Insurance,Racial/Ethnic,SES-Related Disparities in Quality of Care Among US Adults with Diabetes

Diabetes-related quality improvement initiatives are typically aimed at improving outcomes and reducing complications. Studies have found that disparities in quality persist for certain racial/ethnic and socioeconomically disadvantaged groups; however, results are mixed with regard to insurance-based differences. The purpose of this study is to investigate the independent associations between type of health insurance coverage, race/ethnicity, and socioeconomic status (SES), and quality of care, as measured by benchmark indicators of diabetes-related primary care. This study used the Diabetes Care Survey of the 2010 Medical Expenditure Panel Survey. Bivariate and multivariate logistic regressions were used to examine the association between quality of diabetes care and type of insurance coverage, race/ethnicity, and SES. Multivariate analyses also controlled for additional demographic and health status characteristics. Respondents with insurance coverage (particularly those with private insurance or with Medicare and Medicaid coverage) were more likely to receive quality diabetes care than uninsured individuals. Few significant disparities based on race/ethnicity or SES persisted in subsequent multivariate analyses. Findings suggest that insurance coverage may make the greatest impact in ensuring equitable distribution of quality diabetes care, regardless of race/ethnicity or socioeconomic status. With the implementation of Affordable Care Act under which more people could potentially gain access to insurance, policymakers should next track insurance-based diabetes care disparities.     

Socioeconomic and Racial/Ethnic Disparities in Unintended Pregnancy Among Postpartum Women in California

Objective: We examined social disparities in unintended pregnancy among postpartum women to better understand 1) the role of socioeconomic factors in racial/ethnic disparities and 2) factors that might explain both socioeconomic and racial/ethnic disparities in the risk for unintended pregnancy among women who give birth. Methods: We used 1999 and 2000 data from a statewide-representative mail and telephone survey of postpartum women in California (N = 7044). We examined associations between unintended pregnancy and race/ethnicity (African American, Asian or Pacific Islander, U.S.-born Latina, foreign-born Latina, European or Middle Eastern), three socioeconomic factors (poverty status, maternal education, paternal education), and several potential explanatory factors. Results: Overall, racial/ethnic disparities in unintended pregnancy were reduced by the three socioeconomic factors individually and collectively (e.g., reducing higher unadjusted odds for African Americans from 3.4 to 1.9); additional adjustment for marital status age, parity, insurance, language, abuse, sense of control, and interaction between marital status and race/ethnicity (each independently associated with unintended pregnancy) reduced the socioeconomic disparities (e.g., reducing odds for the poorest women from 4.1 to 2.3). Although reduced, significant racial/ethnic and socioeconomic disparities remained after adjustment, but generally only among married women. Results for Latinas appeared to vary by nativity, with foreign-born Latinas being at lower odds and U.S.-born Latinas being at higher odds of unintended pregnancy. Conclusions: Racial/ethnic disparities in unintended pregnancy are partly explained by the socioeconomic factors we measured. Several additional factors were identified that suggest possible directions for policies and programs to help reduce social disparities in unintended pregnancy among childbearing women.     

Factors That Mediate Racial/Ethnic Disparities in US Fetal Death Rates

Objectives. We sought to determine the importance of socioeconomic factors, maternal comorbid conditions, antepartum and intrapartum complications of pregnancy, and fetal factors in mediating racial disparities in fetal deaths.Methods. We undertook a mediation analysis on a retrospective cohort study of hospital-based deliveries with a gestational age between 23 and 44 weeks in California, Missouri, and Pennsylvania from 1993 to 2005 (n = 7 104 674).Results. Among non-Hispanic Black women and Hispanic women, the fetal death rate was higher than among non-Hispanic White women (5.9 and 3.6 per 1000 deliveries, respectively, vs 2.6 per 1000 deliveries; P < .01). For Black women, fetal factors mediated the largest percentage (49.6%; 95% confidence interval [CI] = 42.7, 54.7) of the disparity in fetal deaths, whereas antepartum and intrapartum factors mediated some of the difference in fetal deaths for both Black and Asian women. Among Hispanic women, socioeconomic factors mediated 35.8% of the disparity in fetal deaths (95% CI = 25.8%, 46.2%).Conclusions. The factors that mediate racial/ethnic disparities in fetal death differ depending on the racial/ethnic group. Interventions targeting mediating factors specific to racial/ethnic groups, such as improved access to care, may help reduce US fetal death disparities.In the United States, there continue to be racial/ethnic disparities in perinatal outcomes such as fetal death.1–4 Studies have identified factors that are associated with increased rates of fetal death overall, including advanced maternal age,5–7 previous cesarean delivery,8 inadequate prenatal care,9 and some chronic medical conditions.10–12 However, none of these studies examined whether higher fetal death rates seen in minority racial/ethnic groups are potentially mediated by factors that occur later in pregnancy.13–15 Understanding these factors and whether these mediating factors differ between racial/ethnic groups will better focus potential interventions to reduce these disparities.We have identified factors that mediate racial/ethnic differences in fetal death rates between 23 and 44 weeks gestation. We grouped factors into 4 areas using the conceptual framework shown in Figure 1. These sets of factors included socioeconomic factors; maternal preexisting comorbid conditions; antepartum and intrapartum factors, primarily complications of pregnancy; and fetal factors, specifically gestational age at delivery.Open in a separate windowFIGURE 1—Hierarchical conceptual framework: racial/ethnic differences in fetal death, California, Missouri, Pennsylvania, 1993–2005.Note. SES = socioeconomic status. The residual disparity in fetal deaths, or fetal deaths unexplained by any of the included factors, is shown as the bottom pathway.     

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.     

Racial and Ethnic Disparities in Low Birthweight Among Urban Unmarried Mothers

Objectives We examined racial and ethnic disparities in low birthweight (LBW) among unmarried mothers and the extent to which demographic, economic, psychosocial, health, health care, and behavioral factors explain those disparities. Methods Using a sample of 2,412 non-marital births from a national urban birth cohort study, we estimated multiple logistic regression models to examine disparities in LBW between non-Hispanic white (NHW), non-Hispanic black (NHB), U.S.-born Mexican-origin (USMO), and foreign-born Mexican-origin (FBMO) mothers. Results NHW mothers were almost as likely as NHB mothers to have LBW infants. USMO mothers had 60% lower odds and FBMO mothers had 57% lower odds than NHW mothers of having LBW infants. FBMO mothers had no advantage compared to USMO mothers. Controlling for prenatal health and behaviors substantially reduced the LBW advantages for USMO and FBMO mothers. The odds of LBW for NHB mothers relative to NHW mothers increased with the addition of the same covariates. Conclusions Racial and ethnic disparities in LBW among unmarried mothers—an economically disadvantaged population—do not mirror those in the general population. Prenatal health and behaviors are strongly associated with LBW in this group and explain a sizable portion of the Mexican-origin advantage. The lack of a significant black-white disparity in this group suggests that poverty plays an important role in shaping racial disparities in the general population. The finding that controlling for prenatal health and behaviors widens rather than narrows the racial disparity suggests that efforts to ameliorate black-white disparities in LBW should focus on social and health risks throughout the life course.     

Peer Reviewed: Racial/Ethnic and Socioeconomic Disparities in Health-Related Quality of Life Among People With Coronary Heart Disease, 2007

Introduction

Health-related quality of life (HRQOL) refers to a person''s or group''s perceived physical and mental health over time. Coronary heart disease (CHD) affects HRQOL and likely varies among groups. This study examined disparities in HRQOL among adults with self-reported CHD.

Methods

We examined disparities in HRQOL by using the unhealthy days measurements among adults who self-reported CHD in the 2007 Behavioral Risk Factor Surveillance System state-based telephone survey. CHD was based on self-reported medical history of heart attack, angina, or coronary heart disease. We assessed differences in fair/poor health status, 14 or more physically unhealthy days, 14 or more mentally unhealthy days, 14 or more total unhealthy days (total of physically and mentally unhealthy days), and 14 or more activity-limited days. Multivariate logistic regression models included age, race/ethnicity, sex, education, annual household income, household size, and health insurance coverage.

Results

Of the population surveyed, 35,378 (6.1%) self-reported CHD. Compared with non-Hispanic whites, Native Americans were more likely to report fair/poor health status (adjusted odds ratio [AOR], 1.7), 14 or more total unhealthy days (AOR, 1.6), 14 or more physically unhealthy days (AOR, 1.7), and 14 or more activity-limited days (AOR, 1.9). Hispanics were more likely than non-Hispanic whites to report fair/poor health status (AOR, 1.5) and less likely to report 14 or more activity-limited days (AOR, 0.5), and Asians were less likely to report 14 or more activity-limited days (AOR, 0.2). Non-Hispanic blacks did not differ in unhealthy days measurements from non-Hispanic whites. The proportion reporting 14 or more total unhealthy days increased with increasing age, was higher among women than men, and was lower with increasing levels of education and income.

Conclusion

There are sex, racial/ethnic, and socioeconomic disparities in HRQOL among people with CHD. Tailoring interventions to people who have both with CHD and poor HRQOL may assist in the overall management of CHD.     

Exploring Ethnic and Racial Differences in Falls Among Older Adults

Falls are common events that threaten the independence and health of older adults. Studies have found a wide range of fall statistics in different ethnic and racial groups throughout the world. These studies suggest that fall rates may differ between different racial and ethnic groups. Studies also suggest that the location of falls, circumstances of falls, and particular behaviors may also be different by population. Also migration to new locations may alter an individual’s fall risk. However, there are few studies that directly compare ethnic and racial differences in falls statistics or examine how known fall risk factors change based on race and ethnicity. This paper reviews the existing literature on how falls may differ between different racial and ethnic groups, highlights gaps in the literature, and explores directions for future research. The focus of this paper is community dwelling older adults and immigrant populations in the United States.     

Association Between Perceived Discrimination and Racial/Ethnic Disparities in Problem Behaviors Among Preadolescent Youths

Objectives. We examined the contribution of perceived racial/ethnic discrimination to disparities in problem behaviors among preadolescent Black, Latino, and White youths.Methods. We used cross-sectional data from Healthy Passages, a 3-community study of 5119 fifth graders and their parents from August 2004 through September 2006 in Birmingham, Alabama; Los Angeles County, California; and Houston, Texas. We used multivariate regressions to examine the relationships of perceived racial/ethnic discrimination and race/ethnicity to problem behaviors. We used values from these regressions to calculate the percentage of disparities in problem behaviors associated with the discrimination effect.Results. In multivariate models, perceived discrimination was associated with greater problem behaviors among Black and Latino youths. Compared with Whites, Blacks were significantly more likely to report problem behaviors, whereas Latinos were significantly less likely (a “reverse disparity”). When we set Blacks’ and Latinos’ discrimination experiences to zero, the adjusted disparity between Blacks and Whites was reduced by an estimated one third to two thirds; the reverse adjusted disparity favoring Latinos widened by about one fifth to one half.Conclusions. Eliminating discrimination could considerably reduce mental health issues, including problem behaviors, among Black and Latino youths.Racial/ethnic disparities in mental health, including problem behaviors (e.g., disruptive or aggressive behaviors), are substantial among US youths. Black adolescents report higher rates of problem behaviors than do their White counterparts.1,2 Latino adolescents generally report lower rates of these behaviors than do Blacks but greater rates than do Whites. In a nationally representative survey of high school students, 41% of Blacks, 36% of Latinos, and 28% of Whites reported involvement in a physical fight in the preceding year.2 However, little research has gone beyond mere documentation of disparities to examine reasons for disparities or why youths of different races/ethnicities show distinct outcomes.One factor that may contribute to disparities in mental health is discrimination.3–7 Biopsychosocial models of discrimination3–7 posit that discrimination can lead to stress responses that are detrimental to physical and mental health, including physiological changes and poor health behaviors. Chronic discrimination can wear away at protective psychological mechanisms and lead to a lower capacity for coping with new stressors, precipitating maladaptive coping responses. Such responses include poor self-control, including substance use and externalizing behaviors (e.g., aggression). A substantial body of work, mostly among adults, indicates that discrimination is significantly related to poor mental and physical health and health behaviors, including problem behaviors among children.8Discrimination experienced at young ages may have implications for mental health disparities across the life course. Nevertheless, a relatively small amount of research has examined health effects of discrimination among children and adolescents.9–24 This work, which has primarily focused on Black youths, has shown relationships between discrimination and greater externalizing symptoms (i.e., problem behaviors),9,10,16,19,20 internalizing symptoms (anxiety, depression),9,11,14,15,21–24 and substance use.12,13 Little is known regarding whether Latino youths similarly experience mental health deficits following discrimination.A major gap in the discrimination literature is examination of the extent to which discrimination explains health disparities, especially among youths.6 Some research indicates that discrimination has a mediating or explanatory effect on the relationship between race/ethnicity and mental and physical health in adults, although no research has examined health behaviors.25–29 These studies have demonstrated that significant associations between race/ethnicity and health outcomes decrease or become nonsignificant when discrimination is controlled, suggesting that discrimination influences inequities. For example, a study found that, after controlling for everyday perceived discrimination, Black (vs White) differences in self-reported health decreased even after adjusting for socioeconomic status.25Although work examining potential roles of discrimination in disparities has advanced the field, it has limitations. No research in this vein has examined the effects of discrimination on disparities among Latino youths. Furthermore, previous analyses have conflated the effects of racial discrimination against Whites and disadvantaged racial/ethnic groups (e.g., Blacks) by measuring perceptions of discrimination among all groups, including Whites. For example, in a study of New Zealand Maori and Europeans, the disparity favoring Europeans on health outcomes was nonsignificant after adjusting for age, gender, socioeconomic status, and discrimination experiences among both Maori (the disadvantaged group) and Europeans (the dominant group).28 Such models do not provide a clear demonstration of the distinct effects of discrimination against a disadvantaged group only, separate from the effects of discrimination against Whites. Rather, these analyses test effects of discrimination against both the dominant and the disadvantaged groups as potential reasons for health inequalities.Conceptually, however, discrimination is posited to be a reason for poor health in disadvantaged groups only,6 because the dominant group tends both to fare better on health outcomes and to perpetrate discrimination and because the nature of discrimination experienced by dominant and minority groups may differ qualitatively. An analysis that considers the effects of discrimination against the disadvantaged group in particular would be more consistent with conceptual models discussing discrimination as a reason for health disparities.We extended previous work on the discrimination–health relationship by testing the magnitude of the statistical contribution of perceived discrimination to disparities in problem behaviors among preadolescent Black and Latino children. Our analytic approach differs from previous approaches, which have documented the extent of disparities and effects of discrimination but have not examined the magnitude of disparities explained by discrimination specifically from the Black and Latino perspectives. We used data from Healthy Passages, a Centers for Disease Control and Prevention–funded study of 5119 fifth graders on risk factors, protective factors, health behaviors, and health outcomes.30 Previous multivariate analyses of these data demonstrated that Black youths were more likely to have perpetrated both physical aggression (e.g., hit another child) and nonphysical aggression (e.g., put down other children to their faces) than were White youths; although Latino youths were more likely to have perpetrated aggression than were White youths in bivariate analyses, this disparity was reversed in multivariate analyses.31 Perceived discrimination was associated with mental health problems for both Black and Latino youths.32     

Racial/Ethnic,Socioeconomic, and Geographic Disparities of Cervical Cancer Advanced-Stage Diagnosis in Texas

BackgroundAdvanced-stage diagnosis is among the primary causes of mortality among cervical cancer patients. With the wide use of Pap smear screening, cervical cancer advanced-stage diagnosis rates have decreased. However, disparities of advanced-stage diagnosis persist among different population groups. A challenging task in cervical cancer disparity reduction is to identify where underserved population groups are.MethodsBased on cervical cancer incidence data between 1995 and 2008, this study investigated advanced-stage cervical cancer disparities in Texas from three social domains: Race/ethnicity, socioeconomic status (SES), and geographic location. Effects of individual and contextual factors, including age, tumor grade, race/ethnicity, as well as contextual SES, spatial access to health care, sociocultural factors, percentage of African Americans, and insurance expenditures, on these disparities were examined using multilevel logistic regressions.FindingsSignificant variations by race/ethnicity and SES were found in cervical cancer advanced-stage diagnosis. We also found a decline in racial/ethnic disparities of advanced cervical cancer diagnosis rate from 1995 to 2008. However, the progress was slower among African Americans than Hispanics. Geographic disparities could be explained by age, race/ethnicity, SES, and the percentage of African Americans in a census tract.ConclusionsOur findings have important implications for developing effective cervical cancer screening and control programs. We identified the location of underserved populations who need the most assistance with cervical cancer screening. Cervical cancer intervention programs should target Hispanics and African Americans, as well as individuals from communities with lower SES in geographic areas where higher advanced-stage diagnosis rates were identified in this study.     

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 the Incidence of Obesity Related to Childbirth

Objectives. We investigated the relationship between childbirth and 5-year incidence of obesity.Methods. We performed a prospective analysis of data on 2923 nonobese, nonpregnant women aged 14 to 22 years from the 1979 National Longitudinal Survey of Youth Cohort, which was followed from 1980 to 1990. We used multivariable logistic regression analyses to determine the adjusted relative risk of obesity for mothers 5 years after childbirth compared with women who did not have children.Results. The 5-year incidence of obesity was 11.3 per 100 parous women, compared with 4.5 per 100 nulliparous women (relative risk [RR] = 3.5; 95% confidence interval [CI] = 2.4, 4.9; P < .001). The 5-year incidence of obesity was 8.6 for primiparous women (RR = 2.8; 95% CI = 1.5, 5.0) and 12.2 for multiparous women (RR = 3.8; 95% CI = 2.6, 5.6). Among parous women, White women had the lowest obesity incidence (9.1 per 100 vs 15.1 per 100 for African Americans and 12.5 per 100 for Hispanics).Conclusions. Parous women have a higher incidence of obesity than do nulliparous women, and minority women have a higher incidence of parity-related obesity than do White women. Thus, efforts to reduce obesity should target postpartum women and minority women who give birth.Women in the United States are disproportionately overweight, particularly minority and socioeconomically disadvantaged women.^1,2 Approximately two thirds of adult women are overweight, and of this group, one third are obese.¹ Among racial/ethnic groups, African American and Hispanic women have the highest prevalences of obesity, at 50% and 40%, respectively.¹ Women who are socioeconomically disadvantaged have higher obesity rates than do women of higher socioeconomic standing.³ In addition, emerging evidence links perinatal factors such as parity (number of births) to obesity in later life,^4–9 although researchers investigating the relationship between parity and major weight gain or obesity have found mixed results.^7,10–17Several studies have reported that multiparous women (those who have had 2 or more live births) were more likely to be overweight than were nulliparous women (those who have never had a live birth).^10–13,15 Another study found that primiparous women (those who have had at least 1 live birth) were more likely to be overweight and to have major long-term weight gain than were multiparous and nulliparous women.¹⁷ Other studies have found little or no relationship between parity and weight gain or obesity.^7,12,14,16 The inconsistencies in these findings may stem from differences in definitions of the main outcomes, the use of cross-sectional study designs versus prospective designs, or the exclusion of prevalent cases of obesity at baseline. The majority of these studies focused on the outcomes of mean body mass index (BMI), mean weight gain, weight change, major weight gain, or prevalence of obesity, but not on the incidence of parity-related obesity. Additionally, these studies did not establish that births occurred before the outcome measured.^10,12,13,16 Nor have these studies investigated whether racial/ethnic or socioeconomic differences exist in the incidence of parity-related obesity. Thus, we used prospective data to determine the 5-year incidence of parity-related obesity among our sample and to investigate whether this incidence varied by race/ethnicity or socioeconomic status.     

Socioeconomic Disparities in Sleep Duration Among Veterans of the US Wars in Iraq and Afghanistan

We characterized socioeconomic disparities in short sleep duration, which is linked to multiple adverse health outcomes, in a population-based sample of veterans of the US wars in Iraq and Afghanistan who had interacted with the Minneapolis VA Health Care System. Lower reported household assets, lower food security, greater reported discrimination, and lower subjective social status were significantly (P < .05) related to less sleep, even after adjusting for demographics, health behaviors, and posttraumatic stress disorder diagnosis. Assisting veterans to navigate social and socioeconomic stressors could promote healthful sleep and overall health.Inadequate sleep is common, with just more than 1 in 4 adults in the United States reporting that they average 6 or less hours of sleep per night.1 Short sleep duration (commonly defined as < 6–8 hr per day) has been linked to serious health problems, including injury,2–4 cardiovascular disease and associated risk factors,5–14 poor mental health,15–19 and all-cause mortality.20–27 Disparities exist in which Blacks28–32 and those who are of lower socioeconomic status (SES)33 are at increased risk for sleep deficiency. Military members and veterans, especially those who have been deployed, appear to be at greater risk for short sleep duration.34–37 This risk may relate to aspects of the deployment cycle such as irregular schedule and shift work, stress, mental health issues such as posttraumatic stress disorder (PTSD), and injury. Of further concern is that short sleep duration and its risk factors may be part of a mutually reinforcing cycle. Indeed, research has indicated that predeployment short sleep duration may contribute to the development of PTSD.38,39In this study, we sought to characterize socioeconomic disparities in short sleep duration among veterans who served in the US wars in Iraq or Afghanistan and to test whether, independent of other known risk factors, socioeconomic obstacles, such as having low income or experiencing discrimination, are linked to short sleep duration.     

Racial/Ethnic Disparities in the Association Between Preeclampsia Risk Factors and Preeclampsia Among Women Residing in Hawaii

Objective To assess differences in the rates of preeclampsia among a multiethnic population in Hawaii. Methods We performed a retrospective study on statewide inpatient data for delivery hospitalizations in Hawaii between January 1995 and December 2013. Multivariable logistic regression was used to assess the impact of maternal race/ethnicity on the rates of preeclampsia after adjusting for age, multiple gestation, multiparity, chronic hypertension, pregestational diabetes, obesity and smoking. Results A total of 271,569 hospital discharges for delivery were studied. The rates of preeclampsia ranged from 2.0 % for Chinese to 4.6 % for Filipinos. Preeclampsia rates were higher among Native Hawaiians who are age <35 and non-obese (OR 1.54; 95 % CI 1.43–1.66), age ≥35 and non-obese (OR 2.31; 95 % CI 2.00–2.68), age ≥35 and obese (OR 1.80; 95 % CI 1.24–2.60); other Pacific Islanders who are age <35 and non-obese (OR 1.40; 95 % CI 1.27–1.54), age ≥35 and non-obese (OR 2.18; 95 % CI 1.79–2.64), age ≥35 and obese (OR 1.68; 95 % CI 1.14–2.49); and Filipinos who are age <35 and non-obese (OR 1.55; 95 % CI 1.43–1.67), age ≥35 and non-obese (OR 2.26; 95 % CI 1.97–2.60), age ≥35 and obese (OR 1.64; 95 % CI 1.04–2.59) compared to whites. Pregestational diabetes (OR 3.41; 95 % CI 3.02–3.85), chronic hypertension (OR 5.98; 95 % CI 4.98–7.18), and smoking (OR 1.19; 95 % CI 1.07–1.33) were also independently associated with preeclampsia. Conclusions for Practice In Hawaii, Native Hawaiians, other Pacific Islanders and Filipinos have a higher risk of preeclampsia compared to whites. For these high-risk ethnic groups, more frequent monitoring for preeclampsia may be needed.