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1.  Enhancing the Careers of Under-Represented Junior Faculty in Biomedical Research: The Summer Institute Program to Increase Diversity (SIPID) 
The Summer Institute Program to Increase Diversity (SIPID) in Health-Related Research is a career advancement opportunity sponsored by the National Heart, Lung, and Blood Institute. Three mentored programs address difficulties experienced by junior investigators in establishing independent research careers and academic advancement. Aims are to increase the number of faculty from under-represented minority groups who successfully compete for external research funding.
Data were collected using a centralized data-entry system from three Summer Institutes. Outcomes include mentees’ satisfaction rating about the program, grant and publications productivity and specific comments.
Fifty-eight junior faculty mentees (38% male) noticeably improved their rates of preparing/submitting grant applications and publications, with a 18–23% increase in confidence levels in planning and conducting research. According to survey comments, the training received in grantsmanship skills and one-on-one mentoring were the most valuable program components.
The SIPID mentoring program was highly valued by the junior faculty mentees. The program will continue in 2011–2014 as PRIDE (PRogram to Increase Diversity among individuals Engaged in health-related research). Long-term follow-up of current mentees will be indexed at five years post training (2013). In summary, these mentoring programs hope to continue increasing the diversity of the next generation of scientists in biomedical research.
PMCID: PMC4324679
2.  Men’s Perspectives on Selecting Their Prostate Cancer Treatment 
Objective
In the context of scientific uncertainty, treatment choices for localized prostate cancer vary, but reasons for this variation are unclear. We explored how black and white American men made their treatment decision.
Methods
Guided by conceptual model, we conducted semistructured interviews of 21 American (14 black and 7 white) men with recently diagnosed localized prostate cancer.
Results
Physician recommendation was very important in the treatment decision, but patient self-perception/values and attitudes/beliefs about prostate cancer were also influential. Patients who chose surgery believed it offered the best chance of cure and were more concerned that the cancer might spread if not surgically removed. Patients who chose radiation therapy believed it offered equal efficacy of cure but fewer side effects than surgery. Fear of future consequences was the most common reason to reject watchful waiting. Anecdotal experiences of family and friends were also important, especially in deciding “what not to do.” The new technology of robotic-assisted prostatectomy provided optimism for men who wanted surgery but feared morbidity associated with traditional open surgery. Few men seemed aware that treatment did not guarantee improved survival.
Conclusion
Most men reported making “the best choice for me” by taking into account medical information and personal factors. Perceptions of treatment efficacy and side effects, which derived mainly from physicians’ descriptions and/or anecdotal experiences of family and friends, were the most influential factors in men’s treatment decision. By understanding factors that influence patients’ treatment decisions, clinicians may be more sensitive to individual patients’ preferences/ concerns and provide more patient-centered care.
PMCID: PMC4283563  PMID: 21830629
prostate cancer; treatment; racial disparities
3.  African American Patient Experiences with a Rapid HIV Testing Program in an Urban Public Clinic 
Background
Of 1,174 new HIV cases diagnosed in Philadelphia in 2008, 771 (66%) were among African Americans. In 2007, Philadelphia introduced a citywide rapid HIV testing program in public clinics.
Methods
We conducted a prospective qualitative study among 60 African Americans undergoing rapid HIV testing in one of Philadelphia’s public clinics located in a zipcode with high HIV incidence. Employing grounded theory, we used semi-structured interviews to assess patients’ motivations, perceptions and clinical experiences with rapid HIV testing. Interviews were transcribed and coded; 20% were double coded to enhance reliability.
Results
Primary motivations for undergoing rapid HIV testing included: testing during routine clinical care, presenting for care with symptomatic STIs or opportunistic infections, knowing someone living with HIV/AIDS, and perceiving oneself at risk for HIV. Most patients reported positive experiences with rapid testing and preferred it to conventional testing because it eliminated the need for return visits and decreased anxiety; however, many expressed concerns about accuracy of rapid HIV testing. Barriers to HIV testing among this population included low self-perceived risk, HIV stigma and reported homophobia in respondents’ communities.
Conclusion
This rapid testing program was acceptable, convenient, and preferred over conventional HIV testing. Providing educational information about rapid and confirmatory HIV testing may further enhance acceptability of rapid HIV testing in this population. Nationwide expansion of rapid HIV testing in public health centers is an important and acceptable means of achieving President Obama’s National AIDS Strategy goals of reducing racial disparities in HIV infection and HIV/AIDS treatment services.
PMCID: PMC4203368  PMID: 22708242
Rapid HIV testing; African American; HIV/AIDS
4.  Cultural Barriers to African American Participation in Anxiety Disorders Research 
Anxiety disorders are understudied, underdiagnosed, and undertreated in African Americans. Research focused on the phenomenology, etiology, and treatment of anxiety in African Americans has been hampered by lack of inclusion of this population in clinical research studies. The reason for exclusion is not well understood, although cultural mistrust has been hypothesized as a major barrier to research participation. This article reviews the relevant literature to date and examines the experience of 6 African American adults who participated in a larger clinical assessment study about anxiety. Drawing upon in-depth semistructured interviews about their subjective experiences, we examined participant perspectives about the assessment process, opinions about African American perception of anxiety studies, and participant-generated ideas about how to improve African American participation. Based on a qualitative analysis of responses, feelings of mistrust emerged as a dominant theme. Concerns fell under 6 categories, including not wanting to speak for others, confidentiality, self and group presentation concerns, repercussions of disclosure, potential covert purposes of the study, and the desire to confide only in close others. Suggestions for increasing African American participation are discussed, including assurances of confidentiality, adequate compensation, and a comfortable study environment.
PMCID: PMC4161612  PMID: 23862294
African Americans; recruitment; barriers; anxiety; race/ethnicity; health disparities
5.  A Cluster Randomized Controlled Trial to Increase Breast Cancer Screening Among African American Women: The Black Cosmetologists Promoting Health Program 
Background
African American women have disproportionately higher rates of breast cancer (BC) mortality than all other ethnic groups, thus highlighting the importance of promoting early detection.
Methods
African American women (N = 984) from San Diego, California participated in a randomized controlled trial testing the efficacy of BC education sessions offered in beauty salons. Cosmetologists received ongoing support, training, and additional culturally aligned educational materials to help them engage their clients in dialogues about the importance of BC early detection. Posters and literature about BC early detection were displayed throughout the salons and cosmetologists used synthetic breast models to show their clients how BC lumps might feel. Participants in the control group received a comparable diabetes education program. Baseline and six month follow-up surveys were administered to evaluate changes in women’s BC knowledge, attitudes and screening behaviors.
Results
This intervention was well received by the participants and their cosmetologists and did not interfere with, or prolong, the client’s salon visit. Women in the intervention group reported significantly higher rates of mammography compared to women in the control group. Training a single educator proved sufficient to permeate the entire salon with the health message and salon clients agreed that cosmetologists could become effective health educators.
Conclusions
Cosmetologists are in an ideal position to increase African American women’s BC knowledge and adherence to BC screening guidelines.
PMCID: PMC4153602  PMID: 22046851
African American; Breast cancer; Early detection; Education; Screening
6.  Barriers to Colorectal Cancer Screening Among Publicly Insured Urban Women: No Knowledge of Tests and No Clinician Recommendation 
Objectives
To assess barriers to colorectal cancer screening among urban publicly insured women and to evaluate how barriers among underscreened urban women have changed between 2001 and 2007-2008.
Methods
Eligible women were selected using Medicaid Managed Care Organization (MMCO) administrative data. MMCO outreach staff interviewed women by phone between October 2007 and February 2008, and assessed their barriers to colorectal cancer screening. We compared the results of these interviews with interviews conducted in 2001 with women in community health center waiting rooms.
Results
Thirty percent of overdue women had never heard of either colonoscopy or sigmoidoscopy, and 55% had never heard of home fecal occult blood testing (FOBT). Among overdue women who had heard of colonoscopy or sigmoidoscopy, 33% reported misconceptions and 28% reported worry as a barrier. No clinician recommendation was the most commonly reported barrier to home FOBT (44%) and was also reported as a barrier to endoscopy by 22% of women. Between 2001 and 2007-2008, the proportion of women reporting that they had not received a clinician's recommendation for endoscopy or home FOBT increased significantly.
Conclusions
A lack of information, no clinician recommendation, misconceptions, and worry persist as barriers to colon cancer screening among this underscreened urban population. An increased focus on clinician recommendation and patient education about stool-based as well as endoscopic screening methods could lead to greater screening compliance.
PMCID: PMC4083754  PMID: 22046852
colorectal cancer; screening; barriers; women's health; urban population
7.  Association of Care in a Medical Home and health care utilization among children with Sickle Cell Disease 
Objective
Sickle cell disease (SCD) is marked by high utilization of medical services. The aim of this study was to determine whether having a patient-centered medical home (PCMH) is associated with a reduction in emergency care (ED) utilization or hospitalizations among children with scd.
Methods
We collected and analyzed data from parents of 150 children, ages 1 to 17 years, who received care within a large children's hospital. The primary dependent variables were rates of parent-reported ED visits and hospitalizations. The principal independent variable was parent-reported experience with an overall PCMH or its four individual components (regular provider, comprehensive care, family-centered care, and coordinated care). Multivariate negative binomial regression, yielding incident rate ratios (irr), was used for analysis.
Results
Children who received comprehensive care had half the rate of ED visits (IRR 0.51, 95% confidence interval, 0.33-0.78) and nearly half the rate of hospitalizations (IRR 0.56, 95% confidence interval, 0.33-0.93) compared to children without comprehensive care. No other component of the PCMH was significantly associated with ED visits or hospitalizations. Children reported to have excellent/very good/good health status had lower odds of ED visits and hospitalizations compared to those reported to be in fair/poor condition.
Conclusions
Children with SCD reported to experience comprehensive care had lower rates of ED encounters and hospitalizations after controlling for demographics and health status. The overall findings highlight that the provision of comprehensive care - having a usual source of care and no problems with referrals - may provide a strategy for improving pediatric SCD care.
PMCID: PMC3834259  PMID: 24079216
Sickle cell disease; Epidemiology; Outcomes research
8.  Characterizing Depression and Comorbid Medical Conditions in African American Women in a Primary Care Setting 
Background
African American women are more likely to seek treatment for depression in primary care settings; however, few women receive guideline-concordant depression treatment in these settings. This investigation focused on the impact of depression on overall functioning in African American women in a primary care setting.
Methods
Data was collected from a sample of 507 African American women in the waiting room of an urban primary care setting. The majority of women were well-educated, insured, and employed. The CESD-R was used to screen for depression, and participants completed the 36-Item Short-Form Survey to determine functional status.
Results
Among the participants with depression, there was greater functional impairment for role-physical (z = −0.88, 95% CI = −1.13, −0.64) when compared to individuals with diabetes and hypertension. Individuals with depression also had greater role-emotional impairment (z=−1.12, 95% CI = −1.37, −0.87) than individuals with diabetes and hypertension. African American women with comorbid hypertension and depression had greater functional impairment in role-physical when compared to African American women with hypertension and no depression (t(124)= −4.22, p<0.01).
Conclusion
African American women with depression are more likely to present with greater functional impairment in role function when compared to African American women with diabetes or hypertension. Because African American women often present to primary care settings for treatment of mental illness, primary care providers need to have a clear understanding of the population, as well as the most effective and appropriate interventions.
PMCID: PMC4039195  PMID: 24079219
depression; African American women; primary care
9.  Opioid Addiction and Abuse in Primary Care Practice: A Comparison of Methadone and Buprenorphine as Treatment Options 
Opioid abuse and addiction have increased in frequency in the United States over the past 20 years. In 2009, an estimated 5.3 million persons used opioid medications nonmedically within the past month, 200 000 used heroin, and approximately 9.6% of African Americans used an illicit drug. Racial and ethnic minorities experience disparities in availability and access to mental health care, including substance use disorders.
Primary care practitioners are often called upon to differentiate between appropriate, medically indicated opioid use in pain management vs inappropriate abuse or addiction. Racial and ethnic minority populations tend to favor primary care treatment settings over specialty mental health settings. Recent therapeutic advances allow patients requiring specialized treatment for opioid abuse and addiction to be managed in primary care settings. The Drug Addiction Treatment Act of 2000 enables qualified physicians with readily available short-term training to treat opioid-dependent patients with buprenorphine in an office-based setting, potentially making primary care physicians active partners in the diagnosis and treatment of opioid use disorders.
Methadone and buprenorphine are effective opioid replacement agents for maintenance and/or detoxification of opioid-addicted individuals. However, restrictive federal regulations and stigmatization of opioid addiction and treatment have limited the availability of methadone. The opioid partial agonist-antagonist buprenorphine/naloxone combination has proven an effective alternative. This article reviews the literature on differences between buprenorphine and methadone regarding availability, efficacy, safety, side-effects, and dosing, identifying resources for enhancing the effectiveness of medication-assisted recovery through coordination with behavioral/psychological counseling, embedded in the context of recovery-oriented systems of care.
PMCID: PMC4039205  PMID: 23092049
substance; abuse/use
10.  Increasing Knowledge of Cardiovascular Risk Factors Among African Americans by Use of Community Health Workers: The ABCD Community Intervention Pilot Project 
African Americans have higher rates of cardiovascular disease (CVD) and poorer outcomes compared to others. The American Diabetes Association and the National Diabetes Education Program have promoted use of the ABC approach (glycated hemoglobin A1c, blood pressure, cholesterol) for identifying and controlling the leading indicators of CVD risk. In the present study, researchers added a D factor, for depression, because this disorder is common and also predictive of CVD risk and of control of diabetes. Particularly among low-income African Americans, depression is frequently not targeted or treated. The current study tests the effectiveness of recruiting African Americans in churches and training community health workers (CHWs) to educate their peers about CVD and risk reduction. For the intervention group, CHWs participated in a 16-hour training session and delivered a 6-week tailored educational program with counseling sessions and demonstrations. The control group received a weekly lecture by clinical experts. The CHW active-learning intervention was more effective than lectures by clinical experts in increasing the knowledge of CVD risk. The only significant difference in clinical measures reflected a worsening of HbA1c levels in the control group; the CHW intervention group showed a slight improvement. Participants also learned self-management skills, such as taking blood pressure, measuring glucose, and reading labels. Nevertheless, more longitudinal research and a larger sample size are needed to confirm the impact of CHWs in community settings to change factors associated with CVD risk.
PMCID: PMC4017345  PMID: 22774385
knowledge, attitudes, and beliefs; hypertension; diabetes; cardiovascular; risk factors; community health workers; African Americans
11.  Perceptions of Colorectal Cancer Among Three Ethnic Subgroups of US Blacks: A Qualitative Study 
Colorectal cancer (CRC) is currently associated with one of the highest burdens of morbidity and mortality among American men and women. Racial/ethnic disparities are well documented and the subject of intense research and intervention. Our understanding of disparities related to awareness and perceptions about causes, risk, factors, and screening for CRC among subgroups of blacks in the United States is limited. This may be in part because grouping. US-born blacks and foreign-born blacks as one homogeneous group obscures possible within-group differences. This study aimed to explore the cultural perceptions of CRC among 3 ethnic subgroups of blacks: African Americans (US born), foreign-born blacks from English-speaking Caribbean countries, and Haitian-born blacks. The study was informed by a community-based participatory research approach, using a cross-sectional mixed qualitative and quantitative methods design. A total of 62 individuals from the 3 ethnic subgroups participated in semistructured, in-depth qualitative and structured quantitative interviews. Qualitative findings revealed no stark differences among the 3 ethnic subgroups in their overall perceptions of cancer as well as their attitudes related to barriers, motivation, and resources for CRC screening. However, there were subtle differences in perceptions of curability, preventive practices, and preferred sources of information among the three ethnic subgroups of US blacks. The study has important implications for the design of educational materials and targeted interventions for diverse groups of US blacks.
PMCID: PMC3999593  PMID: 22046844
colorectal; cancer; screening; health disparities; African Americans; immigrants; research
13.  The Association Among Specialty, Race, Ethnicity, and Practice Location Among California Physicians in Diverse Specialties 
Background
Minority physicians are more likely than their counterparts to work in underserved communities and care for minority, poor, and uninsured patients, but much of this research has examined primary care physicians alone. Few have investigated whether non–primary care specialists of minority backgrounds are more likely to serve the underserved than nonminority specialists.
Objective
We examined whether underrepresented minority (URM) physicians from a wide variety of specialties are more likely than non-URM physicians to practice in underserved communities.
Methods
Using California Medical Board Physician Licensure Survey (2007) data for 48 388 physicians, we geocoded practice zip codes to medically underserved areas (MUAs) and primary care health professional shortage areas (HPSAs). Logistic regression models adjusting for age, gender, specialty, and other characteristics were used to explore associations with race, ethnicity, specialty, and designated underserved areas.
Results
We found that African American, Latino, and Pacific Islanders were more likely to work in MUAs and HPSAs than were white physicians (adjusted odds ratio, 1.22–2.25; p < .05). Similar patterns of practice in MUAs and HPSAs by physician race and ethnicity were found when performing the analyses separately among primary care physicians and physicians in non–primary care specialties.
Conclusion
In summary, our study underscores the importance of underrepresented minority physicians in all specialties for the physician workforce needs of disadvantaged communities. To improve health care for underserved communities, continued efforts to increase physician diversity are essential.
PMCID: PMC3978451  PMID: 22708247
workforce; physicians; access; underserved
14.  Effect of an Eye Health Education Program on Older African Americans' Eye Care Utilization and Attitudes about Eye Care 
We examined the impact of an eye health education program for older African Americans on attitudes about eye care and utilization, using a randomized trial design in a community setting. Participants were older African Americans attending activities at senior centers. Ten centers were randomized to an eye health education (InCHARGE©) or social-contact control presentation. InCHARGE© addressed the importance of annual dilated comprehensive examination and strategies reducing barriers to care. The control presentation was on the importance of physical activity. Outcomes were attitudes about eye care through questionnaire 6 months post-event, and eye care utilization during 12 months post-event through medical record abstraction. At baseline > 80% participants in both arms said transportation and finding, communicating, and trusting a doctor were not problematic and agreed that yearly care was important. One-fourth said eye examination cost was problematic; one-half said spectacle cost was problematic. There were no group differences 6 months post-event. During 12 months pre-event, dilated exam rate was similar in the groups (38.3% InCHARGE©, 40.8% control), and unchanged during 12 months post-event. Results suggest less than half of older African Americans received annual dilated eye care. Group-administered eye health education did not increase this rate. Even before the program, they had positive attitudes about care, yet many cited examination and spectacle cost as problematic, which was not mitigated by health education. Evidence-based strategies in a community setting for increasing eye care utilization rate in older African Americans have yet to be identified. Policy changes may be more appropriate avenues for addressing cost.
PMCID: PMC3718503  PMID: 23862298
eye care utilization; eye health education; barriers to care
15.  Sleep-Related Behaviors and Beliefs Associated With Race/Ethnicity in Women 
Explore how social factors influence sleep, especially sleep-related beliefs and behaviors. Sleep complaints, sleep hygiene behaviors, and beliefs about sleep were studied in 65 black/African American and white/European American women. Differences were found for snoring and discrepancy between sleep duration and need. Sleep behaviors differed across groups for napping, methods for coping with sleep difficulties, and nonsleep behaviors in bed. Beliefs also distinguished groups, with differences in motivation for sleep and beliefs about sleep being important for health and functioning. These findings have important public health implications in terms of developing effective sleep education interventions that include consideration of cultural aspects.
PMCID: PMC3759527  PMID: 23862291
insomnia; race/ethnicity
16.  HIV Testing Among Deep South Residents With Serious Psychological Distress 
Objective
To describe the prevalence of serious psychological distress among Deep South residents and human immunodeficiency virus (HIV) testing among Deep South residents with serious psychological distress.
Methods
Data from the 2007 Behavioral Risk Factor Surveillance System (BRFSS) survey from Georgia, Louisiana, Mississippi, and South Carolina were used for this study. Andersen's behavioral model of health care use provided the conceptual framework for the study. The Kessler 6 was used to dichotomize the sample as having or not having serious psychological distress. χ2 Test and multivariate logistic regression analyses were performed on the weighted data.
Results
Only 5.7% of our sample had experienced serious psychological distress in the past 30 days. A majority proportion of persons with serious psychological distress (54.9%) had been tested for HIV. HIV testing was slightly more prevalent among males with serious psychological distress (63%) than females with serious psychological distress (60%). Predisposing factors (age, race/ethnicity, and urbanization) were confounders of HIV testing among both males and females with serious psychological distress. Enabling factors (income, health care access) were only confounders of HIV testing among males with serious psychological distress.
Conclusion
Future HIV prevention and management efforts should consider the potential role of concurrent serious psychological distress in impacting an individual's daily life and health activities such as self-care, caring for family, and maintaining employment.
PMCID: PMC3964793  PMID: 23560349
HIV/AIDS; psychology; mental health
17.  A Randomized Trial Comparing Web-Based Decision Aids on Prostate Cancer Knowledge for African-American Men 
Objectives
Few decision aids are tailored for African-American men. We sought to determine if web-based decision aids increased knowledge of prostate cancer screening among African men.
Methods
This postintervention, quasiexperimental research measured knowledge of prostate cancer screening among African-American men following receipt of 1 of 2 web-based decision aids: enhanced or usual care. Men ages 40–65 were recruited at the annual convention of the Prince Hall Masons in the summer of 2007, which was attended by 1,170 masons. The primary outcome was knowledge of prostate cancer screening.
Results
There were 87 participants in the sample with a mean age of 52 years (standard deviation=6.9). Forty-six masons were randomized to the enhanced decision aid, and 41 masons were randomized to the usual care decision aid. Knowledge scores were statistically significantly higher among the men receiving the enhanced decision aid compared to the usual care decision aid after simultaneously adjusting for age, educational level, marital status, family history, previous prostate specific antigen test and digital rectal exam (p=0.01).
Conclusion
We found evidence that the enhanced web decision aid was significantly more effective than the usual care decision aid in promoting knowledge of the benefits, limitations and risks of prostate cancer screening. Web-based sites may be effective in facilitating discussions about screening between patients and health care providers.
PMCID: PMC3883720  PMID: 18942274
African Americans; prostate cancer; screening
18.  Effort required to contact primary care providers after newborn screening identifies sickle cell trait 
People with heterozygous status for sickle cell disease (also called “sickle cell trait”) are essentially healthy, but evidence about rare health problems has increased interest in screening adolescents and young adults before athletics or military service. Ironically, almost everyone with sickle cell trait is already identified during routine newborn screening for sickle cell disease, but this identification may never reach the parents. As part of a larger statewide study of communication after newborn screening, we decided to document the amount of labor required to connect sickle cell trait screening results with primary care providers (PCPs). Case review methods examined records and call logs from the first 150 cases in a 42-month project. Our study procedures identified PCPs for 136/150 infants (90.6%); a total of 266 phone calls were needed. We identified nine categories of experiences, ranging from incorrect baby names to restrictions on accepting Medicaid patients. Cases demonstrate that it is possible to connect with most PCPs after newborn screening despite warnings about difficulties with this population. Success was due to persistence, relationships with clinics and hospitals, and Internet search capabilities. If sickle cell trait identification is necessary to protect health, then only modest increases in effort will be needed to reduce disparities in service.
PMCID: PMC3880776  PMID: 23560355
Sickle cell trait; Newborn Screening; Genetic screening; Provider-patient communication
19.  Alcohol Dependence and Health Care Utilization in African Americans 
Objective
Ethnic and cultural differences in patterns of alcohol use disorders must be understood in order to address improvement in prevention of such disorders and accessibility to health care services. The purpose of this study was to evaluate factors that influence the utilization of medical and mental health services among alcohol-dependent and non alcohol–dependent African Americans.
Method
A cohort of 454 African Americans was evaluated. Alcohol-dependent participants were recruited from various inpatient treatment facilities in the Washington, DC, metropolitan area and through advertisement and word of mouth. Non–alcohol-dependent participants were recruited by advertisements. Each participant was administered the Semi-Structured Assessment for the Genetics of Alcoholism to assess alcohol dependency and the Family History Assessment module to access family history of alcoholism. χ2 Test and analysis of variance were used to analyze the data.
Results
Alcohol dependence was more prevalent among men, those with lower income, those with less education, and they utilized mental health counseling as opposed to medical-based therapy. Increased reports of medical conditions such as migraine (p < .001), loss of consciousness (p = .001), and sexually transmitted diseases (p < .001) were also associated with alcohol dependency. Other factors, including visits to inpatient treatment programs, were directly related to incidence of alcohol dependency regardless of gender status (p < .001).
Conclusions
This study suggests an association exists among alcohol dependence, medical conditions, health care, and mental care utilization among African Americans. Future research may benefit from investigating if an association exists between alcohol use disorders and health care utilization for other ethnic groups.
PMCID: PMC3875316  PMID: 23862295
African Americans; health care utilization; substance abuse/use; gender
20.  Racial Differences in Symptoms, Comorbidity, and Treatment for Major Depressive Disorder Among Black and White Adults 
Objective
Racial differences in the clinical nature of major depressive disorder (MDD) could contribute to treatment disparities, but national data with large samples are limited. Our objective was to examine black-white differences in clinical characteristics and treatment for MDD from one of the largest, national community samples of US adults.
Methods
Non-Hispanic black and white adults (n = 32 752) from the 2001–2002 National Epidemiologic Survey on Alcohol and Related Conditions produced data on 1866 respondents who met criteria for MDD based on the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) in the preceding 12 months. Outcome measures were depressive symptoms, comorbid psychiatric and medical disorders, disability, and treatment.
Results
Blacks with MDD had significantly higher odds of initial insomnia, early-morning awakening, and restlessness than whites. Odds of hypertension (odds ratio [OR], 2.16; 95% confidence interval [CI], 1.48–3.14), obesity (OR, 1.98; 95% CI, 1.45–2.69), and liver disease (OR, 3.68; 95% CI, 1.20–11.30) were higher among blacks than whites. In unadjusted models, blacks had greater impairment than whites in social and physical functioning. However, adjusting for sociodemographic characteristics eliminated these differences. Blacks were less likely than whites to receive outpatient services (OR, 0.51; 95% CI, 0.36–0.72) and be prescribed medications for MDD, but were more likely to receive emergency room and inpatient treatment.
Conclusions
We found few racial differences in depressive symptoms, psychiatric comorbidity, and disability after adjusting for sociodemographic factors. Blacks’ lower utilization of ambulatory treatment for MDD and greater medical comorbidity, emergency department use, and hospitalization suggests that management of MDD among blacks should be emphasized in primary care or other settings where treatment is more accessible.
PMCID: PMC3866690  PMID: 21999032
African Americans; depression; comorbidity; treatment
21.  Racial and Ethnic Disparities in Diabetes Complications in the Northeastern United States: The Role of Socioeconomic Status 
The role of socioeconomic status (SES) in explaining racial/ethnic disparities in diabetes remains unclear. We investigated disparities in self-reported diabetes complications, and the role of macro (e.g., income, education) and micro (e.g., ‘owning a home’ or ‘having a checking account’) SES indicators in explaining these differences. The sample included individuals with a diagnosis of diabetes (N=795) who were on average 55 years old, and 55.6% non-Hispanic White, 25.0% African American, and 19.4% Hispanic. Approximately 8% reported nephropathy, 35% reported retinopathy, and 16% reported cardiovascular disease. There were significant disparities in the rates of complications among non-Hispanic White, African American and Hispanic participants, with Hispanics having the highest rates of nephropathy, retinopathy, and cardiovascular disease. Macro SES indicators (e.g., income) mediated racial differences (i.e., non-Hispanic Whites vs. African Americans) in self-reported retinopathy, a combination of macro and more micro SES indicators (e.g., education, income, and ‘owning a home’ or ‘having a checking account’) mediated racial/ethnic differences (i.e., non-Hispanic Whites vs. Hispanics) in self-reported cardiovascular disease, and only micro SES indicators (e.g., ‘owning a home’ or ‘having a checking account’) mediated differences between lower income SES racial/ethnic minority groups (i.e., African Americans vs. Hispanics) in self-reported retinopathy and cardiovascular disease. Findings underscore that indicators of SES must be sensitive to the outcome of interest and the racial/ethnic groups being compared.
PMCID: PMC3852686  PMID: 23862296
Minority Health; Disparities; Diabetes Complications; Socioeconomic Status
22.  Health Care Workplace Discrimination and Physician Turnover 
Objective
To examine the association between physician race/ethnicity, workplace discrimination, and physician job turnover.
Methods
Cross-sectional, national survey conducted in 2006–2007 of practicing physicians [n = 529] randomly identified via the American Medical Association Masterfile and The National Medical Association membership roster. We assessed the relationships between career racial/ethnic discrimination at work and several career-related dependent variables, including 2 measures of physician turnover, career satisfaction, and contemplation of career change. We used standard frequency analyses, odds ratios and χ2 statistics, and multivariate logistic regression modeling to evaluate these associations.
Results
Physicians who self-identified as nonmajority were significantly more likely to have left at least 1 job because of workplace discrimination (black, 29%; Asian, 24%; other race, 21%; Hispanic/Latino, 20%; white, 9%). In multivariate models, having experienced racial/ethnic discrimination at work was associated with high job turnover [adjusted odes ratio, 2.7; 95% CI, 1.4–4.9]. Among physicians who experienced work-place discrimination, only 45% of physicians were satisfied with their careers (vs 88% among those who had not experienced workplace discrimination, p value < .01], and 40% were con-templating a career change (vs 10% among those who had not experienced workplace discrimination, p value < .001).
Conclusion
Workplace discrimination is associated with physician job turnover, career dissatisfaction, and contemplation of career change. These findings underscore the importance of monitoring for workplace discrimination and responding when opportunities for intervention and retention still exist.
PMCID: PMC3833271  PMID: 20070016
health care careers; hospital/office administration; race/ethnicity
23.  Mammography Screening Trends: The Perspective of African American Women Born Pre/Post World War II 
Researchers have traditionally combined aging women (aged ≥50 years) when reporting their mammography use. This may inadvertently mask important cohort effects in mammography use, which are likely to result from distinct personal life experiences and generational differences. Using the Health and Retirement Study samples of 1998, 2000, and 2004, we examined cohort differences in mammography use between African American women born before 1946 (non–baby boomers) and those born in 1946 to 1953 (baby boomers). Between 1998 and 2004, screening rates for non–baby boomers declined, while those for baby boomers remained relatively steady. Hierarchical linear modeling (HLM) analyses suggest that while screening rates decreased with age (OR, 0.957; 95% CI, 0.947–0.968) cohort effects may have partially reversed the age effect, with non–baby boomers having an increased likelihood of receiving a mammogram compared to baby boomers (OR, 1.697; 95% CI, 1.278–2.254). Because African American women are diagnosed at later stages of breast cancer, documentation of cohort differences in mammography use among older African American women is important as health care professionals design intervention programs that are maximally effective for women from different cohorts. This is particularly critical as more African American women in the baby boomer cohort become part of the aging population.
PMCID: PMC3821170  PMID: 20575209
adherence; screening
24.  Sociodemographic Factors Predict Early Discontinuation of HIV Non-Nucleoside Reverse Transcriptase Inhibitors and Protease Inhibitors 
Background/Objective
HIV infection has a devastating impact on individual and public health, and affects populations disproportionately. Treatment with antiretroviral therapy (ART) saves lives, but long-term adherence to ART is critical to its success. We performed an observational cohort study to determine the influence of race, sex and other sociodemographic factors on early ART discontinuations among HIV-infected persons.
Methods
TennCare-enrolled adults of black or white non-Hispanic race beginning ART with either a non-nucleoside reverse transcriptase inhibitor (NNRTI) or protease inhibitor (PI) between 1996–2003 (N=3,654) were assessed for early discontinuation. A subgroup of discontinuations was validated using the primary medical record.
Results
Blacks were more likely than whites to discontinue NNRTIs (37 vs. 28%; P=0.003) and PIs (36 vs. 25%; P≤0.001). In multivariable models adjusting for race, sex, age, early HIV-related medical encounter, urban residence and TennCare enrollment category, black race, female sex and younger age were independent predictors of discontinuation among those starting PIs. Among persons starting NNRTIs, black race, younger age and a disability-based enrollment category predicted early drug discontinuation, but female sex did not.
Conclusions
Our results suggest that sociodemographic factors were associated with early NNRTI and PI discontinuation in this population, and some factors were ART class specific.
PMCID: PMC3816354  PMID: 19110909
HIV/AIDS; treatment; health insurance
25.  Relationships among Blood Pressure, Triglycerides and Verbal Learning in African Americans 
Background
Individuals at greater risk for cardiovascular disease (CVD) display poorer cognitive functioning across various cognitive domains. This finding is particularly prevalent among older adults; however, few studies examine these relationships among younger adults or among African Americans.
Purpose
The objective was to examine the relationships among 2 cardiovascular risk factors, elevated blood pressure and elevated triglycerides, and verbal learning in a community-based sample of African Americans.
Methods
Measurements of blood pressure and triglycerides were obtained in 121 African-American adults and compared to performance on 3 domains of the California Verbal Learning Test-II (CVLT-II).
Results
Blood pressure was not related to CVLT-II performance. Triglyceride levels were inversely related to CVLT-II performance. Higher triglyceride levels were associated with poorer immediate, short delay and long delay recall.
Conclusions
Consistent with studies involving older participants, the current investigation shows that in a nonelderly sample of African Americans, triglyceride levels may be related to cognitive functioning. Because early detection and intervention of vascular-related cognitive impairment may have a salutary effect, future studies should include younger adults to highlight the impact of cardiovascular risk on cognition.
PMCID: PMC3804020  PMID: 18942281
cognitive functioning; African Americans; cardiovascular

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