A nationwide analysis of US racial/ethnic disparities in smoking behaviors, smoking cessation, and cessation-related factors

Objectives. We used nationally representative data to examine racial/ethnic disparities in smoking behaviors, smoking cessation, and factors associated with cessation among US adults.Methods. We analyzed data on adults aged 20 to 64 years from the 2003 Tobacco Use Supplement to the Current Population Survey, and we examined associations by fitting adjusted logistic regression models to the data.Results. Compared with non-Hispanic Whites, smaller proportions of African Americans, Asian Americans/Pacific Islanders, and Hispanics/Latinos had ever smoked. Significantly fewer African Americans reported long-term quitting. Racial/ethnic minorities were more likely to be light and intermittent smokers and less likely to smoke within 30 minutes of waking. Adjusted models revealed that racial/ethnic minorities were not less likely to receive advice from health professionals to quit smoking, but they were less likely to use nicotine replacement therapy.Conclusions. Specific needs and ideal program focuses for cessation may vary across racial/ethnic groups, such that approaches tailored by race/ethnicity might be optimal. Traditional conceptualizations of cigarette addiction and the quitting process may need to be revised for racial/ethnic minority smokers.Racial/ethnic minorities in the United States experience a disproportionate burden of smoking-related diseases, including cancer and heart disease, despite having larger proportions of light and intermittent smokers and generally lower adult smoking prevalence rates than non-Hispanic Whites.^1–3 Racial/ethnic minorities are also less likely to quit smoking successfully than are non-Hispanic Whites.^4–8 For example, rates of successful smoking cessation among African American smokers are lower than they are among non-Hispanic Whites, despite reports citing lower cigarette consumption.^2,5,7,9 Similarly, Hispanics/Latinos do not experience higher rates of successful quitting than non-Hispanic Whites, despite being more likely to be light and intermittent smokers.^2,9 There is currently no evidence indicating that Asian Americans quit at higher rates than non-Hispanic Whites in the United States.¹⁰ The examination of racial/ethnic disparities in smoking behaviors, successful quitting, and factors associated with quitting can provide valuable information for focusing strategies for groups currently experiencing lower rates of successful smoking cessation, and can lead to decreases in smoking-related disease rates across all racial/ethnic populations.Previous research on population-level data has found several factors to be associated with successful smoking cessation. For example, banning smoking in one''s home can greatly increase the chances of successfully quitting smoking. The presence of a complete ban on smoking in one''s home is associated with being quit for at least 90 days¹¹ and with being a former smoker.¹² However, an analysis of national data found that smaller percentages of non-Hispanic Whites (64.0%) and African Americans (64.4%) have a complete home smoking ban than do Hispanics/Latinos (78.0%) and Asian Americans/Pacific Islanders (79.2%).¹³ Being advised to quit smoking by health care professionals, especially physicians, has also been associated with increased rates of smoking cessation.^14–17 Despite progress in smokers being advised to quit by health care practitioners in the past 5 years, African American and Hispanic/Latino smokers remain less likely than non-Hispanic Whites to be advised to quit.^16,18 Finally, although evidence of the effectiveness of nicotine replacement therapy (NRT) at the population level has been challenged recently,^19,20 there is evidence that NRT can aid successful cessation.^17,21–23 There is substantial evidence that racial/ethnic minorities are less likely to be prescribed NRT^14,15,18 and to use NRT to quit smoking.^23–25The Tobacco Use Supplements to the Current Population Surveys (TUS-CPS) have provided invaluable data for the examination of various smoking-related issues at the national level.^11,13 In 2003, the TUS-CPS included a special supplement that focused heavily on smoking cessation. This supplement was the first TUS-CPS with this focus (and is the only one to date), and it provides arguably the richest representative national-level data on smoking cessation in the United States. This special supplement thus presented a unique opportunity to examine in detail the disparities between racial/ethnic groups in smoking cessation and important related factors.For our study, we hypothesized the following: (1) African Americans would experience less success in quitting smoking than would non-Hispanic Whites, (2) Asian Americans/Pacific Islanders and Hispanics/Latinos would be more likely to have a complete home smoking ban than would non-Hispanic Whites, (3) African Americans and Hispanics/Latinos would be less likely than would non-Hispanic Whites to report being advised by a health professional to quit smoking, and (4) racial/ethnic minorities would be less likely to use NRT than would non-Hispanic Whites.To examine these hypotheses, we conducted a secondary data analysis of the 2003 TUS-CPS to assess smoking cessation rates and examine how factors associated with successful smoking cessation differed across racial/ethnic groups among adults in the United States. Findings from this report may provide insight into optimal design of targeted smoking cessation interventions for members of specific racial/ethnic groups.     

Racial/Ethnic and Socioeconomic Differences in Short-Term Breast Cancer Survival Among Women in an Integrated Health System

Objectives. We examined the combined influence of race/ethnicity and neighborhood socioeconomic status (SES) on short-term survival among women with uniform access to health care and treatment.Methods. Using electronic medical records data from Kaiser Permanente Northern California linked to data from the California Cancer Registry, we included 6262 women newly diagnosed with invasive breast cancer. We analyzed survival using multivariable Cox proportional hazards regression with follow-up through 2010.Results. After consideration of tumor stage, subtype, comorbidity, and type of treatment received, non-Hispanic White women living in low-SES neighborhoods (hazard ratio [HR] = 1.28; 95% confidence interval [CI] = 1.07, 1.52) and African Americans regardless of neighborhood SES (high SES: HR = 1.44; 95% CI = 1.01, 2.07; low SES: HR = 1.88; 95% CI = 1.42, 2.50) had worse overall survival than did non-Hispanic White women living in high-SES neighborhoods. Results were similar for breast cancer–specific survival, except that African Americans and non-Hispanic Whites living in high-SES neighborhoods had similar survival.Conclusions. Strategies to address the underlying factors that may influence treatment intensity and adherence, such as comorbidities and logistical barriers, should be targeted at low-SES non-Hispanic White and all African American patients.Breast cancer is the most common cancer among women in the United States, and it is the second leading cause of cancer death.1 Despite significant improvements in breast cancer survival from 1992 to 2009,1,2 racial/ethnic and socioeconomic survival disparities have persisted.3,4 African American women have consistently been found to have worse survival after breast cancer,3,5–11 Hispanic women have worse or similar survival,3,9,11,12 and Asian women as an aggregated group have better or similar survival3,9,11,12 than do non-Hispanic White women. Underlying factors thought to contribute to these racial/ethnic disparities include differences in stage at diagnosis,8,12,13 distributions of breast cancer subtypes,14–16 comorbidities,12,13,17 access to and utilization of quality care,13,18 and treatment.12,13Numerous studies also have found poorer survival after breast cancer diagnosis among women residing in neighborhoods of lower socioeconomic status (SES).6,9,19,20 Research has shown that inadequate use of cancer screening services, and consequent late stage diagnosis and decreased survival, contribute to the SES disparities.21,22 Similar to racial/ethnic disparities, SES disparities have been attributed to inadequate treatment and follow-up care and comorbidities.18 Previous population-based studies have continued to observe racial/ethnic survival disparities after adjusting for neighborhood SES, but these studies have not considered the combined influence of neighborhood SES and race/ethnicity.3,9,11,12,23 These disparities may remain because information on individual-level SES, health insurance coverage, comorbidities, quality of care, and detailed treatment regimens have typically not been available.3,8,9,11,13 Even among studies using national Surveillance Epidemiology and End Results–Medicare linked data, in which more detailed information on treatment and comorbidities are available among some patients aged 65 years and older, survival disparities have remained.12,23,24 However, not all data on medical conditions and health care services are captured in Medicare claims, including data on Medicare beneficiaries enrolled in HMOs (health maintenance organizations).25,26Using electronic medical records data from Kaiser Permanente Northern California (KPNC) linked to data from the population-based California Cancer Registry (CCR), we recently reported that chemotherapy use followed practice guidelines but varied by race/ethnicity and neighborhood SES in this integrated health system.27 Therefore, to overcome the limitations of previous studies and address simultaneously the multiple social28 and clinical factors affecting survival after breast cancer diagnosis, we used the linked KPNC–CCR database to determine whether racial/ethnic and socioeconomic differences in short-term overall and breast cancer–specific survival persist in women in a membership-based health system. Our study is the first, to our knowledge, to consider the combined influence of neighborhood SES and race/ethnicity and numerous prognostic factors, including breast cancer subtypes and comorbidities, thought to underlie these long-standing survival disparities among women with uniform access to health care and treatment.     

A Systematic Review of Neighborhood Disparities in Point-of-Sale Tobacco Marketing

We systematically reviewed evidence of disparities in tobacco marketing at tobacco retailers by sociodemographic neighborhood characteristics. We identified 43 relevant articles from 893 results of a systematic search in 10 databases updated May 28, 2014. We found 148 associations of marketing (price, placement, promotion, or product availability) with a neighborhood demographic of interest (socioeconomic disadvantage, race, ethnicity, and urbanicity).Neighborhoods with lower income have more tobacco marketing. There is more menthol marketing targeting urban neighborhoods and neighborhoods with more Black residents. Smokeless tobacco products are targeted more toward rural neighborhoods and neighborhoods with more White residents. Differences in store type partially explain these disparities.There are more inducements to start and continue smoking in lower-income neighborhoods and in neighborhoods with more Black residents. Retailer marketing may contribute to disparities in tobacco use. Clinicians should be aware of the pervasiveness of these environmental cues.Tobacco products and their marketing materials are ubiquitous in US retailers from pharmacies to corner stores.1 A similar presence is found across the globe, except in countries that ban point-of-sale (POS) tobacco marketing (e.g., Australia, Canada, Thailand2). In the United States, the POS has become the main communications channel for tobacco marketing3,4 and is reported as a source of exposure to tobacco marketing by more than 75% of US youths.5 Burgeoning evidence6,7 suggests that marketing at the POS is associated with youths’ brand preference,8 smoking initiation,9 impulse purchases,10,11 and compromised quit attempts.12,13The marketing of tobacco products is not uniform; it is clear from industry documents that the tobacco industry has calibrated its marketing to target specific demographic groups defined by race,14 ethnicity,15 income,16 mental health status,17 gender,18,19 and sexual orientation.20 Framed as an issue of social and environmental justice,14 research has documented historical racial, ethnic, and socioeconomic disparities in the presence of tobacco billboards,21–25 racial disparities in total tobacco marketing volume,24 and targeting of menthol cigarettes to communities with more Black residents.25,26 Targeted marketing of a consumer product that kills up to half27 of its users when used as directed exacerbates inequities in morbidity and mortality. Smoking is estimated to be responsible for close to half of the difference in mortality between men in the lowest and highest socioeconomic groups.28 However, evidence of marketing disparities is scattered across multiple disciplines and marketing outcomes, such as product availability, advertising quantity, presence of promotional discounts, and price. A synthesis of this literature would provide valuable information for intervention on tobacco marketing in the retail environment and inform etiological research on health disparities.To address this gap in the literature, we systematically reviewed observational studies that examined the presence and quantity of POS tobacco marketing to determine the extent to which marketing disparities exist by neighborhood demographic characteristic (i.e., socioeconomic disadvantage, race, ethnicity, and urbanicity).     

Comparative Effectiveness of a Faith-Based HIV Intervention for African American Women: Importance of Enhancing Religious Social Capital

Objectives. We assessed the effectiveness of P4 for Women, a faith-based HIV intervention.Methods. We used a 2-arm comparative effectiveness trial involving 134 African American women aged 18 to 34 years to compare the effectiveness of the Centers for Disease Control and Prevention–defined evidence-based Sisters Informing Sisters about Topics on AIDS (SISTA) HIV intervention with P4 for Women, an adapted faith-based version of SISTA. Participants were recruited from a large black church in Atlanta, Georgia, and completed assessments at baseline and follow-up.Results. Both SISTA and P4 for Women had statistically significant effects on this study’s primary outcome—consistent condom use in the past 90 days—as well as other sexual behaviors. However, P4 for Women also had statistically significant effects on the number of weeks women were abstinent, on all psychosocial mediators, and most noteworthy, on all measures of religious social capital. Results were achieved by enhancing structural social capital through ministry participation, religious values and norms, linking trust and by reducing negative religious coping. High intervention attendance may indicate the feasibility of conducting faith-based HIV prevention research for African American women.Conclusions. P4 for Women enhanced abstinence and safer sex practices as well as religious social capital, and was more acceptable than SISTA. Such efforts may assist faith leaders in responding to the HIV epidemic in African American women.One little-understood social determinant of health is religion.1 Although 56% of all Americans consider religion very important in their lives, this percentage approaches 80% among African Americans.2 Of all major racial and ethnic groups in the United States, African Americans are most likely to report a formal religious affiliation. Nearly 60% of Black adults are affiliated with historically Black Protestant churches. African Americans in the South are more likely than African Americans from other regions of the United States to belong to historically Black churches. The Black church is often among the most visible, respected and credible agencies in the African American community3,4 and is acknowledged as a critical partner in improving ethical engagement of African Americans in health research.Research has demonstrated that religious participation reduces mortality risks5–14 and improves health status6,7 and quality of life for African Americans.6,7,15–17 As early as the 1920s, Black churches were involved in outreach programs to address the health needs of community members through the provision of free clinics.18 Today, churches remain increasingly popular settings in which to conduct health research among African Americans. Scarce resources as well as conflicts between the historically Black church’s role of worship and its role in providing HIV-related services initially hindered efforts to address HIV.19 However, recently, faith-based HIV prevention research emphasizing abstinence among adolescents has emerged.20African American women are disproportionately affected by HIV.21 Because African American women constitute more than 60% of the congregation in historically Black churches,2 serve in key positions in sustaining the churches’ social programs (ministries), and tend to seek solace from faith-based institutions, a closer examination of the church’s role in HIV prevention efforts with this population should be explored. The current effectiveness study hypothesized that P4 for Women would be more appropriate in faith-based settings compared with the widely disseminated, Centers for Disease Control and Prevention (CDC)-defined, evidence-based HIV intervention for African American women called Sisters Informing Sisters about Topics on AIDS (SISTA),22 which is often delivered in public health venues. P4 for Women was created as a faith-based adaptation of SISTA23,24 delivered at a historically Black church in the Atlanta, Georgia, metropolitan area.     

HIV Testing and HIV Service Delivery to Populations at High Risk Attending Sexually Transmitted Disease Clinics in the United States, 2011–2013

Objectives. We evaluated HIV testing and service delivery in Centers for Disease Control and Prevention (CDC)–funded sexually transmitted disease (STD) clinics.Methods. We assessed HIV testing, HIV positivity, receipt of HIV test results, linkage to medical care, and referral services from 61 health department jurisdictions from 2011 to 2013.Results. In 2013, 18.6% (621 010) of all CDC-funded HIV-testing events were conducted in STD clinics, and 0.8% were newly identified as HIV-positive. In addition, 27.3% of all newly identified HIV-positive persons and 30.1% of all newly identified HIV-positive men who have sex with men were identified in STD clinics. Linkage to care within any time frame was 63.8%, and linkage within 90 days was 55.3%. Although there was a decrease in first-time HIV testers in STD clinics from 2011 to 2013, identification of new positives increased.Conclusions. Although linkage to care and referral to partner services could be improved, STD clinics appear successful at serving populations disproportionately affected by HIV. These clinics may reach persons who may not otherwise seek HIV testing or medical services and provide an avenue for service provision to these populations.More than 1.2 million people are living with HIV in the United States, and approximately 14% are not diagnosed.1,2 Although HIV incidence has remained stable over the past several years, some groups are disproportionately affected by HIV, particularly gay men, bisexual men, and other men who have sex with men (collectively referred to as MSM) as well as racial/ethnic minority populations, specifically Blacks or African Americans (hereinafter referred to as African Americans) and Hispanics or Latinos.3,4 Men who have sex with men account for approximately 2% of the US population.5,6 However, they accounted for 63% of all new HIV infections in 2010 and 54% of people living with HIV in 2011.1,3 In addition, although African Americans account for 12% of the US population, they accounted for 44% of all new HIV infections in 2010 and 41% of people living with HIV in 2011.1,3 In 2013, the rate of HIV diagnoses was 55.9 (per 100 000) for African Americans, in comparison with 18.7 for Hispanics or Latinos and 6.6 for Whites.7 Finally, Hispanics or Latinos account for approximately 17% of the US population,8 but accounted for 21% of new HIV infections in 2010 and 20% of people living with HIV in 2011.1,3The Centers for Disease Control and Prevention (CDC) recommends routine HIV screening in health care settings, including sexually transmitted disease (STD) clinics, for clients aged 13 to 64 years where prevalence is 0.1% or more.9 HIV testing and knowledge of HIV status are the first steps along the HIV continuum of care and serve as an important entry point to prevention services and linkage to HIV medical care. Previous research has indicated that early initiation of antiretroviral therapy has substantial medical benefits to HIV-positive individuals and prevention benefits to their HIV-negative partners by reducing transmission by up to 96%.10,11 The National HIV/AIDS Strategy12 has also emphasized the importance of knowledge of HIV status, reducing health-related disparities, and treatment as prevention, particularly increasing access to HIV medical care and strengthening linkage and retention in care. In light of the national priorities to reduce new HIV infections, it is important to gain a better understanding of HIV testing programs and service delivery to populations who may be at high risk for HIV infection.Sexually transmitted disease clinics often serve minority populations and persons who may be economically disadvantaged, have limited access to health care, and have comorbid physical and medical concerns.13,14 As reflected by high coinfection rates between HIV and several STDs,15 STD clinics often reach clients who are at high risk for HIV infection and who may be unaware of their HIV status.13,16,17 In addition, they are more likely to reach clients who are younger, male, African American, and heterosexual persons who are at high risk for HIV infection, as well as MSM.13,18–20 Previous studies have indicated that STD clinics report a higher frequency of HIV testing than other health care settings and are more likely to identify persons who are HIV-positive.13,20,21The STD clinics provide essential sexual health services to clients who may not otherwise have access to health care services but are at high risk for HIV infection. We evaluated HIV testing and HIV service delivery among CDC-funded STD clinics in 2013. To our knowledge, this is one of the first articles to present national-level program data from STD clinics on HIV testing and HIV service delivery. Our aims were to assess

1. HIV testing, including first-time testers;
2. identification of newly diagnosed HIV-positive persons;
3. linkage to HIV medical care;
4. referral and interview for partner services; and
5. referral to HIV prevention services.

In addition, we compared the proportion of HIV testing and identification of new HIV-positive persons that occurred in STD clinics with national data from all CDC-funded sites. Finally, we examined the demographic characteristics of the populations who received HIV services in STD clinics and the differences in HIV testing and HIV service delivery in CDC-funded STD clinics from 2011 to 2013.     

Connecting Race and Place: A County-Level Analysis of White,Black, and Hispanic HIV Prevalence,Poverty, and Level of Urbanization

Objectives. We evaluated the role of poverty in racial/ethnic disparities in HIV prevalence across levels of urbanization.Methods. Using national HIV surveillance data from the year 2009, we constructed negative binomial models, stratified by urbanization, with an outcome of race-specific, county-level HIV prevalence rates and covariates of race/ethnicity, poverty, and other publicly available data. We estimated model-based Black–White and Hispanic–White prevalence rate ratios (PRRs) across levels of urbanization and poverty.Results. We observed racial/ethnic disparities for all strata of urbanization across 1111 included counties. Poverty was associated with HIV prevalence only in major metropolitan counties. At the same level of urbanization, Black–White and Hispanic–White PRRs were not statistically different from 1.0 at high poverty rates (Black–White PRR = 1.0, 95% confidence interval [CI] = 0.4, 2.9; Hispanic–White PRR = 0.4, 95% CI = 0.1, 1.6). In nonurban counties, racial/ethnic disparities remained after we controlled for poverty.Conclusions. The association between HIV prevalence and poverty varies by level of urbanization. HIV prevention interventions should be tailored to this understanding. Reducing racial/ethnic disparities will require multifactorial interventions linking social factors with sexual networks and individual risks.Within the United States, disparities in diagnosed HIV prevalence among the 3 major racial/ethnic groups (White, Black, and Hispanic) are striking. At the end of 2009, 43% of people living with an HIV diagnosis were Black, 35% White, and 19% Hispanic.1 Concurrently, Blacks constituted only 12% of the population, non-Hispanic Whites 65%, and Hispanics 16%.2 In the 46 states with confidential name-based HIV reporting since at least January 2007, the estimated diagnosed HIV prevalence rate at the end of 2009 was 952 per 100 000 people among Blacks (near the threshold for a generalized epidemic),1 320 per 100 000 among Hispanics, and 144 per 100 000 among Whites; compared with Whites, therefore, Blacks and Hispanics were respectively 6.6 times and 2.2 times more likely to be living with an HIV diagnosis.A number of mechanisms, primarily structural and social factors, have been proposed to explain these stark racial/ethnic disparities in HIV prevalence.3,4 Structural factors, such as oppression and mistrust in government, may hinder receptivity to prevention outreach and increase HIV prevalence.3 Social constructs (e.g., homophobia and HIV stigma) may discourage open discussion of risk behaviors and limit HIV testing and treatment. Additionally, limited access to health care resources has been identified as a key driver of racial/ethnic health disparities.5 Finally, Black men are more likely than White men to be both incarcerated and infected with HIV while incarcerated.6,7 All of these factors are, in turn, associated with poverty.8 However, specific relationships among these multiple factors and racial/ethnic HIV prevalence disparities, and variation of these relationships across levels of urbanization, are not well understood.Previous analyses of national surveillance and survey data in the United States have focused on associations between HIV prevalence rates, poverty, and race exclusively in urban areas, finding no disparities in poverty-adjusted HIV prevalence rates among heterosexuals in urban settings.9,10 Furthermore, among heterosexuals living in US urban areas with high AIDS prevalence, HIV prevalence rates among those living at or below the poverty line were 2.2 times as high as rates among those living above the poverty line.10 A more recent analysis of US surveillance data confirmed the complex associations between demographics, social determinants of health, and AIDS diagnosis rates.8However, variation in these factors across the urban–rural continuum may limit generalizability of these findings to nonurban settings, where similar research is lacking. In 2009, the proportions of Black and Hispanic Americans living in poverty were roughly twice that of White Americans.11 For all races/ethnicities, the proportion living in poverty is greater in rural areas than in urban areas.12 Additionally, rural areas, with lower HIV prevalence, are more likely to be medically underserved, with reduced access to HIV care and treatment.13In the context of these complex sociodemographic associations, previously observed associations in the United States between poverty and racial/ethnic disparities in HIV may differ outside of urban areas. Therefore, using publicly available county-level data, we first describe the association between poverty and HIV prevalence by race/ethnicity across levels of urbanization. We subsequently examine racial/ethnic disparities in HIV prevalence across levels of urbanization, after controlling for poverty. We hypothesized that, in all strata of urbanization, poverty-adjusted Black–White and Hispanic–White HIV prevalence rate ratios (PRRs) would statistically differ from 1.0.     

Explaining Racial Disparities in Infant Health in Brazil

Objectives. We sought to quantify how socioeconomic, health care, demographic, and geographic effects explain racial disparities in low birth weight (LBW) and preterm birth (PTB) rates in Brazil.Methods. We employed a sample of 8949 infants born between 1995 and 2009 in 15 cities and 7 provinces in Brazil. We focused on disparities in LBW (< 2500 g) and PTB (< 37 gestational weeks) prevalence between infants of African ancestry alone or African mixed with other ancestries, and European ancestry alone. We used a decomposition model to quantify the contributions of conceptually relevant factors to these disparities.Results. The model explained 45% to 94% of LBW and 64% to 94% of PTB disparities between the African ancestry groups and European ancestry. Differences in prenatal care use and geographic location were the most important contributors, followed by socioeconomic differences. The model explained the majority of the disparities for mixed African ancestry and part of the disparity for African ancestry alone.Conclusions. Public policies to improve children’s health should target prenatal care and geographic location differences to reduce health disparities between infants of African and European ancestries in Brazil.Large health disparities exist between Black and White infants in Brazil.1−4 Infant mortality is more than twice as common among Black as White infants in Southern Brazil (30.4 vs 13.9 per 1000).5 Poor birth outcomes including low birth weight (LBW) and preterm birth (PTB) are also more common among Black infants. Racial disparities are also reported in prenatal and postnatal care, with White mothers having more and higher-quality prenatal visits and greater use of postnatal care.6,7Documenting the prevalence and magnitude of racial disparities in infant’s and children’s health is important. However, of more importance is explaining these disparities and identifying the pathways through which they arise to identify contributors that can be targeted by policy interventions. Such effort has lifelong implications because of the importance of children’s health for adult health and human capital attainment.8−12 Because children’s health may have multiplicative effects on health over life, early health disparities may extend into large health and human capital disparities later in life.13,14Studies in the United States have shed light on several pathways that lead to racial disparities in infant’s and children’s health.15−21 Individual-level factors including socioeconomic status (SES),22 maternal age, prenatal care use,22−24 and stressful life events before delivery,17 as well as differences in health care access and quality25−27 and social inequalities because of residential segregation and poverty,15,28,29 are thought to be important contributors to racial disparities in infants’ health in the United States.To our knowledge, there are no studies that simultaneously quantify the contributions of a large number of conceptually relevant factors to racial disparities in infants’ health in Brazil. In this study, we examined the extent to which socioeconomic, health care, demographic, and geographic effects explain disparities in LBW (< 2500 grams) and PTB (< 37 gestational weeks) rates by African ancestry in Brazil. Unlike any previous study for Brazil, we evaluated the contributions of the explanatory factors to the disparities by different degrees of African ancestry. We focused on disparities by African ancestry because they are the most prevalent and affect a large percentage of the Brazilian population.1−5Our study is the first to simultaneously quantify the contributions of several factors both as a group and each on its own (with control for the others) to explaining racial disparities in infant health in Brazil. Such a study is needed not only because Brazil is the largest country in South America but also because there are many historical, demographic, economic, social, cultural, and health care system differences between Brazil and other racially admixed countries such as the United States. These differences limit the generalizability of studies of racial infant health disparities in the United States to the Brazilian population as these differences may modify the underlying factors and the extent of their contributions to the disparities.There is a sharp contrast in perception of race between Brazil and the United States.30 Race for individuals of African and European ancestry in Brazil has been historically and socially defined on a “continuum” of skin color including Black, Brown (mixed between Black and White), or White, instead of the Black or White color line as in the United States. This is in part because of the large racial admixing in Brazil.31 The difference in perceptions of racial identity between Brazil and the United States implies potential differences in cultural and socioeconomic factors related to race and how these may affect health and contribute to racial disparities. Brazil also differs significantly in its economic growth and extent of economic disparities by race from the United States.32 Finally, there are major differences in access to and quality of health care between Brazil and the United States.33,34 For all of these reasons, a study that explains the racial disparities in LBW and PTB in Brazil is needed to draw inferences that can help to inform policymaking and interventions to reduce these disparities in that country.     

Life-Course Socioeconomic Position and Incidence of Diabetes Mellitus Among Blacks and Whites: The Alameda County Study, 1965�C1999

Objectives. We examined associations between several life-course socioeconomic position (SEP) measures (childhood SEP, education, income, occupation) and diabetes incidence from 1965 to 1999 in a sample of 5422 diabetes-free Black and White participants in the Alameda County Study.Methods. Race-specific Cox proportional hazard models estimated diabetes risk associated with each SEP measure. Demographic confounders (age, gender, marital status) and potential pathway components (physical inactivity, body composition, smoking, alcohol consumption, hypertension, depression, access to health care) were included as covariates.Results. Diabetes incidence was twice as high for Blacks as for Whites. Diabetes risk factors independently increased risk, but effect sizes were greater among Whites. Low childhood SEP elevated risk for both racial groups. Protective effects were suggested for low education and blue-collar occupation among Blacks, but these factors increased risk for Whites. Income was protective for Whites but not Blacks. Covariate adjustment had negligible effects on associations between each SEP measure and diabetes incidence for both racial groups.Conclusions. These findings suggest an important role for life-course SEP measures in determining risk of diabetes, regardless of race and after adjustment for factors that may confound or mediate these associations.Diabetes mellitus is a major cause of morbidity and mortality in the United States.^1,2 Type 2 diabetes disproportionately affects Hispanics, as well as non-Hispanic Black Americans, American Indians/Alaska Natives, and some Asian/Pacific Islander groups. In the United States, members of racial and ethnic minority groups are almost twice as likely to develop or have type 2 diabetes than are non-Hispanic Whites.^2–5 Significant racial and ethnic differences also exist in the rates of diabetes-related preventive services, quality of care, and disease outcomes.^6–10Researchers have attempted to determine why, relative to Whites, members of racial and ethnic minority groups are disproportionately affected by diabetes. For example, compared with White Americans, Black Americans are presumed to have stronger genetic^5,11 or physiological^11–13 susceptibility to diabetes, or greater frequency or intensity of known diabetes risk factors, such as obesity, physical inactivity, and hypertension.^14–17Black Americans also are more likely than are White Americans to occupy lower socioeconomic positions.¹⁸ Low socioeconomic position (SEP) across the life course is known to influence the prevalence^19–24 and incidence^3,19,25–30 of type 2 diabetes. The risk of diabetes also is greater for people who are obese,^3,17,31 physically inactive,^3,32 or have hypertension,^33,34 all of which are conditions more common among people with lower SEP.^16,35–37Several studies have focused on the extent to which socioeconomic factors, body composition (i.e., weight, height, body mass index, and waist circumference), and behaviors explain the excess risk of diabetes attributed to race.^4,12,19,30 For example, 2 separate studies, one with data from the Health and Retirement Study¹⁹ and the other with data from the Atherosclerosis Risk in Communities Study,³⁰ used race to predict diabetes incidence. Attempting to separate the direct and indirect effects of race on diabetes,³⁸ these studies assessed, via statistical adjustment, which socioeconomic measures and diabetes-related risk factors, when adjusted, could account for the excess risk among Black participants relative to White participants.^19,30 Adjustment for education lessened the effect of Black race on diabetes incidence in the Atherosclerosis Risk in Communities Study.³⁰ In the Health and Retirement Study, excess risk attributed to Black race was not explained by early-life socioeconomic disadvantage, but it was reduced after adjustment for education and later-life economic resources.¹⁹ The validity of this analytic approach has been challenged, however, because the socioeconomic measures used were assumed to have the same meaning across all racial/ethnic groups, a questionable assumption³⁸ in the United States, especially in 1965.We sought to explore the predictive effects of several life-course socioeconomic factors on the incidence of diabetes among both Black and White Americans. We examined demographic confounders (age, gender, marital status) and diabetes risk factors (obesity, large waist circumference, physical inactivity, high blood pressure, depression, access to health care) as possible mediators of the observed associations between SEP and incident diabetes (i.e., the development of new cases of diabetes over time).     

Socioeconomic Status and Lung Cancer: Unraveling the Contribution of Genetic Admixture

Objectives. We examined the relationship between genetic ancestry, socioeconomic status (SES), and lung cancer among African Americans and Latinos.Methods. We evaluated SES and genetic ancestry in a Northern California lung cancer case–control study (1998–2003) of African Americans and Latinos. Lung cancer case and control participants were frequency matched on age, gender, and race/ethnicity. We assessed case–control differences in individual admixture proportions using the 2-sample t test and analysis of covariance. Logistic regression models examined associations among genetic ancestry, socioeconomic characteristics, and lung cancer.Results. Decreased Amerindian ancestry was associated with higher education among Latino control participants and greater African ancestry was associated with decreased education among African lung cancer case participants. Education was associated with lung cancer among both Latinos and African Americans, independent of smoking, ancestry, age, and gender. Genetic ancestry was not associated with lung cancer among African Americans.Conclusions. Findings suggest that socioeconomic factors may have a greater impact than genetic ancestry on lung cancer among African Americans. The genetic heterogeneity and recent dynamic migration and acculturation of Latinos complicate recruitment; thus, epidemiological analyses and findings should be interpreted cautiously.Associations between socioeconomic status (SES) and cancer incidence or mortality and accompanying racial/ethnic differences are common findings across cancers and populations.1–9 An inverse association between socioeconomic measures and lung cancer incidence and mortality is a consistent observation among populations,7,10–18 especially among men, although for lung cancer mortality in the United States, this pattern is a reversal of that of earlier decades.19 Socioeconomic measurements are also known to vary across diverse populations.20 In the United States, African Americans and Latinos have, on average, lower education, larger household sizes, and lower income and are frequently unmarried compared with Whites.21–24 Smoking is more prevalent among people characterized by low socioeconomic factors such as low education, low income, and working-class occupations.20,25–27 Studies examining the relationship between SES and lung cancer, or cancer in general, have used surveys and registries with large sample sizes, thereby increasing the precision of effect estimates.7,11,12 However, these studies have been constrained by the lack of data on important risk factors for lung cancer11 or have linked aggregate socioeconomic exposure data to individual-level disease status.6,7,11 Ascribing attributes of a group to an individual may not be appropriate and can result in inaccurate inferences, especially if the exposure, SES, is misclassified.28,29Despite known disparities in lung cancer incidence30 and consistently observed associations between SES and both lung cancer and race/ethnicity, few studies have examined this interrelationship, which is thought to result from a complex interplay of environmental, social, economic, and genetic factors. Using incident cancer registry data, Krieger et al.31 observed an inverse relationship between lung cancer incidence and socioeconomic deprivation among African Americans but an increase in incidence with economic prosperity among Latinos. A study examining lung cancer among Latinos found that incidence increased as income increased and the percentage of Latinos residing in the census tract decreased.32 Many studies examining socioeconomic differences in lung cancer risk have suggested the increased risk cannot be fully explained by smoking, occupational, or dietary exposures,13,15,16,33,34 whereas others have found that controlling for several measures such as smoking,35 dietary fat, and perceived health removed associations with SES.17 Some studies examining racial/ethnic differences in lung cancer found ethnic differences disappeared after adjusting for SES.6,7,11 Together, these findings highlight the complexities of understanding the relationship among SES, lung cancer, and race/ethnicity.Self-reported race/ethnicity represents a combination of several factors—genetic, social, economic, and environmental.36 Moreover, because of the ancestral heterogeneity of Latinos and African Americans, self-reported race/ethnicity does not provide precise genetic information. Recent advances in statistical tools and identification of genetic markers informative for ancestry have enabled the genetic heterogeneity of populations to be described and applied to epidemiological studies. Genetic ancestry associations are a useful tool to suggest that a genetic component contributes to disease disparities and admixture mapping is implemented to identify genetic factors contributing to disease.37,38 Of importance is that genetic ancestry may be associated with socioeconomic factors.39–43 For example, Sánchez et al.42 revealed Amerindian ancestry was greater in individuals with fewer years of education. Complex associations among SES, ancestry, and lung cancer require examination to disentangle their contributions to lung cancer. We examined the relationship among SES, genetic ancestry, and lung cancer in a case–control study conducted with African Americans and Latinos.     

Enhancing Cultural and Contextual Intervention Strategies to Reduce HIV/AIDS Among African Americans

I describe 4 protective strategies that African Americans employ that may challenge current HIV prevention efforts: (1) an adaptive duality that protects identity, (2) personal control influenced by external factors, (3) long-established indirect communication patterns, and (4) a mistrust of “outsiders.” I propose the Sexual Health Model as a conceptual framework for HIV prevention interventions because it incorporates established adaptive coping strategies into new HIV-related protective skills. The Sexual Health Model promotes interconnectedness, sexual ownership, and body awareness, 3 concepts that represent the context of the African American historical and cultural experience and that enhance rather than contradict future prevention efforts.AS THE UNITED STATES enters the third decade of the AIDS epidemic, the rates of new HIV/AIDS cases among African Americans continue to increase compared with those of other ethnic groups.¹ Consequently, the Centers for Disease Control and Prevention has proposed a heightened national response to the HIV/AIDS crisis for African Americans.² Community advocates, including the National Black Leadership Commission on AIDS and the National Medical Association, have called for a state of emergency³ to address disparities in infection rates.Among the population as a whole, evidence-based interventions have achieved some success in reducing HIV-related risks and infection rates.^4–6 Although biomedical and behavioral issues related to the transmission of HIV/AIDS have been well-addressed in these interventions,^7,8 some of the related key culture-bound protective strategies and their historical roots are not routinely included in HIV preventions targeted for African Americans.^2,3,9In the following section, I give 4 assumptions derived from HIV intervention research^4–6 regarding how and by whom HIV prevention messages should be conveyed to those at risk and how decisions are made about behavior change. For each of these 4 assumptions, I describe a culture-bound protective strategy used by African Americans that contradicts it: (1) an adaptive duality that protects identity, (2) patterns of personal control developed in response to external factors such as oppression and gender-based socialization, (3) long-established indirect communication patterns, and (4) a mistrust of “outsiders” that limits acceptance of HIV prevention and care.Finally, I propose the Sexual Health Model—a conceptual framework that addresses these adaptive coping strategies and promotes African Americans'' protective skills. I discuss new methods to aid implementation of this model in future interventions, making HIV prevention research more historically and culturally congruent.     

Learning From Successful Interventions: A Culturally Congruent HIV Risk�CReduction Intervention for African American Men Who Have Sex With Men and Women

Few HIV prevention interventions have been developed for African American men who have sex with men or who have sex with both men and women. Many interventions neglect the historical, structural or institutional, and sociocultural factors that hinder or support risk reduction in this high-risk group.We examined ways to incorporate these factors into Men of African American Legacy Empowering Self, a culturally congruent HIV intervention targeting African American men who have sex with men and women.We also studied how to apply key elements from successful interventions to future efforts. These elements include having gender specificity, a target population, a theoretical foundation, cultural and historical congruence, skill-building components, and well-defined goals.AFRICAN AMERICAN MEN WHO have sex with men (MSM) or who have sex with both men and women (MSMW) have the highest HIV prevalence among African Americans and among other racial/ethnic groups of MSM.^1–3 However, HIV risk behaviors alone do not explain the disproportionate HIV rates among African American MSM.^4,5 Attention to the sociocultural challenges facing African American MSM is needed.Only 1 published HIV behavioral intervention targets African American MSM⁶; none specifically target African American MSMW. Inclusion of culture is believed to improve the ability of public health programs to meet members'' needs.^7–9 However, inherent abstractness and a lack of operationalized definitions and cultural competency pose challenges for those designing and implementing interventions.^10–14 Understanding the experiences of African American MSM requires attention to definitions of what it means to be African American and of male sexuality that are rooted in African American history and culture. Choices regarding identification with gay or bisexual labels and disclosure of Black same-gender sexual activities must be contextualized within African American communities.^15–17Health improvement among African American MSM requires attention to racism; gender role expectations; connection to partners, families, and communities; and HIV-related stigma.^18–22 Double minority status is made worse by high HIV rates and perceived responsibility for spreading HIV.^23–25 Even if family and community provide social support, homophobia and racism can deter African American MSM from disclosing their sexuality and seeking HIV prevention and care.²⁶ Interventions must engage protective factors and address structural or institutional and sociocultural barriers to prevention.     

Redressing Past Wrongs: Changing the Common Rule to Increase Minority Voices in Research

Numerous diseases disproportionately affect African Americans across socioeconomic, age, gender, and geographic groups. Despite the need for research into these disparities, African Americans are often underrepresented in research. The Tuskegee Syphilis Study receives much of the blame for this problem, but other contributing factors have also been identified.To date, government policies seeking to increase African American participation have had limited success, and recently proposed changes to the Common Rule do not address this problem. Therefore, we have proposed 3 changes: treating racial minorities as vulnerable, requiring community consultation in minority research, and increasing minority representation on institutional review boards.Coupled with other efforts, these changes could help increase minority representation in researching health disparities.African Americans are disproportionately affected by numerous diseases and health problems, such as high blood pressure, diabetes, obesity, low birth weight, and AIDS, and these disparities persist across socioeconomic, age, gender, and geographic groups.1–3 Although research is needed to formulate effective and appropriate public health programs to respond to these health disparities, African Americans are often underrepresented in research.4,5The mistrust engendered by the now infamous government-run Tuskegee Syphilis Study, which followed several hundred African American men with syphilis for 40 years, receives much of the blame for the underrepresentation of African Americans in research.6 However, research abuses and African American mistrust of medicine did not start and end with the Tuskegee study. Stories of medical and research abuse circulating in the African American community date back to antebellum times.7,8 More contemporary examples of questionable research involving African American populations include the EZ measles vaccine,7 the Kennedy Krieger lead paint abatement,9 and the polyheme synthetic blood10 studies. Research has identified other factors besides mistrust that may account for underrepresentation, including provider biases and lack of access to care.5 Despite disagreement about the exact causes of the problem, there is general agreement that the problem exists.11To date, government policies, such as the 1993 NIH Revitalization Act (Pub L 103–43; 42 USC 289a-1), which mandated inclusion of women and minorities in research, and researchers’ efforts to increase minority enrollment have had limited success.12 The US Department of Health and Human Services 2011 Advanced Notice of Proposed Rule Making, which proposed several significant changes to the regulations governing human participant research for the first time in decades,13 offered an opportunity to address the persistent underrepresentation of African Americans and other minorities in research; however, the US Department of Health and Human Services failed to address this important issue.We believe that systemic changes to the research oversight system are a necessary, but not sufficient, factor in increasing this enrollment. Accordingly, we suggest that future efforts to amend the regulations explicitly require inclusion of minority voices for research focused on minority health issues. As a beginning point for further discussion of possible regulatory changes, we recommend that the Common Rule treat racial minority populations as vulnerable, require community consultation as part of the institutional review board (IRB) process for research involving minority populations, and increase minority participation on IRBs that evaluate such research. We believe that these recommendations, coupled with other efforts—such as increasing the number of minority physicians and researchers and involving minority communities in developing research questions through methods such as community-based participatory research—could address some of the identified barriers to greater research participation of racial and ethnic minorities and thus facilitate the research that is needed on the health issues that disproportionately affect African Americans.The legacy of slavery, Jim Crow laws, and Tuskegee has focused researcher attention on health disparities and underrepresentation of African Americans in research. Accordingly, we frame our discussion in the context of the well-documented African American experience, recognizing that similar experiences support expanding our analysis to other minority populations.     

Racial residential segregation and low birth weight in Michigan's metropolitan areas

Objectives. We examined the influence of racial residential segregation, independent of neighborhood economic factors, on the overall and specific etiological risks of low birth weight.Methods. We geocoded all singleton births in Michigan metropolitan areas during 2000 to census tracts. We used hierarchical generalized linear models to investigate the association between low birth weight (< 2500 g) and neighborhood-level economic and racial segregation, controlling for individual and neighborhood characteristics. We analyzed competing risks of the 2 etiologies of low birth weight: intrauterine growth restriction and preterm birth.Results. Living in a Black segregated area was associated with increased odds (odds ratio [OR] = 1.15; 95% confidence interval [CI] = 1.03, 1.29; P < .05) of low birth weight after adjusting for individual- and tract-level measures. The analysis suggested that the association between low birth weight and racial segregation was attributable primarily to increased risk of intrauterine growth restriction (OR = 1.19; 95% CI = 1.03, 1.37; P < .05).Conclusions. Odds of low birth weight are higher in racially segregated Black neighborhoods in Michigan''s metropolitan areas, independent of economic factors. The association appears to operate through intrauterine growth restriction rather than preterm birth.As the leading cause of death among non-Hispanic Black infants and second-leading cause of death among non-Hispanic White infants, complications related to short gestation and low birth weight represent a significant clinical and public health issue.^1–3 Low birth weight also leads to long-term health consequences through increased rates of childhood and adult chronic diseases.^3–6 Racial disparities in rates of low birth weight have persisted even as total infant mortality has declined and prenatal care utilization among women of color has increased.^1–3 Because differences in individual-level risk factors cannot completely explain the differences in outcomes for White and Black mothers,^3,7 researchers have begun investigating contextual influences on racial disparities in birth outcomes.^3,8Racial segregation is a contextual factor that might contribute to racial disparities in low birth weight by isolating Blacks from the resources and opportunities found more frequently in White communities.^9–13 Residents in Black segregated neighborhoods accumulate less home equity,^14,15 have decreased access to quality primary education,¹⁶ and are exposed to greater residential and economic instability than are residents of nonsegregated communities.⁹ The accumulation of disadvantages in racially isolated neighborhoods could lead to negative birth outcomes for women by limiting opportunities associated with improved health (e.g., educational opportunities or access to quality medical care) and by exposing them to increased stress from neighborhood-level factors.Evidence from a small number of studies suggests that low birth weight is associated with racial residential segregation.^17–24 With few exceptions,^17,25,26 studies link metropolitan-level segregation or the percentage of Black residents in a community to low birth weight. However, because isolation is inherently spatial, to understand how the racial isolation of an individual mother''s neighborhood affects her pregnancy outcomes, isolation is most appropriately measured by considering her neighborhood along with its immediate surroundings (e.g., bordering neighborhoods) rather than by the metropolitan area or a single neighborhood.¹⁷Some authors have argued that racial segregation simply serves as a proxy for economic segregation.^27,28 By contrast, we posit that racial segregation is a distinct form of neighborhood-level disadvantage that presents an increased risk for low birth weight beyond that caused by economic segregation. Sociologists have shown that, even in the presence of economic segregation, the circumstances of racially segregated Black neighborhoods differ from those of White neighborhoods at similar socioeconomic levels.^29–32 This means that although residents of Black middle-class neighborhoods may live in residential areas that are separate from poor Black neighborhoods, they have greater exposure than do middle-class Whites to negative contextual factors and have fewer resources in their vicinity. This also suggests that any attempt to distinguish between the effects of racial and economic segregation on low birth weight requires that economic segregation also be measured spatially, taking a mother''s neighborhood and its immediate surroundings into account.It is also important to consider that the drivers of low birth weight—preterm birth and intrauterine growth restriction—have distinct physiological mechanisms.^33–35 Assessing the degree to which racial isolation is associated with each can provide important insight into the etiological mechanisms relating racial segregation to low birth weight. Spontaneous preterm birth is commonly precipitated by an infection,^36–40 which could be associated with racial segregation if, for instance, racial segregation reduces access to quality care.²⁵ Intrauterine growth restriction, on the other hand, typically stems from a chronic deficiency in oxygen and nutrient delivery to the fetus.^41–46 Chronic stress associated with the circumstances of racially isolated neighborhoods might affect placental vasculature function, creating an oxygen–nutrient insufficiency that leads to intrauterine growth restriction.⁴⁷ We know of no research that has considered the competing risks of growth restriction and preterm birth in the relationship of neighborhood environments with low birth weight.We examined births to mothers living in Michigan metropolitan areas to ascertain whether neighborhood racial segregation was associated with low birth weight independent of economic factors. We explicitly captured the spatial nature of both racial and economic segregation through a localized segregation index. We also analyzed the degree to which racial segregation was associated with different etiologies of low birth weight.     

Racial and Ethnic Disparities in Depression Care in Community-Dwelling Elderly in the United States

Objectives. We investigated racial/ethnic disparities in the diagnosis and treatment of depression among community-dwelling elderly.Methods. We performed a secondary analysis of Medicare Current Beneficiary Survey data (n = 33 708) for 2001 through 2005. We estimated logistic regression models to assess the association of race/ethnicity with the probability of being diagnosed and treated for depression with either antidepressant medication or psychotherapy.Results. Depression diagnosis rates were 6.4% for non-Hispanic Whites, 4.2% for African Americans, 7.2% for Hispanics, and 3.8% for others. After we adjusted for a range of covariates including a 2-item depression screener, we found that African Americans were significantly less likely to receive a depression diagnosis from a health care provider (adjusted odds ratio [AOR] = 0.53; 95% confidence interval [CI] = 0.41, 0.69) than were non-Hispanic Whites; those diagnosed were less likely to be treated for depression (AOR = 0.45; 95% CI = 0.30, 0.66).Conclusions. Among elderly Medicare beneficiaries, significant racial/ethnic differences exist in the diagnosis and treatment of depression. Vigorous clinical and public health initiatives are needed to address this persisting disparity in care.Depression is a significant public health concern for older Americans.1 It has been estimated that 6.6% of older Americans experience an episode of major depression during 1 year.2 If untreated or undertreated, depression can significantly diminish quality of life3 and increase mortality.4 Depression can complicate several comorbid general medical conditions that are common in older populations, including congestive heart failure,5,6 diabetes,7 and arthritis.8 Antidepressant treatment and psychotherapy have been shown to be effective in increasing rates of remission for depression in older adults.9Several studies during the 1990s identified racial/ethnic differences in the diagnosis and treatment of depression, both in the general adult population and among the elderly.10–14 Although there was a general increase in rates of depression diagnosis and antidepressant use during this period, some studies suggest that these increases are not consistent across racial/ethnic subgroups15 and that disparities in the treatment of diagnosed depression are persistent.10,16,17More recent studies (often combining the nonelderly and elderly adult population rather than considering these groups separately) have provided mixed findings. Some evidence indicates that minority group members with depression continue to receive less mental health care than do non-Hispanic Whites, and some studies suggest that mental health treatment differences by race/ethnicity may have worsened in the early 2000s.18–21 By contrast, 1 recent national study reported that although overall increases in treatment rates were modest in the 2000s, there were significant increases in treatment rates among African Americans, possibly narrowing the racial/ethnic gap among adults in general.22 However, this study did not examine disparities in treatment separately among older adults and was founded on household reported conditions that are only modestly related to provider diagnoses.23 The pattern of diffusion of depression treatment may differ between elderly and nonelderly adults. Consequently, racial/ethnic differences in diagnosis and treatment among the elderly remain a potentially important public health concern.We investigated whether there are racial/ethnic differences (1) in the rate of diagnosis of depression among the elderly, controlling for sociodemographic characteristics and depression symptoms (depressed mood and anhedonia) reported on a 2-item screener; and (2) in the treatment provided to those diagnosed with depression by a health care provider, adjusting for these covariates. In a large, nationally representative sample, we examined whether relationships between race/ethnicity and depression diagnosis or depression treatment are mediated by insurance coverage and perceived access to medical care, depression symptoms, and severity, or by other global measures of health such as self-reported health status and impairment in daily activities.     

Community Poverty and Trends in Racial/Ethnic Survival Disparities Among People Diagnosed With AIDS in Florida, 1993–2004

Objectives. We described the racial/ethnic disparities in survival among people diagnosed with AIDS in Florida from 1993 to 2004, as the availability of highly active antiretroviral therapy (HAART) became widespread. We determined whether these disparities decreased after controlling for measures of community-level socioeconomic status.Methods. We compared survival from all causes between non-Hispanic Blacks and non-Hispanic Whites vis-a-vis survival curves and Cox proportional hazards models controlling for demographic, clinical, and area-level poverty factors.Results. Racial/ethnic disparities in survival peaked for those diagnosed during the early implementation of HAART (1996–1998) with a Black-to-White hazard ratio (HR) of 1.72 (95% confidence interval [CI] = 1.62, 1.83) for males and 1.40 (95% CI = 1.24, 1.59) for females. These HRs declined significantly to 1.48 (95% CI = 1.35, 1.64) for males and nonsignificantly to 1.25 (95% CI = 1.05, 1.48) for females in the 2002 to 2004 diagnosis cohort. Disparities decreased significantly for males but not females when controlling for baseline demographic factors and CD4 count and percentage, and became nonsignificant in the 2002 to 2004 cohort after controlling for area poverty.Conclusions. Area poverty appears to play a role in racial/ethnic disparities even after controlling for demographic factors and CD4 count and percentage.The HIV/AIDS epidemic has disproportionately affected the non-Hispanic Black population in the United States. In 2008, an estimated 545 000 non-Hispanic Blacks were living with HIV/AIDS.1 The estimated prevalence of HIV infection for 2008 among non-Hispanic Blacks was 18.2 per 1000 population, more than 7 times higher than the estimated rate for non-Hispanic Whites (non-Hispanic Whites; 2.4 per 1000).1 Non-Hispanic Blacks as a group not only have a higher prevalence of HIV/AIDS, but once infected also have a lower survival rate. The 3-year survival rate in the United States for people diagnosed with AIDS between 2001 and 2005 was 80% among non-Hispanic Blacks compared with 84% for non-Hispanic Whites, 83% for Hispanics, and 88% for Asians,2 further contributing to the disparities in the HIV mortality rate of 16.8 per 100 000 among non-Hispanic Blacks compared with 1.6 per 100 000 among non-Hispanic Whites during 2007.3 Race/ethnicity is a fundamentally social as opposed to a biological construct,4,5 and survival disparities between non-Hispanic Blacks and non-Hispanic Whites have not generally been seen in settings with universal health care access such as in the Veterans Administration health care system,6 the military health care system,7 or a health maintenance organization.8 Therefore, potentially modifiable social explanations for the observed racial/ethnic disparities in survival should be examined.A most remarkable advance in medical treatment in the past century was the development of highly active antiretroviral therapy (HAART). It led to a significant improvement in survival from HIV/AIDS, 9–12 but racial/ethnic disparities in HIV/AIDS survival remain2, 13–16 and in New York City appeared to widen.17 Despite these well-recognized health disparities, there is a critical gap in the knowledge about why the disparity exists. Two population-based studies, both in San Francisco, California (a city that has provided free HIV care for those who cannot afford it), found that Black race was no longer associated with survival between 1996 and 2001 after controlling for neighborhood socioeconomic status (SES), and that this SES effect seemed to be related to HAART use.18,19 However, in a study using HIV surveillance data from 33 states, racial/ethnic disparities in 5-year survival after HIV diagnosis between 1996 and 2003 persisted after adjusting for county-level SES and other factors.20 The objective of this study was to describe the racial/ethnic disparities in AIDS survival in Florida among people diagnosed with AIDS between 1993 and 2004 (a period spanning the time before and during the widespread availability of HAART) and to determine if these disparities decrease after controlling for community-level SES.     

The State of Research on Racial/Ethnic Discrimination in The Receipt of Health Care

Objectives. We conducted a review to examine current literature on the effects of interpersonal and institutional racism and discrimination occurring within health care settings on the health care received by racial/ethnic minority patients.Methods. We searched the PsychNet, PubMed, and Scopus databases for articles on US populations published between January 1, 2008 and November 1, 2011. We used various combinations of the following search terms: discrimination, perceived discrimination, race, ethnicity, racism, institutional racism, stereotype, prejudice or bias, and health or health care. Fifty-eight articles were reviewed.Results. Patient perception of discriminatory treatment and implicit provider biases were the most frequently examined topics in health care settings. Few studies examined the overall prevalence of racial/ethnic discrimination and none examined temporal trends. In general, measures used were insufficient for examining the impact of interpersonal discrimination or institutional racism within health care settings on racial/ethnic disparities in health care.Conclusions. Better instrumentation, innovative methodology, and strategies are needed for identifying and tracking racial/ethnic discrimination in health care settings.Racial/ethnic minorities suffer disproportionate morbidity and mortality from chronic diseases, including cancer, heart disease, diabetes, and stroke. US racial/ethnic health disparities are a consequence of several factors including the disproportionate prevalence of less healthy lifestyles, low socioeconomic status, resource-poor neighborhood environments, and poorer access to care. Another factor is the poorer care received by minority patients after they enter the health care system. The 2005 National Healthcare Disparities Report indicated that White patients receive better quality of care than 53% of Hispanic, 43% of African American, 38% of American Indian/Alaska Native, and 22% of Asian and Pacific Islander patients.1 An updated report in 2010 showed no changes in disparities in 30 of 41 quality core measures for Hispanics, 40 of 47 measures for African Americans, 13 of 19 measures for Asians, and 15 of 22 measures for American Indian or Alaska Natives compared with Non-Hispanic Whites.2 Efforts to eliminate these disparities are hampered by the lack of a full understanding of all proximal causes including any role that racial/ethnic discrimination within the health care system might play.Racial discrimination is defined as “(1) differential treatment on the basis of race that disadvantages a racial group and, (2) treatment on the basis of inadequately justified factors that disadvantage a racial group,”^3(p39) and has been linked to racial/ethnic disparities in health outcomes. Not all discrimination occurs at the individual level or is intended. Seemingly benign policies, practices, structures, and regulations also have the potential to be discriminatory and are collectively referred to as institutional racism. Individual level discrimination and institutional racism may compound the negative effects of other health determinants,4 thereby placing racial/ethnic minorities in double jeopardy.Results of a recent nationwide poll of the United States showed that 74% of African Americans, 69% of other non-Whites, and 30% of Whites report personally experiencing general race-based discrimination.5 Research studies have shown that general experiences with racial/ethnic discrimination are associated with a variety of adverse health outcomes including higher mortality6; lower use of cancer screening7; elevated blood pressure8,9; higher levels of C-reactive protein10; substance use11,12; mental and physical health13,14 including mood, anxiety, and psychiatric disorders12; increased depressive symptoms15; weight gain16; high body mass index17; and smoking.18 Not all studies, however, have found a significant association between general race/ethnicity-based discrimination and health.19,20 Although racial/ethnic discrimination within health care settings and health systems has also been implicated in health disparities,21 little is known about the empirical evidence supporting its prevalence or the association with poor health outcomes.We provide a review of the scientific literature on the prevalence, perception of and effect of racial/ethnic discrimination and institutional racism within health care settings. Our specific objectives were to examine the extent to which recent literature addressed the following research questions:

1. What research methods are currently being used to measure receipt of discriminatory health care?
2. What is the current prevalence of racial/ethnic discrimination in health care settings?
3. Has the perception of or receipt of discriminatory health care changed over time?
4. How does racial/ethnic discrimination influence health in health care settings?
5. How do system level factors, such as institutional practices, policies and regulations contribute to discriminatory health care services?

This review summarizes results of recent research, identifies currently used instrumentation and methodology, and identifies areas where additional research is needed and is a resource for researchers with interest in working in this topic area.     

Recommendations From a Research Consultation to Address Intervention Strategies for HIV/AIDS Prevention Focused on African Americans

Despite substantial federal resources spent on HIV prevention, research, treatment, and care, as well as the availability and dissemination of evidence-based behavioral interventions, the disparate impact of HIV on African Americans continues.In October 2007, 3 federal agencies convened 20 HIV/AIDS prevention researchers and care providers for a research consultation to focus on new intervention strategies and current effective intervention strategies that should be more widely disseminated to address the HIV/AIDS epidemic among African Americans.The consultants focused on 2 areas: (1) potential directions for HIV prevention interventions, defined to include behavioral, community, testing, service delivery, structural, biomedical, and other interventions; and (2) improved research methods and agency procedures to better support prevention research focused on African American communities.IN THE UNITED STATES, African Americans are the racial group most affected by HIV/AIDS. Although comprising approximately 13% of the US population, at the end of 2007 African Americans accounted for 46% of the estimated 1.1 million cases of HIV or AIDS, including 60% of cases among women.^1,2 Of the adult and adolescent HIV/AIDS cases reported during 2007, 47% were among African Americans, and new HIV incidence estimates indicate that 45% of new HIV cases in 2006 were among African Americans.^2,3 For African American men, the leading cause of infection is men having sex with other men, and for women the leading transmission route is heterosexual sex.^1,2Meta-analyses show that behavioral interventions are efficacious in reducing HIV risk behaviors and rates of sexually transmitted infections among heterosexually active African Americans,⁴ African American women,⁵ and African American and Hispanic patients in sexually transmitted disease clinics.⁶ In December 2008, the Centers for Disease Control and Prevention (CDC) released the 2008 Compendium of Evidence-Based HIV Prevention Interventions,⁷ which identifies 57 individual and group-level evidence-based interventions, including many such interventions for African Americans. A number of these evidence-based interventions, as well as additional community-level interventions, have been packaged⁸ and disseminated⁹ to a variety of community-based organizations, health departments, and HIV clinics.Despite the substantial resources spent by federal agencies on HIV prevention, research, treatment, and care, as well as the availability and dissemination of evidence-based behavioral interventions, the disproportionate impact of HIV on the African American community continues. Issues may include inadequate scale (e.g., more resources are needed for broader dissemination of evidence-based interventions), implementation challenges, and the need for stronger or different types of interventions. On October 17 and 18, 2007, the CDC, the National Institutes of Health (NIH), and the Health Resources and Services Administration (HRSA) convened a collaborative research consultation in Atlanta, Georgia, to discuss novel intervention strategies (with a focus on new intervention strategies and current effective intervention strategies that should be more widely disseminated) to address the HIV/AIDS epidemic among African Americans. Twenty consultants attended; these were primarily HIV/AIDS prevention researchers and providers who had experience in conducting research on determinants of health disparities or in developing, implementing, and evaluating HIV/AIDS prevention interventions targeting African Americans.The discussion focused on 2 areas: (1) future directions for HIV prevention interventions for African Americans, defined to include behavioral, community-level, testing, service delivery, structural, biomedical, and other interventions; and (2) improved research methods and agency procedures to better support prevention research focused on African American communities. The consultants were divided into 3 groups that focused on 3 populations—adult heterosexuals, youths, and men who have sex with men and men who have sex with men and women. Cross-cutting issues such as substance abuse and incarceration were discussed in each group. All consultants then reconvened as a large group, and recommendations from each group were presented and discussed with an eye toward advising agencies on future HIV/AIDS prevention research initiatives targeting African Americans.We summarize the recommendations from the consultation. Many of the recommendations were common across the 3 subpopulations, so the recommendations are provided around the 2 main areas of focus—namely, directions for HIV prevention interventions and research methods and support needed for HIV prevention research with African American communities.