Abstract This article reports on a quantitative study of the national datasets for adult social care in England. Building on recent analysis of trends in demand and expenditure, the aim of the study was to investigate the relationship between local authority (LA) characteristics, levels of demand for state-funded services and rates of short- and long-term provision. Publicly available data on short- and long-term activity and finances were collected for all LAs in England from 2016 to 2019 and combined with other indicators including population demographics and the Index of Multiple Deprivation. Correlation analysis was undertaken to investigate patterns of demand and provision and their link to contextual factors. Findings showed that variation between LAs was to some extent shaped by contextual factors such as deprivation and demographics, but was also subject to the effects of rationing and the impact of the self-funded market on levels of demand. Implications are discussed for efforts to reform the adult social system and address longstanding inequalities that have been both highlighted and exacerbated by the COVID-19 pandemic.

Prevalence of common mental disorders and treatment receipt for people from ethnic minority backgrounds in England: repeated cross-sectional surveys of the general population in 2007 and 2014.

Concerns persist that some ethnic minority groups experience longstanding mental health inequalities in England. It is unclear if these have changed over time. To assess the prevalence of common mental disorders (CMDs) and treatment receipt by ethnicity, and changes over time, using data from the nationally representative probability sample in the Adult Psychiatric Morbidity Surveys. We used survey data from 2007 (n = 7187) and 2014 (n = 7413). A Clinical Interview Schedule - Revised score of ≥12 indicated presence of a CMD. Treatment receipt included current antidepressant use; any counselling or therapy; seeing a general practitioner about mental health; or seeing a community psychiatrist, psychologist or psychiatric nurse, in the past 12 months. Multivariable logistic regression assessed CMD prevalence and treatment receipt by ethnicity. CMD prevalence was highest in the Black group; ethnic variation was explained by demographic and socioeconomic factors. After adjustment for these factors and CMDs, odds ratios for treatment receipt were lower for the Asian (0.62, 95% CI 0.39-1.00) and White Other (0.58, 95% CI 0.38-0.87) groups in 2014, compared with the White British group; for the Black group, this inequality appeared to be widening over time (2007 treatment receipt odds ratio 0.68, 95% CI 0.38-1.23; 2014 treatment receipt odds ratio 0.23, 95% CI 0.13-0.40; survey year interaction P < 0.0001). Treatment receipt was lower for all ethnic minority groups compared with the White British group, and lowest among Black people, for whom inequalities appear to be widening over time. Addressing socioeconomic inequality could reduce ethnic inequalities in mental health problems, but this does not explain pronounced treatment inequalities.

Spatio-temporal patterns of domestic water distribution, consumption and sufficiency: Neighbourhood inequalities in Nairobi, Kenya

Whilst there are longstanding and well-established inequalities in safe-drinking water-access between urban and rural areas, there remain few studies of changing intra-urban inequalities over time. In this study, we determined the spatio-temporal patterns of domestic piped water distribution in Nairobi, Kenya between 1985 and 2018, and the implications of socio-economic and neighbourhood inequalities in water sufficiency. Using data from the Nairobi water and sewerage utility company for the period 2008–2018, we examined the sufficiency of monthly domestic water consumption per capita for 2380 itineraries (areas with an average population of 700) in relation to a residential neighbourhood classification, population and neighbourhood age and also examined water rationing patterns by neighbourhood type. Water sufficiency differed by residential areas, age of neighbourhood and population per itinerary. Compared to residents of low-income areas, those in high- and middle-income areas were six and four times more likely to receive the recommended 1500 L per capita per month respectively. Newer neighbourhoods and less densely populated areas were more likely to receive higher volumes of water. Non-revenue water loss accounted for 29% (average 3.5 billion litres per month) of water distributed across Nairobi, and was more than two times the amount of water needed for all residents to access the recommended monthly per capita water consumption. The observed spatial inequality in distribution, and access to piped water associated with socio-economic status and neighbourhood age highlights the need for deliberate planning and governance to improve water distribution to match the speed of growth of low/middle- and low-income residential areas and enhance equity.

The Autonomy-Representation Dilemma: Indigenous Groups and Distributive Benefits in the Americas

AbstractAutonomy carries the promise of resolving longstanding distributive inequalities between indigenous and non-indigenous groups. Yet, contemporary autonomy arrangements have often been associated instead with a reduction in native communities' access to needed public goods and services. I situate these negative effects within a broader autonomy-representation dilemma: autonomy provides indigenous groups with more responsive coethnic leaders, but these leaders frequently face difficulties in collecting and deploying revenue. These capacity constraints often arise from the way national governments have recognized autonomy. As such, pursuing coethnic representation within the state might—under certain conditions—be more likely to provide indigenous groups with needed goods and services. Drawing on natural experimental evidence and an original survey of indigenous community presidents from Peru, I first demonstrate that achieving coethnic political representation within the state can expand indigenous groups' access to the public good they most need: water. I then illustrate how capacity constraints that arise from autonomy have prevented native groups in Bolivia's autonomous municipalities from achieving similar distributive gains. Ultimately, the findings provide insights for understanding the sources of—and potential institutional remedies for—indigenous groups' unequal access to local public goods in the Americas and beyond.

Community–academic partnerships addressing local health inequalities during COVID-19: a qualitative evaluation

BackgroundDuring the COVID-19 pandemic, inequalities among communities were amplified and local organisations had reductions in resources. In response, seven community organisations, an academic primary care and public health department, and 25 medical students partnered to co-create tailored projects to address community-defined goals. We aimed to explore community perspectives from such a partnership approach. MethodsWe did a qualitative realist evaluation to explore what works, why, and for whom regarding the community–academic partnerships. Data were gathered through ten semistructured interviews and one focus group. Themes were constructed from iterative deductive and inductive coding conducted in NVivo 10. These themes were used to continually test and refine propositions co-created with the community partners that hypothesised key components of successful partnerships that could provide a useful response during a pandemic. FindingsBetween June 9 and Aug 20, 2020, we gathered data from 12 community partners (nine women and three men). The community–academic partnerships led to co-creation of tangible outputs that responded to challenges facing communities experiencing poor health outcomes pre-pandemic. Enablers of effective partnerships included developing faculty–community relationships, articulating common goals tailored around local priorities, recognition of community value, and adopting a flexible, collaborative process throughout. Short timelines and long quality assurance processes were perceived as barriers. Longstanding inequalities impeded the ability of outputs to address needs for certain communities. For example, a video about COVID-19 was produced in multiple languages but not translated into Somali quickly enough, despite the absence of appropriate communications for this community. The medical students were perceived by community partners to add capacity and technical expertise. An example output was a co-produced resource pack for low-income, single parent families, accompanied by a public health campaign encouraging participation in healthy, creative activities. InterpretationThe findings highlighted the enablers and barriers to successful community–academic partnerships that achieved their goals, as defined by the community. Community-academic partnerships have the potential to offer increased capacity for community interventions as a response to the COVID-19 pandemic through student involvement. FundingWest London Health Partnership funded two of the projects mentioned in the Abstract. This abstract presents independent work commissioned by the National Institute for Health Research (NIHR) under the Applied Health Research programme for North West London. The views expressed in this publication are those of the authors and not necessarily those of the NHS, the NIHR, or the Department of Health.

Life during a pandemic in Australia: wellbeing and social determinants of health

BackgroundThe COVID-19 pandemic has had effects on populations worldwide. The social determinants of health affect an individual's capacity to cope during a crisis which could potentially impact on their wellbeing. The aim of this study was to examine the relationship between wellbeing and the social determinants of health among Australian adults during the COVID-19 pandemic.MethodsA cross-sectional study of adults residing in Australia was conducted using SurveyMonkey (an online survey) between August - October 2020. Participants were recruited via social media. Wellbeing was measured using the 10-item Multicultural Quality of Life Index and social determinants of health were measured using validated tools and investigator developed questions. Data were analysed using SPSS version 25. Inferential statistics, including independent t-test and one-way ANOVA were undertaken. Multiple regression analysis was used to investigate the predictors of wellbeing.ResultsIn total, 1211 responses were received. Females accounted for 80.7% of the responses, men 16.7% and transgender/non-binary 2.6%. The mean age of the respondents was 43 years (SD 14.5). The mean score for total wellbeing was 62.58 (SD 21.22). Housing insecurity (p = 0.000), food insecurity (p = 0.000, social support (p = 0.000) and access to health care (p = 0.000) were all predictors of poor total wellbeing. Being a male (p = .0380) was the only predictor of higher wellbeing.ConclusionsThis study demonstrates that adults in Australia who had poor social support, had difficultly accessing health care, had insecure housing and food insecurity had significantly poorer wellbeing during the COVID-19 pandemic. This study exposes the social determinants of health that are responsible for health and social inequalities. It shows that the COVID-19 pandemic has exacerbated the social vulnerabilities and highlights the need take action on the social determinants of health and inequalities.Key messages The COVID-19 pandemic has further exposed the longstanding health and social inequalities that exist in Australia.Action on social determinants of health is required in a post COVID-19 world to rebuild social protection and safeguard populations from any future public health emergencies.

Who declines to respond to the reactions to race module?: findings from the South Carolina Behavioral Risk Factor Surveillance System, 2016\u20132017

BackgroundThe inclusion of self-reported differential treatment by race/ethnicity in population-based public health surveillance and monitoring systems may provide an opportunity to address long-standing health inequalities. While there is a growing trend towards decreasing response rates and selective non-response in health surveys, research examining the magnitude of non-response related to self-reported discrimination warrants greater attention. This study examined the distribution of sociodemographic variables among respondents and non-respondents to the South Carolina Behavioral Risk Factor Surveillance System (SC-BRFSS) Reactions to Race module (6-question optional module capturing reports of race-based treatment).MethodsUsing data from SC-BRFSS (2016, 2017), we examined patterns of non-response to the Reactions to Race module and individual items in the module. Logistic regression models were employed to examine sociodemographic factors associated with non-response and weighted to account for complex sampling design.ResultsAmong 21,847 respondents, 15.3% were non-responders. Significant differences in RTRM non-response were observed by key sociodemographic variables (e.g., age, race/ethnicity, labor market participation, and health insurance status). Individuals who were younger, Hispanic, homemakers/students, unreported income, and uninsured were over-represented among non-respondents. In adjusted analyses, Hispanics and individuals with unreported income were more likely to be non-responders in RTRM and across item, while retirees were less likely to be non-responders. Heterogeneity in levels of non-responses were observed across RTRM questions, with the highest level of non-response for questions assessing differential treatment in work (54.8%) and healthcare settings (26.9%).ConclusionsNon-responders differed from responders according to some key sociodemographic variables, which could contribute to the underestimation of self-reported discrimination and race-related differential treatment and health outcomes. While we advocate for the use of population-based measures of self-reported racial discrimination to monitor and track state-level progress towards health equity, future efforts to estimate, assess, and address non-response variations by sociodemographic factors are warranted to improve understanding of lived experiences impacted by race-based differential treatment.

Acceptability of human papillomavirus (HPV) self-sampling among never- and under-screened Indigenous and other minority women: a randomised three-arm community trial in Aotearoa New Zealand.

BackgroundInternationally, self-sampling for human papillomavirus (HPV) has been shown to increase participation in cervical-cancer screening. In Aotearoa New Zealand, there are long-standing ethnic inequalities in cervical-cancer screening, incidence, and mortality, particularly for indigenous Māori women, as well as Pacific and Asian women.MethodsWe invited never- and markedly under-screened (≥5 years overdue) 30-69-year-old Māori, Pacific, and Asian women to participate in an open-label, three-arm, community-based, randomised controlled trial, with a nested sub-study. We aimed to assess whether two specific invitation methods for self-sampling improved screening participation over usual care among the least medically served populations. Women were individually randomised 3:3:1 to: clinic-based self-sampling (CLINIC – invited to take a self-sample at their usual general practice); home-based self-sampling (HOME – mailed a kit and invited to take a self-sample at home); and usual care (USUAL – invited to attend a clinic for collection of a standard cytology sample). Neither participants nor research staff could be blinded to the intervention. In a subset of general practices, women who did not participate within three months of invitation were opportunistically invited to take a self-sample, either next time they attended a clinic or by mail.FindingsWe randomised 3,553 women: 1,574 to CLINIC, 1,467 to HOME, and 512 to USUAL. Participation was highest in HOME (14.6% among Māori, 8.8% among Pacific, and 18.5% among Asian) with CLINIC (7.0%, 5.3% and 6.9%, respectively) and USUAL (2.0%, 1.7% and 4.5%, respectively) being lower. In fully adjusted models, participation was statistically significantly more likely in HOME than USUAL: Māori OR=9.7, (95%CI 3.0-31.5); Pacific OR=6.0 (1.8-19.5); and Asian OR=5.1 (2.4-10.9). There were no adverse outcomes reported. After three months, 2,780 non-responding women were invited to participate in a non-randomised, opportunistic, follow-on substudy. After 6 months,192 (6.9%) additional women had taken a self-sample.InterpretationUsing recruitment methods that mimic usual practice, we provide critical evidence that self-sampling increases screening among the groups of women (never and under-screened) who experience the most barriers in Aotearoa New Zealand, although the absolute level of participation through this population approach was modest. Follow-up for most women was routine but a small proportion required intensive support.Trial registrationANZCTR Identifier: ACTRN12618000367246 (date registered 12/3/2018) https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=371741&isReview=true; UTN: U1111-1189-0531FundingHealth Research Council of New Zealand (HRC 16/405)Protocolhttp://publichealth.massey.ac.nz/assets/Uploads/Study-protocol-V2.1Self-sampling-for-HPV-screening-a-community-trial.pdf

“So, Don’t You Want Us Here No More?” Slow Violence, Frustrated Hope, and Racialized Struggle on London’s Council Estates

ABSTRACT Since 1997, over 50,000 homes have been demolished to allow for the “renewal” of council estates in London. This has involved the “decanting” of short and long-term tenants, as well as those leaseholders who bought their homes under “right to buy” legislation. Often described as “social cleansing”, the racialized dimensions of these displacements remain under-explored despite asizable literature documenting the connections between race, place and state-subsidized housing in Britain. Drawing on interviews with Black, Asian, and Minority Ethnic estate residents– including many active in housing movements– this paper shows that this displacement is understood in relation to histories of racial discrimination, the destruction of ethno-cultural infrastructures, and long-standing racialized inequalities. These themes resonate with apolitics of resistance grounded in aracialized class consciousness that seeks to intervene more broadly in the politics of capital and the state.

Student Debt and Geographic Disadvantage: Disparities by Rural, Suburban, and Urban Background*

AbstractAmerican youth from rural backgrounds have made great strides to overcome challenges in college enrollment and completion since the 2000s. Yet little is known about how rural youth are financing these attainment increases—a pressing question in light of high college costs, rising student debt, and spatial inequality in the resources that students have to pay for college. This paper examines disparities in young adults' student debt by geographic background using data from the National Longitudinal Survey of Youth 1997 Cohort. Regression analyses reveal that college‐goers from rural backgrounds accumulate more debt than those from suburban and urban backgrounds, adjusting for differences in sociodemographic characteristics. Rural college‐goers' higher debt can be partially attributed to differences in socioeconomic backgrounds and rates of inter‐county migration during college, and there is evidence that the additive influences of geographic background and gender contribute to particularly high debt among rural women. The findings suggest that longstanding spatial inequalities contribute to disparities in student debt and raise questions about the experiences of rural youth and communities in a debt‐based society.

Governing ‘levelling-up’ in the UK: challenges and prospects

ABSTRACT Following the Conservative Party’s victory in the 2019 UK General Election, and its success in achieving significant electoral gains across traditional Labour Party ‘red’ areas in the north of England, Prime Minister Boris Johnson vowed not to let down the new Conservative voters and pledged that his government would address longstanding regional inequalities in the UK. Consequently, ‘levelling up’ became part of the public policy lexicon, and, in March 2021, the government published its Levelling Up Fund prospectus. The concept of levelling up enjoys widespread political support, has featured in important policy initiatives beyond the UK, and has been the subject of considerable theorising. This article considers how social scientists might evaluate the success or otherwise of the UK government’s levelling-up agenda. The article suggests that any evaluation of this agenda requires the need to take into account aspects of network complexity, the resource allocation arrangements attached to the policy, and what the policy signifies in terms of governance leadership in the context of delivering public value. The article concludes that the UK government’s plans risk falling short of delivering a sustained reform programme to reduce area-based inequalities.

What You Want Is Not Always What You Get: Gender Differences in Employer-Employee Exchange Relationships during the COVID-19 Pandemic

Relational Inequality Theory (RIT) argues that relational claims-making- the process of employer-employee exchange relationships explicitly regarding negotiations over resources and rewards- is the central mechanism that produces social inequalities at work. Yet, the COVID-19 pandemic has significantly affected employees and employers, possibly altering their behavior in relational claims-making. Hence, this paper aims to explore if long-standing gender inequalities in employer-employee exchange relationships have reproduced or changed during the COVID-19 pandemic. It is examined (1) whether women and men differ in their response to the pandemic regarding expected employer support with further training to work from home (WFH) and (2) whether employers’ decisions on adequate support depend on employees’ gender. The hypotheses were tested using a linked employer-employee dataset (LEEP-B3) with information on German employees’ working conditions before and during COVID-19. OLS regression models predicted no gender differences in training expectations. However, women are more likely to be provided with less training than they expect from their employers. Thus, employers’ decision-making has not been altered, but gender remains an important determinant in relational claims-making, thereby reproducing gender inequalities. Finally, the workforces’ pre-COVID-19 gender ideologies predicted whether mechanisms are mitigated or enhanced. Hence, these findings underline the crucial role of the workplace context in which employer-employee exchange relationships are embedded.

Differential impact of mitigation policies and socioeconomic status on COVID-19 prevalence and social distancing in the United States

BackgroundThe spread of COVID-19 has highlighted the long-standing health inequalities across the U.S. as neighborhoods with fewer resources were associated with higher rates of COVID-19 transmission. Although the stay-at-home order was one of the most effective methods to contain its spread, residents in lower-income neighborhoods faced barriers to practicing social distancing. We aimed to quantify the differential impact of stay-at-home policy on COVID-19 transmission and residents’ mobility across neighborhoods of different levels of socioeconomic disadvantage.MethodsThis was a comparative interrupted time-series analysis at the county level. We included 2087 counties from 38 states which both implemented and lifted the state-wide stay-at-home order. Every county was assigned to one of four equally-sized groups based on its levels of disadvantage, represented by the Area Deprivation Index. Prevalence of COVID-19 was calculated by dividing the daily number of cumulative confirmed COVID-19 cases by the number of residents from the 2010 Census. We used the Social Distancing Index (SDI), derived from the COVID-19 Impact Analysis Platform, to measure the mobility. For the evaluation of implementation, the observation started from Mar 1st 2020 to 1 day before lifting; and, for lifting, it ranged from 1 day after implementation to Jul 5th 2020. We calculated a comparative change of daily trends in COVID-19 prevalence and Social Distancing Index between counties with three highest disadvantage levels and those with the least level before and after the implementation and lifting of the stay-at-home order, separately.ResultsOn both stay-at-home implementation and lifting dates, COVID-19 prevalence was much higher among counties with the highest or lowest disadvantage level, while mobility decreased as the disadvantage level increased. Mobility of the most disadvantaged counties was least impacted by stay-at-home implementation and relaxation compared to counties with the most resources; however, disadvantaged counties experienced the largest relative increase in COVID-19 infection after both stay-at-home implementation and relaxation.ConclusionsNeighborhoods with varying levels of socioeconomic disadvantage reacted differently to the implementation and relaxation of COVID-19 mitigation policies. Policymakers should consider investing more resources in disadvantaged counties as the pandemic may not stop until most neighborhoods have it under control.

The urban syndemic of COVID-19: insights, reflections and implications

ABSTRACT This editorial introduces the origin, purpose and scope of a Special Issue on COVID-19. It brings together 43 contributions from across the globe that examine the way in which COVID-19 has challenged the way we think about urban design, spatial planning and city governance. The editorial draws out a number of key messages from this body of work, highlighting how the impact of COVID-19 has been most devastating when combined with the existing vulnerabilities and chronic ill-health experienced in pre-pandemic cities. Following The Lancet, we, therefore, characterise this as a syndemic rather than pandemic, due to the way it interacts with existing urban NCDs. This provides further resolve to address long-standing urban health inequalities and challenges, while seeking more holistic ways of addressing these, for example through the Sustainable Development Goals. The editorial explains the role of our partners in the Special Issue (ISUH, Design Council and BOVA Network), draws out some of the themes from the collected papers, and finally highlights an agenda for future contributions to Cities & Health that will allow us to better understand and respond to the aftermath of the COVID-19 syndemic.

“I Hope to Hell Nothing Goes Back to The Way It Was Before”: COVID-19, Marginalization, and Native Nations

We draw on new and original data to examine both partisan and systemic inequities that have fueled the spread of COVID-19 in Native America. We show how continued political marginalization of Native Americans has compounded longstanding inequalities and endangered the lives of Native peoples. Native nations have experienced disproportionate effects from prior health epidemics and pandemics, and in 2020, Native communities have seen greater rates of infection, hospitalization, and death from COVID-19. We find that Native nations have more COVID-19 cases if they are located in states with a higher ratio of Trump supporters and reside in states with Republican governors. Where there is longstanding marginalization, measured by lack of clean water on tribal lands and health information in Native languages, we find more COVID-19 cases. Federal law enables non-members to flout tribal health regulations while on tribal lands, and correspondingly, we find that COVID-19 cases rise when non-members travel onto tribal lands. Our findings engage the literatures on Native American politics, health policy within U.S. federalism, and structural health inequalities, and should be of interest to both scholars and practitioners interested in understanding COVID-19 outcomes across Tribes in the United States.

Confronting Disparities: Race, Ethnicity, and Immigrant Status as Intersectional Determinants in the COVID-19 Era.

The COVID-19 (coronavirus disease-2019) pandemic has exposed long-standing inequalities in U.S. health care. Historically, racial and ethnic minorities have been the most likely to suffer from inadequate health care access and insurance coverage. With the spread of COVID-19, these disparities have dramatically increased. Focusing on native and foreign-born racial/ethnic minorities, this article discusses how entrenched health inequities and structural discrimination have led to COVID-19 morbidities and mortalities. Considering that "essential" frontline workers are disproportionately native and foreign-born racial/ethnic minorities, this work evaluates the impact(s) of social exclusion and the lack of support systems for these workers. Using the framework of intersectionality, this work also examines how race and immigrant status affect COVID-19 spread in prisons and immigration detention centers-facilities that often lack effective health and sanitary conditions and where inmates are also likely to be racial/ethnic minorities.

We Must Speak to Patients and Their Families About Racism

Back to table of contents Previous article Next article ProfessionalFull AccessWe Must Speak to Patients and Their Families About RacismJanet Baek, M.D., Latoya Frolov, M.D., M.P.H., Balkozar Adam, M.D.Janet BaekSearch for more papers by this author, M.D., Latoya FrolovSearch for more papers by this author, M.D., M.P.H., Balkozar AdamSearch for more papers by this author, M.D.Published Online:22 Apr 2021https://doi.org/10.1176/appi.pn.2021.5.15AbstractAs psychiatrists, it is our responsibility to have conversations with patients about race and racism, no matter how difficult. APA’s Council on Children, Adolescents, and Their Families created a resource document on how to engage in such a dialogue.As the nation addresses longstanding and entrenched inequalities, we as psychiatrists need to talk about racism in our clinical work. Whether individual, internalized, or structural, racial discrimination has an adverse effect on mental health. As psychiatrists, we should be comfortable exploring its impact with patients and their families.For many, it is difficult to talk about race or racism, and some may be prevented from having such conversations by the fear of inadvertently offending the patient. Yet, while each patient is different, engaging in healthy conversations about race and racism can improve the therapeutic alliance, keep patients in treatment longer, increase trust, and help them feel comfortable sharing their innermost lives with us.Alternatively, not having such conversations can make some patients feel isolated and less likely to engage in treatment. Especially for patients from minority or underserved communities, having their experiences with racism go unacknowledged in the therapeutic setting can lead them to believe their psychiatrist is not willing to listen to them, and they will go on suffering in silence. Worse, if we exhibit our own unchallenged implicit biases while interacting with patients, they may question if we see them as whole people or if the treatment we offer is really in their best interest.At the request of Dr. Cheryl Wills, chair of APA’s Presidential Task Force to Address Structural Racism Throughout Psychiatry, the Council on Children, Adolescents, and Their Families sought to create an educational resource document that would provide some guidance and suggestions around discussing race and racial discrimination with patients, their parents, and their family members.The council’s chair, Gabrielle Shapiro, M.D., appointed Tresha Gibbs, M.D., to lead the work group to develop the resource document. The work group was composed of members from different parts of the country, career stages, and ethnic backgrounds. The work group also included Anish Dube, M.D., M.P.H., Asha Martin, M.D., Brandon Newsome, M.D., and Jordan Wong, M.D. APA Staff Liaison Ricardo Juarez was critical in formatting the final product and ensuring its timely release to members.In creating the document, we held numerous conversations on how we could make it user friendly while also addressing a challenging and broad topic, including the evolving nature of definitions and language around race and racism. The document is based on the premise that it is helpful to ask patients questions rather than make assumptions or rely on stereotypes. We included guidelines on how to provide both culturally and structurally competent clinical care, informal questions that could be used to prompt a discussion about race or racism, and resources to aid in the process of having these conversations.The document also includes numerous vignettes that illustrate situations related to race that a psychiatrist might encounter with a patient. Some of the vignettes are focused on approaching children and adolescents, while others are aimed at situations that may occur within a general psychiatric practice. We hope these vignettes will spark conversations about how to engage with patients about race or racism and create opportunities for all psychiatrists to consider and challenge their own implicit biases.The document is not meant to be a monolithic or static product but rather serve as the first edition of a dynamic resource document.Racism impacts the work of all psychiatrists, no matter where or how they practice. It also plays a significant role in the lives of our patients. We hope this document supports our patients by increasing awareness about the health impacts of racism among mental health professionals and facilitates dialogue about patients’ experiences of race and culture in a thoughtful, open environment. ■“How Psychiatrists Can Talk to Patients and Families About Race and Racism” is posted here.Janet Baek, M.D., is an APA/APAF SAMHSA Minority Fellow; a member of APA’s Council on Children, Adolescents, and Their Families; and a PGY-3 psychiatry resident at San Mateo County.Latoya Frolov, M.D., M.P.H., is an APA/APAF Diversity Leadership Fellow; a member of APA’s Council on Children, Adolescents, and Their Families; and a PGY-6 child and adolescent psychiatry fellow at New York-Presbyterian Hospital-Columbia University and Weill Cornell.Balkozar Adam, M.D., is a member of APA’s Council on Children, Adolescents, and Their Families and a clinical professor of psychiatry at the University of Missouri. ISSUES NewArchived

Shared humanity, awareness of socio-economic privilege, and classism during the pandemic as predictors of supporting equal socio-economic policies

The coronavirus pandemic has caused unemployment to skyrocket, exposed the longstanding inequalities in health care services and working conditions, and mainly affected the poor in different parts of the world. In the current study, we focus on social identity and social class-related factors that are critical during the pandemic to gain insights into what predicts support for policies favoring economic equality in the post-pandemic period. We argue that to the extent that individuals 1) identify with all humanity during the pandemic, 2) are aware of their socio-economic status-based privilege, 3) do not hold classist attitudes, they would support policies favoring economic equality. In Study 1, survey data from 1212 participants in Turkey were analyzed by means of hierarchical linear regression analysis. The findings showed that stronger identification with all humanity, higher awareness of socio-economic status-based privilege, and less endorsement of classist attitudes predict more support for socio-economic equality policies in the post-pandemic period, after controlling for socio-demographic and socio-political characteristics of participants. Study 2 (N = 212) replicated the findings in a different context, namely the U.S. Our findings extend previous studies by showing the importance of a global identity, such as shared human identity, in the ongoing and potentially in the aftermath of the pandemic. In addition, our findings highlight the joint contributions of socio-economic factors such as classist attitudes and awareness of class-based privilege to the support for socio-economic policies.

Geographic Inequalities in Cardiovascular Mortality in the United States: 1999 to 2018

ObjectiveTo evaluate the trends in cardiovascular, ischemic heart disease (IHD), stroke, and heart failure mortality in the stroke belt in comparison with the rest of the United States. Patients and MethodsWe evaluated the nationwide mortality data of all Americans from the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research database from 1999 to 2018. Cause-specific deaths were identified in the stroke belt and nonstroke belt populations using International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes. The relative percentage gap was estimated as the absolute difference computed relative to nonstroke belt mortality. Piecewise linear regression and age-period-cohort modeling were used to assess, respectively, the trends and to forecast mortality across the 2 regions. ResultsThe cardiovascular mortality rate (per 100,000 persons) was 288.3 (95% CI, 288.0 to 288.6; 3,684,273 deaths) in the stroke belt region and 251.2 (95% CI, 251.0 to 251.3; 13,296,164 deaths) in the nonstroke belt region. In the stroke belt region, age-adjusted mortality rates due to all cardiovascular causes (average annual percentage change [AAPC] in mortality rates, −2.4; 95% CI, −2.8 to −2.0), IHD (AAPC, −3.8; 95% CI, −4.2 to −3.5), and stroke (AAPC, −2.8; 95% CI, −3.4 to −2.1) declined from 1999 to 2018. A similar decline in cardiovascular (AAPC, −2.5; 95% CI, −3.0 to −2.0), IHD (AAPC, −4.0; 95% CI, −4.3 to −3.7), and stroke (AAPC, −2.9; 95% CI, −3.2 to −2.2) mortality was seen in the nonstroke belt region. There was no overall change in heart failure mortality in both regions (PAAPC>.05). The cardiovascular mortality gap was 11.8% in 1999 and 15.9% in 2018, with a modest reduction in absolute mortality rate difference (~7 deaths per 100,000 persons). These patterns were consistent across subgroups of age, sex, race, and urbanization status. An estimated 101,953 additional cardiovascular deaths need to be prevented from 2020 to 2025 in the stroke belt to ameliorate the gap between the 2 regions. ConclusionDespite the overall decline, substantial geographic disparities in cardiovascular mortality persist. Novel approaches are needed to attenuate the long-standing geographic inequalities in cardiovascular mortality in the United States, which are projected to increase.

Courage, Justice, and Practical Wisdom as Key Virtues in the Era of COVID-19.

Fowers et al. (2017) recently made a general argument for virtues as the characteristics necessary for individuals to flourish, given inherent human limitations. For example, people can flourish by developing the virtue of friendship as they navigate the inherent (healthy) human dependency on others. This general argument also illuminates a pathway to flourishing during the COVID-19 pandemic, the risks of which have induced powerful fears, exacerbated injustices, and rendered life and death decisions far more common. Contexts of risk and fear call for the virtue of courage. Courage has emerged more powerfully as a central virtue among medical personnel, first responders, and essential workers. Longstanding inequalities have been highlighted during the pandemic, calling for the virtue of justice. When important personal and public health decisions must be made, the central virtue of practical wisdom comes to the fore. Wise decisions and actions incorporate the recognition of relevant moral concerns and aims, as well as responding in fitting and practical ways to the specifics of the situation. Practicing courage, justice, and practical wisdom illuminates a path to flourishing, even in a pandemic.