SSM - Population Health

IntroductionExperiences of discrimination and bias in health care contribute to health disparities for LGBTQ+ and other minority populations. To avoid discrimination, many LGBTQ+ people go to great lengths to find healthcare providers who they trust and are knowledgeable about their health needs. This study examines whether access to an LGBTQ+ affirming provider may improve health outcomes for LGBTQ+ populations across a range of preventive health and chronic disease management outcomes. MethodsThis cross-sectional study uses Poisson regression models to examine original survey data (n=1,120) from Wave 1 of the Vanderbilt University Social Networks, Aging, and Policy Study (VUSNAPS), a panel study examining older (50{square}76 years) LGBTQ+ adults health and aging, collected between April 2020 and September 2021. ResultsOverall, access to an LGBTQ+ affirming provider is associated with greater uptake of preventive health screenings and improved management of mental health conditions among older LGBTQ+ adults. Compared to participants reporting a usual source of care that is not affirming, participants with an LGBTQ+ affirming provider are more likely to have ever and recently received several types of preventive care, including past year provider visit, flu shot, colorectal cancer screening, and HIV test. Access to an LGBTQ+ affirming provider is also associated with better management of mental health conditions. ConclusionsInclusive care is essential for reducing health disparities among LGBTQ+ populations. Health systems can reduce disparities by expanding education opportunities for providers regarding LGBTQ+ medicine, adopting nondiscrimination policies for LGBTQ+ patients and employees, and ensuring LGBTQ+ care is included in health insurance coverage.

Place-based disorder and social cohesion may influence LGBTQIA+ adults physical and mental health in meaningful ways given their heightened exposure to minority stress and discrimination. However, few studies have examined these associations. Using a sample of 3790 LGBTQIA+ adults in 786 counties from The Population Research in Identity and Disparities for Equality Study, we assessed associations of place-based disorder and social cohesion with depressive symptoms, perceived stress, and physical health using linear mixed models. We tested effect modification by gender modality and ethnoracial group. Residing in counties with higher social cohesion by 1-unit was associated with 1.06 lower points (95% CI -1.56, -0.56) for depressive symptoms, 1.60 lower points (95% CI -2.26, -0.94) for perceived stress, and 1.17 higher points (95% CI 0.43, 1.90) for physical health. Residence in counties with higher place-based disorder by 1-unit was only associated with 1.17 higher points (95% CI 0.32, 2.01) for perceived stress; no association was observed for depressive symptoms or physical health. Findings indicate that physical and social environments are important to the health of LGBTQIA+ individuals.

IntroductionLow educational attainment is associated with increased risk of COVID-19 mortality, but it remains unclear whether the link between education and COVID-19 mortality is causal or due to confounding factors, such as childhood socio-economic status or cognitive skills. To address this question, we evaluated whether older adults risk of COVID-19 mortality was associated with historical state-level compulsory schooling laws (CSLs) applicable when they were school-aged. We also evaluated whether that impact was unique to COVID-19 mortality or also applied to all-cause mortality, both before and during the pandemic. MethodsWe defined mortality outcomes using US death certificate data from Mar 2019-Dec 2021 for people born in the US before 1964 in three time periods: the year prior to the pandemic (Mar 2019-Feb 2020), pandemic year 1 (Mar 2020-Feb 2021), and pandemic year 2 (Mar-Dec 2021). We determined the population at risk using 2019 American Community Survey PUMS data with population weights, representing 78.7 million individuals born in the US before 1964. We linked individuals to the number of mandatory years of education defined by CSLs specific to their state of birth and years when school age. We estimated intention-to-treat effects of CSLs on mortality using logistic regressions controlling for state-of-birth fixed effects, birth year (linear and quadratic), sex, race, ethnicity, and state-level factors including percent urban, Black, and foreign-born (at age 6) and manufacturing jobs per capita and average manufacturing wages (at age 14). ResultsWe identified a dose-response relationship between CSLs and mortality. In the first year of the pandemic, people mandated to receive 8 vs 9 (reference) years of education had higher odds of COVID-19 mortality (Odds Ratio [OR]: 1.15; 95% Confidence Interval [CI]: 1.10, 1.19), while those mandated to receive 10 vs 9 (reference) years of education had lower odds of COVID-19 mortality (OR: 0.96; 95% CI: 0.94, 0.98). The association of CSLs with COVID-19 mortality was similar in pandemic years 1 and 2; for all-cause mortality in pandemic years 1 and 2; and for all-cause mortality in the year prior to the pandemic. Results were robust to alternative model specifications. ConclusionsThese findings support a causal benefit of education for reduced mortality during the COVID-19 pandemic. State investments in childrens education may have reduced pandemic-era mortality decades later. Our research has implications beyond the pandemic context, as our results suggest the observed relationship mirrors a pre-existing relationship between CSLs and all-cause mortality.

BackgroundMental health disparities persist as a significant public health concern in the United States, with certain populations experiencing disproportionate burdens of mental illness and barriers to care. This systematic review aims to synthesize current evidence on mental health disparities across various demographic groups and identify key factors contributing to these inequities. MethodsWe conducted a comprehensive search of peer-reviewed literature published between 2010 and 2024 using PubMed, PsycINFO, and Scopus databases. Studies examining mental health outcomes, access to care, and treatment efficacy across racial/ethnic, socioeconomic, gender, sexual orientation, and geographic groups in the US were included. Two independent reviewers screened articles, extracted data, and assessed study quality. ResultsOf 2,345 initially identified studies, 127 met inclusion criteria. Consistent disparities were observed across multiple domains, with racial/ethnic minorities, low-income individuals, LGBTQ+ populations, and rural residents experiencing higher rates of mental health disorders, lower access to quality care, and poorer treatment outcomes. Key contributing factors included systemic racism, socioeconomic barriers, stigma, lack of culturally competent care, and inadequate insurance coverage. ConclusionThis review highlights persistent and multifaceted mental health disparities in the US. Addressing these inequities requires comprehensive policy interventions, increased funding for community-based mental health services, improved cultural competence in healthcare delivery, and targeted research to develop effective, culturally-tailored interventions for underserved populations.

Survey measurements of sexual orientation have become increasingly common in national population surveys although validation of these measurements is rare and inherently problematic. We instead assess the reproducibility of parallel measurements from two independent samples of the USA population made in the 2008-2018 General Social Surveys and the adult probability subsets of the 2013-2018 National Health Interview Survey (Ns = 12,098 and 190,113). Restricting analysis to the categories gay/lesbian, bisexual, and straight, we obtain similar estimates of the proportion of the U.S. population who consider themselves gay/lesbian (NHIS: 1.59% vs. GSS: 1.93%, p = 0.059) but not bisexual (NHIS: 1.03% vs. GSS: 2.90%, p < 0.001). Fitting multinomial logistic regression models controlling for year, gender, birth cohort, education, and race, we find that compared to the NHIS, the GSS had 1.248 (p=0.022) times higher relative odds of eliciting a response of Gay-Lesbian (vs. Straight) and 2.980 (p<0.001) times higher relative odds of eliciting a response of Bisexual (vs. Straight). Expanding the model by adding 3-way interaction terms for orientation-by-predictor-by-survey, we find that we cannot reject the null hypothesis that trends over time and across subpopulations in reporting of sexual orientation were statistically equivalent for the two survey programs.

IntroductionThe national Youth Risk Behavior Survey (YRBS) has experienced considerable declines in response rates, increases in missing data on sexual experience, and shifts in data collection - all of which raise questions about bias in estimates for sexual experience among US high school students. MethodsWe used weighted data from the YRBS for 2011-2023 (n=110,409). We explored the impact of declining school and student response rates, missing data, and shifts in age distribution in 2021 on reported sexual intercourse. Using statistical decomposition, we estimated the percentage change in this outcome between 2019 and 2021 due to change in the age structure versus changes in reported behavior. ResultsFrom 2011 and 2023, school and student survey response rates declined (school 81% to 40%, student 87% to 71%, and overall, 71% to 35%). Missing data on ever had sex increased over time from 7.0% in 2011 to 29.5% in 2019 and 19.8% in 2023. The age structure in the YRBS national sample was similar from 2011-2019 and in 2023, but substantially younger in 2021. Statistical decomposition estimated that 50% of the change in sexual experience among adolescent women between 2019 and 2021 and 30% of the change for adolescent men was due to a change in the age distribution. ImplicationsDeclining response rates, increased missing data, and changes in the age structure of 2021 YRBS raise serious concerns about the validity of trends in the YRBS. A concerted national effort is needed to build support for the collection of YRBS and other public health surveillance data.

BackgroundResearch suggests gender inequalities in adolescent mental health are context dependent. This implies they may be preventable through social/structural change. However, there is also some evidence that gender mental health gaps are larger in ostensibly more gender equal societies, e.g., 2-3-fold larger in the UK vs. Japan. Using data and methods that overcome important limitations of existing evidence, we tested the hypothesis that gender inequalities in depressive symptom trajectories are larger in London than in Tokyo, and that these differences are not due to incomparable measurement. MethodsWe used three waves of data from representative adolescent cohorts in Tokyo (TTC; n=2,813) and London (REACH; n=4,287) (n=7,100; age 11-16y). We used multigroup and longitudinal confirmatory factor analysis to examine measurement invariance of the 13-item Short Mood and Feelings Questionnaire (SMFQ) across cohorts, genders, and ages. Latent growth models compared depressive symptom trajectories of boys and girls in London and Tokyo. OutcomesScalar invariance was well-supported. In London, gender inequalities in depressive symptoms were evident at age 11y (girls: +0{middle dot}8 [95% CI: 0{middle dot}3-1{middle dot}2]); in Tokyo, the difference emerged between 11-14y. In both places, the disparity widened year-on-year, but by age 16y was around twice as large in London. Annual rate of increase in depressive symptoms was around four times steeper among girls in London (1{middle dot}1 [0{middle dot}9-1{middle dot}3]) vs. girls in Tokyo (0{middle dot}3 [0{middle dot}2-0{middle dot}4]). InterpretationGender inequalities in emotional health are context dependent and may be preventable through social/structural change. FundingJapanese Society for the Promotion of Science; Economic and Social Research Council. RESEARCH IN CONTEXTO_ST_ABSEvidence before this studyC_ST_ABSWomen are around two-to-four times more likely than men to experience emotional problems such as depression and anxiety. Our understanding of the causes is surprisingly limited. Typically, these gender inequalities in emotional health emerge in early adolescence, at around the age of puberty, so much research has focussed on biological explanations. However, a growing body of evidence suggests gender inequalities in adolescent mental health may be context dependent, varying in size - and sometimes direction - across countries. This implies it may be possible to prevent the excess of mental distress among teenage girls through social/structural change. However, there is also some evidence to suggest that gender inequalities in teenage mental health are larger, on average, in countries with higher levels of societal gender equity, e.g., around 2-3 times larger in the UK (which ranks 15th on global gender equity) compared with Japan (ranked 125th). Reasons for this seemingly paradoxical trend are unclear. However, there are important limitations to the international evidence that preclude robust inference about the contexts and conditions that give rise to (and those that mitigate and prevent) gender inequalities in emotional health. It is mostly cross-sectional, relates to older age groups, or - importantly - fails or is unable to robustly examine measurement invariance between countries. We reviewed the reference lists in two successive reviews (published in 2000 and 2017) on the causes of gender inequalities in depression and searched PubMed for original and review articles published as of January 2023. Search terms included: gender inequalities (sex/gender differences, inequalities, disparities, etc.) AND mental health (mental distress, depression, depressive symptoms, etc.) AND young people (child*, adolesc*, youth, etc.) AND international comparisons (international comparisons, cross-cohort, cross-cultural, etc.). We screened titles and abstracts to identify studies with longitudinal data on mental health in population-based adolescent samples. We found: one cross-sectional study reporting gender inequalities in mental distress and wellbeing at age 15 years in 73 countries, with measurement invariance considered at the regional level (e.g., Americas, Eastern Mediterranean); one cross-sectional study of all age groups (except children under 12) in 90 countries, with no examination of measurement invariance; and four longitudinal studies comparing gender inequalities in mental health across countries in mid-adolescence, that either (a) used unrepresentative samples, (b) compared countries with very similar levels of societal gender equity, or (c) did not examine - or only partly supported - measurement invariance between countries. Added value of this studyWe used three waves of data from large, representative cohorts of young people in Tokyo and London and examined (a) the extent to which a widely used measure of depressive symptoms is invariant (comparable) across place, gender, and age, and (b) whether inequalities in depressive symptom trajectories between adolescent boys and girls are larger in London than in Tokyo. We found strong evidence that inequalities in depressive symptom trajectories between adolescent boys and girls are around twice as large, and may emerge earlier, among young people in London than in Tokyo. Notably, the annual rate of increase in depressive symptoms from age 11 to age 16 was around four times steeper among girls in London than among girls in Tokyo. Importantly, we found little evidence to suggest these differences are due to incomparable measurement. We co-wrote this paper with ten young people, five in London and five in Tokyo, and their perspectives are integrated throughout and presented in the Supplement. Implications of all the available evidenceThere is strong evidence that the size and course of gender inequalities in emotional health are driven by social/structural context. Against a backdrop of high and rising rates of emotional health problems among young women and girls in many countries, there is an urgent need to understand the contexts and conditions that enable young girls to thrive.

Different estimation methods produce diverging accounts of racial/ethnic disparities in COVID-19 mortality in the United States. The CDCs decision to present the racial/ethnic distribution of COVID-19 deaths at the state level alongside re-weighted racial/ethnic population distributions--in effect, a geographic adjustment--makes it seem that Whites have the highest death rates. Age adjustment procedures used by others, including the New York City Department of Health and Mental Hygiene, lead to the opposite conclusion that Blacks and Hispanics are dying from COVID-19 at higher rates than Whites. In this paper, we use indirect standardization methods to adjust per-capita death rates for both age and geography simultaneously, avoiding the one-sided adjustment procedures currently in use. Using CDC data, we find age-and-place-adjusted COVID-19 death rates are 80% higher for Blacks and more than 50% higher for Hispanics, relative to Whites, on a national level, while there is almost no disparity for Asians. State-specific estimates show wide variation in mortality disparities. Comparison with non-epidemic mortality reveals potential roles for pre-existing health disparities and differential rates of infection and care.

BackgroundThe refugee population increases around the world each year, and 25% of these individuals are capable of pregnancy. We sought to understand the potential impact to refugees lives, with regard to their ability to access abortion services, as they crossed international borders. MethodsWe analyzed global refugee movement in 2022 and country-level abortion law data to identify patterns of forced migration. We conducted a scoping review to identify emerging topics and research gaps related to refugee fertility intentions and access to reproductive health services. Results6,860,398 female refugees aged 12-59 years moved between countries in 2022. 76% of these refugees went to host countries without abortion on request. 16% of these refugees sought asylum in countries with more restrictive abortion laws than their country of origin, 44% sought asylum in countries with similarly restrictive laws, and 40% sought asylum in countries with less restrictive laws. We identified fifty-two items in our scoping review with the following themes: unintended fertility; intended fertility; need to space, postpone and/or limit fertility; changing fertility intentions; and access to reproductive health services. These items revealed mixed fertility intentions among newly resettled adult refugees and clear evidence that adolescent refugees want to control their fertility despite significant barriers. DiscussionThe results reveal the need for renewed commitment to ensuring that refugees capable of pregnancy have access to the full range of sexual and reproductive health services, so they can exercise their human right to decide if, when, and how many children to have. Plain language summaryThe refugee population increases each year and approximately 25% of refugees are capable of pregnancy. The purpose of this study is to understand how refugee status affects refugees ability to access abortion. We analyzed refugee movement in 2022 and countries abortion law data to identify patterns of forced migration and associated changes in law. We conducted a scoping review to identify emerging or evolving topics and research gaps related to refugee fertility intentions and access to reproductive health services. 6,860,398 female refugees aged 12-59 years moved from 159 origin countries to 111 host countries in 2022. Around 76% of these refugees went to host countries that did not provide abortion on request: 16% of these refugees sought asylum in countries with more restrictive abortion laws than their country of origin, 44% sought asylum in countries with similarly restrictive abortion laws, and 40% sought asylum in countries with less restrictive abortion laws. Fifty-two items in our scoping review revealed mixed fertility intentions among newly resettled adult refugees and clear evidence that adolescent refugees want to control their fertility, despite significant barriers. The study results point to the need for a renewed commitment to ensuring that refugees capable of pregnancy have access to the full range of sexual and reproductive health services, so they can exercise their human right to decide if, when, and how many children to have.

BackgroundLiterature on sexual assault prevalence among homeless women is limited, with few studies disaggregating risk by geography, resource access, mental health, LGBTQ status, or disability. ObjectiveThis study provides two distinct meta-analyses to ascertain the aggregated overall prevalence (k=20 studies) and the aggregated 12-month prevalence (k=14 studies) of sexual assault among homeless women. By examining each recall period independently, we elucidate cumulative burden throughout the life cycle and annual risk, offering unique insights for public health interventions. By synthesizing global data, we aimed to clarify risks for women with disabilities, mental illness, or Lesbian, Gay, Bisexual, Transgender, Queer or Questioning, Plus (LGBTQ+) identities to inform crisis care interventions. MethodsFollowing PRISMA 2020 guidelines, six databases were searched for studies published after 2010 reporting sexual assault prevalence in homeless women. Twenty studies met the inclusion criteria. Random-effects meta-analyses were performed using a logit transformation. Heterogeneity was assessed with I{superscript 2} and Cochrans Q; publication bias with funnel plots and Eggers test. ResultsThe pooled lifetime prevalence of sexual assault was 39.2 % (95 % CI 25-56 %), and 12-month prevalence was 22 % (95 % CI 16-30 %). Heterogeneity was extreme (I{superscript 2} = 97 %). Subgroup analyses showed the highest prevalence among women with disabilities (92 %, single study), followed by LGBTQ+ (33 %) and women with mental illness (34 %). HIV-positive women had the lowest prevalence (2.6 %). Eggers test indicated no publication bias (p = 0.64). ConclusionHomeless women face disproportionately high rates of sexual assault, far exceeding the general female population, with particularly elevated estimates among women with disabilities, LGBTQ+ women, and those with mental illness. These preliminary findings highlight the need for improved screening practices and tailored public health interventions to address sexual assault in doubly vulnerable populations. Standardizing definitions of sexual assault and investigating risk factors could lead to more tailored public health interventions. HighlightsO_LIMarked Epidemiologic Burden: Nearly 40% of homeless women report lifetime sexual assault. C_LIO_LIPersistent risk: One in five homeless women assaulted within the past 12 months. C_LIO_LIMarginalized Impact: Rates highest among disabled, LGBTQ+, and HIV+ women. C_LIO_LIHigh Variability: Extreme heterogeneity (I{superscript 2} {approx} 97%) shows research inconsistency. C_LIO_LIResearch Priority: Standardize methods and definitions to improve accuracy. C_LI

To date, the discourse on bodily autonomy has been narrowly focused on contraception and abortion and needs to be expanded to include experiences of agency during pregnancy and birth. Disrespect and mistreatment are widely reported in low resource countries but very little is known about experiences of perinatal care in high resource countries and how to improve care for minoritized populations. MethodsWe examine experiences of autonomy in decision-making during pregnancy among people who were pregnant in Canada between 2009 and 2022, using a large national dataset of patient-reported experiences and outcomes that were collected via a cross-sectional online survey. We measured autonomy with a globally validated patient-reported experience measure, the My Autonomy in Decision-Making (MADM) scale. To assess variations in autonomy by identity or life circumstances, we conducted multivariable regression analyses, controlling for pregnancy year, repeat observations, and place of residence and stratifying by model of care (physician or midwife-led). In a separate analysis, we tested contextual factors such as onset of prenatal care, length of appointments, and model of care (physician-led or midwife-led) that might reduce disparities in autonomy among minoritized childbearing people. FindingsDiverse participants (n=5389) reported on 7049 interactions with healthcare providers. In the adjusted models, autonomy scores were significantly lower among those with high school education or less (physician-led care: IRR=0.86, 95 % CI: 0.82-0.92; midwife-led care: IRR=0.93, 95% CI: 0.88-0.98) and newcomers to Canada (physician-led care: IRR=0.97, 95 % CI: 0.93-0.99). Scores were higher among pregnant people with majorized identities and circumstances, i.e. those who reported low discrimination (physician-led care: IRR=1.21, 95 % CI: 1.15-1.26; midwife-led care: IRR=1.06, 95% CI: 1.02-1.11), no disability (physician-led care: IRR=1.07, 95 % CI: 1.02-1.13; midwife-led care: IRR=1.04, 95% CI: 1.00-1.09), no need for social services (physician-led care: IRR=1.11, 95 % CI: 1.04-1.19; midwife-led care: IRR=1.13, 95% CI: 1.06-1.21), identified as heterosexual (physician-led care: IRR=1.10, 95 % CI: 1.06-1.15; midwife-led care: IRR=1.03, 95% CI: 1.01-1.06), Cis gender (midwife-led care: IRR=1.08, 95% CI: 1.01-1.16), and had sufficient income to meet financial obligations (physician-led care: IRR=1.18, 95 % CI: 1.11-1.24), compared to the reference groups. Several modifiable factors were linked to higher autonomy, including early entry into prenatal care, sufficient time during prenatal appointments, and midwife-led care. Midwife led care was the only contextual factor that was associated with significant increases in autonomy scores for minoritized people. ConclusionsSelf-determination, including the ability to lead decisions during pregnancy, birth and the postpartum period, is a reproductive right, yet minoritized communities reported significant loss of autonomy. Differences persisted across models of care, pointing to structural inequities in patient-led decision-making during pregnancy.

AO_SCPLOWBSTRACTC_SCPLOWO_ST_ABSBackgroundC_ST_ABSPrior research has identified higher rates of COVID-19 mortality among people of color (relative to non-Hispanic whites) and populations in high-poverty neighborhoods (relative to wealthier neighborhoods). It is unclear, however, whether non-Hispanic whites in high-poverty neighborhoods experience elevated mortality, or whether people of color living in wealthy areas are relatively protected. Exploring socioeconomic position in combination with race/ethnicity can lead to a more detailed understanding of the specific processes that result in COVID-19 inequities. Methods and FindingsWe used census and individual-level mortality data for the non-Hispanic white, non-Hispanic Black, and Hispanic/Latinx populations of Cook County, Illinois, USA. We excluded deaths related to nursing homes and other institutions. We calculated age and gender-adjusted mortality rates by race/ethnicity, census tract poverty quartile, and age group (0-64 and [&ge;]65 years). Within all racial/ethnic groups, COVID-19 mortality rates were greatest in the highest-poverty quartile and lowest in the lowest-poverty quartile. The mortality rate for younger non-Hispanic whites in the highest-poverty quartile was 13.5 times that of younger non-Hispanic whites in the lowest-poverty quartile (95% CI: 8.5, 21.4). For young people in the highest-poverty quartile, the non-Hispanic white and Black mortality rates were similar. Among younger people in the lowest-poverty quartile, non-Hispanic Black and Hispanic/Latinx people had mortality rates nearly three times that of non-Hispanic whites. For the older population, the mortality rate among non-Hispanic whites in the highest-poverty quartile was less than that of lowest-poverty non-Hispanic Black and Hispanic/Latinx populations. ConclusionsOur findings suggest racial/ethnic inequalities in COVID-19 mortality are partly, but not entirely, attributable to the higher average socioeconomic position of non-Hispanic whites relative to the non-Hispanic Black and Hispanic/Latinx populations. Future research on health equity in COVID-19 outcomes should collect and analyze individual-level data on the potential mechanisms driving population distributions of exposure, severe illness, and death.

BackgroundLife expectancy at birth in Mexico has stagnated since the early 2000s. As the COVID-19 pandemic hit, Mexico experienced sizable excess mortality, albeit with large regional variation. We aimed to assess the contribution of violence, COVID-19, and causes of death amenable to healthcare to life expectancy changes between 2015 and 2021 in Mexico. MethodsWe used administrative mortality data by causes of death, and adjusted population exposures from the National Population Council. We applied demographic decomposition methods to assess life expectancy changes at the subnational level, by year and sex. FindingsLife expectancy between 2015 and 2019 declined from 71.8 to 71.1 years for males and stagnated at 77.6 years for females. Violence among young males accounted for 54.3% of life expectancy losses. Between 2019 and 2020, life expectancy decreased by 7.1 and 4.4 years for males and females, respectively. COVID-19 deaths accounted for 55.4% (males) and 57.7% (females). In 2021, male life expectancy stagnated at 64.1 years due to reductions in deaths due to amenable diseases but continued increasing for females by 0.44 years mainly due to reductions in COVID-19 deaths. InterpretationWe document large variations in life expectancy losses across Mexican states, which are associated with preexistent high levels of violence, and socioeconomic disadvantages across geographical areas. Our results serve as a reminder that violence has negative health implications for both sexes and that COVID-19 affected more socially disadvantaged states. FundingSupport from the Netherlands Interdisciplinary Demographic Institute-KNAW, AXA Research Fund, Economic and Social Research Council, and European Unions Horizon 2020 Research and Innovation. Research in context.O_ST_ABSEvidence before this studyC_ST_ABSWe searched for studies in English and Spanish that analyzed life expectancy losses in Mexico before and during the COVID-19 pandemic in PubMed. Most studies that assessed life expectancy during the COVID-19 rely on all-cause mortality and indirect demographic methods. We also identified studies on causes of death, those focused on age-standardized mortality or excess deaths, but as of April 2024, we did not find articles assessing the impact of multiple causes of death on life expectancy. Added value of this studyTo our knowledge, this is the first study to assess the impact of different causes of death on life expectancy before and during the COVID-19 pandemic at the subnational level and by sex in Mexico. We focus on the main causes of death including COVID-19, homicides, and causes amenable to health care (e.g. diabetes). Our findings reveal that before the COVID-19 pandemic (2015-2019) life expectancy decreased for males and remained the same for females. During 2019-2020 life expectancy decreased sharply for both males and females, while in the subsequent years (2020-2021), life expectancy roughly remained the same for males, and continued decreasing for females. Most of the life expectancy losses before the pandemic for males were due to violence and homicides, while since 2020 they were due to COVID-19, but diabetes and causes of death amenable to health care also contributed to reduced life expectancy. Life expectancy losses were unevenly distributed at the subnational level, states from southern and central Mexico experienced the largest life expectancy losses compared to states from north of Mexico. Implications of all the available evidenceThis study contributes to understanding life expectancy changes before and during the COVID-19 pandemic years. By quantifying life expectancy losses we uncover the unequal and devastating impact of the pandemic at the subnational level in Mexico. Moreover, our results highlight the continued failure on reducing homicides and violence in the country.

IntroductionRecent research underscores the exceptionally young age distribution of Covid-19 deaths in the United States compared with international peers. This brief characterizes how high levels of Covid mortality at midlife ages (45-64) are deeply intertwined with continuing racial inequity in Covid-19 mortality. MethodsMortality data from Minnesota in 2020-2022 were analyzed in June 2022. Death certificate data and published vaccination rates in Minnesota allow vaccination and mortality rates to be observed with greater age and temporal precision than national data. ResultsBlack, Hispanic, and Asian adults under age 65 were all more highly vaccinated than white populations of the same ages during most of Minnesotas substantial and sustained Delta surge and all of the subsequent Omicron surge. However, white mortality rates were lower than those of all other groups. These disparities were extreme; at midlife ages (ages 45-64), during the Omicron period, more highly-vaccinated populations had COVID-19 mortality that was 164% (Asian-American), 115% (Hispanic), or 208% (Black) of white Covid-19 mortality at these ages. In Black, Indigenous, and People of Color (BIPOC) populations as a whole, Covid-19 mortality at ages 55-64 was greater than white mortality at 10 years older. ConclusionsThis discrepancy between vaccination and mortality patterning by race/ethnicity suggests that, if the current period is a "pandemic of the unvaccinated," it also remains a "pandemic of the disadvantaged" in ways that can decouple from vaccination rates. This result implies an urgent need to center health equity in the development of Covid-19 policy measures.

Males and certain racial/ethnic minority groups have borne a disproportionate burden of COVID-19 mortality in the United States, and substantial scientific research has sought to quantify and characterize population-level disparities in COVID-19 mortality outcomes by sex and across categories of race/ethnicity. However, there has not yet been a national population-level study to quantify disparities in COVID-19 mortality outcomes across the intersection of these demographic dimensions. Here, we analyze a publicly available dataset from the National Center for Health Statistics comprising COVID-19 death counts stratified by race/ethnicity, sex, and age for the year 2020, calculating mortality rates for each race/ethnicity-sex-age stratum and age-adjusted mortality rates for each race/ethnicity-sex stratum, quantifying disparities in terms of mortality rate ratios and rate differences. Our results reveal persistently higher COVID-19 age-adjusted mortality rates for males compared to females within every racial/ethnic group, with notable variation in the magnitudes of the sex disparity by race/ethnicity. However, non-Hispanic Black, Hispanic, and non-Hispanic American Indian or Alaska Native females have higher age-adjusted mortality rates than non-Hispanic White and non-Hispanic Asian/Pacific Islander males. Moreover, persistent racial/ethnic disparities are observed among both males and females, with higher COVID-19 age-adjusted mortality rates observed for non-Hispanic Blacks, Hispanics, and non-Hispanic American Indian or Alaska Natives relative to non-Hispanic Whites.

BackgroundMedical students frequently experience heightened levels of anxiety, depression, and burnout. These challenges are disproportionately borne by students from underrepresented backgrounds, who are exposed to systemic inequities, discrimination, and reduced access to supportive resources. While precision well-being approaches, characterized by identifying distinct well-being phenotypes for personalized interventions, hold promise, standard machine learning clustering algorithms such as K-Means may inadvertently exacerbate these disparities. Furthermore, the underlying factors contributing to poorer mental health outcomes among underrepresented students remain insufficiently understood. ObjectiveWe aim to identify well-being phenotypes that achieve an equitable distribution of clustering costs across racial groups, identify conditions under which fair and standard clustering solutions converge, and investigate the demographic and socioeconomic factors that shape mental health patterns in students underrepresented in medicine. MethodsDrawing on a diverse sample of 4161 medical students from multiple U.S. institutions participating in the Healthy Minds Survey (2016-2021), we compared the outcomes of socially fair and standard k-Means clustering algorithms using Patient Health Questionnaire-9, General Anxiety Disorder-7, and Flourishing scores. We then employed average treatment effect analyses to identify factors that exacerbate mental health challenges and those that enhance resilience, with a particular emphasis on underrepresented populations. ResultsThe socially fair clustering algorithm significantly reduced the disproportionate burden on minority populations, aligning with standard clustering outcomes when student groups were racially and socioeconomically homogeneous. Perceived discrimination emerged as a key factor driving poorer mental health, while stable financial conditions, robust social engagement, and involvement in culturally or ethnically oriented organizations were linked to greater resilience and improved well-being. ConclusionsIncorporating fairness objectives into clustering algorithms substantially reduced the disproportionate burden on minority students and yielded a more equitable understanding of their mental health patterns. By identifying factors that influence mental health outcomes, our socially-fair precision well-being approach allows for more personalized well-being interventions. These insights equip educators and policymakers with actionable targets for developing culturally responsive, data-driven interventions that not only alleviate distress but also support resilience, ultimately advancing more inclusive, effective precision well-being strategies for all medical students.

Life satisfaction represents a relatively universal social goal. Research suggests familiar interactions of diverse types may shape life satisfaction, but many questions remain about the valence and relative importance of variables shaping life satisfaction. In this exploratory study, we examined the relationships between frequency of shared parent-child activities in early life stages and self-reported parental life-satisfaction after children leave home using a case study of NC State University and University of Texas at El Paso students parents (n=92). Frequency of shared housework with young children was the most important, and positive, predictor of life satisfaction among parents after the children left home, and shared religious activities were also a positive predictor. Conversely, frequency of playing sports with young children was a negative predictor of later life satisfaction among parents. We did not detect a relationship for shared visits to local parks. Current activity level and income level both positively predicted life satisfaction, but we did not detect relationships for gender or marital status. This preliminary research highlights several novel ways shared family activities may affect later life satisfaction among older parents, but requires larger scale research to assess if an how findings apply in other contexts.

In June 2022, the U.S. Supreme Court overturned Roe v Wade. Half of states now face proposed or in-effect abortion bans, which affect the ability of obstetrics and gynecology (ObGyn) residency programs to provide abortion training. Prior to the Supreme Court decision, we surveyed ObGyn residents at all four programs in Wisconsin and Minnesota to assess residents attitudes toward abortion, desire to learn about abortion, and intentions about providing abortion care in their future practice. We found that participants overwhelmingly support abortion, find the issue to be important, and plan to incorporate abortion into future practice. The reversal of Roe v Wade and its impact on access to abortion training may have implications for ObGyn residency recruitment and training, related career decision-making, and future workforce.

People who are structurally disadvantaged and marginalized often report poor health care experiences due to intersecting forms of stigma and discrimination. There are many measures of patient experiences of care, however, few are designed to measure equity-oriented care. In alignment with ongoing calls to integrate actions in support of health equity, we report on the development and testing of patient experiences of care measures that explicitly use a health equity and intersectional lens. Our analysis focuses on two different equity-oriented health care scales. The first was piloted in a primary health care setting, where patients have an ongoing relationship with providers over time. The second was piloted in an emergency department, where care is provided on an episodic basis. Item Response Theory was used to develop the scales and evaluate their psychometric properties. The primary health care scale, tested with a cohort of 567 patients, showed that providing more equity-oriented health care predicted improvements in important patient self-report health outcomes over time. The episodic scale, tested in an emergency department setting with 284 patients, showed evidence of concurrent validity, based on a high correlation with quality of care. Both scales are brief, easy-to-administer self-report measures that can support organizations to monitor quality of care using an equity lens. The availability of both scales enhances the possibility of measuring equity-oriented health care in diverse contexts. Both scales can shed light on experiences of care using an intersectional lens and equity-oriented lens, providing a nuanced understanding of quality of care.

As the number of confirmed COVID-19 cases now exceeds 100 million cases in the United States and continues to climb, concerns have been increasingly raised over the future public health and economic burden of long COVID including disability and concomitant declines in labor force participation. Only a handful of US population-based studies have explored sociodemographic and socioeconomic characteristics that put people at risk of long COVID or have investigated its mental health and socioeconomic sequelae. Herein, I report findings from the largest multivariable analysis to date using US nationally-representative data on 153,543 adults including 19,985 adults with long COVID to explore key predictors and sequelae of long COVID. An estimated 14.0% of adults aged 18-84 y (35.11 million adults) and 15.5% of working-aged adults aged 18-64 y (30.65 million adults) had developed long COVID by November 2022. Several sociodemographic and socioeconomic factors predicted long COVID including lower household income, being aged 30-49 y, Hispanic, female, gay/lesbian or bisexual, and divorced/separated. Even after accounting for such factors, having long COVID was linked to higher risks of recent unemployment, financial hardship, and anxiety and depressive symptomatology, with evidence of dose-response relationships. Overall, an estimated 27.7 million US adults aged 18-84 y and 24.2 million working-aged adults with long COVID who had been or may still be at risk of adverse socioeconomic and mental health outcomes. Lost work was further calculated to be the equivalent of 3 million workers annually, and the estimated annual lost earnings due to long COVID among working-aged adults totaled $175 billion. These preliminary findings highlight the substantial public health and economic implications of long COVID among Americans and should prompt further inquiry and intervention.