• A Partnership Between Researchers and the Navajo Nation to Study a Junk Food Tax

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    Co-Authored By
    Regina Eddie, Ph.D., Northern Arizona University School of Nursing
    Hendrik “Dirk” de Heer, Ph.D., Department of Health Sciences, Northern Arizona University
    Del Yazzie, M.P.H., Navajo Epidemiology Center

    Eight years ago, the Navajo Nation enacted the first junk food tax within the United States and the first in any sovereign tribal nation in the world. The Healthy Diné Nation Act (HDNA) of 2014 created a 2% tax on foods and beverages that had little to no nutritional value. A companion piece of legislation removed the usual sales tax (then 5%, now 6%) for healthy foods, including water, nuts, fruits, and vegetables. The revenue from the unhealthy food tax is designated for local wellness projects in the 110 local communities that make up the Navajo Nation.

    Because they are sovereign nations, tribal nations are uniquely able to implement policies aimed at improving public health that may be difficult to implement in other places. Through partnerships with researchers at academic institutions, tribal nations can also measure the effects of these policies and share that information widely.

    Over the last five years, we have worked together to study the effects of this change in food policy on the Navajo Nation. The process was complex, but the rewards were great: The Navajo Nation acquired evidence to inform its decision about whether to extend the policy and the scientists learned about the effects of junk food taxes. Together, we increased the capacity for research in the Navajo Nation.

    Other tribes and researchers can learn from our example by partnering to advance both the research needs of Indigenous people and the research community’s understanding of the effects of public health policies.

    The legislature gave the Navajo Department of Health until 2020 to determine whether the policy was achieving the desired goals: promoting healthier diets and lifestyles in the Navajo Nation and supporting local community wellness projects. If the law was helping, it would be extended. If not, it would expire at the end of that year. That gave the department about five years to determine whether the tax was working. That’s where our research team came in, collaboratively building a partnership between the Navajo Epidemiology Center, Northern Arizona University, and Brigham and Women’s Hospital affiliate Community Outreach and Patient Empowerment (COPE).

    In this example of community-directed research, community interests and academic research interests were closely aligned. The Navajo Nation needed to know whether this tax was working or not, and the researchers needed to study the effects of junk food taxes.

    We based our evaluation on data already being collected by the tribal government, along with federal government data and new data that we collected as part of this partnership.

    We learned that the tax revenue decreased by about 3% every year, despite the lack of changes in overall sales tax revenue in the Navajo Nation, suggesting that people weren’t buying as much junk food as before. We also learned that more than 99% of the revenue was successfully allocated to local communities, an impressive feat. With the tax revenue, the local communities focused primarily on supporting the built recreational environment (such as walking trails and playgrounds), exercise equipment, nutrition and fitness classes, and social events. We further learned that stores in the Navajo Nation implemented the tax with nearly 90% accuracy, about the same as in major cities implementing soda taxes. Modest improvements in the food environment were found, with pricing and healthy food availability more aligned with those in nearby areas outside of the Navajo Nation. Informed by these findings, in 2020, the Navajo Nation Tribal Council reauthorized the tax with no expiration date.

    When collaborating with tribal nations, researchers must understand the historical context of relations between tribes and outsiders. For the Navajo Nation, this includes forced relocations, hundreds of environmentally damaging uranium mines, and children being sent to boarding schools against their families’ wishes. And, until the late 1980s, the Navajo people did not have control over what kind of research was done about their lives.

    Now the Navajo Nation Human Research Review Board makes decisions about what kind of research can be done in the Navajo Nation. One of us is a member of that board, and the partnership with that board has been crucial to the success of this project. The board also reviews all scientific publications about research conducted in the Navajo Nation. Through this collaboration, we have been able to publish eight scientific articles. All are open access and available on the Navajo Epidemiology Center’s website alongside our educational materials.

    Research protections and government processes exist to protect the Navajo people from exploitation. Although it is possible to hire consultants who specialize in navigating tribal government for outsiders, we recommend that researchers instead take the time to understand a tribal nation’s protections and processes, including the historical background that explains why the protections and processes are needed. Working through these processes has given our research team perspective and helped build the partnership between researchers and the Navajo Nation. This close relationship has made it possible to work through the variety of issues that come up while conducting research.

    In addition, this partnership has enabled us to build capacity for research in the Navajo Nation. This includes figuring out infrastructure issues, such as creating templates for frequently used documents and renewing a federal registration number that allowed the Navajo Department of Health to receive federal funds.

    The partnership has also involved supporting students. This project has supported eight Navajo students in master’s programs at Northern Arizona University. Six have graduated, and the other two are on track to do so at the end of this academic year; one of our graduate students is now in a doctoral program at the University of Arizona. Junior faculty have also been able to work on the project. We are advancing careers and supporting scholars’ advancement to higher levels of leadership. Eventually, these trainees will be able to lead research projects in their own tribal communities.

    Our partnership over the past five years has advanced the needs of both the Navajo Nation and the research community. We recommend that other tribal nations and researchers follow our lead and pursue common goals together. Our communities share interests and goals, and with thoughtful cooperation, we can work together toward a better future.

  • The Dementia Epidemic Among Older Black Americans

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    Co-authored by

    Mark D. Hayward, Ph.D.
    University of Texas at Austin

    Mateo P. Farina, Ph.D.
    University of Southern California

    November is Alzheimer’s Awareness month. While it is a time to recognize the importance of supporting persons living with dementia, it is also a time to acknowledge the glaring disparities in dementia in our country. One such disparity is the epidemic levels of dementia among older Black Americans compared to White Americans.

    The prevalence of dementia among Black Americans aged 65 years and older is about 2.5 times that for White Americans of the same age. In 2012, for example, a nationally representative study reported that 19.3% of older Black people had dementia compared to 7.4% of older White people1. These differences are starker at older ages. For Black persons aged 75 years and older, the prevalence of dementia is 31%, compared to 9% for White persons of that age2. Research reporting race differences in dementia onset—that is, new cases of dementia—document a similar race gap: Black people have about a 2.7 times greater risk of onset compared to White people3. These numbers translate into an extraordinary and disproportionate burden for Black individuals, their families, and their communities. This burden is often compounded by older Black Americans having fewer personal, social, economic, clinical, and community resources compared to White Americans. Moreover, the COVID-19 pandemic has increased these inequities, making care more difficult to obtain and placing a greater burden on familial caregivers.

    The race disparity in dementia prevalence and incidence is largely reflective of the differences in exposures that Black Americans and White Americans experience throughout their lives, and not innate biological differences (e.g., genetic differences). For example, recent studies have documented a decline in both Black people and White people living with dementia from 2000-20142. The reason for the declining trend was unclear. Several hypotheses have been suggested: education improvements across birth cohorts, better control of hypertension, positive health behaviors, and improved childhood conditions. The evidence for this period points to a straightforward explanation. The downward trend in dementia prevalence for both Black people and White people since 2000 has been driven by increased educational attainment—shown by research to be one of the major risk factors contributing to the Black-White disparity—and is, largely, unrelated to changes in other major risk factors. This shows that improvements in education, and not medical interventions, had far-reaching benefits for dementia trends, although it is clear that the persistence of the race gap over time likely reflects Black individuals’ continued challenges in obtaining greater levels of education. This finding also provides additional evidence that improvements in social risk factors in early life can dramatically move the needle and reduce the burden of dementia decades later in the older population.

    There is little doubt that cognitive health disparities defined by both race and education are enormous, and that highly educated White people and less educated Black people anchor the tail ends of the disparity. For example, highly educated 65-year-old White people can expect to live free of dementia for more than 17 years—an expectancy even greater than the total life expectancy for less educated Black people4. Less educated 65-year-old Black people, on the other hand, can only expect 10.59 years of life without dementia. The 7-year difference in life expectancy without dementia shows how stark these cognitive health inequalities can be. This difference is even more striking when considering the educational composition of the race groups; more than 50% of older Black individuals do not have a high school diploma, while about 38% of older White individuals have more than a high school education.

    How, then, can we explain the higher rates of dementia among older Black people compared to White people? Addressing this problem is not straightforward. The lives of many older Black people differed in fundamental ways from the lives of older White people. About 80% of older Black Americans were born in the pre-1964 Jim Crow South, although many now live elsewhere as older adults. Growing up in the Jim Crow South not only meant dramatically different childhoods for Black Americans compared to White Americans due to curtailed economic, political, and social rights, but also because of living with the threat of violence. These childhood exposures may have had developmental consequences through stressors and limited opportunities, which reverberate decades later and place older Black Americans at greater risk of dementia. Research clearly documents that early life in a Southern context is associated with poor cognitive health. This association remains after controlling for educational attainment and adult risk factors. Understanding how and why a Southern context in childhood may be associated with poor cognitive health is essential to understand today’s disparities in cognitive health. What the future holds is unclear, yet it is clear that the racial divide in dementia will almost certainly reflect future disparities in resources, risks and opportunities.


    1. Chen, C. and J.M. Zissimopoulos, Racial and ethnic differences in trends in dementia prevalence and risk factors in the United States. Alzheimer’s & dementia (New York, N. Y.), 2018. 4: p. 510-520.
    2. Hayward, M.D., et al., The Importance of Improving Educational Attainment for Dementia Prevalence Trends From 2000 to 2014, Among Older Non-Hispanic Black and White Americans. The Journals of Gerontology: Series B, 2021.
    3. Zhang, Z., M.D. Hayward, and Y.-L. Yu, Life Course Pathways to Racial Disparities in Cognitive Impairment among Older Americans. Journal of Health and Social Behavior, 2016. 57(2): p. 184-199.
    4. Farina, M.P., et al., Racial and Educational Disparities in Dementia and Dementia-Free Life Expectancy. The Journals of Gerontology: Series B, 2020. 75: p. e105-e112. PMC7530490.

  • Helping Youth from Racial and Ethnic Minority Groups Access Effective ADHD Treatment

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    By Lauren Haack, Ph.D.
    Associate Professor
    Department of Psychiatry and Behavioral Sciences
    University of California, San Francisco

    Attention-Deficit, Hyperactivity/Impulsivity Disorder (ADHD) is one of the most common mental health disorders impacting approximately 5% of children across cultures.1 Brain differences related to ADHD influence those affected in several ways.1,2 To begin, new or challenging tasks seem overwhelming, making it hard to map out a plan for completion and self-motivate initiation.3 In addition, individuals with ADHD have a tendency to over-perceive negative feedback and under-perceive positive feedback,2,4 which relates to difficulty regulating emotions.2 Unfortunately, as children with ADHD reach school age, they encounter more difficulties and more opportunities for critical rather than positive feedback from parents, teachers, and peers.2,5 As a result, ineffective patterns of interaction between children with ADHD and others in their lives can become entrenched, contributing to stress, confusion, and even hopelessness.4,5

    Fortunately, behavioral ADHD treatments help parents/caregivers and teachers use strategies that have been found to be effective but can be difficult to put into place consistently without support.5,6 Three key goals for behavioral ADHD treatments can be thought of as the “3 C’s”

    1. Clarity – well-defined and reasonable expectations that children can achieve
    2. Coordination – communication between families and teachers to provide children a clear roadmap for success
    3. Celebration – frequent and specific praise, as well as rewards, when children meet expectations.

    Consistent use of “3 C” strategies by parents/caregivers and teachers can help mend broken bonds, improve child functioning, and convey optimism and hope for all.5,6

    Unfortunately, there are barriers across all stages of ADHD help-seeking that prevent youth in need from receiving treatments that work.7 Many barriers are especially pronounced for families from racial and ethnic minority groups.7,8

    ADHD Help-Seeking Stages

    Recognizing there is a problem that needs support
    The first step in ADHD help-seeking involves recognizing there is a problem that needs support. Barriers in this stage include limited knowledge about ADHD, as well as differing beliefs about the causes of—and developmental expectations for—child behavior.7–10 For example, if one believes that impulsivity is just part of the typical childhood experience (“Boys will be boys; no big deal”) and they have never heard a biopsychosocial explanation for ADHD, they may be less likely to recognize a need for treatment even if the child’s behavior becomes impairing.

    Deciding to seek help and selecting a service
    If one does identify problematic child behaviors warranting support, they may progress to the next steps of deciding to seek help and selecting a service. A primary barrier here can be finding treatment in one’s native language.7,8 Additionally, given that families from racial and ethnic minority groups are disproportionately uninsured and financially strained in the United States, their decisions to seek help may be obstructed by out-of-pocket costs.7,8 There also may be hesitancy to seek treatment due to societal stigma and distrust, perceived lack of family support, fears about revealing undocumented status, and prior experiences with discrimination and racism by care providers.7–9

    Utilizing the service selected
    The final step in ADHD help-seeking is utilizing the service selected. Even if one can locate affordable treatment in their native language, they may have difficulty securing transportation, time off work, and/or child care, thus impeding consistent attendance.7,8 They also may lack genuine connection with providers or find that services focus on strategies which don’t feel relevant in their communities, which can lead to dissatisfaction, dropout, or poorer treatment outcomes.7–9

    • A potential solution addressing many of the barriers to ADHD help-seeking outlined above is offering services for free in familiar and accessible settings, such as schools.5,11 Research supports the following recommendations when using this approach:
      Redeploy school resources from ADHD practices with limited evidence (such as individual counseling) to treatments that work (such as behavioral parent/caregiver groups and classroom management)5,6,11
    • Offer linguistically and culturally appropriate services whenever possible; for example, the Collaborative Life Skills (CLS) school-based program11 shows feasibility, acceptability, and effectiveness in Spanish with Latinx families in the U.S. and Mexico12,13
    • Describe services using words that carry less stigma, such as “a program to improve youth attention and behavior” rather than “treatment for ADHD and related disorders”13
    • Harness technology to improve service reach and feasibility; for example, offer groups via videoconference for those who can’t attend in-person14

    For more information on clinical research programs focused on culturally-attuned school-based ADHD services in English and Spanish, see https://clsprogram.ucsf.edu and strivelab.ucsf.edu.


    1. Faraone, S. V., Banaschewski, T., Coghill, D., Zheng, Y., Biederman, J., Bellgrove, M. A., Newcorn, J. H., Gignac, M., Al Saud, N. M., Manor, I., Rohde, L. A., Yang, L., Cortese, S., Almagor, D., Stein, M. A., Albatti, T. H., Aljoudi, H. F., Alqahtani, M. M. J., Asherson, P., … Wang, Y. (2021). The World Federation of ADHD International Consensus Statement: 208 Evidence-based Conclusions about the Disorder. Neuroscience & Biobehavioral Reviews. https://doi.org/10.1016/j.neubiorev.2021.01.022
    2. Shaw, P., Stringaris, A., Nigg, J., & Leibenluft, E. (2014). Emotion Dysregulation in Attention Deficit Hyperactivity Disorder. American Journal of Psychiatry, 171(3), 276–293.
    3. Sibley, M. H., Graziano, P. A., Ortiz, M., Rodriguez, L., & Coxe, S. (2019). Academic impairment among high school students with ADHD: The role of motivation and goal-directed executive functions. Journal of School Psychology, 77, 67–76. https://doi.org/10.1016/j.jsp.2019.10.005
    4. Babinski, D. E., Kujawa, A., Kessel, E. M., Arfer, K. B., & Klein, D. N. (2019). Sensitivity to Peer Feedback in Young Adolescents with Symptoms of ADHD: Examination of Neurophysiological and Self-Report Measures. Journal of Abnormal Child Psychology, 47(4), 605–617. https://doi.org/10.1007/s10802-018-0470-2
    5. Pfiffner, L. J., & Haack, L. M. (2014). Behavior Management for School-Aged Children with ADHD. Child and Adolescent Psychiatric Clinics of North America, 23(4), 731–746. https://doi.org/10.1016/j.chc.2014.05.014
    6. Friedman, L. M., & Pfiffner, L. J. (2020). Chapter 7—Behavioral interventions. In M. M. Martel (Ed.), The Clinical Guide to Assessment and Treatment of Childhood Learning and Attention Problems (pp. 149–169). Academic Press. https://doi.org/10.1016/B978-0-12-815755-8.00007-1
    7. Eiraldi, R. B., Mazzuca, L. B., Clarke, A. T., & Power, T. J. (2006). Service utilization among ethnic minority children with ADHD: A model of help-seeking behavior. Administration and Policy in Mental Health and Mental Health Services Research, 33, 607–622.
    8. Gerdes, A. C., Lawton, K. E., Haack, L. M., & Schneider, B. W. (2014). Latino Parental Help Seeking for Childhood ADHD. Administration and Policy in Mental Health and Mental Health Services Research, 41(4), 503–513. https://doi.org/10.1007/s10488-013-0487-3
    9. Araujo, E. A., Pfiffner, L., & Haack, L. M. (2017). Emotional, Social and Cultural Experiences of Latino Children with ADHD Symptoms and their Families. Journal of Child and Family Studies, 26(12), 3512–3524. https://doi.org/10.1007/s10826-017-0842-1
    10. Lawton, K. E., Gerdes, A. C., Haack, L. M., & Schneider, B. (2014). Acculturation, cultural values, and Latino parental beliefs about the etiology of ADHD. Administration and Policy in Mental Health, 41(2), 189–204. https://doi.org/10.1007/s10488-012-0447-3
    11. Pfiffner, L. J., Rooney, M., Haack, L., Villodas, M., Delucchi, K., & McBurnett, K. (2016). A Randomized Controlled Trial of a School-Implemented School–Home Intervention for Attention-Deficit/Hyperactivity Disorder Symptoms and Impairment. Journal of the American Academy of Child & Adolescent Psychiatry, 55(9), 762–770. https://doi.org/10.1016/j.jaac.2016.05.023
    12. Haack, L. M., Araujo, E. J., Delucchi, K., Beaulieu, A., & Pfiffner, L. (2019). The Collaborative Life Skills Program in Spanish (CLS-S): Pilot Investigation of Intervention Process, Outcomes, and Qualitative Feedback. Evidence-Based Practice in Child and Adolescent Mental Health, 4(1), 18–41. https://doi.org/10.1080/23794925.2018.1560236
    13. Haack, L. M., Araujo, E. A., Meza, J., Friedman, L. M., Spiess, M., Beltrán, D. K. A., Delucchi, K., Herladez, A. M., & Pfiffner, L. (2020). Can School Mental Health Providers Deliver Psychosocial Treatment Improving Youth Attention and Behavior in Mexico? A Pilot Randomized Controlled Trial of CLS-FUERTE: Journal of Attention Disorders. https://doi.org/10.1177/1087054720959698
    14. Haack, L. M., Lai, J., Guerrero, M. F. A., Valdez, M. E. U., Beltrán, D. K. A., Rivera, E. C. Z., Saldaña, D. M. L., García, K. D., Candil, E. M., Beltran, J. U. M., & Araujo, E. A. (2022, November). Adapting a Comprehensive ADHD Intervention and School Clinician Training Program for Fully Remote Delivery in Mexico: The CLS-R-FUERTE Program. In M. Dvorksy’s and L.M. Haack’s (Chairs) Optimizing Interventions for ADHD Using Technology: Designs to Improve Treatment Engagement and Implementation. Association for Behavioral and Cognitive Therapies Annual Convention, New York, NY,

  • Community Organizations Lead Structural Interventions Research with Novel NIH Initiative

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    By Nathan Stinson Jr., Ph.D., M.D., M.P.H.
    Director, Division of Community Health and Population Science
    National Institute on Minority Health and Health Disparities

    To make greater advances in promoting health and preventing disease among populations experiencing health disparities, NIH launched the Community Partnerships to Advance Science for Society (ComPASS) Program. The program aims to put community organizations at the helm of research programs that will help accelerate discoveries in research to improve health equity across all populations. Traditionally, academic institutions have led research efforts with engagement from community partners. ComPASS, however, is novel because it’s transformative, and it has the potential to develop a new health equity research model for community-led, multisectoral structural intervention research across NIH and other federal agencies.

    Why focus on structural interventions? What we’ve learned from decades of research on health disparities is that health inequities are deeply rooted in structures, systems and policies that create social and economic disadvantage. To accelerate progress toward reducing health disparities and advancing health equity, research efforts must focus directly and intentionally on the structural drivers of health disparities. By addressing structural determinants such as economic and social policies and resources that impact healthcare access, employment, housing and education, we can improve health, well-being and quality of life for all communities. Community organizations are vital to local structural systems due to their roles addressing structural determinants as well as their deep knowledge of the social needs, and the barriers and pathways to address those needs. By taking this community-led research approach, we hope to empower communities and researchers to work collaboratively as equal partners, in all phases of the research process.

    ComPASS is composed of three main initiatives: The Community-Led, Health Equity Structural Interventions (CHESI), The ComPASS Coordination Center (CCC), and The Health Equity Research Hubs (Hubs).

    The ComPASS program is currently accepting letters of intent (LOIs) for CHESI. CHESI represents a unique departure from the conventional model of health disparities research. Through the CHESI initiative, NIH seeks to realign the conventional power dynamic that has characterized the limited participation of community-based organizations in academic research by empowering these organizations to:

    • Guide health disparities research decision-making
    • Lead collaborative investigations into positive changes for policies, systems, programs, and practices
    • Pursue their own research ambitions
    • Collaborate with research partners of their choosing
    • Shift expectations for what structural health intervention research can look like

    At NIH, we hope to hear from organizations with good ideas and meaningful questions. Through this initiative, such organizations will have the opportunity to set the research agenda and serve as thought leaders in driving their projects of choice.

    We Want to Hear from You
    Are you a member of the biomedical or behavioral research community who works in or with community-based organizations dedicated to addressing health disparities? Are you aware of other community-based organizations with strong ideas and the passion to commit to leading a major health disparities research project? Share this unique opportunity with your colleagues and counterparts to advance health equity and change the landscape of the health disparities research field.

    LOIs for CHESI must be submitted by November 18, 2022. Select organizations will be invited to submit full applications.

    Learn more about this initiative and how your organization can drive tomorrow’s health disparities research: https://commonfund.nih.gov/sites/default/files/OTA-22-007.pdf.

  • Environmental Risk Factors for Prostate Cancer in Overburdened, Understudied Populations

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    By Lauren Hurwitz, Ph.D., MHS
    2022 Coleman Research Innovation Awardees
    National Institute on Minority Health and Health Disparities
    Postdoctoral Fellow
    National Cancer Institute

    Prostate cancer is the second most frequently diagnosed cancer among men globally, and the leading cause of cancer death among men in 48 countries, most of which are in Africa, the Caribbean, and South America1. In the United States, prostate cancer is also the cancer with the largest disparities by race, with incidence rates 60-70% higher and mortality rates 100-120% higher in Black men as compared to non-Hispanic White men2. The underlying drivers of prostate cancer racial disparities are not well understood but likely involve a complex interplay of genetic, social, structural, and environmental factors2.

    As a Postdoctoral Fellow at the National Cancer Institute (NCI), I am part of group studying environmental and occupational risk factors for prostate cancer, including how they may be inequitably distributed and contributing to these disparities. Using studies of highly exposed occupational groups in the U.S., we have been investigating pesticide exposure and its potential impact on prostate cancer risk among farmers. Evidence from the Agricultural Health Study, a large prospective cohort study, suggests that specific pesticides (certain organophosphate and organochlorine insecticides) are associated with risk of more aggressive forms of prostate cancer3, 4. Similar associations have been observed in case-control studies as well5. While informative, the prior studies have one major limitation—most studies of pesticides and prostate cancer risk have been conducted in non-Hispanic White populations.

    These prior studies indicate that exposure to specific pesticides may increase prostate cancer risk among White men. However, we do not know if these same pesticides also increase risk of prostate cancer among Black men from the U.S., or men from the Caribbean and sub-Saharan Africa, where both exposure to pesticides and prostate cancer incidence and mortality rates are particularly high. Men from different racial and ethnic groups may be exposed to different types or levels of pesticides due to different historical patterns of pesticide use within and across countries, and due to interacting social and structural factors. This was highlighted in the news recently6 in studies from the French islands of Martinique and Guadeloupe—islands with primarily African-descent populations, and some of the highest prostate cancer incidence rates in the world. These studies found a link between prostate cancer risk and chlordecone and the dichlorodiphenyltrichloroethane (DDT) metabolite DDE, organochlorine insecticides that were widely used on these islands7,8, underscoring the need to investigate pesticides and cancer risk across geographically and racially diverse populations.

    Sub-Saharan Africa is another region of the world with heavy use of pesticides and a high burden of prostate cancer, yet no epidemiologic studies to date have investigated pesticides and prostate cancer risk among African men9. Exposure to organochlorine insecticides, and specifically DDT and its metabolites, may be particularly high in sub-Saharan Africa; though most countries have now banned the use of DDT for agricultural purposes, many countries in this region still use DDT to combat mosquitos that spread malaria. Like other organochlorine insecticides, DDT is extremely persistent and known to have detrimental effects on the environment, but the human health effects of exposure are not fully understood.

    To address this gap, our group initiated a study to measure blood levels of organochlorine insecticides among men with and without prostate cancer from the Greater Accra Region of Ghana. This work is still ongoing, but our pilot results indicate that exposure to DDT in this population is ubiquitous; all samples in the pilot had detectable levels of p,p’- DDE, the primary DDT metabolite, and levels were much higher than those of men from the U.S. Overall, we hope this work will further our understanding of the relationship between pesticide exposures and prostate cancer risk, while shedding light on environmental risk factors that may disproportionately affect overburdened yet understudied populations.


    1. Sung, H., et al., Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. CA Cancer J Clin., 2021. 71(3): p. 209-249. doi: 10.3322/caac.21660. Epub 2021 Feb 4.
    2. Nyame, Y.A., et al., Deconstructing, Addressing, and Eliminating Racial and Ethnic Inequities in Prostate Cancer Care. Eur Urol, 2022. 30(22): p. 01677-3.
    3. Koutros, S., et al., Risk of total and aggressive prostate cancer and pesticide use in the Agricultural Health Study. Am J Epidemiol., 2013. 177(1): p. 59-74. doi: 10.1093/aje/kws225. Epub 2012 Nov 21.
    4. Pardo, L.A., et al., Pesticide exposure and risk of aggressive prostate cancer among private pesticide applicators. Environ Health., 2020. 19(1): p. 30. doi: 10.1186/s12940-020-00583-0.
    5. Koutros, S., et al., Prediagnostic Serum Organochlorine Concentrations and Metastatic Prostate Cancer: A Nested Case-Control Study in the Norwegian Janus Serum Bank Cohort. Environ Health Perspect., 2015. 123(9): p. 867-72. doi: 10.1289/ehp.1408245. Epub 2015 Mar 3.
    6. Whewell, T., The Caribbean islands poisoned by a carcinogenic pesticide, in BBC News. 2020.
    7. Emeville, E., et al., Associations of plasma concentrations of dichlorodiphenyldichloroethylene and polychlorinated biphenyls with prostate cancer: a case-control study in Guadeloupe (French West Indies). Environ Health Perspect., 2015. 123(4): p. 317-23. doi: 10.1289/ehp.1408407. Epub 2014 Nov 21.
    8. Multigner, L., et al., Chlordecone exposure and risk of prostate cancer. J Clin Oncol., 2010. 28(21): p. 3457-62. doi: 10.1200/JCO.2009.27.2153. Epub 2010 Jun 21.
    9. United Nations Environment Programme Chemicals, Regionally Based Assessment of Persistent Toxic Chemicals: Sub-Saharan Africa Regional Report. 2002: Switzerland.
  • Striving Towards Health Equity: Understanding the Impact of Discrimination on LGBTQ+ Communities

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    Posted on

    Updated June 27, 2022

    By Eliseo J. Pérez-Stable, M.D.
    Director, National Institute on Minority Health and Health Disparities

    For Pride Month, learn how NIMHD is working to understand health disparities that impact SGM populations

    Sexual and gender minority (SGM) populations, including those who are lesbian, gay, bisexual, transgender, or queer (LGBTQ+)1, experience health disparities and face barriers to accessing health care. SGM populations have higher burdens of certain diseases, such as depression, certain cancers, and tobacco-related conditions. But the extent and causes of health disparities are not fully known, mechanisms remain unclear, and more research on how to close these gaps is needed.

    Stigmatization, hate-related violence, and discrimination are still major barriers to the health and well-being of SGM populations. Research shows that sexual and gender minorities who live in communities with high levels of anti-SGM prejudice die sooner—12 years on average—than those living in more accepting communities.

    SGM individuals who are also from racial, ethnic, and/or immigrant minority communities may be even more vulnerable because they face similar barriers, discrimination, and health challenges that are unique to those experienced by all minority populations.

    The National Institute on Minority Health and Health Disparities (NIMHD) is dedicated to understanding the effects of these complex and dynamic intersections and supports research on the role discrimination plays in SGM health disparities. For example, in a recently published study, NIMHD researchers examined whether race and ethnicity influenced any associations that may exist between sexual minority status and substance use (tobacco, cannabis, and alcohol) disorders. Overall, sexual minority adults showed a higher prevalence of substance use and disorders. Racial and ethnic minority individuals who were bisexual showed an even stronger association than heterosexuals. In addition, African American or Black bisexual persons were more than twice as likely to be using tobacco. These results underscore the importance of studying the intersectionality of race and ethnicity with sexual orientation, and the need for increased screening and treatment of substance use disorders among sexual minority adults, especially those from racial and ethnic minority groups.

    While NIMHD continues to delve into the factors of health disparities experienced by SGM populations, large gaps in the understanding of SGM health continue to persist, in part, due to the lack of adequate, consistent, and standardized data collection of sex, sexual orientation, gender identity, and sexual behavior in research studies, administrative records, surveillance databases, and clinical settings.

    The “Don’t Ask, Don’t Know” approach to SGM populations has been a challenge in health care and clinical research. In recent years standardized sexual orientation and gender identity questions have been increasingly incorporated into epidemiological surveys and in electronic health records, so that the era of hidden from sight is ending for SGM populations in clinical and public health studies.

    In addition, the National Institutes of Health Sexual & Gender Minority Research Office, NIMHD, and 17 other components of the agency commissioned a recently published study, “Measuring Sex, Gender Identity, and Sexual Orientation.” This report serves as an important cornerstone for the scientific community to enhance its data collection and improve measurements to fully reflect community experiences and recognize the diversity of the SGM population.

    With enhanced sexual orientation and gender identity (SOGI) data collection, researchers can better track health outcomes and develop tailored prevention strategies, interventions, and treatments to ultimately improve the health and well-being of SGM individuals across the nation. We now ask and will learn to reduce disparities in the SGM community.

    NIMHD envisions an America in which all populations will have an equal opportunity to live long, healthy, and productive lives. By understanding biological, behavioral, environmental, cultural, and structural components that affect SGM health, as well as the role clinical care can play, we can best address health disparities and identify interventions that improve the overall health of the SGM community.


    1 Sexual and gender minority (SGM) populations include, but are not limited to, individuals who identify as lesbian, gay, bisexual, asexual, transgender, Two-Spirit, queer, and/or intersex. Individuals with same-sex or -gender attractions or behaviors and those with a difference in sex development are also included. These populations also encompass those who do not self-identify with one of these terms but whose sexual orientation, gender identity or expression, or reproductive development is characterized by non-binary constructs of sexual orientation, gender, and/or sex. [This study was retracted in March 2018. Details ]

  • HDPulse: A Comprehensive Resource to Access Health Disparities Data and Minority Health Resources

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    By Tilda Farhat, Ph.D., M.P.H.
    Director, Office of Science Policy, Planning, Evaluation, and Reporting
    National Institute on Minority Health and Health Disparities

    NIMHD’s redesigned HDPulse portal provides minority health and health disparities data and accompanying tools and materials.

    It has been 37 years since the release of the ground-breaking Heckler report underscoring the disproportionate burden of premature illness and death experienced by people from racial and ethnic minority groups in the U.S. Since then, great strides have been made in addressing and improving minority health and health disparities through improved data collection, research opportunities, and proven interventions. However, despite these efforts, health disparities persist and progress to date is suboptimal.

    While minority health and health disparities researchers, intervention developers, and public health professionals strive to reduce health disparities, some may have difficulty accessing data and evidence-based resources that can help them design, implement, and evaluate health disparities-related programs. They often rely on multiple sources that may differ in data quality, completeness and other important attributes. The HDPulse resource, developed by the National Institute on Minority Health and Health Disparities (NIMHD), is perhaps the most comprehensive resource that provides national, state, and county level data on minority health and health disparities, as well as evidence-based interventions and accompanying tools and materials.

    Reintroducing HDPulse Data Portal

    The HDPulse Data Portal, one of two portals on the HDPulse website, was first introduced in 2017. It has been redesigned to better serve researchers, public health professionals, and policymakers who are interested in improving minority health and reducing health disparities. The redesigned website features the continuum of health disparities outcomes (ranging from incidence to mortality) as a point of access to related statistics to identify disparities. It also organizes determinants of minority health and health disparities across four domains along the social-ecological framework:

    1. Healthcare system
    2. Knowledge, attitudes, and behavior
    3. Physical environment
    4. Social, economic, and cultural environment.

    Users will be pleased about the functionality and ease of use of the HDPulse Data Portal. The site offers user-friendly interactive mapping capabilities, charts and graphs to assess the magnitude of health disparities, explore spatial and temporal trends, and identify geographic patterns that, all together, contribute to better understanding of minority health and health disparities data over space and time. This data portal provides full public accessibility of data visualization capabilities.

    HDPulse Interventions Portal Coming Soon

    Complementing the HDPulse Data Portal is the HDPulse Interventions Portal. While the Data Portal can be used to generate a profile of a health disparity problem and to inform priority setting, the Interventions Portal allows researchers and public health practitioners to make informed decisions about appropriate interventions to use for the population impacted in a particular setting. The Interventions Portal provides access to a repository of interventions and resources that can help users design, implement, and evaluate evidence-based interventions. Minority health and health disparities researchers and intervention developers are encouraged to submit their interventions to the portal to promote and give visibility to their successful work. As noted by implementation scientist Dr. Russ Glasgow in his RE-AIM framework, while much of research informs guidelines or contributes to the development of effective interventions, these interventions are only as useful as they are actually implemented in practice. The availability of evidence-based interventions in minority health and health disparities contributes to moving research into practice.

    HDPulse Will Give Your Community a Boost

    This month’s National Minority Health Month introduces the theme “Give Your Community a Boost!” and earlier in the month, National Public Health Week (April 4-9) highlighted Public Health is Where You Are. These themes are essential features of HDPulse. The Data Portal characterizes the burden of disparities across the U.S. and within communities to facilitate identifying needs and resources to address the burden of health disparities at the national and local levels. The Interventions Portal is designed to provide researchers, community organizations, and community practitioners access to effective interventions that have improved minority health or reduced health disparities, thereby assisting in their efforts to improve the health of their communities, and giving their communities a boost.

    HDPulse is a valuable tool for anyone interested in depicting and communicating the health disparity burden within minority populations and other populations that are socially disadvantaged.

    HDPulse can assist with determining how best to control health disparities through proven interventions. The redesigned Data Portal is now available for use and the Interventions Portal will be launched later in 2022. Explore HDPulse now and give your community a boost with valuable health disparities data and minority health resources. Find additional information and resources to share at https://www.nimhd.nih.gov/resources/hd-pulse.html.

  • Boost Your Community: NIMHD’s Role in Increasing COVID-19 Vaccine Uptake and Community Interventions

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    By Eliseo J. Pérez-Stable, M.D.
    Director, National Institute on Minority Health and Health Disparities

    Dr. Eliseo J. Pérez-Stable reflects on National Minority Health Month and how NIMHD supports research projects that increase vaccine uptake.

    April is National Minority Health Month (NMHM), and this year we are joining the U.S. Department of Health and Human Services Office of Minority Health to highlight the key role individuals and organizations can play in helping to reduce health disparities and improve the health of people who are disadvantaged by social and economic conditions, geographic location, or the environment in which they live.

    This year’s theme, “Give Your Community a Boost!,” focuses on the continued importance of COVID-19 vaccination, including COVID-19 boosters, and sharing credible information as important tools to end the COVID-19 pandemic that has disproportionately affected communities already dealing with long-standing social and health inequities. Ongoing vaccination against COVID-19 is the single most important way to blunt the effects of severe disease, the consequences of stress on the health care system, and excess deaths of the most vulnerable people.

    The mission and work of NIMHD has never been more visible and crucial than it is now. NIMHD has been on the frontlines raising awareness about the connection of social determinants of health to the disproportionate impact of COVID-19 on communities experiencing health disparities. Through its mission to lead scientific research to improve minority health and reduce health disparities, NIMHD has established scientific programs to respond to many COVID-19 issues, such as evaluating interventions to promote testing through the Rapid Acceleration of Diagnostics Underserved Populations (RADx-UP) initiative, and conducting community-based research and outreach to provide trustworthy, science-based information through the Community Engagement Alliance (CEAL) Against COVID-19 Disparities. In addition, NIMHD has also supported research projects that are working to directly address misinformation, increase vaccine uptake, and evaluate interventions aimed to improve the health of communities experiencing COVID-19 health disparities across the nation.

    Impact of COVID-19 Outbreak on Minority Health and Health Disparities

    In spring 2020, shortly after the World Health Organization declared the COVID-19 outbreak a global pandemic, NIMHD announced a notice of special interest inviting researchers to apply for funding supplements to evaluate community-level interventions aimed to address the impact of the pandemic on populations that experience health disparities. A few of these supplements included:

    However, it has also become evident that the impact of the COVID-19 pandemic and the mitigation strategies implemented in response that led to closing of businesses have had significant psychosocial, behavioral, socioeconomic, and health impacts, which are exacerbated in populations that experience health disparities and in other vulnerable groups.

    To respond to this, NIMHD is supporting 6 projects through the “Community Interventions to Address the Consequences of the COVID-19 Pandemic among Health Disparity and Vulnerable Populations” funding opportunity announcement (PAR 20-237). These studies are investigating the effects of locally mandated and community-based interventions among American Indian communities, Latino/Hispanic families and day laborers, and vulnerable populations such as people who are incarcerated or homeless. A few examples of these include evaluating:

    • A point of care COVID-19 testing and education program provided by community health workers for justice-involved individuals recently released from incarceration.
    • The impact of COVID-19 mitigation strategies on non-COVID-19 health care utilization for American Indians.
    • A promotores-led intervention to increase COVID-19 mitigation practices such as physical distancing, handwashing, and use of personal protective equipment for Latino day laborers.

    Vaccine Uptake Initiative

    Responding to public health experts’ recommendation on the importance of getting a COVID-19 vaccine, NIMHD has taken a leading role in supporting research to determine which interventions are effective in increasing vaccination rates. In June 2021, NIMHD launched a vaccine uptake initiative, which funds research studies to evaluate interventions designed to promote vaccine uptake and facilitate vaccine access for populations that experience health disparities. The first set of research projects supported are evaluating interventions for African American/Black, Latino/Hispanic, and low-income populations. Using community-engaged research approaches, investigators are working with community leaders, local organizations, and trusted messengers to understand the barriers to and facilitators of receiving a COVID-19 vaccine and to address misinformation, distrust, structural barriers, and vaccine hesitancy. A few of these studies include:

    • A digital health intervention, Tough Talks COVID, for African American young adults (AA-YA) in the South that uses choose your own adventure journeys and digital storytelling to help with vaccine decision making.
    • A smartphone-based embodied conversational agent intervention for African Americans that addresses misinformation using culturally tailored messages developed in collaboration with a Black church alliance in Boston.
    • An intervention providing primary care physicians (PCP) at Federally Qualified Health Centers with educational resources, including an online library of videos, evidence-based text messaging, and concise educational materials to support PCP conversations with patients about the COVID-19 vaccine.

    The consequences of the pandemic will be felt for a very long time, and it is important that we persist and take direct and deliberate action to alleviate the effects of the pandemic. We must continue to encourage access to credible information from trusted sources and develop sustainable and effective interventions to reduce health disparities. As the Director of the Institute, I can confidently confirm NIMHD’s unwavering commitment and support to improve the health of all communities, especially those that have been disadvantaged for far too long.

  • A Different Kind of Leader

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    By Giselle Corbie, M.D., MSc
    Kenan Distinguished Professor of Social Medicine
    Director, Center for Health Equity Research
    University of North Carolina School of Medicine

    On her podcast Dr. Giselle Corbie shares her passion for learning about different leadership styles. She recently spoke with NIMHD Director Dr. Eliseo J. Pérez-Stable about what makes a leader great.

    As a female scholar of color, early in my career I often sought out leaders that embodied the characteristics that I hoped to cultivate throughout my career—a different way of leading that harnesses the power of diverse perspectives. More recently, I began reflecting on the early days of my career and wished my younger self had had access to the insights and pieces of wisdom from leaders from diverse backgrounds. While I do not have the ability to time travel, I do have a voice and passion for telling the stories of diverse leaders. It was realizing that there was still a void that those voices could fill that led to the creation of the podcast A Different Kind of Leader. For over two years, four seasons, and 48 episodes, A Different Kind of Leader (DKL) has been dedicated to featuring incredible, diverse leaders and their journeys, insights, and experiences in their personal and leadership journey. In this day and age, the problems that our organizations face are complex, and we benefit from having as many perspectives and voices as possible to help develop the most creative and sustainable solutions.

    When in the production stages for our fourth season, DKL reflected on our lineup, and we could not think of a more perfect addition than Eliseo J. Pérez-Stable, M.D., Director of the National Institute on Minority Health and Health Disparities (NIMHD) at the National Institutes of Health (NIH). Dr. Pérez-Stable shared his leadership journey from the early days of clinical work to his leadership role at the NIMHD. Throughout the episode, Dr. Pérez-Stable touched on key actions and skills that make an effective leader.

    "I think people need to be humble and not overextend themselves,” he shared, “There’s this balance of listening and trying to make sure you’re addressing all the constituents under your leadership. At the same time, you need to make decisions and exert authority."

    In addition to sharing his personal experience with leadership characteristics, Dr. Pérez-Stable also recommended listeners learn more about themselves and their personality preferences. He mentioned an example through the Myers-Briggs Typology Indicator, a self-reported inventory that helps identify how they perceive the world and make decisions. Through his own results, Dr. Pérez-Stable was better able to understand his preferences as a leader and learn to work more effectively with the range of diverse personalities on his team.

    Throughout the entire episode, Dr. Pérez-Stable shares advice on several leadership aspects and gives words of encouragement to all our listeners. “I like to use this phrase, “Learn how to say yes,” because you never know those yeses are going to lead to real change in your trajectory.” We are so thankful he said yes to share his insight and reflections on the podcast and appreciative of his time to join us for this season of A Different Kind of Leader.

  • The COVID-19 Pandemic Has Amplified the Effects of Racism on Mental Health

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    By Celia B. Fisher, Ph.D.
    Marie Ward Doty University Chair in Ethics
    Professor of Psychology
    Director, Center for Ethics Education
    Director, HIV/Drug Abuse Prevention Research Ethics Institute
    Fordham University

    Dr. Celia Fisher shares how COVID-19 is affecting the mental health of people from racial and ethnic minorities communities

    People from racial and ethnic minorities in the United States have borne a disproportionately higher burden of COVID-19 infection and mortality. During the pandemic, depression and anxiety among American Indian/Alaska Native (AI/AN), Asian, Black, and Hispanic people have also increased. These disparities are rooted in long-standing racial and ethnic inequities in medical and behavioral health treatment utilization and access to culturally relevant health services.

    Racial discrimination has long been documented as a psychosocial stressor among racial and ethnic minority individuals and national surveys indicate racism increased during the current pandemic. During the pandemic racially and ethnically marginalized persons in the U.S. were also more likely to be employed in the health care work force or as frontline workers in industries such as food services, pharmacies, personal care and public transportation. Employment in these positions not only increased risk of COVID-19 infection, but increased public perception that racial and ethnic groups were more likely to be infected with the coronavirus. Simultaneously, the U.S, saw an upsurge in racially based hate crimes, particularly directed against Asian Americans. The surge in racial bias and violence underscores the urgency of studying the effects of pandemic-related forms of victimization and discrimination on the mental health of racial and ethnic youth and adults in the U. S.

    In online national surveys involving AI/AN, Asian, Black and Hispanic adolescents and adults, my colleagues and I examined the mental health effects of coronavirus victimization distress (i.e., distress in response to being verbally or physically harassed “because someone thought I had the coronavirus”) and coronavirus-related increases in racial bias (belief that the country has become more dangerous for people in one’s racial and ethnic group because of fear of the coronavirus). Across racial and ethnic groups of adults, we found that beyond the effects of pre-existing COVID-19 health risks, any employment or employment disruption during this period (whether as an essential or “non-essential” worker) or financial, health care, and housing insecurity, coronavirus victimization distress and perceived national increases in racial biases contributed to symptoms of depression and anxiety. Perhaps not surprisingly, given the sociopolitically fomented pandemic related anti-Asian bias, Asian participants reported the highest levels of pandemic related national biases against their racial and ethnic group. Sleep quality and duration have also been associated with corresponding mental health disparities among racial and ethnic minority populations in the U.S. Compared to AI/AN, Asian, Latinx and non-Hispanic White young adults during the pandemic, Black individuals reported less hours of sleep duration and quality, explained in part by their reported higher engagement as essential workers and higher levels of reported coronavirus victimization distress.

    Racial and ethnic minority youth have also been affected by increases in racial discrimination during COVID. Pandemic shelter-at-home policies and the reignited racial justice movement increased the use of social media among youth of color, potentially exposing them to social media racial discrimination. Whereas offline civic engagement has been associated with positive development among minority youth, online racial justice activities can expose youth to anonymous actors who subject them to different forms of social media racial discrimination. During the pandemic, we found that among 15- to 18-year-old AI/AN, Asian, Black and Latinx youth, hours of use and racial justice civic engagement were associated with increased exposure to social media racial discrimination directed at them both personally and vicariously to members of their racial groups. These experiences were in turn related to increases in depressive symptoms, anxiety, and substance use.

    The COVID-19 pandemic has created new pathways to mental health disparities among adolescents and adults of color by reversing formerly protective factors such as employment and social justice civic engagement, and by exacerbating existing mental health and societal inequities linked to race. These patterns highlight the necessity of moving away from aggregated findings that may mask differences among racial groups and call for creating mental health services tailored to the specific needs of different racial and ethnic minority groups during ongoing and future health crises. The pandemic has also highlighted the importance of identifying strategies to mitigate the negative effects of social media racial discrimination on youth mental health and calls for additional public discourse on whether social media algorithms are amplifying exposure to racial bias in ways that jeopardize psychological well-being of racial and ethnic minority adolescents.


    Artiga, S., Hill, L., & Halar, S. (2021). COVID-19 cases and deaths by race/ethnicity: Current data and changes over time. https://www.kff.org/racial-equity-and-health-policy/issue-brief/covid-19-cases-and-deaths-by-race-ethnicity-current-data-and-changes-over-time/

    Ballard, P. J., Hoyt, L. T. & & Pachucki, M. C. (2019). Impacts of adolescent and young adult civic engagement on health and socioeconomic status in adulthood. Child Development, 90, 1138-1154. doi: 10.1111/cdev.12998

    Fisher, C. B., Tao, X., Liu, T., Giorgi, S., & Curtis, B. L. (2021). COVID-Related Victimization, Racial Bias and Employment and Housing Disruption Increase Mental Health Risk Among US Asian, Black and Latinx Adults. Frontiers in Public Health, 1625. doi: 10.3389/fpubh.2021.772236.

    Fisher, C. B., Tao., & Yip, T. (2020, preprint). The effects of coronavirus victimization distress and coronavirus racial bias on mental health among AIAN, Asian, Black and Latinx young adults. https://doi.org/10.1101/2020.08.19.20178343

    Fisher, C. B., & Yip, T. (2020). The coronavirus racial bias scale (CRBS). https://www.phenxtoolkit.org/toolkit_content/PDF/Fordham_CRBS_2021.pdf

    Fisher, C. B. & Yip, T. (2020). The coronavirus victimization distress scale (CVDS). https://www.phenxtoolkit.org/toolkit_content/PDF/Fordham_CVDS_2021.pdf

    McKnight-Eily, L. R., Okoro, C. A., Strine, T. W., Verlenden, J., Hollis, N. D., Njai, R., Mitchell, E. W., Board, A., Puddy, R., & Thomas, C. (2021). Racial and Ethnic Disparities in the Prevalence of Stress and Worry, Mental Health Conditions, and Increased Substance Use Among Adults During the COVID-19 Pandemic—United States, April and May 2020. Morbidity and Mortality Weekly Report, 70(5), 162. https:// doi: 10.15585/mmwr.mm7005a3

    Paine, L., de la Rocha, P., Eyssallenne, A. P, Andrews, C. A., Loo, L. Jones, C. P., Collins, A. M., & orse, M. (2021). Declaring racism a public health crises in the United States: Cure, poison, or both. Frontiers in Public Health, https://doi.org/10.3389/fpubh.2021.676784

    Tao, X., & Fisher, C. B. (2021). Exposure to social media racial discrimination and mental health among adolescents of color. Journal of Youth and Adolescence. https://doi.org/10.1007/s10964-021-01514-z

    Yip, T., Feng, Y., Fowle, J. & Fisher, C. B. (2021). Sleep disparities during the COVID-19 pandemic An Investigation of AIAN, Asian, Black, Latinx and White young adults. Sleep Health: Journal of the National Sleep Foundation, 7, 459-467. https://doi.org/10.1016/j.sleh.2021.05.008

    Yip T., Cheon, Y.M. (2020). Sleep, psychopathology and cultural diversity. Curr Opin Psychol, 34:123-127. doi: 10.1016/j.copsyc.2020.02.006. Epub 2020 Feb 22. PMID: 32203913; PMCID: PMC7308190.