PMCC PMCC

Search tips
Search criteria

Advanced
Results 1-25 (1017002)

Clipboard (0)
None

Related Articles

1.  The Promise of Prevention: The Effects of Four Preventable Risk Factors on National Life Expectancy and Life Expectancy Disparities by Race and County in the United States 
PLoS Medicine  2010;7(3):e1000248.
Majid Ezzati and colleagues examine the contribution of a set of risk factors (smoking, high blood pressure, elevated blood glucose, and adiposity) to socioeconomic disparities in life expectancy in the US population.
Background
There has been substantial research on psychosocial and health care determinants of health disparities in the United States (US) but less on the role of modifiable risk factors. We estimated the effects of smoking, high blood pressure, elevated blood glucose, and adiposity on national life expectancy and on disparities in life expectancy and disease-specific mortality among eight subgroups of the US population (the “Eight Americas”) defined on the basis of race and the location and socioeconomic characteristics of county of residence, in 2005.
Methods and Findings
We combined data from the National Health and Nutrition Examination Survey and the Behavioral Risk Factor Surveillance System to estimate unbiased risk factor levels for the Eight Americas. We used data from the National Center for Health Statistics to estimate age–sex–disease-specific number of deaths in 2005. We used systematic reviews and meta-analyses of epidemiologic studies to obtain risk factor effect sizes for disease-specific mortality. We used epidemiologic methods for multiple risk factors to estimate the effects of current exposure to these risk factors on death rates, and life table methods to estimate effects on life expectancy. Asians had the lowest mean body mass index, fasting plasma glucose, and smoking; whites had the lowest systolic blood pressure (SBP). SBP was highest in blacks, especially in the rural South—5–7 mmHg higher than whites. The other three risk factors were highest in Western Native Americans, Southern low-income rural blacks, and/or low-income whites in Appalachia and the Mississippi Valley. Nationally, these four risk factors reduced life expectancy at birth in 2005 by an estimated 4.9 y in men and 4.1 y in women. Life expectancy effects were smallest in Asians (M, 4.1 y; F, 3.6 y) and largest in Southern rural blacks (M, 6.7 y; F, 5.7 y). Standard deviation of life expectancies in the Eight Americas would decline by 0.50 y (18%) in men and 0.45 y (21%) in women if these risks had been reduced to optimal levels. Disparities in the probabilities of dying from cardiovascular diseases and diabetes at different ages would decline by 69%–80%; the corresponding reduction for probabilities of dying from cancers would be 29%–50%. Individually, smoking and high blood pressure had the largest effect on life expectancy disparities.
Conclusions
Disparities in smoking, blood pressure, blood glucose, and adiposity explain a significant proportion of disparities in mortality from cardiovascular diseases and cancers, and some of the life expectancy disparities in the US.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Life expectancy (a measure of longevity and premature death) and overall health have increased steadily in the United States over recent years. New drugs, new medical technologies, and better disease prevention have all helped Americans to lead longer, healthier lives. However, even now, some Americans live much longer and much healthier lives than others. Health disparities—differences in how often certain diseases occur and cause death in groups of people classified according to their ethnicity, geographical location, sex, or age—are extremely large and persistent in the US. On average, black men and women in the US live 6.3 and 4.5 years less, respectively, than their white counterparts; the gap between life expectancy in the US counties with the lowest and highest life expectancies is 18.4 years for men and 14.3 years for women. Disparities in deaths (mortality) from chronic diseases such as cardiovascular diseases (for example, heart attacks and stroke), cancers, and diabetes are known to be the main determinants of these life expectancy disparities.
Why Was This Study Done?
Preventable risk factors such as smoking, high blood pressure, excessive body fat (adiposity), and high blood sugar are responsible for many thousands of deaths from chronic diseases. Exposure to these risk factors varies widely by race, state of residence, and socioeconomic status. However, the effects of these observed disparities in exposure to modifiable risk factors on US life expectancy disparities have only been examined in selected groups of people and it is not known how multiple modifiable risk factors affect US health disparities. A better knowledge about how disparities in risk factor exposure contribute to health disparities is needed to ensure that prevention programs not only improve the average health status but also reduce health disparities. In this study, the researchers estimate the effects of smoking, high blood pressure, high blood sugar, and adiposity on US life expectancy and on disparities in life expectancy and disease-specific deaths among the “Eight Americas,” population groups defined by race and by the location and socioeconomic characteristics of their county of residence.
What Did the Researchers Do and Find?
The researchers extracted data on exposure to these risk factors from US national health surveys, information on deaths from different diseases in 2005 from the US National Center for Health Statistics, and estimates of how much each risk factor increases the risk of death from each disease from published studies. They then used modeling methods to estimate the effects of risk factor exposure on death rates and life expectancy. The Asian subgroup had the lowest adiposity, blood sugar, and smoking rates, they report, and the three white subgroups had the lowest blood pressure. Blood pressure was highest in the three black subgroups, whereas the other three risk factors were highest in Western Native Americans, Southern rural blacks, and whites living in Appalachia and the Mississippi Valley. The effects on life expectancy of these factors were smallest in Asians and largest in Southern rural blacks but, overall, these risk factors reduced the life expectancy for men and women born in 2005 by 4.9 and 4.1 years, respectively. Other calculations indicate that if these four risk factors were reduced to optimal levels, disparities among the subgroups in deaths from cardiovascular diseases and diabetes and from cancers would be reduced by up to 80% and 50%, respectively.
What Do These Findings Mean?
These findings suggest that disparities in smoking, blood pressure, blood sugar, and adiposity among US racial and geographical subgroups explain a substantial proportion of the disparities in deaths from cardiovascular diseases, diabetes, and cancers among these subgroups. The disparities in risk factor exposure also explain some of the disparities in life expectancy. The remaining disparities in deaths and life expectancy could be the result of preventable risk factors not included in this study—one of its limitations is that it does not consider the effect of dietary fat, alcohol use, and dietary salt, which are major contributors to different diseases. Thus, suggest the researchers, reduced exposure to preventable risk factors through the implementation of relevant policies and programs should reduce life expectancy and mortality disparities in the US and yield health benefits at a national scale.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000248.
The US Centers for Disease Control and Prevention, the US Office of Minority Health, and the US National Center on Minority Health and Health Disparities all provide information on health disparities in the US
MedlinePlus provides links to information on health disparities and on healthy living (in English and Spanish)
The US Centers for Disease Control and Prevention provides information on all aspects of healthy living
The American Heart Association and the American Cancer Society provide information on modifiable risk factors for patients and caregivers
Healthy People 2010 is a national framework designed to improve the health of people living in the US
The US National Health and Nutrition Examination Survey (NHANES) and the Behavioral Risk Factor Surveillance System (BRFSS) collect information on risk factor exposures in the US
doi:10.1371/journal.pmed.1000248
PMCID: PMC2843596  PMID: 20351772
2.  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.
Background
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.
Conclusions
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
Background
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 http://dx.doi.org/10.1371/journal.pmed.1000263.
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
doi:10.1371/journal.pmed.1000263
PMCID: PMC2857652  PMID: 20421924
3.  Eight Americas: Investigating Mortality Disparities across Races, Counties, and Race-Counties in the United States 
PLoS Medicine  2006;3(9):e260.
Background
The gap between the highest and lowest life expectancies for race-county combinations in the United States is over 35 y. We divided the race-county combinations of the US population into eight distinct groups, referred to as the “eight Americas,” to explore the causes of the disparities that can inform specific public health intervention policies and programs.
Methods and Findings
The eight Americas were defined based on race, location of the county of residence, population density, race-specific county-level per capita income, and cumulative homicide rate. Data sources for population and mortality figures were the Bureau of the Census and the National Center for Health Statistics. We estimated life expectancy, the risk of mortality from specific diseases, health insurance, and health-care utilization for the eight Americas. The life expectancy gap between the 3.4 million high-risk urban black males and the 5.6 million Asian females was 20.7 y in 2001. Within the sexes, the life expectancy gap between the best-off and the worst-off groups was 15.4 y for males (Asians versus high-risk urban blacks) and 12.8 y for females (Asians versus low-income southern rural blacks). Mortality disparities among the eight Americas were largest for young (15–44 y) and middle-aged (45–59 y) adults, especially for men. The disparities were caused primarily by a number of chronic diseases and injuries with well-established risk factors. Between 1982 and 2001, the ordering of life expectancy among the eight Americas and the absolute difference between the advantaged and disadvantaged groups remained largely unchanged. Self-reported health plan coverage was lowest for western Native Americans and low-income southern rural blacks. Crude self-reported health-care utilization, however, was slightly higher for the more disadvantaged populations.
Conclusions
Disparities in mortality across the eight Americas, each consisting of millions or tens of millions of Americans, are enormous by all international standards. The observed disparities in life expectancy cannot be explained by race, income, or basic health-care access and utilization alone. Because policies aimed at reducing fundamental socioeconomic inequalities are currently practically absent in the US, health disparities will have to be at least partly addressed through public health strategies that reduce risk factors for chronic diseases and injuries.
US mortality rates were calculated according to "race-county" units and divided into the "eight Americas", across which there are enormous disparities in life expectancy.
Editors' Summary
Background.
It has been recognized for a long time that the number of years that people in the United States can expect to live (“life expectancy”) varies enormously. For example, white Americans tend to live longer than black Americans, and life expectancy is much greater in some of the roughly 3,000 counties of the US than it is in others. However, there is a lack of information and understanding on how big a part is played in “health inequalities” by specific diseases and injuries, by risk factors (such as tobacco, alcohol, and obesity), and by variations in access to effective health care.
Why Was This Study Done?
The researchers wanted to find a way of dividing the people of the US into groups based on a small number of characteristics—such as location of county of residence, race, and income—that would help demonstrate the most important factors accounting for differences in life expectancy.
What Did the Researchers Do and Find?
The researchers used figures from the US Census Bureau and the National Center for Health Statistics to calculate mortality (death) rates for the years 1982–2001. They took note of the county of residence and of the race of all the people who died during that period of time. This enabled them to calculate the mortality rates for all 8,221 “race-county units” (all of the individuals of a given race in a given county). They experimented with different ways of combining the race-counties into a small and manageable number of groups. They eventually settled on the idea of there being “eight Americas,” defined on the basis of race-county, population density, income, and homicide rate. Each group contains millions or tens of millions of people. For each of the eight groups the researchers estimated life expectancy, the risk of mortality from specific diseases, the proportion of people who had health insurance, and people's routine encounters with health-care services. (The researchers also created maps of life expectancies for the US counties.) They describe their eight Americas as follows: Asians, northland low-income rural whites, Middle America, low-income whites in Appalachia and the Mississippi Valley, western Native Americans, black Middle America, low-income southern rural blacks, and high-risk urban blacks.
Many striking differences in life expectancy were found between the eight groups. For example, in 2001, the life expectancy gap between the 3.4 million high-risk urban black males and the 5.6 million Asian females was nearly 21 years. Within the sexes, the life expectancy gap between the best-off and the worst-off groups was 15.4 years for males (Asians versus high-risk urban blacks) and 12.8 years for females (Asians versus low-income rural blacks in the South). The causes of death that were mainly responsible for these variations were various chronic diseases and injury. The gaps between best-off and worst-off were similar in 2001 to what they were in 1987.
What Do These Findings Mean?
Health inequalities in the US are large and are showing no sign of reducing. Social and economic reforms would certainly help change the situation. At the same time, the public health system should also improve the way in which it deals with risk factors for chronic diseases and injuries so that groups with the highest death rates receive larger benefits.
Additional Information.
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0030260.
A Perspective article by Gregory Pappas in this issue of PLoS Medicine (DOI: 10.1371/journal.pmed.0030357) discusses the methods of this piece of research and the findings
The American Medical Students' Association deals with the question “What are Health Disparities?” on its web site
The National Institutes of Health's “Strategic Research Plan to Reduce and Ultimately Eliminate Health Disparities” may be seen at the NIH web site
The Office of Minority Health at the Centers for Disease Control and Prevention has a Web page called “Eliminating Racial and Ethnic Health Disparities”
The issue of health inequalities in the US has also been dealt with by the Robert Wood Johnson Foundation
doi:10.1371/journal.pmed.0030260
PMCID: PMC1564165  PMID: 16968116
4.  Trans-population Analysis of Genetic Mechanisms of Ethnic Disparities in Neuroblastoma Survival 
Background
Black patients with neuroblastoma have a higher prevalence of high-risk disease and worse outcome than white patients. We sought to investigate the relationship between genetic variation and the disparities in survival observed in neuroblastoma.
Methods
The analytic cohort was composed of 2709 patients. Principal components were used to assign patients to genomic ethnic clusters for survival analyses. Locus-specific ancestry was calculated for use in association analysis. The shorter spans of linkage disequilibrium in African populations may facilitate the fine mapping of causal variants in regions previously implicated by genome-wide association studies conducted primarily in patients of European descent. Thus, we evaluated 13 single nucleotide polymorphisms known to be associated with susceptibility to high-risk neuroblastoma from genome-wide association studies and all variants with highly divergent allele frequencies in reference African and European populations near the known susceptibility loci. All statistical tests were two-sided.
Results
African genomic ancestry was associated with high-risk neuroblastoma (P = .007) and lower event-free survival (P = .04, hazard ratio = 1.4, 95% confidence interval = 1.05 to 1.80). rs1033069 within SPAG16 (sperm associated antigen 16) was determined to have higher risk allele frequency in the African reference population and statistically significant association with high-risk disease in patients of European and African ancestry (P = 6.42×10−5, false discovery rate < 0.0015) in the overall cohort. Multivariable analysis using an additive model demonstrated that the SPAG16 single nucleotide polymorphism contributes to the observed ethnic disparities in high-risk disease and survival.
Conclusions
Our study demonstrates that common genetic variation influences neuroblastoma phenotype and contributes to the ethnic disparities in survival observed and illustrates the value of trans-population mapping.
doi:10.1093/jnci/djs503
PMCID: PMC3691940  PMID: 23243203
5.  Disparities in Breast Cancer Characteristics and Outcomes by Race/Ethnicity 
Purpose
Disparities in breast cancer stage and mortality by race/ethnicity in the United States are persistent and well known. However, few studies have assessed differences across racial/ethnic subgroups of women broadly defined as Hispanic, Asian, or Pacific Islander, particularly using more recent data.
Methods
Using data from 17 population-based cancer registries in the Surveillance, Epidemiology, and End Results (SEER) Program, we evaluated the relationships between race/ethnicity and breast cancer stage, hormone receptor status, treatment, and mortality. The cohort consisted of 229,594 women 40-79 years of age diagnosed with invasive breast carcinoma between January 2000 and December 2006, including 176,094 non-Hispanic whites, 20,486 blacks, 15,835 Hispanic whites, 14,951 Asians, 1,224 Pacific Islanders and 1,004 American Indians/Alaska Natives.
Results
With respect to statistically significant findings, American Indian/Alaska Native, Asian Indian/Pakistani, black, Filipino, Hawaiian, Mexican, Puerto Rican, and Samoan women had 1.3 to 7.1-fold higher odds of presenting with stage IV breast cancer compared to non-Hispanic white women. Almost all groups were more likely to be diagnosed with estrogen receptor-negative/progesterone receptor-negative (ER-/PR-) disease with black and Puerto Rican women having the highest odds ratios (2.4 and 1.9-fold increases, respectively) compared to non-Hispanic whites. Lastly, black, Hawaiian, Puerto Rican, and Samoan patients had 1.5 to 1.8-fold elevated risks of breast cancer specific mortality.
Conclusions
Breast cancer disparities persist by race/ethnicity, though there is substantial variation within subgroups of women broadly defined as Hispanic or Asian. Targeted, multi-pronged interventions that are culturally appropriate may be important means of reducing the magnitudes of these disparities.
doi:10.1007/s10549-010-1191-6
PMCID: PMC3081535  PMID: 21076864
Breast cancer; disparities; race; ethnicity; stage; estrogen receptor; progesterone receptor; mortality
6.  Ethnic differences in bladder cancer survival 
Urology  2011;78(3):544-549.
Objectives
Racial disparities in bladder cancer outcomes have been documented with poorer survival observed among blacks. Bladder cancer outcomes in other ethnic minority groups are less well described. We examined trends in bladder cancer survival among whites, blacks, Hispanics, and Asian/Pacific Islanders in the US over a 30-year period.
Methods
From the Surveillance, Epidemiology and End Results cancer registry data, we identified patients diagnosed with transitional cell carcinoma of the bladder between 1975 and 2005. This cohort included 163,973 white, 7,731 black, 7,364 Hispanic and 5,934 Asian/Pacific Islander patients. We assessed the relationship between ethnicity and patient characteristics. Disease-specific 5-year survival was estimated for each ethnic group and for subgroups of stage and grade.
Results
Blacks presented with higher stage disease than whites, Hispanics and Asian/Pacific Islanders, although a trend toward earlier stage presentation was observed in all groups over time. Five-year disease-specific survival was consistently worse for blacks than for other ethnic groups, even when stratified by stage and grade. Five-year disease-specific survival was 82.8% in whites compared with 70.2% in blacks, 80.7% in Hispanics and 81.9% in Asian/Pacific Islanders. There was a persistent disease-specific survival disadvantage in black patients over time which was not seen in the other ethnic groups.
Conclusions
Ethnic disparities in bladder cancer survival persist between whites and blacks, while survival in other ethnic minority groups appears similar to that of whites. Further study of access to care, quality of care and treatment decision making among black patients is needed to better understand these disparities.
doi:10.1016/j.urology.2011.02.042
PMCID: PMC3710780  PMID: 21782222
ethnic groups; healthcare disparities; survival; urinary bladder; urinary bladder neoplasms
7.  Prostate Cancer Risk Profiles in Asian Americans: Disentangling the Effects of Immigration Status and Race/Ethnicity 
The Journal of urology  2013;191(4):952-956.
Purpose
Asian-American men with prostate cancer have been reported to present with higher grade and later stage disease than White Americans. However, Asian Americans comprise a heterogeneous population with distinct health outcomes. We compared prostate cancer risk profiles among the diverse racial and ethnic groups in California.
Materials and Methods
We used data from the California Cancer Registry for 90,845 Non-Hispanic White, Non-Hispanic Black, and Asian-American men diagnosed with prostate cancer between 2004 and 2010. Patients were categorized into low, intermediate, or high-risk groups based on clinical stage, Gleason score, and PSA value at diagnosis. Using polytomous logistic regression, we estimated adjusted odds ratios for the association of race/ethnicity and nativity with risk group.
Results
In addition to Non-Hispanic Blacks, six Asian-American groups (US-born Chinese, foreign-born Chinese, US-born Japanese, foreign-born Japanese, foreign-born Filipino, and foreign-born Vietnamese) were more likely to have an unfavorable risk profile compared to Non-Hispanic Whites. The odds ratios for high vs. intermediate-risk disease ranged from 1.23 (95% CI, 1.02–1.49) for US-born Japanese to 1.45 (95% CI, 1.31–1.60) for foreign-born Filipinos. These associations appeared to be driven by higher grade and PSA values, rather than advanced clinical stage at diagnosis.
Conclusions
In this large, ethnically diverse population-based cohort, we found that Asian-American men were more likely to have unfavorable risk profiles at diagnosis. This association varied by racial/ethnic group and nativity, and was not attributable to later stage at diagnosis, suggesting that Asian men may have biological differences that predispose to the development of more severe disease.
doi:10.1016/j.juro.2013.10.075
PMCID: PMC4051432  PMID: 24513166
Asian Americans; prostatic neoplasms; epidemiology; SEER Program
8.  Chronic physical health conditions among children of different racial/ethnic backgrounds 
Public health  2013;127(6):546-553.
Objectives
It is estimated that 20% of children in the USA are affected by at least one chronic disease. Although the burden of chronic conditions is greater for minority populations of children, research that has explored the prevalence and risk factors of chronic disease across different racial/ethnic groups is scarce. The aim of this study was to examine racial/ethnic disparities in the prevalence rates of common physical, chronic diseases in White, Black and Hispanic children; and assess the effect of several factors on the risk of having a chronic disease.
Methods
Using the 2007 National Survey of Childrens Health, prevalence estimates were calculated for asthma, hearing impairment, visual impairment, joint/bone/muscle problems, brain injury and other illnesses for each racial/ethnic group. Multivariate logistic regression analyses were conducted to examine the effects of several risk factors on the risk of each of these health conditions.
Results
The findings show that the prevalence for all health conditions was significantly higher (25.3%) among Black children than White (19.8%) and Hispanic (18.6%) children. Furthermore, 19.5% of Black children have had or currently have asthma compared with 12.2% of White and Hispanic children. More Black and Hispanic children were covered by public health insurance, while 19% of Hispanic children were currently uninsured. White children whose mothers had a health problem were associated with asthma, hearing impairment, visual impairment and joint/bone/muscle problems, while Black children were more likely to report asthma and Hispanics reported visual impairment and joint/ bone muscle problems. Hispanic children who were living in poverty or were uninsured were at lower risk for any chronic disease. Regardless of race/ethnicity, children living in a single-parent household were more likely to be associated with any health condition.\
Conclusions
This study provides evidence that racial/ethnic disparities in chronic physical conditions and health care among US children are extensive. It underscores that uninsured children who do not have access to the healthcare system are not being screened for chronic diseases, or are not obtaining medical care for such health problems. Healthcare providers should educate families about prevention measures and community services that might be able to assist them in improving the health of their children.
doi:10.1016/j.puhe.2013.02.006
PMCID: PMC4086459  PMID: 23583033
Chronic; Physical health illnesses; Children; Race and ethnicity; Asthma; Hearing and vision; Health disparities
9.  Rethinking race/ethnicity, income, and childhood asthma: racial/ethnic disparities concentrated among the very poor. 
Public Health Reports  2005;120(2):109-116.
OBJECTIVE: Past studies of the prevalence of childhood asthma have yielded conflicting findings as to whether racial/ethnic disparities remain after other factors, such as income, are taken into account. The objective of this study was to examine the association of race/ethnicity and family income with the prevalence of childhood asthma and to assess whether racial/ethnic disparities vary by income strata. METHODS: Cross-sectional data on 14,244 children aged <18 years old in the 1997 National Health Interview Survey were examined. The authors used logistic regression to analyze the independent and joint effects of race/ethnicity and income-to-federal poverty level (FPL) ratio, adjusting for demographic covariates. The main outcome measure was parental report of the child having ever been diagnosed with asthma. RESULTS: Bivariate analyses, based on weighted percentages, revealed that asthma was more prevalent among non-Hispanic black children (13.6%) than among non-Hispanic white children (11.2%; p<0.01), but the prevalence of asthma did not differ significantly between Hispanic children (10.1%) and non-Hispanic white children (11.2%; p=0.13). Overall, non-Hispanic black children were at higher risk for asthma than non-Hispanic white children (adjusted odds ratio [OR]=1.20; 95% confidence interval [CI] 1.03, 1.40), after adjustment for sociodemographic variables, including the ratio of annual family income to the FPL. Asthma prevalence did not differ between Hispanic children and non-Hispanic white children in adjusted analyses (adjusted OR=0.85; 95% CI 0.71, 1.02). Analyses stratified by income revealed that only among children from families with incomes less than half the FPL did non-Hispanic black children have a higher risk of asthma than non-Hispanic white children (adjusted OR=1.99; 95% CI 1.09, 3.64). No black vs. white differences existed at other income levels. Subsequent analyses of these very poor children that took into account additional potentially explanatory variables did not attenuate the higher asthma risk for very poor non-Hispanic black children relative to very poor non-Hispanic white children. CONCLUSIONS: Non-Hispanic black children were at substantially higher risk of asthma than non-Hispanic white children only among the very poor. The concentration of racial/ethnic differences only among the very poor suggests that patterns of social and environmental exposures must overshadow any hypothetical genetic risk.
PMCID: PMC1497701  PMID: 15842111
10.  Comorbid disease and the effect of race and ethnicity on in-hospital mortality from aspiration pneumonia. 
BACKGROUND: Racial and ethnic disparities in mortality have been demonstrated in several diseases. African Americans are hospitalized at a significantly higher rate than whites for aspiration pneumonia; however, no studies have investigated racial and ethnic disparities in mortality in this population. OBJECTIVE: To assess the independent effect of race and ethnicity on in-hospital mortality among aspiration pneumonia discharges while comprehensively controlling for comorbid diseases, and to assess whether the prevalence and effects of comorbid illness differed across racial and ethnic categories. DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort study of 41,581 patients admitted to California hospitals for aspiration pneumonia from 1996 through 1998, using principal and secondary diagnoses present on admission. MEASUREMENT: The primary outcome measure was in-hospital mortality. RESULTS: The adjusted odds of in-hospital death for African-American compared with white discharges [odds ratio (OR)=1.01; 95% confidence interval (CI), 0.91-1.11] was not significantly different. The odds of death for Asian compared with white discharges was significantly lower (OR=0.83; 95% CI, 0.75-0.91). Hispanics had a significantly lower odds of death (OR=0.90; 95% CI, 0.82-0.988) compared to non-Hispanics. Comorbid diseases were more prevalent among African Americans and Asians than whites, and among Hispanics compared to non-Hispanics. Differences in effects of comorbid disease on mortality risk by race and ethnicity were not statistically significant. CONCLUSION: Asians have a lower risk of death, and the risk of death for African Americans is not significantly different from whites in this analysis of aspiration pneumonia discharges. Hispanics have a lower risk of death than non-Hispanics. While there are differences in prevalence of comorbid disease by racial and ethnic category, the effects of comorbid disease on mortality risk do not differ meaningfully by race or ethnicity.
PMCID: PMC2568617  PMID: 15586650
11.  Measures of racial/ethnic health disparities in cancer mortality rates and the influence of socioeconomic status. 
OBJECTIVES: In the 1990s, U.S. cancer mortality rates declined due to reductions in tobacco use among men and beneficial cancer interventions, such as mammography and Pap smears. We examined the cancer rates by racial/ethnic group, socioeconomic status and time period to identify disparities underlying the overall mortality trend. METHODS: We examined racial/ethnic disparities by measuring excess cancer burden [rate ratio (RR) and ratio differences (RD)] and trends in their cancer rates for nine cancer sites. The trend (T) is calculated as a ratio of the average annual cancer mortality rate for 1995-2000 relative to the rate for 1990-1994 for three levels of poverty (counties with <10% living below the poverty level, 10% - <20% and > or =20%) for the major racial/ethnic populations. We also compared the trend for each racial/ethnic SES group to the trend for lowest SES white group (TD). RESULTS: Blacks have RR disparities relative to whites for each cancer site examined, except for female lung cancer, while the other minorities had RR disparities for cervical cancer (RR>1). There are increases in RR disparities from 1990-1994 to 1995-2000 (RD>0) for colorectal cancer, prostate cancer and breast cancer for each racial/ethnic minority. Whites and blacks had declining trends for every SES group (T<1) and positive high SES gradients (the highest SES group had the best trend and the lowest SES group had the worst trend) at each cancer site, except female lung cancer (T>1). In contrast, American Indians/Alaska natives, Hispanics and Asians/ Pacific Islanders had increasing trends for some of their cancer sites, and their trends did not have the SES gradients. CONCLUSIONS: Increases in racial/ethnic disparities (RD>0) for colorectal, breast and prostate cancer were largest in the lowest SES groups. At some cancer sites, the highest SES group for minorities had worse trend results than the trends for the lowest SES white group (TD>0).
PMCID: PMC2574395  PMID: 17987912
12.  Race/Ethnicity and Risk of AIDS and Death Among HIV-infected Patients with Access to Care 
Journal of General Internal Medicine  2009;24(9):1065-1072.
ABSTRACT
BACKGROUND
Prior studies evaluating racial/ethnic differences in responses to antiretroviral therapy (ART) among HIV-infected patients have not adequately accounted for many potential confounders, and few have included Hispanic patients.
OBJECTIVE
To identify racial/ethnic differences in ART adherence, and risk of AIDS and death after ART initiation for HIV patients with similar access to care.
DESIGN
Retrospective cohort study.
PARTICIPANTS
4,686 HIV-infected patients (66% White, 20% Black, and 14% Hispanic) initiating ART and who were enrolled in an integrated healthcare system.
MEASUREMENTS
Main outcomes evaluated were ART adherence, new AIDS clinical events, and all-cause mortality. The potential confounding effects of demographics, socioeconomic status, ART parameters, HIV disease stage, and other clinical parameters were considered in multivariable models.
RESULTS
Adjusted mean adherence levels were higher among White (70.1%; ref) compared with Black (64.2%;  < 0.001) and Hispanic patients (65.2%;  < 0.001). Adjusted hazard ratios (HR) for the risk of new AIDS events (White patients as reference) were 1.3 ( = 0.09) for Black and 0.9 ( = 0.64) for Hispanic patients. The adjusted HR for AIDS comparing Hispanic to Black patients was 0.7 ( = 0.11). Hispanic patients had fewer deaths compared with other racial/ethnic groups, particularly cancer and cardiovascular-related. However, adjusted HRs for death were 1.2 ( = 0.37) and 0.9 ( = 0.62) for Black and Hispanic patients, respectively, compared with White patients and 0.9 ( = 0.63) for Hispanic compared with Black patients. Adjustment for adherence did not change inferences for AIDS or death.
CONCLUSIONS
In the setting of similar access to care, we did not observe a disparity for the risk of clinical events for racial/ethnic minorities, despite lower ART adherence.
doi:10.1007/s11606-009-1049-y
PMCID: PMC2726884  PMID: 19609624
race; ethnicity; AIDS; survival
13.  Reinterpreting Ethnic Patterns among White and African American Men Who Inject Heroin: A Social Science of Medicine Approach 
PLoS Medicine  2006;3(10):e452.
Background
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.
Conclusions
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
Background.
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 http://dx.doi.org/10.1371/journal.pmed.0030452.
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
doi:10.1371/journal.pmed.0030452
PMCID: PMC1621100  PMID: 17076569
14.  Racial/Ethnic Differences in Early Life Risk Factors for Childhood Obesity 
Pediatrics  2010;125(4):10.1542/peds.2009-2100.
Background
By the preschool years, racial/ethnic disparities in obesity prevalence are already present.
Objective
To examine racial/ethnic differences in early life risk factors for childhood obesity.
Design, Setting, Participants
343 white, 355 black, and 128 Hispanic mother-child pairs in a prospective study.
Main Exposure
Mother’s report of child’s race/ethnicity.
Main Outcome Measures
Risk factors from the prenatal period through age 4 years known to be associated with child obesity.
Results
In multivariable models, compared to their white counterparts, black and Hispanic children exhibited a range of risk factors related to child obesity. In pregnancy, these included higher rates of maternal depression (OR: 1.55 for blacks; 1.89 for Hispanics); in infancy more rapid weight gain (OR: 2.01 for blacks; 1.75 for Hispanics), more likely to introduce solid foods before 4 months of age (OR: 1.91 for blacks; 2.04 for Hispanics), higher rates of maternal restrictive feeding practices (OR: 2.59 for blacks; 3.35 for Hispanics), and after age 2 years, more televisions in their bedrooms (OR: 7.65 for blacks; 7.99 for Hispanics), higher intake of sugar-sweetened beverages (OR: 4.11 for blacks; 2.48 for Hispanics), and higher intake of fast food (OR: 1.65 for blacks; 3.14 for Hispanics). Blacks and Hispanics also had lower rates of exclusive breastfeeding and were less likely to sleep at least 12 hours/day in infancy.
Conclusions
Racial/ethnic differences in risk factors for obesity exist prenatally and in early childhood. Racial/ethnic disparities in childhood obesity may be determined by factors operating at the earliest stages of life.
doi:10.1542/peds.2009-2100
PMCID: PMC3836212  PMID: 20194284
Obesity; Race/Ethnicity; Pregnancy; Infancy; Childhood; Prevention
15.  ARID5B Genetic Polymorphisms Contribute to Racial Disparities in the Incidence and Treatment Outcome of Childhood Acute Lymphoblastic Leukemia 
Journal of Clinical Oncology  2012;30(7):751-757.
Purpose
Recent genome-wide screens have identified genetic variations in ARID5B associated with susceptibility to childhood acute lymphoblastic leukemia (ALL). We sought to determine the contribution of ARID5B single nucleotide polymorphisms (SNPs) to racial disparities in ALL susceptibility and treatment outcome.
Patients and Methods
We compared the association between ARID5B SNP genotype and ALL susceptibility in whites (> 95% European genetic ancestry; 978 cases and 1,046 controls) versus in Hispanics (> 10% Native American ancestry; 330 cases and 541 controls). We determined the relationships between ARID5B SNP genotype and ALL relapse risk in 1,605 children treated on the Children's Oncology Group (COG) P9904/9905 clinical trials.
Results
Among 49 ARID5B SNPs interrogated, 10 were significantly associated with ALL susceptibility in both whites and Hispanics (P < .05), with risk alleles consistently more frequent in Hispanics than in whites. rs10821936 exhibited the most significant association in both races (P = 8.4 × 10−20 in whites; P = 1 × 10−6 in Hispanics), and genotype at this SNP was highly correlated with local Native American genetic ancestry (P = 1.8 × 10−8). Multivariate analyses in Hispanics identified an additional SNP associated with ALL susceptibility independent of rs10821936. Eight ARID5B SNPs were associated with both ALL susceptibility and relapse hazard; the alleles related to higher ALL incidence were always linked to poorer treatment outcome and were more frequent in Hispanics.
Conclusion
ARID5B polymorphisms are important determinants of childhood ALL susceptibility and treatment outcome, and they contribute to racial disparities in this disease.
doi:10.1200/JCO.2011.38.0345
PMCID: PMC3295551  PMID: 22291082
16.  Physician Effects on Racial and Ethnic Disparities in Patients’ Experiences of Primary Care 
Journal of General Internal Medicine  2008;23(10):1666-1672.
Background
Few studies have clarified the mechanisms that contribute to racial and ethnic disparities in primary care quality among comparably-insured patients.
Objective
To examine relative contribution of “between-” and “within-” physician effects on disparities in patients’ experiences of primary care.
Design
Regression models using physician fixed effects to account for patient clustering were specified to assess “between-” and “within-”physician effects on observed racial and ethnic disparities in patients’ experiences of primary care.
Participants
The Ambulatory Care Experiences Survey (ACES) was administered to patients visiting 1,588 primary care physicians (PCPs) from 27 California medical groups. The analytic sample included 49,861 patients (31.4 per PCP) who confirmed a PCP visit during the preceding 12 months.
Main Results
Most racial and ethnic minority groups were significantly clustered within physician practices (p < 0.001). “Between-physician” effects were mostly negative and larger than “within-physician” effects for Latinos, Blacks, and American Indian/Alaskan Natives, indicating that disparities are mainly attributable to patient clustering within physician practices with lower performance on patient experience measures. By contrast, “within-physician” effects accounted for most disparities for Asians and Pacific Islanders, indicating these groups report worse experiences relative to Whites in the same practices. Practices with greater concentration of Blacks, Latinos and Asians had lower performance on patient experience measures (p < 0.05).
Conclusions
Targeting patient experience improvement efforts at low performing practices with high concentrations of racial and ethnic minorities might efficiently reduce disparities. Urgent study is needed to assess the contribution of “within-” and “between-” physician effects to racial and ethnic disparities in the technical quality of primary care.
doi:10.1007/s11606-008-0732-8
PMCID: PMC2533359  PMID: 18651194
physician effects; primary care; racial disparities; patients’ experiences of care; quality improvement
17.  Racial/ethnic disparities in access to physician care and medications among US stroke survivors 
Neurology  2010;76(1):53-61.
Background:
Mexican Americans and non-Hispanic blacks have higher stroke recurrence rates and lower rates of secondary stroke prevention than non-Hispanic whites. As a potential explanation for this disparity, we assessed racial/ethnic differences in access to physician care and medications in a national sample of US stroke survivors.
Methods:
Among all 4,864 stroke survivors aged ≥45 years who responded to the National Health Interview Survey years 2000–2006, we compared access to care within the last 12 months by race/ethnicity before and after stratification by age (45–64 years vs ≥65 years). With logistic regression, we adjusted associations between access measures and race/ethnicity for sex, comorbidity, neurologic disability, health status, year, income, and health insurance.
Results:
Among stroke survivors aged 45–64 years, Mexican Americans, non-Hispanic blacks, and non-Hispanic whites reported similar rates of no generalist physician visit (approximately 15%) and inability to afford medications (approximately 20%). However, among stroke survivors aged ≥65 years, Mexican Americans and blacks, compared with whites, reported greater frequency of no generalist visit (15%, 12%, 8%; p = 0.02) and inability to afford medications (20%, 11%, 6%; p < 0.001). Mexican Americans and blacks more frequently reported no medical specialist visit (54%, 49%, 40%; p < 0.001) than did whites and rates did not differ by age. Full covariate adjustment did not fully explain these racial/ethnic differences.
Conclusions:
Among US stroke survivors at least 65 years old, Mexican Americans and blacks reported worse access to physician care and medications than whites. This reduced access may lead to inadequate risk factor modification and recurrent stroke in these high-risk minority groups.
doi:10.1212/WNL.0b013e318203e952
PMCID: PMC3030224  PMID: 21084692
18.  Racial and Ethnic Disparities in Indicators of Physical Health Status: Do They Still Exist Throughout Late Life? 
Physical health problems become more common as people age and are associated with a great deal of disability. Although racial/ethnic disparities have been reported in physical health, little is known about whether these disparities remain in the latest part of older adulthood. Accordingly, the current study sought to examine racial/ethnic differences in the physical health status of three age groups of older adults, using the 2005 and 2007 California Health Interview Survey. The sample for the current study included 40,631 individuals aged 55 and older, with 33,488 non-Hispanic whites, 1,858 African American/blacks, 2,872 Asian/Pacific Islanders, and 2,412 Latinos. Respondents were compared with regard to three indicators of physical health, which included presence of four chronic health conditions, difficulties with activities of daily living, and self-rated health. Analyses were conducted with and without adjustment for gender, marital status, education, English language proficiency, nativity, and insurance status. Results revealed that, in general, racial/ethnic disparities existed for physical health in late adulthood, with differences less pronounced for Asian/Pacific Islanders and Latinos ≥ 75 years after multivariable adjustment. Disparities between African American/blacks and non-Hispanic whites, as well as disparities across all racial/ethnic minorities in self-rated health, still existed, however. These findings suggest that in order to reduce racial/ethnic disparities, clinicians need to address specific sociodemographic and lifestyle factors related to racial/ethnic differences in health before these conditions are manifested in late adulthood.
doi:10.1111/j.1532-5415.2010.03033.x
PMCID: PMC2953730  PMID: 20929470
indicators of physical health status; older adults; racial and ethnic disparities; California Health Interview Survey
19.  Reducing Racial/Ethnic Disparities in Childhood Obesity: The Role of Early Life Risk Factors 
JAMA pediatrics  2013;167(8):10.1001/jamapediatrics.2013.85.
Importance
Many early life risk factors for childhood obesity are more prevalent among blacks and Hispanics than among whites and may explain the higher prevalence of obesity among racial/ethnic minority children.
Objective
To examine the extent to which racial/ethnic disparities in adiposity and overweight are explained by differences in pregnancy (gestational diabetes and depression), infancy (rapid infant weight gain, non-exclusive breastfeeding, early introduction of solid foods) and early childhood (sleeping less than 12 hours/day, presence of a television in the bedroom, any intake of sugar-sweetened beverages, and any intake of fast food) risk factors.
Design
Prospective, pre-birth cohort study.
Setting
Multi-site group practice in Massachusetts.
Participants
1116 (63% white, 17% black, and 4% Hispanic) mother-child pairs.
Main Exposure
Mother’s report of child’s race/ethnicity.
Main Outcome Measures
Age- and sex-specific body mass index (BMI) z-score, total fat mass index (FMI) from dual-energy X-ray absorptiometry, and overweight/obesity defined as a BMI ≥ 85th percentile at age 7.
Results
Black (0.48 units [95% CI: 0.31, 0.64]) and Hispanic (0.43 [0.12, 0.74]) children had higher BMI z-scores, as well as higher total FMI and overweight/obesity prevalence, than white children. After adjusting for socioeconomic confounders and parental BMI, differences in BMI z-score were attenuated for blacks (0.22 [0.05, 0.40]) and Hispanics (0.22 [−0.08, 0.52]). Adjustment for pregnancy risk factors did not substantially change these estimates. However, after further adjustment for infancy and childhood risk factors, we observed only minimal differences in BMI z-score for whites, blacks (0.07 [−0.11, 0.26]) and Hispanics (0.04 [−0.27, 0.35]). We observed similar attenuation of racial/ethnic differences in adiposity and overweight/obesity prevalence.
Conclusions and Relevance
Racial/ethnic disparities in childhood adiposity and obesity are determined by factors operating in infancy and early childhood. Efforts to reduce obesity disparities should focus on preventing early life risk factors.
doi:10.1001/jamapediatrics.2013.85
PMCID: PMC3835398  PMID: 23733179
Obesity; Race/Ethnicity; Pregnancy; Infancy; Childhood; Prevention
20.  Race/Ethnicity, Language, and Patients' Assessments of Care in Medicaid Managed Care 
Health Services Research  2003;38(3):789-808.
Objective
Consumer assessments of health care provide important information about how well health plans and clinicians meet the needs of the people they serve. The purpose of this study was to examine whether consumer reports and ratings of care in Medicaid managed care vary by race/ethnicity and language.
Data Sources
Data were derived from the National CAHPS ® Benchmarking Database (NCBD) 3.0 and consisted of 49,327 adults enrolled in Medicaid managed care plans in 14 states in 2000.
Data Collection
The CAHPS® data were collected by telephone and mail. Surveys were administered in Spanish and English. The response rate across plans was 38 percent.
Study Design
Data were analyzed using linear regression models. The dependent variables were CAHPS ® 2.0 global rating items (personal doctor, specialist, health care, health plan) and multi-item reports of care (getting needed care, timeliness of care, provider communication, staff helpfulness, plan service). The independent variables were race/ethnicity, language spoken at home (English, Spanish, Other), and survey language (English or Spanish). Survey respondents were assigned to one of nine racial/ethnic categories based on Hispanic ethnicity and race: White, Hispanic/Latino, Black/African American, Asian/Pacific Islanders, American Indian/Alaskan native, American Indian/White, Black/White, Other Multiracial, Other Race/Ethnicity. Whites, Asians, and Hispanics were further classified into language subgroups based on the survey language and based on the language primarily spoken at home. Covariates included gender, age, education, and self-rated health.
Principal Findings
Racial/ethnic and linguistic minorities tended to report worse care than did whites. Linguistic minorities reported worse care than did racial and ethnic minorities.
Conclusions
This study suggests that racial and ethnic minorities and persons with limited English proficiency face barriers to care, despite Medicaid-enabled financial access. Health care organizations should address the observed disparities in access to care for racial/ethnic and linguistic minorities as part of their quality improvement efforts.
doi:10.1111/1475-6773.00147
PMCID: PMC1360917  PMID: 12822913
Race/ethnicity; consumer assessments; CAHPS®; patient experiences; patient reports and ratings
21.  Chlamydia Positivity in Women Screened in Family Planning Clinics: Racial/Ethnic Differences and Trends in the Northwest U.S., 1997–2006 
Public Health Reports  2012;127(1):38-51.
SYNOPSIS
Objectives.
We assessed chlamydia trends, individual-level risk factors, and population-level area-based socioeconomic measures (ABSMs) associated with chlamydia infection in women attending U.S. Public Health Service (PHS) Region X Infertility Prevention Project (IPP) family planning (FP) clinics from 1997–2006. We then explored these measures within racial/ethnic subpopulations.
Methods.
Using data from 667,223 chlamydia tests obtained from women aged 15–24 years screened in 201 FP clinics, we employed a generalized mixed model with logistic link, incorporating clinic and ZIP code as random effects to adjust for risk of chlamydia associated with individual- and population-level (areal) measures for the overall population and for each racial/ethnic subpopulation.
Results.
Significant racial/ethnic differences in chlamydia persisted after adjusting for individual and aggregate factors. Relatively steep chlamydia gradients were found across racial/ethnic ABSM levels. Compared with white women, infection risk was significantly higher for black (adjusted odds ratio [AOR] = 1.93), American Indian/Alaska Native (AOR=1.62), Asian/Pacific Islander (AOR=1.42), and Hispanic (AOR=1.28) women. The impact of population-level ABSMs on chlamydia varied across racial/ethnic groups and was generally modest. Among white women, there was a significant 4% relative annual increase in predicted chlamydia during the 10-year period 1997–2006. Chlamydia positivity over time did not change for racial/ethnic minority groups after adjusting for individual- and population-level factors.
Conclusions.
Racial/ethnic differences in chlamydia persisted over time and were not mitigated by adjustment for aggregate socioeconomic position or areal racial/ethnic measures. Changes in project strategies will be needed to address racial/ethnic disparities for chlamydial infection among young female FP clinic clients.
PMCID: PMC3234396  PMID: 22298921
22.  US Birth Weight/Gestational Age-Specific Neonatal Mortality: 1995–1997 Rates for Whites, Hispanics, and Blacks 
Pediatrics  2003;111(1):e61-e66.
Objective
In recent years, gains in neonatal survival have been most evident among very low birth weight, preterm, and low birth weight (LBW) infants. Most of the improvement in neonatal survival since the early 1980s seems to be the consequence of decreasing birth weight-specific mortality rates, which occurred during a period of increasing preterm and LBW rates. Although the decline in neonatal mortality has been widely publicized in the United States, research suggests that clinicians may still underestimate the chances of survival of an infant who is born too early or too small and may overestimate the eventuality of serious disability. So that clinicians may have current and needed ethnic- and race-specific estimates of the “chances” of early survival for newborn infants, we examined birth weight/gestational age-specific neonatal mortality rates for the 3 largest ethnic/racial groups in the United States: non-Hispanic whites, Hispanics, and non-Hispanic blacks. Marked racial variation in birth weight and gestational age-specific mortality has long been recognized, and growing concerns have been raised about ongoing and increasing racial disparities in pregnancy outcomes. Our purpose for this investigation was to provide an up-to-date national reference for birth weight/gestational age-specific neonatal mortality rates for use by clinicians in care decision making and discussions with parents.
Methods
The National Center for Health Statistics linked live birth-infant death cohort files for 1995–1997 were used for this study. Singleton live births to US resident mothers with a reported maternal ethnicity/race of non-Hispanic white, non-Hispanic black, or Hispanic (n = 10 610 715) were selected for analysis. Birth weight/gestational age-specific neonatal mortality rates were calculated using 250 g/2-week intervals for each ethnic/racial group.
Results
The overall neonatal mortality rates for whites, Hispanics, and blacks were 3.24, 3.45, and 8.16 neonatal deaths per 1000 live births, and the proportion of births <28 weeks was 0.35%, 0.45%, and 1.39%, respectively. Newborns who weighed <1500 g comprised <2.5% of all births in each racial/ethnic group but accounted for >50% of neonatal deaths. For whites, Hispanics, and blacks, >50% of newborns 24 to 25 weeks of gestational age survived. For most combinations of birth weights <3500 g and gestational ages of <37 weeks, the neonatal mortality rate was lowest among blacks, compared with whites or Hispanics. At these same gestational age/birth weight combinations, Hispanics have slightly lower mortality rates than whites. For combinations of birth weights >3500 g and gestational ages of 37 to 41 weeks, Hispanics had the lowest neonatal mortality rate. In these birth weight/gestational age combinations, where approximately two thirds of births occur, blacks had the highest neonatal mortality rate.
Conclusions
Compared with earlier reports, these data suggest that a substantial improvement in birth weight/gestational age-specific neonatal mortality has occurred in the United States. Regardless of ethnicity/race, the risk of a neonatal death does not exceed 50% (the suggested definition for the limit of viability), except for birth weights below 500 g and gestational ages <24 weeks. Notwithstanding, ethnic/racial variations in neonatal mortality rates continue to persist, both in overall rates and within birth weight/gestational age categories. Blacks continue to have higher proportions for preterm and LBW births, compared with either whites or Hispanics. At the same time, blacks experience lower risks of neonatal mortality for preterm and LBW infants, while having higher risks of mortality among term, postterm, normal birth weight, and macrosomic births.
doi:10.1542/peds.111.1.e61
PMCID: PMC1382183  PMID: 12509596
VLBW, very low birth weight; LBW, low birth weight; BG-NMR, birth weight/gestational age-specific neonatal mortality rate; NCHS, National Center for Health Statistics; LMP, last normal menstrual period
23.  Ethnic and racial differences in patients with Ewing sarcoma 
Cancer  2010;116(4):983-988.
Background
Ewing sarcoma (ES) is a malignant tumor of bone or soft tissue. One of the few risk factors for developing ES is race, with a higher incidence in populations of European rather than African or Asian ancestry. The goal of this study was to evaluate racial and ethnic differences in presentation and overall survival (OS) among patients diagnosed with ES before age 40.
Methods
Data from the SEER database identified1715 patients with ES <40 years of age from 1973–2005. Racial and ethnic group differences were compared using chi square tests. OS was estimated by Kaplan-Meier analysis and compared using log-rank tests and Cox models.
Results
Black patients had significantly more soft-tissue tumors compared to white non-Hispanic patients (p < 0.0001). Asian and white Hispanic patients had an intermediate frequency of soft tissue tumors that also differed from white non-Hispanic patients (p < 0.0001). White Hispanic patients presented with a higher proportion of larger tumors compared to white non-Hispanic patients (p = 0.042). Black patients were older than white non-Hispanic patients (p = 0.012). Sex, frequency of pelvic tumors, and metastatic status did not differ by ethnicity or race. OS was different according to race and ethnicity. Even after controlling for known confounders, OS was significantly worse for black, Asian, and white Hispanic patients compared to white non-Hispanic patients (p=0.0031, p= 0.0182 and p=0.0051, respectively).
Conclusion
Ethnic and racial differences in characteristics and outcomes for patients with ES exist. Understanding the etiology of these differences requires further study.
doi:10.1002/cncr.24865
PMCID: PMC2819622  PMID: 20052725
Ewing sarcoma family of tumors; prognosis; soft-tissue; race; ethnicity; SEER
24.  The Role of Race/Ethnicity in Alcohol-attributable Injury in the United States 
Epidemiologic Reviews  2011;34(1):89-102.
A substantial proportion of injuries worldwide are attributable to alcohol consumption, and US estimates indicate that the drinking patterns of racial/ethnic groups vary considerably. The authors reviewed evidence from 19 publications regarding racial/ethnic differences in overall alcohol-attributable injury as well as percent blood alcohol content positivity for injury deaths in the United States. They found that Native Americans evidence higher rates of alcohol-attributable motor vehicle crash fatality, suicide, and falls compared with other racial/ethnic groups; conversely, Asians evidence lower rates of alcohol-attributable injury than other racial/ethnic groups. The rate of alcohol positivity and intoxication among Hispanics is disproportionately high relative to estimates of alcohol use. Black subgroups also evidence higher rates of alcohol positivity than would be expected given estimates of alcohol use, including for alcohol positivity among drivers of fatally injured black children and homicide. These findings highlight the continued need for public health focus on Native American populations with respect to alcohol consumption and injury. Further, the disparity in alcohol-attributable injury mortality among black and Hispanic groups relative to their reported rates of alcohol consumption is an overlooked area of research. The authors review potential social determinants of racial/ethnic disparities in alcohol-attributable injuries and identify directions for further research on these patterns.
doi:10.1093/epirev/mxr018
PMCID: PMC3283099  PMID: 21930592
accidents; alcohol drinking; alcoholic intoxication; homicide; minority health; motor vehicles; suicide; wounds and injuries
25.  Race/Ethnic Disparities in Left Ventricular Diastolic Function in a Tri-Ethnic Community Cohort 
American heart journal  2010;160(1):152-158.
Background
Racial-ethnic disparities exist in cardiovascular risk factors, morbidity and mortality. Left ventricular (LV) diastolic dysfunction is a predictor of mortality and of cardiovascular outcome including incident heart failure. We sought to assess whether race-ethnic differences in diastolic function exist. Such differences may contribute to the observed disparities in cardiovascular outcomes.
Methods
Two-dimensional echocardiography was performed in 760 participants (539 Hispanic, 117 non-Hispanic black, 104 non-Hispanic white) from the Cardiac Abnormalities and Brain Lesions (CABL) study. LV diastolic function was assessed by standard Doppler flow profile and tissue Doppler imaging (TDI). Early (E) and late (A) trans-mitral diastolic flow, and mitral annulus early diastolic velocities (E’) were recorded and E/A and E/E’ ratios were calculated.
Results
Blacks and Hispanics had higher body mass index (p=0.04, p<0.01), higher prevalence of hypertension (both p≤0.05) and diabetes (both p<0.01), and lower level of education (both p<0.01) compared to whites. In age- and sex-adjusted analyses, Hispanics and blacks showed worse indices of diastolic function than whites. Hispanics had lower E/A ratio (p=0.01), lower E’ and higher E/E’ (both p<0.01) than whites, whereas blacks had lower E’ (p<0.05) and a trend toward a higher E/E’ ratio (p=0.09) compared with whites. These race-ethnic differences in diastolic function were attenuated in multivariate models adjusted for cardiovascular risk factors.
Conclusions
Differences in LV diastolic function exist between race-ethnic groups. However, modifiable cardiovascular risk factors and socio-demographic variables, rather than intrinsic race-ethnic heterogeneity, seem to explain most of the observed differences.
doi:10.1016/j.ahj.2010.04.010
PMCID: PMC2898748  PMID: 20598986
Diastolic function; Race; Ethnicity; Risk factors; Echocardiography

Results 1-25 (1017002)