Racial Discrimination and Metabolic Syndrome in Young Black Adults.

Importance: Metabolic syndrome (MetS) is a common health condition that predisposes individuals to cardiovascular disease (CVD) and disproportionately affects Black and other racially and ethnically minoritized people. Concurrently, Black individuals also report more exposure to racial discrimination compared with White individuals; however, the role of discrimination in the development of MetS over time and associated mediators in these pathways remain underexplored. Objective: To evaluate the association between racial discrimination and MetS in rural Black individuals transitioning from late adolescence into early adulthood and to identify potential mediating pathways. Design, Setting, and Participants: This longitudinal cohort study included Black adolescents enrolled in the Strong African American Families Healthy Adults (SHAPE) Project between June 2009 and May 2021. Families resided in rural counties of Georgia, where poverty rates are among the highest in the nation. Analyses included 322 of the 500 participants who originally enrolled in SHAPE and who were eligible to participate. Guardians provided information about socioeconomic disadvantage. Analyses were conducted in April 2023. Exposures: Youths reported exposure to racial discrimination annually from ages 19 to 21 years. Main Outcomes and Measures: MetS was the main health outcome and was measured at ages 25 and 31 years. MetS was diagnosed according to the International Diabetes Federation guidelines, which requires central adiposity (ie, waist circumference ≥94 cm for males and ≥80 cm for females) and at least 2 of the 4 additional components: signs of early hypertension (ie, systolic blood pressure ≥130 mm Hg or diastolic blood pressure ≥85 mm Hg); elevated triglyceride levels (ie, >150 mg/dL); elevated fasting glucose level (ie, ≥100 mg/dL); or lowered high-density lipoprotein levels (ie, <40 mg/dL in men and <50 mg/dL in women). At age 25 years, markers of inflammatory activity (ie, soluble urokinase plasminogen activator receptor [suPAR]) and sleep problems were collected to consider as potential mediators. Results: In 322 participants (210 [65.2%] female) ages 19 to 21 years, more frequent exposure to racial discrimination was associated with higher suPAR levels (b = 0.006; 95% CI, 0.001-0.011; P = .01) and more sleep problems at age 25 years (b = 0.062; 95% CI, 0.028-0.097; P < .001) as well as a 9.5% higher risk of MetS diagnosis at age 31 years (odds ratio [OR], 1.10; 95% CI, 1.01-1.20; P = .03). Both suPAR (b = 0.015; 95% CI, 0.002-0.037) and sleep problems (b = 0.020; 95% CI, 0.002-0.047) at age 25 years were significant indirect pathways. No significant interactions between sex and discrimination emerged. Conclusions and Relevance: This study suggests that racial discrimination in late adolescence is associated with MetS among Black young adults through biobehavioral pathways. Thus, health interventions for MetS in Black adults will need to contend with sleep behaviors and inflammatory intermediaries as well as address and reduce exposure to racial discrimination to narrow disparities and promote health equity.

Adverse Childhood Experiences and Trajectories of Firearm Exposure in Childhood.

OBJECTIVE: To examine the longitudinal relationship between exposure to adverse childhood experiences (ACEs) in early life and trajectories of firearm exposure from early to middle childhood (ages 5-9 years old). STUDY DESIGN: Data from the Longitudinal Studies of Child Abuse and Neglect (LOGSCAN) study were used. The LONGSCAN study was a prospective study in the United States and contained data from 1354 children from age 4 to age 18 years old. Exposure to ACEs was measured through the wave 1 interview (age 5 years old) and trajectories of firearm exposure were created using data from waves 1 (age 5 years old) and two (age 9 years old). RESULTS: Two trajectories of firearm exposure in childhood were identified: a low exposure group and a group with persistently-high firearm exposure from ages 5 to 9 years old. ACEs were associated with membership in the high exposure group and children with four or more ACEs had over twice the odds of membership in the high exposure group compared with children with zero ACEs. CONCLUSION: ACEs exposure in early childhood is associated with persistently-high exposure to firearms from early to middle childhood. This finding highlights the need for pediatricians to consider screening for both ACEs and firearm exposure in routine examinations, as well as the need for future research to identify and evaluate interventions intended to address exposure to adversity and firearms.

Exposure to parental depression in adolescence and proinflammatory phenotypes 20 years later.

Although the biological embedding model of adversity proposes that stressful experiences in childhood create a durable proinflammatory phenotype in immune cells, research to date has relied on study designs that limit our ability to make conclusions about whether the phenotype is long-lasting. The present study leverages an ongoing 20-year investigation of African American youth to test research questions about the extent to which stressors measured in childhood forecast a proinflammatory phenotype in adulthood, as indicated by exaggerated cytokine responses to bacterial stimuli, monocyte insensitivity to inhibitory signals from hydrocortisone, and low-grade inflammation. Parents reported on their depressive symptoms and unsupportive parenting tendencies across youths' adolescence. At age 31, youth participants (now adults) completed a fasting blood draw. Samples were incubated with lipopolysaccharide and doses of hydrocortisone to evaluate proinflammatory processes. Additionally, blood samples were tested for indicators of low-grade inflammation, including IL-6, IL-8, IL-10, and TNF-α, and soluble urokinase plasminogen activator receptor. Analyses revealed that parental depression across youths' adolescence prospectively predicted indicators of proinflammatory phenotypes at age 31. Follow-up analyses suggested that unsupportive parenting mediated these associations. These findings suggest that exposure to parental depression in adolescence leaves an imprint on inflammatory activity that can be observed 20 years later.

Racial and ethnic inequities in the quality of paediatric care in the USA: a review of quantitative evidence.

Racial and ethnic inequities in paediatric care have received increased research attention over the past two decades, particularly in the past 5 years, alongside an increased societal focus on racism. In this Series paper, the first in a two-part Series focused on racism and child health in the USA, we summarise evidence on racial and ethnic inequities in the quality of paediatric care. We review studies published between Jan 1, 2017 and July 31, 2022, that are adjusted for or stratified by insurance status to account for group differences in access, and we exclude studies in which differences in access are probably driven by patient preferences or the appropriateness of intervention. Overall, the literature reveals widespread patterns of inequitable treatment across paediatric specialties, including neonatology, primary care, emergency medicine, inpatient and critical care, surgery, developmental disabilities, mental health care, endocrinology, and palliative care. The identified studies indicate that children from minoritised racial and ethnic groups received poorer health-care services relative to non-Hispanic White children, with most studies drawing on data from multiple sites, and accounting for indicators of family socioeconomic position and clinical characteristics (eg, comorbidities or condition severity). The studies discussed a range of potential causes for the observed disparities, including implicit biases and differences in site of care or clinician characteristics. We outline priorities for future research to better understand and address paediatric treatment inequities and implications for practice and policy. Policy changes within and beyond the health-care system, discussed further in the second paper of this Series, are essential to address the root causes of treatment inequities and to promote equitable and excellent health for all children.

Policy solutions to eliminate racial and ethnic child health disparities in the USA.

Societal systems act individually and in combination to create and perpetuate structural racism through both policies and practices at the local, state, and federal levels, which, in turn, generate racial and ethnic health disparities. Both current and historical policy approaches across multiple sectors-including housing, employment, health insurance, immigration, and criminal legal-have the potential to affect child health equity. Such policies must be considered with a focus on structural racism to understand which have the potential to eliminate or at least attenuate disparities. Policy efforts that do not directly address structural racism will not achieve equity and instead worsen gaps and existing disparities in access and quality-thereby continuing to perpetuate a two-tier system dictated by racism. In Paper 2 of this Series, we build on Paper 1's summary of existing disparities in health-care delivery and highlight policies within multiple sectors that can be modified and supported to improve health equity, and, in so doing, improve the health of racially and ethnically minoritised children.

A pilot recruitment strategy to enhance ethical and equitable access to Covid-19 pediatric vaccine trials.

BACKGROUND/AIMS: The SARS-CoV-2 pandemic disproportionately impacted communities with lower access to health care in the United States, particularly before vaccines were widely available. These same communities are often underrepresented in clinical trials. Efforts to ensure equitable enrollment of participants in trials related to treatment and prevention of Covid-19 can raise concerns about exploitation if communities with lower access to health care are targeted for recruitment. METHODS: To enhance equity while avoiding exploitation, our site developed and implemented a three-part recruitment strategy for pediatric Covid-19 vaccine studies. First, we publicized a registry for potentially interested participants. Next, we applied public health community and social vulnerability indices to categorize the residence of families who had signed up for the registry into three levels to reflect the relative impact of the pandemic on their community: high, medium, and low. Finally, we preferentially offered study participation to interested families living in areas categorized by these indices as having high impact of the Covid-19 pandemic on their community. RESULTS: This approach allowed us to meet goals for study recruitment based on public health metrics related to disease burden, which contributed to a racially diverse study population that mirrored the surrounding community demographics. While this three-part recruitment strategy improved representation of minoritized groups from areas heavily impacted by the Covid-19 pandemic, important limitations were identified that would benefit from further study. CONCLUSION: Future use of this approach to enhance equitable access to research while avoiding exploitation should test different methods to build trust and communicate with underserved communities more effectively.

Parental Incarceration in the United States: 2016-2021.

BACKGROUND AND OBJECTIVES: Parental incarceration (PI) is both an adverse childhood experience (ACE) and an influencer of pediatric health. Despite evidence that rural America sees the highest incarceration rates and substantial inequities in pediatric health care access and services, it is unclear how the prevalence of PI and associated sociodemographic factors vary across urban, suburban, and rural regions of the United States. METHODS: This study used data from the National Survey of Children's Health (2016-2021; N = 145 281). Based on proximity and population, households were categorized as urban, suburban, or rural. Caregivers reported on household income, race/ethnicity, and living arrangements as well as children's exposure to ACEs, including PI. Chi-squared and t-tests compared the prevalence of PI across communities and assessed regional differences in ACEs and sociodemographic characteristics in the context of PI. RESULTS: PI was most common in rural (12%) versus urban (8%) and suburban (6%) areas. ACEs were more prevalent among PI children compared with non-PI peers across regions, with slight differences between PI children across locales. Within all regions, PI was highest for Black, Latinx, Native, and multiracial children; those in poverty; and those in nonparent caregiver placements. However, these prevalences were consistently highest among rural children. CONCLUSIONS: This study points to high rates of adversity and concern racial, economic, and residential disparities for PI children, particularly those in rural communities. Evidence from this study can be used as a foundation for future prevention and intervention pediatric health responses that address inequities and unmet needs for rural populations.

Anti-racist strategies for clinical and translational research: Design, implementation, and lessons learned from a new course.

Translational research should examine racism and bias and improve health equity. We designed and implemented a course for the Master of Science in Clinical Investigation program of the Northwestern University Clinical and Translational Sciences Institute. We describe curriculum development, content, outcomes, and revisions involving 36 students in 2 years of "Anti-Racist Strategies for Clinical and Translational Science." Ninety-six percent of students reported they would recommend the course. Many reported changes in research approaches based on course content. A course designed to teach anti-racist research design is feasible and has a positive short-term impact on learners.

Effective Communication for Child Advocacy: Getting the Message out Beyond Clinic Walls.

Clinicians who want to communicate child advocacy messages, stories, and arguments can draw on their clinical and scientific experience, but effective communication to wider--and nonmedical--audiences requires careful thought. We discuss choosing and honing the message, developing writing and speaking skills that fit both the exigencies of the chosen medium and format, including op-eds, essays, social media, public testimony, and speeches. We provide guidance on proposing articles, working with editors, shaping language and diction for a general audience, and drawing on clinical experiences while respecting confidentiality. all with the goal of effective communication, spoken and written, in the service of children and child advocacy.

Health Care Access and Use Among Children & Adolescents Exposed to Parental Incarceration-United States, 2019.

OBJECTIVE: The United States has the highest incarceration rate in the world, with spillover impacts on 5 million children with an incarcerated parent. Children exposed to parental incarceration (PI) have suboptimal health care access, use, and outcomes in adulthood compared to their peers. However, little is known about their access and utilization during childhood. We evaluated relationships between PI and health care use and access throughout childhood and adolescence. METHODS: We analyzed the nationally representative 2019 National Health Interview Survey Child Sample to examine cross-sectional associations between exposure to incarceration of a residential caregiver, access to care, and health care use among children aged 2-17. Respondents were asked about measures of preventive care access, unmet needs due to cost, and acute care use over the last year. We estimated changes associated with PI exposure using multiple logistic regression models adjusted for age, sex, race, ethnicity, parental education, family structure, rurality, income, insurance status, and disability. RESULTS: Of 7405 sample individuals, 467 (weighted 6.2% [95% CI 5.5-6.9]) were exposed to PI. In adjusted analyses to produce national estimates, exposure to PI was associated with an additional 2.2 million children lacking a usual source of care, 2 million with forgone dental care needs, 1.2 million with delayed mental health care needs, and 865,000 with forgone mental health care needs. CONCLUSIONS: Exposure to PI was associated with worse access to a usual source of care and unmet dental and mental health care needs. Our findings highlight the need for early intervention by demonstrating that these barriers emerge during childhood and adolescence.

Moving Beyond Words: Leveraging Financial Resources to Improve Diversity, Equity, and Inclusion in Academic Medical Centers.

Diversity, equity, and inclusion (DEI) efforts at academic medical centers (AMCs) began prior to 2020, but have been accelerated after the death of George Floyd, leading many AMCs to recommit their support for DEI. Institutions crafted statements to decry racism, but we assert that institutions must make a transparent, continuous, and robust financial investment to truly show their commitment to DEI. This financial investment should focus on (1) advocacy efforts for programs that will contribute to DEI in health, (2) pipeline programs to support and guide minoritized students to enter health professions, and (3) the recruitment and retention of minoritized faculty. While financial investments will not eliminate all DEI concerns within AMCs, investing significant financial resources consistently and intentionally will better position AMCs to truly advance diversity, equity, and inclusion within healthcare, the community, and beyond.

Experiences of the Flint Water Crisis Among Reproductive-Age Michigan Women in Communities Outside of Flint: Differences by Race and Ethnicity.

We sought to understand how women in Michigan communities outside of Flint experienced the Flint water crisis, an avoidable public health disaster widely attributed to structural racism. Using survey data from 950 Michigan women aged 18-45 from communities outside of Flint, we examined racial and ethnic differences in personal connections to Flint, perceived knowledge about the water crisis, and beliefs about the role of anti-Black racism in the water crisis factors that could contribute to poor health via increased psychological stress. We found that White (OR = 0.32; 95% CI: 0.22, 0.46) and Hispanic (OR = 0.21; 95% CI: 0.09, 0.49) women had lower odds than Black women of having family or friends who lived in Flint during the water crisis. Compared to Black women, White women were less likely to be moderately or very knowledgeable about the water crisis (OR = 0.58; 95% CI: 0.41, 0.80). White women (OR = 0.26; 95% CI: 0.18, 0.37), Hispanic women (OR = 0.38; 95% CI: 0.21, 0.68), and women of other races (OR = 0.28; 95% CI: 0.15, 0.54) were less likely than Black women to agree that the water crisis happened because government officials wanted to hurt Flint residents. Among those who agreed, White women (OR = 0.47; 95% CI: 0.30, 0.74) and women of other races (OR = 0.33; 95% CI: 0.12, 0.90) were less likely than Black women to agree that government officials wanted to hurt people in Flint because most residents are Black. We conclude that the Flint water crisis was a racialized stressor, with potential implications for the health of reproductive-age Black women.

United States Youth Arrest and Health Across the Life Course: A Nationally Representative Longitudinal Study.

BACKGROUND: Youth are arrested at high rates in the United States; however, long-term health effects of arrest remain unmeasured. We sought to describe the sociodemographic characteristics and health of adults who were arrested at various ages among a nationally representative sample. METHODS: Using the National Longitudinal Study of Adolescent to Adult Health, we describe sociodemographics and health status in adolescence (Wave I, ages 12-21) and adulthood (Wave V, ages 32-42) for people first arrested at age younger than 14 years, 14 to 17 years, and 18 to 24 years, compared to never arrested adults. Health measures included physical health (general health, mobility/functional limitations, death), mental health (depressive symptoms, suicidal thoughts), and clinical biomarkers (hypertension, diabetes). We estimate associations between age of first arrest and health using covariate adjusted regressions. RESULTS: Among the sample of 10,641 adults, 28.5% had experienced arrest before age 25. Individuals first arrested as children (ie, age <14) were disproportionately Black, compared to White. Compared to individuals never arrested, people arrested before age 25 had more depressive symptoms and higher rates of suicidal thoughts during adolescence. Arrest before age 25 was associated with worse self-reported health, higher rates of functional limitations, more depressive symptoms, and greater mortality by adulthood (ages 32-42). CONCLUSIONS: Arrest before age 25 was associated with worse physical and mental health--and even death in adulthood. Child arrest was disproportionately experienced by Black children. Reducing arrests of youth may be associated with improved health across the life course, particularly among Black youth, thereby promoting health equity.

Commercial Sexual Exploitation During Adolescence: A US-Based National Study of Adolescent to Adult Health.

OBJECTIVES: National data on the health of children and adolescents exposed to commercial sexual exploitation (CSE) are lacking, during both adolescence and adulthood. Using nationally representative data, we examined the health of male and female adolescents in grades 7-12 who experienced CSE exposure and subsequent adult health outcomes and access to health care. METHODS: Our retrospective cohort study used data from Waves I-IV of the National Longitudinal Study of Adolescent to Adult Health (1994-2008) to characterize relationships between CSE exposure before or during adolescence and health during adolescence and adulthood. The analytic sample included 10 918 adult participants aged 24-34 in Wave IV. We performed bivariate analyses, stratified by sex, to quantify the relationship between CSE exposure before or during adolescence and adolescent and adult health outcomes. RESULTS: Four percent of participants reported having a CSE exposure before or during adolescence (5% of males, 3% of females). Factors associated with CSE exposure among adolescents included race/ethnicity, parental education level, previous abuse, same-sex romantic attractions, history of ever having run away from home, and substance use. During adolescence, exposure to CSE was associated with worse overall health, depressive symptoms, and suicidal thoughts for both males and females. In adulthood, adolescent CSE exposure was associated with depression among males and functional limitations among females. A higher percentage of males with CSE exposure before or during adolescence, compared with their non-CSE-exposed peers, used the emergency department as their usual source of care during adulthood. CONCLUSIONS: CSE exposure before or during adolescence was associated with poor adolescent and adult health outcomes and health care access. Observed differences between males and females warrant further exploration.