Interpersonal discrimination and health-related quality of life among black and white men and women in the United States

Objective

We assessed associations between discrimination and health-related quality of life among black and white men and women in the United States.

Methods

We examined data from the National Health Measurement Study, a nationally representative sample of 3,648 adults aged 35–89 in the non-institutionalized US population. These data include self-reported lifetime and everyday discrimination as well as several health utility indexes (EQ-5D, HUI3, and SF-6D). Multiple regression was used to compute mean health utility scores adjusted for age, income, education, and chronic diseases for each race-by-gender subgroup.

Results

Black men and women reported more discrimination compared to white men and women. Health utility tended to be worse as reported discrimination increased. With a few exceptions, differences between mean health utility scores in the lowest and highest discrimination groups exceeded the 0.03 difference generally considered to be a clinically significant difference.

Conclusions

Persons who experienced discrimination tended to score lower on health utility measures. The study also revealed a complex relationship between experiences of discrimination and race and gender. Because of these differential social and demographic relationships caution is urged when interpreting self-rated health measures in research, clinical, and policy settings.     

Does equal socioeconomic status in black and white men mean equal risk of mortality?

Although concerns have been expressed that mortality from coronary disease and all other causes is greater among Blacks than Whites, we hypothesized that, when socioeconomic status is adequately considered, mortality inequalities between Blacks and Whites are insignificant. The study population was a random sampling of Black and White men who were 35 years of age or older when recruited into the Charleston Heart Study in 1960. Education level and occupational status at baseline were used to compare mortality over the ensuing 28 years between Black and White men, who were classified as low or high socioeconomic status. In no instance were Black-White differences in all-cause or coronary disease mortality rates significantly different when socioeconomic status was controlled. We conclude that socioeconomic status is an important predictor of mortality and that, when socioeconomic status is considered, differences in Black-White mortality rates may be small.     

Differences in socioeconomic status and survival among white and black men with prostate cancer

After diagnosis with prostate cancer, Black men in the United States have poorer survival than White men, even after controlling for differences in cancer stage. The extent to which these racial survival differences are due to biologic versus non-biologic factors is unclear, and it has been hypothesized that differences associated with socioeconomic status (SES) might account for much of the observed survival difference. The authors examined this hypothesis in a cohort study, using cancer registry and US Census data for White and Black men with incident prostate cancer (n = 23,334) who resided in 1,005 census tracts in the San Francisco Bay Area during 1973-1993. Separate analyses were conducted using two endpoints: death from prostate cancer and death from other causes. For each endpoint, death rate ratios (Blacks vs. Whites) were computed for men diagnosed at ages <65 years and at ages > or =65 years. These data suggest that differences associated with SES do not explain why Black men die from prostate cancer at a higher rate when compared with White men with this condition. However, among men with prostate cancer, SES-associated differences appear to explain almost all of the racial difference in risk of death from other causes.     

Rose Questionnaire angina among United States black, white, and Mexican-American women and men. Prevalence and correlates from The Second National and Hispanic Health and Nutrition Examination Surveys

The prevalence of Rose Questionnaire angina and its association with coronary heart disease risk factors and manifestations were investigated in representative samples of the US population. The study populations included 1,135 black and 8,323 white subjects aged 25-74 years examined in the Second National Health and Nutrition Examination Survey, 1976-1980, and 2,775 Mexican-American subjects aged 25-74 years examined in the Hispanic Health and Nutrition Examination Survey, Mexican-American portion, 1982-1983. Age-adjusted prevalence rates of Rose angina were similar among black, white, and Mexican-American women (6.8%, 6.3%, and 5.4%, respectively). An excess in the prevalence of Rose angina was observed in women compared with men for white and Mexican-American persons under age 55 years, but not for those over age 55. Electrocardiographic evidence of myocardial infarction and self-reported heart attack were strongly associated with prevalent Rose angina among white men and women aged 55 years and over, but not among those below age 55. Serum cholesterol, body mass index (weight (kg)/height (m)2), current cigarette smoking, and dyspnea were independently associated with an increased risk of prevalent angina in multivariate logistic models for white women, excluding those with a prior heart attack. Because many younger women with chest pain who may consult physicians are likely to have elevations in cardiovascular risk factors, their self-reported chest pain can be used as an opportunity to intervene and reduce their future risk of cardiovascular disease.     

Erratum to: Interpersonal discrimination and health-related quality of life among black and white men and women in the United States

Objective

We assessed associations between discrimination and health-related quality of life among black and white men and women in the United States.

Methods

We examined data from the National Health Measurement Study, a nationally representative sample of 3,648 adults aged 35–89 in the non-institutionalized US population. These data include self-reported lifetime and everyday discrimination as well as several health utility indexes (EQ-5D, HUI3, and SF-6D). Multiple regression was used to compute mean health utility scores adjusted for age, income, education, and chronic diseases for each race-by-gender subgroup.

Results

Black men and women reported more discrimination than white men and women. Health utility tended to be worse as reported discrimination increased. With a few exceptions, differences between mean health utility scores in the lowest and highest discrimination groups exceeded the 0.03 difference generally considered to be a clinically significant difference.

Conclusions

Persons who experienced discrimination tended to score lower on health utility measures. The study also revealed a complex relationship between experiences of discrimination and race and gender. Because of these differential social and demographic relationships caution is urged when interpreting self-rated health measures in research, clinical, and policy settings.     

Race and region are associated with nutrient intakes among black and white men in the United States

Stroke mortality rates and prevalence of several chronic diseases are higher in Southern populations and blacks in the US. This study examined the relationships of race (black, white) and region (Stroke Belt, Stroke Buckle, other) with selected nutrient intakes among black and white American men (n = 9229). The Block 98 FFQ assessed dietary intakes and multivariable linear regression analysis was used to examine whether race and region were associated with intakes of fiber, saturated fat, trans fat, sodium, potassium, magnesium, calcium, and cholesterol. Race and region were significant predictors of most nutrient intakes. Black men consumed 1.00% lower energy from saturated fat compared with white men [multivariable-adjusted β: 1.00% (95% CI = -0.88, -1.13)]. A significant interaction between race and region was detected for trans fat (P < 0.0001), where intake was significantly lower among black men compared with white men only in the Stroke Belt [multivariable-adjusted β: -0.21 (95% CI = -0.11, -0.31)]. Among black men, intakes of sodium, potassium, magnesium, and calcium were lower, whereas cholesterol was higher, compared with white men (P < 0.05 for all). Comparing regions, men in the Stroke Buckle had the lowest intakes of fiber, potassium, magnesium, and calcium compared with those in the Stroke Belt and other regions; men in both the Stroke Buckle and Stroke Belt had higher intakes of cholesterol compared with those in other regions (P < 0.005 for all). Given these observed differences in dietary intakes, more research is needed to understand if and how they play a role in the health disparities and chronic disease risks observed among racial groups and regions in the US.     

Striking variation in coronary heart disease mortality in the United States among black and white women aged 45-54 by state

Coronary heart disease (CHD) is the leading cause of death for women in the United States. There has been a substantial decrease in CHD mortality in the past few decades in the United States for both women and men. The change in lifestyle after World War II may affect the incidence of and mortality from CHD in a more recent birth cohort, such as the 45-54-year-old age group. CHD mortality among women aged 45-54 by state and race in the United States and other countries in 1994 was evaluated. Correlation of the CHD mortality with state-specific and race-specific educational attainment (% of not a high school graduate) and state-specific prevalence of smoking was examined. There was a 2.5-fold difference in CHD mortality (ICD 410-414, 429.2) between black and white women aged 45-54: 78/100,000 for black versus 31/100,000 for white women; a 3-fold difference in CHD mortality among white women by state: 16/100,000 in Colorado versus 53/100,000 in Louisiana; and a 3-fold difference in CHD mortality among black women by state: 45/100,000 in New Jersey versus 124/100,000 in Arkansas. CHD mortality was correlated with educational attainment among white women (r = 0.62, p = 0.001) and with prevalence of smoking (r = 0.39, p = 0.021). There is a large variation in CHD mortality among women aged 45-54 in the United States by race and state. These differences may reflect variations in coronary risk factors. More detailed evaluation of determinants of CHD mortality by area is needed, as are public health programs that can reduce the marked disparity in CHD mortality in the United States.     

Excess black mortality in the United States and in selected black and white high-poverty areas, 1980-2000

Objectives. Black working-aged residents of urban high-poverty areas suffered severe excess mortality in 1980 and 1990. Our goal in this study was to determine whether this trend persisted in 2000.Methods. We analyzed death certificate and census data to estimate age-standardized all-cause and cause-specific mortality among 16- to 64-year-old Blacks and Whites nationwide and in selected urban and rural high-poverty areas.Results. Urban men''s mortality rate estimates peaked in 1990 and declined between 1990 and 2000 back to or below 1980 levels. Evidence of excess mortality declines among urban or rural women and among rural men was modest, with some increases. Between 1980 and 2000, there was little decline in chronic disease mortality among men and women in most areas, and in some instances there were increases.Conclusions. In 2000, despite improved economic conditions, working-age residents of the study areas still died disproportionately of early onset of chronic disease, suggesting an entrenched burden of disease and unmet health care needs. The lack of consistent improvement in death rates among working-age residents of high-poverty areas since 1980 necessitates reflection and concerted action given that sustainable progress has been elusive for this age group.In their seminal article, McCord and Freeman estimated that in 1980 Black male youths in Harlem, New York City, were less likely to survive to the age of 65 years than were male youths in Bangladesh.¹ Mortality rates in 1980 were approximately 6 times greater among Harlem women aged 25 to 34 years and Harlem men aged 35 to 44 years than among White women and men in the same age groups nationwide. Geronimus et al. estimated that Black youths in a geographically diverse set of US high-poverty urban areas faced even worse mortality outcomes through middle age in 1990 than in 1980, including when these youths were compared with Black residents of equally poor rural communities.^2,3These striking findings suggest that national or statewide studies of population mortality may conceal important local variations. In addition, comparisons that include all age groups may obscure trends among working-age adults. For example, measures of life expectancy may be disproportionately influenced by survival probabilities of elderly people and infants, with life expectancy increasing with increased access to tertiary care. Variations in mortality among working-age adults may be more sensitive to circumstances that affect chronic disease trajectories, including access to and continuity of primary care, health education, work environments, neighborhood conditions, and the extent to which competing work and family obligations trigger sustained stress responses.^4–6Whether the severe mortality profiles of Black urban working-age adults persisted through the end of the 20th century is unknown. The 1990s witnessed significant socioeconomic, population health, and health care changes with potentially countervailing effects. On the positive side, the middle to late 1990s saw unprecedented economic growth, unemployment rates fell to all-time lows, poverty was deconcentrated in urban centers,⁷ highly active antiretroviral therapy became widely available, and the incidence of homicide declined.⁸Yet, the extent to which economic growth affected residents of segregated urban communities varied by race and gender, with low-skilled Black men, in particular, being “left behind.”^9–11 For poor mothers, Aid to Families with Dependent Children was replaced with Temporary Assistance to Needy Families, establishing lifetime limits, setting stringent work requirements, and reducing Medicaid enrollments. Studies revealed that Temporary Assistance to Needy Families participants expressed pride in employment but reported exhaustion and chronic anxiety, with possibly adverse health implications.^6,12,13 Poor Black individuals faced additional challenges to accessing medical care in the context of a more privatized, market-based health care delivery system¹⁴; the movement of private practitioners out of the inner city¹⁵; and lack of health insurance for the working poor. Gentrification may have reduced the presence of inner-city federally qualified health centers.¹⁶ Antiretroviral treatment was less available to high-poverty populations than to more advantaged groups.^17,18In light of these competing and significant changes to the socioeconomic, health, and medical care landscape during the 1990s, we extended the analyses of McCord and Freeman¹ and Geronimus et al.^2,3 to the year 2000, the most recent year for which necessary census data were available.     

Depression in black and white women : The role of marriage and socioeconomic status

The degree to which the relationship between race and depression in US black and white women is modified by socioecanomic and marital status was investigated. Data on 534 black and 836 white women, 25 to 64 years old, obtained from the 1986 Americans' Changing Lives national survey were utilized. Depression was measured by the Centers for Epidemiologic Studies Depression scale. Poverty status and education were used as indicators of socioeconomic status (SES). For both black and white women, the prevalence of depression was higher among those with lower as compared to higher SES, and among the unmarried as compared to the married. The unstratified, age-adjusted odds of depression for black women was twice that for white women (odds ratio (OR) = 2.2; 95% confidence interval (CI), 1.7 to 2.8); however, when stratified by poverty status, race effects were observed for nonpoor (OR = 2.2; 95% CI, 1.6 to 3.0) but not for poor women (OR = 1.3; 95% CI, 0.7 to 2.1). Race effects were also more pronounced among married (OR = 2.0; 95% CI, 1.4 to 2.9) than unmarried women (OR = 1.6; 95% CI, 1.1 to 2.4). Controlling for known confounders did not alter these results. Additional analyses revealed that the black excess risk for depression was concentrated among higher SES, married women, with marital difficulties appearing to pay a major role in their elevated depression scores.     

Contribution of neighbourhood socioeconomic status and physical activity resources to physical activity among women

INTRODUCTION: Residence in a deprived neighbourhood is associated with lower rates of physical activity. Little is known about the manifestation of deprivation that mediates this relationship. This study aimed to investigate whether access to physical activity resources mediated the relationship between neighbourhood socioeconomic status and physical activity among women. METHOD: Individual data from women participating in the Stanford Heart Disease Prevention Program (1979-90) were linked to census and archival data from existing records. Multilevel regression models were examined for energy expenditure and moderate and vigorous physical activity as reported in physical activity recalls. RESULTS: After accounting for individual-level socioeconomic status, women who lived in lower-socioeconomic status neighbourhoods reported greater energy expenditure, but undertook less moderate physical activity, than women in moderate-socioeconomic status neighbourhoods. In contrast, women living in higher-socioeconomic status neighbourhoods reported more vigorous physical activity than women in moderate-socioeconomic status neighbourhoods. Although availability of physical activity resources did not appear to mediate any neighbourhood socioeconomic status associations, several significant interactions emerged, suggesting that women with low income or who live in lower-socioeconomic status neighbourhoods may differentially benefit from greater physical activity resource availability. DISCUSSION: Although we found expected relationships between residence in a lower-socioeconomic status neighbourhood and undertaking less moderate or vigorous physical activity among women, we also found that these same women reported greater overall energy expenditure, perhaps as a result of greater work or travel demands. Greater availability of physical activity resources nearby appears to differentially benefit women living in lower-socioeconomic status neighbourhoods and low-income women, having implications for policy-making and planning.     

Demographic and socioeconomic factors associated with blood lead levels among Mexican-American children and adolescents in the United States

OBJECTIVE: This study was designed to assess demographic and socioeconomic differences in blood lead levels (BLLs) among Mexican-American children and adolescents in the United States. METHODS: We analyzed data from the Third National Health and Nutrition Examination Survey, 1988-1994, for 3,325 Mexican-American youth aged 1 to 17 years. The main study outcome measures included a continuous measure (microg/dL) of BLL and two dichotomous measures of BLL (> or =5 microg/dL and > or =10 microg/dL). RESULTS: The mean BLL among Mexican-American children in the United States was 3.45 microg/dL (95% confidence interval [CI] 3.07, 3.87); 20% had BLL > or =5 microg/dL (95% CI 15%, 24%); and 4% had BLL > or =10 microg/dL (95% CI 2%, 6%). In multivariate analyses, gender, age, generational status, home language, family income, education of head of household, age of housing, and source of drinking water were statistically significant independent predictors (p<0.05) of having higher BLLs and of having BLL > or =5 microg/dL, whereas age, family income, housing age, and source of drinking water were significant predictors (p<0.05) of having BLL > or =10 microg/dL. CONCLUSIONS: Significant differences in the risk of having elevated BLLs exist among Mexican-American youth. Those at greatest risk should be prioritized for lead screening and lead exposure abatement interventions.     

Effects of neighbourhood socioeconomic status and convenience store concentration on individual level smoking

OBJECTIVES: To assess the effects of neighbourhood level socioeconomic status (SES) and convenience store concentration on individual level smoking, after consideration of individual level characteristics. DESIGN: Individual sociodemographic characteristics and smoking were obtained from five cross sectional surveys (1979-1990). Participants' addresses were geocoded and linked with census data for measuring neighbourhood SES and with telephone yellow page listings for measuring convenience store concentration (density in a neighbourhood, distance between a participant's home and the nearest convenience store, and number of convenience stores within a one mile radius of a participant's home). The data were analysed with multilevel Poisson regression models. SETTING: 82 neighbourhoods in four northern California cities. PARTICIPANTS: 8121 women and men aged 25-74 from the Stanford heart disease prevention programme. MAIN RESULTS: Lower neighbourhood SES and higher convenience store concentration, measured by density and distance, were both significantly associated with higher level of individual smoking after taking individual characteristics into account. The association between convenience store density and individual smoking was modified by individual SES and neighbourhood SES. CONCLUSIONS: These findings are consistent with a growing body of literature suggesting that the socioeconomic and physical environments of neighbourhoods are associated with individual level smoking.     

Differences in HIV-related hospitalization among white, black, and Hispanic men and women of Florida

Patients hospitalized for Human immunodeficiency virus (HIV) disease among the multi-ethnic population of Florida have been incompletely characterized to date. The objectives of the present study were to determine the race/ethnic (whites, blacks, Hispanics) differences in characteristics of patients by gender and the correlates of HIV-related mortality among them. A retrospective analysis of 9,113 discharge records (January to December 2001) with primary diagnosis of HIV disease was performed. Characteristics of patients in six sex-race/ethnic groups were compared using the X2 tests and multiple regression models. A multiple logistic regression modeling was used to evaluate the odds of HIV-related death associated with these characteristics. Approximately 64%, 23%, and 13% of records were for blacks, whites, and Hispanics, respectively. The adjusted length of stay (LOS) and hospital charges significantly differed only between black men and women. The insurance status, LOS, and age were significant correlates of HIV-related deaths. The potential causes of disparities between sex-ethnic groups of patients should be further explored.     

Occupational risks of bladder cancer among white women in the United States

The relation between occupation and bladder cancer in women was examined based on data collected during the National Bladder Cancer Study, a population-based, case-control study conducted in 10 areas of the United States. Occupational hazards among women have received little attention in previous bladder cancer studies, in part because most studies have included too few females to accurately estimate risks. In this large case-control study, 652 white female bladder cancer patients and 1,266 white female controls were interviewed to obtain lifetime occupational histories. Patterns of bladder cancer risk by occupation in women tended to be similar to those previously observed among men. Increased risk was apparent for women ever employed in metal working and fabrication occupations (relative risk (RR) = 1.5; 95% confidence interval (CI) 0.9-2.6). Within this summary occupation category, punch and stamping press operatives had a significant trend in risk with increasing duration of employment (p = 0.012); the RR for women employed 5 years or more was 5.6 (95% CI 1.4-26.4). The authors also observed an increased risk for women employed as chemical processing workers (RR = 2.1; 95% CI 0.9-5.1 = with a significant, contrast, a decreased risk was apparent for female textile workers (RR = 0.6; 95% CI 0.3-1.1) with a significant, negative trend in risk with increasing duration of employment (p = 0.031); the relative risk for textile workers employed 10 years or more was 0.4. The authors estimate that 11% of bladder cancer diagnosed among white women in the United States is attributable to occupational exposures; this percentage is considerably lower than the 21-25% previously reported for white men in this study.     

Gender differences in education effects on all-cause mortality for white and black adults in the United States

The existence of education differentials in adult mortality has been well established. The issue of gender differences in the education-mortality association, however, remains an open question, despite its importance for understanding of causal pathways through which education affects health outcomes. The goal of this paper is to analyze gender differences in education gradients in mortality among non-Hispanic white and black U.S. adults born between 1906 and 1965. The analysis is based on data from the 1986–2000 National Health Interview Surveys linked to the National Death Index through 2002 (NHIS-LMF) with over 700,000 respondents. Full-sample and cohort-stratified Cox proportional hazard models of all-cause mortality were estimated. Results indicate a great deal of similarity between men and women in the education-mortality association, with some exceptions. The most notable difference is the steeper educational gradient at high schooling levels for white men compared to white women. This difference was fully explained by marital status. No systematic gender differences in the relationship between education and adult mortality were observed among black adults in any birth cohorts. The findings suggest that men do not benefit from educational attainment uniformly more than women.     

Fetal deaths in Mexican-American,black, and white non-Hispanic women seeking government-funded prenatal care

Hispanics of Mexican origin constitute the largest minority population in the Southwestern United States, yet little is known about their reproductive health. This study assessed ethnic differentials in fetal mortality at 20 or more weeks gestation and identified the social and behavioral predictors associated with this outcome among low-income Hispanic, black non-Hispanic and white non-Hispanic women. Records were used of 80,431 patients attending federally funded prenatal care clinics in California from 1984 through 1989. The fetal death rate per 1,000 liver births and fetal deaths was 7.8 for Hispanic, 8.4 for white non-Hispanic and 20.5 for black non-Hispanic women. These rates indicated favorable reproductive outcomes for Mexican Americans despite their social risk profile. An analysis of stillbirths by gestational age showed that Hispanic women stood a significantly lower risk of short-gestational stillbirths than non-Hispanics. In contrast, Hispanic women had a higher proportion of term stillbirths. Hispanic acculturation was a significant predictor of short-term gestation fetal deaths only. The inability to pay for health care was a strong predictor of fetal deaths for all ethnic groups, underscoring the need to ensure adequate access to maternity care for low-income women.This study was conducted under contract from the California Department of Health Services, Maternal and Child Health Branch, #90-11768. We appreciate the assistance and data support provided by Penelope Stephenson, Chief, Planning and Evaluation Section and the helpful comments provided by Dr. Rugmini Shah, Director, Maternal and Child Health Branch. The authors would also like to thank Connie Gee for her clerical support.