Race/ethnic differences in adult mortality: the role of perceived stress and health behaviors

We examine the role of perceived stress and health behaviors (i.e., cigarette smoking, alcohol consumption, physical inactivity, sleep duration) in shaping differential mortality among whites, blacks, and Hispanics. We use data from the 1990 National Health Interview Survey (N = 38,891), a nationally representative sample of United States adults, to model prospective mortality through 2006. Our first aim examines whether unhealthy behaviors and perceived stress mediate race/ethnic disparities in mortality. The black disadvantage in mortality, relative to whites, closes after adjusting for socioeconomic status (SES), but re-emerges after adjusting for the lower smoking levels among blacks. After adjusting for SES, Hispanics have slightly lower mortality than whites; that advantage increases after adjusting for the greater physical inactivity among Hispanics, but closes after adjusting for their lower smoking levels. Perceived stress, sleep duration, and alcohol consumption do not mediate race/ethnic disparities in mortality. Our second aim tests competing hypotheses about race/ethnic differences in the relationships among unhealthy behaviors, perceived stress, and mortality. The social vulnerability hypothesis predicts that unhealthy behaviors and high stress levels will be more harmful for race/ethnic minorities. In contrast, the Blaxter (1990) hypothesis predicts that unhealthy lifestyles will be less harmful for disadvantaged groups. Consistent with the social vulnerability perspective, smoking is more harmful for blacks than for whites. But consistent with the Blaxter hypothesis, compared to whites, current smoking has a weaker relationship with mortality for Hispanics, and low or high levels of alcohol consumption, high levels of physical inactivity, and short or long sleep hours have weaker relationships with mortality for blacks.     

A new conceptualization of ethnicity for social epidemiologic and health equity research

Although social stratification persists in the US, differentially influencing the well-being of ethnically defined groups, ethnicity concepts and their implications for health disparities remain under-examined. Ethnicity is a complex social construct that influences personal identity and group social relations. Ethnic identity, ethnic classification systems, the groupings that compose each system and the implications of assignment to one or another ethnic category are place-, time- and context-specific. In the US, racial stratification uniquely shapes expressions of and understandings about ethnicity. Ethnicity is typically invoked via the term, ‘race/ethnicity’; however, it is unclear whether this heralds a shift away from racialization or merely extends flawed racial taxonomies to populations whose cultural and phenotypic diversity challenge traditional racial classification. We propose that ethnicity be conceptualized as a two-dimensional, context-specific, social construct with an attributional dimension that describes group characteristics (e.g., culture, nativity) and a relational dimension that indexes a group’s location within a social hierarchy (e.g., minority vs. majority status). This new conceptualization extends prior definitions in ways that facilitate research on ethnicization, social stratification and health inequities. While federal ethnic and racial categories are useful for administrative purposes such as monitoring the inclusion of minorities in research, and traditional ethnicity concepts (e.g., culture) are useful for developing culturally appropriate interventions, our relational dimension of ethnicity is useful for studying the relationships between societal factors and health inequities. We offer this new conceptualization of ethnicity and outline next steps for employing socially meaningful measures of ethnicity in empirical research. As ethnicity is both increasingly complex and increasingly central to social life, improving its conceptualization and measurement is crucial for advancing research on ethnic health inequities.     

Comparing social determinants of self-rated health across the United States and Canada

A large body of research shows that social determinants of health have significant impact on the health of Canadians and Americans. Yet, very few studies have directly compared the extent to which social factors are associated with health in the two countries, in large part due to the historical lack of comparable cross-national data. This study examines differences in the effect of a wide-range of social determinants on self-rated health across the two populations using data explicitly designed to facilitate comparative health research-Joint Canada/United States Survey of Health. The results show that: 1) sociodemographic and socioeconomic factors have substantial effects on health in each country, though the size of the effects tends to differ-gender, nativity, and race are stronger predictors of health among Americans while the effects of age and marital status on health are much larger in Canada; the income gradient in health is steeper in Canada whereas the education gradient is steeper in the U.S.; 2) Socioeconomic status (SES) mediates or links sociodemographic variables with health in both countries-the observed associations between gender, race, age, and marital status and health are considerably weakened after adjusting for SES; 3) psychosocial, behavioural risk and health care access factors are very strong determinants of health in each country, however being severely/morbidly obese, a smoker, or having low life satisfaction has a stronger negative effect on the health of Americans, while being physically inactive or having unmet health care needs has a stronger effect among Canadians; and 4) risk and health care access factors together play a relatively minor role in linking social structural factors to health. Overall, the findings demonstrate the importance of social determinants of health in both countries, and that some determinants matter more in one country relative to the other.     

National environmental health measures for minority and low-income populations: tracking social disparities in environmental health

Healthy People 2010 [US Department of Health and Human Services, 2004. Healthy People 2010. Available: http://www.healthypeople.gov/Publications/ [accessed May 22, 2004]] has established as a top priority the elimination of health disparities. Current research suggests that characteristics of the social, physical and built environment contribute to these disparities. In order to track progress and to assess the potential contributions of the various components of the "environment," tools specific to environmental health disparities are required. In this paper, we discuss one potential tool, a set of candidate measures that may be used to track disparities in outcomes, as well as measures that may be used analytically to assess potential causal pathways. Several other reports on health and environmental measures have been produced, including the Environmental Protection Agency's (EPA) America's Children and the Environment. However, there has not been a comprehensive discussion about environmental measures that focus on racial, ethnic and socioeconomic disparities in health. Therefore, we focus on measures specific to historically disadvantaged populations. Based on a conceptual framework that views health disparities as partially driven by differential access to resources and exposures to hazards, we group the measures into four categories: social processes, environmental contaminants/exposures, bodyburdens of environmental contaminants, and health outcomes. We provide a few examples to illustrate each category, including residential segregation, PM(2.5) exposures, blood mercury concentrations, and asthma morbidity and mortality. These measures and categories are derived from a review of environmental health disparities from several disciplines. As a next step in a long-term effort to better understand the relationship between social disadvantage, environment, and health disparities, we hope that the proposed measures and literature review serve as a foundation for future monitoring of environmental health disparities. These efforts may aid community organizations, local agencies, scientists and policy makers in allocating resources and developing interventions.     

美国卫生公平社会决定因素分析与对策

卫生不公平是当前全球普遍面临的重大课题,但导致不同国家卫生不公平的原因又各有不同。本文对影响美国卫生公平的社会决定因素进行了分析,并对美国政府及相关机构采取的相应措施及难点进行了阐述。造成美国卫生不公平的主要原因在于种族及阶级歧视、贫富不均、就业及生活环境、生活习惯等方面存在差异;采取的相应措施包括成立促进卫生公平的相关组织,研究并揭示导致卫生不公平的社会决定因素,唤醒公民主动追求公平的意识,为决策者提供改善公平性的政策建议。最后提出了对我国的启示,如提高公众对卫生公平性的认识、缩小贫富差距、杜绝种族歧视、加强劳动保护和健康管理、保护环境等。     

Workshop summary: connecting social and environmental factors to measure and track environmental health disparities

On May 24-25, 2005 in Ann Arbor, Michigan, the US Environmental Protection Agency, the National Institute of Environmental Health Sciences, and the University of Michigan sponsored a technical workshop on the topic of connecting social and environmental factors to measure and track environmental health disparities. The workshop was designed to develop a transdisciplinary scientific foundation for exploring the conceptual issues, data needs, and policy applications associated with social and environmental factors used to measure and track racial, ethnic, and class disparities in environmental health. Papers, presentations, and discussions focused on the use of multilevel analysis to study environmental health disparities, the development of an organizing framework for evaluating health disparities, the development of indicators, and the generation of community-based participatory approaches for indicator development and use. Group exercises were conducted to identify preliminary lists of priority health outcomes and potential indicators and to discuss policy implications and next steps. Three critical issues that stem from the workshop were: (a) stronger funding support is needed for community-based participatory research in environmental health disparities, (b) race/ethnicity and socioeconomic position need to be included in environmental health surveillance and research, and (c) models to elucidate the interrelations between social, physical, and built environments should continue to be developed and empirically tested.     

Racial and ethnic differences in general health status and limiting health conditions among American children: parental reports in the 1999 national survey of America's families

Objectives . This research investigates the association between race/ethnicity and child health, and examines the role of family structure, family socioeconomic status (SES), and healthcare factors in this association. Five major racial/ethnic groups in the US are studied. Two child health outcomes, including parent-rated health and limiting health condition, are examined. The analysis is stratified into three age groups: age 0–5, age 6–11, and age 12–17.

Design . Cross-sectional study using data from a large, nationally representative sample collected in 1999 in the US.

Results . Older age groups tend to exhibit larger racial/ethnic disparities in child health. Except for some age groups of Asian youths, minority children and adolescents generally show higher risks of fair or poor parent-rated health and limiting health condition relative to Whites. Family SES partly explains the effects of Black, Hispanic, and Native American groups, but significant amount of residual effects remain. Family structure explains some Black effects, but not for other minority groups. Healthcare factors do not contribute much to the racial/ethnic differences. Both family structure and healthcare factors are important factors of child health in their own right. None of the social factors examined can explain the effects of the Asian group. Data also show that economic resources play a more salient role in child health than parental education, especially in young children. In addition, healthcare factors, to some extent, can explain why children from higher SES families fare better in health.

Conclusion . Racial/ethnic disparities in health start early in life. Except for Asians, class explains a substantial amount, but not all, of these disparities. Healthcare factors play some role in explaining health disparities by class. Structural solution seems to be needed to reduce disparities by race/ethnicity among youths.     

Social rank and adult male nutritional status: evidence of the social gradient in health from a foraging-farming society

Research with humans and non-human primate species has found an association between social rank and individual health. Among humans, a robust literature in industrial societies has shown that each step down the rank hierarchy is associated with increased morbidity and mortality. Here, we present supportive evidence for the social gradient in health drawing on data from 289 men (18+ years of age) from a society of foragers-farmers in the Bolivian Amazon (Tsimane'). We use a measure of social rank that captures the locally perceived position of a man in the hierarchy of important people in a village. In multivariate regression analysis we found a positive and statistically significant association between social rank and three standard indicators of nutritional status: body mass index (BMI), mid-arm circumference, and the sum of four skinfolds. Results persisted after controlling for material and psychosocial pathways that have been shown to mediate the association between individual socioeconomic status and health in industrial societies. Future research should explore locally-relevant psychosocial factors that may mediate the association between social status and health in non-industrial societies.     

The relative contributions of race/ethnicity, socioeconomic status, health, and social relationships to life satisfaction in the United States

Purpose  To evaluate racial/ethnic disparities in life satisfaction and the relative contributions of socioeconomic status (SES; education, income, employment status, wealth), health, and social relationships (social ties, emotional support) to well-being within and across racial/ethnic groups. Methods  In two cross-sectional, representative samples of U.S. adults (the 2001 National Health Interview Survey and the 2007 Behavioral Risk Factor Surveillance System; combined n > 350,000), we compared life satisfaction across Whites, Hispanics, and Blacks. We also evaluated the extent to which SES, health, and social relationships ‘explained’ racial/ethnic group differences and compared the magnitude of variation explained by life satisfaction determinants across and within these groups. Results  Relative to Whites, both Blacks and Hispanics were less likely to be very satisfied. Blacks were somewhat more likely to report being dissatisfied. These differences were reduced or eliminated with adjustment for SES, health, and social relationships. Together, SES and health explained 12–15% of the variation in life satisfaction, whereas social relationships explained an additional 10–12% of the variance. Conclusions  Racial/ethnic life satisfaction disparities exist for Blacks and Hispanics, and these differences are largest when comparing those reporting being ‘satisfied’ to ‘very satisfied’ versus ‘dissatisfied’ to ‘satisfied.’ SES, health, and social relationships were consistently associated with life satisfaction, with emotional support having the strongest association with life satisfaction.     

Stroke and active life expectancy in the United States, 1999–2009

BackgroundStroke reduces active life expectancy, both years lived and their proportion without disability. However, active life expectancy studies have provided limited information about strokes in the United States, those occurring throughout older life, or those affecting African Americans.ObjectiveTo measure associations between strokes throughout older life and active life expectancy for African American and White women and men.MethodsUsing data from the Panel Study of Income Dynamics, 1999–2009 (n = 1862, 13,603 person-years), we estimated monthly probabilities of death and disability in activities of daily living with multinomial logistic Markov models adjusted for age, sex, ethnicity, stroke in the past two years, earlier stroke, and education. A random effect accounted for the panel data repeated measures. Microsimulation created large populations with stroke incidence throughout older life, identifying life expectancy and the proportions of remaining life with and without disability. We matched individuals with strokes with randomly selected persons without strokes by age at first stroke, sex, ethnicity, and previous disability.ResultsAverage age at first stroke was higher for women, lower for African Americans. African American and White women were disabled for about two-thirds of life after stroke; results for men were 61.8% for African Americans and 37.2% for Whites. Compared to matched participants, those with strokes lived 33% fewer remaining years (95% confidence interval, CI 30.9%–34.7%) with a 31.6% greater proportion of remaining life with disability (CI 14.4%–55.6%).ConclusionsStroke greatly reduces both life expectancy and the proportion of life without disability, particularly for women and African Americans.     

Discrimination and health in an English study

In this study we examine the relationship between education, racial discrimination and health among white (n=227), African Caribbean (n=213) and Indian and Pakistani (n=233) adults aged between 18 and 59 years living in Leeds, England, as measured in a stratified population survey. Measures of discrimination included any physical attack, verbal abuse and a combined variable, any discrimination due to race, colour, ethnicity or sex. Analyses were conducted examining the relationship between education and discrimination, discrimination and health, and discrimination and health controlling for education. People educated above secondary level were more likely than people educated to secondary level or below to report being physically attacked, verbally abused and exposed to discrimination. People from minority ethnic groups (African Caribbean and Indian Pakistani) were more likely to be verbally abused and exposed to discrimination than the white group. Ethnicity and education interacted for African Caribbeans, such that respondents with post-school qualifications were more likely to report verbal abuse or any discrimination. There was no association between having been exposed to any kind of discrimination and having fair or poor health. Physical attack and any discrimination were associated with anxiety, worry and depression. The results remained unchanged when ethnicity and education were included in the models. Education and ethnicity were associated with differences in exposure to discrimination. In turn, exposure to discrimination was associated with higher levels of anxiety, worry or depression although there was no association between discrimination and health. The results support the contention that racial discrimination may play an important role in modifying the relationship between ethnicity, socioeconomic position and health. The counter-intuitive relationship between education and levels of reported discrimination in non-minority ethnic groups highlights the value of explicitly modeling discrimination to gain a better understanding of the social determinants of health.     

Racism and mental health: the African American experience

This paper provides an overview of United States-based research on the ways in which racism can affect mental health. It describes changes in racial attitudes over time, the persistence of negative racial stereotypes and the ways in which negative beliefs were incorporated into societal policies and institutions. It then reviews the available scientific evidence that suggests that racism can adversely affect mental health status in at least three ways. First, racism in societal institutions can lead to truncated socioeconomic mobility, differential access to desirable resources, and poor living conditions that can adversely affect mental health. Second, experiences of discrimination can induce physiological and psychological reactions that can lead to adverse changes in mental health status. Third, in race-conscious societies, the acceptance of negative cultural stereotypes can lead to unfavorable self-evaluations that have deleterious effects on psychological well-being. Research directions are outlined.     

The color of death: race,observed skin tone,and all-cause mortality in the United States

ABSTRACT

Objective: This paper examines how mortality covaries with observed skin tone among blacks and in relation to whites. Additionally, the study analyzes the extent to which social factors such as socioeconomic status affect this relationship.

Design: This study uses data from the 1982 General Social Survey (N?=?1,689) data linked to the National Death Index until 2008. We use this data to examine the links between race, observed skin tone among blacks, and all-cause mortality. Piecewise exponential hazard modeling was used to estimate disparities in skin tone mortality among blacks, and relative to whites. The multivariate models control for age, education, gender, region, metropolitan statistical area, marital status, labor force status, and household income.

Results: Observed skin tone is a significant determinant of mortality among blacks and in relation to whites. Light skinned blacks had the lowest mortality hazards among blacks, while respondents with medium and dark brown skin experienced significantly higher mortality. The observed skin tone mortality disparities covaried with education; there are significant mortality disparities across observed skin tone groups among black respondents with high school or more education, and nonsignificant disparities among those with less education.

Conclusion: It is crucial to identify the social processes driving racial disparities in health and mortality. The findings reveal that the nuanced social experiences of blacks with different observed skin tones markedly change the experience of racial inequality. Research on the nuanced social processes and biological mechanisms that connect differences in observed skin tone to mortality outcomes promises to better illuminate the experience of racial inequality and policy mechanisms we can use to undermine it.     

The riskscape and the color line: examining the role of segregation in environmental health disparities

Environmental health researchers, sociologists, policy-makers, and activists concerned about environmental justice argue that communities of color who are segregated in neighborhoods with high levels of poverty and material deprivation are also disproportionately exposed to physical environments that adversely affect their health and well-being. Examining these issues through the lens of racial residential segregation can offer new insights into the junctures of the political economy of social inequality with discrimination, environmental degradation, and health. More importantly, this line of inquiry may highlight whether observed pollution--health outcome relationships are modified by segregation and whether segregation patterns impact diverse communities differently. This paper examines theoretical and methodological questions related to racial residential segregation and environmental health disparities. We begin with an overview of race-based segregation in the United States and propose a framework for understanding its implications for environmental health disparities. We then discuss applications of segregation measures for assessing disparities in ambient air pollution burdens across racial groups and go on to discuss the applicability of these methods for other environmental exposures and health outcomes. We conclude with a discussion of the research and policy implications of understanding how racial residential segregation impacts environmental health disparities.     

Social inequalities and the early provision and dispersal of COVID-19 vaccinations in the United States: A population trends study

BackgroundIn December 2020 the U.S. began a massive COVID-19 vaccination campaign, an action that researchers felt could catalyze inequalities in COVID-19 vaccination utilization. While vaccines have the potential to be accessible regardless of social status, the objective of this study was to examine how and when socioeconomic status (SES) and racial/ethnic inequalities would emerge in vaccination distribution.MethodsPopulation vaccination rates reported at the county level by the Centers for Disease Control and Prevention across 46 states on 3/30/2021. Correlates included SES, the share of the population who were Black, Hispanic, Female, or aged ≥65 years, and urbanicity (thousands of residents per square mile). Multivariable-adjusted analyses relied on zero-inflated negative binomial regression to estimate the odds of providing any vaccine, and vaccination rate ratios (aVRR) comparing the distribution rate for vaccinations across the U.S.ResultsAcross the U.S., 16.3 % of adults and 37.9 % of adults aged 65 and older were vaccinated in lower SES counties, while 20.45 % of all adults and 48.15 % of adults aged 65 and older were vaccinated in higher SES counties. Inequalities emerged after 41 days, when < 2 % of Americans were vaccinated. Multivariable-adjusted analyses revealed that higher SES was associated with improved vaccination distribution (aVRR = 1.127, [1.100–1.155], p < 1E−06), while increases in the percent reporting Black or Hispanic race/ethnicity was associated with lower vaccination distribution (aVRR = 0.998, [0.996–0.999], p = 1.03E−04).ConclusionsSocial inequalities in COVID-19 vaccines reflect an inefficient and inequitable distribution of these technologies. Future efforts to improve health should recognize the central role of social factors in impacting vaccine delivery.     

Social capital and health among the aged: comparisons between the United States and Germany

Through a cross-national investigation of the United States and Germany, this study examines how individual level social capital relates to the health of the elderly. Data from two national telephone surveys conducted in Germany (N=682) and the United States (N=608) with probability samples of non-institutionalized persons aged 60 and older was used. Indicators of social capital including both norms (reciprocity and civic trust) and behaviors (participation) were tested with three self-reported health indicators-overall health, depression (CES-D) and functional limitations. Housing variables and social support were controlled for in the study. Lack of reciprocity was associated with poorer self-rated health in both countries. Civic mistrust was associated with poorer self-rated health in both countries as well as with depression and functional limitations in America. Lack of participation was, in Germany, associated with poorer self-rated health and depression. The cross-national results indicate that individual-level analysis of social capital along with marco-level determinants are important for understanding the health of the elderly.     

Social cohesion, social support, and health among Latinos in the United States

The role of individual versus community level social connections in promoting health is an important factor to consider when addressing Latino health. This analysis examines the relationships between social support, social cohesion, and health in a sample of Latinos in the United States. Using data from the National Latino and Asian American Study, the analysis uses ordered logistic regression to explore the relationships of family support, friend support, family cultural conflict, and neighborhood social cohesion with self-rated physical and mental health, taking into account language proficiency and use, nativity, and sociodemographic variables. Family support, friend support, and neighborhood social cohesion were positively related to self-rated physical and mental health, and family cultural conflict was negatively related when controlled only for sex and age. After controlling for education, income, and other demographic measures, only family support was found to have a weak association with self-rated physical health; however, the relationship seemed to be mediated by language. In contrast, family support and family cultural conflict were strongly associated with self-rated mental health, after controlling for language, education, income, and other demographic measures. The study did not find neighborhood social cohesion to be significantly related to either self-rated physical or mental health, after accounting for the effects of the other social connection variables. Language of interview did not explain the highly significant effects of language proficiency and use. Social connections are important for health and mental health, but language and other sociodemographic factors seem to be related to how Latinos establish these social linkages. Further investigation into the role of language in the development and maintenance of social connections may help unravel the mechanisms by which they promote or decrease health.     

Factors influencing the effectiveness of interventions to reduce racial and ethnic disparities in health care

Reducing racial and ethnic disparities in health care has become an important policy goal in the United States and other countries, but evidence to inform interventions to address disparities is limited. The objective of this study was to identify important dimensions of interventions to reduce health care disparities. We used qualitative research methods to examine interventions aimed at improving diabetes and/or cardiovascular care for patients from racial and ethnic minority groups within five health care organizations. We interviewed 36 key informants and conducted a thematic analysis to identify important features of these interventions. Key elements of interventions included two contextual factors (external accountability and alignment of incentives to reduce disparities) and four factors related to the organization or intervention itself (organizational commitment, population health focus, use of data to inform solutions, and a comprehensive approach to quality). Consideration of these elements could improve the design, implementation, and evaluation of future interventions to address racial and ethnic disparities in health care.     

County-level contextual factors associated with diabetes incidence in the United States

Purpose

Health and administrative systems are facing spatial clustering in chronic diseases such as diabetes. This study explores how geographic distribution of diabetes in the United States is associated with socioeconomic and built environment characteristics and health-relevant policies.