Why are African Americans under‐represented in medical research studies? Impediments to participation

Objectives. In accordance with the NIH Revitalization Act of 1993, the National Institutes of Health and the Alcohol, Drug and Mental Health Administration require grant applicants and cooperative agreement participants to include minorities in human subject research. In an environment characterized by diminishing research dollars, this mandate has increased the pressure on investigators to determine factors that impede minority participation and to develop strategies to overcome these impediments.

Methods. An extensive review of the literature was conducted to identify the factors possibly responsible for the low participation levels of African Americans in medical research studies and to highlight areas for further research. The items examined included the historical relationship between African Americans and medical researchers and the attitudes, perceptions and beliefs of potential participants and researchers as they relate to the low representation of African Americans in medical research.

Results. The factors identified as possible impediments to African American participation included distrust of the medical/scientific community, poor access to primary medical care, the failure of researchers to recruit African Americans actively, the alienation of minority health professionals, lack of knowledge about clinical trials, language and cultural barriers.

Conclusions. Well‐designed, relevant, ethical research in conjunction with an appreciation of the many barriers to participation are paramount to increasing African American presence in clinical research.     

Increased gallbladder‐related mortality among hispanics: Does education play a role?

Objective. Hispanics, particularly Mexican Americans, are known to have a higher incidence of mortalities whose underlying cause is a gallbladder‐related disorder. These analyses evaluate the role of educational attainment in the differential mortality experiences of these populations.

Methods. US mortality data for 1989–1991 were examined to determine ethnically‐specific death rates using ‘any mention’ of the disease on the death certificate.

Results. Age‐adjusted multiple cause mortality was found to be higher for all gallbladder‐related disorders among Hispanics, particularly Mexican Americans. Mortality due to gallbladder cancer, gallstones and ‘other gallbladder diseases’ were found to be inversely proportional to educational attainment in all ethnic groups. When both age and education were used to adjust mortality, the gallstone and other gallbladder disease mortality among Hispanics was non‐significantly higher than white, non‐Hispanics. However, mortality due to gallbladder cancer remained significantly higher among Hispanics.

Conclusion. Gallbladder cancer mortality is elevated in Hispanic populations, especially Mexican Americans, independent of educational attainment. However, increased mortality associated with gallstones or other gallbladder diseases among Hispanics may be partially due to differences in factors associated with educational attainment. Research and public health efforts to address these educational‐related factors may improve this mortality pattern among Hispanics.     

Gender and ethnic differences in the co-occurrence of adolescent risk behaviors

Design

Results

Conclusion

We consider gender and ethnic differences in the co-occurrence of adolescent behaviors related to health and well-being.

Using a nationally representative sample of adolescents in the National Longitudinal Survey of Youth (1997–2000), we examine behavior among students as well as school drop-outs. We use latent class models (LCMs) to identify subpopulations of adolescents with similar patterns of co-occurring behaviors. The generalizability of the findings for African American adolescents in the 1970s is considered using a sample of inner-city youth from the Pathways to Adulthood Survey.

For all ethnic groups, we find a subpopulation with ‘problem behavior’ characteristics (in which early sexual initiation, alcohol use, smoking, marijuana use, and truancy are all highly prevalent). This cluster is most common among European American adolescents and among young men. A subpopulation characterized by behaviors often leading to poor social outcomes (e.g. truancy, early sexual initiation and fighting) is most common for African American adolescents, especially young African American men.

Our findings suggest that multi-factorial interventions which address the interrelationships between all of the behaviors are relevant regardless of gender or ethnicity. However, the ethnic and gender differences in the likelihood of specific patterns of interrelationships highlight the importance of considering the ethnic and gender composition of a population when developing future research and interventions.     

Ethnicity is associated with alterations in oxytocin relationships to pain sensitivity in women

It is well established that African Americans (AA) experience greater pain associated with a variety of clinical conditions, and greater pain sensitivity to experimental pain tasks relative to non-Hispanic Whites (W). Notably, African Americans do not show the same relationships involving endogenous pain regulatory mechanisms and pain sensitivity documented in Caucasians, including positive associations between blood pressure, norepinephrine, cortisol and greater pain tolerance.

Objectives. The purpose of this study was to examine the relationship between plasma oxytocin (OT) and pain sensitivity and to explore the relation of OT to other factors known to influence pain perception.

Design. OT concentration and sensitivity to ischemic, cold pressor, and thermal pain tasks were assessed in African American (n=25) and non-Hispanic White (n=23) pre-menopausal women.

Results. African American women demonstrated significantly lower pain tolerance across tasks compared with Whites (F _1,46=6.31, p=0.0156) and also exhibited lower plasma OT levels (AA: 3.90, W: 7.05 pg/mL; p=0.0014). Greater OT levels were correlated with greater tolerance to ischemic pain (r=0.36, p=0.013) and accounted for a marginally significant portion of the ethnic difference in ischemic pain tolerance (B=+0.29, p=0.06). Greater OT was also correlated with greater tolerance of cold pressor pain (r=0.31, p=0.03); however, this association was no longer seen after the variance due to ethnicity was accounted for.

Conclusion. These data suggest that reduced oxytocinergic function may be one of multiple biological factors contributing to the greater sensitivity to experimental ischemic pain, and to the greater burden of some types of clinical pain experienced by African Americans compared with Whites.     

Dietary implications of oral health decrements among African‐American and white older adults

Objective. Older African‐Americans are at disproportionate risk of chronic, nutritionally‐related diseases. To begin to understand factors that may contribute to the disproportionate prevalence of life‐threatening illnesses among African‐Americans, this study investigates ethnic differences in the prevalence of oral health decrements.

Design. The Florida Dental Care Study (FDCS), a longitudinal study of changes in the oral health of 873 subjects age 45 +, was used to explore a broad range of oral health status differences between African‐American and White adults in the United States. The FDCS consists of clinical and self‐reported measures of oral health, sociodemographic information, and other indicators of oral functional status.

Results. The prevalence of oral health decrements in this sample using a broad range of clinical and self‐reported measures was substantial. African‐American elders were at a heightened risk of poor oral health profiles, including having fewer teeth and being more likely to have a carious surface, fractured cusp or incisai edge, severely mobile teeth and severe periodontal levels than their White counterparts. Furthermore, the African‐American respondents in our sample were significantly more likely to report a lower self‐rated oral health and functioning than their White counterparts. These findings persist regardless of poverty status or educational level, two factors commonly thought to confound racial differences in health outcomes.

Conclusion. Our study provides evidence that the widespread prevalence of oral health decrements and accompanying functional disability among this sample of dentate older adults impacts their daily lives. Of particular concern is the oral health status of older African‐Americans who may be nutritionally vulnerable due, in part, to these oral health decrements and disabilities. We suggest enhancing the access of health services in order to prevent those oral health decrements that presumably undermine adequate dietary intake.     

Health outcomes among african american and caucasian adults following a randomized trial of an asthma education program∗

Objectives. Re‐analysis of a randomized trial of an asthma education program designed to assess the effects of the intervention on emergency department visits, limited days of activity and asthma knowledge and beliefs separately for African American and Caucasian adults with asthma.

Design. Two hundred and forty‐one respondents between the ages of 18 and 70 were evaluated in two emergency departments (one inner city and one suburban location) of a large, midwestem health care system and were randomized to an intervention or control group.

Results. Regardless of race, members of the intervention group showed a decrease in the number of post‐intervention emergency department visits (ANOVA interaction between race and group effect p value = 0.93). The greatest decrease occurred during the first four post‐intervention months. No differential effect of the asthma education intervention by race was found on the change in asthma knowledge and beliefs over the study period (ANCOVA interaction between race and group effect p value = 0.60).

Conclusion. This study demonstrates that post‐intervention, both African American and Caucasian study participants showed a decrease in emergency department visits and an increase in asthma self‐management. This finding is especially important for African Americans, who face increasing asthma mortality and morbidity.     

Caregiving outside of the home: the effects of race on depression

Objective . This research examines the conditions that determine whether Blacks experience lower or higher levels of depression while caregiving outside of the home, as compared to Whites. Some prior literature has found that African Americans report a lesser caregiver burden despite an increased likelihood that they will acquire this role, and decreased resources to do so. Others have found that African Americans experience the same caregiver burden and distress as Whites. Given these mixed findings, we use the stress process model to examine whether African American caregivers experience lower or higher levels of depression when they provide care outside of the home.

Design . A sample of care workers who provide care to others outside of the home was drawn from the 1992–4 National Survey of Families and Households. The final sample included 275 (11%) Blacks, and 2,218 (89%) Whites (not of Hispanic origin). The primary statistical method for predicting differences in caregivers’ depressive symptomatology was OLS regression analysis with progressive adjustment.

Results . We examined sociodemographics, family structure, resources, and stressors and found that African Americans, those with lower socioeconomic status, the unmarried, spending more weeks caregiving, having a physical impairment, and surprisingly receiving more help from parents are associated with higher depressive symptomatology. Stronger religious beliefs decreased depressive symptomatology for Blacks. The race effect was, in part, explained by family structure, amount of caregiving, and impairment of care worker.

Conclusion . Contrary to prior literature, we found that Blacks are more depressed than White caregivers in large part because of lower socioeconomic status and greater stressors, and higher levels of physical impairment. Yet, strength in religious belief has a stress-buffering effect for African Americans. We suggest that policies that attempt to eliminate racial disparities in socioeconomic status and health could benefit these caregivers.     

Use of selected high‐fat foods by Hispanic adults in the Northeastern US

Objective. To add to the limited information of dietary fat intake of US Hispanic adults, in particular for subgroups other than Mexican Americans.

Methods. The frequency of eating 13 high‐fat food items commonly consumed in the US was examined in 665 Hispanic adults 20–74 years old in Connecticut and Long Island, New York, sampled from Spanish‐surname telephone listings and surveyed by telephone in 1992.

Results. Mean estimated fat intake from the 13 items was significantly greater for the 357 men than the 308 women; the largest gender differences were for hamburgers/ cheeseburgers and French fries. Whole milk was an important contributor to the fat intake of persons with the highest fat intakes. In multiple linear regression analyses, age (negative association) and gender, but not education and acculturation (based on language spoken, read and written), were statistically significant predictors of fat intake from the 13 items.

Conclusions. Longitudinal studies using diet diaries are needed in these Hispanic populations.     

Breast cancer histology in Caucasians,African Americans,Hispanics, Asians,and pacific islanders

Study objectives. To investigate the association between race/ethnicity and histologic types of breast cancer.

Design. Cross‐sectional study.

Setting. Population‐based data from the Northern California Tumor Registry, which is part of the National Cancer Institute's Surveillance, Epidemiology and End Results Program.

Participants. A total of 2759 breast cancer cases diagnosed in 1988.

Main results. Tumors were classified as ductal, lobular, and mixed/unspecified carcinoma. Ductal carcinoma was the most common (83.6%) and lobular carcinoma was the rarest. Most cases were diagnosed in the localized stage (56.3%). Caucasian women had the highest rates of total breast cancer (240.9/100 000), ductal and lobular. In African‐American women, the odds of ductal carcinoma were twice that of lobular carcinoma, compared with Caucasian women (odds ratio [OR] = 2.0, 95% confidence interval [CI] 1.0–3.9) after adjusting for age, site, and stage at diagnosis. Similarly, Asian and Hispanic women also had higher, non‐statistically significant odds of ductal versus lobular carcinoma compared with Caucasians (OR = 1.8 [95% CI 0 9–3.7] and 1.6 [95% CI 0.8–3.4], respectively).

Conclusions. Future studies should investigate how racial/ethnic differences in histology among breast cancer patients will influence life expectancy, against a backdrop of health care access, sociocultural issues, lifestyle habits, reproductive history, family history, and tumor characteristics.     

Patterns of informal care among Puerto Rican,African American,and white stroke survivors

Background. There has been an increase in the number of non-institutionalized stroke survivors over the past few decades leading to larger numbers of family caregivers. Less is known about the patterns of informal caregiving within racially and ethnically diverse families even though there is greater post-stroke morbidity and mortality for these groups.

Research aims. The purpose of our research is to examine the informal caregiving networks of white, African American, and Puerto Rican caregivers.

Methodology. We examine data collected from 118 stroke survivors and caregivers to explore the dynamics of caregiving. Data are drawn from a diverse group of whites, African Americans, and Puerto Ricans living on the US Mainland and Puerto Rico at three different time points over the course of 12 months.

Analysis. We examine the size, stability, change, and family dynamics of informal caregiving networks.

Findings and implications. We find that whites, African Americans, and Puerto Ricans each have differing caregiving structures highlighted by expansion and contraction across time, size of network, and relationship to the stroke survivor. Greater cultural awareness among health professionals can lead to improved coordination of information or formal care services. These findings may also be used as a baseline for understanding the caregiving patterns of other Spanish-speaking Caribbean nations.     

Is there a link between wealth and cardiovascular disease risk factors among Hispanic/Latinos? Results from the HCHS/SOL sociocultural ancillary study

Objective: To examine the relationship between wealth and cardiovascular disease risk factors among Hispanic/Latinos of diverse backgrounds.

Design: This cross-sectional study used data from 4971 Hispanic/Latinos, 18–74 years, who participated in the Hispanic Community Health Study/Study of Latinos (HCHS/SOL) baseline exam and the HCHS/SOL Sociocultural Ancillary Study. Three objectively measured cardiovascular disease risk factors (hypertension, hypercholesterolemia, and obesity) were included. Wealth was measured using an adapted version of the Home Affluence Scale, which included questions regarding the ownership of a home, cars, computers, and recent vacations.

Results: After adjusting for traditional socioeconomic indicators (income, employment, education), and other covariates, we found that wealth was not associated with hypertension, hypercholesterolemia or obesity. Analyses by sex showed that middle-wealth women were less likely to have hypercholesterolemia or obesity. Analyses by Hispanic/Latino background groups showed that while wealthier Central Americans were less likely to have obesity, wealthier Puerto Ricans were more likely to have obesity.

Conclusion: This is the first study to explore the relationship between wealth and health among Hispanic/Latinos of diverse backgrounds, finding only partial evidence of this association. Future studies should utilize more robust measures of wealth, and address mechanisms by which wealth may impact health status among Hispanic/Latinos of diverse backgrounds in longitudinal designs.     

Understanding the role of clergy in African American organ and tissue donation decision-making

Objectives. To describe and understand the attitudes, beliefs, and experiences towards organ and tissue donation among African American clergy in Atlanta, Georgia, USA. The secondary objective is to understand what messages clergy are providing to their parishioners relative to organ and tissue donation, and what their perceived role is in donation education.

Design. A qualitative study in which African American clergy (n=26) participated in four focus groups.

Results. African American clergy, though generally supportive of organ and tissue donation in principle, have serious reservations about donation due to perceived inequalities in the donation and transplantation system. The clergy did not personally hold religious concerns about donation, but expressed that these concerns were a major barrier to donation among their parishioners. None of the clergy knew the written position that their religion took on donation; they acknowledged the need for more education for them and their parishioners on this topic. They also felt that as religious leaders, they could play an important role in promoting organ and tissue donation among African American parishioners.

Conclusions. African American clergy and religious leaders may play an important role towards improving willingness to donate among African American parishioners, but more education and advocacy is needed to prepare them for this role.     

Ethnic differences in the reliability and validity of a Panic Disorder Screen

Purpose. The purpose of this study was to compare the reliability and validity of the Brief Panic Disorder Screen (BPDS) in samples of African American and Caucasian American primary care patients.

Methods. The BPDS was administered to 295 patients scheduled to visit a primary care clinic for medical reasons. The presence or absence of a panic disorder diagnosis was established during a clinical interview with a psychiatrist. Measures of reliability (internal consistency) and validity (criterion validity) were compared between the two ethnic subgroups.

Findings. The BPDS demonstrated greater reliability and validity for Caucasians than African Americans. This effect was maintained even after controlling for group differences in key demographic variables. Differences between ethnic groups were apparent in both those with and those without panic disorder (PD). BPDS responses of African Americans with PD demonstrated very low internal consistency whereas a high rate of false positive PD diagnoses was related to higher than expected BPDS scores among African Americans without PD, particularly on the level of fear felt when experiencing shortness of breath or heart palpitations.

Discussion. These findings support the notion that cultural differences in the language and meaning associated with anxiety disorders contribute to the difficulty of accurately diagnosing PD in primary care populations. Additional research is needed to provide a better understanding of the cultural aspects of the anxiety experience. Such research would facilitate the development of better screening tools for panic and other anxiety disorders for ethnic minority primary care populations.     

Obesity in Inner‐city African Americans

Objective. Obesity, a risk factor for chronic diseases, has a high prevalence in African Americans and low‐income individuals. However, little is known about perceptions of overweight, attempts to lose weight, and strategies used to lose weight among African Americans in inner cities.

Design. A 1990 cross‐sectional telephone survey (n = 1445) of north St Louis and central Kansas City, USA.

Results. Obesity was common (44%) in this sample of inner‐city African Americans. The obese perceived themselves as overweight (70%) and were trying to lose weight (66%). The majority of the obese (68%) were both dieting and exercising to lose weight. Smoking prevalence was not higher among the obese or those trying to lose weight. Many of the obese had received medical advice recently on low‐fat diets (51%) and had been advised to lose weight (40%). Factors independently associated with perception, attempts to lose weight and medical advice differed, but included degree of obesity.

Conclusions. These results corroborate US national data that obesity is a public health problem in this population and that obese inner‐city African Americans perceive themselves as overweight and are trying to lose weight, especially as degree of obesity increases. It also appears that smoking is not being used as a weight loss strategy and that the obese, as a group, are receiving some medical advice on low‐fat diets. This information is critical for designing culturally sensitive weight‐control programmes.     

Assessing the effects of race and ethnicity on use of complementary and alternative therapies in the USA

Objective To investigate the use of alternative therapies among different racial/ethnic groups in the USA. Specifically, we examined whether alternative medicine use differs for working aged whites, Asian Americans, African Americans, and Hispanics.

Design Using the 1996 Medical Expenditure Panel Survey, racial differences in utilization were investigated at two levels: (1) the bivariate level with no controls for other factors and (2) at the multivariate level with controls for age, sex, region, marital status, education, income, health status, satisfaction with conventional healthcare, and access measures.

Results Americans in this sample population used alternative and complementary therapies at a fairly low rate (6.5%). This 6.5%, however, was not consistent across all groups. African Americans and Hispanics were less likely than whites to utilize alternative therapies, whereas Asian Americans did not differ significantly from whites.

Conclusions The use of alternative and complementary therapies varied across racial/ethnic groups. Evidence showed that individuals who were dissatisfied with the availability of conventional healthcare, who were in poor health, but very satisfied with their conventional provider were more likely to use complementary and alternative medicine (CAM) therapies. The addition of these variables to a logistic regression model did not change the findings for differential use by ethnicity, the relative ranking of groups, or the overall strength of the relationship.     

Trends in motor vehicle traffic fatalities among Hispanics,non‐Hispanic whites and American Indians in New Mexico, 1958–1990

Objective. New Mexico has had the highest motor vehicle fatality rate in the nation for many years. Our objective was to examine ethnic differences and trends in motor vehicle fatality rates.

Design. Using death certificate data from the New Mexico Bureau of Vital Records and Health Statistics, we compiled age‐adjusted motor vehicle‐related mortality rates from 1958–1990 among the three major ethnic groups in New Mexico—Hispanics, white non‐Hispanics and American Indians.

Results. Over the 33‐year study period, American Indians of both sexes had two to three times higher mortality rates than white non‐Hispanics. Hispanic males also had higher motor vehicle death rates than white non‐Hispanic males. During the 1970s fatality rates peaked, with age‐adjusted death rates of 233/100 000 for American Indian males, 74.7 for Hispanic males and 49.3 for white non‐Hispanics for the period 1973–1977. Evaluation of successive 5‐year birth cohorts showed highest mortality rates for ages 15–29 years for each ethnic group and both sexes, and a dramatic decline in most ethnic, sex and age‐specific rates during the last eight years of the study period.

Conclusion. Although the recent trends indicate favorable changes in motor vehicle fatality rates, our data highlight the need for ethnic and age‐specific interventions to further reduce rates of motor vehicle‐related mortality in this state.     

Epidemiology of self‐reported past heavy drinking in Hispanic adults

Objectives. Self‐reports of past heavy drinking correlate with the current drinking practices and with risk of mortality in non‐Hispanic males. The prevalence of past heavy drinking has not been reported in Hispanic populations.

Methods. Using data from the Hispanic Health and Nutrition Examination Survey (HHANES) we (1) report on the prevalence, duration and severity of past heavy drinking in three Hispanic groups, (2) compare the current alcohol consumption patterns among past heavy drinkers and those who do not report a history of past heavy drinking and (3) compare the risk factor profiles and health indicators in these two groups.

Results. The prevalence of past heavy drinking among Mexican American and Puerto Rican males ranged from 28–35% while the rates for Cuban American males ranged from 7–16%. The rates for Hispanic women were much lower (1–8%). The average years of past heavy drinking ranged from 2.3–14.9 years, while the alcohol consumption during the past heavy drinking period ranged from 24.4–44.0 drinks per week. Past heavy drinkers tended to consume more alcohol at present than did never heavy drinkers with the greatest differences found for Mexican American females. Comparisons of the risk factors and health indicators by drinking status revealed a higher prevalence of smoking among past heavy drinkers (50–60%) versus never heavy drinkers (34–43%). Past heavy drinking Mexican American females also reported significantly more chronic conditions and depressive symptoms than did never heavy drinkers.

Conclusions. Prevalence rates of past heavy drinking among Mexican American and Puerto Rican males are approximately three times higher than rates reported for non‐Hispanic male populations.     

Changing the conversation about prostate cancer among African Americans: results of formative research

Objectives. To understand obstacles to and opportunities for improving prostate cancer communication to and within African American communities.

Design. Researchers conducted interviews with 19 community leaders and five focus groups with healthy men and survivors. The team also conducted process evaluations of two outreach projects in which survivors spoke to African American men about prostate cancer and screening.

Results. Three levels of obstacles to prostate cancer screening and treatment were identified. Individual-level obstacles included limited knowledge about the condition, about prevention and treatment, and fear of cancer. Socio-cultural barriers included distrust of the medical system, lack of a provider for routine and preventive care, reluctance to talk about cancer, and aversion to aspects of screening. Institutional deficits included the scarcity of educational efforts targeting prostate cancer. Outreach project evaluations suggested that survivors can be effective in building prostate cancer knowledge, promoting positive attitudes toward screening, and fostering conversations about prostate cancer. Educational efforts included little information about screening risks and decision-making however.

Conclusions. The findings suggest that most potent interventions may combine survivor-led education with mass media and institution-based outreach. Such comprehensive programs could shift social norms that inhibit conversation and foster fear, leading in turn to more informed decisions and better treatment outcomes.     

The portrayal of depression in the three most popular English-language Black-American magazines in the USA: Ebony,Essence, and Jet

Objective. To examine how depression is portrayed within a specific racialized group.

Design. Manifest and latent content analysis of the three highest circulating magazines directed toward Black-American readers, Essence, Ebony, and Jet, from 2000 to 2007.

Results. The findings demonstrate ambiguity and contradictions about depression's meaning and incidence, as well as the availability, accessibility, and suitability of medical treatment. All of these are linked to racialized identities among Black Americans.

Conclusion. Magazine portrayal of depression in these magazines can only be understood in the context of experienced racism, oppression, and ethnic identity among Blacks.     

Investigating the mental abilities of rural Zulu primary school children in South Africa

Introduction. Maximising the full potential of health and educational interventions in South African schools requires assessment of the current level of mental abilities of the school children as measured by cognitive and scholastic tests and the identification of any barriers to improved performance.

Objectives. This study reports on the application and interpretation of a selected battery of mental ability tests among Zulu school children and the methodological and analytical issues that need to be addressed.

Design The test scores of 806 primary school children from a rural community are presented, based on four tests: Raven's Coloured Progressive Matrices (CPM), an Auditory Verbal Learning Test (AVLT), the Symbol Digit Modalities Test (SDMT) and Young's Group Mathematics Test (GMT).

Results. Significant gender differences were found in the test scores, and the mean scores of Zulu children in this study were lower than those reported in other studies. The results of this selected test battery provide data for the further development of appropriate test instruments for South African conditions.

Conclusion. These results can contribute towards the development of a test battery for South African children that can be used to assess and improve their school performance.