Ethnicity and Health Disparities

1
Ethnicity and Health Disparities

• Eliseo J. Pérez-Stable, M.D.
• Professor of Medicine, UCSF
• April 9, 2002

2
Summary of Presentation

• Race and/or Ethnicitywhat to ask
• Social Class, Wealth, Discrimination
• Determinants of Health Disparities
• Latino Paradox
• Cardiovascular Disease
• Smoking and Cancer
• Factors in Communication

3
Definition of Race

• Societally constructed taxonomy that reflects
  intersection of particular historical conditions
  with economic, political, legal, social and
  cultural factors, as well as racism.
• David Williams, PhD, 1994

4
Ethnicity is Preferred Terminology

• Race as a biological construct is invalid and
  should be abandoned
• Ethnicity refers to self-identity with a
  group--this is consistent with diversity in the
  U.S.
• National background, cultural identity

5
Validity of Health Statistics for Racial and
Ethnic Groups

• Validity of health statistics for racial/ethnic
  minority groups based on 4 assumptions
• categories of racial/ethnic subgroups are
  consistently defined and ascertained
• categories are understood by the populations
• survey enumeration and response rates are
  similar
• responses of persons are consistent over time and
  across data sources.
• Problems especially in American Indian, Latino
  and Asian/PI populations
• Problem due to growing multicultural population

6
Why is it Important to Study Race and Ethnicity?

• Public health surveillance - to assess the impact
  of morbidity and mortality for specific groups
  given their disproportionately higher incidence
  and mortality
• Race/ethnicity need to be uniformly assessed to
  monitor the impact of organizational changes in
  the health care system (managed care) on quality
  of care for vulnerable groups
• Given the increasing evidence of treatment
  disparities, we need to track processes and
  outcomes of care by race and ethnicity (often not
  collected by medical intake staff due to privacy)

7
Implications for Research on Race/Ethnicity

• Race and ethnicity data should be collected and
  analyzed to assess their relationship to
  potential intervening variables, e.g. SES, health
  behaviors, access to care, knowledge,
  discrimination
• Self-identification should be the gold standard
  method of identifying race/ethnicity for
  consistency and to avoid under reporting
• Need to clearly state reason for analyzing data
  by race/ethnicity
• Method of measuring race/ethnicity should be
  clearly described
• Need to over sample ethnic groups or perform
  targeted surveys to address issues of unreliable
  estimates associated with small sample sizes and
  to facilitate within group analysis.
• Definitions and methods of measurement of race
  and ethnicity should be determined by the
  usefulness of various approaches

8
OMB Directive 15

• Sets guidelines for the collection of racial and
  ethnic categories to provide for the collection
  and use of compatible, nonduplicated,
  exchangeable racial and ethnic data by Federal
  agencies.
• Bureau of Census has treated race and ethnicity
  as 2 separate constructs and follow Directive 15
  guidelines that state
• Federal agencies must collect data on at least 4
  racial groups white, black, American Indian and
  Alaska Native, and Asian/Pacific Islander and on
  1 ethnic group Hispanic

9
1990 U.S. Census

• Ethnicity question
• Is this person of Spanish/Hispanic origin?
• Fill ONE circle for each person
• Ethnicity response options
• o No (not Spanish/Hispanic
• o Yes, Mexican, Mexican-Am., Chicano
• o Yes, Puerto Rican
• o Yes, Cuban
• o Yes, other Spanish/Hispanic (Print one group,
  for example Argentinean, Colombian, Dominican,
  Nicaraguan, Salvadoran, Spaniard, and so on.)

10
1990 U.S. Census

• Race question
• Fill ONE circle for the race that the person
  considers himself/herself to be.
• Race response options
• o White
• o Black or Negro
• o Indian (Amer.) (Print the name of the enrolled
  or principal tribe.)
• o Eskimo
• o Aleut
• Asian or Pacific Islander (API)
• o Chinese o Japanese o Filipino
• o Asian Indian o Hawaiian o Samoan
• o Korean o Guamanian o Vietnamese
• o Other API (write in)
• o Other race (Print race) ___

11
2000 U.S. Census

• New OMB standards
• allow for reporting more than 1 race
• separate Asian or Pacific Islander into 2
  categories Asian and Native Hawaiian or Other
  Pacific Islander
• change term Hispanic to Hispanic or Latino
• change black to black or African American
• strongly endorse self-identification
• maintain 2 question format for race and Hispanic
  ethnicity with Hispanic origin question preceding
  race question.

12
2000 U.S. Census

• Ethnicity question
• Is this person Spanish/Hispanic Latino? Mark X
  the No box if not Spanish/Hispanic/Latino
• Ethnicity response options
• o No, not Spanish/Hispanic/Latino
• o Yes, Mexican, Mexican-Am., Chicano
• o Yes, Puerto Rican
• o Yes, Cuban
• o Yes, other Spanish/Hispanic/Latino - Print
  one group.

13
2000 U.S. Census

• Race question
• What is this persons race? Mark one or more
  races to indicate what this person considers
  himself/herself to be.
• Race response options
• o White
• o Black, African Am., or Negro
• o American Indian or Alaska Native - Print name
  of enrolled or principal tribe.
• o Asian Indian o Korean o Samoan
• o Chinese o Vietnamese o Other Pacific
  Islander -
• o Filipino o Native Hawaiian Print race.
• o Japanese o Guamanian or Chamorro
• o Other Asian - Print race.
• o Some other race - Print race.

14
Social Class Measures

• Education and income are insufficient measures of
  social class
• Wealthassets, property
• Generation of class1st in family to attend
  college, earn above .
• Community measures are needed segregation,
  safety, inequality, acculturation

15
Measurement of Social Class

• Collect socioeconomic data at 3 levels
  individual, household and neighborhood
• Evidence that neighborhood measures of SES result
  in increased risk of death controlling for
  individual measures of income, race, employment,
  risk behaviors, social support, and psychological
  factors
• Indicates sociophysical environment may
  contribute independent of individual factors

16
Measurement of Social Class

• May need to look at changes in SES over time
• health outcomes may be related to childhood or
  adult SES or both, or age at entry into the labor
  market
• Socioeconomic variation in levels of psychosocial
  and environmental risk factors (health behaviors,
  stressors, self-efficacy, sense of control)
  appears to be relatively small in early
  adulthood, greater during middle and early old
  age, and then smaller again in older age

17
Inconsistency of Data Collection

• Prior to 1989, birth statistics reported infant
  race according to complex algorithm with
  information about race from both parents. Post
  1989, only mothers race is used.
• Funeral directors are responsible for recording
  race of decedent by consulting next of kin
• Most rates are calculated with census population
  estimates as the denominator which depends on
  self-identification.
• Inconsistencies in terminology and methodologies
• In 1990 Census, of 10 million reporting Other
  Race, 98 self-identified as Hispanic
• Misclassification at time of death varies from
  23.7 of American Indians and 21 of Asians
  compared to .5 of whites and 1 of African
  Americans

18
Residential Factors

• House JS, et al (2000) national probability
  sample
• For whites, living in urban area resulted in
  excess mortality relative to small-town residents
  among men, but not women suburbanites had
  intermediate risk
• Among African American men and to some degree
  among African American women, suburban residence
  carried the greatest risk (House JS, 2000)

19
Social Class and Race/Ethnicity

• Has race been a substitute for defining social
  class in the U.S.?
• Gradient of health outcomes at all levels within
  race/ethnic group--especially true for African
  Americans
• Does Ethnicity (Race) matter?
• How does the biology interact?

20
Race and Education

• Charleston Health Study less education not RF
  for CAD mortality
• Education stronger RF than race in other studies
• Correlation with life expectancy in pts gt 65 is
  stronger than race
• Accounts for observed racial difference survival
  from Cancer

21
TB Rate Ratio by EthnicityDemographics and SES
22
Perception of DiscriminationDoes It Affect
Health?

• Physical and mental health status of African
  Americans--U.S.
• Administering analgesics to Latinos with long
  bone fractures--UCLA
• Obtaining technical services
  Revascularization procedures for CAD
• Surgery for lung cancer
• Renal Transplants for ESRD

23
Race and Biology

• More genetic variance within than between racial
  groups
• Most diseases are multi-factorial
• Gene pool predisposition often confused with
  racial characteristic
• HTN in Caribbean Blacks lt Whites lt Southern AA
• Fang, NEJM,
  19963351545

24
Lets just forget for a moment that youre
black.
25
Determinants of Disparities

• Demographic, Social, Biological

26
Adverse Demographic Profile

• Less household income on average
• Less wealth at every level of income
• Fewer average years of education
• Fewer college graduates
• More single-parent households
• Lower functional health literacy
• Limited English proficiency

27
Access to Health Care Services

• Rate of uninsured among California Latinos 18 to
  64 y is 40
• More primary care physicians in the higher
  income, predominantly White urban neighborhoods
• Hospitalization rate for ambulatory care
  sensitive conditions varies

28
Cancer Incidence by Ethnicity, U.S., 1988-92(per
100,000 population, age-adjusted)
29
LBW Rates (), by Ethnicity
Fuentes-Afflick E and Lurie P, Arch Pediatr
Adolesc Med 1997
30
Explanations for Ethnic Disparities in Health

• Poverty-explains much but not all eg, infant
  mortality gap is just as wide or wider between
  higher income, college-educated African Americans
  and whites as for poorer counterparts babies of
  poor West African immigrants survive just as well
  as whites
• Sense of control-
• British Whitehall study in civil servants found
  that with every rise on power and position, there
  was a corresponding rise in health and life
  expectancy
• Same economic ladder is found in within ethnic
  groups in the U.S., but often not evident because
  Latinos and African Americans have 3 times the
  poverty rates of whites and smaller middle and
  upper income groups

31
Explanations for Ethnic Disparities in Health

• Racism-
• can involve a loss of sense of control
• even crude self-reported measures linked to
  health outcomes
• Less or poorer health care
• even within system, (HMOs, VA, and Medicare pop.)
  studies have found ethnic differences
• Genes
• Dangerous or stressful environments
• Risky behaviors

32
The Latino Paradox

• SES Model is Not Perfect

33
Latinos in the U.S.

• More similarities than differences
• Central role of Spanish language
• Cultural themes unify
• Racial admixture500 years
• Common heritage
• Catholic Church Spain

34
Death Rate by Ethnicity, US 1996

• W AA L A/PI
• Heart Disease 130 191 89 72
• Stroke 25 44 20 24
• Diabetes 12 29 19 9
• Age-adjusted per 100,000 NCHS

35
Behavioral Risk Factor Surveillance 1997

• Median percent by Ethnicity
• W B L
• Hypertension 23 31 19
• Diabetes 4.4 7.6 5.5
• No Leisure
• time PA 25 38 37
• Smoker 24 23 23

36
NHANES III Hypertension Rate

• Men Women Total
• Mexican Am 23 22 23
• African Am 34 31 32
• White 25 21 23
• Burt Hypertension 1995 25305

37
Role of AcculturationNHANES III Are Bicultural
Latinos at highest risk?

• Mexican Americans born in the US and speaking
  Spanish had higher adjusted SBP than English
  speaking- 123.9 vs. 121.5 mm Hg
• US born Spanish speaking was significant in
  logistic regression models for men and women for
  SBP, BMI and current smoking
• Sundquist, AJPH 1999 89723

38
Latino Paradox in CV Disease

• Lower SES by income, education
• More Obesity especially women
• More Diabetes2 to 4 times
• Less Physical Activity
• Hypertension rate similar
• Less heart disease

39
Is culture a protective factor?

• Differences in health status are not predicted by
  known risk factors
• Lower heart disease mortality rates despite
  higher cardiovascular risk
• Unidentified factors that are protective against
  chronic diseases?
• Increased acculturation may be bad for
  healthespecially for women

40
Measures of Acculturationand Cultural Factors

• Studies need to isolate changes in health and
  health behaviors associated with contextual
  factors (exogenous factors) that shape them,
  i.e., immigration experience, minority status,
  racism, and health practices due to internalized
  individual level cultural factors (endogenous)
• Measures rely heavily on language-based and
  global indicators
• May reflect a variety of factors income,
  education, access, language proficiency and
  preference, ethnic identification, cultural
  attitudes
• Do not identify changes in cultural norms that
  may affect health behaviors

41
Surrogate measures

• Surrogate measures of acculturation and
  enculturation often used in research
• ethnicity
• generation
• birthplace
• years in the U.S.
• Need to develop reliable and valid indicators of
  cultural factors that measure specific changes
  associated with sociodemographic markers

42
Methodological Challenges

• Links between socioeconomic position and health
  may be affected by discrimination, acculturation,
  migration, generational status, English fluency
• Because of the complexity of these relationships,
  we need more complete measures and improved
  statistical methods for understanding complex
  interrelated variables

43
CHD Prediction Scores By EthnicityColor in
Framingham?

• Applied sex specific CHD functions to 6
  ethnically diverse cohorts
• White and Black men and women prediction of CHD
  events works well
• Japanese Latino men and American Indian men
  womenrisk is overestimated
• Adjust for different rates of risk factors and
  underlying rate of CHD
• JAMA 2001 286180-7

44
Cardiac Interventions and African Americans

• What Factors Explains the Data

45
Cardiac Procedures--VA

46
Duke --Procedures

• Used angiography results to adjust for disease
  severity
• 12,400 patients, 10.3 AA, 1984-92
• Similar number of diseased vessels
• Decreased EF W 19, B 25, plt0.01
• Severe disease W 43, B 39, p0.02
• Peterson, NEJM 1997336480

47
Procedures-- Duke

• PTCA OR 1.15 (1.37-0.97)
• CABG OR 1.47 (1.79-1.22)
• Either OR 1.54 (1.79-1.32)
• Adjusted for age, sex, CHF,MI, HTN, DM,
  cholesterol, angina, EF, severity score, admit
  service, year
• Peterson, NEJM 1997336480

48
Any Revascularization By Number of Diseased
Arteries
NS

49
Duke -- Outcomes

• 5-year mortality higher in AA patients 27 vs
  20 p lt 0.001
• Adjustment for prognostic factors
• B/W Mortality RR 1.18 (1.05-1.32)
• Adj for treatment RR 1.08 (0.97-1.20)
• Peterson, NEJM 1997
  336480

50
Cardiac Procedures SummaryDifferences by Race

• AA receive fewer procedures than W
• Racial difference greatest for CABG
• Suggestion that AA decline CABG
• Suggestion of racial bias in decision
  makingSchulman study
• Fewer procedures (medications) results in worse
  outcomes
• Not different by race of treating MD

51
Cigarette Smoking and Cancer

• Health Disparities May Have Biological as well as
  Behavioral Explanations

52
Cigarette Smoking in the U.S. 1999National
Health Interview Survey
53
Ethnic Differences in Serum Cotinine Levels
NHANES 3
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54
Latino Smoking BehaviorSummary of Convenient
Sample Research

• lower rates compared to Anglos
• average fewer cigarettes per day
• less likely to smoke due to habitual cues
• as likely to smoke due to emotional cues
• more likely to want to quit because of
• cigarette smoke's effects on others
  interpersonal relations
• own health

55
Multivariate Model Results for Latino Ethnicity
Reasons to Quit or Continue
OR 95 CI Criticized by
family 1.93 (1.26, 2.98) Burn
clothes 1.57 (1.02, 2.42) Children's'
health 1.67 (1.08, 2.57) Bad
breath 2.07 (1.40, 3.06) Family
pressure 1.69 (1.10, 2.60) Good
example 1.83 (1.21, 2.76) Not to gain
weight 0.38 (0.24, 0.59)
56
Cancer Incidence by Site and Ethnicity in Men,
U.S. 1988-1992(per 100,000 age-adjusted)
57
Nicotine Metabolism and Intake in African
Americans

• African Americans have 50 more lung cancer and
  higher cotinine levels per cigarette despite
  fewer cigarettes/day
• Total and renal clearance of cotinine were 20
  lower in African Americans
• Nicotine intake per cigarette was 30 greater in
  African Americans
• JAMA 1999280152-56

58
Nicotine Metabolism in Chinese and Latinos

• Metabolic clearance of nicotine and cotinine in
  Latinos was similar to Whites and lower among
  Chinese
• Intake of nicotine per cigarette
• Chinese 0.73 mg (0.53 to 0.94)
• Latinos 1.05 mg (0.85 to 1.25)
• Whites 1.10 (0.91 to 1.30)
• Nicotine intake tobacco smoke

59
Cancer Incidence by Site and Ethnicity in Women,
U.S. 1988-1992(per 100,000 age-adjusted)
60
Factors in Communication

• The Generalist Approach to Health Disparities

61
Ethnicity in Patient-Doctor Relationship

• Refusal whose issue?
• DNR discussionsRace independent RF for DNR
  discussion in HIV patients
• Nonwhite patients discuss DNR more if physician
  is also nonwhite
• Studies on bias in decision making
• Analgesia in ED after fracture

62
Ethnicity and Attitudes toward Patient Autonomy
among Persons 65 yrs
63
Flu/Pneumonia Vaccination RatesIn Persons ? 65
years old by Ethnicity
(please use the "respond to all" so we all
know...thanks!)
Source Behavioral Risk Factor Surveillance
System, United States, 1999. MMWR 200150532-7
64
Language Matters

• Monolingual Spanish speaking patients with
  Spanish speaking physicians feel better
• Patients using interpreters ask less, say less,
  answer less
• Language fluency is a gradient
• Literacy, understanding, jargon

65
Health Related Quality of Life by Ethnicity - Los
Angeles 1999
Poor and Unhealthy Activity N
Fair Health Days Limitation D White
3376 13.1 7.1 2.7 Latino
3267 35.6 6.3 2.4 AA 835 21.2
8.3 3.5 API 716 15.3 4.7
1.7 MMWR 2001 50556-9
66
Minority Physicians in California

• Practice in areas with fewer doctors
• Practice in areas with higher percent minorities
• Provide care for more uninsured and MediCal
  patients
• 2000 Medical school graduates 10
• Population 30
• Cultural and linguistic competency

67
Do SES and Race Influence MD Perceptions of
Patients?

• Patient race was associated with MDs perception
  of patients intelligence, feelings of
  affiliation toward the patient, and beliefs about
  patients likelihood of adherence with medical
  advice and likelihood of risky behaviors
• Patient SES was associated with MD perceptions of
  patients personality, abilities, behavioral
  tendencies, and role demands

68
Do SES and Race Influence MD Perceptions of
Patients?

• Very little research on how patient demographic
  characteristics affect MD perceptions
• A study of 842 patient encounters with 73 of MDs
  responding found that MDs tended to perceive
  African Americans and those of low and middle SES
  groups more negatively than whites and upper SES
  patients. (Ryn M, Burke J, 2000)

69
Factors to Consider in Treatment of Latinos

• Familismo - Helps Adherence?
• Simpatía Cultural Script for positive
  interpersonal interactions
• Personalismoinformal friendliness
• Confianza trust
• Respeto For Authority of MD

70
discrimination color
ancestry

• income nationality
• beliefs
  education
• birth place
• gene pool RACE Ethnicity biology
• status history
• genetics wealth
  culture
• other health seeking behavior