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.     

Prenatal,Perinatal, Early Life,and Sociodemographic Factors Underlying Racial Differences in the Likelihood of High Body Mass Index in Early Childhood

Objectives. We investigated early childhood disparities in high body mass index (BMI) between Black and White US children.Methods. We compared differences in Black and White children’s prevalence of sociodemographic, prenatal, perinatal, and early life risk and protective factors; fit logistic regression models predicting high BMI (≥ 95th percentile) at age 4 to 5 years to 2 nationally representative samples followed from birth; and performed separate and pooled-survey estimations of these models.Results. After adjustment for sample design–related variables, models predicting high BMI in the 2 samples were statistically indistinguishable. In the pooled-survey models, Black children''s odds of high BMI were 59% higher than White children''s (odds ratio [OR] = 1.59; 95% confidence interval [CI]= 1.32, 1.92). Sociodemographic predictors reduced the racial disparity to 46% (OR = 1.46; 95% CI = 1.17, 1.81). Prenatal, perinatal, and early life predictors reduced the disparity to nonsignificance (OR = 1.18; 95% CI = 0.93, 1.49). Maternal prepregnancy obesity and short-duration or no breastfeeding were among predictors for which racial differences in children’s exposures most disadvantaged Black children.Conclusions. Racial disparities in early childhood high BMI were largely explained by potentially modifiable risk and protective factors.Over recent decades, as the prevalence of high body mass index (BMI; defined as at or above the Centers for Disease Control and Prevention 95th percentile1) has increased dramatically among all children,2,3 racial disparities have been documented in nationally representative samples of children at very young ages.4–7 Reviews and prevalence studies highlight the need for a better understanding of the predictors of these disparities in BMI and other indicators of childhood obesity,8,9 especially in early childhood.7Previous research on high BMI in early childhood with racially and ethnically diverse samples has identified risk and protective factors at multiple developmental stages. In the prenatal and perinatal period, risks include higher birth weight,10–13 maternal prepregnancy BMI,14 and maternal smoking during pregnancy.14,15 In infancy and early life, risks include maternal employment,11 especially among highly educated women,12,16 nonparent child care,13,17,18 and television viewing hours.12,19–21 Protective factors include breastfeeding10,12,14 and family meals.12,21,22Studies have shown that young racial/ethnic minority children are exposed to more of these risks and fewer of these protections.23,24 Nevertheless, in analyses of nationally representative samples, high BMI remains more common among Black than White children even after adjusting for sociodemographic characteristics and risk and protective factors.6,11,12,14,16 We suspect that the persistence of racial disparities in these studies might be attributable to omitted predictors or less detailed measurement of the age and duration of children’s exposures. This type of comprehensive assessment is methodologically challenging because of the number of variables and observations required to draw statistically valid inferences.We employed a novel 2-survey methodological design to overcome these challenges. We used data from 2 nationally representative samples of US children followed from birth to age 4 to 5 years in separate and pooled-survey analyses to identify prenatal, perinatal, early life, and sociodemographic factors that may explain Black–White disparities in early childhood high BMI. The separate analyses in 2 surveys that cover a historical period of more than 10 years increased the robustness of our findings to differences in sample design, measurement protocols, and period variability in unobserved confounders. The pooled-survey analyses enhanced the statistical power of our study and thereby strengthened our conclusions about which factors explain Black–White disparities in early childhood high BMI.     

Race,Place, and Obesity: The Complex Relationships Among Community Racial/Ethnic Composition,Individual Race/Ethnicity,and Obesity in the United States

Objectives. We explored the association between community racial/ethnic composition and obesity risk.Methods. In this cross-sectional study, we used nationally representative data from the Medical Expenditure Panel Survey linked to geographic data from the US Decennial Census and Census Business Pattern data.Results. Living in communities with a high Hispanic concentration (≥ 25%) was associated with a 0.55 and 0.42 increase in body mass index (BMI; defined as weight in kilograms divided by the square of height in meters) and 21% and 23% higher odds for obesity for Hispanics and non-Hispanic Whites, respectively. Living in a community with a high non-Hispanic Asian concentration (≥ 25%) was associated with a 0.68 decrease in BMI and 28% lower odds for obesity for non-Hispanic Whites. We controlled for individual- and community-level social, economic, and demographic variables.Conclusions. Community racial/ethnic composition is an important correlate of obesity risk, but the relationship differs greatly by individual race/ethnicity. To better understand the obesity epidemic and related racial/ethnic disparities, more must be learned about community-level risk factors, especially how built environment and social norms operate within communities and across racial/ethnic groups.The prevalence of obesity has risen significantly over the past few decades and is now considered one of the most pressing public health problems in the United States.1–5 Currently, more than one third of adults older than 20 years are obese, defined as having a body mass index (BMI; defined as weight in kilograms divided by the square of height in meters) of 30 or more.2 Obesity and sedentary lifestyle are risk factors for a variety of chronic conditions and are leading causes of premature mortality and years of life lost.6–9 Various estimates put the number of deaths attributable to obesity in the United States between 112 000 and 300 000, second only to cigarette smoking.10–12 Members of the current US generation may have a shorter life expectancy than their parents if the obesity epidemic continues.13–16 There are large financial costs associated with obesity, too.17 For example, a recent study found that the annual medical burden of obesity and overweight is nearly 10% of total medical spending, or $147 billion in 2008.18The US obesity epidemic has disproportionately affected certain racial and ethnic minority groups.2,5,19 For example, approximately 50% of African American women are obese compared with only 33% of White women.2 Individual factors such as income and education explain some of the observed racial/ethnic differences in obesity, but wide differences persist even after a large number of individual characteristics are held constant.20 Recent research suggests that community-level characteristics such as the availability and accessibility of sidewalks, parks, and recreational facilities21–26 and food selection and cost27–30 are related to obesity independent of individual characteristics. Thus, one line of research documents wide racial/ethnic disparities in the risk of obesity at the individual level, whereas another identifies several community characteristics that are associated with both the risk of obesity and related racial/ethnic disparities. There is a gap between these 2 lines of research; little is known about how the racial and ethnic composition of residential communities is associated with individual-level obesity risk and how this association might differ by individual-level race/ethnicity. Investigating community-level racial/ethnic composition as a risk factor for obesity, above and beyond individuals’ own characteristics, will help improve understanding of racial/ethnic disparities in health, and guide future interventions to eliminate health disparities, which is a national priority.31Although little empirical evidence exists on the possible relationship between community racial/ethnic composition and obesity, there is reason to hypothesize that a relationship might exist. Social norms regarding body weight may differ significantly across ethnic groups. For example, perceived ideal body size for non-Hispanic Black women is larger than for non-Hispanic White women, and non-Hispanic White women report dissatisfaction with their bodies at significantly lower weights than do non-Hispanic Black women.32 Furthermore, non-Hispanic Black men report a preference for larger body sizes in female partners than do non-Hispanic White men.33 Given that obesity rates and norms regarding body weight differ across racial and ethnic groups and, at the same time, the United States is highly segregated along racial and ethnic lines, it is plausible that norms regarding body weight could develop at the community level. This, in turn, may give rise to an association between community-level racial/ethnic composition and the risk of obesity independent of the characteristics of individuals.This study addresses 2 main questions. First, is the racial/ethnic composition of communities associated with obesity beyond what would be expected given the characteristics of the individuals? Second, if an association exists, does it differ on the basis of an individual’s own racial/ethnic identity? Our findings will enhance understanding of disparities in the US obesity epidemic, and the mechanisms by which certain racial/ethnic minorities are disproportionately affected.     

Racial/Ethnic Disparities in Health Care Receipt Among Male Cancer Survivors

Objectives. We examined racial/ethnic disparities in health care receipt among a nationally representative sample of male cancer survivors.Methods. We identified men aged 18 years and older from the 2006–2010 National Health Interview Survey who reported a history of cancer. We assessed health care receipt in 4 self-reported measures: primary care visit, specialist visit, flu vaccination, and pneumococcal vaccination. We used hierarchical logistic regression modeling, stratified by age (< 65 years vs ≥ 65 years).Results. In adjusted models, older African American and Hispanic survivors were approximately twice as likely as were non-Hispanic Whites to not see a specialist (odds ratio [OR] = 1.78; 95% confidence interval [CI] = 1.19, 2.68 and OR = 2.09; 95% CI = 1.18, 3.70, respectively), not receive the flu vaccine (OR = 2.21; 95% CI = 1.45, 3.37 and OR = 2.20; 95% CI = 1.21, 4.01, respectively), and not receive the pneumococcal vaccine (OR = 2.24; 95% CI = 1.54, 3.24 and OR = 3.10; 95% CI = 1.75, 5.51, respectively).Conclusions. Racial/ethnic disparities in health care receipt are evident among older, but not younger, cancer survivors, despite access to Medicare. These survivors may be less likely to see specialists, including oncologists, and receive basic preventive care.Gender and racial/ethnic disparities in health care utilization are prevalent. Men are less likely than are women to use health care services, including physician office visits and preventive care visits.1,2 Minorities are also less likely to use health care services than are non-Hispanic Whites.3–6 Contributors to these disparities include low socioeconomic status7–10 and lack of health insurance.7,8,11,12 Even after controlling for socioeconomic status and health insurance coverage, racial/ethnic disparities in health care utilization persist.4 These disparities are associated with poorer health and higher mortality rates among minorities and have important implications for survival and well-being for men with serious and chronic health conditions such as cancer.5Although numerous studies have documented racial/ethnic disparities in cancer screening, diagnosis, treatment, and mortality,10,13–18 little is known about how racial/ethnic disparities in health care among posttreatment cancer survivors influence follow-up care. Such care includes monitoring and managing late and long-term effects and follow-up tests to monitor for recurrence and detect second cancers. Management of noncancer comorbidities (e.g., diabetes) and preventive health care19 (e.g., vaccinations) are also recommended for cancer survivors.20–22 Follow-up care may include visits to both primary care and specialist providers.13,23–25 It is strongly recommended that cancer survivors receive lifelong follow-up care because of increased risk of recurrence, morbidity, and mortality.19Prior studies have used administrative data to explore this issue,13,24,26,27 but few of these studies have focused on male cancer survivors and none included younger survivors who are not covered by Medicare. Additionally, it is not known how patterns of health care receipt might differ among men with and without a history of cancer.We assessed racial/ethnic disparities in health care receipt among adult male cancer survivors and men without cancer using the National Health Interview Survey (NHIS).28 We first wanted to compare cancer survivors to a noncancer group to shed light on whether the disparities are specific to cancer or reflect underlying disparities. We explored (1) racial/ethnic disparities in health care receipt among cancer survivors compared with men with no cancer history, (2) racial/ethnic disparities in cancer survivors, and (3) the extent to which predisposing, enabling, and need factors explain racial/ethnic disparities in health care receipt among male cancer survivors.     

Dental Caries: Racial and Ethnic Disparities Among North Carolina Kindergarten Students

Objectives. We examined racial/ethnic disparities in dental caries among kindergarten students in North Carolina and the cross-level effects between students’ race/ethnicity and school poverty status.Methods. We adjusted the analysis of oral health surveillance information (2009–2010) for individual-, school-, and county-level variables. We included a cross-level interaction of student’s race/ethnicity (White, Black, Hispanic) and school National School Lunch Program (NSLP) participation (< 75% vs ≥ 75% of students), which we used as a compositional school-level variable measuring poverty among families of enrolled students.Results. Among 70 089 students in 1067 schools in 95 counties, the prevalence of dental caries was 30.4% for White, 39.0% for Black, and 51.7% for Hispanic students. The adjusted difference in caries experience between Black and White students was significantly greater in schools with NSLP participation of less than 75%.Conclusions. Racial/ethnic oral health disparities exist among kindergarten students in North Carolina as a whole and regardless of school’s poverty status. Furthermore, disparities between White and Black students are larger in nonpoor schools than in poor schools. Further studies are needed to explore causal pathways that might lead to these disparities.Disparities in access to dental health services and oral health status exist among population subgroups in the United States.1–4 Among the most pronounced and persistent disparities in pediatric oral health are those defined by race and ethnicity.2,3,5–8 According to the 2011–2012 National Health and Nutrition Examination Survey, 45.7% of Hispanic children aged 2 to 8 years had experienced dental caries in their primary dentitions, compared with 43.6% of non-Hispanic Black children and 30.5% of non-Hispanic White children.5Although disparities in oral health are well described and have been recognized as important, the causes of racial/ethnic disparities have not been fully explained in previous research. Individual-level studies generally identify residual differences in racial/ethnic groups after control for socioeconomic status (SES) and other confounders.4,6–9 One promising direction in understanding and resolving these disparities, particularly at the conceptual level, is the consideration of risk factors occurring at multiple levels, such as the individual child, family, community, or society as a whole.10–13 This approach might help explain reported residual racial/ethnic disparities, and such knowledge could lead to the design of interventions that target risk factors at the appropriate levels.Several studies have used multilevel analysis to explore the role of community-level factors in child oral health.14–17 However, to our knowledge, only 1 study has considered determinants of racial/ethnic disparities in oral health in a pediatric population in the United States. Fisher-Owens et al.3 used information from 2 levels (children and states) to test a conceptual model with 4 levels (child, family, neighborhood, and state). They found that state-level factors had almost no impact on racial/ethnic disparities in a global measure of self-reported oral health status. This negative finding likely resulted because their definition of community (i.e., the state) was too large a geographic area to be causally related to the outcome.Other multilevel studies of children have also found that determinants beyond the individual level tend to be weakly associated with oral health.15,16 Yet given the small number of multilevel dental studies of racial/ethnic disparities in children, their potential limitations in defining the higher levels, and the repeated finding of residual racial/ethnic disparities in oral health after controlling for a large number of individual factors, an exploration of higher-level determinants might lead to a better understanding of the mechanism through which racial/ethnic disparities affect oral health.Further justification for a multilevel study of oral health disparities is provided by research on other health conditions demonstrating that determinants of disease at one level can be modified by determinants at other levels.18–20 Only 1 study has explored cross-level interactions for predictors of child oral health. Martins et al.16 examined the interaction between children’s household income and type of school attended (public or private) on dental caries experience in primary teeth; they found no statistically significant cross-level effect. To our knowledge, no study has explored the effect of a cross-level interaction involving individual race/ethnicity and pediatric oral health outcomes in a US population.In this study, we examine racial/ethnic differences in dental caries experience among kindergarten students in North Carolina using a multilevel analysis with 2 levels, examining individual students within schools. Our particular interest is in the variation in dental caries experience by race/ethnicity at the individual level and its cross-level interaction with a compositional school-level variable measuring poverty among families of enrolled students.     

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 Novel Look at Racial Health Disparities: The Interaction Between Social Disadvantage and Environmental Health

Objectives. We explored the notion that social disadvantage increases vulnerability to the health effects of environmental hazards. Specifically, we examined (1) whether race modifies the association between blood lead and blood pressure and (2) whether socioeconomic status (SES) plays a role in this modifying effect.Methods. Using the National Health and Nutrition Examination Survey (2001–2008) and linear regression, we estimated the association between blood lead and blood pressure. Using interactions among race, SES, and lead, we estimated this association by levels of social disadvantage.Results. Black men and women showed a 2.8 (P < .001) and 4.0 (P < .001) millimeters mercury increase in SBP, respectively, for each doubling of blood lead. White adults showed no association. This lead–SBP association exhibited by Blacks was primarily isolated to Blacks of low SES. For example, poor but not nonpoor Black men showed a 4.8 millimeters mercury (P < .001) increase in SBP for each doubling of blood lead.Conclusions. Our results suggest that social disadvantage exacerbates the deleterious health effects of lead. Our work provides evidence that social and environmental factors must be addressed together to eliminate health disparities.Black–White disparities in hypertension have been well-documented for decades.1–3 A 2010 American Heart Association report put nationwide prevalence estimates at roughly 33% for White adults but 43% for Black adults.4 Economically, if Black Americans had the hypertension rates of White Americans, about $400 million would have been saved in out-of-pocket health care expenses, about $2 billion would have been saved in private insurance costs, and $375 million would have been saved from Medicare and Medicaid—per year.5 More seriously, disparities are also seen in outcomes related to hypertension. For example, mortality rates because of hypertension are roughly 15 deaths per 100 000 people for White men and women; but 40 and more than 50 per 100 000 for Black men and women, respectively.4 Disparities in hypertension account for the greatest disparities in years of lost life compared with any other health condition.6A growing body of literature in different disciplines indicates that both social and environmental factors are important in the production and maintenance of hypertension disparities.7–10 There are racial disparities in numerous social factors, such as socioeconomic status (SES), that have a robust association with hypertension.2 For example, 2009 estimates put 26% of Blacks living in poverty compared with only 12% of Whites.11 Importantly, however, controlling for poverty does not attenuate the racial disparities in hypertension, indicating that there are complex mechanisms at work.12 There are also racial disparities in numerous environmental hazards, some of which are associated with hypertension. For example, lead is causally associated with a modest increase in blood pressure and risk of hypertension in a dose-dependent manner13–16 through several biological mechanisms, including increases in oxidative stress and alterations in control of the cardiovascular system.17 Furthermore, racial disparities in lead have been reported for decades.18,19In the environmental health literature, researchers have described the notion of differential vulnerability to the deleterious health effects of environmental hazards.20,21 Some have shown that psychosocial stress and social stressors potentiate the association between lead and blood pressure. For example, in 1 study, men who report high levels of perceived stress show an association between bone lead and blood pressure, whereas men who do not report high levels of stress do not reveal this association.22 Similarly, those adults who have higher allostatic load scores, a measure of stress-related wear and tear on the body, show a stronger association between blood lead and the odds of hypertension compared with adults with lower allostatic load scores.23,24It may be that this differential vulnerability, resulting from differential exposure to social factors, contributes to racial disparities in hypertension.25 In other words, it may be that the greater social stressors and psychosocial stress experienced by Black compared with White Americans may exacerbate the health effects of environmental hazards, including lead. In fact, researchers have reported that there is a modifying effect of race on the association between blood lead and blood pressure. Specifically, Black adults exhibit a roughly 1 millimeter mercury increase in systolic blood pressure for every 3 micrograms increase in blood lead.26 Yet, no such association is seen for Whites.19,26,27 It may be that, compared with White adults, Black adults show a stronger association between lead and blood pressure because they experience greater social stressors, such as higher levels of poverty.In the present study, we have updated and expanded on previous work by examining the notion that social disadvantage, as marked by race and SES, modifies the association between blood lead and blood pressure. Specifically, we first updated the literature on the modifying effect of race on the association between blood lead and blood pressure. The most recent work in this area is based on data from 1988 to 1991. Blood lead levels have continued to decline for both Blacks and Whites.19 Because there is a dose-dependent association between lead and blood pressure, it is not known whether blood lead and blood pressure are associated for Black adults using current data (2001 to 2008). Second, we examined the role of SES, specifically education and poverty, in the stronger association between blood lead and blood pressure seen in Black compared with White adults.     

Racial/Ethnic Disparities in Hypertension Prevalence: Reconsidering the Role of Chronic Stress

Objectives. We investigated the association between anticipatory stress, also known as racism-related vigilance, and hypertension prevalence in Black, Hispanic, and White adults.Methods. We used data from the Chicago Community Adult Health Study, a population-representative sample of adults (n = 3105) surveyed in 2001 to 2003, to regress hypertension prevalence on the interaction between race/ethnicity and vigilance in logit models.Results. Blacks reported the highest vigilance levels. For Blacks, each unit increase in vigilance (range = 0–12) was associated with a 4% increase in the odds of hypertension (odds ratio [OR] = 1.04; 95% confidence interval [CI] = 1.00, 1.09). Hispanics showed a similar but nonsignificant association (OR = 1.05; 95% CI = 0.99, 1.12), and Whites showed no association (OR = 0.95; 95% CI = 0.87, 1.03).Conclusions. Vigilance may represent an important and unique source of chronic stress that contributes to the well-documented higher prevalence of hypertension among Blacks than Whites; it is a possible contributor to hypertension among Hispanics but not Whites.Racial and ethnic disparities in hypertension are some of the most widely studied and consequential sources of social disparities in health in the United States.1–3 For example, recent prevalence estimates show that roughly 40% of Black adults but only 30% of White adults have hypertension.4 In addition, the incidence of hypertension occurs at younger ages for Blacks than Whites.1 These disparities are reflected in the larger burden of hypertension-related health and economic costs carried by non-White than White Americans. For example, mortality rates attributable to hypertension are roughly 15 deaths per 100 000 people for White men and women; the mortality rate for Black women is 40 per 100 000 and more than 50 per 100 000 for Black men.5 Among all health conditions, hypertension accounts for the greatest portion of disparities in years of lost life.6 Economically speaking, if Black Americans had the hypertension prevalence of White Americans, about $400 million would be saved in out-of-pocket health care expenses, about $2 billion would be saved in private insurance costs, and $375 million would be saved from Medicare and Medicaid—per year.7Despite the tremendous amount of research devoted to clarifying the factors that generate these disparities, most studies find that they persist after adjustment for a wide range of socioeconomic, behavioral, and biomedical risk factors.8 In fact, although disparities exist for several of these risk factors (e.g., socioeconomic status), numerous studies have shown no disparities in many others (e.g., smoking, obesity for men, lipid profile).2 Despite substantial investment in interventions to eliminate hypertension disparities, evidence suggests that these disparities have actually grown over the past few decades,9 suggesting that numerous unknown factors drive disparities in hypertension.3     

Preconception Stress,Birth Weight,and Birth Weight Disparities Among US Women

Objectives. We examined the impact of preconception acute and chronic stressors on offspring birth weight and racial/ethnic birth weight disparities.Methods. We included birth weights for singleton live first (n = 3512) and second (n = 1901) births to White, Mexican-origin Latina, other-origin Latina, and Black women reported at wave IV of the National Longitudinal Study of Adolescent Health (2007–2008; ages 24–32 years). We generated factor scores for preconception acute and chronic stressors from wave I (1994–1995; ages 11–19 years) or wave III (2001–2002; ages 18–26 years) for the same cohort of women.Results. Linear regression models indicated that chronic stressors, but not acute stressors, were inversely associated with birth weight for both first and second births (b = −192; 95% confidence interval = −270, −113; and b = −180; 95% confidence interval = −315, −45, respectively), and partially explained the disparities in birth weight between the minority racial/ethnic groups and Whites.Conclusions. Preconception chronic stressors contribute to restricted birth weight and to racial/ethnic birth weight disparities.Birth weight, a marker of infant health, predicts infant survival and subsequent health status. Low birth weight, defined as weight less than 2500 grams, is associated with increased risk of developing both short-term and long-term health problems.1 The prevalence of restricted birth weight has been increasing since the 1980s in the United States,2 and marked differences in birth weight persist by race/ethnicity.3,4 Limitations of prenatal care and other pregnancy interventions to address the increase over time and disparities in prevalence of adverse birth outcomes1,5 have led to a focus on preconception health, defined broadly as health before a pregnancy (although often used in public health practice to denote health during the reproductive years) and including interconception health, or health between pregnancies.6,7 Drawing on a life course framework,8–10 the concept of preconception health suggests that infants are affected not only by maternal exposures in the 9-month prenatal period, but also by maternal development before the pregnancy.One preconception exposure of interest is stress. Pearlin’s stress process model posits that social characteristics including those surrounding race/ethnicity in the United States lead to stress exposures that affect health,11–13 and has been used to understand elevated risk of adverse health outcomes among minority groups.14,15 It is worth noting that elevated stress is not inherent to persons of minority race/ethnicity, because race/ethnicity is a social construct and not a biological one. Rather, stress results from historical and societal constraints leading to differential life chances across groups.16In studies of its health consequences, stress was defined most frequently as exposure to an inventory of life events within a specified period of time.17 These acute stressors, such as a death in the family or exposure to a crime, are relatively brief in duration but may have continued ramifications.17,18 Consistent with a life course perspective, more recent studies examined chronic stressors as a risk factor for health outcomes.18,19 These stressful life conditions, including individual and neighborhood socioeconomic disadvantage, recur or accumulate throughout a respondent’s life. However, measurement of chronic stressors is less standardized across studies than that of acute stressors; validated scales of acute events19 but not chronic conditions have been developed.Physiologic mechanisms have been hypothesized to link maternal stress to maternal and infant health.20–22 For example, cumulative stress exposure may result in accelerated aging, or “weathering,” wearing down the body’s adaptive systems.21,22 Weathering in particular was proposed as a source of racial/ethnic disparities in perinatal health, such that the higher stress experienced by African American women causes their reproductive functioning to deteriorate more rapidly than that of White women.22 Other possible pathways through which stress can lead to birth outcome disparities include infection,23 nutrition,19 and pregnancy complications.24The majority of studies assessing the effects on birth outcomes of stress and related factors have relied on prenatal measurement with mixed results.19,25,26 A smaller number of studies have examined effects of acute stressors or specific chronic stressors in the reproductive period.27–30 Although several of these analyses suggested associations, this work included limitations such as small sample sizes,27 European cohorts not generalizable to the United States,29 or retrospectively reported preconception measures.30 Furthermore, none included both acute and chronic stressors or compared racial/ethnic differences for groups besides non-Hispanic Black and non-Hispanic White.To address these gaps in the literature, the objective of this study was to examine the impact of maternal preconception acute stressors (or stressful life events) and preconception chronic stressors (or stressful life conditions) on offspring birth weight and racial/ethnic birth weight disparities. Our hypotheses were as follows: (1) acute and chronic stressors will be inversely associated with birth weight, (2) the distributions of birth weight and stress will vary by maternal race/ethnicity, and (3) stress will partially explain racial/ethnic differences in birth weight where such differences exist. Our conceptual model is shown in Figure 1.Open in a separate windowFIGURE 1—Conceptual model depicting hypothesized relationships among maternal race/ethnicity, preconception stress, and offspring birth weight: National Longitudinal Study of Adolescent Health, United States, 1994–2008.     

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.     

The Role of Socioeconomic Factors in Black–White Disparities in Preterm Birth

Objectives. We investigated the role of socioeconomic factors in Black–White disparities in preterm birth (PTB).Methods. We used the population-based California Maternal and Infant Health Assessment survey and birth certificate data on 10 400 US-born Black and White California residents who gave birth during 2003 to 2010 to examine rates and relative likelihoods of PTB among Black versus White women, with adjustment for multiple socioeconomic factors and covariables.Results. Greater socioeconomic advantage was generally associated with lower PTB rates among White but not Black women. There were no significant Black–White disparities within the most socioeconomically disadvantaged subgroups; Black–White disparities were seen only within more advantaged subgroups.Conclusions. Socioeconomic factors play an important but complex role in PTB disparities. The absence of Black–White disparities in PTB within certain socioeconomic subgroups, alongside substantial disparities within others, suggests that social factors moderate the disparity. Further research should explore social factors suggested by the literature—including life course socioeconomic experiences and racism-related stress, and the biological pathways through which they operate—as potential contributors to PTB among Black and White women with different levels of social advantage.Higher rates of preterm birth (PTB) among Blacks than Whites have been documented in the United States since at least the early 20th century.1–3 This racial disparity is of great concern because PTB strongly predicts infant mortality4,5 and adverse health and neurodevelopmental outcomes in childhood,4,6,7 and has been linked with chronic disease, disability, and premature mortality in adulthood.8–10The underlying reasons for the racial disparity in PTB are not well understood.4 A range of socioeconomic factors—including income, wealth, and education at the individual, household, and area levels—vary across racial/ethnic groups11–16 and are biologically plausible underlying causes of PTB.4,17–20 Socioeconomic effects on health, including PTB, could operate independently of and in concert with the effects of stressful experiences related more directly to racial discrimination.4,16,21,22 Many studies have observed different PTB risks associated with socioeconomic or socioeconomically linked characteristics of the geographic areas where women reside,4,11,23–32 including area-level measures of poverty, unemployment,26 segregation,24,28 and crime rates.25 Various individual-, household-, and neighborhood-level socioeconomic factors could plausibly affect PTB through diverse causal pathways, including those involving poor nutrition or prepregnancy health status, adverse health-related behaviors, lack of medical care, social isolation, stress, and hazardous physical exposures in the home, neighborhood, workplace, or in transit.4 Biological pathways leading from stressful experiences to PTB through neuroendocrine processes have been described.33–36A systematic review17 of studies examining relationships between adverse birth outcomes and socioeconomic factors found that 93 of 106 studies reported a significant association, overall or within a subgroup, between a socioeconomic measure and a birth outcome; effects varied, however, across racial/ethnic groups and socioeconomic measures. Several birth outcome studies have examined interactions between variables reflecting racial/ethnic group and socioeconomic factors, with inconsistent results. Some studies have found minimal or no Black–White differences in PTB among highly disadvantaged women.37–39 Others have observed a significant racial disparity among socioeconomically disadvantaged women, but an even greater disparity among more socioeconomically advantaged women.24,40,41 Some other studies, however, have not reported differences in the racial disparity in PTB across socioeconomic subgroups.4 Although the biological mechanisms for low birth weight are thought to be distinct from those for PTB,4 several studies42–49 have observed relatively smaller—but not necessarily small—racial disparities in low birth weight or infant mortality within socioeconomically disadvantaged versus more advantaged subgroups.In some studies, the Black–White disparity in PTB has persisted after adjustment for socioeconomic and other known or suspected risk factors,31,50–52 leading some researchers to conclude that the Black–White disparity in PTB reflects underlying genetic differences.53–56 Others have challenged this, noting that the disparity may reflect significant unmeasured socioeconomic factors and other social experiences including those related to racial discrimination throughout life, not only during pregnancy.18,21,57–62 With few exceptions,30,31,39,63,64 however, most studies of the Black–White disparity in PTB have had limited socioeconomic information, and few have examined systematically how the disparity may vary at different socioeconomic levels.The goal of this study was to investigate the role of socioeconomic factors in the Black–White disparity in PTB by using a unique population-based data source on California births with more extensive information than generally available in previous PTB research, including multiple socioeconomic measures at the individual, household, and area levels and a wide range of covariables reflecting potential confounders suggested by the literature. The aim was to assess the combined contribution of multiple socioeconomic factors—representing different dimensions of social advantage and disadvantage—to the racial disparity in PTB, and to examine whether and how these socioeconomic factors might moderate the relationship between racial group and PTB.     

Association Between Community Socioeconomic Position and HIV Diagnosis Rate Among Adults and Adolescents in the United States, 2005 to 2009

Objectives. We examined the association between socioeconomic position (SEP) and HIV diagnosis rates in the United States and whether racial/ethnic disparities in diagnosis rates persist after control for SEP.Methods. We used cases of HIV infection among persons aged 13 years and older, diagnosed 2005 through 2009 in 37 states and reported to national HIV surveillance through June 2010, and US Census data, to examine associations between county-level SEP measures and 5-year average annual HIV diagnosis rates overall and among race/ethnicity–sex groups.Results. The HIV diagnosis rate was significantly higher for individuals in the low-SEP tertile than for those in the high-SEP tertile (rate ratios for low- vs high-SEP tertiles range = 1.68–3.38) except for White males and Hispanic females. The SEP disparities were larger for minorities than for Whites. Racial disparities persisted after we controlled for SEP, urbanicity, and percentage of population aged 20 to 50 years, and were high in the low-SEP tertile for males and in low- and high-SEP tertiles for females.Conclusions. Findings support continued prioritization of HIV testing, prevention, and treatment to persons in economically deprived areas, and Blacks of all SEP levels.Community socioeconomic characteristics are key determinants of population health.1 Stratifying population health data by community socioeconomic position (SEP) is a useful approach to analyze and monitor public health inequities. Such analyses quantify health differences between socioeconomic groups or areas and can provide insights for identifying groups or areas that may benefit from prevention, treatment, and other support services. Several analyses have been conducted in investigating cancer and other diseases.2–8 However, 30 years into HIV, there has been limited use of the method in assessing socioeconomic inequities in HIV infection in the United States. Differences in HIV burden among Whites, Blacks, and Hispanics/Latinos (Hispanics) have long been noted in the United States. In 2009, Blacks and Hispanics constituted about 12% and 16% of the US population but accounted for about 44% and 20% of estimated new infections9 and, at year-end 2008, 48% and 17% of persons estimated to be living with a diagnosis of HIV infection.10It is less clear what the magnitudes of differences in HIV diagnosis rates are across communities of different SEP in the United States and whether low SEP contributes to racial/ethnic and sex disparities in HIV. Studies have shown higher rates of HIV infection and lower relative survival in low-income populations overall,11–15 but only 1 study examined the association between SEP and HIV diagnosis rates stratified by sex and race/ethnicity.14 In addition, existing studies were carried out for specific metropolitan areas rather than for the country as a whole.11–13 The purposes of this analysis were to investigate the association between rates of HIV diagnosis and county SEP overall and among various race/ethnicity–sex groups in 37 states of the United States and to determine if racial/ethnic differences in HIV diagnosis rates persist after control for SEP.     

Racial Differences in Breast Cancer Stage at Diagnosis in the Mammography Era

Objectives. We assessed racial differences in breast cancer mortality by stage at diagnosis, since mammography became available.Methods. We calculated adjusted odds of distant (versus local or regional) tumors for 143 249 White and 13 571 Black women aged 50 to 69 years, diagnosed with breast cancer between 1982 and 2007 and living in a Surveillance, Epidemiology, and End Results region. We compared linear trends in stage at diagnosis before and after 1998.Results. Distant-stage cancer was diagnosed in 5.8% of White and 10.2% of Black participants. The Black–White disparity in distant tumors narrowed until 1998 (1998 adjusted difference = 0.65%), before increasing. Between 1982 and 1997, the proportion of distant tumors decreased for Blacks (adjusted odds ratio [AOR]/y = 0.973; 95% confidence interval [CI] = 0.960, 0.987) and Whites (AOR/y = 0.978; 95% CI = 0.973, 0.983), with no racial differences (P = .47). From 1998 to 2007, the odds of distant versus local or regional tumors increased for Blacks (AOR/y = 1.036; 95% CI = 1.013, 1.060) and Whites (AOR/y = 1.011; 95% CI = 1.002, 1.021); the rate of increase was greater for Blacks than Whites (P = .04).Conclusions. In the mammography era, racial disparities remain in stage at diagnosis.Despite a lower incidence of invasive breast cancer, Black women in the United States are more likely than are White women to die of the disease.1,2 Since 1992, although breast cancer deaths have declined in both White and Black women, the overall disparity in mortality has increased.3 Stage at diagnosis is the strongest predictor of survival in breast cancer,4–6 and Black women are more often diagnosed with advanced-stage disease than are White women.7–10Mammography is an important tool in the early detection of breast cancer.11–13 First introduced in the United States in the early 1980s,14 mammography was initially most prevalent among White women. Racial disparities in mammography rates narrowed by the mid-1990s,12,15 and Black women had rates equivalent to or greater than those of White women between 1996 and 2000.10,15,16 From 2000 to 2005, mammography use declined nationally in women aged 50 to 64 years (78.6% to 71.8%), with a slightly larger decrement for White (−4.0%) than Black (−3.3%) women.13The survival benefit of any screening program, including mammography, is related to its ability to detect tumors at earlier stages. Meta-analyses continue to find mortality benefit for mammography, although uncertainty remains regarding both the appropriate target population and the optimal screening interval.11,17,18 Consistent with the expected effect of screening, an observational cohort analysis found that improvements in screening rates for both Black and White women during the 1990s contributed to diagnosis at an earlier stage in both groups.10Nevertheless, despite generally equivalent rates of mammography for the past 15 years, the racial disparity in breast cancer mortality between Black and White women persists. Although previous meta-analyses suggested a mortality benefit for mammography, randomized controlled data regarding the efficacy of screening programs in minority populations are limited.18,19 Because stage at diagnosis is an important predictor of survival in breast cancer, we assessed temporal changes in the distribution of stage at diagnosis between 1982 and 2007, in both Black and White women, adjusting for covariates known to affect stage at diagnosis.     

Adolescent Substance Use and Other Illegal Behaviors and Racial Disparities in Criminal Justice System Involvement: Findings From a US National Survey

We used data from a national survey to examine arrest rate disparities between African American and White adolescents (aged 12–17 years; n = 6725) in relation to drug-related and other illegal behaviors. African American adolescents were less likely than Whites to have engaged in drug use or drug selling, but were more likely to have been arrested. Racial disparities in adolescent arrest appear to result from differential treatment of minority youths and to have long-term negative effects on the lives of affected African American youths.Racial disparities in the juvenile and criminal justice systems are important in both criminology and public health. African American youths have higher rates of arrest and detention than White youths.1–4 The US governmental policies known collectively as the War on Drugs have contributed significantly to increases in rates of arrest and incarceration, especially of African Americans,5–13 although rates of substance use and abuse among African Americans are either similar to14^,15 or even lower than those of Whites.16Two main hypotheses address the overrepresentation of racial/ethnic minorities in the juvenile and criminal justice systems: (1) the “differential offending” hypothesis (that this overrepresentation generally reflects racial and ethnic differences in the incidence, seriousness, and persistence of engagement in delinquent and criminal behavior) and (2) the “differential treatment” hypothesis (that this overrepresentation is attributable to inequities—intended or unintended—in justice system practices as they affect particular populations).2,17–20We used data from a nationally representative survey of youths to examine the relationship of substance use and other illegal behaviors with arrest among African American and White youths to better understand racial disparities in arrest by testing whether the differential offending hypothesis or the differential treatment hypothesis best explains observed disparities, and by examining the longitudinal impact of arrest in adolescence on educational attainment.     

Sources of Racial/Ethnic Differences in Awareness of HIV Vaccine Trials

Objectives. We explored the relative effects of 2 awareness components—exposure and attention—on racial/ethnic differences in HIV vaccine trial awareness among men who have sex with men (MSM).Methods. Surveys assessing awareness of and attitudes toward HIV vaccine trials were administered to 1723 MSM in 6 US cities. Proxy measures of exposure included use of HIV resources and other health care services, community involvement, income, and residence. Attention proxy measures included research attitudes, HIV susceptibility, and HIV message fatigue. Using logistic regression models, we assessed the extent to which these proxies accounted for racial/ethnic differences in vaccine trial awareness.Results. White MSM reported significantly (P < .01) higher rates of HIV vaccine trial awareness (22%) compared with Latino (17%), Black (13%) and “other” (13%) MSM. Venue-based exposure proxies and research-directed attitudinal attention proxies were significantly associated with awareness, but only accounted for the White-Latino disparity in awareness. No proxies accounted for the White-Black or White-“other” differentials in awareness.Conclusions. Sources of disparities in awareness of HIV vaccine trials remain to be explained. Future trials seeking to promote diverse participation should explore additional exposure and attention mediators.Although antiretrovirals improve the survival, health, and virulence of HIV-positive individuals,1–7 the population impact of current HIV treatment is hindered by disparities in testing rates, uneven access to and quality of care, treatment side effects, and drug resistance.8–16 Similarly, behavioral prevention interventions have limited effects on the various cultural, situational, environmental, and structural factors associated with HIV risk.17–24 Development of a preventive HIV vaccine that is efficacious across diverse genetic, physiological, behavioral, and environmental settings could help resolve these issues.25Although there has been a marked increase in the proportion of minority participants in US phase I and phase II preventive vaccine trials, these numbers do not reflect the HIV epidemic’s impact in the United States. For example, Blacks accounted for an estimated 44% of all new HIV infections in the United States in 201026 but represented only 10% to 22% of volunteers enrolled in preventive HIV vaccine trials.27,28 Potential reasons for the limited participation of people of color in clinical trials have been discussed elsewhere.29–41 Awareness of such trials is one important predictor of racial/ethnic and other disparities in trial participation.32,37,42–44Few studies have explored the reasons for racial/ethnic differences in awareness of clinical trials.43,45 We postulate that such differences reflect variations in exposure to information on trials or attention to the information provided.43 Exposure refers to, for example, provision of materials and messages in venues frequented by members of certain groups, including provision of information through physical and online venues that may differ in their racial/ethnic composition.46,47 Even when people are exposed to such materials, a number of factors can influence their attention to this information. For instance, the racial/ethnic composition of advertisement models or the cultural appropriateness of the messaging used can influence the duration and type of attention (e.g., favorable or unfavorable) devoted to messaging.48–50 Moreover, attention to messages focusing on health promotion is often associated with perceived health risk and susceptibility.51,52We explored the relative importance of exposure and attention in racial/ethnic differences in awareness of HIV vaccine trials among men who have sex with men (MSM) who resided in one of 6 US cities and had never taken part in such a trial. Exposure and attention factors may serve as mediators of the relationship between race/ethnicity and awareness, or race/ethnicity may be an effect modifier of the association of exposure and attention with awareness.     

Association of Discrimination-Related Trauma With Sexual Risk Among HIV-Positive African American Men Who Have Sex With Men

Objectives. We investigated whether 1 form of traumatic stress, discrimination-related trauma (e.g., physical assault because of race), was associated with unprotected anal intercourse, especially when compared with non–discrimination-related trauma, among African American men who have sex with men.Methods. A convenience sample of 131 HIV-positive African American men who have sex with men receiving antiretroviral treatment completed audio computer-assisted self-interviews that covered unprotected anal intercourse, interpersonal trauma, and whether trauma was because of discrimination on the basis of race/ethnicity, HIV serostatus, or sexual orientation.Results. Sixty percent reported at least 1 interpersonal trauma; they attributed at least 1 trauma to being gay (47%), African American (17%), or HIV positive (9%). In a multivariate regression, experiencing discrimination-related trauma was significantly associated with unprotected anal intercourse (adjusted odds ratio [AOR] = 2.4; 95% confidence interval [CI] = 1.0, 5.7; P = .04), whereas experiencing non–discrimination-related trauma was not (AOR = 1.3; 95% CI = 0.6, 3.1; P = .53).Conclusions. HIV-positive African American men who have sex with men experience high levels of discrimination-related trauma, a stressor associated with greater risk taking. HIV prevention interventions should consider the potential damaging effects of discrimination in the context of trauma.HIV disproportionately affects African American men who have sex with men (MSM). Twenty-eight percent of African American MSM are estimated to be HIV positive, compared with 16% of White MSM1 and 2% of the general African American male population.2 Young African American males (aged 13–29 years) who have sex with males have had a higher increase in HIV incidence in recent years than has any other racial/ethnic subgroup in the United States.3 Rates of unprotected anal intercourse (UAI) fail to account for racial/ethnic disparities in HIV prevalence.4 However, UAI remains the highest risk factor for HIV transmission among MSM. Understanding the sociocultural variables associated with UAI among African American MSM is likely to be important for developing appropriate HIV prevention strategies for this population. One such sociocultural variable is interpersonal trauma, including childhood sexual abuse (CSA),5 intimate partner violence,6 forced sex,7 and other physical assault. Interpersonal violence disproportionately affects African Americans in general8 as well as MSM.9,10 Although few studies have examined forced sex and physical assault among African American MSM, several have reported a higher prevalence of CSA among African American MSM than among White MSM.9,11 Furthermore, MSM who experience trauma may be more likely to engage in sexual risk behaviors. For example, 1 study reported that MSM with a history of CSA had more sexual contacts and acts of UAI than did MSM who had no history of CSA.11Other research suggests that African American MSM are faced with multiple forms of discrimination associated with their HIV serostatus, race, and sexual orientation12 and that such discrimination may sometimes be experienced as interpersonal trauma. A qualitative study of 87 African American MSM reported that victims may perceive experiences of CSA to be related to their sexual orientation.13 A small quantitative study of a convenience sample of 56 HIV-positive patients recruited from an AIDS treatment clinic reported that of HIV-positive men of color and MSM who reported intimate partner violence, slightly more than one quarter believed that their abuse was related to their HIV serostatus.14The minority stress model posits that social discrimination leads to excess stress among minority persons, which may be more damaging than are other types of stressors because discrimination on the basis of one’s social group may threaten individuals’ core sense of identity.15–18 Consistent with this model, a survey of lesbians and gays found that those who had experienced a bias-related crime showed worse mental health consequences (e.g., symptoms of depression, anxiety, anger, and posttraumatic stress) than did those who had experienced non–bias-related crimes.19 The effect of social discrimination on mental health outcomes has been well documented across various populations, including people living with HIV.12,20 Furthermore, some research indicates an association of perceived social discrimination with sexual risk among MSM,21–28 but none has included an examination of the distinct association of discrimination-related trauma with sexual risk behavior, beyond the effects of other types of trauma. The minority stress model suggests that social discrimination–related trauma would have a greater association with sexual risk than would trauma alone. Although previous research has indicated an association of sexual risk with both trauma5–7 and chronic discrimination,21–28 the effects of trauma resulting from discrimination on sexual risk do not appear to have been investigated in the literature.We examined the association of prior trauma with sexual risk among African American MSM living with HIV. In multivariate models, we examined the distinct effects of discrimination-related and -unrelated interpersonal trauma on sexual risk. We were especially interested in assessing whether experiences of discrimination-related interpersonal trauma had a unique association with UAI beyond variables related to sexual risk in previous research. We were also interested in whether there was a distinct association of UAI with discrimination-related interpersonal trauma beyond any association with interpersonal trauma in general (including discrimination-related and -unrelated interpersonal trauma). Such findings would suggest a need to focus on the added effects of discrimination from interpersonal trauma in both research and secondary HIV prevention interventions targeting this population.     

Socioeconomic and Racial/Ethnic Disparities in the Incidence of Bacteremic Pneumonia Among US Adults

Objectives. We examined associations between the socioeconomic characteristics of census tracts and racial/ethnic disparities in the incidence of bacteremic community-acquired pneumonia among US adults.Methods. We analyzed data on 4870 adults aged 18 years or older with community-acquired bacteremic pneumonia identified through active, population-based surveillance in 9 states and geocoded to census tract of residence. We used data from the 2000 US Census to calculate incidence by age, race/ethnicity, and census tract characteristics and Poisson regression to estimate rate ratios (RRs) and 95% confidence intervals (CIs).Results. During 2003 to 2004, the average annual incidence of bacteremic pneumonia was 24.2 episodes per 100 000 Black adults versus 10.1 per 100 000 White adults (RR = 2.40; 95% CI = 2.24, 2.57). Incidence among Black residents of census tracts with 20% or more of persons in poverty (most impoverished) was 4.4 times the incidence among White residents of census tracts with less than 5% of persons in poverty (least impoverished). Racial disparities in incidence were reduced but remained significant in models that controlled for age, census tract poverty level, and state.Conclusions. Adults living in impoverished census tracts are at increased risk of bacteremic pneumonia and should be targeted for prevention efforts.Bacterial pneumonia is an important cause of morbidity and mortality in adults¹ and is a potentially serious complication of influenza infection.^2,3 Racial/ethnic disparities in the incidence of bacterial pneumonia are a public health problem. Among US adults, rates of bacteremic pneumonia caused by Streptococcus pneumoniae (pneumococcus), the leading cause of community-acquired pneumonia, are higher among Blacks than among Whites.⁴ Vaccination against pneumococcal disease is recommended for persons aged 65 years and older, for cigarette smokers, and for persons with certain chronic conditions.⁵ Vaccination coverage with 23-valent pneumococcal polysaccharide vaccine is lower, however, among Hispanic and non-Hispanic Black adults with indications for vaccination than among non-Hispanic White adults.^6,7 The introduction of pneumococcal conjugate vaccination for children in 2000 led to lower pneumococcal disease incidence in all age groups^8,9 and narrowed the difference between incidence in Black and White children, although disparities persist among adults.^10,11 Less is known about the factors influencing racial/ethnic disparities in the incidence of bacteremic pneumonia caused by other common pathogens. A better understanding of the underlying factors that sustain disparities in bacterial disease would help to direct prevention efforts.Several previous studies examined the contributions of socioeconomic inequalities to racial/ethnic disparities in invasive pneumococcal disease.^12–15 Between 1960 and 1970, a series of population-based studies in US communities identified socioeconomic measures, including average income and education, as strongly associated with both race/ethnicity and bacterial meningitis incidence.^16–18 However, socioeconomic data have not routinely been collected in US surveillance systems for invasive bacterial disease. With geocoding software, individual cases can be mapped to census tract of residence.¹⁵ Census tract–level socioeconomic measures can then be included in analyses of health outcomes to better understand racial/ethnic disparities in disease incidence.¹⁹ We used a large population-based surveillance system for invasive bacterial infections to examine associations between the socioeconomic characteristics of census tracts and racial/ethnic disparities in the incidence of bacteremic community-acquired pneumonia among US adults. We sought to identify a single, publicly available census tract characteristic that could be used to target interventions to geographic areas likely to have high incidences of bacteremic pneumonia and to monitor inequalities in disease burden.     

Research on Discrimination and Health: An Exploratory Study of Unresolved Conceptual and Measurement Issues

Objectives. Our goal in this study was to better understand racial and socioeconomic status (SES) variations in experiences of racial and nonracial discrimination.Methods. We used 1999 and 2000 data from the YES Health Study, which involved a community sample of 50 Black and 50 White respondents drawn from 4 neighborhoods categorized according to racial group (majority Black or majority White) and SES (≤ 150% or > 250% of the poverty line). Qualitative and quantitative analyses examined experiences of discrimination across these neighborhoods.Results. More than 90% of Blacks and Whites described the meaning of unfair treatment in terms of injustice and felt certain about the attribution of their experiences of discrimination. These experiences triggered similar emotional reactions (most frequently anger and frustration) and levels of stress across groups, and low-SES Blacks and Whites reported higher levels of discrimination than their moderate-SES counterparts.Conclusions. Experiences of discrimination were commonplace and linked to similar emotional responses and levels of stress among both Blacks and Whites of low and moderate SES. Effects were the same whether experiences were attributed to race or to other reasons.Racial discrimination persists in the United States,1–3 and perceptions of discrimination are associated with negative health outcomes,4–20 whether discrimination is attributed to race or not and whether its targets are members of racial or ethnic minority groups or Whites.5,17–19 Discrimination also helps to account for racial disparities in health.8–16In this study, we focused on 4 core questions about potential race and socioeconomic differences relevant to assessments of discrimination. First, to what extent do White and Black, poor and nonpoor Americans understand race-based discrimination differently? Second, do these groups differ in their uncertainty about how to make sense of incidents of perceived unfairness, given that such attributional ambiguity can lead to health-damaging worry and rumination?5,20 Third, do these groups differ in frequency of discrimination experiences across life domains? Finally, do they differ in the extent to which they attribute unfair treatment to racial versus non–race-based discrimination? Some researchers frame questions about discrimination in terms of unfair treatment and then ascertain the reason for the experience with a follow-up question,8,21 but it is unclear whether questions framed in this manner truly capture racial discrimination.22     

Disparities in Diabetes: The Nexus of Race,Poverty, and Place

Objectives. We sought to determine the role of neighborhood poverty and racial composition on race disparities in diabetes prevalence.Methods. We used data from the 1999–2004 National Health and Nutrition Examination Survey and 2000 US Census to estimate the impact of individual race and poverty and neighborhood racial composition and poverty concentration on the odds of having diabetes.Results. We found a race–poverty–place gradient for diabetes prevalence for Blacks and poor Whites. The odds of having diabetes were higher for Blacks than for Whites. Individual poverty increased the odds of having diabetes for both Whites and Blacks. Living in a poor neighborhood increased the odds of having diabetes for Blacks and poor Whites.Conclusions. To address race disparities in diabetes, policymakers should address problems created by concentrated poverty (e.g., lack of access to reasonably priced fruits and vegetables, recreational facilities, and health care services; high crime rates; and greater exposures to environmental toxins). Housing and development policies in urban areas should avoid creating high-poverty neighborhoods.In the United States, 25.6 million or 11.3% of adults aged 20 years and older had diabetes in 2010.1 Non-Hispanic Blacks had the highest prevalence at 12.6% compared with non-Hispanic Whites at 7.1%.1 Traditional explanations for the observed race disparity in diabetes prevalence include differences in health behaviors, socioeconomic factors, family history of diabetes, biological factors, and environmental factors.2–4 Little work has been conducted to understand how individual and environment-level factors operate together to produce disparities in diabetes prevalence.A relatively new line of research has begun to show that risk of diabetes is associated with neighborhood attributes that are also associated with race. Auchincloss et al. found that higher diabetes rates were related to lack of availability of neighborhood resources that support physical activity and healthy nutrition.5 Schootman et al. found that poor housing conditions were associated with diabetes prevalence.6 Black neighborhoods are more likely to be characterized by these risk factors (i.e., having food deserts, being less likely to have recreational facilities, and tending to have lower-quality housing than White neighborhoods).7–18 As such it stands to reason that failing to adjust national estimates of diabetes prevalence for these social conditions might influence perceptions of diabetes disparities. LaVeist et al. compared disparities in diabetes in an urban, racially integrated, low-income community with a national sample from the National Health Interview Survey.19,20 They found that when urban Whites and Blacks resided in the same low-income community, the race disparity in diabetes prevalence disappeared, largely because the prevalence rate for Whites increased substantially.19 Ludwig et al. used data from the Moving to Opportunity demonstration project and found a lower prevalence of diabetes among low-income adults who moved from high-poverty neighborhoods to low-poverty neighborhoods compared with low-income adults who moved from a high-poverty neighborhood to another high-poverty neighborhood.21 Findings from these studies suggest the need to further explore the role of place in race disparities in diabetes.We explored whether the nexus of race, poverty, and neighborhood racial composition and poverty concentration illuminates the race disparities in diabetes. Specifically, we examined (1) whether diabetes prevalence increases in predominantly Black neighborhoods compared with predominantly White neighborhoods, (2) whether diabetes prevalence is higher in poor neighborhoods than in nonpoor neighborhoods, and (3) whether the impact of neighborhood racial composition and poverty concentration on the risk of diabetes varies by race. We hypothesized that residential segregation and concentrated poverty (1) increase Black individuals’ exposure to environmental risks associated with poor health, (2) reduce their access to community amenities that promote good health and healthy behaviors, and (3) limit their access to social determinants that promote good health such as quality jobs, education, public safety, and social networks.7,22–24