Flavonols and pancreatic cancer risk: the multiethnic cohort study

Only a few prospective studies have investigated flavonols as risk factors for cancer, none of which has included pancreatic cancer. The latter is usually fatal, rendering knowledge about prevention particularly important. The authors estimated intakes of three flavonols-quercetin, kaempferol, and myricetin-for 183,518 participants in the Multiethnic Cohort Study and examined associations with incidence of pancreatic cancer. Baseline data were collected in Hawaii and California in 1993-1996. Diet was assessed by using a quantitative food frequency questionnaire. During 8 years of follow-up, 529 cases of exocrine pancreatic cancer occurred. Multivariate Cox regression models were calculated to estimate relative risks. Intake of total flavonols was associated with a reduced pancreatic cancer risk (relative risk for the highest vs. lowest quintile = 0.77, 95% confidence interval: 0.58, 1.03; p trend = 0.046). Of the three individual flavonols, kaempferol was associated with the largest risk reduction (relative risk = 0.78, 95% confidence interval: 0.58, 1.05; p trend = 0.017). Total flavonols, quercetin, kaempferol, and myricetin were all associated with a significant inverse trend among current smokers (relative risks for the highest vs. lowest quartile = 0.41, 0.55, 0.27, 0.55, respectively) but not never or former smokers. This study provides evidence for a preventive effect of flavonols on pancreatic cancer, particularly for current smokers.     

Vegetable intake and pancreatic cancer risk: the multiethnic cohort study

Investigators studying associations between vegetable intake and pancreatic cancer risk have reported inconsistent findings to date. To further explore these associations, the authors analyzed data on 183,522 participants enrolled in the Hawaii-Los Angeles Multiethnic Cohort Study in 1993-1996. Intakes of total vegetables, light green, dark green, yellow-orange, and cruciferous vegetables, tomato products, and legumes were estimated from a quantitative food frequency questionnaire. After an average of 8.3 years of follow-up, 529 pancreatic cancer cases were identified. Multivariate-adjusted Cox proportional hazards models were created. All statistical tests were two-sided. Overall, total vegetable intake was not associated with pancreatic cancer risk, nor was intake of vegetable subgroups. Current smokers, who were at increased risk of pancreatic cancer (relative risk = 1.78, 95% confidence interval: 1.40, 2.27), had a decreased risk with higher intake of dark green vegetables (for comparison of extreme quartiles, relative risk = 0.50, 95% confidence interval: 0.27, 0.92; p-trend = 0.029). The inverse association for dark green vegetables was also seen in African Americans (p-trend = 0.043). In stratified analyses, inverse associations with total vegetables, light green vegetables, and legumes were significant in overweight/obese subjects. In conclusion, the authors found no evidence for an inverse association between vegetable intake and pancreatic cancer overall, but inverse associations in high-risk persons suggest the need for further investigation.     

Mammographic density and breast cancer risk: the multiethnic cohort study

In a nested case-control study (2001-2004), the authors investigated the association between mammographic density and breast cancer risk among women of Caucasian, Japanese, and Native Hawaiian ancestry in the Hawaii component of the Multiethnic Cohort Study. The authors retrieved several prediagnostic mammograms for breast cancer cases and for controls frequency-matched to cases by age and ethnicity. A reader who was blinded to case status and year of mammogram performed computer-assisted density assessment. Suitable mammographic readings were obtained for 607 cases and 667 controls. The authors used unconditional logistic regression to estimate odds ratios and 95% confidence intervals while adjusting for confounders. Mean percent density and mean dense area were significantly greater for cases than for controls: 39.6% vs. 29.7% and 37.3 cm2 vs. 28.4 cm2, respectively. For the earliest mammogram taken, the overall odds ratio for a 10% increase in breast density was 1.22 (95% confidence interval: 1.14, 1.30), and the overall odds ratio for a 10-cm2 increase in dense area was 1.17 (95% confidence interval: 1.11, 1.24). The similar sizes of the areas under the receiver operating characteristic curve (0.66) confirmed that percent density and dense area predicted breast cancer equally well. Because the risk estimates appeared higher for Caucasians and Native Hawaiians than for Japanese women, ethnicity-specific models may be necessary to predict risk from breast density in different ethnic groups.     

Racial differences in bladder cancer risk: a case-control study

To determine why the incidence rate of transitional cell bladder cancer in whites in the United States is approximately twice that in blacks, the authors examined data from a large population-based case-control study of bladder cancer conducted in 1978 involving 2,982 cases and 5,782 controls. The relative risk of transitional cell carcinoma for whites compared with blacks was 1.9 before adjustment for the major bladder cancer risk factors, whereas after adjustment for cigarette smoking and occupation it was 1.6 (95% confidence interval (CI): 1.3-2.1). Further adjustment for other risk factors, including history of a bladder infection and a family history of urinary tract cancer, did not alter this estimate. The elevated risk of white compared with blacks was limited, however, to cases whose disease was confined to the mucosa and submucosa. Among cases whose disease had extended to the bladder musculature or beyond, whites were at slightly reduced risk compared with blacks. This suggests that whites may be diagnosed with conditions that go undetected in blacks but that are unlikely as a group to progress to more extensive disease. Because of the population-based nature of the study, it was possible to determine that if bladder cancer incidence among whites of both sexes was reduced to the level among blacks, total incidence in the United States would fall by 36 per cent.     

Racial/ethnic differences in the risk of AIDS in the United States.

We analyzed the variation in the risk of AIDS in US Blacks, Hispanics, and other racial/ethnic groups relative to that in Whites (non-Hispanic) by geographic area and mode of acquiring HIV infection, based on data reported between June 1, 1981 and January 18, 1988 to the Centers for Disease Control and 1980 US census data. Relative risks (RRs) in Blacks and Hispanics were highest in the northeast region, and higher in suburbs than in central cities of metropolitan areas. RRs in Blacks and Hispanics were greatest for AIDS directly or indirectly associated with intravenous-drug abuse by heterosexuals (range: 5.7-26.9) and were also high for AIDS associated with male bisexuality (range: 2.5-4.8), suggesting that these behaviors may be more prevalent in Blacks and Hispanics than in Whites. Prevention strategies should take into account these racial/ethnic differences.     

Multivitamin use and the risk of mortality and cancer incidence: the multiethnic cohort study

Although multivitamin/mineral supplements are commonly used in the United States, the efficacy of these supplements in preventing chronic disease or premature death is unclear. To assess the relation of multivitamin use with mortality and cancer, the authors prospectively examined these associations among 182,099 participants enrolled in the Multiethnic Cohort Study between 1993 and 1996 in Hawaii and California. During an average 11 years of follow-up, 28,851 deaths were identified. In Cox proportional hazards models controlling for tobacco use and other potential confounders, no associations were found between multivitamin use and mortality from all causes (for users vs. nonusers: hazard ratio = 1.07, 95% confidence interval: 0.96, 1.19 for men; hazard ratio = 0.96, 95% confidence interval: 0.85, 1.09 for women), cardiovascular diseases, or cancer. The findings did not vary across subgroups by ethnicity, age, body mass index, preexisting illness, single vitamin/mineral supplement use, hormone replacement therapy use, and smoking status. There also was no evidence indicating that multivitamin use was associated with risk of cancer, overall or at major sites, such as lung, colorectum, prostate, and breast. In conclusion, there was no clear decrease or increase in mortality from all causes, cardiovascular disease, or cancer and in morbidity from overall or major cancers among multivitamin supplement users.     

Nonsteroidal antiinflammatory drugs and breast cancer risk: the multiethnic cohort

Previous studies on nonsteroidal antiinflammatory drugs (NSAIDs) and breast cancer have produced mixed results. Incident invasive cases of breast cancer from the Multiethnic Cohort (African Americans, Caucasians, Japanese Americans, Latinas, and Native Hawaiians from Hawaii and California) were identified from 1993 to 2002. Data on aspirin, acetaminophen, and other NSAID (ibuprofen, naproxen, indomethacin) use were based on a self-administered questionnaire at baseline (1993-1996). Multivariate Cox proportional hazards models provided estimates of hazard rate ratios and 95% confidence intervals. The authors observed no associations between breast cancer risk and duration of aspirin use for current or past users (hazard rate ratio = 1.05, 95% confidence interval: 0.88, 1.25 and hazard rate ratio = 1.04, 95% confidence interval: 0.84, 1.27 for > or =6 years of use, respectively) compared with nonusers. However, duration of current other NSAID use was protective (hazard rate ratio = 0.70, 95% confidence interval: 0.51, 0.95 for > or =6 years of use; p(trend) = 0.01) against the risk of breast cancer, while past use was not (hazard rate ratio = 0.90, 95% confidence interval: 0.62, 1.30 for > or =6 years of use). Analyses by ethnicity and hormone receptor status showed that the protective effect of current other NSAID use was limited to Caucasians and African Americans and to women with at least one positive hormone receptor. This study found duration of current other NSAID use to be protective against breast cancer risk.     

Racial/ethnic and gender differences in individual workplace injury risk trajectories: 1988-1998

Objectives. I examined workplace injury risk over time and across racial/ethnic and gender groups to observe patterns of change and to understand how occupational characteristics and job mobility influence these changes.Methods. I used hierarchical generalized linear models to estimate individual workplace injury and illness risk over time (“trajectories”) for a cohort of American workers who participated in the National Longitudinal Survey of Youth (1988–1998).Results. Significant temporal variation in injury risk was observed across racial/ethnic and gender groups. At baseline, White men had a high risk of injury relative to the other groups and experienced the greatest decline over time. Latino men demonstrated a pattern of lower injury risk across time compared with White men. Among both Latinos and non-Latino Whites, women had lower odds of injury than did men. Non-Latino Black women''s injury risk was similar to Black men''s and greater than that for both Latino and non-Latino White women. Occupational characteristics and job mobility partly explained these differences.Conclusions. Disparities between racial/ethnic and gender groups were dynamic and changed over time. Workplace injury risk was associated with job dimensions such as work schedule, union representation, health insurance, job hours, occupational racial segregation, and occupational environmental hazards.Employers reported 5.2 million nonfatal workplace injuries to the Bureau of Labor Statistics for 2001.¹ Although workplace injuries are common and account for 30% of medically treated injuries in the United States,² few studies have examined racial/ethnic or gender disparities in workplace injury outcomes. Virtually nothing is known about how individual workplace injury risk changes across occupations or how racial/ethnic and gender disparities in risk change over time.Men and women belonging to a racial/ethnic minority are less likely to hold jobs in professional or managerial occupations, have lower wages,³ and are concentrated in sectors of the economy characterized by more-hazardous working conditions,⁴ such as agriculture, domestic service,^5,6 and hospital aide work,⁷ compared with their White counterparts. For these reasons, one might expect rates of workplace injury to be higher among these workers and perhaps different across specific racial/ethnic and gender groups. Despite these disparities, few studies have addressed racial/ethnic and gender subgroup differences in workplace injury outcomes. The existing literature on race/ethnicity and workplace injury is inconsistent, sometimes finding a disparity^5,8 and sometimes finding no disparity between racial/ethnic majority and minority workers.^9,10 Findings for gender are more conclusive; women consistently report fewer workplace injuries than do men.¹¹Few studies have examined men and women of color as separate subgroups, even though race/ethnicity and gender jointly determine labor market position. This omission is problematic because previous research has found that race/ethnicity and gender interact to produce different employment outcomes for men and women of color that are not apparent in additive models.¹² The few exceptions that present data jointly by race/ethnicity and gender rely on data from the 1980s⁵ or focus on single industries.^6,7 As a notable exception, an analysis of National Longitudinal Survey of Youth (NLSY) data revealed that Black men and women missed more days of work after an injury compared with Whites.⁹Over the course of a working life, workers may be able to move out of risky jobs and, thus, decrease their risk of injury. Because of the strong influence of race/ethnicity and gender on economic outcomes and upward mobility,^3,13 disadvantaged groups, namely women and minorities, may be less able to move out of risky jobs. Testing this hypothesis was the focus of my analysis.Analyses of panel data are invaluable in the study of workplace injury disparities and changes over time. Because most previous research was cross-sectional in nature and often relied on officially reported cases or on case studies, it could not address research questions about patterns of change for individuals. Some recent studies used panel data from the NLSY⁹ to examine workplace injury, but none have used trajectory analysis to examine individual racial/ethnic and gender disparities over time or the effects of job mobility on workplace injury risk.Characteristics of jobs and occupations that correlate with race/ethnicity, gender, and workplace injuries were control variables in my study. Because minority workers disproportionately work rotating shifts and nonstandard hours,¹⁴ receive lower wages, and work in more-hazardous occupations, these factors may account for potential racial/ethnic and gender differences in workplace injury trajectories. Racially segregated work is a potential risk factor for workplace injury,⁴ although no previous studies of workplace injury included measures of occupational racial segregation as predictors of individual workplace injury. Union representation and health insurance benefits are linked to workplace injury risk, because risky jobs in some sectors are represented by unions organized around health and safety issues. These factors are associated with workplace injury, and changes along these dimensions could account for changes in racial/ethnic or gender differences in workplace injury over time.I used nationally representative panel data from the NLSY to estimate individual workplace injury and illness risks over time (“trajectories”) during a 10-year period. I sought to answer 2 research questions. First, are individual workplace injury trajectories modified by race/ethnicity or gender? I expected men of color to fare worse and face the highest risk of injury over time, and I expected women of color to have more injuries compared with non-Latino White women. Second, does job mobility account for any observed racial/ethnic and gender differences in individual time trajectories? Because different labor market characteristics are associated with race/ethnicity and gender and with workplace injury, I hypothesized that job mobility would account for racial/ethnic and gender differences in workplace injury trajectories.     

Racial/ethnic differences in children's access to care

OBJECTIVES: This study explored reasons for racial and ethnic differences in children's usual sources of care. METHODS: Data from the 1996 Medical Expenditure Panel Survey were examined by means of logistic regression techniques. RESULTS: Black and Hispanic children were substantially less likely than White children to have a usual source of care. These differences persisted after control for health insurance and socioeconomic status. Control for language ability, however, eliminated differences between Hispanic and White children. CONCLUSIONS: Results suggest that the marked Hispanic disadvantage in children's access to care noted in earlier studies may be related to language ability.     

Racial/ethnic differences in body image and eating behaviors

There is a growing literature on the relationship between race/ethnicity and body image and eating disorders, but the conclusions are still unclear. We therefore examined racial/ethnic influences on body image and eating behaviors in 108 Caucasian, 46 African American, and 40 Asian female undergraduates. Participants completed the Figure Rating Scale (FRS) and the Eating Habits Questionnaire (EHQ) to assess body image and eating pathology. Caucasians had greater body discrepancy (difference between current and ideal) than Asians (P=.05) and higher EHQ scores (P<.0001) than both Asians and African Americans. African Americans chose a larger ideal body size than the other groups (P=.005). However, Asian women had a significantly lower body mass index (BMI) than both groups (P<.0001). After controlling for BMI, ideal body size differences were minimized (P=.08). Also, now, both Caucasians and Asians had greater body discrepancy (P<.0001) and EHQ scores (P<.0001) than African Americans. Our findings help reconcile inconsistencies in the literature by demonstrating the impact of controlling for BMI when comparing body image and eating behaviors in individuals from different racial/ethnic backgrounds.     

Racial/ethnic differences in access to substance abuse treatment

A secondary dataset, Collaborative Psychiatric Epidemiology Surveys (CPES), 2001-2003, was employed to examine racial/ethnic differences in access to specialty and non-specialty substance abuse treatment (compared with no access to treatment). The study found that non-Hispanic White Americans were (1) likelier than members of all racial/ethnic minority groups (other than Hispanics) to address substance abuse by accessing care through specialty addiction-treatment facilities, and were (2) also less likely to access substance abuse care through non-specialty facilities. Because non-specialty facilities may have staffs whose professional training does not target treating chronic, bio-psycho-social illness such as substance abuse, our results imply that treatment facilities deemed non-specialty may need to enhance staff training, in order to ensure individuals are properly screened for substance use conditions and are referred for or provided with effective counseling and medications as appropriate.     

Racial/ethnic differences in influenza vaccination coverage in high-risk adults

OBJECTIVES: This study identified racial/ethnic disparities in influenza vaccination in high-risk adults. METHODS: We analyzed data on influenza vaccination in 7655 adults with high-risk conditions, using data from the 1999 National Health Interview Survey (NHIS). We stratified data by age and used multiple logistic regression to adjust for gender, education, income, employment, and health care access. RESULTS: After control for covariates, White patients with diabetes, chronic heart conditions, and cancer had a higher prevalence of influenza vaccination than did Black patients with the same conditions. Similarly, White patients with 2 or more high-risk conditions were more likely to receive the influenza vaccine than Black patients with the same conditions. CONCLUSIONS: Significant racial/ethnic differences exist in influenza vaccination of high-risk individuals, and missed vaccination opportunities seem to contribute to the less-than-optimal influenza vaccination coverage in the United States.     

Racial/ethnic differences in the development of disability among older adults

Objectives. We investigated differences in the development of disability in activities of daily living among non-Hispanic Whites, African Americans, Hispanics interviewed in Spanish, and Hispanics interviewed in English.Methods. We estimated 6-year risk for disability development among 8161 participants 65 years or older and free of baseline disability. We evaluated mediating factors amenable to clinical and public health intervention on racial/ethnic difference.Results. The risk for developing disability among Hispanics interviewed in English was similar to that among Whites (hazard ratio [HR]=0.99; 95% confidence interval [CI] = 0.6, 1.4) but was substantially higher among African Americans (HR=1.6; 95% CI=1.3, 1.9) and Hispanics interviewed in Spanish (HR=1.8; 95% CI=1.4, 2.1). Adjustment for demographics, health, and socioeconomic status reduced a large portion of those disparities (African American adjusted HR=1.1, Spanish-interviewed Hispanic adjusted HR=1.2).Conclusions. Higher risks for developing disability among older African Americans, and Hispanics interviewed in Spanish compared with Whites were largely attenuated by health and socioeconomic differences. Language- and culture-specific programs to increase physical activity and promote weight maintenance may reduce rates of disability in activities of daily living and reduce racial/ethnic disparities in disability.Disability among older adults (those 65 years or older) is a major health issue involving high personal and economic costs. The number of Americans 65 years or older with chronic disability exceeds 7 million.1 Maintaining the quality of life for older adults by delaying disability may be as important as prolonging life.2^,3 Disability is more strongly associated with medical spending than with life expectancy.4^,5 Long-term care expenditures for older people are projected to reach $161 billion per year by 2010, of which two thirds will be paid by government programs.6The composition of the US population is changing. In 2000, 18% of people in the United States spoke a language at home other than English, up from 11% in 1980.7 The fastest-growing part of the older US population comprises minority groups, particularly African Americans and Hispanics.8 As the number of older people belonging to minority groups increases, there are growing public health concerns about racial/ethnic disparities in health outcomes.9 Although overall rates of disability among older Americans have declined over time, racial/ethnic disparities persist.1^,10^–13 The literature on racial/ethnic disparities in disability mostly focuses on African Americans; national studies investigating disability among Hispanics are limited.1^,12^,14^,15Despite the common practice of conducting interviews in languages other than English to allow respondents to participate in their primary language, few national studies have considered the influence of language differences on health outcomes.16 There are known differences in health and mortality related to immigration and acculturation.16^–19 Use of an interview language other than that of the host culture may be a proxy for acculturation and a predictor of future poor health.20^–23 Insight from a broader investigation of risk factors that includes language differences in relation to disparities in the development of disability is essential to the development of population-based public health programs to help maintain independence among older adults.We investigated racial/ethnic differences in disability among people 65 years and older using 6 years of data from the Health and Retirement Study (HRS),24 Finally, we investigated whether factors amenable to public health and policy intervention mediate minority differences in the development of disability among these Medicare-aged adults.     

Racial/ethnic and gender differences in the association between self-reported experiences of racial/ethnic discrimination and inflammation in the CARDIA cohort of 4 US communities

Inflammation is etiologically implicated in cardiometabolic diseases for which there are known racial/ethnic disparities. Prior studies suggest there may be an association between self-reported experiences of racial/ethnic discrimination and inflammation, particularly C-reactive protein (CRP). It is not known whether that association is influenced by race/ethnicity and gender. In separate hierarchical linear models with time-varying covariates, we examined that association among 901 Black women, 614 Black men, 958 White women, and 863 White men in the Coronary Artery Risk Development in Young Adults (CARDIA) study in four US communities. Self-reported experiences of racial/ethnic discrimination were ascertained in 1992-93 and 2000-01. Inflammation was measured as log-transformed CRP in those years and 2005-06. All analyses were adjusted for blood pressure, plasma total cholesterol, triglycerides, homeostatic model assessment for insulin resistance (HOMA-IR), age, education, and community. Our findings extend prior research by suggesting that, broadly speaking, self-reported experiences of racial/ethnic discrimination are associated with inflammation; however, this association is complex and varies for Black and White women and men. Black women reporting 1 or 2 experiences of discrimination had higher levels of CRP compared to Black women reporting no experiences of discrimination (β = 0.141, SE = 0.062, P < 0.05). This association was not statistically significant among Black women reporting 3 or more experiences of discrimination and not independent of modifiable risks (smoking and obesity) in the final model. White women reporting 3 or more experiences of discrimination had significantly higher levels of CRP compared to White women reporting no experiences of discrimination independent of modifiable risks in the final model (β = 0.300, SE = 0.113, P < 0.01). The association between self-reported experiences of racial/ethnic discrimination and CRP was not statistically significant among Black and White men reporting 1 or 2 experiences of discrimination. Further research in other populations is needed.     

Racial/ethnic differences in rates of depression among preretirement adults

OBJECTIVES: We estimated racial/ethnic differences in rates of major depression and investigated possible mediators. METHODS: Depression prevalence rates among African American, Hispanic, and White adults were estimated from a population-based national sample and adjusted for potential confounders. RESULTS: African Americans (odds ratio [OR] = 1.16, 95% confidence interval [CI] = 0.93, 1.44) and Hispanics (OR = 1.44, 95% CI = 1.02, 2.04) exhibited elevated rates of major depression relative to Whites. After control for confounders, Hispanics and Whites exhibited similar rates, and African Americans exhibited significantly lower rates than Whites. CONCLUSIONS: Major depression and factors associated with depression were more frequent among members of minority groups than among Whites. Elevated depression rates among minority individuals are largely associated with greater health burdens and lack of health insurance, factors amenable to public policy intervention.     

Racial/ethnic differences in preferences for total knee replacement surgery

OBJECTIVES: To determine whether there are ethnic differences in preferences for surgery vs. medical treatment of knee osteoarthritis (OA). STUDY DESIGN AND SETTING: Cross-sectional in-person interviews using conjoint analysis methodology, a technique often used in marketing, involved individuals making choices between alternative hypothetical scenarios for medical or surgical treatment of knee OA. One hundred ninety-three individuals over the age of 20 were recruited through random digit dialing in Harris County, TX, and 198 individuals with knee OA were recruited from a large outpatient health care provider in Houston, TX. RESULTS: African Americans were significantly less likely to chose surgery than whites (odds ratio 0.63 [0.42, 0.93]). Women and older individuals were also less likely to choose surgery (0.69 [0.51, 0.94], 0.98 [0.97, 0.99]). Larger reductions in negative symptoms with surgery significantly increased the likelihood of choosing surgery. There was no difference between the public and patients, and no effect of income level. CONCLUSIONS: Disparities in knee replacement rates among ethnic groups may be partly due to differences in preferences for surgery. Conjoint analysis was shown to be a feasible methodology for collecting preferences in health research. This methodology has great promise in contributing to our knowledge of drivers of health care decision making in individuals.     

Racial/ethnic differences in adult vaccination among individuals with diabetes

OBJECTIVES: This study examined whether differences in access to health care, health coverage, and socioeconomic status (SES) explained racial differences in influenza and pneumococcal vaccination rates in individuals with diabetes. METHODS: We analyzed data on 1906 individuals from the 1998 National Health Interview Survey. We used multiple logistic regression to adjust for race/ethnicity, age, access to care, health insurance, and SES, and used SUDAAN for statistical analyses to yield national estimates. RESULTS: Whites had higher vaccination rates than did African Americans or Hispanics. After adjustment for covariates, race/ethnicity predicted receipt of both vaccines independent of age, access to care, health care coverage, and SES. CONCLUSIONS: Racial disparity in vaccination rates for adults with diabetes is independent of access to care, health care coverage, and SES.     

Racial/ethnic differences in influenza vaccination in the Veterans Affairs Healthcare System

BACKGROUND: Racial/ethnic differences in influenza vaccination exist among elderly adults despite nearly universal Medicare health insurance coverage. Overall influenza vaccination prevalence in the Veterans Affairs (VA) Healthcare System is higher than in the general population; however, it is not known whether racial/ethnic differences exist among older adults receiving VA healthcare. Racial/ethnic differences in influenza vaccination in VA were assessed, and barriers to and facilitators of influenza vaccination were examined among veteran outpatients aged 50 years and older. METHODS: A random sample of 121,738 veterans receiving care at VA outpatient clinics during the 2003-2004 influenza season completed the mailed Survey of Health Experiences of Patients (77% response rate). Multivariate logistic regression was used to examine associations among race/ethnicity and influenza vaccination prevalence, barriers, and facilitators. Analyses were conducted during 2005 and 2006. RESULTS: Based on unadjusted prevalences, non-Hispanic blacks, Hispanics, and American Indian/Alaskan Natives were significantly less likely to be vaccinated for influenza compared to non-Hispanic whites (71%, 79%, and 74%, respectively, vs 82%). After adjustment for age, gender, marital status, education level, employment, having a primary care provider, confidence and/trust in provider, and health status, only non-Hispanic blacks remained significantly less likely to be vaccinated compared to non-Hispanic whites (75% vs 81%). Influenza vaccination barriers and facilitators varied by race/ethnic group. CONCLUSIONS: Compared to non-Hispanic whites, non-Hispanic blacks were less likely to receive influenza vaccination in the VA healthcare system during the 2003-2004 influenza season. Although these differences were small, results suggest the need for further study and culturally informed interventions.