Do measures matter? Comparing surface-density-derived and census-tract-derived measures of racial residential segregation

Background  

Racial residential segregation is hypothesized to affect population health by systematically patterning health-relevant exposures and opportunities according to individuals' race or income. Growing interest into the association between residential segregation and health disparities demands more rigorous appraisal of commonly used measures of segregation. Most current studies rely on census tracts as approximations of the local residential environment when calculating segregation indices of either neighborhoods or metropolitan areas. Because census tracts are arbitrary in size and shape, reliance on this geographic scale limits understanding of place-health associations. More flexible, explicitly spatial derivations of traditional segregation indices have been proposed but have not been compared with tract-derived measures in the context of health disparities studies common to social epidemiology, health demography, or medical geography. We compared segregation measured with tract-derived as well as GIS surface-density-derived indices. Measures were compared by region and population size, and segregation measures were linked to birth record to estimate the difference in association between segregation and very preterm birth. Separate analyses focus on metropolitan segregation and on neighborhood segregation.     

A multi-group path analysis of the relationship between perceived racial discrimination and self-rated stress: how does it vary across racial/ethnic groups?

Objective: The objective of this study was to answer three questions: (1) Is perceived discrimination adversely related to self-rated stress via the social capital and health care system distrust pathways? (2) Does the relationship between perceived discrimination and self-rated stress vary across race/ethnicity groups? and (3) Do the two pathways differ by one’s race/ethnicity background?

Design: Using the Philadelphia Health Management Corporation’s Southeastern Pennsylvania Household Survey, we classified 9831 respondents into 4 race/ethnicity groups: non-Hispanic White (n?=?6621), non-Hispanic Black (n?=?2359), Hispanic (n?=?505), and non-Hispanic other races (n?=?346). Structural equation modeling was employed to simultaneously estimate five sets of equations, including the confirmatory factor analysis for both social capital and health care distrust and both direct and indirect effects from perceived discrimination to self-rated stress.

Results: The key findings drawn from the analysis include the following: (1) in general, people who experienced racial discrimination have higher distrust and weaker social capital than those without perceived discrimination and both distrust and social capital are ultimately related to self-rated stress. (2) The direct relationship between perceived discrimination and self-rated stress is found for all race/ethnicity groups (except non-Hispanic other races) and it does not vary across groups. (3) The two pathways can be applied to non-Hispanic White and Black, but for Hispanic and non-Hispanic other races, we found little evidence for the social capital pathway.

Conclusions: For non-Hispanic White, non-Hispanic Black, and Hispanic, perceived discrimination is negatively related to self-rated stress. This finding highlights the importance of reducing interpersonal discriminatory behavior even for non-Hispanic White. The health care system distrust pathway can be used to address the racial health disparity in stress as it holds true for all four race/ethnicity groups. On the other hand, the social capital pathway seems to better help non-Hispanic White and Black to mediate the adverse effect of perceived discrimination on stress.     

Are state patterns of smoking different for different racial/ethnic groups? an application of multilevel analysis

OBJECTIVES: Tobacco use research has often assumed "average" effects across place, race, and socioeconomic position. We explored and mapped the variation in smoking prevalence for racial/ethnic groups by gender and state after adjusting for demographic factors. METHODS: We executed a cross-sectional, weighted, two-level multilevel multiple regression analysis (individuals in states), with current smoking as the outcome, using the 1995-1996 Current Population Survey Tobacco Use Supplement, for non-Hispanic (NH) whites, NH blacks, and Hispanics. We also calculated adjusted smoking prevalence, 95% confidence intervals, Spearman correlations, and state residual-based maps to examine state patterns. RESULTS: We found different smoking patterns for each racial group. Black women's smoking rates were markedly lower than the national subgroup rate in six clustered states in the deep South. Smoking rates for whites were higher than the subgroup national rate in several Great Lakes states, Texas, Nevada, and North Carolina. For white women, several rural Midwest states displayed lower-than-expected smoking rates (Idaho, Utah, South Dakota, and Nebraska). We documented positive correlations for smoking prevalence between men and women within each racial group, but not between racial groups, indicating a race-specific pattern of smoking. We found that state tobacco variables (taxation and agriculture) did not account for remaining state smoking variance after inclusion of demographic variables. CONCLUSION: Multilevel modeling may enhance surveillance of tobacco use patterns. Focusing on race-specific state smoking patterns may illuminate why racial/ethnic minority groups exhibit lower smoking prevalence compared to their white counterparts, by examining context of smoking that may be race-specific.     

Communities of color? Client-to-client racial concordance in the selection of mental health programs for Caucasians and African Americans

A discrete-choice logit model was applied to study the determinants of mental health provider choice using data from a large urban county in the Northeast US. The study subjects were 9,544 adult Medicaid recipients who received outpatient treatment from the 20 Community Mental Health Center (CMHC) programs in 2001. In addition to a conventional set of variables representing client and provider characteristics, the regression model included several interaction terms to examine whether racial concordance level among patients influences the choice of an outpatient program. The results revealed that racial concordance among the clients seems to be a factor in choosing a program. In particular, Caucasian clients are much more likely to select a program with a higher percentage of Caucasian clients, even though they have to travel further. More generally, our results suggest that program choice may be driven more by the racial composition of the clients served than by spatial proximity to the program.     

Searching for chronic hepatitis B patients in a low prevalence area – role of racial origin

Background

Clinical studies for testing new drugs against hepatitis B ought to be carried out in low prevalence areas despite difficulties on patient recruitment. In such areas, relatives of chronic hepatitis B patients are considered to be at risk of acquiring the hepatitis B virus (HBV). The aim of this study was to evaluate the prevalence of HBV markers (anti-HBc, HBsAg and anti-HBs) in familial members of chronic hepatitis B (CHB) patients according to their origin (Asian or Western) in a low prevalence area, the city of São Paulo, Brazil.

Methods

Twenty three Asian CHB probands and their 313 relatives plus 31 CHB probands of Western origin and their 211 relatives were screened for HBV serological markers; the study was carried out in the outpatient clinic of the University of São Paulo School of Medicine.

Results

Mother to child transmission was greater in the Asian group whereas sexual transmission was more frequent in the Western group (p < 0.0001). Anti-HBc was positive in 90% and 57% of the Asian and Western parents (p = 0.0432) and in 97% and 33% of the Asian and Western brothers (p = 0.0001), respectively. HBsAg was more frequent among the Asian (66%) than the Western (15%) mothers (p = 0.0260) as well as among the Asian (81%) than the Western (19%) brothers (p = 0.0001). We could detect 110 new HBsAg-positive subjects related to the 54 index patients, being the majority (81%) of Asian origin.

Conclusion

In low prevalence area of hepatitis B, family members and household contacts of chronic HBV carriers are at high risk for acquiring hepatitis B.

     

Distribution of African Americans in residential care/assisted living and nursing homes: more evidence of racial disparity?

OBJECTIVES: In this study, we examined racial separation in long-term care. METHODS: We used a survey of a stratified sample of 181 residential care/assisted living (RC/AL) facilities and 39 nursing homes in 4 states. RESULTS: Most African Americans resided in nursing homes and smaller RC/AL facilities and tended to be concentrated in a few predominantly African American facilities, whereas the vast majority of Whites resided in predominantly White facilities. Facilities housing African Americans tended to be located in rural, nonpoor, African American communities, to admit individuals with mental retardation and difficulty in ambulating, and to have lower ratings of cleanliness/maintenance and lighting. CONCLUSIONS: These racial disparities may result from economic factors, exclusionary practices, or resident choice. Whether separation relates to inequities in care is undetermined.     

Does health predict the reporting of racial discrimination or do reports of discrimination predict health? Findings from the National Longitudinal Study of Youth

Racial discrimination may contribute to diminished well-being, possibly through stress and restricted economic advancement. Our study examines whether reports of racial discrimination predict health problems, and whether health problems predict the reporting of racial discrimination. Data come from years 1979 to 1983 of the US National Longitudinal Study of Youth, focusing on respondents of Black (n = 1851), Hispanic (n = 1170), White (n = 3450) and other (n = 1387) descent. Our analyses indicate that reports of racial discrimination in seeking employment predict health-related work limitations, although these limitations develop over time, and not immediately. We also find that reports of discrimination at two time-points appear more strongly related to health-related work limitations than reports at one time-point. A key finding is that these limitations do not predict the subsequent reporting of racial discrimination in seeking employment. These findings inform our knowledge of the temporal ordering of racial discrimination in seeking employment and health-related work conditions among young adults. The findings also indicate that future research should carefully attend to the patterns and timing of discrimination.     

Illustrating a “consequential” shift in the study of health inequalities: a decomposition of racial differences in the distribution of body mass

Purpose

We present a conceptual introduction to “distributional inequalities”—differences in distributions of risk factors or other outcomes between social groups—as a consequential shift for research on health inequalities. We also review a companion analytical methodology, “distributional decomposition”, which can assess the population characteristics that explain distributional inequalities.

Does Medicare coverage of colonoscopy reduce racial/ethnic disparities in cancer screening among the elderly?

Racial and ethnic disparities in colorectal cancer screening have been documented extensively in the literature. In July 2001 Medicare began covering colonoscopy for average-risk beneficiaries. We examined the effect of Medicare reimbursement on the rate and disparity of colorectal cancer screening among the elderly in the United States. This policy alleviated the screening disparity between non-Hispanic whites and blacks, but the gap between Hispanics and non-Hispanic whites has widened. Overall, fewer than half of the elderly are screened, even though Medicare now covers colonoscopy.     

Trends in racial/ethnic disparities of new AIDS diagnoses in the United States, 1984–2013

PurposeIn the United States, human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS) disproportionately impacts racial/ethnic minorities. We describe and evaluate trends in the Black-White and Hispanic-White disparities of new AIDS diagnoses from 1984 to 2013 in the United States.MethodsAIDS diagnosis rates by race/ethnicity for people ≥13 years were calculated using national HIV surveillance and Census data. Black-White and Hispanic-White disparities were measured as rate ratios. Joinpoint Regression was used to identify time periods across which to estimate rate-ratio trends. We calculated the estimated annual percent change in disparities for each time period using log-normal linear regression modeling.ResultsBlack-White disparity increased from 1984 to 1990, followed by a large increase from 1991 to 1996, and a smaller increase from 1997 to 2001. Black-White disparity moderated from 2002 to 2005 and rose again from 2006 to 2013. Hispanic-White disparity increased from 1984 to 1997 but declined after 1998. Black-White and Hispanic-White disparities increased for men who have sex with men during 2008 to 2013.ConclusionsRecent increases in racial/ethnic disparities of AIDS diagnoses were observed and may be due in part to care continuum inequalities. We suggest assessing disparities in AIDS diagnoses as a high-level measure to capture changes at multiple stages of the care continuum collectively. Future research should examine determinants of racial/ethnic differences at each step of the continuum to better identify characteristics driving disparities.     

Are there racial differences in attitudes toward hospice care? A study of hospice-eligible patients at the Visiting Nurse Service of New York

Research on African American and white attitudes, perceptions, and knowledge of hospice care has focused predominantly on patients and providers in institutions and community-based care settings. Little is known about patients receiving home health services, despite growing trends toward noninstitutional care in the United States. This study of home health clients who are eligible for hospice, but not currently receiving it, found few differences between racial groups with regard to attitudes about end-of-life care. An alarming proportion of African American and white home health clients held erroneous ideas about hospice care and had not discussed this option with their providers. These findings suggest that increased referrals to home-based hospice care among home health clients depend on the availability and professional dissemination of accurate, spiritually sensitive information.     

Can racial disparity in health between black and white americans be attributed to racial disparities in body weight and socioeconomic status?

Few studies have examined to what extent racial disparities in chronic health conditions (CHCs) are attributable to racial differences in body weight (measured as body mass index [BMI]) and socioeconomic status (SES) among older adults. To address this gap, using longitudinal data from the Health and Retirement Study, the current study examined risk factors of CHC trajectory including race, BMI, and SES. The sample consists of 22,560 in 1998, 20,825 in 2000, and 19,004 in 2002. Data analysis was done through latent growth curve modeling. As expected, older adults presented an increasing trajectory of CHCs over time. Black Americans presented a significantly more negative CHC trajectory than did their white counterparts, confirming racial disparity in health over time. Consequent hierarchical analyses revealed that racial disparity in CHC trajectory can be explained by racial disparity in BMI and that racial disparity in BMI can be attributed to racial disparity in SES. Because low SES is closely related to unhealthy diet and negative health behaviors that may subsequently lead to obesity and chronic health conditions, the findings suggest that to address racial disparity in CHCs, it is important for social workers to continuously try to mitigate racial inequality in SES.     

Are racial disparities in health conditional on socioeconomic status?

Racial health inequality is related to socioeconomic status (SES), but debate ensues on the nature of the relationship. Using the US National Health and Nutrition Examination Survey I and the subsequent follow-up interviews, this research examines health disparities between white and black adults and whether the SES/health gradient differs across the two groups in the USA. Two competing mechanisms for the conditional or interactive relationship between race and SES on health are examined during a 20-year period for black and white Americans. Results show that black adults began the study with more serious illnesses and poorer self-rated health than white adults and that the disparity continued over the 20 years. Significant interactions were found between race and education as well as race and employment status on health outcomes. The interaction effect of race and education showed that the racial disparity in self-rated health was largest at the higher levels of SES, providing some evidence for the "diminishing returns" hypothesis; as education levels increased, black adults did not have the same improvement in self-rated health as white adults. Overall, the findings provide evidence for the continuing significance of both race and SES in determining health status over time.     

Do nonprofit HMOs eliminate racial disparities in cardiac care?

African-Americans have far less access to treatment for heart disease than similar white Americans. In this article, we explore the sector difference theory hypothesis that treatment provided by a nonprofit Medicaid managed care plan can reduce or even eliminate the race gap. Specifically, we compare the treatment offered to patients in for-profit Medicaid managed care programs to the treatment offered to similar patients in nonprofit Medicaid managed care programs. Data are from the Maryland Health Services Cost Review Commission and cover all patients discharged from hospitals in Maryland during calendar year 1998 with principal diagnoses indicating diseases of the circulatory system (ICD-9-CM codes 390 through 459) or chest pain (ICD-9-CM codes 786.50 through 786.52 and code 786.59). African-Americans were significantly less likely to receive the three treatments of interest, even after controlling for principal diagnosis, blood pressure, co-morbidities, and age. In regard to African-American access to treatment, there were no significant differences between the sectors.     

Patient–physician racial/ethnic concordance and blood pressure control: the role of trust and medication adherence

Objectives. To examine the associations between racial/ethnic concordance and blood pressure (BP) control, and to determine whether patient trust and medication adherence mediate these associations.

Design. Cross-sectional study of 723 hypertensive African-American and white patients receiving care from 205 white and African-American providers at 119 primary care clinics, from 2001 to 2005. Racial/ethnic concordance was characterized as dyads where both the patient and physician were of the same race/ethnicity; discordance occurred in dyads where the patient was African-American and the physician was white. Patient perceptions of trust and medication adherence were assessed with self-report measures. The BP readings were abstracted from patients' medical charts using standardized procedures.

Results. Six hundred thirty-seven patients were in race/ethnic-concordant relationships; 86 were in race/ethnic-discordant relationships. Concordance had no association with BP control. White patients in race/ethnic-concordant relationships were more likely to report better adherence than African-American patients in race/ethnic-discordant relationships (OR: 1.27, 95% CI: 1.01, 1.61, p = 0.04). Little difference in adherence was found for African-American patients in race/ethnic-concordant vs. discordant relationships. Increasing trust was associated with significantly better adherence (OR: 1.17, 95% CI: 1.04, 1.31, p < 0.01) and a trend toward better BP control among all patients (OR: 1.26, 95% CI: 0.97, 1.63, p = 0.07).

Conclusions. Patient trust may influence medication adherence and BP control regardless of patient–physician racial/ethnic composition.     

Are racial disparities in preterm birth larger in hypersegregated areas?

The causes of the racial/ethnic disparity in preterm birth (PTB) remain largely unknown; traditional risk factors such as smoking and prenatal care fail to account for it. The authors examined whether living in metropolitan areas (MAs) with high levels of residential racial segregation along multiple dimensions (hypersegregation) was associated with higher rates of PTB or larger racial disparities in PTB and whether segregation modified the established race-age association in PTB. The authors merged 2000 natality data (n = 1,944,703) with US Census measures of Black-White hypersegregation. They executed two-level hierarchical logistic regression analyses among White and Black mothers in 237 MAs to estimate the odds of PTB by hypersegregation, race, and age, after controlling for covariates. In unadjusted and adjusted models, Black infants in hypersegregated MAs were more likely to be preterm than Black infants in nonhypersegregated MAs (p < 0.001). Black-White PTB disparities were larger in hypersegregated areas than in nonhypersegregated areas (p < 0.001), and the age-race association with PTB was modified by hypersegregation (p < 0.001). Living in a hypersegregated MA had a more pronounced association with PTB among older Black women, and racial disparities in PTB were larger in hypersegregated areas among older mothers (p < 0.001). Since over 40% of Black childbearing women live in hypersegregated areas, residential segregation may be an important social determinant of racial birth disparities.