Grantee Research Project Results

Final Report: Environmental Health Disparities Research in NOCEMHD

EPA Grant Number: NIMHD008
Title: Environmental Health Disparities Research in NOCEMHD
Investigators: Luchsinger, José A , Link, Bruce , March, Dana , Teresi, Jeanne
Institution: Columbia University Medical Center
EPA Project Officer: Callan, Richard
Project Period: August 1, 2011 through July 31, 2014
Project Amount: $850,638
RFA: Transdisciplinary Networks of Excellence on the Environment and Health Disparities (2012) RFA Text |  Recipients Lists
Research Category: Environmental Justice , Human Health

Objective:

In September 2011, the NIMHD P60 Center of Excellence (COE) at Columbia University Medical Center (named the Northern Manhattan Center of Excellence in Minority Health and Health Disparities, [NOCEMHD]) obtained funding to establish one of the 10 National Institute on Minority Health and Health Disparities (NIMHD)/U.S. Environmental Protection Agency (EPA) COEs in the country, with the goal of adding a comprehensive battery of social determinants of health (SDOH) to three community-based clinical trials and one cohort study that were ongoing projects in the NIMHD P60 COE. The overall objective of the project was to examine how SDOH modified the effect of the interventions in the clinical trial on the primary outcomes and the effect of exposures over the outcomes in the cohort study. The three clinical trials and the cohort study were the following:

• The Northern Manhattan Diabetes Community Outreach Project (NOCHOP; NCT00787475) was a clinical trial comparing a community health worker (CHW) intervention versus usual care among 360 Hispanics with poorly controlled diabetes, lasting 12 months. NOCHOP found that the effect of the intervention at 12 months was similar to usual care. ¹
• Counseling Older Adults to Control Hypertension (COACH; NCT01180673) was a clinical trial of 250 elderly Hispanic and Non-Hispanic Black persons with hypertension 60 years and older comparing a community-based behavioral intervention with usual care, lasting 12 months.² The trial found no difference between the arms at 12 months in the primary outcome of changes in blood pressure.
• The Northern Manhattan Caregiver Intervention Project (NOCIP; NCT01306695) was a randomized trial comparing the New York University Caregiver Intervention + case management versus case management alone among 139 Hispanic dementia caregivers, lasting 6 months.³ NOCIP found that both study arms had improvements in depressive symptoms and self-reported caregiver burden.
• The Northern Manhattan Study of Metabolism and Mind (NOMEM; NCT02470260) is a cohort study of 600 Hispanic men and women ages 55 to 64 years with the primary goal of studying the relation of diabetes and related disorders with mental health. ⁴ Thus far, data in NOMEM have revealed that over two-thirds of middle aged Hispanics in Northern Manhattan are overweight or obese and have pre-diabetes or diabetes. We have also found that pre-diabetes and diabetes and strongly associated with worse cognitive performance in multiple domains. ⁴

Summary/Accomplishments (Outputs/Outcomes):

The battery of SDOH that was collected in these participants includes the following:

• Socioeconomic status (SES) was measured using tools from the MacArthur Network on SES and health (http://www.macses.ucsf.edu).
• Neighborhood physical and social characteristics were assessed by geocoding participants' addresses and locating them in their respective census tracts (administrative proxies for neighborhoods) and linking to decennial Census data and New York City Census data using GIS.
• Interpersonal discrimination was measured in all subjects using a 12-item measure^5,6 of major and everyday interpersonal discrimination, modified to include primary and secondary attributions, and attributions particularly relevant to the Northern Manhattan Community (e.g., language proficiency).
• Anticipated discrimination was assessed using a scale employed in the U.S.-U.K. study. ⁷
• Social support from the respondents' identified social network is assessed in a shortened version of a measure developed by sociologists to assess emotional and instrumental social support from community ties, social networks and intimate ties. ⁸
• Racial/ethnic socialization was measured using a measure validated across ethnic groups ^{9, 10} modified to determine the source (e.g., parents and other family members), context (e.g., home, school, work), and timing (e.g., childhood, adolescence, at time of migration) of socialization messages.
• Ethnic identity was measured in all subjects using a multi-group ethnic identity measure. ¹¹
• John Henryism (i.e., high-level coping in response to adversity) was measured in all subjects using a modified version of the 12-item John Henryism Active Coping Scale. ¹²
• Coping with stressors included items referring to emotional and behavioral responses to general life stress and discrimination stressors.
• Migration and mobility were measured by asking about migration history, age at migration, residential history, number and timing of moves, and frequency with which the respondent returns to his/her home country, if applicable (providing another indicator of acculturation).
• Acculturation was measured using the Bidimensional Acculturation Scale.¹³
• Health behaviors were assessed in the following areas: current and past smoking, alcohol (whiskey, wine and beer) consumption habits, physical activity, sleep and diet. Physical activity was measured using the International Physical Activity Questionnaire long form. ¹⁴ Diet assessment focused on consumption of fruits and vegetables, since diets high in consumption have lower energy density and are associated with lower BMI. ¹⁵

The relevant information from each project is in Table 1 below:

Table 1. Summary of Key Constructs and Measures in NOCEMHD Studies.

Study	Primary Exposure	Covariates/Other Significant Variables (Measures reference)	Outcomes (Measures reference)
COACH	Randomization group	Demographics, Medication adherence (Morisky scale16), self efficacy, hypertension characteristics, Medical comorbidity (Charlson comorbidity index17)	Primary outcome: blood pressure reduction. Secondary outcomes: changes in physical activity (Diet/Physical activity self efficacy questionnaire18), body weight, daily servings of fruits and vegetables (NCI fruit vegetable and fat brief dietary questionnaire19), blood pressure control.
NOCHOP	Randomization group	Demographics, body mass index, depression (Patient Health Questionnaire [PHQ9]20)	Primary outcome: HbA1c Secondary outcomes: blood pressure, low density lipoprotein, self reported medication adherence (Morisky Medication adherence survey21), Medication intensification (MESA medications questionnaire), physical activity (physical activity recall interview18), diet (NCI fruit vegetable and fat brief dietary questionnaire19).
NOCIP	Randomization group	Demographics	Primary outcomes: changes in caregiver depressive symptoms (geriatric depression scale [GDS]22), and in caregiver burden (Zarit caregiver burden interview23). Secondary outcomes: caregiver health (caregiver physical health form24), Revised Memory and Problem Behavior Checklist25, the Stokes Social Network scale26, and severity of patient dementia (Global Deterioration Scale27).
NOMEM	T2D status (NGT, pre-T2D, T2D. following 2010 ADA criteria28).	Demographics, Apoe-ε4, body mass index, cystatin C,, hsCRP, health literacy (Functional Health Literacy in Adults (TOFHLA) 29), lipids, medications, blood pressure, reading level30	Primary outcomes: memory score from The Selective Reminding Test (SRT)31; executive score from WAIS-R Similarities: This Wechsler Adult Intelligence Scale- Revised32; Non-Verbal Similarities: the Identities and Oddities subtest of the Mattis Dementia Rating Scale 33; Color Trails Test34; Verbal Fluency: Controlled Word Association Test35. Secondary outcome: depression (PHQ920 and the PROMIS depression scale36)

2. Summary of Findings
2.1. Psychometric Properties

Psychometric analyses (in Table 2) of the SDOH scales showed good internal consistency for most (Cronbach's alpha's in the 0.80s and 0.90s). The McDonald's Omega total reliability estimates, based on factor analyses, were high as well. Finally, the explained common variance, a measure of essential unidimensionality, was relatively high for the total scales. The performance of these scales was not examined within ethnic subgroups (e.g., Puerto Rican vs. Dominican), nor across age, gender or education groups.

Table 2. Reliability and dimensionality estimates for scales reflecting social stress exposure, diet and exercise
Scale	N	Number of Items	Cronbach Alpha	Corrected Item Total Correlation Range	Explained Common Variance (Eignenvalues)	McDonald's Omega Total
John Henryism	728	12	0.865	0.432, 0.656	41.784 (5.014)	0.938
Major Discrimintation	733	13	0.690	0.122, 0.452	21.545 (2.801, 1.232, 1.115, 1.072)	0.872
Day to Day Discrimination	733	10	0.892	0.562, 0.687	51.447 (5.145, 1.098)	0.944
Coping with Stress	731	9	0.687	0.161, 0.589	29.872 (2.689, 1.432)	0.761
Coping with Unfair Treatments	732	9	0.584	.0273, 0.687	46.235 (4.161, 1.300)	0.912
BAS Non-Hispanic Domain	-	-	-	-	-	-
Language Use	326	3	0.922	0.841, 0.863	87.192 (2.616)	-
Linguistic Proficiency	325	6	0.979	0.908, 0.952	90.553 (5.433)	0.991
Electronic Media	323	3	0.926	0.806, 0.884	87.370 (2.621)	-
Total	326	12	0.977	0.827, 0.930	81.692 (9.803)	0.991
BAS Hispanic Domain	-	-	-	-	-	-
Language Use	315	3	0.974	0.934, 0.951	95.004 (2.850)	-
Linguistic Proficiency	315	6	0.995	0.967, 0.990	97.398 (5.844)	0.999
Electronic Media	313	3	0.955	0.895, 0.911	91.724 (2.752)	-
Total	315	12	0.990	0.833, 0.975	89.784 (10.774)	0.997
Social Support Questionnaire	-	-	-	-	-	-
Number Score	730	6	0.877	0.654, 0.723	62.683 (3.761)	0.887
Satisfaction Score	700	6	0.890	0.593, 0.816	64.933 (3.896)	0.933
Multi-Ethnic Identity Measure	-	-	-	-	-	-
Total	727	14	0.819	0.213, 0.633	36.080 (5.051, 1.323, 1.170)	0.911
Affirmation and Belonging	727	5	0.817	0.545, 0.688	58.915 (2.946)	0.892
Ethnic Identity Achievement	727	7	0.606	0.017, 0.546	34.773 (2.434, 1.294)	0.757
Ethnic Behaviors	715	2	0.257	-	-	0.757
Other Group Orientation	728	6	0.735	0.310, 0.635	45.479 (2.729)	0.845
Behavioral Risk Factor Surveillance System: Diet	626	5	0.562	0.277, 0.360	36.939 (1.847)	0.609

2.2. Relationships of SDOH to Hyperglycemia in NOMEM

Cross-sectional analyses showed that social contacts, coping tactics and ethnic identity relate significantly to hyperglycemia (pre-diabetes or diabetes) in the expected direction (see Table 3). Those without diabetes have higher mean scores on measures of coping tactics (John Henryism, p = 0.021), social support (p < 0.001) and ethnic identity (p = 0.007). The normal and hyperglycemic groups were not significantly different in mean scores of discrimination. We also examined whether SDOH were related to cognitive performance in NOMEM but found that only educational attainment was related to lower cognitive performance. No other variable was related to cognitive performance after adjustment for education.

Table 3. SDOH variables by hyperglycemia status (t-tests).	None			Any hyperglyncemia			P-Value
	N	Mean	S.D.	N	Mean	S.D.
John Henryism: Prorated (Direction: high coping)	152	43.28	4.42	437	42.23	5.80	0.021
Coping with stress: Prorated (high, greater)	137	20.72	5.04	491	20.76	4.33	0.932
Coping with unfair treatment: Prorated	96	20.46	4.89	292	19.55	4.68	0.103
Major discrimination: Prorated (high, greater)	154	1.34	2.02	439	1.02	1.52	0.078
Day-to-day unfair treatment: Prorated (high, greater)	153	16.49	6.59	440	15.57	6.82	0.147
SSQ Number of persons reported (high, greater)	152	11.42	8.11	438	8.47	5.75	<0.001
SSQ Number score	152	1.90	1.35	438	1.41	0.96	<0.001
SSQ Satisfaction score (high, greater)	143	5.01	1.24	424	7.78	1.34	0.065
Multi-group measure of ethnic identity (high, greater)	151	4.21	0.65	436	4.04	0.64	0.007

2.3. SDOH in NOCHOP

Table 4 shows a within-group comparison of changes in A1c, stratified by the SDOH moderators of interest. Although the results were not statistically significant, the influence of social support on the direction and magnitude of change in A1c was inconsistent for the different intervention arms. In the control arm, participants with high or low social support exhibited reductions in A1c over time. In the intervention arm, only participants with low social support exhibited A1c reductions over time. Nonetheless, those reductions were comparable in magnitude to the A1c reductions among participants in the control arm who reported a high degree of social support.

Table 4. SDOH and HbA1c in NOCHOP
-	CHW							EUC
	Social Support						P-value	Social Support						P-value
	Low			High				Low			High
	(n)	(m)	(SD)	(n)	(m)	(SD)		(n)	(m)	(SD)	(n)	(m)	(SD)
Δ HbA1c (%)	86	-0.42	1.82	19	0.03	1.75	.0329	78	-0.07	1.74	24	-0.51	1.44	0.262
-	Discrimination in Physical Health Care Setting						-	Discrimination in Physical Health Care Setting						-
	No			Yes			-	No			Yes
	(n)	(n)	(SD)	(n)	(m)	(SD)	-	(n)	(m)	(SD)	(n)	(m)	(SD)
Δ HbA1c (%)	100	-0.28	1.72	5	-1.51	3.18	0.138	95	-0.31	1.65	7	1.66	0.75	0.002
-	Biculturalism						-	Biculturalism
	No-			Yes			-	No			Yes
	(n)	(m)	(SD)	(n)	(m)	(SD)	-	(n)	(m)	(SD)	(n)	(m)	(SD)
Δ HbA1c (%(	14	-0.88	1.58	6	-0.85	3.71	0.984	14	-0.79	1.40	8	0.44	1.17	0.048

Discrimination appeared to have a strong influence on the effect of the intervention. The mean reduction in A1c was greatest among participants in the intervention arm who had experienced discrimination in a physical health care setting. In contrast, participants in the control arm who had experienced a similar form of discrimination exhibited an increase in A1c over time, comparable in magnitude to the A1c reduction among their counterparts in the intervention arm.

With respect to acculturation, non-bicultural participants in the intervention arm exhibited the largest reduction in A1c over time. In the control arm, at the end of follow-up bicultural participants had statistically greater A1c values than non-bicultural participants. Social support was not statistically associated with change in A1c among participants in either intervention arm. Discrimination, both experiences specifically in the health care domain and the total number of domains in which discrimination was experienced, had a strong effect on change in HbA1c among participants in the control arm. Acculturation also had an effect on change in HbA1c among participants in the control arm. There was a statistical interaction between experiences of discrimination, both the total number of domains and the health care domain specifically, and the effect of the intervention on change in A1c. Among participants who reported past experiences of discrimination, better outcomes were achieved with the CHW intervention.

2.4. SDOH in NOCIP

In ITT analyses, social support was not related with changes in depressive symptoms between the intervention arms (Table 5), but participants who deployed fewer coping behaviors for general stress showed more improvement in their depressive symptoms over time (Table 6). As reflected in the gender composition of this sample, caregivers are predominantly female. However, men may experience a different degree of benefit with an intervention designed to bolster social support. In this sample, men in the CHW-only arm demonstrated greater improvement in depressive symptoms over time (change in GDS score [mean + SD] = -3.7 + 3.2). However, the sample size was small, therefore limiting inferences. This study demonstrated that SDOH moderate the response to a CHW intervention to reduce depressive symptoms among Hispanic caregivers of persons with dementia.

Table 5. Comparison of GDS Score by Group, Stratified by Level of Social Support

-	NYUCI							CHW Only
	Social Support						-	Social Support						-
	Low			High			-	Low			High			-
	(n)	(m)	(SD)	(n)	(m)	(SD)	P-value	(n)	(m)	(SD)	(n)	(m)	(SD)	P-value
GDS Score
Baseline	41	10.63	7.88	15	9.67	5.14	0.661	28	12.46	6.89	21	9.90	7.04	0.209
6-month	37	10.27	7.20	15	7.67	6.68	0.234	27	10.41	6.82	21	9.33	7.41	0.605
Change	37	-0.43	4.17	15	-2.00	4.77	0.244	27	-1.93	5.33	21	-0.57	4.14	0.342

Table 6. Comparison of GDS Score by Group, Stratified by Frequency of Coping Behaviors for Stress

-	NYUCI							CHW Only
	Frequency of Coping Behaviors						-	Frequency of Coping Behaviors						-
	Low			High			-	Low			High			-
	(n)	(m)	(SD)	(n)	(m)	(SD)	P-value	(n)	(m)	(SD)	(n)	(m)	(SD)	P-value
GDS Score
Baseline	7	16.29	10.94	48	9.52	6.30	0.020	6	9.83	6.24	42	11.79	7.10	0.526
6-month	6	12.67	11.00	45	9.16	6.55	0.263	6	6.50	5.36	41	10.63	7.11	0.179
Change	6	-3.33	3.62	45	-0.51	4.42	0.141	6	-3.33	2.58	41	-1.05	5.10	0.291

2.5. SDOH in COACH

At the time of the submission of this progress report, preliminary analyses failed to find a relationship of SDOH with changes in blood pressure in response to the interventions.

2.6. Systematic Review of the Literature of Moderation by SDOH in Clinical Trials

We conducted a systematic review of randomized controlled trials that examined the role of SDOH in moderating the response to interventions. ³⁷ The final sample of 22 articles explicitly examined baseline characteristics as moderators of intervention response and described the interaction between the intervention and the moderator. Articles included in the review addressed individual-level ^38-61 and group-level ^{62, 63} interventions (i.e., in which individuals and groups are randomized, respectively); pharmacological, ^{39, 45}, behavioral, ^{38, 52, 54, 59, 63} clinical, ^{38, 46-51, 55-57, 60, 61} and community-based ^{38-44, 53, 58, 62, 64} interventions. Similarly, targeted outcomes spanned mental ^{39, 41, 43, 45-50, 53, 55, 57, 60, 65} and physical health, ^{51, 55, 56, 58} as well as behavioral or process outcomes. ^{40, 42-44, 52-55, 59, 61-64, 66, 67} Per the WHO Commission on SDOH, ⁶⁸ we classified the studies by the primary moderators: individual characteristics and lifestyle factors, including minority group status ^{39, 49, 50, 60} socioeconomic characteristics ^{38, 42, 45, 46, 51, 56, 61} and psychosocial factors; ^{39-41, 47, 52, 53, 57, 60, 61} social and community networks; ^{44, 52, 53, 55, 57} and general socioeconomic, cultural and environmental conditions. ^{43, 58, 63} Six of the studies^{39, 52, 53, 57, 60, 61} addressed more than one category. Only five (22.7%) of the 22 studies failed to find evidence of moderation,^{39, 40, 42, 45, 51}, and one reported evidence of moderation that was close to statistical significance. ³⁸ Among the studies that examined minority group status, three out of four studies found that minorities benefited most from the intervention through enhanced access to care. ^{49, 50, 60} Among the seven studies that examined SES as a moderator, only one found that those with low SES benefited less, ³⁸ and two found that those with lower SES benefited most. ^{46, 56} Five of seven studies addressing social support and relationships found that the intervention was more effective among those with low social support ^{41, 44, 47, 57} or psychosocial resources. ⁵⁵ One of three studies examining life stressors reported that those with higher burden were less responsive to the intervention, ⁴³ while two reported that those with higher burden were more responsive. ^{44, 53}

Conclusions:

We found that relevant pertinent SDOH moderate the effectiveness of interventions in clinical trials in which the community and social environment was important. This was illuminated by the results of our studies with primary data collection and in our systematic review of the literature. For example, in NOCIP, participants who deployed less stress coping behaviors demonstrated greater improvement in depressive symptoms over time, suggesting that these participants should be targeted for interventions. Perhaps the SDOH profile of participants should be taken into account to create customized interventions, concordant with the growing field of personalized medicine. However, our systematic review of the literature demonstrated a post-hoc approach to examining the role of SDOH in the effectiveness of interventions in clinical trials. We propose that there needs to be a harmonization across studies in deciding: (1) What pertinent SDOH to measure depending on the interventions, the outcomes and the target populations; (2) What instruments to use to measure SDOH; and (3) Establish analyses of moderation by SDOH a priori, taking them into account in power analyses and sample size estimation.

Overall, we collected SDOH data at the individual and contextual level on over 1,300 study participants from under-represented minorities that we are still analyzing, and that form part of a data and biospecimen repository that we are using for training purposes and for secondary analyses projects that will help elucidate the role of SDOH in the moderating the effectiveness of interventions.

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Journal Articles on this Report : 3 Displayed | Download in RIS Format

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Other project views:	All 7 publications	3 publications in selected types	All 3 journal articles

Publications

Type	Citation	Project	Document Sources
Journal Article	March D, Luchsinger JA, Teresi JA, Eimicke JP, Findley SE, Carrasquillo O, Palmas W. High rates of depressive symptoms in low-income urban Hispanics of Caribbean origin with poorly controlled diabetes: correlates and risk factors. Journal of Health Care for the Poor and Underserved 2014;25(1):321-331.	NIMHD008 (Final)	Full-text from PubMed Abstract from PubMed Associated PubMed link Abstract: Johns Hopkins-Abstract Exit
Journal Article	March D, Williams J, Wells S, Eimicke JP, Teresi JA, Almonte C, Link BG, Findley SE, Palmas W, Carrasquillo O, Luchsinger JA. Discrimination and depression among urban Hispanics with poorly controlled diabetes. Ethnicity & Disease 2015;25(2):130-137.	NIMHD008 (Final)	Full-text from PubMed Abstract from PubMed Associated PubMed link Abstract: U Miami Research Profiles-Abstract Exit
Journal Article	Shea S, Kothari D, Teresi JA, Kong J, Eimicke JP, Lantigua RA, Palmas W, Weinstock RS. Social impact analysis of the effects of a telemedicine intervention to improve diabetes outcomes in an ethnically diverse, medically underserved population: findings from the IDEATel Study. American Journal of Public Health 2013;103(10):1888-1894.	NIMHD008 (Final)	Full-text from PubMed Abstract from PubMed Associated PubMed link Abstract: AJPH-Abstract Exit

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