Faculty Bibliography

OBJECTIVES/OBJECTIVE:Despite the potential importance of the neighborhood social environment for cognitive health, the connection between neighborhood characteristics and dementia remains unclear. This study investigated the association between the prospective risk of dementia and three distinct aspects of neighborhood social environment: socioeconomic deprivation, disorder, and social cohesion. We also examined whether objective and subjective aspects of individual-level social isolation may function as mediators. METHODS:Leveraging data from the Health and Retirement Study (2006-2018; N = 9,251), we used Cox proportional hazards models to examine the association between time-to-dementia incidence and each neighborhood characteristic, adjusting for covariates and the propensity to self-select into disadvantaged neighborhoods. We used inverse odds weighting to decompose significant total effects of neighborhood characteristics into mediational effects of objective and subjective social isolation. RESULTS:The risk of dementia was associated with deprivation and disorder but not low cohesion. In deprived neighborhoods, individuals had an 18% increased risk of developing dementia (cause-specific hazard ratio [CHR] = 1.18, 95% CI: 1.02 to 1.38), and those in disordered areas had a 27% higher risk (CHR = 1.27, 95% CI: 1.03 to 1.59). 20% of the disorder's effects were mediated by subjective social isolation, while the mediational effects of objective isolation were nonsignificant. Deprivation's total effects were not partitioned into mediational effects given its nonsignificant associations with the mediators. DISCUSSION/CONCLUSIONS:Neighborhood deprivation and disorder may increase middle to older adults' risks of dementia. The disorder may adversely affect cognitive health through increasing loneliness. Our results suggest a clear need for dementia prevention targeting upstream neighborhood contexts, including the improvement of neighborhood conditions to foster social integration among residents.

BACKGROUND:The projected increase in extreme heat days is a growing public health concern. While exposure to extreme heat has been shown to negatively affect mortality and physical health, very little is known about its long-term consequences for late-life cognitive function. We examined whether extreme heat exposure is associated with cognitive decline among older adults and whether this association differs by race/ethnicity and neighbourhood socioeconomic status. METHODS:Data were drawn from seven waves of the Health and Retirement Study (2006-2018) merged with historical temperature data. We used growth curve models to assess the role of extreme heat exposure on trajectories of cognitive function among US adults aged 52 years and older. RESULTS:We found that high exposure to extreme heat was associated with faster cognitive decline for blacks and residents of poor neighbourhoods, but not for whites, Hispanics or residents of wealthier neighbourhoods. CONCLUSION/CONCLUSIONS:Extreme heat exposure can disproportionately undermine cognitive health in later life for socially vulnerable populations. Our findings underscore the need for policy actions to identify and support high-risk communities for increasingly warming temperatures.

Despite higher chronic disease prevalence, minoritized populations live in highly walkable neighborhoods in US cities more frequently than non-minoritized populations. We investigated whether city-level racial residential segregation (RRS) was associated with city-level walkability, stratified by population density, possibly explaining this counterintuitive association. RRS for Black-White and Latino-White segregation in large US cities was calculated using the Index of Dissimilarity (ID), and walkability was measured using WalkScore. Median walkability increased across increasing quartiles of population density, as expected. Higher ID was associated with higher walkability; associations varied in strength across strata of population density. RRS undergirds the observed association between walkability and minoritized populations, especially in higher population density cities.

OBJECTIVE:Individuals with criminal legal involvement have high rates of substance use and other mental disorders. Before implementation of the Affordable Care Act's Medicaid expansion, they also had low health insurance coverage. The objective of this study was to assess the impact of Medicaid expansion on health insurance coverage and use of treatment for substance use or other mental disorders in this population. METHODS:The authors used restricted data (2010-2017) from the National Survey on Drug Use and Health (NSDUH). Using a difference-in-differences approach, the authors estimated the impact of Medicaid expansion on health insurance coverage and treatment for substance use or other mental disorders among individuals with recent criminal legal involvement. RESULTS:The sample consisted of 9,910 NSDUH respondents who were ages 18-64 years, had a household income ≤138% of the federal poverty level, and reported past-year criminal legal involvement. Medicaid expansion was associated with an 18 percentage-point increase in insurance coverage but no change in receipt of substance use treatment among individuals with substance use disorder. Individuals with any other mental illness had a 16 percentage-point increase in insurance coverage but no change in receipt of mental health treatment. CONCLUSIONS:Despite a large increase in health insurance coverage among individuals with criminal legal involvement and substance use or other mental disorders, Medicaid expansion was not associated with a significant change in treatment use for these conditions. Insurance access alone appears to be insufficient to increase treatment for substance use or other mental disorders in this population.

BACKGROUND:Little is known about the long-term cognitive impact of internet usage among older adults. This research characterized the association between various measures of internet usage and dementia. METHODS:We followed dementia-free adults aged 50-64.9 for a maximum of 17.1 (median = 7.9) years using the Health and Retirement Study. The association between time-to-dementia and baseline internet usage was examined using cause-specific Cox models, adjusting for delayed entry and covariates. We also examined the interaction between internet usage and education, race-ethnicity, sex, and generation. Furthermore, we examined whether the risk of dementia varies by the cumulative period of regular internet usage to see if starting or continuing usage in old age modulates subsequent risk. Finally, we examined the association between the risk of dementia and daily hours of usage. Analyses were conducted from September 2021 to November 2022. RESULTS:In 18,154 adults, regular internet usage was associated with approximately half the risk of dementia compared to non-regular usage, CHR (cause-specific hazard ratio) = 0.57, 95% CI = 0.46-0.71. The association was maintained after adjustments for self-selection into baseline usage (CHR = 0.54, 95% CI = 0.41-0.72) and signs of cognitive decline at the baseline (CHR = 0.62, 95% CI = 0.46-0.85). The difference in risk between regular and non-regular users did not vary by educational attainment, race-ethnicity, sex, and generation. In addition, additional periods of regular usage were associated with significantly reduced dementia risk, CHR = 0.80, 95% CI = 0.68-0.95. However, estimates for daily hours of usage suggested a U-shaped relationship with dementia incidence. The lowest risk was observed among adults with 0.1-2 h of usage, though estimates were non-significant due to small sample sizes. CONCLUSIONS:Regular internet users experienced approximately half the risk of dementia than non-regular users. Being a regular internet user for longer periods in late adulthood was associated with delayed cognitive impairment, although further evidence is needed on potential adverse effects of excessive usage.

OBJECTIVE:To compare COVID-19 stigmatization at two pandemic time points (1) August 2020-during lockdowns and prior to vaccine rollout, and (2) May 2021-during vaccine rollout, when approximately half of U.S. adults were vaccinated. METHODS:Comparison of COVID19-related stigmatization and associated factors in two national internet surveys conducted in August 2020 (N = 517) and May 2021 (N = 812). Factors associated with endorsing stigmatization were identified using regression analysis. The main outcomes included endorsement of stigmatization and behavioral restrictions towards persons with COVID-19 and towards persons of Chinese descent. A previously developed "stigmatizing attitudes and behavioral restrictions" scale was adapted to measure the intersection of negative attitudes toward COVID-19 disease and negative attitudes toward persons of Chinese descent. RESULTS:COVID-19 related stigmatization declined significantly from August 2020 to May 2021. Many factors were associated with stigmatizing in both surveys: full time employment, Black race, Hispanic ethnicity, worry about contracting COVID-19, probable depression, and Fox News and social media as sources of information (all positively associated), and self-assessed knowledge about COVID-19, contact with Chinese individuals, and publicly funded news as sources (all negatively associated). Positive attitudes toward vaccination were associated with stigmatization. CONCLUSIONS:COVID-19 related stigmatization reduced substantially over these two points in the pandemic, with many continuities in the factors associated with stigmatizing. Despite the reduction in stigmatizing, however, some stigmatizing attitudes for both COVID-19 and Chinese individuals remained.

Even though vaccination is the most effective measure against COVID-19 infections, vaccine rollout efforts have been hampered by growing anti-vaccine attitudes. Based on current knowledge, we identified three domains (beliefs, discrimination, and news) as our correlates of primary interest to examine the association with anti-vaccine attitudes. This is one of the first studies to examine key correlates of anti-vaccine attitudes during the critical early stages of vaccine implementation in the United States. An online survey was administered in May 2021 to a non-representative, nationally based sample of adults (N = 789). Using multivariable logistic regression analysis, we found that individuals who expressed worry about COVID-19 (OR = 0.34, 95% CI 0.21, 0.55) and had greater knowledge of COVID-19 (OR = 0.50, 95% CI 0.25, 0.99) were less likely to hold anti-vaccine attitudes. Conversely, individuals who held stigmatizing views of COVID-19 (OR = 2.47, 95% CI 1.53, 3.99), had experienced racial discrimination (OR = 2.14, 95% CI 1.25, 3.67) and discrimination related to COVID-19 (OR = 2.84, 95% CI 1.54, 5.24), and who had been watching Fox News (OR = 3.95, 95% CI 2.61, 5.97) were more likely to hold anti-vaccine attitudes. These findings suggest COVID-19 beliefs, experiences of discrimination, and news sources should be considered when designing targeted approaches to address the anti-vaccine movement.

BACKGROUND:Effective patient-provider communication (PPC) can improve clinical outcomes and therapeutic alliance. While PPC may have improved over time due to the implementation of various policies for patient-centered care, its nationwide trend remains unclear. OBJECTIVE:The objective of this study was to examine trends in PPC quality among US adults and whether trends vary with race-ethnicity. RESEARCH DESIGN/METHODS:A repeated cross-sectional study. PARTICIPANTS/METHODS:We examine noninstitutionalized civilian adults who made 1 or more health care visits in the last 12 months and self-completed the mail-back questionnaire in the Medical Expenditure Panel Survey, 2002-2016. MEASURES/METHODS:Outcomes include 4 top-box measures, each representing the odds of patients reporting that their providers always (vs. never, sometimes, usually) used a given communication behavior in the past 12 months regarding listening carefully, explaining things understandably, showing respect, and spending enough time. A linear mean composite score (the average of ordinal responses for the behaviors above) is also examined as an outcome. Exposures include time period and race-ethnicity. RESULTS:Among 124,158 adults (181,864 observations), the quality of PPC increases monotonically between 2002 and 2016 for all outcomes. Between the first and last periods, the odds of high-quality PPC increase by 37% [95% confidence interval (CI)=32%-43%] for listen, 25% (95% CI=20%-30%) for explain, 41% (95% CI=35%-47%) for respect, and 37% (95% CI=31%-43%) for time. The composite score increases by 3.24 (95% CI=2.87-3.60) points. While increasing trends are found among all racial groups, differences exist at each period. Asians report the lowest quality throughout the study period for all outcomes, while Blacks report the highest quality. Although racial differences narrow over time, most changes are not significant. CONCLUSIONS:Our findings suggest that providers are increasingly likely to use patient-centered communication strategies. While racial differences have narrowed, Asians report the lowest quality throughout the study period, warranting future research.

INTRODUCTION/BACKGROUND:Identifying racial differences in trends in prescription opioid use (POU) is essential for formulating evidence-based responses to the opioid epidemic. This study analyzes trends in the prevalence of POU and exclusive nonopioid analgesic use (ENA) by race-ethnicity. METHODS:The Medical Expenditure Panel Survey was used to examine analgesic use among civilian adults without cancer (age ≥18 years) between 1996 and 2017. The outcome classified individuals into 3 mutually exclusive categories of prescription analgesic use: no prescription analgesic, POU, and ENA. Analyses were conducted between December 2020 and April 2021. RESULTS:Among 250,596 adults, baseline analgesic usage varied with race-ethnicity, where non-Hispanic Whites had the highest POU (11.9%), and it was as prevalent as ENA (11.3%). Non-Hispanic Blacks and Hispanics had lower POU at baseline (9.3% and 9.6%, respectively), and ENA exceeded POU. Subsequently, POU increased across race-ethnicity with concomitant decreases in ENA, eventually eclipsing ENA in Whites and Blacks but not among Hispanics. Although POU among Blacks became as prevalent as it was among Whites in the 2000s-2010s, POU among Hispanics remained lower than the other groups throughout the 2000s-2010s. After the adoption of prescribing limits, POU declined across race-ethnicity by comparable levels in 2016-2017. CONCLUSIONS:Blacks and Hispanics were less likely to use opioids when they first became widely available for noncancer pain. Subsequently, POU displaced ENA among Whites and Blacks. Although POU is often associated with Whites, a significant proportion of the Black population may also be at risk. Finally, although lower POU among Hispanics may be protective of misuse, it could represent undertreatment.