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The "Personhood" of Patients -- The Patient-Physician Relationship -- Developing Solutions to Health Care Disparities -- The Center for Health Equity -- From Research to Practice and Policy -- A Global Perspective on Health Equity -- Health Equity in the Era of Covid.

During August 30-31, 2017, the National Heart, Lung, and Blood Institute's Center for Translation Research and Implementa­tion Science (CTRIS) hosted a two-day workshop with thought leaders and experts in the fields of implementation science, pre­vention science, health inequities research, and training and research workforce devel­opment. The workshop addressed critical challenges and compelling questions from the NHLBI Strategic Vision, as well as the Department of Health and Human Services' Action Plan to Reduce Racial and Ethnic Health Disparities. Participants discussed: best practices for designing and executing implementation research training programs; approaches to increase participation in implementation research to address health inequities; innovative training methods and models, including team science approaches; and best practices for developing and sustaining a cadre of mentors for individuals who conduct implementation research.As part of this workshop, the Saunders-Wat­kins Memorial Lecture, named posthumous­ly for Dr. Elijah Saunders, a Baltimore car­diologist, and Dr. Levi Watkins, a Baltimore cardiothoracic surgeon, was established. Both men dedicated their lives to patient care, teaching, research, and community service. The lecture honors them for their pioneering efforts to advance health equity for medically underserved communities in the United States and around the globe, at a time when it was neither popular nor safe to do so. The lecture is also designed to stimulate a future generation of research­ers committed to advancing health equity research and the elimination of health iniq­uities. The inaugural lecture was delivered by Lisa A. Cooper, MD, MPH, Bloomberg Distinguished Professor and James F. Fries Professor of Medicine at Johns Hopkins Uni­versity, and inaugural recipient of the Ameri­can Heart Association's Watkins-Saunders Award, which recognizes excellence in clini­cal, medical, and community work focused on diminishing health care disparities in Maryland. This article captures the essence of that lecture. Ethn Dis. 2018;28(4):579-585; doi:10.18865/ed.28.4.579.

This paper provides an overview of the scientific evidence pointing to critically needed steps to reduce racial inequities in health. First, it argues that communities of opportunity should be developed to minimize some of the adverse impacts of systemic racism. These are communities that provide early childhood development resources, implement policies to reduce childhood poverty, provide work and income support opportunities for adults, and ensure healthy housing and neighborhood conditions. Second, the healthcare system needs new emphases on ensuring access to high quality care for all, strengthening preventive health care approaches, addressing patients' social needs as part of healthcare delivery, and diversifying the healthcare work force to more closely reflect the demographic composition of the patient population. Finally, new research is needed to identify the optimal strategies to build political will and support to address social inequities in health. This will include initiatives to raise awareness levels of the pervasiveness of inequities in health, build empathy and support for addressing inequities, enhance the capacity of individuals and communities to actively participate in intervention efforts and implement large scale efforts to reduce racial prejudice, ideologies, and stereotypes in the larger culture that undergird policy preferences that initiate and sustain inequities.

Purpose: Few family-oriented cardiovas­cular risk reduction interventions exist that leverage the home environment to produce health behavior change among multiple family members. We identified opportu­nities to adapt disease self-management interventions included in a blood pressure control comparative effectiveness trial for hypertensive African American adults to ad­dress family-level factors.Methods: We conducted and analyzed semi-structured interviews with five inter­vention study staff (all study intervention­ists and the study coordinator) between December 2016 and January 2017 and with 11 study participants between Septem­ber and November 2015.1 All study staff involved with intervention delivery and co­ordination were interviewed. We sampled adult participants from the parent study, and we analyzed interviews that were originally obtained as part of a previous study based on their status as a caregiver of an adoles­cent family member.1Results: Thematic analysis identified family influences on disease management and the importance of relationships between index patients and family members, between in­dex patients and study peers, and between index patients and study staff through study participation to understand social effects on healthy behaviors. We identified four themes: 1) the role of family in health behavior change; 2) the impact of family dynamics on health behaviors; 3) building peer relationships through intervention par­ticipation; and 4) study staff role conflict.Conclusions: These findings inform development of family-oriented interven­tions to improve health behaviors among African American index patients at high risk for cardiovascular disease and their family members.Ethn Dis. 2019;29(4):549-558; doi:10.18865/ed.29.4.549

OBJECTIVES: Walking is older adults' second most preferred mode of transport and preferred recreational activity. This leads to greater exposure to traffic, increasing their risk of pedestrian-vehicle crashes, with older adults being more likely to die as a pedestrian when compared to other modes of transport. However, less focus has been placed on this particularly vulnerable group. This review summarises issues associated with older adult pedestrian and motorised mobility scooters (MMS) safety and interventions that have been conducted. METHODS: A literature search was undertaken from Pub Med, MUARC publications, Curtin University Library Catalogue and Google Scholar. Keywords included older pedestrians, older adult road injury, mobility scooter injury, and injury prevention. Publications from 2000 onwards were used, unless an earlier publication had significant relevance and worth. CONCLUSION: Maintaining older adults' mobility and independence during a time of decreasing physical and mental capacity is a priority. Walking provides a key mode of transport that needs to be given higher priority within the road environment by policy makers, transport planners and drivers. Therefore governments need to consider appropriate and comprehensive urban planning and road safety policies that accommodate 'active ageing' to provide pedestrians and MMS users with environments that facilitate active living and safe transport. In addition there is a need for community programs that raise awareness about safe road crossing for this growing vulnerable age group.

Abstract
Objective
Evidence suggests that racial discrimination causes stress among non-Hispanic Black women, and some Black women may cope with exposure to vicarious racial discrimination by engaging in maladaptive eating behaviors.

Methods
We examined eating behaviors among Black women (N = 254) before and after Freddie Gray's death while in police custody. Maladaptive eating behaviors were assessed using the three-factor eating questionnaire. Our independent variables included the following: (1) time period and (2) geographic proximity to the event. Three two-way analysis of covariance tests were conducted to assess potential effects of geographic proximity (close, distant), time period in relation to unrest (before, after unrest), and their interaction on emotional eating, uncontrolled eating, and cognitive restraint controlling for participant age.

Results
There was a statistically significant main effect of proximity to the unrest on emotional eating, F (1, 252) = 5.64, p = .018, and partial η2 = .022 such that women living in close geographic proximity to the unrest reported higher mean levels of emotional eating as compared to those living more distant to the unrest. There was also a borderline statistically significant interaction between geographic proximity and time period on cognitive restraint, F (1, 252) = 3.89, p = .050, and partial η2 = .015.

Conclusion
Our study found a relationship between vicarious racial discrimination and maladaptive eating behaviors among Black women. Future work should examine stress related to vicarious racial discrimination and maladaptive eating behaviors longitudinally.

Objective: Community health worker (CHW) interventions have been cited as a best practice for reducing health disparities, but patient-level attributes may contribute to differential uptake. We examined patient characteristics associated with the extent of exposure to a CHW coaching interven­tion among a predominantly low-income, African American population participating in a randomized controlled trial of hyperten­sion interventions.Design: We conducted a within-group longitudinal analysis of those receiving a CHW intervention from a study conducted between September 2003 and August 2005. We employed mixed effects models to ascertain relationships between patients' characteristics, length of time spent with the CHW, and the number of topics discussed during the intervention.Setting: Baltimore, MDParticipants: 140 patients with a diagnosis of hypertension in the CHW intervention arm.Results: Marital status, stress, depression symptomology, and having multiple comor­bid conditions were each independently and positively related to the length of time patients spent with CHWs. An indirect rela­tionship between higher perceived physical health and time spent with the CHW was observed. Patients with multiple comorbid conditions discussed more intervention-related topics, while patients who perceived themselves as being healthier discussed fewer topics. Marital status and extreme poverty were the strongest predictors of the length of time spent with the CHW, while having multiple comorbid conditions was the strongest predictor of the number of coaching topics discussed.Conclusions: Differential exposure to a CHW intervention is influenced by patients' physical, psychosocial, and sociodemographic characteristics. Ethn Dis. 2019;29(2):261-266; doi:10.18865/ ed.29.2.261

Background: Uncontrolled hypertension is a significant risk factor for cardiovascu­lar morbidity and mortality. In the United States, many patients remain uncontrolled, in part, due to poor medication adherence. Efforts to improve hypertension control include not only attending to medical management of the disease but also the social determinants of health, which impact medication adherence, and ultimately blood pressure control.Purpose: To determine which social deter­minants – health care access or community and social stressors - explain medication adherence.Methods: In this cross-sectional analysis, we used baseline data (N=1820, col­lected August 2017 to October 2019) from a pragmatic trial, which compares the effectiveness of a multi-level intervention including collaborative care and a stepped approach with enhanced standard of care for improving blood pressure. We used logistic regression analyses to examine the association between patient experiences of care and community and social stressors with medication adherence.Results: The participants represented a diverse sample: mean age of 60 years; 59% female; 57.3% Black, 9.6% Hispanic, and 33.2% White. All participants had a blood pressure reading ≥140/90 mm Hg (mean blood pressure – 152/85 mm Hg). Half of the participants reported some level of non-adherence to medication. Regression analy­sis showed that, compared with Whites, Blacks (AOR .47; 95% CIs: .37-.60, P<.001) and Hispanics (AOR .48; 95% CIs: .32- .73, P<.001) were less likely to report medica­tion adherence. Also part-time workers (AOR .57; 95% CIs: .38-.86, P<.05), and those who reported greater perceived stress (AOR .94; 95% CIs: .91 – .98, P<.001) and everyday discrimination (AOR .73; 95% CIs: .59 – .89; P<.001) had lower odds of medication adherence. Among Blacks, greater perceived stress (AOR .93; 95% CIs: .88-.98, P<.001) and everyday discrimina­tion (AOR .63; 95% CIs: .49 - .82, P<.005) were negatively associated with medication adherence. Among Hispanics, greater report of everyday discrimination (AOR .36; 95% CIs: .14 – .89, P<.005) was associated with lower odds of medication adherence. Among Whites, the negative effect of per­ceived stress on medication adherence was attenuated by emotional support.Conclusions: Using the social determinants of health framework, we identified associa­tions between stress, everyday discrimina­tion and medication adherence among non-Hispanic Blacks and Hispanics that were independent of health status and other social determinants. Programs to enhance self-management for African American and Hispanic patients with uncontrolled blood pressure should include a specific focus on addressing social stressors.Ethn Dis. 2021;31(1):97-108; doi:10.18865/ ed.31.1.97

Little is known about how patient and primary care physician characteristics are associated with quality of depression care. The authors conducted structured interviews of 404 randomly selected primary care physicians after their interaction with CD-ROM vignettes of actors portraying depressed patients. Vignettes varied along the dimensions of medical comorbidity, attributions regarding the cause of depression, style, race/ethnicity, and gender. Results show that physicians showed wide variation in treatment decisions; for example, most did not inquire about suicidal ideation, and most did not state that they would inform the patient that there can be a delay before an antidepressant is therapeutic. Several physician characteristics were significantly associated with management decisions. Notably, physician age was inversely correlated with a number of quality-of-care measures. In conclusion, quality of care varies among primary care physicians and appears to be associated with physician characteristics to a greater extent than patient characteristics.

As part of a pragmatic trial to reduce hypertension disparities, we conducted a baseline organizational assessment to identify aspects of organizational functioning that could affect the success of our interventions. Through qualitative interviewing and the administration of two surveys, we gathered data about health care personnel's perceptions of their organization's orientations toward quality, patient centeredness, and cultural competency. We found that personnel perceived strong orientations toward quality and patient centeredness. The prevalence of these attitudes was significantly higher for these areas than for cultural competency and varied by occupational role and race. Larger percentages of survey respondents perceived barriers to addressing disparities than barriers to improving safety and quality. Health care managers and policy makers should consider how we have built strong quality orientations and apply those lessons to cultural competency.

Background: African Americans and other persons of African descent in the United States are disproportionately affected by cardiovascular diseases (CVD). Discrimi­nation is associated with higher CVD risk among US adults; however, this relationship is unknown among African immigrants.Objective: To examine the associations among discrimination, resilience, and CVD risk in African immigrants.Methods: The African Immigrant Health Study was a cross-sectional study of African immigrants in Baltimore-Washington, DC, with recruitment and data collection taking place between June 2017 and April 2019. The main outcome was elevated CVD risk, the presence of ≥3 CVD risk factors includ­ing hypertension, diabetes, high choles­terol, overweight/obesity, tobacco use, and poor diet. The secondary outcomes were these six individual CVD risk factors. The exposure was discrimination measured with the Everyday Discrimination Scale; summed scores ≥2 on each item indicated frequent experiences of discrimination. Resilience was assessed with the 10-item Connor- Davidson resilience scale. Logistic regression was used to examine the odds of elevated CVD risk, adjusting for relevant covariates.Results: We included 342 participants; 61% were females. The mean (±SD) age was 47(±11) years, 61% had at least a bachelor's degree, 18% had an income <$40,000, and 49% had lived in the US ≥15 years. Persons with frequent experi­ences of discrimination were 1.82 times (95%CI: 1.04–3.21) more likely to have elevated CVD risk than those with fewer experiences. Resilience did not moderate the relationship between CVD risk and discrimination.Conclusion: African immigrants with frequent experiences of discrimination were more likely to have elevated CVD risk. Tar­geted and culturally appropriate interven­tions are needed to reduce the high burden of CVD risk in this population. Health care providers should be aware of discrimina­tion as a meaningful social determinant of CVD risk. At the societal level, policies and laws are needed to reduce the occurrence of discrimination among African immi­grants and racial/ethnic minorities. Ethn Dis. 2020;30(4):651-660;doi:10.18865/ed.30.4.651

Objectives: The use of collaborative care teams, comprising nurse care managers and community health workers, has emerged as a promising strategy to tackle hyperten­sion disparities by addressing patients' social determinants of health. We sought to identify which social determinants of health are associated with a patient's likelihood of engaging with collaborative care team members and with the nurse care manager's likelihood of enlisting community health workers (CHW) to provide additional sup­port to patients.Methods: We conducted a within-group longitudinal analysis of patients assigned to receive a collaborative care intervention in a pragmatic, cluster randomized trial that aims to reduce disparities in hypertension control (N=888). Generalized estimating equations were used to identify which social deter­minants of health, reported on the study's baseline survey, were associated with the odds of patients engaging with the col­laborative care intervention, and of nurses deploying community health workers.Results: Patients who were unable to work and those with higher health literacy were less likely to engage with the collaborative care team than those who were employed full time or had lower health literacy, respectively. Patients had a greater likeli­hood of being referred to a community health worker by their care manager if they reported higher health literacy, perceived stress, or food insecurity, while those report­ing higher numeracy had lower odds of receiving a CHW referral.Implications/Conclusions: A patient's social determinants of health influence the extent of engagement in a collaborative care intervention and nurse care manager appraisals of the need for supplementary support provided by community health workers.Ethn Dis. 2021;31(1):47-56; doi:10.18865/ed.31.1.47