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Objectives. To describe national- and county-level trends and variation in a novel measure of hope. Methods. Using data from the Gallup National Health and Well-Being Index (n = 2 766 728), we summarized the difference between anticipated life satisfaction (ALS) and current life satisfaction (CLS), measured by the Cantril Self-Anchoring Scale, for each year from 2008 to 2020 and by county over two 5-year periods in the United States. Results. Across all years, there was a significant positive trend in the difference between ALS and CLS for the nation (P = .024), which remained positive but not significant when we excluded 2020. Maintenance of ALS with a decrease in CLS drove the 2020 increase. From 2008–2012 to 2013–2017, 14.5% of counties with 300 or more responses (n = 599) experienced an increase in the difference of more than 1 SD, whereas 13.9% experienced a more than 1 SD decrease. Fifty-two counties experienced decreases in ALS and CLS. Conclusions. Responding to trends in the gap between ALS and CLS at national and local levels is essential for the collective well-being of our nation, especially as we navigate and emerge from crisis.

Background: The classical 3-point composite outcome MACE (major adverse cardiovascular events) includes incident stroke, myocardial infarction, and cardiovascular death. Conventional use of MACE may fail to account for important neurological consequences of vascular risk factors. We sought to report incidence rates of a novel composite neurologic outcome called major adverse brain events (MABE), comprised of incident stroke, dementia, and impaired balance in individuals with the vascular risk factor of hypertension. Methods: We analyzed TriNetX, the Health and Retirement Study (HRS), and Atherosclerosis Risk in Communities (ARIC), three longitudinal, publicly available datasets. We ascertained MABE as well as MACE and MACABE (MABE & MACE) as comparators by applying distinct adjudication methodologies in each dataset. We also evaluated the effect of good vascular health (maintenance of systolic blood pressure Results: We included 10,496,366 hypertensive individuals aged ≥40 years in the TriNetX sample with up to 4 years of follow-up, 2,251 hypertensive individuals aged ≥60 years in HRS with 4 years of follow-up, and 1,409 hypertensive individuals in ARIC with a mean of 4.9 years of follow-up. The incidence of MABE was 10.5% in TriNetX (Figure 1), 35.9% in HRS, and 33.3% in ARIC, of MACE was 17.5%, 40.8% and 12.9%, and of MACABE was 21.2%, 56.3%, and 39.9%, respectively. MABE incidence was highest in older, female, and Black individuals. In HRS, the adjusted OR in those with GVH was 0.50 (95% CI 0.34-0.73) for MABE, 0.71 (95% CI 0.51-0.99) for MACE, and 0.59 (95% CI 0.43-0.82) for MACABE. Conclusions: These data suggest that MABE is common among patients with hypertension, even in administrative datasets which are expected to have lower event rates. MABE may be useful for interventions that target brain health.

BACKGROUND Public health measures to control the COVID-19 pandemic have led to feelings of loneliness among older adults, which, prior to COVID, has been associated with subsequent morbidity and mortality. We sought to identify differences in feelings of loneliness, sadness, and social disconnection early in the pandemic across racial groups, and possible mitigating factors. METHODS We performed a cross-sectional analysis using the weighted nationally-representative Medicare Current Beneficiaries Survey COVID-19 supplement, collected summer 2020. We included all Medicare beneficiaries over 65 who did not respond by proxy. We examined changes in loneliness, sadness, or feelings of social disconnection. Multivariable logistic regression models accounted for sociodemographic variables, access to primary care and the internet, and history of depression or dementia. RESULTS Among 8125 beneficiaries, representative of 43.7 million Medicare beneficiaries, 22.6% reported loneliness or sadness, and 37.1% feeling socially disconnected. In fully-adjusted models, Hispanic/Latinx beneficiaries were most likely to report loneliness or sadness (OR = 1.3, CI: 1.02-1.65; P = 0.02) and Black beneficiaries were least likely to report feeling socially disconnected (OR = 0.55; CI: 0.42-0.73; P

We investigated the relationship between measures of self-reported health and well-being and concurrent and prospective healthcare utilization and costs to assess the added value of these self-reported measures in understanding utilization and cost.Kaiser Permanente members (N = 6752) completed a 9-item survey measuring life evaluation, financial situation, social support, meaning and purpose, physical health, and mental health. Responses were linked to medical record information during the period 12 months before and after the survey.Correlations between health and well-being measures and healthcare utilization and cost variables were generally weak, with stronger correlations for future life evaluation and selected health measures (ρ = .20-.33, ps .001). Better overall life evaluation had a significant but weak association with lower total cost and hospital days in the following year after controlling for age, sex, and race/ethnicity (p .001). Full multivariate models, adjusting for age, sex, race/ethnicity, prior utilization, and relative risk models, showed weak associations between health and well-being measures and following year total healthcare cost and utilization, though the associations were relatively stronger for the health variables than the well-being variables.Overall, the health and well-being variables added little to no predictive utility for future utilization and cost beyond prior utilization and cost and the inclusion of predictive models based on clinical information. Perceptions of well-being may be associated with factors beyond healthcare utilization. When information about prior use is unavailable, self-reported health items have some predictive utility.

BackgroundRacial and ethnic disparities in delayed medical care due to reasons not related to cost of care remain understudied. We aimed to describe recent 20-year trends in such disparities.MethodsThe study used data from the National Health Interview Survey from 1999–2018 and included individuals ≥18 years of age. Respondents were categorized by their sex, income, and self-reported race and ethnicity. The main outcomes were trends in disparities in any of 5 specific barriers to timely medical care: inability to get through by phone, no appointment available soon enough, long waiting times, inconvenient doctor’s office/clinic hours, or lack of transportation.ResultsThe study included 590,603 adults (mean age 46.0 [SE, 0.07] years; 51.9% female). Of these, 4.7% were Asian, 11.8% Black, 13.8% Latino/Hispanic, and 69.7% White. In 1999, the proportion reporting any of the barriers to timely medical care was 7.3% among Asian, 6.9% among Black, 7.9% among Latino/Hispanic, and 7.0% among White individuals (P >0.05 for each difference with White individuals). From 1999 to 2018, this proportion increased across all 4 race/ethnicity groups (PConclusionsFrom 1999 to 2018, barriers to timely medical care increased for all populations with increasing disparities between racial/ethnic groups.

Optimism is associated with better cardiovascular health, yet little is known about the underlying mechanisms and whether protective relationships are consistently observed across diverse groups. This study examines optimism's association with lipid profiles over time and separately among Black and White men and women.Data were from 3,206 middle-aged adults in the Coronary Artery Risk Development in Young Adults study. Optimism was measured in 2000-2001 using the Revised Life Orientation Test. Triglyceride, total cholesterol, high-density lipoprotein cholesterol, and low-density lipoprotein cholesterol measurements were obtained at 5-year intervals through 2015-2016. Linear mixed models evaluated relationships between optimism and lipids, adjusting for covariates, including prebaseline lipids. Subgroup differences were examined using interaction terms and stratification. All analyses were conducted in 2020.Higher optimism was associated with both lower baseline total cholesterol (β= -2.33, 95% CI= -4.31, -0.36) and low-density lipoprotein cholesterol levels (β= -1.93, 95% CI= -3.65, -0.21) and a more rapid incremental increase in both markers over time (total cholesterol: β=0.09, 95% CI=0.00, 0.18; low-density lipoprotein cholesterol: β=0.09, 95% CI=0.01, 0.16). No associations were apparent with baseline triglycerides, high-density lipoprotein cholesterol, or changes in either lipid over time. Tests for interaction only found evidence of heterogeneous associations with baseline triglyceride levels, but stratified models hinted at stronger protective associations with baseline levels of total cholesterol and low-density lipoprotein cholesterol among White women.Optimism may help diverse individuals establish healthy total cholesterol and low-density lipoprotein cholesterol levels before midlife. Although associations were largely consistent across subgroups, stronger associations among White men and White women highlight a need to study optimism's health impact in diverse samples.

Background People who have been incarcerated have high rates of cardiovascular risk factors, such as hypertension and smoking, and cardiovascular disease (CVD) is a leading cause of hospitalizations and mortality in this population. Despite this, little is known regarding what pathways mediate the association between incarceration exposure and increased rates of CVD morbidity and especially what incarceration specific factors are associated with this risk. The objective of this study is to better understand CVD risk in people exposed to incarceration and the pathways by which accumulate cardiovascular risk over time. Methods and Analysis The Justice-Involved Individuals Cardiovascular Disease Epidemiology (JUSTICE) study is a prospective cohort study of individuals released from incarceration with known cardiovascular risk factors. We are recruiting 500 individuals within three months after release from jail/prison. At baseline we are assessing traditional risk factors for CVD, including diet, exercise, and smoking, and exposure to incarceration-related policies, psychosocial stress, and self-efficacy. Cardiovascular risk factors are measured at baseline through point of care testing. We are following these individuals for the 12 months following the index release from incarceration with re-evaluation of psychosocial factors and clinical risk factors every 6 months. Using these data, we will estimate the direct and indirect latent effects of incarceration on cardiovascular risk factors and the paths via which these effects are mediated. We will also model the anticipated 10-year burden of CVD incidence, health care use, and mortality associated with incarceration. Discussion Our study will identify factors associated with CVD risk factor control among people released from incarceration. Our measurement of incarceration-related exposures, psychosocial factors, and clinical measures of cardiovascular risk will allow for identification of unique targets for intervention to modify CVD risk in this vulnerable population.

IntroductionCommunities are seeking to learn if and how they can improve the well-being of their residents. We therefore examined the impact of a community-led, collective-impact initiative, deployed through Blue Zones Project by Sharecare, aimed at improving health and well-being in one set of US communities.MethodsWe used data from cross-sectional surveys of the Well-Being Index (2010–2017) to assess how the Life Evaluation Index (LEI) in Hermosa Beach, Manhattan Beach and Redondo Beach in California (Beach Cities) changed over time and how this change compares with change for similar cities (Beach Cities-like) and for the USA as a whole. We examined types of interventions, perceived impacts, and relationships between intervention type and change in LEI.ResultsThe Beach Cities experienced greater increases in LEI than Beach Cities-like communities and the nation. The entire portfolio of interventions was positively associated with change in LEI in the Beach Cities (+1.12, p=0.012), with process-oriented interventions most closely associated with improvement.ConclusionsCommunity-led collective action that leverages community engagement and activation, strategic use of programming and large-scale built-environment and policy change can improve health and well-being at scale.

ImportanceMinoritized racial and ethnic groups are generally more likely to experience sleep deficiencies. It is unclear how these sleep duration disparities have changed over recent years.ObjectiveTo determine 15-year trends in the racial and ethnic differences in self-reported sleep duration among adults in the US.DesignSerial cross-sectional study of the National Health Interview Survey from years 2004– 2018. Analyses were performed between July 26, 2021 and February 10, 2022.SettingUS population-based.Participants429,195 non-institutionalized adults.ExposuresSelf-reported race, ethnicity, household income, and sex/gender.Main OutcomesTemporal trends and racial/ethnic differences in short- and long-sleep duration (9 hours in a 24-hour period, respectively), and racial/ethnic differences in the relationship between sleep duration and age.ResultsThe study sample consisted of 429,195 individuals (mean age 46.5 [SE, 0.08] years; 51.7% female) of which 5.1% identified as Asian, 11.8% as Black, 14.7% as Latino/Hispanic, and 68.5% as White. In 2004, the adjusted estimated prevalence of short-sleep duration and long-sleep duration, respectively, were 31.3% and 2.5% among Asian individuals, 35.3% and 6.4% among Black individuals, 27.0% and 4.6% among Latino/Hispanic individuals, and 27.8% and 3.5% among White individuals. Over the study period, there was a significant increase in the short sleep prevalence among Black, Latino/Hispanic, and White individuals (P≤0.001 for each), whereas prevalence of long sleep changed significantly only among Latino/Hispanic individuals (−1.4 points, P=0.01). In 2018, compared with White individuals, short sleep prevalence among Black and Latino/Hispanic individuals was higher by 10.7 points and 2.4 points, respectively(P≤0.03 each), and long sleep prevalence was higher only among Black people (+1.4 points; P=0.01). The short-sleep disparities were the greatest among women and among those with middle/high household income. In addition, across age groups, Black individuals had a higher short- and long-sleep duration prevalence compared with White individuals of their same age. ConclusionsIn this serial cross-sectional study from 2004 to 2018, the prevalence of short and long sleep duration was persistently higher among Black individuals. The Black-White disparities in short-sleep were highest among women, individuals who had middle or high income, and among young or middle-aged adults.KEY POINTSQuestionHow have racial and ethnic differences in self-reported sleep duration among US adults changed between 2004 and 2018?FindingsIn this serial cross-sectional study that included 429,195 adults, the prevalence of both short and long sleep duration were persistently higher among Black individuals over the 15-year study period. The disparities in short sleep duration were highest for Black women, Black individuals with middle or high income, and young and middle-aged Black adults.MeaningThere were marked racial and ethnic differences in sleep duration that persisted from 2004 to 2018, which may be contributing to health disparities.

Physical activity and social support are associated with better outcomes after surviving acute myocardial infarction (AMI), and greater walkability has been associated with activity and support. We used data from the SILVER-AMI study (November 2014 – June 2017), a longitudinal cohort of community-living adults ≥75 years hospitalized for AMI to assess associations of neighborhood walkability with health outcomes, and to assess whether physical activity and social support mediate this relationship, if it exists. We included data from 1345 participants who were not bedbound, were discharged home, and for whom we successfully linked walkability scores (from Walk Score®) for their home census block. Our primary outcome was hospital-free survival time (HFST) at six months after discharge; secondary outcomes included physical and mental health at six months, assessed using SF-12. Physical activity and social support were measured at baseline. Covariates included cognition, functioning, comorbidities, participation in rehabilitation or physical therapy, and demographics. We employed survival analysis to examine associations between walkability and HFST, before and after adjustment for covariates; we repeated analyses using linear regression with physical and mental health as outcomes. In adjusted models, walkability was not associated with physical health (s = 0.010; 95% CI: -0.027, 0.047), mental health (s = -0.08; 95% CI: -0.175, -0.013), or HFST (s = 0.008; 95% CI: -0.023, 0.009). Social support was associated with mental health in adjusted models. Neighborhood walkability was not predictive of outcomes among older adults with existing coronary disease, suggesting that among older adults, mobility limitations may supercede neighborhood walkability.

Background Harnessing health-related data posted on social media in real time can offer insights into how the pandemic impacts the mental health and general well-being of individuals and populations over time. Objective This study aimed to obtain information on symptoms and medical conditions self-reported by non-Twitter social media users during the COVID-19 pandemic, to determine how discussion of these symptoms and medical conditions changed over time, and to identify correlations between frequency of the top 5 commonly mentioned symptoms post and daily COVID-19 statistics (new cases, new deaths, new active cases, and new recovered cases) in the United States. Methods We used natural language processing (NLP) algorithms to identify symptom- and medical condition–related topics being discussed on social media between June 14 and December 13, 2020. The sample posts were geotagged by NetBase, a third-party data provider. We calculated the positive predictive value and sensitivity to validate the classification of posts. We also assessed the frequency of health-related discussions on social media over time during the study period, and used Pearson correlation coefficients to identify statistically significant correlations between the frequency of the 5 most commonly mentioned symptoms and fluctuation of daily US COVID-19 statistics. Results Within a total of 9,807,813 posts (nearly 70% were sourced from the United States), we identified a discussion of 120 symptom-related topics and 1542 medical condition–related topics. Our classification of the health-related posts had a positive predictive value of over 80% and an average classification rate of 92% sensitivity. The 5 most commonly mentioned symptoms on social media during the study period were anxiety (in 201,303 posts or 12.2% of the total posts mentioning symptoms), generalized pain (189,673, 11.5%), weight loss (95,793, 5.8%), fatigue (91,252, 5.5%), and coughing (86,235, 5.2%). The 5 most discussed medical conditions were COVID-19 (in 5,420,276 posts or 66.4% of the total posts mentioning medical conditions), unspecified infectious disease (469,356, 5.8%), influenza (270,166, 3.3%), unspecified disorders of the central nervous system (253,407, 3.1%), and depression (151,752, 1.9%). Changes in posts in the frequency of anxiety, generalized pain, and weight loss were significant but negatively correlated with daily new COVID-19 cases in the United States (r=-0.49, r=-0.46, and r=-0.39, respectively; P Conclusions COVID-19 and symptoms of anxiety were the 2 most commonly discussed health-related topics on social media from June 14 to December 13, 2020. Real-time monitoring of social media posts on symptoms and medical conditions may help assess the population’s mental health status and enhance public health surveillance for infectious disease.

ImportanceRacial and ethnic disparities in delayed medical care for reasons that are not directly associated with the cost of care remain understudied.ObjectiveTo describe trends in racial and ethnic disparities in barriers to timely medical care among adults during a recent 20-year period.Design, Setting, and ParticipantsThis was a serial cross-sectional study of 590 603 noninstitutionalized adults in the US using data from the National Health Interview Survey from 1999 to 2018. Data analyses were performed from December 2021 through August 2022.ExposuresSelf-reported race, ethnicity, household income, and sex.Main Outcomes and MeasuresTemporal trends in disparities regarding 5 specific barriers to timely medical care: inability to get through by telephone, no appointment available soon enough, long waiting times, inconvenient office or clinic hours, and lack of transportation.ResultsThe study cohort comprised 590 603 adult respondents (mean [SE] age, 46.00 [0.07] years; 329 638 [51.9%] female; 27 447 [4.7%] Asian, 83 929 [11.8%] Black, 98 692 [13.8%] Hispanic/Latino, and 380 535 [69.7%] White). In 1999, the proportion of each race and ethnicity group reporting any of the 5 barriers to timely medical care was 7.3% among the Asian group; 6.9%, Black; 7.9%, Hispanic/Latino; and 7.0%, White (P > .05 for each difference compared with White individuals). From 1999 to 2018, this proportion increased across all 4 race and ethnicity groups (by 5.7, 8.0, 8.1, and 5.9 percentage points [pp] among Asian, Black, Hispanic/Latino, and White individuals, respectively; P P = .03 and P = .001, respectively). There was no significant difference in prevalence between Asian and White individuals. There was a significant increase in the difference in prevalence between Black individuals and White individuals who reported delaying care because of long waiting times at the clinic or medical office and because of a lack of transportation (1.5 pp and 1.8 pp; P = .03 and P = .01, respectively). In addition, the difference in prevalence between Hispanic/Latino and White individuals who reported delaying care because of long waiting times increased significantly (2.6 pp; P Conclusions and RelevanceThe findings of this serial cross-sectional study of data from the National Health Interview Survey suggest that barriers to timely medical care in the US increased for all population groups from 1999 to 2018, with associated increases in disparities among race and ethnicity groups. Interventions beyond those currently implemented are needed to improve access to medical care and to eliminate disparities among race and ethnicity groups.

ObjectivesWell-being is a holistic, positively framed conception of health, integrating physical, emotional, social, financial, community and spiritual aspects of life. High well-being is an intrinsically worthy goal for individuals, communities and nations. Multiple measures of well-being exist, yet we lack information to identify benchmarks, geographical disparities and targets for intervention to improve population life evaluation in the USA.DesignUsing data from the Gallup National Health and Well-Being Index, we conducted retrospective analyses of a series of cross-sectional samples.Setting/participantsWe summarised select well-being outcomes nationally for each year, and by county (n=599) over two time periods, 2008–2012 and 2013–2017.Main outcome measuresWe report percentages of people thriving, struggling and suffering using the Cantril Self-Anchoring Scale, percentages reporting high or low current life satisfaction, percentages reporting high or low future life optimism, and changes in these percentages over time.ResultsNationally, the percentage of people that report thriving increased from 48.9% in 2008 to 56.3% in 2017 (pConclusionsThe percentage of the US population thriving increased from 2008 to 2017 while the percentage suffering remained unchanged. Marked geographical variation exists indicating priority areas for intervention.

BACKGROUND Harnessing health-related data posted on social media in real time can offer insights into how the pandemic impacts the mental health and general well-being of individuals and populations over time. OBJECTIVE This study aimed to obtain information on symptoms and medical conditions self-reported by non-Twitter social media users during the COVID-19 pandemic, to determine how discussion of these symptoms and medical conditions changed over time, and to identify correlations between frequency of the top 5 commonly mentioned symptoms post and daily COVID-19 statistics (new cases, new deaths, new active cases, and new recovered cases) in the United States. METHODS We used natural language processing (NLP) algorithms to identify symptom- and medical condition–related topics being discussed on social media between June 14 and December 13, 2020. The sample posts were geotagged by NetBase, a third-party data provider. We calculated the positive predictive value and sensitivity to validate the classification of posts. We also assessed the frequency of health-related discussions on social media over time during the study period, and used Pearson correlation coefficients to identify statistically significant correlations between the frequency of the 5 most commonly mentioned symptoms and fluctuation of daily US COVID-19 statistics. RESULTS Within a total of 9,807,813 posts (nearly 70% were sourced from the United States), we identified a discussion of 120 symptom-related topics and 1542 medical condition–related topics. Our classification of the health-related posts had a positive predictive value of over 80% and an average classification rate of 92% sensitivity. The 5 most commonly mentioned symptoms on social media during the study period were anxiety (in 201,303 posts or 12.2% of the total posts mentioning symptoms), generalized pain (189,673, 11.5%), weight loss (95,793, 5.8%), fatigue (91,252, 5.5%), and coughing (86,235, 5.2%). The 5 most discussed medical conditions were COVID-19 (in 5,420,276 posts or 66.4% of the total posts mentioning medical conditions), unspecified infectious disease (469,356, 5.8%), influenza (270,166, 3.3%), unspecified disorders of the central nervous system (253,407, 3.1%), and depression (151,752, 1.9%). Changes in posts in the frequency of anxiety, generalized pain, and weight loss were significant but negatively correlated with daily new COVID-19 cases in the United States (r=-0.49, r=-0.46, and r=-0.39, respectively; PP CONCLUSIONS COVID-19 and symptoms of anxiety were the 2 most commonly discussed health-related topics on social media from June 14 to December 13, 2020. Real-time monitoring of social media posts on symptoms and medical conditions may help assess the population’s mental health status and enhance public health surveillance for infectious disease.

BACKGROUND COVID-19 has continued to spread in the United States and globally. Closely monitoring public engagement and perceptions of COVID-19 and preventive measures using social media data could provide important information for understanding the progress of current interventions and planning future programs. OBJECTIVE The aim of this study is to measure the public’s behaviors and perceptions regarding COVID-19 and its effects on daily life during 5 months of the pandemic. METHODS Natural language processing (NLP) algorithms were used to identify COVID-19–related and unrelated topics in over 300 million online data sources from June 15 to November 15, 2020. Posts in the sample were geotagged by NetBase, a third-party data provider, and sensitivity and positive predictive value were both calculated to validate the classification of posts. Each post may have included discussion of multiple topics. The prevalence of discussion regarding these topics was measured over this time period and compared to daily case rates in the United States. RESULTS The final sample size included 9,065,733 posts, 70% of which were sourced from the United States. In October and November, discussion including mentions of COVID-19 and related health behaviors did not increase as it had from June to September, despite an increase in COVID-19 daily cases in the United States beginning in October. Additionally, discussion was more focused on daily life topics (n=6,210,255, 69%), compared with COVID-19 in general (n=3,390,139, 37%) and COVID-19 public health measures (n=1,836,200, 20%). CONCLUSIONS There was a decline in COVID-19–related social media discussion sourced mainly from the United States, even as COVID-19 cases in the United States increased to the highest rate since the beginning of the pandemic. Targeted public health messaging may be needed to ensure engagement in public health prevention measures as global vaccination efforts continue.

Historically marginalized racial and ethnic groups are generally more likely to experience sleep deficiencies. It is unclear how these sleep duration disparities have changed during recent years.To evaluate 15-year trends in racial and ethnic differences in self-reported sleep duration among adults in the US.This serial cross-sectional study used US population-based National Health Interview Survey data collected from 2004 to 2018. A total of 429 195 noninstitutionalized adults were included in the analysis, which was performed from July 26, 2021, to February 10, 2022.Self-reported race, ethnicity, household income, and sex.Temporal trends and racial and ethnic differences in short (7 hours in 24 hours) and long (9 hours in 24 hours) sleep duration and racial and ethnic differences in the association between sleep duration and age.The study sample consisted of 429 195 individuals (median [IQR] age, 46 [31-60] years; 51.7% women), of whom 5.1% identified as Asian, 11.8% identified as Black, 14.7% identified as Hispanic or Latino, and 68.5% identified as White. In 2004, the adjusted estimated prevalence of short and long sleep duration were 31.4% and 2.5%, respectively, among Asian individuals; 35.3% and 6.4%, respectively, among Black individuals; 27.0% and 4.6%, respectively, among Hispanic or Latino individuals; and 27.8% and 3.5%, respectively, among White individuals. During the study period, there was a significant increase in short sleep prevalence among Black (6.39 [95% CI, 3.32-9.46] percentage points), Hispanic or Latino (6.61 [95% CI, 4.03-9.20] percentage points), and White (3.22 [95% CI, 2.06-4.38] percentage points) individuals (P .001 for each), whereas prevalence of long sleep changed significantly only among Hispanic or Latino individuals (-1.42 [95% CI, -2.52 to -0.32] percentage points; P = .01). In 2018, compared with White individuals, short sleep prevalence among Black and Hispanic or Latino individuals was higher by 10.68 (95% CI, 8.12-13.24; P .001) and 2.44 (95% CI, 0.23-4.65; P = .03) percentage points, respectively, and long sleep prevalence was higher only among Black individuals (1.44 [95% CI, 0.39-2.48] percentage points; P = .007). The short sleep disparities were greatest among women and among those with middle or high household income. In addition, across age groups, Black individuals had a higher short and long sleep duration prevalence compared with White individuals of the same age.The findings of this cross-sectional study suggest that from 2004 to 2018, the prevalence of short and long sleep duration was persistently higher among Black individuals in the US. The disparities in short sleep duration appear to be highest among women, individuals who had middle or high income, and young or middle-aged adults, which may be associated with health disparities.

ImportanceThirty-five years ago, the Heckler Report described health disparities among minority populations in the US. Since then, policies have been implemented to address these disparities. However, a recent evaluation of progress towards improving the health and health equity among US adults is lacking.ObjectivesTo evaluate racial/ethnic disparities in the physical and mental health of US adults over the last 2 decades.DesignCross-sectional.SettingNational Health Interview Survey data, years 1999–2018.ParticipantsAdults aged 18–85 years.ExposureRace/ethnicity subgroups (non-Hispanic White, non-Hispanic Black, non-Hispanic Asian, Hispanic).Main outcome and measuresProportion of adults reporting poor/fair health status, severe psychological distress, functional limitation, and insufficient sleep. We also estimated the gap between non-Hispanic White and the other subgroups for these four outcomes.ResultsWe included 596,355 adults (mean age 46 years, 51.8% women), of which 69.7%, 13.8%, 11.8% and 4.7% identified as non-Hispanic White, Hispanic, non-Hispanic Black, and non-Hispanic Asian, respectively. Between 1999 and 2018, Black individuals fared worse on most measures of health, with 18.7% (95% CI 17.1–20.4) and 41.1% (95% CI 38.7–43.5) reporting poor/fair health and insufficient sleep in 2018 compared with 11.1% (95% CI 10.5– 11.7) and 31.2% (95% CI 30.3–32.1) among White individuals. Notably, between 1999–2018, there was no significant decrease in the gap in poor/fair health status between White individuals and Black (−0.07% per year, 95% CI −0.16–0.01) and Hispanic (−0.03% per year, 95% CI −0.07– 0.02) individuals, and an increase in the gap in sleep between White individuals and Black (+0.2% per year, 95% CI 0.1–0.4) and Hispanic (+0.3% per year, 95% CI 0.1–0.4) individuals. Additionally, there was no significant decrease in adults reporting poor/fair health status and an increase in adults reporting severe psychological distress, functional limitation, and insufficient sleep.Conclusions and RelevanceThe marked racial/ethnic disparities in health of US adults have not improved over the last 20 years. Moreover, the self-perceived health of US adults worsened during this time. These findings highlight the need to re-examine the initiatives seeking to promote health equity and improve health.

ImportanceRacial and ethnic disparities plague the US health care system despite efforts to eliminate them. To understand what has been achieved amid these efforts, a comprehensive study from the population perspective is needed.ObjectivesTo determine trends in rates and racial/ethnic disparities of key access to care measures among adults in the US in the last two decades.DesignCross-sectional.SettingData from the National Health Interview Survey, 1999–2018.ParticipantsIndividuals >18 years old.ExposureRace and ethnicity: non-Hispanic Black, non-Hispanic Asian, non-Hispanic White, Hispanic.Main outcome and measuresRates of lack of insurance coverage, lack of a usual source of care, and foregone/delayed medical care due to cost. We also estimated the gap between non-Hispanic White and the other subgroups for these outcomes.ResultsWe included 596,355 adults, of which 69.7% identified as White, 11.8% as Black, 4.7% as Asian, and 13.8% as Hispanic. The proportion uninsured and the rates of lacking a usual source of care remained stable across all 4 race/ethnicity subgroups up to 2009, while rates of foregone/delayed medical care due to cost increased. Between 2010 and 2015, the percentage of uninsured diminished for all, with the steepest reduction among Hispanics (−2.1% per year). In the same period, rates of no usual source of care declined only among Hispanics (−1.2% per year) while rates of foregone/delayed medical care due to cost decreased for all. No substantial changes were observed from 2016–2018 in any outcome across subgroups. Compared with 1999, in 2018 the rates of foregone/delayed medical care due to cost were higher for all (+3.1% among Whites, +3.1% among Blacks, +0.5% among Asians, and +2.2% among Hispanics) without significant change in gaps; rates of no usual source of care were not significantly different among Whites or Blacks but were lower among Hispanics (−4.9%) and Asians (−6.4%).Conclusions and RelevanceInsurance coverage increased for all, but millions of individuals remained uninsured or underinsured with increasing rates of unmet medical needs due to cost. Those identifying as non-Hispanic Black and Hispanic continue to experience more barriers to health care services compared with non-Hispanic White individuals.KEY POINTSQuestionIn the last 2 decades, what has been achieved in reducing barriers to access to care and race/ethnicity-associated disparities?FindingsUsing National Health Interview Survey data from 1999–2018, we found that insurance coverage increased across all 4 major race/ethnicity groups. However, rates of unmet medical needs due to cost increased without reducing the respective racial/ethnic disparities, and little-to-no change occurred in rates of individuals who have no usual source of care.MeaningDespite increased coverage, millions of Americans continued to experience barriers to access to care, which were disproportionately more prevalent among those identifying as Black or Hispanic.

Women physicians must balance implicit social expectations to be nice, caretaking, and other-focused while carrying out the requisites of being a competent clinician, researcher, educator, and/or administrative leader. Considered “second-generation gender bias,” these cultural assumptions are not intentional or overt. However, they impact how women are evaluated, promoted, and therefore compensated in the healthcare workplace. The effects of gender-based differences in performance assessments, specialty choice, burden of domestic responsibilities, penalties for childbearing and negotiation, allocation of professional resources, sponsorship, and clinical productivity and patient satisfaction measures are cumulative across a woman’s career in medicine, resulting in inequities in advancement and compensation.

ObjectiveTo identify county characteristics associated with high versus low well-being among high-poverty counties.DesignObservational cross-sectional study at the county level to investigate the associations of 29 county characteristics with the odds of a high-poverty county reporting population well-being in the top quintile versus the bottom quintile of well-being in the USA. County characteristics representing key determinants of health were drawn from the Robert Wood Johnson Foundation County Health Rankings and Roadmaps population health model.SettingCounties in the USA that are in the highest quartile of poverty rate.Main outcome measureGallup-Sharecare Well-being Index, a comprehensive population-level measure of physical, mental and social health. Counties were classified as having a well-being index score in the top or bottom 20% of all counties in the USA.ResultsAmong 770 high-poverty counties, 72 were categorised as having high well-being and 311 as having low well-being. The high-well-being counties had a mean well-being score of 71.8 with a SD of 2.3, while the low-well-being counties had a mean well-being score of 60.2 with a SD of 2.8. Among the six domains of well-being, basic access, which includes access to housing and healthcare, and life evaluation, which includes life satisfaction and optimism, differed the most between high-being and low-well-being counties. Among 29 county characteristics tested, six were independently and significantly associated with high well-being (pConclusionsAmong 770 high-poverty counties, approximately 9% outperformed expectations, reporting a collective well-being score in the top 20% of all counties in the USA. High-poverty counties reporting high well-being differed from high-poverty counties reporting low well-being in several characteristics.

Introduction: Optimism is consistently associated with better cardiovascular health but underlying mechanisms are poorly understood. This study examines prospective links between optimism and lipids in adulthood, and tests possible effect modification by social factors. Hypothesis: Greater optimism will predict healthier lipid profiles. Methods: Participants were 3,016 adults (mean age=40.2) recruited in 1985-6 from the Coronary Artery Risk Development in Young Adults Study. Optimism was measured in year 15 using the 6-item Life Orientation Test-Revised. Log-transformed triglyceride levels (TG) and total cholesterol to high-density lipoprotein cholesterol ratio (TC/HDL-C) were assessed from blood samples in years 15, 20, 25, and 30. Linear mixed models evaluated relationships between optimism and lipids controlling for relevant covariates. Stratified analyses tested associations by gender, race/ethnicity, and income. Results: On average, TG increased over time while TC/HDL-C decreased. Figure 1 shows unadjusted differences in mean lipid levels by optimism tertiles. In fully-adjusted models, higher optimism was associated with lower TG averaged over the follow-up (β=-0.028; 95% CI: -0.047, -0.010); a similar trend (though non-significant) was observed with TC/HDL-C (β=-0.024; 95% CI: -0.066, 0.018). In stratified analyses, optimism was more strongly associated with lower TG among women (vs. men), but no differences were noted by race/ethnicity or income. Associations with TC/HDL-C were stronger for women (vs. men) and white (vs. black) participants. Optimism was not related to increases in TG over time, but was associated with a slightly faster decline in TC/HDL-C (time interaction β=0.003; 95% CI: 0.001, 0.006). Declines in TC/HDL-C also varied by sex and race/ethnicity. Conclusion: Optimism contributes to lower lipid levels in adulthood, but associations vary by social status. The relationship between optimism and lipids may underlie previously noted associations with cardiovascular health.

Objectives. To assess causes of premature death and whether race/ethnicity or education is more strongly and independently associated with premature mortality in a diverse sample of middle-aged adults in the United States. Methods. The Coronary Artery Risk Development in Young Adults study (CARDIA) is a longitudinal cohort study of 5114 participants recruited in 1985 to 1986 and followed for up to 29 years, with rigorous ascertainment of all deaths; recruitment was balanced regarding sex, Black and White race/ethnicity, education level (high school or less vs. greater than high school), and age group (18–24 and 25–30 years). This analysis included all 349 deaths that had been fully reviewed through month 348. Our primary outcome was years of potential life lost (YPLL). Results. The age-adjusted mortality rate per 1000 persons was 45.17 among Black men, 25.20 among White men, 17.63 among Black women, and 10.10 among White women. Homicide and AIDS were associated with the most YPLL, but cancer and cardiovascular disease were the most common causes of death. In multivariable models, each level of education achieved was associated with 1.37 fewer YPLL (P = .007); race/ethnicity was not independently associated with YPLL. Conclusions. Lower education level was an independent predictor of greater YPLL.

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Objectives. To assess the association between exposure to the US criminal legal system and well-being. Methods. We used data from the 2018 Family History of Incarceration Survey, a nationally representative cross-sectional study of family incarceration experience (n = 2815), which includes measures of participants’ own criminal legal system exposure, including police stops, arrests, and incarceration. We measured well-being across 5 domains—physical, mental, social, spiritual, and overall life evaluation—and analyzed trends in well-being by criminal legal system exposure using logistic regression. Results. Exposure to police stops, arrests, and incarceration were each associated with lower well-being in every domain compared with those not exposed. Longer durations of incarceration and multiple incarcerations were associated with progressively lower well-being. Those who were stopped and frisked by the police had low well-being similar to that of those who had been incarcerated multiple times. Conclusions. Any exposure to police contact or incarceration is associated with lower well-being in every domain. More involved exposure is associated with even lower well-being. Public Health Implications. Jail diversion and broader criminal justice reform may improve population-level well-being by reducing police contact and incarceration.

Chronic stress is a risk factor for incident cardiovascular disease. Emotion regulation is the ability to modulate one’s state or behavior in response to a given situation or stressor, and may mitigate the effect of chronic stress on cardiovascular disease (CV) risk. Data from a cohort of 754 community-dwelling young to middle-aged adults who were assessed between 2007–12 on stress, emotion regulation and CV risk measures were used to test the hypothesis that emotion regulation mitigates the effect of chronic stress on CV risk. Emotion regulation was measured using the Difficulties in Emotion Regulation Scale (DERS). We created a composite stress score using data from the Cumulative Adversity Interview and the Perceived Stress Scale. Our outcomes included blood pressure, body mass index, and insulin resistance separately and combined into a composite CV risk score. Covariates included age, sex, race, years of education, and smoking status. We used multivariable logistic regression to evaluate associations between stress measures and CV risk among participants and the impact of emotion regulation (DERS scores) on this association. We found that composite stress interacted significantly with the DERS score to affect CV risk (p=0.007). A median split of the DERS scores indicated that CV risk was associated with the composite stress score in the fully adjusted model (ß=0.206; p=0.005) among participants with low emotion regulation, but not among those with high emotion regulation (ß=0.048; p=0.59). Chronic stress was associated with CV risk only among participants with poor emotion regulation. Emotion regulation is a teachable skill, and may play a role in preventing CV disease.

Key Points Question What factors are associated with facilitating and obstructing COVID-19 vaccine acceptance and access among Black and Latinx communities? Findings This qualitative study of 72 participants who identified as Black and/or Latinx identified 3 themes to understanding factors associated with facilitating or obstructing COVID-19 vaccination: pervasive mistreatment of Black and Latinx communities and associated distrust; informing trust via trusted messengers and messages, choice, social support, and diversity; and addressing structural barriers to vaccination access. Meaning These findings suggest that community-informed insights may inform health care strategies to maximize vaccine acceptance and access in communities hardest hit by the COVID-19 pandemic., This qualitative study examines factors associated with facilitating and obstructing COVID-19 vaccine access and acceptance among Black and Latinx communities., Importance Black and Latinx communities have faced disproportionate harm from the COVID-19 pandemic. Increasing COVID-19 vaccine acceptance and access has the potential to mitigate mortality and morbidity from COVID-19 for all communities, including those most impacted by the pandemic. Objective To investigate and understand factors associated with facilitating and obstructing COVID-19 vaccine access and acceptance among Black and Latinx communities. Design, Setting, and Participants This community-partnered qualitative study conducted semistructured, in-depth focus groups with Black and Latinx participants from March 17 to March 29, 2021, using a secure video conferencing platform. Participants were recruited through emails from local community-based organizations, federally qualified health centers, social service agencies, the New Haven, Connecticut, Health Department, and in-person distribution of study information from community health workers. A total of 8 focus groups were conducted, including 4 in Spanish and 4 in English, with 72 participants from a diverse range of community roles, including teachers, custodial service workers, and health care employees, in New Haven, Connecticut. Data were analyzed from March 17 to July 30, 2021. Main Outcomes and Measures Interviews were audio-recorded, transcribed, translated, and analyzed using an inductive content analysis approach. Themes and subthemes were identified on the acceptability and accessibility of the COVID-19 vaccine among participants who identified as Black and/or Latinx. Results Among 72 participants, 36 (50%) identified as Black, 28 (39%) as Latinx, and 8 (11%) as Black and Latinx and 56 (78%) identified as women and 16 (22%) identified as men. Participants described 3 major themes that may represent facilitators and barriers to COVID-19 vaccinations: pervasive mistreatment of Black and Latinx communities and associated distrust; informing trust via trusted messengers and messages, choice, social support, and diversity; and addressing structural barriers to vaccination access. Conclusions and Relevance The findings of this qualitative study may impact what health care systems, public health officials, policy makers, health care practitioners, and community leaders can do to facilitate equitable uptake of the COVID-19 vaccine. Community-informed insights are imperative to facilitating COVID-19 vaccine access and acceptance among communities hardest hit by the pandemic. Preventing the further widening of inequities and addressing structural barriers to vaccination access are vital to protecting all communities, especially Black and Latinx individuals who have experienced disproportionate death and loss from COVID-19.

Importance The elimination of racial and ethnic differences in health status and health care access is a US goal, but it is unclear whether the country has made progress over the last 2 decades. Objective To determine 20-year trends in the racial and ethnic differences in self-reported measures of health status and health care access and affordability among adults in the US. Design, Setting, and Participants Serial cross-sectional study of National Health Interview Survey data, 1999-2018, that included 596 355 adults. Exposures Self-reported race, ethnicity, and income level. Main Outcomes and Measures Rates and racial and ethnic differences in self-reported health status and health care access and affordability. Results The study included 596 355 adults (mean [SE] age, 46.2 [0.07] years, 51.8% [SE, 0.10] women), of whom 4.7% were Asian, 11.8% were Black, 13.8% were Latino/Hispanic, and 69.7% were White. The estimated percentages of people with low income were 28.2%, 46.1%, 51.5%, and 23.9% among Asian, Black, Latino/Hispanic, and White individuals, respectively. Black individuals with low income had the highest estimated prevalence of poor or fair health status (29.1% [95% CI, 26.5%-31.7%] in 1999 and 24.9% [95% CI, 21.8%-28.3%] in 2018), while White individuals with middle and high income had the lowest (6.4% [95% CI, 5.9%-6.8%] in 1999 and 6.3% [95% CI, 5.8%-6.7%] in 2018). Black individuals had a significantly higher estimated prevalence of poor or fair health status than White individuals in 1999, regardless of income strata (P

We previously defined teaching domains necessary for successful inpatient medicine attending rounds from the trainees' perspective in Role Modeling, Learning Environment, Teaching Process and Team Management. We sought to understand whether trainee characteristics and daily fluctuations in workload influence the prioritization of these domains. We conducted a prospective observational study in general medicine inpatient wards at a university, Veterans Affairs, and a county hospital affiliated with one academic institution over the course of 6 months. All student and resident trainees on internal medicine inpatient wards were eligible to participate. We designed a daily assessment tool on which trainees were asked to identify the teaching domain most important to them, along with information on sex, training level, call-cycle day, patient census, and number of team members absent during rounds. We examined associations between training level and workload factors with the prioritized teaching domain using Pearson's chi-square analysis, adjusted for clustering effects. We collected 1,378 daily assessment cards evaluating 53 (91%) attending physicians. Students valued Teaching Process (𝑃 < 0.001), while senior residents sought Team Management (𝑃 < 0.001). On most days, Teaching Process was prioritized (𝑃 = 0.005). On post-call days and days with a high patient census, Team Management was prioritized (𝑃 < 0.001). Attending physicians may consider tailoring rounds in response to work-related pressures. Days with a high workload are better suited for demonstrating efficient and effective patient care skills.