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1.  Reinterpreting Ethnic Patterns among White and African American Men Who Inject Heroin: A Social Science of Medicine Approach 
PLoS Medicine  2006;3(10):e452.
Street-based heroin injectors represent an especially vulnerable population group subject to negative health outcomes and social stigma. Effective clinical treatment and public health intervention for this population requires an understanding of their cultural environment and experiences. Social science theory and methods offer tools to understand the reasons for economic and ethnic disparities that cause individual suffering and stress at the institutional level.
Methods and Findings
We used a cross-methodological approach that incorporated quantitative, clinical, and ethnographic data collected by two contemporaneous long-term San Francisco studies, one epidemiological and one ethnographic, to explore the impact of ethnicity on street-based heroin-injecting men 45 years of age or older who were self-identified as either African American or white. We triangulated our ethnographic findings by statistically examining 14 relevant epidemiological variables stratified by median age and ethnicity. We observed significant differences in social practices between self-identified African Americans and whites in our ethnographic social network sample with respect to patterns of (1) drug consumption; (2) income generation; (3) social and institutional relationships; and (4) personal health and hygiene. African Americans and whites tended to experience different structural relationships to their shared condition of addiction and poverty. Specifically, this generation of San Francisco injectors grew up as the children of poor rural to urban immigrants in an era (the late 1960s through 1970s) when industrial jobs disappeared and heroin became fashionable. This was also when violent segregated inner city youth gangs proliferated and the federal government initiated its “War on Drugs.” African Americans had earlier and more negative contact with law enforcement but maintained long-term ties with their extended families. Most of the whites were expelled from their families when they began engaging in drug-related crime. These historical-structural conditions generated distinct presentations of self. Whites styled themselves as outcasts, defeated by addiction. They professed to be injecting heroin to stave off “dopesickness” rather than to seek pleasure. African Americans, in contrast, cast their physical addiction as an oppositional pursuit of autonomy and pleasure. They considered themselves to be professional outlaws and rejected any appearance of abjection. Many, but not all, of these ethnographic findings were corroborated by our epidemiological data, highlighting the variability of behaviors within ethnic categories.
Bringing quantitative and qualitative methodologies and perspectives into a collaborative dialog among cross-disciplinary researchers highlights the fact that clinical practice must go beyond simple racial or cultural categories. A clinical social science approach provides insights into how sociocultural processes are mediated by historically rooted and institutionally enforced power relations. Recognizing the logical underpinnings of ethnically specific behavioral patterns of street-based injectors is the foundation for cultural competence and for successful clinical relationships. It reduces the risk of suboptimal medical care for an exceptionally vulnerable and challenging patient population. Social science approaches can also help explain larger-scale patterns of health disparities; inform new approaches to structural and institutional-level public health initiatives; and enable clinicians to take more leadership in changing public policies that have negative health consequences.
Bourgois and colleagues found that the African American and white men in their study had a different pattern of drug use and risk behaviors, adopted different strategies for survival, and had different personal histories.
Editors' Summary
There are stark differences in the health of different ethnic groups in America. For example, the life expectancy for white men is 75.4 years, but it is only 69.2 years for African-American men. The reasons behind these disparities are unclear, though there are several possible explanations. Perhaps, for example, different ethnic groups are treated differently by health professionals (with some groups receiving poorer quality health care). Or maybe the health disparities are due to differences across ethnic groups in income level (we know that richer people are healthier). These disparities are likely to persist unless we gain a better understanding of how they arise.
Why Was This Study Done?
The researchers wanted to study the health of a very vulnerable community of people: heroin users living on the streets in the San Francisco Bay Area. The health status of this community is extremely poor, and its members are highly stigmatized—including by health professionals themselves. The researchers wanted to know whether African American men and white men who live on the streets have a different pattern of drug use, whether they adopt varying strategies for survival, and whether they have different personal histories. Knowledge of such differences would help the health community to provide more tailored and culturally appropriate interventions. Physicians, nurses, and social workers often treat street-based drug users, especially in emergency rooms and free clinics. These health professionals regularly report that their interactions with street-based drug users are frustrating and confrontational. The researchers hoped that their study would help these professionals to have a better understanding of the cultural backgrounds and motivations of their drug-using patients.
What Did the Researchers Do and Find?
Over the course of six years, the researchers directly observed about 70 men living on the streets who injected heroin as they went about their usual lives (this type of research is called “participant observation”). The researchers specifically looked to see whether there were differences between the white and African American men. All the men gave their consent to be studied in this way and to be photographed. The researchers also studied a database of interviews with almost 7,000 injection drug users conducted over five years, drawing out the data on differences between white and African men. The researchers found that the white men were more likely to supplement their heroin use with inexpensive fortified wine, while African American men were more likely to supplement heroin with crack. Most of the white men were expelled from their families when they began engaging in drug-related crime, and these men tended to consider themselves as destitute outcasts. African American men had earlier and more negative contact with law enforcement but maintained long-term ties with their extended families, and these men tended to consider themselves as professional outlaws. The white men persevered less in attempting to find a vein in which to inject heroin, and so were more likely to inject the drug directly under the skin—this meant that they were more likely to suffer from skin abscesses. The white men generated most of their income from panhandling (begging for money), while the African American men generated most of their income through petty crime and/or through offering services such as washing car windows at gas stations.
What Do These Findings Mean?
Among street-based heroin users, there are important differences between white men and African American men in the type of drugs used, the method of drug use, their social backgrounds, the way in which they identify themselves, and the health risks that they take. By understanding these differences, health professionals should be better placed to provide tailored and appropriate care when these men present to clinics and emergency rooms. As the researchers say, “understanding of different ethnic populations of drug injectors may reduce difficult clinical interactions and resultant physician frustration while improving patient access and adherence to care.” One limitation of this study is that the researchers studied one specific community in one particular area of the US—so we should not assume that their findings would apply to street-based heroin users elsewhere.
Additional Information.
Please access these Web sites via the online version of this summary at
The US Centers for Disease Control (CDC) has a web page on HIV prevention among injection drug users
The World Health Organization has collected documents on reducing the risk of HIV in injection drug users and on harm reduction approaches
The International Harm Reduction Association has information relevant to a global audience on reducing drug-related harm among individuals and communities
US-focused information on harm reduction is available via the websites of the Harm Reduction Coalition and the Chicago Recovery Alliance
Canada-focused information can be found at the Street Works Web site
The Harm Reduction Journal publishes open-access articles
The CDC has a web page on eliminating racial and ethnic health disparities
The Drug Policy Alliance has a web page on drug policy in the United States
PMCID: PMC1621100  PMID: 17076569
2.  The role of the African-American physician in reducing traffic-related injury and death among African Americans: consensus report of the National Medical Association. 
ISSUE: Traffic-related injuries and fatalities disproportionately affect the African American community. These high rates of traffic-related death and injury among African Americans manifest in multiple areas of traffic safety, including: Failure to use seat belts and child restraints. High incidence of alcohol-impaired driving. Failure to follow child passenger and seat belt safety laws and recommendations. High rates of pedestrian accidents, ofen brought on by impairments of drivers and/or pedestrians. Research indicates that national public information campaigns, with general messages only slightly modified for African American audiences, have not been culturally appropriate or effective in changing traffic safety behavior. In addition, traditional distribution mechanisms for these messages have not effectively reached the target population. Evidence suggests that in the African American community, there is a pervasive lack of knowledge of the devastating impact of traffic-related accidents on the overall health status of the community. This lack of information has resulted in a tragic cycle, in which parents fail to model safe operation of motor vehicles, and generation after generation copy this behavior, increasing the community's vulnerability to serious injuries and untimely deaths. This trend toward improper traffic safety habits among African Americans persists despite federal, state and local laws to enforce and promote sound traffic safety practices. OBJECTIVE: To study the existence of disparities in traffic-related injury and death among African Americans and to determine what kinds of traffic safety messages and campaigns will be effective in encouraging African Americans to respond to safety laws in sufficient numbers to reduce the disproportionately high rate of injury and death. Traffic safety issues were examined to effectively recommend policy, address barriers, best practices, and intervention strategies for the National Medical Association, its physician members, their patients, and their communities. CONSENSUS PROCESS: A literature review, driven by research instruments from numerous organizations included reports and materials from the National Highway Traffic Safety Administration (NHTSA), American Academy of Pediatrics, National Committee for Injury Prevention and Control, U.S. Centers for Disease Control and Prevention (CDC), Mothers Against Drunk Driving (MADD), and the National SAFE KIDS Campaign. Both the Meharry Medical College report, Achieving a Credible Health and Safety Approach to Increasing Seat Belt Use Among African-Americans, and the U.S. Department of Transportation's Blue Ribbon Panel to Increase Seat Belt Use Among African Americans: A Report to the Nation, provided substantial background for the panel. More than 60 pieces of traffic safety literature have been examined to date. Based on the literature review, a short list of the most relevant issues affecting African Americans and traffic safety was devised. It includes: The disproportionately high rate of traffic-related injury and death among African Americans. The cost in health, monetary costs and other associated costs of traffic safety accidents and injuries. The number of traffic-related injuries and deaths that could be prevented if more African Americans observed good traffic safety practices. Barriers to practicing good traffic safety habits among African Americans. Failure of laws and public information campaigns to influence improved traffic safety practices among African Americans sufficient to reduce disparities in traffic-related injury and death. In July 2001, NMA convened a consensus panel of experts in St. Thomas, U.S. Virgin Islands, to review a briefing document summarizing the most salient traffic safety issues among African Americans. The panel elaborated on key issues, including existing policy and standards for the use of child restraint devices to secure infants and toddlers, existing data regarding disparities in traffic-related injury and death among African Americans, and the cultural, age and developmental appropriateness of existing safety campaigns. SUMMARY: Public information campaigns have successfully improved traffic safety practices among the general public but in large part have been unsuccessful among minority populations-including African Americans. This may be due to: A failure to use techniques and messages that are culturally sensitive to African Americans. Campaigns that have targeted geographic and social centers where African Americans are not broadly present. Lack of awareness of the disproportionate effect motor vehicle crashes are having on African Americans. Scientifically based, culturally appropriate intervention strategies need to be devised and implemented by African American institutions and organizations to improve traffic safety practices and reduce the high rate of traffic-related injury and deaths among African Americans.
PMCID: PMC2594128  PMID: 11858225
3.  Relationship of African Americans' sociodemographic characteristics to belief in conspiracies about HIV/AIDS and birth control. 
Although prior research shows that substantial proportions of African Americans hold conspiracy beliefs, little is known about the subgroups of African Americans most likely to endorse such beliefs. We examined the relationship of African Americans' sociodemographic characteristics to their conspiracy beliefs about HIV/AIDS and birth control. Anonymous telephone surveys were conducted with a targeted random-digit-dial sample of 500 African Americans (15-44 years) in the contiguous United States. Respondents reported agreement with statements capturing beliefs in HIV/AIDS conspiracies (one scale) and birth control conspiracies (two scales). Sociodemographic variables included gender, age, education, employment, income, number of people income supports, number of living children, marital/cohabitation status, religiosity and black identity. Multivariate analyses indicated that stronger HIV/AIDS conspiracy beliefs were significantly associated with male gender, black identity and lower income. Male gender and lower education were significantly related to black genocide conspiracy beliefs, and male gender and high religiosity were significantly related to contraceptive safety conspiracy beliefs. The set of sociodemographic characteristics explained a moderately small amount of the variance in conspiracy beliefs regarding HIV/AIDS (R2 range=0.07-0.12) and birth control (R2 range=0.05-0.09). Findings suggest that conspiracy beliefs are not isolated to specific segments of the African-American population.
PMCID: PMC2569474  PMID: 16895286
4.  Knowledge, beliefs and barriers associated with prostate cancer prevention and screening behaviors among African-American men. 
African-American men have the highest prostate cancer rates worldwide, and innovative efforts are needed to increase cancer prevention and screening behaviors among this population. Formative research was conducted to assess attitudes and behaviors linked to prostate cancer prevention activities that could be used to develop a culturally relevant intervention for an African-American church-based population. Four gender-specific focus groups were conducted with 29 men and women at two African-American churches in central North Carolina. Three primary themes emerged from the focus group discussions: culturally and gender-influenced beliefs and barriers about cancer prevention and screening; barriers related to the healthcare system: and religious influences, including the importance of spiritual beliefs and church support. These discussions revealed the importance of the black family, the positive influence of spouses/partners on promoting cancer screening and healthy behaviors, the roles of faith and church leadership, and beliefs about God's will for good health. These findings also revealed that there are still major barriers and challenges to cancer prevention among African Americans, including continued mistrust of the medical community and negative attitudes toward specific screening tests. Findings provide important insights to consider in implementing successful prostate cancer prevention interventions designed for church-based audiences.
PMCID: PMC2569547  PMID: 16916126
5.  Patient-Centered mHealth Living Donor Transplant Education Program for African Americans: Development and Analysis 
JMIR Research Protocols  2015;4(3):e84.
There is a critical need to expand the pool of available kidneys for African Americans who are on the transplant wait-list due to the disproportionally lower availability of deceased donor kidneys compared with other races/ethnic groups. Encouraging living donation is one method to fill this need. Incorporating mHealth strategies may be a way to deliver educational and supportive services to African American transplant-eligible patients and improve reach to those living in remote areas or unable to attend traditional group-session-based programs. Before program development, it is essential to perform formative research with target populations to determine acceptability and cultivate a patient-centered and culturally relevant approach to be used for program development.
The objectives of this study were to investigate African American kidney transplant recipients’ and kidney donors’/potential donors’ attitudes and perceptions toward mobile technology and its viability in an mHealth program aimed at educating patients about the process of living kidney donation.
Using frameworks from the technology acceptance model and self-determination theory, 9 focus groups (n=57) were administered to African Americans at a southeastern medical center, which included deceased/living donor kidney recipients and living donors/potential donors. After a demonstration of a tablet-based video education session and explanation of a group-based videoconferencing session, focus groups examined members’ perceptions about how educational messages should be presented on topics pertaining to the process of living kidney donation and the transplantation. Questionnaires were administered on technology use and perceptions of the potential program communication platform. Transcripts were coded and themes were examined using NVivo 10 software.
Qualitative findings found 5 major themes common among all participants. These included the following: (1) strong support for mobile technology use; (2) different media formats were preferred; (3) willingness to engage in video chats, but face-to-face interaction sometimes preferred; (4) media needs to be user friendly; (5) high prevalence of technology access. Our results show that recipients were willing to spend more time on education than the donors group, they wanted to build conversation skills to approach others, and preferred getting information from many sources, whereas the donor group wanted to hear from other living donors. The questionnaires revealed 85% or more of the sample scored 4+ on a 5-point Likert scale, which indicates high degree of interest to use the proposed program, belief that other mHealth technologies would help with adherence to medical regimens, and doctors would make regimen adjustments quicker. In addition, high utilization of mobile technology was reported; 71.9% of the participants had a mobile phone and 43.9% had a tablet.
Our study supports the use of an mHealth education platform for African Americans to learn about living donation. However, potential recipients and potential donors have differing needs, and therefore, programs should be tailored to each target audience.
PMCID: PMC4705021  PMID: 26265532
kidney transplantation; living donors; mobile apps; qualitative research; telemedicine
6.  Effects of gender-matching and racial self-labeling on paranoia in African-American men with severe mental illness. 
OBJECTIVE: The present study examined the effects of gender-matching and racial self-labeling on the paranoid symptoms of African-American men with severe mental illness. It was hypothesized that gender matching would: 1) reduce self-reports of both interpersonal and cultural paranoia in these male participants with severe mental illness, and 2) the gender effect would be strongest among those patients who racially self-label as African-American. METHOD: One-hundred-twenty-four African-American male psychiatric patients were interviewed by a male or female black psychologist. A multivariate analysis of variance (MANOVA) was conducted with the Fenigstein Paranoia Scale (FPS) and Cultural Mistrust Inventory (CMI) as dependent variables, and the male gender-matched group (0=no, 1=yes) and racial self-labeling as the independent variables controlling for age; education; never married (0=no, 1=yes); diagnosis of schizophrenia (0=no, 1=yes); need for approval; self-esteem; and the scales of Distrust, Perceived Hostility of Others, and False Beliefs and Perceptions from the Psychiatric Epidemiology Research Interview. RESULTS: There was a significant main effect for male gender-matching on the FPS. Participants in the male gender-matched group scored lower than the other group on the FPS. For the CMI, there was a significant interaction of male gender match by racial self-labeling effect. Participants who were male gender-matched and self-labeled as African-American reported the highest scores on the CMI. CONCLUSION: The findings provide partial support for the hypotheses. Both gender-matching and racial identity together may be important considerations for black males needing mental health services.
PMCID: PMC2569233  PMID: 16623068
7.  What makes African American health disparities newsworthy? An experiment among journalists about story framing 
Health Education Research  2011;26(6):937-947.
News stories reporting race-specific health information commonly emphasize disparities between racial groups. But recent research suggests this focus on disparities has unintended effects on African American audiences, generating negative emotions and less interest in preventive behaviors (Nicholson RA, Kreuter MW, Lapka C et al. Unintended effects of emphasizing disparities in cancer communication to African-Americans. Cancer Epidemiol Biomarkers Prev 2008; 17: 2946–52). They found that black adults are more interested in cancer screening after reading about the progress African Americans have made in fighting cancer than after reading stories emphasizing disparities between blacks and whites. This study builds on past findings by (i) examining how health journalists judge the newsworthiness of stories that report race-specific health information by emphasizing disparities versus progress and (ii) determining whether these judgments can be changed by informing journalists of audience reactions to disparity versus progress framing. In a double-blind-randomized experiment, 175 health journalists read either a disparity- or progress-framed story on colon cancer, preceded by either an inoculation about audience effects of such framing or an unrelated (i.e. control) information stimuli. Journalists rated the disparity-frame story more favorably than the progress-frame story in every category of news values. However, the inoculation significantly increased positive reactions to the progress-frame story. Informing journalists of audience reactions to race-specific health information could influence how health news stories are framed.
PMCID: PMC3219884  PMID: 21911844
8.  The Utility of Cancer-Related Cultural Constructs to Understand Colorectal Cancer Screening Among African Americans 
Data suggest that colorectal cancer could be cut by approximately 60% if all people aged 50 years or older received regular screening. Studies have identified socio-cultural attitudes that might inform cancer education and screening promotion campaigns. This article applies item response theory (IRT) to a set of survey items selected to assess sociocultural attitudes in order to determine how current measures may affect what we know about how these attitudes affect colorectal cancer screening (CRCS).
Design and Methods
A survey of colorectal cancer screening, screening attitudes and cultural beliefs was administered to 1021 African Americans – 683 women and 338 men, ages 50 to 75. Eligibility criteria for participation included being born in the United States, self-identified African American male or female, age 50 to 75 years. The IRT analysis was performed on 655 individuals with complete data for the 43 observed variables.
Twenty-nine items comprise the Multi-construct African American Cultural Survey (MAACS) that addresses seven cultural constructs: mistrust/distrust, privacy, ethnic identity, collectivism, empowerment, and male gender roles. The items provide adequate information about the attitudes of the population across most levels of the constructs assessed. Among the sociocultural variables considered, empowerment (OR=1.078; 95% CI: 1.008, 1.151) had the strongest association with CRCS adherence and privacy showed promise.
The MAACS provides a fixed length questionnaire to assess African American CRCS attitudes, two new constructs that might assist in CRCS promotion, and a suggested focus for identification of additional constructs of interest.
Significance for public healthThe 29 items of the Multi-construct African American Cultural Survey, identified through IRT analyses, can be used by community health researchers interested in determining the relevance of cultural constructs in the design and implementation of colorectal cancer screening programs in the African American community. With appropriate identification of sociocultural concerns, CRC health education materials and promotion strategies may avoid unnecessary conflicts with community beliefs and values. Avoiding conflicts between beliefs and values increases the likelihood that evidence and the recommended behaviours are considered for adoption. In addition, the short survey, as well as the broader item set, may be useful as a starting point for surveys to be used with other cancer sites. The application of IRT analysis to measures of cultural constructs to facilitate the development of accurate and efficient measures may prove useful in other racial/ethnic communities where cultural concerns may be relevant for health education and promotion.
PMCID: PMC4147735  PMID: 25170482
cancer; cultural beliefs; colorectal cancer; screening; African American
9.  Sociocultural Differences and Colorectal Cancer Screening Among African American Men and Women 
Oncology Nursing Forum  2012;39(1):100-107.
To examine sociocultural factors that influence an informed decision about colorectal cancer (CRC) screening among African American men and women.
Descriptive, cross-sectional.
A medical center, a National Cancer Institute-designated comprehensive cancer center, and various social organizations and barbershops in a midwestern city of the United States.
A purposive sample of African American women (n = 65) and African American men (n = 64) aged 50 years and older.
Participants completed a self-administered survey.
Main Research Variables
Cultural identity, CRC beliefs, family support, and informed decision.
Family support was positively related to CRC beliefs among participants, and CRC beliefs were positively related to an informed decision. However, among men, family support positively related to an informed decision about CRC screening. In addition, t-test results indicated that the men and women were significantly different. Family support predicted CRC beliefs among men (p < 0.01) and women (p < 0.01). CRC beliefs predicted CRC screening informed decisions among men (p < 0.01) and women (p < 0.05). However, the accounted variance was dissimilar, suggesting a difference in the impact of the predictors among the men and women.
Family support has a significant impact on CRC beliefs about CRC screening among African Americans. However, how men and women relate to the variables differs.
Implications for Nursing
To improve CRC screening rates, informed decision-making interventions for African Americans should differ for men and women and address family support, CRC beliefs, and elements of cultural identity.
PMCID: PMC3354616  PMID: 22201660
10.  Health status among black African-born women in Kansas City: a preliminary assessment 
BMC Research Notes  2015;8:540.
Health information and statistics for Black foreign-born women in the United States are under-reported or not available. Black foreign-born women typically are classified under the general category of African American, ignoring the heterogeneity that exists in the United States Black population. It is important to identify health issues and behaviors of African-born women to effectively address health disparities.
Black African-born women (N = 29), 20 years or older completed a survey about general and women’s health, health history, acculturation, lifestyle, social and health challenges, beliefs about breast cancer. Data were analyzed using SPSS 14.0 software. Categorical variables were summarized with frequencies and percentages and continuous variables were summarized with means and standard variation. A Likert scale (strongly agree, agree, disagree, and strongly disagree) was used to assess beliefs about breast cancer.
Most (71.4 %) participants had a high school education or more, 70 % were employed, and 50 % had health insurance. Two-thirds received health care from primary care doctors, 20.7 % from health departments, and 39.3 % got annual checkups. Lack of jobs, healthcare cost, language barrier, discrimination, and child care were the top social issues faced by participants. High blood pressure, obesity, oral health, HIV/AIDS, and diabetes were indicated as the most common health problems. The percent of participants (60 %) that had not had a mammogram within the previous 2 years was more than the state average (24 %) for women 40 years and older reported by the Kansas Department of Health and Environment. The percent of participants (40 %) that had a mammogram within the previous 2 years was lower than the national average (73.2 %) for African American women.
Study provides a snapshot of social concerns and health issues in an African population residing in Midwestern United States. Understanding the socio-cultural characteristics of this population is necessary to address health disparities.
PMCID: PMC4594965  PMID: 26437935
Women’s health; Health disparities; African-born women’s health
11.  The African American Women and Mass Media Campaign: A CDC Breast Cancer Screening Project 
Journal of women's health (2002)  2012;21(11):1107-1113.
For decades, black radio has reached African American communities with relevant, culturally appropriate information, and it continues to be an ideal communication channel to use for contemporary health promotion. In an effort to combat excess breast cancer mortality rates and help eliminate cancer disparities among low-income African American women, the Centers for Disease Control and Prevention’s (CDC) Division of Cancer Prevention and Control designed, implemented, and evaluated the African American Women and Mass Media (AAMM) pilot campaign. The AAMM campaign uses black radio, radio stations with broad African American listenership, as a platform for targeted, culturally competent health promotion and outreach to low-income, African American women. The AAMM campaign uses radio advertisements and print materials disseminated in predominantly African American neighborhoods to promote awareness of breast cancer, early detection, and the CDC’s National Breast and Cervical Cancer Early Detection Program (NBCCEDP). Evaluation of the AAMM campaign found that the campaign successfully reached its target audience of low-income, African American women and increased women’s awareness of breast cancer screening services through the Breast and Cervical Cancer Program in Savannah and Macon, Georgia.
PMCID: PMC4568548  PMID: 23072329
12.  Intervention Approaches for Addressing Breast Cancer Disparities among African American Women 
African American women in the U.S. have a higher mortality rate from breast cancer than white women. Black-white differences in survival persist even after accounting for disease stage and tumor characteristics suggesting that the higher rates of breast cancer mortality are due to social factors. Several factors may account for racial differences in breast cancer mortality including socioeconomic factors, access to screening mammography and timely treatment, and biological factors. Efforts to prevent deaths from breast cancer and to address breast cancer disparities have focused on early detection through routine mammography and timely referral for treatment. There is a need for culturally appropriate, tailored health messages for African American women to increase their knowledge and awareness of health behaviors for the early detection of breast cancer. Several promising intervention approaches are reviewed in this article including: 1) the use of cell phone text messaging and smart phone apps to increase breast cancer screening; 2) the use of radio stations that target African American audiences (“black radio”) for health promotion activities; and 3) church-based behavioral interventions to promote breast cancer screening among African American women.
PMCID: PMC4283773  PMID: 25568890
African Americans; Breast cancer; Cell phone; Church; Disparities; Mammography; Mass media; Survival
13.  The Malawi Developmental Assessment Tool (MDAT): The Creation, Validation, and Reliability of a Tool to Assess Child Development in Rural African Settings 
PLoS Medicine  2010;7(5):e1000273.
Melissa Gladstone and colleagues evaluate the reliability and validity of an assessment tool for evaluating child development in rural African settings.
Although 80% of children with disabilities live in developing countries, there are few culturally appropriate developmental assessment tools available for these settings. Often tools from the West provide misleading findings in different cultural settings, where some items are unfamiliar and reference values are different from those of Western populations.
Methods and Findings
Following preliminary and qualitative studies, we produced a draft developmental assessment tool with 162 items in four domains of development. After face and content validity testing and piloting, we expanded the draft tool to 185 items. We then assessed 1,426 normal rural children aged 0–6 y from rural Malawi and derived age-standardized norms for all items. We examined performance of items using logistic regression and reliability using kappa statistics. We then considered all items at a consensus meeting and removed those performing badly and those that were unnecessary or difficult to administer, leaving 136 items in the final Malawi Developmental Assessment Tool (MDAT). We validated the tool by comparing age-matched normal children with those with malnutrition (120) and neurodisabilities (80). Reliability was good for items remaining with 94%–100% of items scoring kappas >0.4 for interobserver immediate, delayed, and intra-observer testing. We demonstrated significant differences in overall mean scores (and individual domain scores) for children with neurodisabilities (35 versus 99 [p<0.001]) when compared to normal children. Using a pass/fail technique similar to the Denver II, 3% of children with neurodisabilities passed in comparison to 82% of normal children, demonstrating good sensitivity (97%) and specificity (82%). Overall mean scores of children with malnutrition (weight for height <80%) were also significantly different from scores of normal controls (62.5 versus 77.4 [p<0.001]); scores in the separate domains, excluding social development, also differed between malnourished children and controls. In terms of pass/fail, 28% of malnourished children versus 94% of controls passed the test overall.
A culturally relevant developmental assessment tool, the MDAT, has been created for use in African settings and shows good reliability, validity, and sensitivity for identification of children with neurodisabilities.
Please see later in the article for the Editors' Summary
Editors' Summary
Babies can do very little when they are first born. But, gradually, over the first few years of life, they learn to walk and run (gross motor skills), they learn to manipulate objects with their hands (fine motor skills), they learn to communicate with words and gestures (language skills), and they learn how to interact with other people (social skills). For each of these skill “domains,” experts have identified “developmental milestones,” skills that are acquired by a specific age if development is proceeding normally. So, for example, by one year, a child should be able crawl, put objects into a container, respond to simple verbal requests, and enjoy imitating people during play. Every child attains the various developmental milestones at a slightly different age but their overall development can be monitored using a series of simple tests (items) covering each of the developmental domains. Clinicians and teachers can use these “developmental assessment tools” to identify children whose development deviates significantly from the norm. It is important to identify these children as young as possible because early intervention can help them reach their full developmental potential.
Why Was This Study Done?
In developing countries, poverty, poor health, and malnutrition are responsible for millions of children failing to reach their developmental potential. But because developmental assessment tools have mainly been designed and validated in western, developed countries, they contain many items that are alien to children in non-western cultures (for example, the use of knives and forks for eating and the use of specific gestures). They cannot, therefore, accurately assess whether a child living in, for example, a rural area of Africa, is developing normally. In this study, the researchers describe the creation and testing of a culturally appropriate developmental assessment tool for use in rural Africa—the Malawi Developmental Assessment Tool (MDAT)—from a 162-item draft tool (MDAT Draft I) that they previously developed from Denver II, an assessment tool widely used in developed countries.
What Did the Researchers Do and Find?
The researchers assessed the “face validity” (do the items look acceptable to untrained judges?) and “content validity” (does the tool examine all the domains it is meant to measure?) of MDAT Draft I and modified it to produce MDAT Draft II. After piloting this version on 80 children in rural Malawi, they modified it further to produce MDAT Draft III, which was used to assess 1,426 normal children aged 0–6 years from rural Malawi and to derive age-standardized norms for each item. After statistically analyzing the performance of each item in MDAT Draft III, all the items were considered at a consensus meeting, and items that were badly performing, unnecessary, and difficult to administer were removed, leaving 136 items (MDAT). The researchers then validated MDAT by using it to assess children with neurodisabilities (disorders of the nervous system that impair normal functioning) and children with delayed development because of malnutrition. The tool was reliable (different testers got similar results for individual children and individual testers got similar results when they retested specific children), sensitive (it correctly identified most children with a neurodisability or delayed development), and specific (it correctly identified most children who were developing normally; that is, it did not give false-positive results).
What Do These Findings Mean?
These findings show that MDAT is a culturally relevant assessment tool that reliably identifies children with neurodisabilities and delayed development in rural Malawi. Importantly, they also provide a detailed illustration of how to create and validate a culturally relevant assessment tool. Although MDAT is likely to be applicable in other similar settings, further research is needed to test its generalizability and to test whether it will work in children with more subtle developmental problems. MDAT, the researchers note, should be useful as a clinical tool for the early identification of neurodisabilities and as an outcome measure in clinical trials of interventions designed to improve child development. However, they stress, because developing countries have limited resources available for screening and for helping children whose development is delayed or disrupted, for now tools like MDAT are more likely to be used for research studies than for routine developmental assessments in Malawi and other African countries.
Additional Information
Please access these Web sites via the online version of this summary at
The World Health Organization has information on disability, prevention, and management in children and adults worldwide
UNICEF has a site on early childhood and in particular, provides information on programming experiences for early child intervention programs worldwide
Disability World is a website for international views and perspectives on disability worldwide. It provides information and links about the worldwide state of disability in children and adults in developing countries
Source, the International Information Support Centre has a good website of information about disability, inclusion, and development in children with links to many other sources of information
Wikipedia has a page on child development (note that Wikipedia is a free online encyclopedia that anyone can edit; available in several languages)
The US Centers for Disease Control and Prevention provides information on developmental screening and on developmental milestones
The American Academy of Pediatrics also provides information on developmental stages and on developmental milestones
The UK National Health Service Choices site has an interactive guide to child development
MedlinePlus has links to further resources on infant and toddler development (in English and Spanish)
PMCID: PMC2876049  PMID: 20520849
14.  Black newspapers as a tool for cancer education in African American communities 
Ethnicity & disease  2008;18(4):488-495.
Despite the long history, wide reach and unique influence of Black newspapers in many African American communities, no national studies have examined how these newspapers cover health and cancer issues, or reader perceptions of their coverage.
Design and Participants
A two-year national sample of Black newspapers (n=24) and community-matched general audience newspapers (n=12) was reviewed, and 8,690 health and cancer stories were identified and content analyzed. A survey of 783 Black newspaper readers in the same 24 communities assessed reading frequency and perceptions of reporting for both types of newspapers, as well as readers’ health concerns and cancer screening behaviors.
As a proportion of total health coverage, Black newspapers published more cancer stories than general audience newspapers, and their stories were more likely to contain localized information, address disparities, focus on prevention, include calls to action for readers and refer readers to cancer information resources (all p<.001). Black newspaper readers identified cancer as the health issue that concerned them most, yet rated it the fourth most important health problem affecting African Americans.
Black newspapers hold promise for helping eliminate cancer disparities by increasing cancer awareness, prevention, and screening among African Americans.
PMCID: PMC3955182  PMID: 19157255
Black newspaper; African Americans; cancer disparities; news
15.  Healthy Eating and Risks of Total and Cause-Specific Death among Low-Income Populations of African-Americans and Other Adults in the Southeastern United States: A Prospective Cohort Study 
PLoS Medicine  2015;12(5):e1001830.
A healthy diet, as defined by the US Dietary Guidelines for Americans (DGA), has been associated with lower morbidity and mortality from major chronic diseases in studies conducted in predominantly non-Hispanic white individuals. It is unknown whether this association can be extrapolated to African-Americans and low-income populations.
Methods and Findings
We examined the associations of adherence to the DGA with total and cause-specific mortality in the Southern Community Cohort Study, a prospective study that recruited 84,735 American adults, aged 40–79 y, from 12 southeastern US states during 2002–2009, mostly through community health centers that serve low-income populations. The present analysis included 50,434 African-Americans, 24,054 white individuals, and 3,084 individuals of other racial/ethnic groups, among whom 42,759 participants had an annual household income less than US$15,000. Usual dietary intakes were assessed using a validated food frequency questionnaire at baseline. Adherence to the DGA was measured by the Healthy Eating Index (HEI), 2010 and 2005 editions (HEI-2010 and HEI-2005, respectively). During a mean follow-up of 6.2 y, 6,906 deaths were identified, including 2,244 from cardiovascular disease, 1,794 from cancer, and 2,550 from other diseases. A higher HEI-2010 score was associated with lower risks of disease death, with adjusted hazard ratios (HRs) of 0.80 (95% CI, 0.73–0.86) for all-disease mortality, 0.81 (95% CI, 0.70–0.94) for cardiovascular disease mortality, 0.81 (95% CI, 0.69–0.95) for cancer mortality, and 0.77 (95% CI, 0.67–0.88) for other disease mortality, when comparing the highest quintile with the lowest (all p-values for trend < 0.05). Similar inverse associations between HEI-2010 score and mortality were observed regardless of sex, race, and income (all p-values for interaction > 0.50). Several component scores in the HEI-2010, including whole grains, dairy, seafood and plant proteins, and ratio of unsaturated to saturated fatty acids, showed significant inverse associations with total mortality. HEI-2005 score was also associated with lower disease mortality, with a HR of 0.86 (95% CI, 0.79–0.93) when comparing extreme quintiles. Given the observational study design, however, residual confounding cannot be completely ruled out. In addition, future studies are needed to evaluate the generalizability of these findings to African-Americans of other socioeconomic status.
Our results showed, to our knowledge for the first time, that adherence to the DGA was associated with lower total and cause-specific mortality in a low-income population, including a large proportion of African-Americans, living in the southeastern US.
In a prospective cohort study, Wei Zheng and colleagues study the association between adherence to dietary guidelines and mortality in low-income US adults, two thirds of whom are African-Americans.
Editors' Summary
Certain parts of the population, including women, children, ethnic and racial minorities, and poor people, are often underrepresented in clinical trials and in epidemiological studies (which examine the patterns, causes, and effects of health and disease conditions). In the US population, the link between diet and health has mostly been studied in non-Hispanic white individuals from middle- and high-income households. Such studies formed the basis for the Dietary Guidelines for Americans (DGA), and more recently have shown that adherence to the DGA is associated with lower levels of obesity, as well as lower risks for diabetes, cardiovascular disease (such as heart attacks and strokes), and certain cancers. To measure adherence to the DGA, the Center for Nutrition Policy and Promotion at the US Department of Agriculture developed the Healthy Eating Index (HEI) in 1995. The DGA and the HEI have been updated several times, and the HEI-2010—the latest version—reflects the 2010 DGA.
Why Was This Study Done?
Because research participants are often not representative of the entire US population, it is unknown whether the results of many studies are valid for all Americans. To remedy this situation, efforts have been made to recruit participants from previously underrepresented parts of the population and to address important health questions in such groups. For this study, the researchers wanted to examine whether adherence to the DGA was associated with better health outcomes in poor people and African-Americans, consistent with the results in wealthier non-Hispanic white individuals.
What Did the Researchers Do and Find?
The researchers analyzed data from the Southern Community Cohort Study (SCCS). The SCCS was funded by the National Cancer Institute and was initiated in 2001 with the goal of addressing unresolved questions about the causes of cancer and other chronic diseases, as well as reasons for health disparities. The SCCS recruited most of its participants from community health centers in 12 states in the southeastern US. These centers serve predominantly poor and uninsured people, including many African-Americans. Of approximately 85,000 SCCS participants, over two-thirds were African-American, and over half were poor, with an annual household income of less than US$15,000.
For this study, the researchers used a food frequency questionnaire that was designed to capture foods commonly consumed in the southeastern US, and from this calculated HEI-2010 scores for each participant. They also collected other health- and lifestyle-related information. They then followed all participants for whom they had complete information (over 77,000) for a number of years (half of them for over 6.2 years). During that period, 6,906 participants died; including 2,244 from cardiovascular disease, 1,794 from cancer, and 2,550 from other diseases. When the researchers tested for a possible association between HEI-2010 and death (controlling for other relevant factors such as age, weight, exercise, smoking, and the presence of specific chronic diseases), they found that participants with a higher HEI-2010 score (reflecting better adherence to the DGA) had a lower risk of dying in the follow-up period. Participants with the healthiest diet (those in the top one-fifth of HEI-2010 scores) had only about 80% of the risk of death of those with the unhealthiest diets (those in the bottom one-fifth of HEI-2010 scores). This reduction in the risk of death by approximately 20% was true for death from any disease, death from cancer, and death from cardiovascular disease.
What Do These Findings Mean?
The results support the validity of the DGA for healthy eating across the US population. However, the study had some limitations. For example, participants were asked only once—when they first joined the SCCS—about their diet, their household income, and other factors that can change over time, such as exercise habits and diseases they have been diagnosed with. Besides such changes, there could be other factors not captured in the study that might influence the association between diet and death. Despite these uncertainties, the findings suggest that adherence to the DGA is associated with lower total mortality and mortality from cancer or cardiovascular disease in poor US Americans in general, and in low-income African-Americans.
Additional Information
Please access these websites via the online version of this summary at
Information is available online about the Southern Community Cohort Study
The US Department of Agriculture’s Center for Nutrition Policy and Promotion has information on the Healthy Eating Index, which is based on the Dietary Guidelines for Americans
The World Health Organization provides information on diet as part of its global strategy for diet, physical activity, and health, as well as a factsheet on healthy diet
Wikipedia has a page on race and health in the US (note that Wikipedia is a free online encyclopedia that anyone can edit)
PMCID: PMC4444091  PMID: 26011727
16.  Heart Disease and Stroke Statistics—2011 Update 
Circulation  2010;123(4):e18-e209.
Each year, the American Heart Association (AHA), in conjunction with the Centers for Disease Control and Prevention, the National Institutes of Health, and other government agencies, brings together the most up-to-date statistics on heart disease, stroke, other vascular diseases, and their risk factors and presents them in its Heart Disease and Stroke Statistical Update. The Statistical Update is a valuable resource for researchers, clinicians, healthcare policy makers, media professionals, the lay public, and many others who seek the best national data available on disease morbidity and mortality and the risks, quality of care, medical procedures and operations, and costs associated with the management of these diseases in a single document. Indeed, since 1999, the Statistical Update has been cited more than 8700 times in the literature (including citations of all annual versions). In 2009 alone, the various Statistical Updates were cited ≈1600 times (data from ISI Web of Science). In recent years, the Statistical Update has undergone some major changes with the addition of new chapters and major updates across multiple areas. For this year’s edition, the Statistics Committee, which produces the document for the AHA, updated all of the current chapters with the most recent nationally representative data and inclusion of relevant articles from the literature over the past year and added a new chapter detailing how family history and genetics play a role in cardiovascular disease (CVD) risk. Also, the 2011 Statistical Update is a major source for monitoring both cardiovascular health and disease in the population, with a focus on progress toward achievement of the AHA’s 2020 Impact Goals. Below are a few highlights from this year’s Update.
Death Rates From CVD Have Declined, Yet the Burden of Disease Remains High
The 2007 overall death rate from CVD (International Classification of Diseases 10, I00–I99) was 251.2 per 100 000. The rates were 294.0 per 100 000 for white males, 405.9 per 100 000 for black males, 205.7 per 100 000 for white females, and 286.1 per 100 000 for black females. From 1997 to 2007, the death rate from CVD declined 27.8%. Mortality data for 2007 show that CVD (I00–I99; Q20–Q28) accounted for 33.6% (813 804) of all 2 243 712 deaths in 2007, or 1 of every 2.9 deaths in the United States.
On the basis of 2007 mortality rate data, more than 2200 Americans die of CVD each day, an average of 1 death every 39 seconds. More than 150 000 Americans killed by CVD (I00–I99) in 2007 were <65 years of age. In 2007, nearly 33% of deaths due to CVD occurred before the age of 75 years, which is well before the average life expectancy of 77.9 years.
Coronary heart disease caused ≈1 of every 6 deaths in the United States in 2007. Coronary heart disease mortality in 2007 was 406 351. Each year, an estimated 785 000 Americans will have a new coronary attack, and ≈470 000 will have a recurrent attack. It is estimated that an additional 195 000 silent first myocardial infarctions occur each year. Approximately every 25 seconds, an American will have a coronary event, and approximately every minute, someone will die of one.
Each year, ≈795 000 people experience a new or recurrent stroke. Approximately 610 000 of these are first attacks, and 185 000 are recurrent attacks. Mortality data from 2007 indicate that stroke accounted for ≈1 of every 18 deaths in the United States. On average, every 40 seconds, someone in the United States has a stroke. From 1997 to 2007, the stroke death rate fell 44.8%, and the actual number of stroke deaths declined 14.7%.
In 2007, 1 in 9 death certificates (277 193 deaths) in the United States mentioned heart failure.
Prevalence and Control of Traditional Risk Factors Remains an Issue for Many Americans
Data from the National Health and Nutrition Examination Survey (NHANES) 2005–2008 indicate that 33.5% of US adults ≥20 years of age have hypertension (Table 7-1). This amounts to an estimated 76 400 000 US adults with hypertension. The prevalence of hypertension is nearly equal between men and women. African American adults have among the highest rates of hypertension in the world, at 44%. Among hypertensive adults, ≈80% are aware of their condition, 71% are using antihypertensive medication, and only 48% of those aware that they have hypertension have their condition controlled.
Despite 4 decades of progress, in 2008, among Americans ≥18 years of age, 23.1% of men and 18.3% of women continued to be cigarette smokers. In 2009, 19.5% of students in grades 9 through 12 reported current tobacco use. The percentage of the nonsmoking population with detectable serum cotinine (indicating exposure to secondhand smoke) was 46.4% in 1999 to 2004, with declines occurring, and was highest for those 4 to 11 years of age (60.5%) and those 12 to 19 years of age (55.4%).
An estimated 33 600 000 adults ≥20 years of age have total serum cholesterol levels ≥240 mg/dL, with a prevalence of 15.0% (Table 13-1).
In 2008, an estimated 18 300 000 Americans had diagnosed diabetes mellitus, representing 8.0% of the adult population. An additional 7 100 000 had undiagnosed diabetes mellitus, and 36.8% had prediabetes, with abnormal fasting glucose levels. African Americans, Mexican Americans, Hispanic/Latino individuals, and other ethnic minorities bear a strikingly disproportionate burden of diabetes mellitus in the United States (Table 16-1).
The 2011 Update Expands Data Coverage of the Obesity Epidemic and Its Antecedents and Consequences
The estimated prevalence of overweight and obesity in US adults (≥20 years of age) is 149 300 000, which represents 67.3% of this group in 2008. Fully 33.7% of US adults are obese (body mass index ≥30 kg/m2). Men and women of all race/ethnic groups in the population are affected by the epidemic of overweight and obesity (Table 15-1).
Among children 2 to 19 years of age, 31.9% are overweight and obese (which represents 23 500 000 children), and 16.3% are obese (12 000 000 children). Mexican American boys and girls and African American girls are disproportionately affected. Over the past 3 decades, the prevalence of obesity in children 6 to 11 years of age has increased from ≈4% to more than 20%.
Obesity (body mass index ≥30 kg/m2) is associated with marked excess mortality in the US population. Even more notable is the excess morbidity associated with overweight and obesity in terms of risk factor development and incidence of diabetes mellitus, CVD end points (including coronary heart disease, stroke, and heart failure), and numerous other health conditions, including asthma, cancer, degenerative joint disease, and many others.
The prevalence of diabetes mellitus is increasing dramatically over time, in parallel with the increases in prevalence of overweight and obesity.
On the basis of NHANES 2003–2006 data, the age-adjusted prevalence of metabolic syndrome, a cluster of major cardiovascular risk factors related to overweight/obesity and insulin resistance, is 34% (35.1% among men and 32.6% among women).
The proportion of youth (≤18 years of age) who report engaging in no regular physical activity is high, and the proportion increases with age. In 2007, among adolescents in grades 9 through 12, 29.9% of girls and 17.0% of boys reported that they had not engaged in 60 minutes of moderate-to-vigorous physical activity, defined as any activity that increased heart rate or breathing rate, even once in the previous 7 days, despite recommendations that children engage in such activity ≥5 days per week.
Thirty-six percent of adults reported engaging in no vigorous activity (activity that causes heavy sweating and a large increase in breathing or heart rate).
Data from NHANES indicate that between 1971 and 2004, average total energy consumption among US adults increased by 22% in women (from 1542 to 1886 kcal/d) and by 10% in men (from 2450 to 2693 kcal/d; see Chart 19-1).
The increases in calories consumed during this time period are attributable primarily to greater average carbohydrate intake, in particular, of starches, refined grains, and sugars. Other specific changes related to increased caloric intake in the United States include larger portion sizes, greater food quantity and calories per meal, and increased consumption of sugar-sweetened beverages, snacks, commercially prepared (especially fast food) meals, and higher energy-density foods.
The 2011 Update Provides Critical Data Regarding Cardiovascular Quality of Care, Procedure Utilization, and Costs
In light of the current national focus on healthcare utilization, costs, and quality, it is critical to monitor and understand the magnitude of healthcare delivery and costs, as well as the quality of healthcare delivery, related to CVDs. The Update provides these critical data in several sections.
Quality-of-Care Metrics for CVDs
Chapter 20 reviews many metrics related to the quality of care delivered to patients with CVDs, as well as healthcare disparities. In particular, quality data are available from the AHA’s “Get With The Guidelines” programs for coronary artery disease and heart failure and the American Stroke Association/ AHA’s “Get With the Guidelines” program for acute stroke. Similar data from the Veterans Healthcare Administration, national Medicare and Medicaid data and National Cardiovascular Data Registry Acute Coronary Treatment and Intervention Outcomes Network - “Get With The Guidelines” Registry data are also reviewed. These data show impressive adherence with guideline recommendations for many, but not all, metrics of quality of care for these hospitalized patients. Data are also reviewed on screening for cardiovascular risk factor levels and control.
Cardiovascular Procedure Utilization and Costs
Chapter 21 provides data on trends and current usage of cardiovascular surgical and invasive procedures. For example, the total number of inpatient cardiovascular operations and procedures increased 27%, from 5 382 000 in 1997 to 6 846 000 in 2007 (National Heart, Lung, and Blood Institute computation based on National Center for Health Statistics annual data).
Chapter 22 reviews current estimates of direct and indirect healthcare costs related to CVDs, stroke, and related conditions using Medical Expenditure Panel Survey data. The total direct and indirect cost of CVD and stroke in the United States for 2007 is estimated to be $286 billion. This figure includes health expenditures (direct costs, which include the cost of physicians and other professionals, hospital services, prescribed medications, home health care, and other medical durables) and lost productivity resulting from mortality (indirect costs). By comparison, in 2008, the estimated cost of all cancer and benign neoplasms was $228 billion ($93 billion in direct costs, $19 billion in morbidity indirect costs, and $116 billion in mortality indirect costs). CVD costs more than any other diagnostic group.
The AHA, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current data available in the Statistics Update. The 2007 mortality data have been released. More information can be found at the National Center for Health Statistics Web site,
Finally, it must be noted that this annual Statistical Update is the product of an entire year’s worth of effort by dedicated professionals, volunteer physicians and scientists, and outstanding AHA staff members, without whom publication of this valuable resource would be impossible. Their contributions are gratefully acknowledged. Véronique L. Roger, MD, MPH, FAHAMelanie B. Turner, MPHOn behalf of the American Heart Association Heart Disease and Stroke Statistics Writing Group
Note: Population data used in the compilation of NHANES prevalence estimates is for the latest year of the NHANES survey being used. Extrapolations for NHANES prevalence estimates are based on the census resident population for 2008 because this is the most recent year of NHANES data used in the Statistical Update.
PMCID: PMC4418670  PMID: 21160056
AHA Statistical Update; cardiovascular diseases; epidemiology; risk factors; statistics; stroke
17.  The Potential of Black Radio to Disseminate Health Messages and Reduce Disparities 
Preventing Chronic Disease  2010;7(4):A87.
Radio stations that target African American audiences ("black radio") reach a national African American audience daily, making black radio an ideal medium for health promotion and disparities reduction in the African American community. Black radio can be used to communicate public health messages and to recruit African Americans into public health research.
PMCID: PMC2901585  PMID: 20550845
18.  Pain coping skills training for African Americans with osteoarthritis (STAART): study protocol of a randomized controlled trial 
African Americans bear a disproportionate burden of osteoarthritis (OA), with higher prevalence rates, more severe pain, and more functional limitations. One key barrier to addressing these disparities has been limited engagement of African Americans in the development and evaluation of behavioral interventions for management of OA. Pain Coping Skills Training (CST) is a cognitive-behavioral intervention with shown efficacy to improve OA-related pain and other outcomes. Emerging data indicate pain CST may be a promising intervention for reducing racial disparities in OA symptom severity. However, there are important gaps in this research, including incorporation of stakeholder perspectives (e.g. cultural appropriateness, strategies for implementation into clinical practice) and testing pain CST specifically among African Americans with OA. This study will evaluate the effectiveness of a culturally enhanced pain CST program among African Americans with OA.
This is a randomized controlled trial among 248 participants with symptomatic hip or knee OA, with equal allocation to a pain CST group and a wait list (WL) control group. The pain CST program incorporated feedback from patients and other stakeholders and involves 11 weekly telephone-based sessions. Outcomes are assessed at baseline, 12 weeks (primary time point), and 36 weeks (to assess maintenance of treatment effects). The primary outcome is the Western Ontario and McMaster Universities Osteoarthritis Index, and secondary outcomes include self-efficacy, pain coping, pain interference, quality of life, depressive symptoms, and global assessment of change. Linear mixed models will be used to compare the pain CST group to the WL control group and explore whether participant characteristics are associated with differential improvement in the pain CST program. This research is in compliance with the Helsinki Declaration and was approved by the Institutional Review Boards of the University of North Carolina at Chapel Hill, Durham Veterans Affairs Medical Center, East Carolina University, and Duke University Health System.
This culturally enhanced pain CST program could have a substantial impact on outcomes for African Americans with OA and may be a key strategy in the reduction of racial health disparities.
Trial registration, NCT02560922, registered 9/22/2015.
PMCID: PMC4994196  PMID: 27553385
Osteoarthritis; Knee; Hip; Pain coping skills training; Health disparities
19.  Recruitment of Rural African Americans for Research Projects: Lessons Learned 
Recruiting rural African Americans for research presents special problems because of cultural differences, the view of researchers as cultural “outsiders”, and transportation problems. This paper reports successful strategies in recruiting rural African American adults with type 2 diabetes for research studies. The researchers tested recruitment strategies commonly used in research, such as flyers, advertisements in local newspapers and radio stations. The researchers also encouraged referrals from medical professionals. When recruitment goals were not met, the researchers modified strategies. Twenty-two rural African American participants were recruited and randomly assigned to culturally-tailored Group or Individual Diabetes Self Management Education (DSME). The latter included storytelling and an interactive learning approach. The key recruitment strategies involved spending time in the community, visits to churches, and flyers to key leaders in the Black community. Enrolling rural African Americans required cultural competence, careful planning, and time in the community. Recruiting for clinical research is challenging and more difficult when targeting minority members in rural settings. Research in diabetes care is needed with rural African Americans because of high rates of diabetes, and limited health care access for this population. Effective recruitment and retention strategies are needed to test interventions to reduce health disparities.
PMCID: PMC4004586  PMID: 24791157
recruitment; rural; African Americans; barriers
20.  Community-based breast cancer intervention program for older African American women in beauty salons. 
Public Health Reports  1995;110(2):179-183.
African American women are at high risk for morbidity and mortality from breast cancer. African American women ages 50 and older have been a difficult group to reach through conventional breast cancer intervention programs. Cultural and health beliefs that differ from mainstream society are reported to be factors contributing to the low rates of breast screening among this group. In addition to these attitudinal factors, older African American women are disproportionately represented among uninsured and under-insured Americans. As a result, cost becomes a barrier to mammography screening for many of these women. This project proposes to increase breast cancer screening awareness and provide a referral or free breast screening, or both, for African American women ages 50 and older. This information will be offered in the culturally familiar setting of local beauty salons. The culturally sensitive educational pamphlets developed by the National Cancer Institute (NCI) and video developed by the NCI-funded project, Cancer Prevention Research Unit, will be used to promote mammography, clinical breast examinations, and breast self-examination. Providers staffing a mobile mammography van provided by Dr. Anitha Mitchell of the Association of Black Women Physicians through a grant from the Breast and Cervical Cancer Control Program, funded by the Centers for Disease Control and Prevention, will perform mammograms for women on site during scheduled intervals. A followup telephone survey will be conducted.
PMCID: PMC1382099  PMID: 7630996
21.  The African American Wellness Village in Portland, Ore 
Preventing Chronic Disease  2006;3(3):A104.
More than 80% of African Americans in Oregon reside in the Portland metropolitan area; African Americans comprise 1.7% of the state's population. Although relatively small, the African American population in the state experiences substantial health disparities. The African American Health Coalition, Inc was developed to implement initiatives that would reduce these disparities and to promote increased communication and trust between the African American community and local institutions and organizations. One of these initiatives is an annual Wellness Week featuring an African American Wellness Village. The Wellness Village uses a model of cultural sensitivity to provide access to free health screenings, links between health care organizations and African American community members, and health education and information.
The African American Health Coalition, Inc obtained a Racial and Ethnic Approaches to Community Health (REACH) 2010 grant to sustain this programming. The Wellness Village is supported by five major sponsors; annual attendance has ranged from 700 to 900 participants. The African American Health Coalition's evaluation of the event indicates that more than 50% of respondents identify the Wellness Village as the only place that they receive health screenings. Participants with access to screenings elsewhere report that a culturally sensitive environment that inspires trust is the reason they prefer the screenings offered at the Wellness Village.
Culturally sensitive health fairs such as the Wellness Village may play an important role in bringing preventive health screenings to African American communities. Collaboration between black and white health care providers is critical in this effort. Partnerships must be built at multiple levels, including institutions to provide financial resources and in-kind donations, community members to assist with outreach and recruitment, and health care professionals to conduct screenings and services.
PMCID: PMC1637792  PMID: 16776865
22.  Early Emergence of Ethnic Differences in Type 2 Diabetes Precursors in the UK: The Child Heart and Health Study in England (CHASE Study) 
PLoS Medicine  2010;7(4):e1000263.
Peter Whincup and colleagues carry out a cross-sectional study examining ethnic differences in precursors of of type 2 diabetes among children aged 9–10 living in three UK cities.
Adults of South Asian origin living in the United Kingdom have high risks of type 2 diabetes and central obesity; raised circulating insulin, triglyceride, and C-reactive protein concentrations; and low HDL-cholesterol when compared with white Europeans. Adults of African-Caribbean origin living in the UK have smaller increases in type 2 diabetes risk, raised circulating insulin and HDL-cholesterol, and low triglyceride and C-reactive protein concentrations. We examined whether corresponding ethnic differences were apparent in childhood.
Methods and Findings
We performed a cross-sectional survey of 4,796 children aged 9–10 y in three UK cities who had anthropometric measurements (68% response) and provided blood samples (58% response); ethnicity was based on parental definition. In age-adjusted comparisons with white Europeans (n = 1,153), South Asian children (n = 1,306) had higher glycated haemoglobin (HbA1c) (% difference: 2.1, 95% CI 1.6 to 2.7), fasting insulin (% difference 30.0, 95% CI 23.4 to 36.9), triglyceride (% difference 12.9, 95% CI 9.4 to 16.5), and C-reactive protein (% difference 43.3, 95% CI 28.6 to 59.7), and lower HDL-cholesterol (% difference −2.9, 95% CI −4.5 to −1.3). Higher adiposity levels among South Asians (based on skinfolds and bioimpedance) did not account for these patterns. Black African-Caribbean children (n = 1,215) had higher levels of HbA1c, insulin, and C-reactive protein than white Europeans, though the ethnic differences were not as marked as in South Asians. Black African-Caribbean children had higher HDL-cholesterol and lower triglyceride levels than white Europeans; adiposity markers were not increased.
Ethnic differences in type 2 diabetes precursors, mostly following adult patterns, are apparent in UK children in the first decade. Some key determinants operate before adult life and may provide scope for early prevention.
Please see later in the article for the Editors' Summary
Editors' Summary
Worldwide, nearly 250 million people have diabetes, and the number of people affected by this chronic disease is increasing rapidly. Diabetes is characterized by dangerous amounts of sugar (glucose) in the blood. Blood sugar levels are normally controlled by insulin, a hormone that the pancreas releases when blood sugar levels rise after eating (digestion of food produces glucose). In people with type 2 diabetes (the most common type of diabetes), blood sugar control fails because the fat and muscle cells that usually respond to insulin by removing sugar from the blood become less responsive to insulin (insulin resistant). Type 2 diabetes can be controlled with diet and exercise, and with drugs that help the pancreas make more insulin or that make cells more sensitive to insulin. Long-term complications of diabetes include kidney failure, blindness, nerve damage, and an increased risk of developing cardiovascular problems, including heart disease and stroke.
Why Was This Study Done?
South Asians and African-Caribbeans living in Western countries tend to have higher rates of type 2 diabetes than host populations. South Asian adults living in the UK, for example, have a 3-fold higher risk of developing type 2 diabetes than white Europeans. They also have higher fasting blood levels of glucose, insulin and triglycerides (a type of fat), higher blood levels of “glycated hemoglobin” (HbA1c; an indicator of average of blood-sugar levels over time), more body fat (increased adiposity), raised levels of a molecule called C-reactive protein, and lower levels of HDL-cholesterol (another type of fat) than white Europeans. Most of these “diabetes precursors” (risk factors) are also seen in black African-Caribbean adults living in the UK except that individuals in this ethnic group often have raised HDL-cholesterol levels and low triglyceride levels. Ethnic differences in type 2 diabetes precursors are also present in adolescents, but the extent to which they are present in childhood remains unclear. Knowing this information could have implications for diabetes prevention. In this population-based study, therefore, the researchers investigate patterns of diabetes precursors in 9- to 10-year-old UK children of white European, South Asian, and black African-Caribbean origin.
What Did the Researchers Do and Find?
The researchers enrolled nearly 5,000 children (including 1,153 white European, 1,306 South Asian and 1,215 black African-Caribbean children) from primary schools with high prevalences of ethnic minority pupils in London, Birmingham, and Leicester in the Child Heart and Health study in England (CHASE). They measured and weighed more than two-thirds of the enrolled children and determined their adiposity. They also took blood samples for measurement of diabetes precursors from nearly two-thirds of the children. The recorded ethnicity of each child was based on parental definition. The researchers' analysis of these data showed that, compared with white Europeans, South Asian children had higher levels of HbA1c, insulin, triglycerides, and C-reactive protein but lower HDL-cholesterol levels. In addition, they had higher adiposity levels than the white European children, but this did not account for the observed differences in the other diabetes precursors. Black African-Caribbean children also had higher levels of HbA1c, insulin, and C-reactive protein than white European children, although the differences were smaller than those between South Asians and white Europeans. Similar to black African-Caribbean adults, however, children of this ethnic origin had higher HDL-cholesterol and lower triglyceride levels than white Europeans.
What Do These Findings Mean?
These findings indicate that ethnic differences in diabetes precursors are already present in apparently healthy children before they are 10 years old. Furthermore, most of the ethnic differences in diabetes precursors seen among the children follow the pattern seen in adults. Although these findings need confirming in more children, they suggest that the ethnic differences in type 2 diabetes susceptibility first described in immigrants to the UK are persisting in UK-born South Asian and black African-Caribbean children. Most importantly, these findings suggest that some of the factors thought to be responsible for ethnic differences in type 2 diabetes—for example, varying levels of physical activity and dietary differences—are operating well before adult life. Interventions that target these factors early could, therefore, offer good opportunities for diabetes prevention in high-risk ethnic groups, provided such interventions are carefully tailored to the needs of these groups.
Additional Information
Please access these Web sites via the online version of this summary at
The International Diabetes Federation provides information about all aspects of diabetes (in English, French and Spanish)
The US National Diabetes Information Clearinghouse provides detailed information about diabetes for patients, health-care professionals and the general public, including information on diabetes in specific US populations (in English and Spanish)
The UK National Health Service also provides information for patients and carers about type 2 diabetes (in several languages)
MedlinePlus provides links to further resources and advice about diabetes (in English and Spanish)
The US Agency for Healthcare Research and Quality has a fact sheet on diabetes disparities among racial and ethnic minorities
PMCID: PMC2857652  PMID: 20421924
23.  Ethnic, Racial and Cultural Identity and Perceived Benefits and Barriers Related to Genetic Testing for Breast Cancer among At-Risk Women of African Descent in New York City 
Public Health Genomics  2011;14(6):356-370.
Due to disparities in the use of genetic services, there has been growing interest in examining beliefs and attitudes related to genetic testing for breast and/or ovarian cancer risk among women of African descent. However, to date, few studies have addressed critical cultural variations among this minority group and their influence on such beliefs and attitudes.
We assessed ethnic, racial and cultural identity and examined their relationships with perceived benefits and barriers related to genetic testing for cancer risk in a sample of 160 women of African descent (49% self-identified African American, 39% Black-West Indian/Caribbean, 12% Black-Other) who met genetic risk criteria and were participating in a larger longitudinal study including the opportunity for free genetic counseling and testing in New York City. All participants completed the following previously validated measures: (a) the multi-group ethnic identity measure (including ethnic search and affirmation subscales) and other-group orientation for ethnic identity, (b) centrality to assess racial identity, and (c) Africentrism to measure cultural identity. Perceived benefits and barriers related to genetic testing included: (1) pros/advantages (including family-related pros), (2) cons/disadvantages (including family-related cons, stigma and confidentiality concerns), and (3) concerns about abuses of genetic testing.
In multivariate analyses, several ethnic identity elements showed significant, largely positive relationships to perceived benefits about genetic testing for breast and/or ovarian cancer risk, the exception being ethnic search, which was positively associated with cons/disadvantages, in general, and family-related cons/disadvantages. Racial identity (centrality) showed a significant association with confidentiality concerns. Cultural identity (Africentrism) was not related to perceived benefits and/or barriers.
Ethnic and racial identity may influence perceived benefits and barriers related to genetic testing for breast and/or ovarian cancer risk among at-risk women of African descent. Genetic counseling services may want to take into account these factors in the creation of culturally-appropriate services which best meet the needs of this heterogenous population.
PMCID: PMC3221259  PMID: 21540561
Breast cancer; Cultural identity; Ethnic identity; Genetic testing; Racial identity
24.  Knowledge of the Tuskegee study and its impact on the willingness to participate in medical research studies. 
The under-representation of racial/ethnic minorities among medical research participants has recently resulted in mandates for their inclusion by the National Institutes of Health (NIH). Therefore, there is a need to determine how history, attitudes, cultural beliefs, social issues, and investigator behavior affect minority enrollment in medical research studies. From January 1998 to March 1999, 179 African-American and white residents of the Detroit Primary Metropolitan Statistical Area (PMSA) participated in a mail and telephone survey designed to examine impediments to African-American participation in medical research studies. Chi-square tests were performed to assess differences between the study groups using the Survey Data Analysis Program (SUDAAN). Eighty-one percent of African Americans and 28% of whites had knowledge of the Tuskegee Study (p = <0.001). Knowledge of the Tuskegee Study resulted in less trust of researchers for 51% of African-Americans and 17% of whites (p = 0.02). Forty-six percent of African-Americans and 34% of whites indicated that their knowledge of the study would affect future research participation decisions (p = 0.25). Of these, 49% of African-Americans and 17% of whites would not be willing to participate in future medical research studies (p = 0.05). This study confirms the need for medical researchers to confront the issue of the Tuskegee Study and its continuing impact on African-Americans' trust of medical research studies.
PMCID: PMC2568333  PMID: 11202759
25.  Study protocol for Women of Color and Asthma Control: A randomized controlled trial of an asthma-management intervention for African American women 
BMC Public Health  2012;12:76.
Among adults in the United States, asthma prevalence is disproportionately high among African American women; this group also experiences the highest levels of asthma-linked mortality and asthma-related health care utilization. Factors linked to biological sex (e.g., hormonal fluctuations), gender roles (e.g., exposure to certain triggers) and race (e.g., inadequate access to care) all contribute to the excess asthma burden in this group, and also shape the context within which African American women manage their condition. No prior interventions for improving asthma self-management have specifically targeted this vulnerable group of asthma patients. The current study aims to evaluate the efficacy of a culturally- and gender-relevant asthma-management intervention among African American women.
A randomized controlled trial will be used to compare a five-session asthma-management intervention with usual care. This intervention is delivered over the telephone by a trained health educator. Intervention content is informed by the principles of self-regulation for disease management, and all program activities and materials are designed to be responsive to the specific needs of African American women. We will recruit 420 female participants who self-identify as African American, and who have seen a clinician for persistent asthma in the last year. Half of these will receive the intervention. The primary outcomes, upon which the target sample size is based, are number of asthma-related emergency department visits and overnight hospitalizations in the last 12 months. We will also assess the effect of the intervention on asthma symptoms and asthma-related quality of life. Data will be collected via telephone survey and medical record review at baseline, and 12 and 24 months from baseline.
We seek to decrease asthma-related health care utilization and improve asthma-related quality of life in African American women with asthma, by offering them a culturally- and gender-relevant program to enhance asthma management. The results of this study will provide important information about the feasibility and value of this program in helping to address persistent racial and gender disparities in asthma outcomes.
Trial Registration NCT01117805
PMCID: PMC3317437  PMID: 22272780
Asthma; randomized controlled trials; women; African Americans; chronic disease management; self-regulation; behavioral interventions

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