Race,Ethnicity, and Self-Reported Hypertension: Analysis of Data From the National Health Interview Survey, 1997–2005

Objective. I estimated the association between race and self-reported hypertension among Hispanics and non-Hispanics and determined whether this association was stronger among non-Hispanics.Methods. With data from the 1997–2005 National Health Interview Survey, I used logistic regression to estimate the strength of the association between race/ethnicity and self-reported hypertension among US adults.Results. The overall prevalence of self-reported hypertension was 24.5%, with lower prevalence among Hispanics (16.7%) than among non-Hispanics (25.2%; P < .01). Blacks, regardless of ethnicity, had the highest prevalence. Compared with non-Hispanic Whites, non-Hispanic Blacks had 48% (odds ratio [OR] = 1.48; 95% confidence interval [CI] = 1.41, 1.55) greater odds of reporting hypertension; Hispanic Whites had 23% (OR = 0.81; 95% CI = 0.76, 0.88) lower odds. There was no difference in the strength of the association between race and self-reported hypertension observed among non-Hispanics (OR for Blacks = 1.47) and among Hispanics (OR for Blacks = 1.20; for interaction, P = 0.43).Conclusions. The previously reported hypertension advantage of Hispanics holds for Hispanic Whites only. As Hispanics continue their rapid growth in the United States, race may have important implications on their disease burden, because most US health disparities are driven by race and its socially patterned experiences.Hypertension affects more than 65 million US adults¹ and is a major risk factor for cardiovascular disease (CVD).^2,3 The prevalence of hypertension in the US population increased by 30% between the third National Health and Nutrition Examination Survey (NHANES III, 1988–1994) and NHANES 1999–2000.¹ Previous studies have consistently reported that, compared with non-Hispanic Whites, Hispanics have a lower prevalence of hypertension and that non-Hispanic Blacks have a higher prevalence of hypertension.^1,2,4–7 However, these studies focused mostly on Mexican Americans, ignoring the heterogeneity of the Hispanic population. For example, because of their colonization patterns, Hispanics can be of any race (i.e., White, Black, or some other race).⁸ Despite the impact of race on health in US society^9–11 and the projected growth of the Hispanic population,^12–14 there is a dearth of knowledge addressing the relationship between race and health among Hispanics. However, the evidence that does exist parallels findings observed among non-Hispanics: Hispanic Blacks experience worse health outcomes than do Hispanic Whites.^15–18 Thus, the investigation of race and health outcomes in Hispanics is imperative.Hypertension has been attributed to obesity, sodium and potassium intake, physical inactivity, alcohol consumption, smoking, and psychosocial stress.³ Of these, only psychosocial stress has been shown to be unequally distributed across racial/ethnic groups. Research suggests that racial discrimination—a trigger of psychosocial stress—is common in the everyday life of non-Hispanic Blacks and may lead to CVD.^19–26 Given this, and consistent with the historical pattern of disadvantage among non-Hispanic Blacks,^9,11,27,28 it is possible that Hispanic Blacks could be exposed to the same deleterious experiences of racial discrimination and racism as non-Hispanic Blacks because of the salience and social visibility associated with their race or dark skin color. These experiences may lead to disadvantaged life chances, which then translate into poorer health.The availability of 9 years of data from the National Health Interview Survey (NHIS, 1997–2005) afforded the opportunity to investigate the association between race and self-reported hypertension in Hispanics and non-Hispanics before and after adjustment for selected characteristics and known risk factors and to compare the strength of this association in Hispanics and non-Hispanics. If race as a social construct channels Hispanic Blacks to exposures detrimental to health as it does for non-Hispanic Blacks, the lower odds of hypertension for Hispanics observed in previous studies would apply only to Hispanic Whites whereas Hispanic Blacks would have odds of hypertension similar to those of non-Hispanic Whites or intermediate between non-Hispanic Whites and non-Hispanic Blacks. However, the magnitude of the association between race and hypertension would be stronger among non-Hispanics than among Hispanics.     

Combining Explicit and Implicit Measures of Racial Discrimination in Health Research

Objectives. To improve measurement of discrimination for health research, we sought to address the concern that explicit self-reports of racial discrimination may not capture unconscious cognition.Methods. We used 2 assessment tools in our Web-based study: a new application of the Implicit Association Test, a computer-based reaction-time test that measures the strength of association between an individual''s self or group and being a victim or perpetrator of racial discrimination, and a validated explicit self-report measure of racial discrimination.Results. Among the 442 US-born non-Hispanic Black participants, the explicit and implicit measures, as hypothesized, were weakly correlated and tended to be independently associated with risk of hypertension among persons with less than a college degree. Adjustments for both measures eliminated the significantly greater risk for Blacks than for Whites (odds ratio = 1.4), reducing it to 1.1 (95% confidence interval = 0.7, 1.7).Conclusions. Our results suggest that the scientific rigor of research on racism and health will be improved by investigating how both unconscious and conscious mental awareness of having experienced discrimination matter for somatic and mental health.A small but fast-growing body of public health research is investigating the association between self-reported experiences of racial discrimination and population health.^1–5 To date, the strongest positive and generally linear associations have been observed for what are also the most commonly studied outcomes: self-reported psychological distress and self-reported health behaviors (e.g., smoking, alcohol use, and other drug use).^1–5 By contrast, evidence for somatic health outcomes, chiefly cardiovascular health, has been more mixed, with studies variously reporting linear, nonlinear, and no associations between self-reported experiences of discrimination and health status.^1–5The largest published study on racial discrimination and risk of elevated blood pressure reported a positive linear (dose–response) relationship among professional Blacks but a curvilinear association among working-class Blacks, whose data revealed a J-shaped curve (i.e., blood pressure was higher among respondents reporting no discrimination than among those reporting moderate discrimination and highest among those reporting the most discrimination).⁶ This phenomenon of a linear relationship among persons with more socioeconomic resources but a J-shaped curve among those with fewer has been replicated in other studies on self-reported discrimination and health.^7,8One hypothesis that accounts for these results concerns what people are willing or able to say.^1,6 For persons with more socioeconomic resources, a response of no discrimination may more accurately capture the lack of personally experienced discrimination, whereas among persons with fewer socioeconomic resources, the same response may reflect an accurate report of no discrimination; a positive illusion, denial, or internalized oppression that is not consciously perceived; or a conscious decision not to report the discrimination because it is uncomfortable or dangerous to do so.^1,6 The latter 2 scenarios imply that a health risk may exist, via pathways involving physiological and behavioral responses to racial discrimination as a psychosocial stressor,^1–5 with bodies revealing health effects of exposures that can be subject to distortions in perceptions, memory, and rationalizations.^1,9 If so, reliance solely on self-report measures of racial discrimination, which has been standard to date,^1–5 may be problematic.¹The need to critically assess measurement of exposure to discrimination is demonstrated by what psychologists term person–group discrimination discrepancy (PGDD).^10–15 It is well-documented that people typically report more discrimination for their group than for themselves personally, even though, statistically, the group level cannot be high if every individual''s is low. PGDD is postulated to arise from an automatic protective mechanism,¹⁶ reflecting a larger psychological tendency to view and present oneself positively, even when such denial may not be in one''s ultimate self-interest.^17–19During the past decade, social psychologists, borrowing basic methods of cognitive psychology, have developed a new approach—the Implicit Association Test (IAT), a computer-based reaction-time measure—to study phenomena for which self-report data might not fully capture what people think and feel.^20–23 An outgrowth of several decades of experimental research in the social, cognitive, clinical, and neuropsychological sciences concerned with the general architecture of the human mind, human learning, and unconscious mental processes,^20,24–28 the IAT is now one of the most robust and widely employed measures in social, cognitive, and even clinical psychology; it is used to assess the ease with which the mind makes associations. Building on the central finding that learning involves changes in neural function of different neurons that are active at the same time, the underlying cognitive principle is that concepts in the mind that are more closely associated with each other are more closely linked. These associations can occur both for conscious cognitive processes and for unconscious mental processes that lie beyond the reach of introspective access, with evidence indicating that implicit (unconscious) associations can form about many different phenomena—the self, other people, places, animals, memories, fantasies, inanimate objects, and nontangible ideas.^20,27For example, an IAT could measure how much a person prefers flowers to bugs by contrasting the time it takes to make associations between the word pairs flowers and good and bugs and bad and then comparing what happens when participants are asked to pair flower with bad and bugs with good. A difference in average matching speed for opposite pairings determines the IAT score, a measure of strength of association. Participants are typically aware that they are making these connections but are unable to control them because of the rapid response times and the structure of the test. IAT methods are well-described in the social psychology literature,^21,22 and programming resources to develop IATs are available online.²⁹To address extant questions about measuring experiences of discrimination,^1–5,30,31 we employed a novel application of the IAT to assess unconscious cognition about discrimination and consider the implications of using both explicit (self-report) and implicit measures for research on racism and health. Our work builds on and extends research that used the IAT to study racial prejudice and stereotypes.^32–35 Recent health-related studies found that the IAT for racial prejudice can predict physicians'' clinical decisions.^36,37 Focusing on the somatic health of Black Americans, we hypothesized that the explicit and implicit measures would be weakly associated with each other (because of their varying abilities to measure unconscious processes) and independently associated with risk of hypertension (as modified by socioeconomic position) and with the greater hypertension risk among Blacks than Whites 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     

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.     

Self-Reported Experience of Racial Discrimination and Health Care Use in New Zealand: Results From the 2006/07 New Zealand Health Survey

Objectives. We investigated whether reported experience of racial discrimination in health care and in other domains was associated with cancer screening and negative health care experiences.Methods. We used 2006/07 New Zealand Health Survey data (n = 12 488 adults). We used logistic regression to examine the relationship of reported experience of racial discrimination in health care (unfair treatment by a health professional) and in other domains (personal attack, unfair treatment in work and when gaining housing) to breast and cervical cancer screening and negative patient experiences adjusted for other variables.Results. Racial discrimination by a health professional was associated with lower odds of breast (odds ratio [OR] = 0.37; 95% confidence interval [CI] = 0.14, 0.996) and cervical cancer (OR = 0.51; 95% CI = 0.30, 0.87) screening among Maori women. Racial discrimination by a health professional (OR = 1.57; 95% CI = 1.15, 2.14) and racial discrimination more widely (OR = 1.55; 95% CI = 1.35, 1.79) were associated with negative patient experiences for all participants.Conclusions. Experience of racial discrimination in both health care and other settings may influence health care use and experiences of care and is a potential pathway to poor health.Racism is increasingly recognized as an important determinant of health and driver of ethnic health inequalities.1 Regardless of its health effects, racism breaches fundamental human rights and is morally wrong. It is important to understand how racism operates as a health risk to develop interventions that reduce ethnic inequalities in health within a context of eliminating racism.2Racism is an organized system that categorizes racial/ethnic groups and structures opportunity, leading to inequities in societal goods and resources and a racialized social order.3–5 Racism operates via institutional and individual practices (racial discrimination) and varies in form and type.6,7 The pathways whereby racism leads to poor health are also multiple, with direct and indirect mechanisms such as race-based assaults and violence, physiological and psychological stress mechanisms, differential exposures to health risk factors, differential access to and experiences of health care, and differential access to goods, resources, and power in society.6,8–10Research on racism and health, particularly self-reported racism, has increased. Self-reported experience of racism has been linked to multiple health measures (including mental and physical health outcomes and health risk factors) across a variety of countries and for different ethnic groups.10–12 Research on how self-reported experience of racism may negatively affect health has largely focused on racism as a stressor with mental and physical health consequences.10,13 Comparatively less evidence is available on how experience of racism may influence health service use,10 although this is another potentially important pathway to poor health.14,15Studies on the association between self-reported racism and health care experience and use have included racism experienced within the health care system, outside of the health care system, or both.16–19 Health care measures have included use of specific services such as cancer screening19–24 and receipt of optimal care,20,25 measures of unmet need,16,26 measures of adherence to care,17,27,28 and measures of satisfaction and experiences with care.18,29–31Various mechanisms have been suggested to explain how the experience of racism may negatively affect health care use, experiences of health care, and subsequent poor health. Experiences of racism within the health care system may influence health by shaping decision making of both providers and patients and influencing future health behaviors, including future health care use behaviors and potential disengagement from the health care system.14,18,26 Experiences of racism in wider society also may lead to general mistrust and avoidance of dominant culture institutions, including health care systems.15,30 This is supported by evidence that both experiences of racism and general discrimination within and outside of health care have been associated with negative health care use measures.15,16,19,22New Zealand has a population of approximately 4.4 million people, with the major ethnic groupings being Maori (indigenous peoples, 15% of the population), European (77%), Pacific (7%), and Asian (10%).32 Ethnic inequalities in health and socioeconomic status persist, with racism a potentially important contributor to these inequalities.33 Previous research in New Zealand has shown reported experience of racial discrimination by a health professional to be higher among non-European ethnic groups with experiences of racial discrimination in different settings associated with multiple health outcomes and risk factors.34In this study, we focused on the relationship between racial discrimination and health service use and experience, an area not previously examined in New Zealand. We provide important information on how racial discrimination may affect health care use as a possible pathway to poor health outcomes and ethnic health inequalities in New Zealand. In addition, our study contributes to the limited evidence on racial discrimination and health care internationally.Primary health care in New Zealand is available to all residents and is usually provided at general practices. Costs of visits are universally subsidized by government to enable lower patient copayments with additional limited provision for extra funding based on high need.35 Currently, 2 publicly funded national cancer screening programs are available.36 Breast cancer screening is free to all eligible women through BreastScreen Aotearoa. Cervical cancer screening usually incurs a fee and is available through patients’ usual primary care provider or specific cervical cancer screening providers.We specifically examined the association between self-reported experience of racial discrimination and the use of health care in 2 domains—cancer screening and negative patient perceptions of health care encounters. We hypothesized that experience of racial discrimination both within and outside the health care system may negatively affect how individuals use and experience health care.     

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.     

Racial Disparities in Life Expectancy in Brazil: Challenges From a Multiracial Society

Objectives. We calculated life expectancy at birth for Whites, Blacks, and mixed races in Brazil, and decomposed the differences by causes of death.Methods. We used Ministry of Health death records and 2010 Census population data (190 755 799 residents and 1 136 947 deaths). We applied the Arriaga methodology to calculate decomposition of life expectancy by cause of death. We performed sensitivity analyses for underreporting of deaths, missing data, and numerator–denominator bias.Results. Using standard life table methods, female life expectancy was highest for mixed races (78.80 years), followed by Whites (77.54 years), then Blacks (76.32 years). Male life expectancy was highest for Whites (71.10 years) followed closely by mixed races (71.08 years), and lower for Blacks (70.11 years). Homicides contributed the most to the relative life expectancy increase for Whites, and cancer decreased the gap. After adjustment for underreporting, missing data, and numerator–denominator bias, life expectancy was higher for Whites than for Blacks and mixed races.Conclusions. Despite wide socioeconomic differences between Whites and mixed races, standard life table methods showed that mixed races had higher life expectancy than Whites for women, and similar for men. With the increase of multiracial populations, measuring racial disparities in life expectancy will be a fast-growing challenge.The idea of a “Brazilian racial democracy” first gained traction during the early 20th century and quickly spread thereafter.1 Racial democracy came to signify intense race mixing, in which the blurring of race-group boundaries would foreshadow the creation of a postracial individual, free from discrimination. It is ironic that the ideology of living in a “race-free” society has held back scientific inquiry into the existence of racial/ethnic disparities in Brazil for several decades.2This history of not openly talking about race in Brazil is well exemplified by the 2010 Census, which was the first ever to include a question about race in the national survey applied to every resident.3 (Before 2010 all data about race were based on samples.) The results showed a country divided between Whites and non-Whites, with 47.73% Whites, 7.61% Blacks, 43.13% mixed races (pardos), 1.09% Asians, and 0.43% indigenous. The census also revealed the depth of socioeconomic racial inequalities in Brazil.4 Whites earn an average monthly income that is 84.50% higher than Blacks’ (R$ 1535.47 vs R$ 832.25) and 81.96% higher than mixed races’ (R$ 843.87).Results from a 2008 nationally representative, probability-based, multistage survey of Brazilian households had previously indicated that Whites also have higher education levels and report better self-rated health than Blacks and mixed races.5 Whites were significantly more likely to have 8 years or more of formal education (51.68% vs 41.64% and 36.75%, respectively), and less likely to have no education (11.82% vs 16.40% and 18.41%, respectively).These socioeconomic disparities by race in Brazil compare unfavorably with those in the United States, a country that shares a history of slavery, but unlike Brazil went through an additionally extended period of overt racial segregation (Jim Crow laws) that persisted well into the second half of the 20th century. Nonetheless, recent results show that US Blacks have a lower income disparity in relation to Whites (36.13% lower) in comparison with Brazil (45.8% lower among Blacks compared with Whites).6This association between Black (or mixed) racial status and having both lower income and education, along with high crime rates in the communities in which they live, has had an important effect in perpetuating racial prejudice in Brazil.7 Studies have found that when asked to identify the race of other people, respondents display a tendency to “Whiten” the other person’s race, a bias known as “interviewer Whitening.”8 This is considered to be a way to avoid offending the other person.9Analyzing race and mortality in Brazil has been long problematic for 2 reasons: first, as already mentioned, no complete data existed for population distribution by race; second, the quality of mortality data was considered to be unsatisfactory. As recently as 2000, it was estimated that only 85.4% of deaths were reported to authorities, and by 2010 the proportion had increased to 92.3%, a level of coverage similar to most developed countries.10The objective of the present study was to use the recently released 2010 Census data to compare life expectancy at birth in Brazil for Whites, Blacks, and mixed races. We then aimed to decompose the life expectancy gaps by specific causes of death.     

Trust,Medication Adherence,and Hypertension Control in Southern African American Men

We examined the relationship between trust in the medical system, medication adherence, and hypertension control in Southern African American men. The sample included 235 African American men aged 18 years and older with hypertension. African American men with higher general trust in the medical system were more likely to report better medication adherence (odds ratio [OR] = 1.06), and those with higher self-efficacy were more likely to report better medication adherence and hypertension control (OR = 1.08 and OR = 1.06, respectively).Trust remains an important issue with African Americans (AAs), particularly in the South where its history of mistreatment and racial discrimination at times were highly prevalent.1 Racial and ethnic minorities are more prone than are Whites to distrust the health care establishment, and historically, minority men have had less access to culturally competent providers.2–4 Southern AAs are more likely than are Whites to report perceived racial barriers to care,5 and AA men are more likely than are AA women to report perceived discrimination.6–10 Perceived discrimination and mistreatment are associated with poorer medical adherence and delays in seeking health care.11–14 In addition, higher levels of trust in the health care system are associated with better adherence to recommended care, greater patient satisfaction, and better outcomes.15–18 This has significant implications considering that AA men develop hypertension (HTN) at an earlier age, have higher rates of advanced (stage 3) HTN, are more likely to experience HTN complications, and are less likely to achieve HTN-control compared with White men.19–21 The rates of HTN are even higher in the South for AA men, accounting, in part, for higher stroke (80% higher) and cardiovascular mortality (50% higher) in this subpopulation compared with other groups in other regions.21–23The goal of this brief study was to assess the relationship between trust in the medical, medication adherence,24 and HTN control25 among Southern AA men. Other covariates were perceived discrimination, perceived racism, self-efficacy, and participation in medical decision-making. This study is based on the Race and Health Outcomes Model developed by Williams et al.26     

Joint Effects of Structural Racism and Income Inequality on Small-for-Gestational-Age Birth

Objectives. We examined potential synergistic effects of racial and socioeconomic inequality associated with small-for-gestational-age (SGA) birth.Methods. Electronic medical records from singleton births to White and Black women in 10 US states and the District of Columbia (n = 121 758) were linked to state-level indicators of structural racism, including the ratios of Blacks to Whites who were employed, were incarcerated, and had a bachelor’s or higher degree. We used state-level Gini coefficients to assess income inequality. Generalized estimating equations models were used to quantify the adjusted odds of SGA birth associated with each indicator and the joint effects of structural racism and income inequality.Results. Structural racism indicators were associated with higher odds of SGA birth, and similar effects were observed for both races. The joint effects of racial and income inequality were significantly associated with SGA birth only when levels of both were high; in areas with high inequality levels, adjusted odds ratios ranged from 1.81 to 2.11 for the 3 structural racism indicators.Conclusions. High levels of racial inequality and socioeconomic inequality appear to increase the risk of SGA birth, particularly when they co-occur.In the United States, Black women are more than 1.5 times as likely as White women to give birth to a small-for-gestational-age (SGA) infant, typically defined as an infant with a birth weight below the 10th percentile for a given gestational age; such births increase the risk of neonatal morbidity and long-term deficits in growth and development.1 This disparity has persisted for decades and is not fully explained by differences in health behaviors or access to prenatal care.2–4 Although individual socioeconomic status attenuates some of the increase in risk experienced by Black women, residual disparities remain.5Racial discrimination may be a distinct and critical source of chronic stress among women of color, both during pregnancy and across the life course.6 Disparities in perinatal outcomes, including SGA birth, are of particular interest to researchers concerned with the potential health effects of discrimination. A growing body of research has identified the harmful effects of racial discrimination on the health of Blacks in the United States.7 Evidence suggests that discrimination may be at least partially responsible for the large and persistent disparities in morbidity and mortality that exist between Whites and Americans of color.8 Much of this research has focused on individual experiences of discrimination, but a relatively recent paradigm shift has begun to identify such experiences as part of a larger system of policies and practices that reinforce racial inequity.9This system refers to the concept of structural racism, defined as the exclusion of racial minorities from resources and opportunities (e.g., wealth, housing, education), effectively creating a health disadvantage.10 The historical legacy of racial oppression experienced by Black Americans9,11 and persistent differences in access to resources have resulted in a system of strong links between race and social class at the population level. Inequalities in health therefore are not driven by race or class alone,12 and disentangling the health effects of both racial and socioeconomic disadvantage continues to present conceptual and methodological difficulties.13Previous work highlighting the detrimental effects of structural racism on pregnancy outcomes, including infant size and gestational age at delivery, has been largely limited to analyses of neighborhood or metropolitan area contexts such as segregation patterns,14–19 deprivation,20–23 and crime,24 which may stem from, for example, discriminatory mortgage lending, population differences in buying power, and federal housing policies.25 Furthermore, studies that have considered contextual socioeconomic characteristics have produced inconsistent results in terms of the degree to which these factors explain racial disparities in adverse birth outcomes between neighborhoods.15,19,21It remains unknown whether structural racism measured at the state level is associated with SGA birth. In a recent investigation of structural racism and myocardial infarction, Lukachko et al. developed a series of state-level indicators intended to represent the systematic exclusion of people of color from access to resources, opportunities, and social mobility.26 Using similar indicators, we investigated the potential synergistic effects of state-level structural racism and socioeconomic inequality on the risk of SGA birth among White and Black women in a large US obstetrical cohort study. We aimed to describe the degree of structural racism across the study states, determine whether the effects of structural racism differed according to maternal race and across levels of income inequality, and quantify the risk of SGA birth associated with high levels of both racial and socioeconomic inequality.     

Experiences of Discrimination and Their Impact on the Mental Health Among African American,Asian and Pacific Islander,and Latino Men Who Have Sex With Men

Objectives. We examined the associations between specific types and sources of discrimination and mental health outcomes among US racial/ethnic minority men who have sex with men (MSM) and how these associations varied by race/ethnicity.Methods. A chain-referral sample of 403 African American, 393 Asian and Pacific Islander (API), and 400 Latino MSM recruited in Los Angeles County, California completed a standardized questionnaire. Data were obtained from the Ethnic Minority Men’s Health Study from May 2008 to October 2009.Results. Past-year experiences of racism within the general community and perceived homophobia among heterosexual friends were positively associated with depression and anxiety. Past-year homophobia experienced within the general community was also positively associated with anxiety. These statistically significant associations did not vary across racial/ethnic groups. The positive association of perceived racism within the gay community with anxiety differed by race/ethnicity, and was statistically significant only for APIs. Perceived homophobia within the family was not associated with either depression or anxiety.Conclusions. Higher levels of experiences of discrimination were associated with psychological distress among MSM of color. However, specific types and sources of discrimination were differentially linked to negative mental health outcomes among African American, API, and Latino MSM.Accumulating data indicate that mental health problems are more prevalent among sexual minorities than among heterosexuals.1,2 A recent meta-analysis of 25 epidemiological studies revealed that the lifetime prevalence of depression and anxiety disorders was at least 1.5 times higher among lesbians, gays, and bisexuals, whereas the lifetime risk for suicide attempts was 2.47 times greater in sexual minority groups.2 Research linked a wide range of mental health outcomes among sexual minorities—including depression,3–10 anxiety,6,9,10 panic disorder,6 psychological distress,11–16 suicide attempts,11 and suicidal ideation11,17—to the effects of discrimination. Furthermore, studies showed widespread experiences of discrimination among sexual minorities.6,8,16,18,19 One population-based survey of US adults found that more than three quarters (76%) of gay or bisexual respondents reported a lifetime experience of discrimination.6 In another population-based survey of US adults, close to one quarter (21.4%) of lesbian, gay, or bisexual respondents reported experiencing discrimination in the past year.18Although the disproportionate prevalence of mental health difficulties and experiences of social discrimination among lesbian, gay, and bisexual people are well documented, the association between discrimination and mental health outcomes is not well understood. Among the gaps in our understanding are the following 2 points. First, it is unclear which types and sources of discrimination have an adverse effect on mental health among sexual minorities. Three of the 15 existing studies on the impact of discrimination on mental health outcomes utilized composite measures of overall perceived discrimination that combined various forms of discrimination experiences.6,10,15 Eleven studies examined specific types of discrimination, such as antigay violence,5,9,11,12,14,17 racism,8,16 and homophobia,3,4,8,12,13,16 but made no specific references to their sources (e.g., family, heterosexual friends, a mainstream gay community, a larger general community). One study specified only a single source (i.e., White gay men) for one particular form of discrimination (i.e., perceived devaluation of Asian gay men7).Second, it remains unknown whether previous study findings on the association between discrimination and poor mental health outcomes among sexual minorities are generalizable across racial/ethnic groups, because few studies of sexual minorities have directly compared the effects of discrimination on mental health outcomes among various racial/ethnic minority groups. Studies of discrimination and mental health among sexual minorities have either aggregated multiple racial and ethnic groups,3–6,9,11–14,17 or been limited to 1 (i.e., African Americans,10 Asians,8 Latinos16) or 2 groups (i.e., Asians and Latinos15).The present study addressed these gaps in the literature by examining the associations of specific types and sources of discrimination with mental health outcomes in a sample of African American, Asian or Pacific Islander (API), and Latino men who have sex with men (MSM). First, we examined the prevalence of discrimination based on race/ethnicity and sexual orientation. Second, we determined which types and sources of discrimination were associated with mental health outcomes. Finally, we assessed whether these associations varied by race/ethnicity.     

Socioeconomic Status,Race, and Mortality: A Prospective Cohort Study

Objectives. We evaluated the independent and joint effects of race, individual socioeconomic status (SES), and neighborhood SES on mortality risk.Methods. We conducted a prospective analysis involving 52 965 non-Hispanic Black and 23 592 non-Hispanic White adults taking part in the Southern Community Cohort Study. Cox proportional hazards modeling was used to determine associations of race and SES with all-cause and cause-specific mortality.Results. In our cohort, wherein Blacks and Whites had similar individual SES, Blacks were less likely than Whites to die during the follow-up period (hazard ratio [HR] = 0.78; 95% confidence interval [CI] = 0.73, 0.84). Low household income was a strong predictor of all-cause mortality among both Blacks and Whites (HR = 1.76; 95% CI = 1.45, 2.12). Being in the lowest (vs highest) category with respect to both individual and neighborhood SES was associated with a nearly 3-fold increase in all-cause mortality risk (HR = 2.76; 95% CI = 1.99, 3.84). There was no significant mortality-related interaction between individual SES and neighborhood SES among either Blacks or Whites.Conclusions. SES is a strong predictor of premature mortality, and the independent associations of individual SES and neighborhood SES with mortality risk are similar for Blacks and Whites.From birth through approximately age 85 years, there is a mortality rate disparity between Blacks and Whites in the United States that peaks in early adulthood and slowly narrows thereafter.1–4 Most of the excess deaths among Blacks occur in middle-aged adults, given the confluence of rising mortality rates and the disparity at those ages. During much of the 20th century, this disparity was unyielding,4–6 but recent data point to some narrowing of the gap beginning in the 1990s.7–9 Still, in 2011 the highest age-standardized death rate in the United States was that among non-Hispanic Blacks (877.4 per 100 000 standard population), followed by non-Hispanic Whites (738.1 per 100 000 standard population).10 Also, average life expectancies at birth in 2011 were 4.5 years shorter for Black than White men and 3.1 years shorter for Black than White women.10Although national mortality data are routinely reported by race/ethnicity, their interpretation must consider the determinants of race-specific mortality rates, including behavioral, social, economic, and political factors that determine the resources available to maintain health and prolong life.3 Whether socioeconomic status (SES) completely accounts for mortality differences between Blacks and Whites is not clear. Previous studies have reported that SES alone cannot fully account for the disparity, although in settings where Blacks and Whites are drawn from considerably different SES strata, confounding by SES may be difficult to overcome.11–14 By contrast, in settings where race-specific SES differences are minimal (including the current study), it has been suggested that important health indicators are quite similar by race.15–17 Individual-level SES aside, neighborhood-level SES has also been reported to influence mortality rates,18 but fewer investigations have assessed the joint contribution of individual and neighborhood SES,19–22 and analyses assessing the interplay of these 2 SES domains with race are rare.19,21We thus took the opportunity, within a large prospective study of non-Hispanic Black and White adults (residing in a large area of the United States, enrolled mainly in low-income settings but also non-low-income settings, and representing a range of SES levels), to evaluate the independent and joint contributions of race, individual SES, and neighborhood SES to overall and cause-specific mortality risk.     

Alcohol consumption in early adulthood and schooling completed and labor market outcomes at midlife by race and gender

Objectives. We assessed the relation of alcohol consumption in young adulthood to problem alcohol consumption 10 years later and to educational attainment and labor market outcomes at midlife. We considered whether these relations differ between Blacks and Whites.Methods. We classified individuals on the basis of their drinking frequency patterns with data from the 1982 to 1984 National Longitudinal Survey of Youth 1979 (respondents aged 19–27 years). We assessed alcohol consumption from the 1991 reinterview (respondents aged 26–34 years) and midlife outcomes from the 2006 reinterview (respondents aged 41–49 years).Results. Black men who consumed 12 or more drinks per week at baseline had lower earnings at midlife, but no corresponding relation for Black women or Whites was found. Black men and Black women who consumed 12 or more drinks per week at baseline had lower occupational attainment than did White male non-drinkers and White female non-drinkers, respectively, but this result was not statistically significant.Conclusions. The relation between alcohol consumption in young adulthood and important outcomes at midlife differed between Blacks and Whites and between Black men and Black women, although Blacks’ alcohol consumption at baseline was lower on average than was that of Whites.Alcohol consumption is relatively high among individuals in college or of college age.^1–4 The short-term consequences of heavy drinking—emergency room visits,⁵ intimate partner violence,^6–8 and motor vehicle fatalities,^9,10 among others—are well documented. With a few exceptions,^11,12 until recently a lack of longitudinal data has inhibited researchers’ ability to track events occurring much later in the life course that are associated with alcohol consumption levels in early adulthood.The alcohol consumption of Blacks tends to be similar to or less than that of Whites.^13–18 However, this generalization obscures more subtle differences. For one, there is less of a decline in alcohol consumption after the early 20s among Blacks than Whites.¹⁹Some studies, for example, of mortality and high-density lipoprotein cholesterol,^20,21 have supported a conclusion of no difference between Blacks and Whites in the relation between alcohol consumption and various outcomes. However, other studies, which focused on alcohol use in early adulthood and subsequent occupational attainment (an index of the occupation''s prestige), have found that heavy alcohol use in early adulthood is associated with lower occupational attainment in Blacks but not in Whites.^22,23 These results came from 1 longitudinal database—the Coronary Artery Risk Development in Young Adults study—which was drawn from residents of 4 geographically disperse US cities.Race is a social, not a biological, construct. There is substantially more variation genetically within than among racial categories.²⁴ Yet previous research has documented racial differences in psychosocial factors, which are highly correlated with both baseline drinking and long-term drinking trajectories.^19,23,25,26 Important differences in outcomes among Blacks versus Whites have also been reported.^{22,23,27–29}We investigated the relations of alcohol consumption to educational attainment and labor market outcomes at midlife and how these relations differ between Blacks and Whites. We used national longitudinal data from the National Longitudinal Survey of Youth 1979 (NLSY79) to assess (1) whether there are relations between an individual alcohol consumption level at 19 to 27 years of age and various outcomes at later stages in the life course (alcohol consumption, abuse, and dependence; educational attainment; occupational attainment; and earnings), and (2) whether these relations differ between Blacks and Whites in the full sample and when stratified by gender.     

Perceived Discrimination and DSM-IV–Based Alcohol and Illicit Drug Use Disorders

Objectives. We examined the relationship between everyday and major discrimination and alcohol and drug use disorders in a nationally representative sample of African Americans and Black Caribbeans.Methods. With data from the National Survey of American Life Study, we employed multivariable logistic regression analyses—while controlling for potential confounders—to examine the relationship between everyday and major discrimination and substance use disorders on the basis of Diagnostic and Statistical Manual of Mental Disorders criteria.Results. Every 1 unit increase in the everyday discrimination scale positively predicted alcohol (odds ratio [OR] = 1.02; P < .01) and drug use (OR = 1.02; P < .05) disorders. Similarly, each additional major discrimination event positively predicted alcohol (OR = 1.10; P < .05) and drug use (OR = 1.15; P < .01) disorders.Conclusions. To our knowledge, this study is the first to examine problematic usage patterns rather than infrequent use of alcohol and drugs in a national sample of African American and Black Caribbean adults and the first to examine this particular relationship in a national sample of Black Caribbeans.Alcohol and drug abuse and dependence are risky health behaviors not only to the individuals who engage in these behaviors and their loved ones but also to society. Estimates from the 2000 National Survey on Drug Use and Health suggest that of persons aged 18 years or older, approximately 12.7 million (6.3%) were either dependent on or abused both alcohol and illicit drugs, 3.3 million (1.6%) were dependent on or abused illicit drugs but not alcohol, and 10.9 million (5.5%) were dependent on or abused alcohol but not illicit drugs.1 It is estimated that the overall economic cost of substance abuse in 1992 was $246 billion2 and in 2001 $414 billion.3 Psychoanalytically informed hypotheses, like the self-medication hypothesis, suggest that substance use and abuse are self-soothing behaviors among some individuals who are psychologically distressed. Individuals may use or abuse substances such as alcohol, cigarettes, and illicit and licit drugs to manage emotional pain and anxiety to achieve emotional stability.4–8On the basis of these stress-coping frameworks, a small number of studies suggests that perceived experiences of interpersonal discrimination, a psychosocial stressor, are associated with various risky health behaviors.9,10 Specifically, previous studies posit that in response to perceived experiences of interpersonal discrimination (“discrimination”), some individuals may engage in risky coping behaviors such as alcohol,11–13 tobacco,13–18 and prescribed19 and illicit drug use.13,19 Yen et al.,11,12 for example, showed that Whites who experienced racial/ethnic discrimination (e.g., at school, getting a job) in 5 or more domains consumed more alcoholic drinks than did peers who had not experienced discrimination. Using the CAGE questionnaire,20 Martin et al.21 showed that African American adults who experienced racial/ethnic discrimination were twice as likely to have a problematic drinking behavior as were African Americans who reported no discrimination. Similarly, using a standardized survey for mental illness diagnosis derived from the Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised (DSM-III-R) criteria, Gee et al.19 reported that Filipino Americans who experienced chronic discrimination were more likely to be dependent on alcohol. With regard to tobacco use, similar to other studies,16,17 Landrine and Klonoff14 reported that African Americans who experienced racial/ethnic discrimination and appraised their experiences as more stressful were more likely to smoke cigarettes than were African Americans who did not report discrimination. Beyond alcohol and tobacco use, recent investigations have reported positive associations between discrimination and licit (e.g., medically prescribed medication) and illicit (e.g., marijuana) drug abuse.13,19 Specifically, Borrell et al.13 reported that racial discrimination was associated with increased lifetime use of marijuana and cocaine among African Americans but not among Whites. Gee et al.19 reported that discrimination was positively associated with the usage of illicit drugs among Filipino American adults. Although these studies are not directly comparable, taken together they suggest a relationship between experiences of discrimination and substance use.Despite a growing literature base in this area, our understanding of the relationship between discrimination and clinically diagnosed alcohol and drug use disorders is limited. Although most will agree that alcohol use and illicit drug use (regardless of frequency and quantity) are potential health risk behaviors, infrequent usage patterns, such as those currently studied in most of the published literature, may not indicate the damaging behavior patterns that are associated with a clinical diagnosis of abusing or being dependent on alcohol or drugs, such as recurrently driving an automobile when impaired or continued drinking despite knowledge of a serious physical or psychological problem.22Using the 2001 National Study of American Life (NSAL), we aimed to extend previous research in 2 important ways. The first concerns the generalizability of the current findings in this area. We are aware of only 1 study that has examined problematic usage patterns of alcohol use and none examining problematic drug usage among African Americans.19,21 In a sample of employed African Americans, Martin et al.18 showed that discrimination was positively associated with problematic drinking behavior; however, the sample was not representative of the general population of African Americans in the United States. To date, we are unaware of any studies that have examined the relationship between discrimination and substance use disorders among Black Caribbeans, the second largest subgroup of Blacks living in the United States. To fill these gaps, we examined the relationship between discrimination and alcohol and illicit drug use disorders in a nationally representative sample of African Americans and Black Caribbeans, 2 groups that traditionally report relatively high levels of discrimination.23–25 We subsequently examined whether interpersonal discrimination was related to the co-occurrence of alcohol and drug use disorders, given that alcohol and drug use disorders often co-occur.26–29     

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.     

Factors Explaining Racial/Ethnic Disparities in Rates of Physician Recommendation for Colorectal Cancer Screening

Objectives. Physician recommendation plays a crucial role in receiving endoscopic screening for colorectal cancer (CRC). This study explored factors associated with racial/ethnic differences in rates of screening recommendation.Methods. Data on 5900 adults eligible for endoscopic screening were obtained from the National Health Interview Survey. Odds ratios of receiving an endoscopy recommendation were calculated for selected variables. Planned, sequenced logistic regressions were conducted to examine the extent to which socioeconomic and health care variables account for racial/ethnic disparities in recommendation rates.Results. Differential rates were observed for CRC screening and screening recommendations among racial/ethnic groups. Compared with Whites, Hispanics were 34% less likely (P < .01) and Blacks were 26% less likely (P < .05) to receive this recommendation. The main predictors that emerged in sequenced analysis were education for Hispanics and Blacks and income for Blacks. After accounting for the effects of usual source of care, insurance coverage, and education, the disparity reduced and became statistically insignificant.Conclusions. Socioeconomic status and access to health care may explain major racial/ethnic disparities in CRC screening recommendation rates.Colorectal cancer (CRC) is the third most common cause of cancer death in the United States and a major cause of cancer morbidity.1 Annually in the United States, an estimated 150 000 people are diagnosed and 50 000 people die from this disease.2 With early detection and removal of precancerous polyps, CRC can be preventable, with a 5-year survival rate as high as 90%.3,4Current CRC screening guidelines consist of sigmoidoscopy every 5 years and colonoscopy every 10 years for those aged 50 to 75 years.4 Although an annual fecal occult blood test is also recommended, sigmoidoscopy and colonoscopy have higher sensitivity and specificity for the detection of cancerous lesions.5 Sensitivity ranges from 25% to 87% for fecal occult blood test, compared with 92% to 95% for endoscopy (sigmoidoscopy and colonoscopy).6 Colonoscopy, the most widely used test for CRC detection and prevention, is considered the gold standard because it can detect and remove precancerous polyps, and a positive result from any other screening test must be followed by this advanced modality.1,7,8 Endoscopy has played a major role in the decreasing trend of CRC mortality in the United States9,10Still, minority groups—especially Blacks—carry a disproportionately higher CRC burden.1,11 From the 1980s to 2007—a period of advance in early detection and treatment—the inequality between Blacks and Whites increased to a 44% difference in CRC mortality rates.1 This disparity could be attributable in part to the fact that, compared with Whites, members of racial/ethnic minority groups were less likely to be screened and diagnosed at the localized, more treatable stage of CRC.1 These lower screening rates partially account for the higher rates of late stage detection and subsequent increases in CRC morbidity and mortality rates among racial/ethnic minorities and low-income populations.1,10,12 Thus, it is necessary to promote utilization of effective screening methods, such as endoscopy, to detect CRC in its early stages, especially among minority groups.Trends in CRC screening from 1992 to 2005 show widening gaps between Whites and minority groups: the disparity increased to 10.3% for Blacks and to 20.5% for Hispanics.13,14 Lower rates of cancer screening, including CRC screening, have been strongly associated with lower rates of physician recommendation, particularly among low-income populations, racial/ethnic minority groups, and women.15,16The health care provider’s role in CRC screening is essential because a physician recommendation is necessary for endoscopic screening.17,18 A study found that more than 90% of people who did not undergo endoscopic screening reported not receiving the necessary recommendation.16 A systematic review discovered that patients identified physician recommendation as the sole CRC-screening facilitator and absence of recommendation as the only barrier.19 It is thus crucial to identify factors that influence the likelihood of receiving a CRC screening recommendation.The present study seeks to build on the work of 2 previous analyses of CRC-screening barriers and predictors among respondents to the 2000 National Health Interview Survey (NHIS). Seeff et al. found that “frequent doctor visits in the past year” was the strongest predictor of CRC screening.20 Among the barriers, a “lack of awareness of the need to be screened” was most common, followed by “not receiving a physician recommendation.”20 In bivariate analysis, Coughlin and Thompson found that, among screening-eligible adults who had visited a physician in the past year, members of racial/ethnic minority groups were less likely than Whites to receive an endoscopy recommendation.21 The study mainly focused on reasons for having CRC screenings.We used multivariate analyses and planned sequenced logistic regression to explore patient factors that may explain unequal rates of physician recommendation for endoscopy among Blacks and Hispanics compared with Whites. Factors deemed to have relative importance in terms of statistical significance may help indicate areas of intervention to improve rates of physician recommendation for CRC screening in disadvantaged populations.     

The association between perceived discrimination and obesity in a population-based multiracial and multiethnic adult sample

Objectives. We examined whether perceived chronic discrimination was related to excess body fat accumulation in a random, multiethnic, population-based sample of US adults.Methods. We used multivariate multinomial logistic regression and logistic regression analyses to examine the relationship between interpersonal experiences of perceived chronic discrimination and body mass index and high-risk waist circumference.Results. Consistent with other studies, our analyses showed that perceived unfair treatment was associated with increased abdominal obesity. Compared with Irish, Jewish, Polish, and Italian Whites who did not experience perceived chronic discrimination, Irish, Jewish, Polish, and Italian Whites who perceived chronic discrimination were 2 to 6 times more likely to have a high-risk waist circumference. No significant relationship between perceived discrimination and the obesity measures was found among the other Whites, Blacks, or Hispanics.Conclusions. These findings are not completely unsupported. White ethnic groups including Polish, Italians, Jews, and Irish have historically been discriminated against in the United States, and other recent research suggests that they experience higher levels of perceived discrimination than do other Whites and that these experiences adversely affect their health.It is estimated that 2 of every 3 adults in the United States are overweight or obese.^1,2 Obesity is a major risk factor for chronic health conditions, such as type 2 diabetes, coronary heart disease, hypertension, stroke, some forms of cancer, and osteoarthritis.³ Although it is widely accepted that high-fat diets and physical inactivity are preventable risk factors,⁴ obesity continues to increase.^1,2,5There is a growing interest in the relationship between psychosocial risk factors and excess body fat accumulation.^6–16 In particular, some evidence suggests that psychosocial stressors may play a role in disease progression in general and in excess body fat in particular.^7,8,17 The key factors underlying physiological reactions to psychosocial stress have not been completely elucidated, but McEwen and Seeman¹⁷ and others^7,18,19 posit that the continued adaptation of the physiological system to external challenges alters the normal physiological stress reaction pathways and that these changes are related to adverse health outcomes.^8,17,18,20 For example, in examining the association between psychosocial stress and excess body fat accumulation, Björntorp and others have suggested that psychosocial stress is linked to obesity, especially in the abdominal area.^7,8Perceived discrimination, as a psychosocial stressor, is now receiving increased attention in the empirical health literature.^21–24 Such studies suggest perceived discrimination is inversely related to poor mental and physical health outcomes and risk factors, including hypertension,^24,25 depressive symptoms,^26–28 smoking,^29–31 alcohol drinking,^32,33 low birthweight,^34,35 and cardiovascular outcomes.^36–38Internalized racism, the acceptance of negative stereotypes by the stigmatized group,³⁹ has also been recognized as a race-related psychosocial risk factor.⁴⁰ Recent studies have also suggested that race-related beliefs and experiences including perceived discrimination might be potentially related to excess body fat accumulation. Three of these studies^9,13,41 showed that internalized racism was associated with an increased likelihood of overweight or abdominal obesity among Black Caribbean women in Dominica⁴¹ and Barbados¹³ and adolescent girls in Barbados.⁹ These researchers posit that individuals with relatively high levels of internalized racism have adopted a defeatist mindset, which is believed to be related to the physiological pathway associated with excess body fat accumulation. However, Vines et al.¹⁶ found that perceived racism was associated with lower waist-to-hip ratios among Black women in the United States. Although the assessment of race-related risk factors varied across these studies, the findings suggest that the salience of race-related beliefs and experiences may be related to excess body fat accumulation.Collectively, the results of these studies are limited. First, because they examined the relationship between race-related beliefs and experiences and excess body fat only among women, we do not know if this relationship is generalizable to men.^13,16,41 Second, these studies only examined this relationship among Blacks, even though perceived unfair treatment because of race/ethnicity has been shown to be adversely related to the health of multiple racial/ethnic population groups in the United States^42–49 and internationally.^27,50–55 Third, none of the studies have examined the relationship between excess body fat accumulation and perceived nonracial/nonethnic experiences of interpersonal discrimination. Some evidence suggests that the generic perception of unfair treatment or bias is adversely related to health, regardless of whether it is attributed to race, ethnicity, or some other reason.^45,55,56 Fourth, none of these studies included other measures of stress. We do not know if the association between race-related risk factors and obesity is independent of other traditional indicators of stress.Using a multiethnic, population-based sample of adults, we examined the association of perceived discrimination and obesity independent of other known risk factors for obesity, including stressful major life events. Additionally, because reports of perceived racial/ethnic discrimination and non-racial/ethnic discrimination vary by racial/ethnic groups^24,45,46,57 and because Whites tend to have less excess body fat than do Blacks and Hispanics,^1,3 we examined the relationships between perceived discrimination and excess body fat accumulation among Hispanics, non-Hispanic Whites, and non-Hispanic Blacks.     

Discrimination and Cumulative Disease Damage Among African American Women With Systemic Lupus Erythematosus

Objectives. We examined associations between unfair treatment, attributions of unfair treatment to racial discrimination, and cumulative disease damage among African American women with systemic lupus erythematosus (SLE).Methods. We used multivariable regression models to examine SLE damage among 578 African American women in metropolitan Atlanta, Georgia, recruited to the Georgians Organized Against Lupus cohort.Results. When we controlled for demographic, socioeconomic, and health-related covariates, reporting any unfair treatment was associated with greater SLE damage compared with reporting no unfair treatment (b = 0.55; 95% confidence interval = 0.14, 0.97). In general, unfair treatment attributed to nonracial factors was more strongly associated with SLE damage than was unfair treatment attributed to racial discrimination, although the difference was not statistically significant.Conclusions. Unfair treatment may contribute to worse disease outcomes among African American women with SLE. Unfair treatment attributed to nonracial causes may have a more pronounced negative effect on SLE damage. Future research may further examine possible differences in the effect of unfair treatment by attribution.Systemic lupus erythematosus (SLE) is a multisystem, chronic autoimmune disorder marked by considerable racial disparities in prognosis. In addition to having a greater prevalence of SLE, African American women are more frequently affected by organ damage and comorbid conditions that emerge as a consequence of disease activity and disease-related chronic inflammation and tissue damage.1–3 The prevalence of renal and cardiovascular damage in SLE is higher among African Americans than Whites, and African Americans with SLE suffer these complications at earlier ages.4,5 African Americans with SLE have overall mortality rates that are up to 3 times higher than for Whites and also disproportionately suffer from premature mortality.6,7 Although research on the causes of these divergent outcomes is in its infancy, evidence suggests that genetic and behavioral factors, including differences in access to care, detection, and treatment do not entirely account for racial disparities in SLE.8,9There is increasing interest in broader stressors tied to racial minority status, including unfair treatment and discrimination experienced systematically along racial lines, as social determinants of disease susceptibility and progression among African Americans.10,11 These experiences include everyday forms of racially motivated unfair treatment, such as instances of being treated with less courtesy or respect or of receiving poorer service.12 These social insults are commonly reported as salient sources of psychosocial stress, particularly among African American women, who in addition to contending with the immediate psychological and physical consequences of such experiences have also expressed heightened vigilance in anticipation of being treated unfairly.13Discrimination may lead to greater disease burden by undermining psychological adjustment, as well as through maladaptive behavioral coping responses such as smoking, problem alcohol consumption, and other risk-taking behaviors.14–17 Repetitive experiences of racism-related stressors may also lead to premature physiological deterioration directly through its effects on biological systems engaged in the stress response.18–20 Stress stimulates a cascade of biochemical reactions mediated by the hypothalamic–pituitary–adrenal axis and the sympathetic nervous system, and it can accelerate disease progression by leading to “wear and tear” of the organism, ultimately compromising the body’s ability to effectively respond to such challenges.21,22 Repeated and more severe forms of psychosocial stress result in chronically elevated levels of proinflammatory cytokines and acute-phase proteins, and in a heightened inflammatory state.23Discrimination can exacerbate disease progression via these biological channels, and it has been associated with a range of indicators of oxidative stress and inflammation.23–28 Accordingly, discrimination may have negative consequences for SLE, which is characterized by elevated serum concentration of several biomarkers of inflammation, including interleukin-6, interleukin-1, C-reactive protein, and tumor necrosis factor, which in turn have been linked to greater disease activity.29–32 However, findings on the association between discrimination and health outcomes have been equivocal, with some studies finding no significant association and others reporting curvilinear or inverse associations.11,33–39 These inconsistent findings may be attributable to the ways in which researchers have operationalized discrimination. For example, whereas some studies have explicitly focused on discrimination attributed to racial causes, others have examined unfair treatment without an explicit motivational component.40–42 There is evidence suggesting that the magnitude of the association between unfair treatment and health outcomes may differ according to whether such experiences are perceived as being motivated by racial factors versus nonracial causes.43–46 Some studies have found that reports of general unfair treatment and stress have stronger associations with health indicators than reports of racial discrimination specifically.44,46,47In summary, although there is some evidence that unfair treatment may have negative consequences for SLE progression, there are no studies to our knowledge that have explicitly examined this relationship. Furthermore, studies examining other health outcomes have found mixed evidence for the health consequences of unfair treatment in general versus racial discrimination. We examined whether self-reports of unfair treatment are associated with cumulative disease damage among African American women with SLE. Additionally, we explored potential differences between unfair treatment attributed to nonracial factors versus racial discrimination.     

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     

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

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

Experiences and Perceptions of Medical Discrimination Among a Multiethnic Sample of Breast Cancer Patients in the Greater San Francisco Bay Area,California

Objectives. We conducted qualitative interviews with breast cancer survivors to identify themes related to institutional, personally mediated, and internalized discrimination in the medical setting.Methods. We conducted 7 focus groups and 23 one-on-one interviews with a multiethnic sample of breast cancer survivors randomly selected from a population-based registry covering the Greater San Francisco Bay Area, California.Results. Participants reported experiencing different forms of medical discrimination related to class, race, and language. Among African Americans, participants reported experiencing internalized discrimination and personal or group discrimination discrepancy—perceiving discrimination against them as a racial/ethnic group, yet not perceiving or discussing personal experiences of discrimination. Among Asian immigrants, participants reported experiencing institutional and personally mediated overt types of discrimination, including lack of access to quality and readily available translation services. Our results also indicated well-established coping mechanisms in response to discrimination experiences in both groups.Conclusions. Participants reported experiencing medical discrimination at all 3 levels, which may have deleterious health effects through the biopsychosocial stress pathway and through active coping mechanisms that could lead to delayed- or underutilization of the health care system to avoid discrimination.Breast cancer is the cancer most commonly diagnosed among women in the United States.1 Racial/ethnic disparities in the survivorship experience, including diagnosis, treatment, quality-of-life, and survival, have been documented.2–5 For example, breast cancer survival differences between African Americans and non-Hispanic Whites are among the most striking and consistent of health disparities.1 Research also suggests that certain racial/ethnic groups like African Americans, Latinas, and Asians are more likely to be diagnosed with late-stage disease.6–9 However, prognostic factors including socioeconomic status, access to care, and biological factors, to the extent that they have been examined, do not fully explain the observed differences.10 Research frameworks encompassing a multilevel framework that considers the interactions among social and biological factors, within a historical and ecological perspective (i.e., a socio-ecological framework ¹¹) are needed to examine underlying institutional and societal forces that contribute to health disparities.12There has been a growing interest in examining health impacts from discrimination,13 the process by which members of a defined social group are treated unfairly because of their membership in that group.14 For example, studies have suggested that racial minorities receive fewer referrals for specialty services and poorer quality health care than Whites, after controlling for a number of confounders including socioeconomic status, gender, age, health insurance, and stage of illness.15–17 Studies suggest that some of this may be the result of provider prejudice and medical mistrust on the part of the patient.15,16,18At least 3 pathways have been proposed by which discrimination may impact health. First, discrimination can lead to socioeconomic inequities, which can affect health (e.g., compromising access to care and quality of care and causing disproportionate environmental exposures to toxins). Second, discrimination can increase chronic stress. Chronic and severe social stress trigger the stress-response system, activating adaptive physiologic mechanisms, which, over time, degrades the body’s ability to properly regulate biological systems, resulting in adverse health consequences.19,20 Increasingly, studies have shown that exposure to racial discrimination is associated with numerous physiological disturbances,21 including overcirculation of stress hormones,22 which, among other outcomes, is linked to an uninhibited inflammatory response.23 Chronic inflammation has been associated with breast cancer recurrence and mortality.24Third, discrimination can restrict access to goods and services. Discrimination experienced in health care settings may inadvertently influence individuals to avoid using needed health care.25 The psychological model of stigma-induced identity threat posits that an individual who has experienced discrimination that threatens his or her identity will have involuntary responses (e.g., anxiety and vigilance).26 In turn, the individual may engage in a variety of voluntary coping mechanisms, including engagement (i.e., fight) or disengagement (i.e., flight) strategies. In accordance with the disengagement strategy, an individual who has experienced discrimination may avoid mainstream institutions, such as the health care system, where they fear they may be discriminated against. African Americans, Latinos, and Asians have been found to report more medical mistrust27 and provider discrimination, which is associated with lower satisfaction with care28,29 and delayed health utilization.30 Some studies have found an association among perceived discrimination, screening mammography,31,32 and health care utilization.33,34 As mentioned previously, discrimination may also restrict health care services because of provider bias and differences in referral for specialty services.16,18Whereas there is growing research on the subject of whether discrimination influences health,21,35–42 few studies have investigated the link between discrimination and breast cancer,43 although plausible links are evident. To our knowledge, no studies have investigated the extent of medical discrimination among breast cancer patients.We applied a multilevel concept of discrimination based on Jones’⁴⁴ 3-level framework for understanding racism, in which institutionalized racism is defined as the structural and differential access to goods, services, and opportunities within a society; personally mediated racism encompasses differential assumptions about and actions toward others on the basis of race; and internalized racism is the acceptance of negative assumptions about their own abilities and worth by members of the stigmatized group. The intent of this qualitative research was to explore experiences of medical discrimination among breast cancer patients that would inform future research aimed at understanding the impact of discrimination on breast cancer outcomes.