Physical Health Disparities Research Articles

Health and Health Care Among Transgender Adults in the United States.

Transgender (trans) communities in the USA and globally have long organized for health and social equity but have only recently gained increased visibility within public health. In this review, we synthesize evidence demonstrating that trans adults in the USA are affected by disparities in physical and mental health and in access to health care, relative to cisgender (nontrans) persons. We draw on theory and data to situate these disparities in their social contexts, explicating the roles of gender affirmation, multilevel and intersectional stigmas, and public policies in reproducing or ameliorating trans health disparities. Until recently, trans health disparities were largely made invisible by exclusionary data collection practices. We highlight the importance of, and methodological considerations for, collecting inclusive sex and gender data. Moving forward, we recommend routine collection of gender identity data, an emphasis on intervention research to achieve trans health equity, public policy advocacy, and investment in supporting gender-diverse public health leadership.

Disparities in COVID-19 infection, hospitalisation and death in people with schizophrenia, bipolar disorder, and major depressive disorder: a cohort study of the UK Biobank

People with severe mental illness (SMI; including schizophrenia/psychosis, bipolar disorder (BD), major depressive disorder (MDD)) experience large disparities in physical health. Emerging evidence suggests this group experiences higher risks of infection and death from COVID-19, although the full extent of these disparities are not yet established. We investigated COVID-19 related infection, hospitalisation and mortality among people with SMI in the UK Biobank (UKB) cohort study. Overall, 447,296 participants from UKB (schizophrenia/psychosis = 1925, BD = 1483 and MDD = 41,448, non-SMI = 402,440) were linked with healthcare and death records. Multivariable logistic regression analysis was used to examine differences in COVID-19 outcomes by diagnosis, controlling for sociodemographic factors and comorbidities. In unadjusted analyses, higher odds of COVID-19 mortality were seen among people with schizophrenia/psychosis (odds ratio [OR] 4.84, 95% confidence interval [CI] 3.00–7.34), BD (OR 3.76, 95% CI 2.00–6.35), and MDD (OR 1.99, 95% CI 1.69–2.33) compared to people with no SMI. Higher odds of infection and hospitalisation were also seen across all SMI groups, particularly among people with schizophrenia/psychosis (OR 1.61, 95% CI 1.32–1.96; OR 3.47, 95% CI 2.47–4.72) and BD (OR 1.48, 95% CI 1.16–1.85; OR 3.31, 95% CI 2.22–4.73). In fully adjusted models, mortality and hospitalisation odds remained significantly higher among all SMI groups, though infection odds remained significantly higher only for MDD. People with schizophrenia/psychosis, BD and MDD have higher risks of COVID-19 infection, hospitalisation and mortality. Only a proportion of these disparities were accounted for by pre-existing demographic characteristics or comorbidities. Vaccination and preventive measures should be prioritised in these particularly vulnerable groups.

Introduction to the Special Issue: Disproportionate trauma, stress, and adversities as a pathway to health disparities among disenfranchised groups globally.

Globally, individuals and communities that are marginalized based on their identities are at heightened risk for exposure to traumatic stress and socioeconomic hardship. Marginalization and disproportionate risk for many types of adversities correspond with disparities in physical health, mental health, and overall well-being. Together, the 12 empirical studies, one systematic review, and commentary in this special issue of the Journal of Traumatic Stress highlight the impact of discrimination and disproportionate adversity among groups marginalized based on race, ethnicity, nativity, caste, gender identity, sexual orientation, economic status, and medical status. Although most studies in this issue focus on the United States, the articles that focus on disparities and risk factors in India, El Salvador, Uganda, and Burundi provides a multicontinent global perspective. The global perspective, including the impact of the global pandemic, invites further examination of how disproportionate exposure to traumatic stress and adversity are associated with inequitable burden and health disparities worldwide. This special issue further highlights the developmental and multigenerational burden of systemic marginalization by including studies of children, young adults, adults, and parent-child dyads. Pathways for change and intervention are illustrated through a liberatory consciousness perspective, with one study utilizing liberatory media skills (e.g., positive media images and messages) to mitigate the adverse effects of trauma exposure on at-risk young adults of color. Worldwide, research on the effects of trauma, stress, and adversities must examine contextual factors (e.g., economic hardship), marginalization (e.g., discrimination, identity factors), and the differential impact on health among individuals and communities.

Discrimination in Healthcare and LGBTQ+ Information and Care‐seeking Behaviors

AbstractMembers of the Lesbian, Gay, Bisexual, Transgender, Queer/Questioning, plus (LGBTQ+) community may face discrimination in healthcare, which can subsequently impact information and care‐seeking patterns. A tendency to avoid or delay health care is particularly concerning for LGBTQ+ people who face both physical and mental health disparities. This paper presents a literature review of literature on healthcare discrimination, LGBTQ+ care‐seeking, and associated information behaviors in order to generate a preliminary model of LGBTQ+ decision‐making around care and well‐being, called the Model of the Pathways to LGBTQ+ Well‐Being. This model can be used to investigate links between information behavior and relevant health behaviors and outcomes in a marginalized population.

Selection, experience, and disadvantage: Examining sources of health inequalities among naturalized US citizens

ObjectivesWe integrated major theories in immigrant health and assimilation into a single analytical framework to quantify the degrees to which demographic composition, pathways to citizenship, and socioeconomic assimilation account for physical and mental health disparities between naturalized immigrants by region of origin. MethodsUsing the restricted data from the 2015–2016 California Health Interview Survey, we decomposed differences in physical and mental health into demographic factors, path to citizenship, and socioeconomic characteristics by region of origin using the Karlson, Holm, and Breen (KHB) method. ResultsDifferences in socioeconomic status mediated most of the disparity in physical health between naturalized immigrants from different regions. Factors associated with major immigrant health theories—demographic composition, pathways to citizenship, and socioeconomic assimilation—did not mediate disparities in mental health. ConclusionThis article argues that the study of health disparities among immigrants must simultaneously account for differences in demographic composition, immigration experience, and socioeconomic disadvantage. The findings also underscore the need for theory development that can better explain mental health disparities among immigrants.

Psychological distress as a risk factor for all-cause, chronic disease- and suicide-specific mortality: a prospective analysis using data from the National Health Interview Survey

PurposeThe risk psychological distress (PD) confers on mortality due to specific chronic diseases compared to suicide is unclear. Using the National Health Interview Survey (NHIS), we investigated the association between PD levels and risk of all-cause and chronic disease-specific mortality and compared the contribution of chronic disease-related mortality to that of suicide.MethodsData from 195, 531 adults, who participated in the NHIS between 1997 and 2004, were linked to the National Death Index records through to 2006. Multivariable Cox regression models were used to estimate hazard ratios (HRs) and their 95% confidence intervals (CIs) across four levels of PD, measured using the Kessler-6 scale. Outcomes included all-cause mortality, and mortality due to all CVDs and subtypes, all cancers and subtypes, diabetes mellitus, alcoholic liver disease and suicide.ResultsDuring a mean follow-up time of 5.9 years, 7665 deaths occurred. We found a dose–response association between levels of PD and all-cause mortality, with the adjusted HRs (95% CI) elevated for all levels of PD, when compared to asymptomatic levels: subclinical 1.10 (1.03–1.16), symptomatic 1.36 (1.26–1.46) and highly symptomatic 1.57 (1.37–1.81). A similar association was found for all CVDs and certain CVD subtypes, but not for cancers, cerebrovascular diseases diabetes mellitus. Excess mortality attributable to suicide and alcoholic liver disease was evident among those with levels of PD only.ConclusionPD symptoms, of all levels, were associated with an increased risk of all-cause and CVD-specific mortality while higher PD only was associated with suicide. These findings emphasise the need for lifestyle interventions targeted towards improving physical health disparities among those with PD.Supplementary InformationThe online version contains supplementary material available at 10.1007/s00127-021-02116-7.

COVID-19: Implications for Physical Activity, Health Disparities, and Health Equity.

Physical activity is one of the most efficacious pathways to promoting mental and physical health, preventing disease, and, most important during the COVID-19 pandemic, bolstering a stronger immune system. Efforts to “flatten the curve” have resulted in the temporary closure of exercise facilities and gyms, suspension of sport activities, and advisories to avoid public recreational spaces. All of these changes have made traditional opportunities to be physically active difficult to access. These changes have also exacerbated existing disparities in access to social and environmental supports for physical activity, potentially contributing to a widening gap in physical activity participation among those at greatest risk for COVID-19. Physical activity can play a special role in reducing the inequitable consequences of COVID-19; however, expansion and better targeting of evidence-informed interventions are needed that address the unique barriers present in communities that have been economically and socially marginalized to achieve health equity in COVID-19 outcomes. This review highlights effective and feasible strategies that provide more equitable access to physical activity programs and spaces across the United States. With a renewed investment in physical activity, this behavior can play a crucial role in improving population health and reducing disparities during the COVID-19 pandemic and beyond.

Challenges of diversity and inclusion in defence emergency management and preparedness during the COVID-19 pandemic

LAY SUMMARY The Canadian military’s recent mission in support of long-term-care homes in Ontario, and the alleged abuses reported, demonstrates the urgent need to address challenges associated with diversity and inclusion in defence emergency management and preparedness during the COVID-19 pandemic. This article reviews the social and health impacts of the COVID-19 pandemic on diverse groups within the Canadian Defence Team and across Canada, with a particular focus on visible minorities, Indigenous people, women, older adults, persons with disabilities, and lesbian, gay, bisexual, transgender, queer or questioning, and two-spirit communities. The review indicates that the pandemic widened the existing physical and mental health disparities and socio-economic inequities affecting these groups. To address these challenges, and to better understand the needs of diverse groups in the pandemic context, several recommendations for the Defence Team are proposed to incorporate into daily encounters with diverse groups and communities affected by COVID-19. The recommendations are designed to enable the Defence Team to establish positive and sustainable relations with diverse communities and to increase community resilience and defence emergency operational readiness.

Recruiting cisgender female couples for health disparity-focused daily diary research: challenges, successes, and lessons learned

ABSTRACT The underlying mechanisms of sexual minority women’s (SMW’s) physical and mental health disparities are not well understood. Relationship factors are particularly understudied, and data are rarely collected from both same-sex female partners. Most research is cross sectional limiting our understanding of day-to-day experiences. This paper describes the feasibility of recruiting a large sample of SMW and their female partners for a disparity-focused daily diary study investigating alcohol use and mental health. A firm specializing in sexual minority market research assisted with recruitment from multiple sources and conducted an initial pre-screening of SMW and their female partners, at least one of whom drank alcohol regularly. A total of 4182 individuals completed the pre-screener, and information for 930 individuals (465 couples) was sent to the research team. Then, 376 individuals (188 couples) completed the study screener, met the inclusion criteria, and were invited to participate. Ultimately, 326 individuals (163 couples) consented and completed baseline. A total of 321 individuals, from 162 couples, began the daily diary portion of the study. Compliance with study procedures was excellent. The use of multiple recruitment sources increased the diversity of the sample. Challenges to recruitment, changes in protocol, and characteristics of the final sample are discussed.RM

Minority Stress, Structural Stigma, and Physical Health Among Sexual and Gender Minority Individuals: Examining the Relative Strength of the Relationships.

BackgroundSexual and gender minority (SGM; i.e., non-heterosexual and transgender or gender-expansive, respectively) people experience physical health disparities attributed to greater exposure to minority stress (experiences of discrimination or victimization, anticipation of discrimination or victimization, concealment of SGM status, and internalization of stigma) and structural stigma.PurposeTo examine which components of minority stress and structural stigma have the strongest relationships with physical health among SGM people.MethodsParticipants (5,299 SGM people, 1,902 gender minority individuals) were from The Population Research in Identity and Disparities for Equality (PRIDE) Study. Dominance analyses estimated effect sizes showing how important each component of minority stress and structural stigma was to physical health outcomes.ResultsAmong cisgender sexual minority women, transmasculine individuals, American Indian or Alaskan Native SGM individuals, Asian SGM individuals, and White SGM individuals a safe current environment for SGM people had the strongest relationship with physical health. For gender-expansive individuals and Black, African American, or African SGM individuals, the safety of the environment for SGM people in which they were raised had the strongest relationship with physical health. Among transfeminine individuals, victimization experiences had the strongest relationship with physical health. Among Hispanic, Latino, or Spanish individuals, accepting current environments had the strongest relationship with physical health. Among cisgender sexual minority men prejudice/discrimination experiences had the strongest relationship with physical health.ConclusionSafe community environments had the strongest relationships with physical health among most groups of SGM people. Increasing safety and buffering the effects of unsafe communities are important for SGM health.

Disparities in Social and Economic Determinants of Health by Sexual Identity, Gender, and Age: Results from the 2015-2018 National Survey on Drug Use and Health.

Purpose: We characterize disparities between lesbian, gay, and bisexual (LGB) adults and heterosexual adults across multiple health determinants in a nationally representative sample. Methods: Data on 153,939 adults (including 11,133 LGB adults) were from the 2015-2018 National Survey on Drug Use and Health. Separate Poisson regression models were used to estimate the relative risk (RR) that gay/lesbian and bisexual adults, respectively, experienced each health determinant, relative to heterosexual adults of the same gender and age group (ages 18-25, 26-34, 35-49, and 50-64). Statistically significant RR estimates were interpreted as a disparity. Results: Bisexual females exhibited disparities on all economic/health care access factors (no college degree, household poverty, means-tested assistance, unemployment, and lacking health insurance) across nearly all age groups; lesbian/gay females exhibited disparities in means-tested assistance and health insurance for some age groups. Notably fewer economic disparities were observed among gay and bisexual males. LGB adults (across identity, gender, and age group) were more likely to live alone, to have never been married, and to report low religious service attendance. Bisexual and lesbian/gay females, across age groups, had 1.7-2.2 times the risk of a lifetime arrest for a criminal offense, relative to same-age heterosexual females. Conclusions: Our results highlight that LGB females, particularly bisexual females, experience significant disparities in economic determinants of health, and all LGB subgroups exhibited disparities in some of the examined social determinants of health. The observed disparities, which spanned across age groups, likely contribute to disparities in physical and mental health observed among LGB adults.

Black-White disparities in women’s physical health: The role of socioeconomic status and racism-related stressors

Black women have elevated rates of multiple physical illnesses and conditions when compared to White women – disparities that are only partially explained by socioeconomic status (SES). Consequently, scholars have called for renewed attention to the significance of racism-related stress in explaining Black-White disparities in women's physical health. Drawing on the biopsychosocial model of racism as a stressor and the intersectionality perspective, this study examines the extent to which SES and racism-related stressors – i.e., discrimination, criminalization, and adverse neighborhood conditions – account for disparities in self-rated physical health and chronic health conditions between Black and White women. Results indicate that Black women have lower SES and report greater exposure to racism-related stressors across all domains. Moreover, I find that SES and racism-related stressors jointly account for more than 90% of the Black-White disparity in women's self-rated physical health and almost 50% of the Black-White disparity in chronic health conditions. Theoretical and policy implications of these findings are discussed.

Black-White racial health disparities in inflammation and physical health: Cumulative stress, social isolation, and health behaviors

Black Americans have vastly increased odds and earlier onsets of stress- and age-related disease compared to White Americans. However, what contributes to these racial health disparities remains poorly understood. Using a sample of 1577 older adults (32.7% Black; ages 55–65 at baseline), we examined whether stress, health behaviors, social isolation, and inflammation are associated with racial disparities in self-reported physical health. A latent cumulative stress factor and unique stress-domain specific factors were modeled by applying bifactor confirmatory analysis to assessments across the lifespan (i.e., childhood maltreatment, trauma exposure, discrimination, stressful life events, and indices of socioeconomic status). Physical health, health behavior, and social isolation were assessed using self-report. Interleukin-6 (IL-6) and C-reactive protein (CRP) were assayed from morning fasting serum samples; a z-scored inflammation index was formed across these 2 cytokines. A parallel serial mediational model tested whether race (i.e., Black/White) is indirectly associated with health through the following 3 independent pathways: (1) cumulative stress to preventative health behaviors (e.g., healthy eating) to inflammation, (2) cumulative stress to risky health behaviors (e.g., substance use) to inflammation; and (3) cumulative stress to social isolation to inflammation. There were significant indirect effects between race and self-reported physical health through cumulative stress, preventative health behaviors, and inflammation (B = −0.02, 95% CI: −0.05, −0.01). Specifically, Black Americans were exposed to greater cumulative stress, which was associated with reduced engagement in preventative health behaviors, which was, in turn, associated with greater inflammation and reduced physical health. A unique SES factor also indirectly linked race to physical health through preventative health behaviors. Cumulative stress exposure and unique aspects of socioeconomic status are indirectly associated with Black-White racial health disparities through behavioral (i.e., preventative health behavior) and biological (i.e., inflammation) factors. Culturally responsive evidence-based interventions that enhance engagement in preventative health behaviors are needed to directly confront health disparities. Ultimately, large scale anti-racist public policies that reduce cumulative stress burden (e.g., a living wage, universal healthcare) may best attenuate racial health disparities.

Recruiting and training multilingual family therapists: A content analysis of COAMFTE-accredited marriage and family therapy program websites.

Among U. S. Limited English Proficiency (LEP) communities, language needs and preferences create significant barriers to accessing quality healthcare and contribute to growing physical and mental health disparities. To mitigate these barriers, it is critical to recruit and train a new generation of linguistically diverse providers, including marriage and family therapists (MFTs). This study examined how Marriage and Family Therapy (MFT) program website content promotes a commitment to recruiting and training multilingual MFTs. The study sample consisted of all currently accredited programs (N=122) and included coding for the presence or absence of (a) an explicit commitment to multiculturally and linguistically informed training, (b) specialized multilingual training and supports, and (c) multilingual faculty involved in training multilingual students or engaged in related scholarship. Results indicate that a majority of MFT programs are communicating a commitment to multiculturally informed training, but the same is not true of linguistically responsive training.

The moderation of socio-demographics in physical and mental health disparities among Israeli gay and heterosexual middle-aged and older men

Objectives Physical and mental health disparities were explored among Israeli middle-aged and older gay and heterosexual men alongside the moderating role of age, relationship status, and place of birth. Method 173 middle-aged and older gay men were individually matched with 173 middle-aged and older heterosexual men at the age range of 50–86 (M = 60.56, SD = 8.42). All participants completed measures of doctor visits, physical health comorbidity, depressive symptoms, and anxiety. Results Israeli middle-aged and older gay and heterosexual men did not significantly differ on physical or mental health indicators. However, a more differential analysis revealed that older age and relationship status had a moderating role, such that older gay men reported more physical health comorbidity in comparison to older heterosexual men. Similarly, gay men who were not in a steady relationship reported more frequent visits to the doctor and more anxiety in comparison to heterosexual men who were not in a steady relationship. Additionally, immigration history appeared as a potential resiliency factor, such that gay men who were not born in Israel reported less frequent doctor visits and less anxiety in comparison to heterosexual men who were not born in Israel. Conclusions This study presents a pioneering examination of physical and mental health disparities in an Israeli sample of middle-aged and older gay and heterosexual men. These results may call the attention of clinicians and policymakers to both vulnerabilities and strengths of middle-aged and older gay men.

Prevalence of and relationship between adverse childhood experiences and family context risk factors among children with intellectual disabilities and borderline intellectual functioning

BackgroundAdverse Childhood Experiences (ACEs) are an overlooked risk factor for behavioural, mental and physical health disparities in children with intellectual disabilities (ID) and borderline intellectual functioning (BIF). AimsTo gain insight into the presence of the 10 original Wave II ACEs and family context risk variables in a convenience sample of children with ID and BIF in Dutch residential care. Methods and procedures134 case-files of children with ID (n = 82) and BIF (n = 52) were analysed quantitatively. Outcomes and results81.7 % of the children with ID experienced at least 1 ACE, as did 92.3 % of the children with BIF. The average number of ACEs in children with ID was 2.02 (range 0−8) and in children with BIF 2.88 (range 0−7). About 20 % of the children with moderate and mild ID experienced 4 ACEs or more. Many of their families faced multiple and complex problems (ID: 69.5 %; BIF 86.5 %). Multiple regression analysis indicated an association between family context risk variables and the number of ACEs in children. Conclusions and implicationsThe prevalence of ACEs in children with ID and BIF appears to be considerably high. ACEs awareness in clinical practice is vital to help mitigate negative outcomes.

How Mental Health Professionals Can Address Disparities in the Context of the COVID-19 Pandemic.

The Coronavirus 2019 (COVID-19) pandemic is an unparalleled crisis, yet also a unique opportunity for mental health professionals to address and prioritize mental and physical health disparities that disproportionately impact marginalized populations. Black, Indigenous, and People of Color (BIPOC) have long experienced structural racism and oppression, resulting in disproportionately high rates of trauma, poverty, and chronic diseases that span generations and are associated with increased COVID-19 morbidity and mortality rates. The current pandemic, with the potential of conferring new trauma exposure, interacts with and exacerbates existing disparities. To assist mental health professionals in offering more comprehensive services and programs for those who have minimal resources and the most profound barriers to care, four critical areas are highlighted as being historically problematic and essential to address: (a) recognizing psychology's role in institutionalizing disparities; (b) examining race/ethnicity as a critical variable; (c) proactively tackling growing mental health problems amidst the COVID-19 crisis; and (d) understanding the importance of incorporating historical trauma and discrimination in research and practice. Recommendations are provided to promote equity at the structural (e.g., nationwide, federal), professional (e.g., the mental health professions), and individual (e.g., practitioners, researchers) levels.

Enhancing Wellbeing for Older Adults With Serious Mental Illnesses: Co-Producing a Positive Psychology Course With Certified Older Adult Peer Specialists.

Compared to peers in the general population, persons aging with serious mental illnesses (SMIs) face physical health disparities, increased isolation, and decreased subjective experiences of quality of life and wellbeing. To date, limited intervention research focuses on addressing specific needs of persons aging with SMIs and no interventions targeted for that population are informed by the theory and science of positive psychology. With the aim of co-producing a positive-psychology-based program to enhance wellbeing for older adults with SMIs, the author held a series of focus groups and individual interviews with six certified older adult peer specialists. Analysis of the data developed in-depth insights into helpful processes, values, and priorities of individuals aging with SMIs, as well as the creation of a wellbeing-enhancing course curriculum.

Translating cultural assets research into action to mitigate adverse childhood experience-related health disparities among African American youth.

Adverse childhood experiences (ACEs) including trauma exposure, parent mental health problems, family dysfunction, and community-level adversities put individuals at risk for a host of negative health outcomes. The effects of cumulative ACEs are numerous, diverse, and can predispose an individual to cognitive, emotional, behavioral, and physical health problems as well as premature death. African American youth experience disproportionate exposure to ACEs in the context of racism that increases risk for allostatic load and hinders systems of care responses resulting in physical and mental health disparities. To maximize efforts to mitigate these disparities it is imperative that we translate research into action to respond to ACEs in the context of racism. This article synthesizes African American cultural assets research within a resilience after trauma framework to provide a foundation for translating research into action to mitigate ACE-related disparities among African American youth. We present task shifting and youth-partnered advocacy as two strategies supported by this framework and describe their application to responding to ACEs in the context of racism. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Structural Racism and Chronic Stress The Root Cause of Disparities

This article details the elements and origins of structural racism, illustrates the resultant impact chronic stress has on African Americans, and poses a new paradigm for the Social Determinants of Health (SDoH). Our thesis is that structural racism is the proximate cause of health disparities. My daughter and I found ourselves on similar paths of discovery while she was attending Bryn Mawr College as a psychology and neuroscience major. She was working on her undergraduate thesis regarding the use of fingernail sample assays for cortisol levels. The underlying research was evaluating stress and cortisol levels in minority, specifically African American communities. At the same time, I was interested in mental health and chronic stress in the African American community. As she described her research, I thought we should collaborate on our intersecting interests. Our joint thesis is that structural racism is the proximate cause of health disparities. Structural racism permeates every aspect of American Life making it simultaneously pervasive and elusive. Chronic stress in the African American community leads to disparities in mental and physical health. We identify race as an independent SDoH in the following model.