Classification of race and ethnicity: implications for public health

Factors Contributing to Missed Appointments in a Pediatric Otolaryngology Clinic

OBJECTIVE

To understand why pediatric otolaryngology patients do not attend scheduled clinic appointments and identify factors correlated with no-show status.

STUDY DESIGN

Retrospective cohort study.

METHODS

This is a retrospective cohort study that uses medical record data extraction of patients that was scheduled to attend new patient appointments at a pediatric otolaryngology clinic in 2018.

RESULTS

Factors associated with no-shows included complex psychiatric history (OR (95% CI) 0.789 (0.71-0.88), P < .001), increased appointment lead time (OR (95% CI) 0.981 (0.976-0.987), P < .001), afternoon appointments (OR (95% CI) 0.783 (0.64-0.99), P = .038), and complex maternal medical history (OR (95% CI) 0.987 (0.979-0.996), P < .005). In contrast, factors associated with attendance included complex patients' medical history (OR (95% CI) 1.058 (0.98-1.02), P < .001), primary care physician at the same hospital (OR (95% CI) 2.766 (2.25-3.39), P < .001), and primary language being Spanish (OR (95% CI) 2.536 (1.75-3.67) P < .001). The factors of distance from the hospital (OR (95% CI) 1.001 (0.99-1.01), P = .868), season of appointment (P = .997), race (P = .623), and ethnicity (P = .804) were not associated with attendance or no-shows.

CONCLUSION

Patient and maternal medical problems, mental health history, primary care location, appointment lead time, hour of appointment, and primary language, all contribute to appointment attendance, while appointment timing, race, and ethnicity are not associated with attendance. Further work must be performed to overcome these barriers to minimize healthcare risks and improve patient outcomes.

QUALITY OF EVIDENCE

Level 3 Laryngoscope, 2021.

Alternative Methods for Grouping Race and Ethnicity to Monitor COVID-19 Outcomes and Vaccination Coverage

Population-based analyses of COVID-19 data, by race and ethnicity can identify and monitor disparities in COVID-19 outcomes and vaccination coverage. CDC recommends that information about race and ethnicity be collected to identify disparities and ensure equitable access to protective measures such as vaccines; however, this information is often missing in COVID-19 data reported to CDC. Baseline data collection requirements of the Office of Management and Budget's Standards for the Classification of Federal Data on Race and Ethnicity (Statistical Policy Directive No. 15) include two ethnicity categories and a minimum of five race categories (1). Using available COVID-19 case and vaccination data, CDC compared the current method for grouping persons by race and ethnicity, which prioritizes ethnicity (in alignment with the policy directive), with two alternative methods (methods A and B) that used race information when ethnicity information was missing. Method A assumed non-Hispanic ethnicity when ethnicity data were unknown or missing and used the same population groupings (denominators) for rate calculations as the current method (Hispanic persons for the Hispanic group and race category and non-Hispanic persons for the different racial groups). Method B grouped persons into ethnicity and race categories that are not mutually exclusive, unlike the current method and method A. Denominators for rate calculations using method B were Hispanic persons for the Hispanic group and persons of Hispanic or non-Hispanic ethnicity for the different racial groups. Compared with the current method, the alternative methods resulted in higher counts of COVID-19 cases and fully vaccinated persons across race categories (American Indian or Alaska Native [AI/AN], Asian, Black or African American [Black], Native Hawaiian or Other Pacific Islander [NH/PI], and White persons). When method B was used, the largest relative increase in cases (58.5%) was among AI/AN persons and the largest relative increase in the number of those fully vaccinated persons was among NH/PI persons (51.6%). Compared with the current method, method A resulted in higher cumulative incidence and vaccination coverage rates for the five racial groups. Method B resulted in decreasing cumulative incidence rates for two groups (AI/AN and NH/PI persons) and decreasing cumulative vaccination coverage rates for AI/AN persons. The rate ratio for having a case of COVID-19 by racial and ethnic group compared with that for White persons varied by method but was <1 for Asian persons and >1 for other groups across all three methods. The likelihood of being fully vaccinated was highest among NH/PI persons across all three methods. This analysis demonstrates that alternative methods for analyzing race and ethnicity data when data are incomplete can lead to different conclusions about disparities. These methods have limitations, however, and warrant further examination of potential bias and consultation with experts to identify additional methods for analyzing and tracking disparities when race and ethnicity data are incomplete.

Risk Factors in Adolescence for the Development of Elevated Blood Pressure and Hypertension in American Indian and Alaskan Native Adults

To examine risk factors for elevated blood pressure and hypertension in American Indians and Alaska Natives (AI/ANs), compared to three other ethnic groups in the US. Weighted relative risk regression models, stratified by race/ethnicity, were used to measure the associations between risk factors and elevated blood pressure and hypertension in AI/ANs, compared to non-Hispanic Whites, non-Hispanic Blacks and Hispanics, with data from the National Longitudinal Study of Adolescent to Adult Health. In all groups, females had a lower risk of both elevated blood pressure and hypertension than males. Increasing body mass index raised hypertension risk in all groups. In AI/ANs, financial instability increased the risk of hypertension by 88% (95% CI: 1.27-2.77), but not in other groups. No other statistically significant associations were found. Future interventions should include socio-economic factors in efforts to prevent hypertension in AI/ANs.

Contextual and Parenting Factors Contribute to Shorter Sleep Among Hispanic/Latinx Compared to Non-Hispanic White Infants

BACKGROUND

Sleep is an important aspect of child development and health. Disparities in childhood sleep have been observed as early as infancy, but little is known about the factors contributing to them.

PURPOSE

The objective of this study was to examine whether intrinsic, contextual, and parenting factors contribute to differences in sleep duration between Hispanic/Latinx and non-Hispanic white infants at 6 months of age.

METHODS

We analyzed data of 119 Hispanic/Latinx and 146 non-Hispanic white infants in Rise & SHINE, a prospective birth cohort study of mother-infant dyads. Mothers reported their infant's sleep patterns using the Brief Infant Sleep Questionnaire at 6 months. Mothers also completed surveys measuring intrinsic (sex, gestational length, and birth weight), contextual (cultural, environmental, and familial), and parenting (behaviors and practices) factors. We used multivariable linear and logistic regression analyses to examine the contributing effects of these clusters of variables on the association between racial/ethnic background and infant sleep duration.

RESULTS

Hispanic/Latinx infants slept 38 min less than white infants at 6 months (β: -0.63 [95% confidence interval: -1.07, -0.19]) and were nearly three times more likely to not meet the minimum sleep recommendation. The differences persisted after adjustment for intrinsic factors but were attenuated after additional adjustment for contextual and parenting factors, especially having a foreign-born mother and later bedtime.

CONCLUSIONS

The results of this study demonstrate that differences in sleep duration among Hispanic/Latinx infants compared to their white counterparts are present as early as 6 months of age and that context and parenting matter.

The Impact of Stroke Public Awareness Campaigns Differs Between Sociodemographic Groups

BACKGROUND

Prehospital delays are a major obstacle to timely reperfusion therapy in acute ischemic stroke. Stroke sign recognition, however, remains poor in the community. We present an analysis of repeated surveys to assess the impact of Face, Arm, Speech, Time (FAST) public awareness campaigns on stroke knowledge.

METHODS

Four cross-sectional surveys were conducted between July 2016 and January 2019 in the province of Quebec, Canada (n = 2,451). Knowledge of FAST stroke signs (face drooping, arm weakness and speech difficulties) was assessed with open-ended questions. A bilingual English/French FAST public awareness campaign preceded survey waves 1-3 and two campaigns preceded wave 4. We used multivariable ordinal regression models weighted for age and sex to assess FAST stroke sign knowledge.

RESULTS

We observed an overall significant improvement of 26% in FAST stroke sign knowledge between survey waves 1 and 4 (odds ratio [OR] = 1.26; 95% CI: 1.02, 1.55; p = 0.035). After the last campaign, however, 30.5% (95% CI: 27.5, 33.6) of people were still unable to name a single FAST sign. Factors associated with worse performance were male sex (OR = 0.68; 95% CI: 0.53, 0.86; p = 0.002) and retirement (OR = 0.54; 95% CI: 0.35, 0.83; p = 0.005). People with lower household income and education had a tendency towards worse stroke sign knowledge and were significantly less aware of the FAST campaigns.

CONCLUSIONS

Knowledge of FAST stroke signs in the general population improved after multiple public awareness campaigns, although it remained low overall. Future FAST campaigns should especially target men, retired people and individuals with a lower socioeconomic status.

Developing an Algorithm for Combining Race and Ethnicity Data Sources in the Veterans Health Administration

INTRODUCTION

Racial/ethnic disparities exist in the Veterans Health Administration (VHA), despite financial barriers to care being largely mitigated and Veterans Administration's (VA) organizational commitment to health equity. Accurately identifying minority veterans is critical to monitoring progress toward equity as the VHA treats an increasingly racially and ethnically diverse veteran population. Although the VHA's completeness of race and ethnicity data is generally better than its public sector and private counterparts, the accuracy of the race and ethnicity in the various databases available to VHA is variable, as is the accuracy in identifying specific minority groups. The purpose of this article was to develop an algorithm for constructing race and ethnicity variables from data sources available to VHA researchers, to present demographic differences cross the data sources, and to apply the algorithm to one study year.

MATERIALS AND METHODS

We used existing VHA survey data from the Survey of Healthcare Experiences of Patients (SHEP) and three commonly used administrative databases from 2003 to 2015: the VA Corporate Data Warehouse (CDW), VA Defense Identity Repository (VADIR), and Medicare. Using measures of agreement such as sensitivity, specificity, positive and negative predictive values, and Cohen kappa, we compared self-reported race and ethnicity from the SHEP and each of the other data sources. Based on these results, we propose an algorithm for combining data on race and ethnicity from these datasets. We included VHA patients who completed a SHEP and had race/ethnicity recorded in CDW, VADIR, and/or Medicare.

RESULTS

Agreement between SHEP and other sources was high for Whites and Blacks and substantially lower for other minority groups. The CDW demonstrated better agreement than VADIR or Medicare.

CONCLUSIONS

We developed an algorithm of data source precedence in the VHA that improves the accuracy of the identification of historically under-identified minorities: (1) SHEP, (2) CDW, (3) Department of Defense's VADIR, and (4) Medicare.

Mental health disorders among patients with acute myocardial infarction in the United States

OBJECTIVE

To assess the prevalence, temporal trends and sex- and racial/ethnic differences in the burden of mental health disorders (MHD) and outcomes among patients with myocardial infarction (MI) in the United States.

METHODS

Using the National Inpatient Sample Database, we evaluated a contemporary cohort of patients hospitalized for acute MI in the United States over 10 years period from 2008 to 2017. We used multivariable logistic regression analysis for in-hospital outcomes, yearly trends and estimated annual percent change (APC) in odds of MHD among MI patients.

RESULTS

We included a total sample of 6,117,804 hospitalizations for MI (ST elevation MI in 30.4%), with a mean age of 67.2 ​± ​0.04 years and 39% females. Major depression (6.2%) and anxiety disorders (6.0%) were the most common MHD, followed by bipolar disorder (0.9%), schizophrenia/psychotic disorders (0.8%) and post-traumatic stress disorder (PTSD) (0.3%). Between 2008 and 2017, the prevalences significantly increased for major depression (4.7%-7.4%, APC +6.2%, p ​< ​.001), anxiety disorders (3.2%-8.9%, APC +13.5%, p ​< ​.001), PTSD (0.2%-0.6%, +12.5%, p ​< ​.001) and bipolar disorder (0.7%-1.0%, APC +4.0%, p ​< ​.001). Significant sex- and racial/ethnic-differences were also noted. Major depression, bipolar disorder or schizophrenia/psychotic disorders were associated with a lower likelihood of coronary revascularization.

CONCLUSION

MHD are common among patients with acute MI and there was a concerning increase in the prevalence of major depression, bipolar disorder, anxiety disorders and PTSD over this 10-year period. Focused mental health interventions are warranted to address the increasing burden of comorbid MHD among acute MI.

Racial/Ethnic Representation in United States and Australian Obstetric Research

OBJECTIVE

To describe racial/ethnic representation in United States (US) and Australian obstetric research, represented by the Maternal-Fetal Medicine Units Network (MFMU) and Australian Research Centre for Health of Women and Babies (ARCH) trials.

METHODS

MFMU studies were identified through PubMed and ARCH studies through their online publication listing from 2011 to 2016. Observational and randomized cohorts and primary and secondary data analyses were included. Studies with race-based enrollment were excluded. Racial/ethnic representation was expressed as the mean racial/ethnic percentages of the studies (i.e.,: studies weighted equally regardless of sample size). Racial/ethnic percentages in MFMU studies were compared to US registered births and ARCH compared to Australian census ancestry data.

RESULTS

38 MFMU studies included 580,282 women. Racial/ethnic representation (% [SD]) included White 41.7 [12.3], Hispanic 28.1 [15.4], Black 26.2 [12.3], Asian 3.6 [2.3], and American Indian/Alaskan Native (AI/AN) 0.2 [0.02]. No studies reported Native Hawaiian/other Pacific Islanders (NHOPI) separately. Comparatively, registered US births (%) were White 75.7, Hispanic 28.1, Black 16.1, Asian/Pacific Islander 7.1, and AI/AN 1.1, which differed from the MFMU (P = 0.02). 20 ARCH studies included 51,873 women. The most reported groups were White 76.5 [17.4], Asian 15.2 [14.8], and Aboriginal/Torres Strait Islander 13.9 [30.5], compared to census numbers of White 88.7, Asian 9.4, and Aboriginal/Torres Strait Islander 2.8 (P < 0.01). Two ARCH studies reported African ethnicity.

CONCLUSION

There is racial diversity in studies by MFMU and ARCH, with opportunities to increase enrollment and enhanced reporting of Asian, AI/AN, and NHOPI races in MFMU studies and Black race in ARCH studies.

Disparities in Care Experienced by American Indian and Alaska Native Medicare Beneficiaries

BACKGROUND

Little is known about the health care experiences of American Indians and Alaska Natives (AIANs) due to limited data.

OBJECTIVE

The objective of this study was to investigate the health care experiences of AIAN Medicare beneficiaries relative to non-Hispanic Whites using national survey data pooled over 5 years.

SUBJECTS

A total of 1,193,248 beneficiaries who responded to the nationally representative 2012-2016 Medicare Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys.

METHODS

Linear regression models predicted CAHPS measures from race and ethnicity. Scores on the CAHPS measures were linearly transformed to a 0-100 range and case-mix adjusted. Three AIAN groups were compared with non-Hispanic Whites: single-race AIANs (n=2491; 0.4% of the total sample), multiple-race AIANs (n=15,502; 1.3%), and Hispanic AIANs (n=2264; 0.2%).

RESULTS

Among AIAN groups, single-race AIANs were most likely to live in rural areas and areas served by the Indian Health Service; Hispanic AIANs were most likely to be Spanish-language-preferring (P's<0.05). Compared with non-Hispanic Whites, single-race AIANs reported worse experiences with getting needed care (adjusted disparity of -5 points; a "large" difference), getting care quickly (-4 points; a "medium" difference), doctor communication (-2 points; a "small" difference), care coordination (-2 points), and customer service (-7 points; P<0.001 for all comparisons). Disparities were similar for Hispanic AIANs but more limited for multiple-race AIANs.

CONCLUSIONS

Quality improvement efforts are needed to reduce disparities faced by older AIANs. These findings may assist in developing targeted efforts to address cultural, communication, and health system factors presumed to underlie disparities in health care access and customer service.

Predicting vaginal birth after previous cesarean: Using machine-learning models and a population-based cohort in Sweden

Introduction

Predicting a woman’s probability of vaginal birth after cesarean could facilitate the antenatal decision‐making process. Having a previous vaginal birth strongly predicts vaginal birth after cesarean. Delivery outcome in women with only a cesarean delivery is more unpredictable. Therefore, to better predict vaginal birth in women with only one prior cesarean delivery and no vaginal deliveries would greatly benefit clinical practice and fill a key evidence gap in research. Our aim was to predict vaginal birth in women with one prior cesarean and no vaginal deliveries using machine‐learning methods, and compare with a US prediction model and its further developed model for a Swedish setting.

Material and methods

A population‐based cohort study with a cohort of 3116 women with only one prior birth, a cesarean, and a subsequent trial of labor during 2008‐2014 in the Stockholm‐Gotland region, Sweden. Three machine‐learning methods (conditional inference tree, conditional random forest and lasso binary regression) were used to predict vaginal birth after cesarean among women with one previous birth. Performance of the new models was compared with two existing models developed by Grobman et al (USA) and Fagerberg et al (Sweden). Our main outcome measures were area under the receiver‐operating curve (AUROC), overall accuracy, sensitivity and specificity of prediction of vaginal birth after previous cesarean delivery.

Results

The AUROC ranged from 0.61 to 0.69 for all models, sensitivity was above 91% and specificity below 22%. The majority of women with an unplanned repeat cesarean had a predicted probability of vaginal birth after cesarean >60%.

Conclusions

Both classical regression models and machine‐learning models had a high sensitivity in predicting vaginal birth after cesarean in women without a previous vaginal delivery. The majority of women with an unplanned repeat cesarean delivery were predicted to succeed with a vaginal birth (ie specificity was low). Additional covariates combined with machine‐learning techniques did not outperform classical regression models in this study.

Demographic and Socioeconomic Differences in Outpatient Ophthalmology Utilization in the United States

PURPOSE

The purpose was to assess differences in outpatient ophthalmologic usage based on patient characteristics such as race/ethnicity, income, insurance type, geographical region, and educational attainment.

DESIGN

Retrospective cross-sectional study.

METHODS

The Medical Expenditure Panel Survey (MEPS) is a nationally representative data set for the noninstitutionalized population cosponsored by the Agency for Healthcare Research. This study involved 183,054 MEPS respondents from 2007 to 2015. Primary outcome measure was patient utilization of outpatient ophthalmologic care. Secondary outcome measure was annual health care use and costs by patients in outpatient, inpatient, and the emergency department settings based on race.

RESULTS

Overall, 21,673 participants self-reported an ophthalmologic condition, and 12,462 had at least 1 outpatient ophthalmologic visit. Hispanic (adjusted odds ratio [aOR] 0.72; P < .001) and black patients (aOR 0.74; P < .001) had fewer outpatient visits than their non-Hispanic white counterparts. Uninsured (aOR 0.41; P = .009) and Medicare/Medicaid (aOR 0.92; P < .001) patients had less outpatient care than their privately insured counterparts. Increasing income and education was associated with higher outpatient ophthalmologic care utilization. In the emergency department, non-Hispanic white patients had the least encounters (1.1 per 100 patients) and highest costs ($25,314.05) when compared to non-Hispanic black patients (3.2 encounters per 100 patients and $10,780.22 respectively) and Hispanic patients (2.2 encounters per 100 patients and $9,837.03 respectively).

CONCLUSIONS

This study's findings demonstrate differences in outpatient ophthalmologic utilization based on demographic and socioeconomic characteristics. Concurrently, minority Americans had more ophthalmic emergency department visits but lower cost per visit. There is a need to further characterize these differences to predict future ophthalmologic care needs.

Racial/Ethnic Minority Children With Cancer Experience Higher Mortality on Admission to the ICU in the United States

OBJECTIVE

We investigated whether differences in survival exist between children of various racial/ethnic groups with cancer admitted to the PICU.

DESIGN

A retrospective multicenter analysis was conducted using Virtual Pediatric Systems data from reporting centers. Demographic information, Pediatric Risk for Mortality III score, and outcome variables were analyzed using mixed-effects logistic regression modeling to assess for differences in mortality.

SETTING

One hundred thirty-five PICUs in the United States.

PATIENTS

Pediatric patients with cancer admitted to PICUs in the United States.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

This study details the analysis of 23,128 PICU admissions of 12,232 unique oncology patients representing 3% of all PICU admissions with 1,610 deaths (7.0% case fatality). African American (8.5%) and Hispanic children (8.1%) had significantly higher mortality (p < 0.05) compared with Caucasian children (6.3%). Regional analysis showed Hispanic patients to have higher mortality in the West in the United States, whereas African American patients in the South in the United States had higher mortality. A pulmonary disease diagnosis in Hispanics increased odds of mortality (odds ratio, 1.39; 95% CI, 1.13-1.70), whereas a diagnosis of shock/sepsis increased risk for mortality in African Americans (odds ratio, 1.56; 95% CI, 1.11-2.20) compared with Caucasians. There were no differences between races/ethnic groups in the rates of limitations of care. After controlling for Pediatric Risk of Mortality III, PICU length of stay, stem cell transplant status, readmissions, cancer type (solid, brain, hematologic), mechanical ventilation days, and sex, Hispanic (odds ratio, 1.24; 95% CI, 1.05-1.47) and African Americans (odds ratio, 1.37; 95% CI, 1.14-1.66) had significantly higher odds of mortality compared with Caucasians.

CONCLUSIONS

The results show that after controlling for severity and cancer type, a child's race, ethnicity, and region of presentation influence mortality in the PICU. This suggests that additional investigation is warranted along with a need to rethink our approach to the evaluation and treatment of critically ill African American and Hispanic children with cancer.

Ethnic and Gender Diversity Comparison between Surgical Patients and Caring Surgeons

BACKGROUND

Diversity within the medical workforce remains a topic of discussion in academia, particularly when it comes to the underrepresentation of certain ethnic groups and gender in the surgical specialties. In this article, we look at how the gender and ethnicity of surgeons at a large academic institution in a rural setting compare with those of the population it serves.

METHODS

We looked at demographic data from 2008 to 2018 and compared population trends among surgeons and patients.

RESULTS

We found that while whites represent the large majority in both the surgeon and patient populations, absolute number and percentage of whites in the patient population seem to be trending downward from 2008 to 2018, but trending upward among surgeons (attendings and residents). In addition, we found that while Asians make up only 1% of the patient population, they represent the second largest group (17%) among surgeons, with more than twice the proportion percentage of the second largest group within the patient population, composed of Hispanics (6%). Finally, we found a significant gender difference between the 2 populations with almost two-thirds of the surgeons being men, compared with the nearly even split of men and women within the patient population.

CONCLUSIONS

Ultimately, understanding how gender and ethnic diversity in the surgical workforce compares with that of the patient population being served may aid in designing training programs to address cultural competency and awareness as well as in impacting administrative decisions and hiring.

Ethnicity classification systems for public health surveys: experiences from HIV behavioural surveillance among men who have sex with men

Background

Race and ethnicity classification systems have considerable implications for public health, including the potential to reveal or mask inequities. Given increasing “super-diversity” and multiple racial/ethnic identities in many global settings, especially among younger generations, different ethnicity classification systems can underrepresent population heterogeneity and can misallocate and render invisible Indigenous people and ethnic minorities. We investigated three ethnicity classification methods and their relationship to sample size, socio-demographics and sexual health indicators.

Methods

We examined data from New Zealand’s HIV behavioural surveillance programme for men who have sex with men (MSM) in 2006, 2008, 2011, and 2014. Participation was voluntary, anonymous and self-completed; recruitment was via community venues and online. Ethnicity allowed for multiple responses; we investigated three methods of dealing with these: Prioritisation, Single/Combination, and Total Response. Major ethnic groups included Asian, European, indigenous Māori, and Pacific. For each classification method, statistically significant associations with ethnicity for demographic and eight sexual health indicators were assessed using multivariable logistic regression.

Results

Overall, 10,525 MSM provided ethnicity data. Classification methods produced different sample sizes, and there were ethnic disparities for every sexual health indicator. In multivariable analysis, when compared with European MSM, ethnic differences were inconsistent across classification systems for two of the eight sexual health outcomes: Māori MSM were less likely to report regular partner condomless anal intercourse using Prioritisation or Total Response but not Single/Combination, and Pacific MSM were more likely to report an STI diagnosis when using Total Response but not Prioritisation or Single/Combination.

Conclusions

Different classification approaches alter sample sizes and identification of health inequities. Future research should strive for equal explanatory power of Indigenous and ethnic minority groups and examine additional measures such as socially-assigned ethnicity and experiences of discrimination and racism. These findings have broad implications for surveillance and research that is used to inform public health responses.

Information Loss in Harmonizing Granular Race and Ethnicity Data: Descriptive Study of Standards

BACKGROUND

Data standards for race and ethnicity have significant implications for health equity research.

OBJECTIVE

We aim to describe a challenge encountered when working with a multiple-race and ethnicity assessment in the Eastern Caribbean Health Outcomes Research Network (ECHORN), a research collaborative of Barbados, Puerto Rico, Trinidad and Tobago, and the US Virgin Islands.

METHODS

We examined the data standards guiding harmonization of race and ethnicity data for multiracial and multiethnic populations, using the Office of Management and Budget (OMB) Statistical Policy Directive No. 15.

RESULTS

Of 1211 participants in the ECHORN cohort study, 901 (74.40%) selected 1 racial category. Of those that selected 1 category, 13.0% (117/901) selected Caribbean; 6.4% (58/901), Puerto Rican or Boricua; and 13.5% (122/901), the mixed or multiracial category. A total of 17.84% (216/1211) of participants selected 2 or more categories, with 15.19% (184/1211) selecting 2 categories and 2.64% (32/1211) selecting 3 or more categories. With aggregation of ECHORN data into OMB categories, 27.91% (338/1211) of the participants can be placed in the "more than one race" category.

CONCLUSIONS

This analysis exposes the fundamental informatics challenges that current race and ethnicity data standards present to meaningful collection, organization, and dissemination of granular data about subgroup populations in diverse and marginalized communities. Current standards should reflect the science of measuring race and ethnicity and the need for multidisciplinary teams to improve evolving standards throughout the data life cycle.

Historic and recent trends in county-level coronary heart disease death rates by race, gender, and age group, United States, 1979-2017

Given recent slowing of declines in national all-cause, heart disease, and stroke mortality, examining spatiotemporal distributions of coronary heart disease (CHD) death rates and trends can provide data critical to improving the cardiovascular health of populations. This paper documents county-level CHD death rates and trends by age group, race, and gender from 1979 through 2017. Using data from the National Vital Statistics System and a Bayesian multivariate space-time conditional autoregressive model, we estimated county-level age-standardized annual CHD death rates for 1979 through 2017 by age group (35–64 years, 65 years and older), race (white, black, other), and gender (men, women). We then estimated county-level total percent change in CHD death rates during four intervals (1979–1990, 1990–2000, 2000–2010, 2010–2017) using log-linear regression models. For all intervals, national CHD death rates declined for all groups. Prior to 2010, although most counties across age, race, and gender experienced declines, pockets of increasing CHD death rates were observed in the Mississippi Delta, Oklahoma, East Texas, and New Mexico across age groups and gender, and were more prominent among non-white populations than whites. Since 2010, across age, race, and gender, county-level declines in CHD death rates have slowed, with a marked increase in the percent of counties with increasing CHD death rates (e.g. 4.4% and 19.9% for ages 35 and older during 1979–1990 and 2010–2017, respectively). Recent increases were especially prevalent and geographically widespread among ages 35–64 years, with 40.5% of counties (95% CI: 38.4, 43.1) experiencing increases. Spatiotemporal differences in these long term, county-level results can inform responses by the public health community, medical providers, researchers, and communities to address troubling recent trends.

Clinical Genetics Lacks Standard Definitions and Protocols for the Collection and Use of Diversity Measures

Genetics researchers and clinical professionals rely on diversity measures such as race, ethnicity, and ancestry (REA) to stratify study participants and patients for a variety of applications in research and precision medicine. However, there are no comprehensive, widely accepted standards or guidelines for collecting and using such data in clinical genetics practice. Two NIH-funded research consortia, the Clinical Genome Resource (ClinGen) and Clinical Sequencing Evidence-generating Research (CSER), have partnered to address this issue and report how REA are currently collected, conceptualized, and used. Surveying clinical genetics professionals and researchers (n = 448), we found heterogeneity in the way REA are perceived, defined, and measured, with variation in the perceived importance of REA in both clinical and research settings. The majority of respondents (>55%) felt that REA are at least somewhat important for clinical variant interpretation, ordering genetic tests, and communicating results to patients. However, there was no consensus on the relevance of REA, including how each of these measures should be used in different scenarios and what information they can convey in the context of human genetics. A lack of common definitions and applications of REA across the precision medicine pipeline may contribute to inconsistencies in data collection, missing or inaccurate classifications, and misleading or inconclusive results. Thus, our findings support the need for standardization and harmonization of REA data collection and use in clinical genetics and precision health research.

A Smartphone App (mDASHNa-CC) to Support Healthy Diet and Hypertension Control for Chinese Canadian Seniors: Protocol for Design, Usability and Feasibility Testing

BACKGROUND

This proposed study aims to translate the Dietary Approach to Stop Hypertension with Sodium (Na) Reduction for Chinese Canadians (DASHNa-CC), a classroom-based, antihypertensive, dietary educational intervention, to an innovative smartphone app (mDASHNa-CC). This study will enable Chinese Canadian seniors to access antihypertensive dietary interventions anytime, regardless of where they are. It is hypothesized that senior Chinese Canadians will be satisfied with their experiences using the mDASHNa-CC app and that the use of this app could lead to a decrease in their blood pressure and improvement in their health-related quality of life.

OBJECTIVE

The goal of this study is to design and test the usability and feasibility of a smartphone-based dietary educational app to support a healthy diet and hypertension control for Chinese Canadian seniors.

METHODS

A mixed-method two-phase design will be used. The study will be conducted in a Chinese immigrant community in Toronto, Ontario, Canada. Chinese Canadian seniors, who are at least 65 years old, self-identified as Chinese, living in Canada, and with elevated blood pressure, will be recruited. In Phase I, we will design and test the usability of the app using a user-centered approach. In Phase II, we will test the feasibility of the app, including implementation (primary outcomes of accrual and attrition rates, technical issues, acceptability of the app, and adherence to the intervention) and preliminary effectiveness (secondary outcomes of systolic and diastolic blood pressure, weight, waist circumference, health-related quality of life, and health service utilization), using a pilot, two-group, randomized controlled trial with a sample size of 60 participants in a Chinese Canadian community.

RESULTS

The study is supported by the Startup Research Grant from Nipissing University, Canada. The research ethics application is under review by a university research ethics review board.

CONCLUSIONS

The study results will make several contributions to the existing literature, including illustrating the rigorous design and testing of smartphone app technology for hypertension self-management in the community, exploring an approach to incorporating traditional medicine into chronic illness management in minority communities and promoting equal access to current technology among minority immigrant senior groups.

TRIAL REGISTRATION

Clinicaltrials.gov NCT03988894; https://clinicaltrials.gov/ct2/show/NCT03988894.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/15545.

Socially-assigned race and health: a scoping review with global implications for population health equity

Self-identified race/ethnicity is largely used to identify, monitor, and examine racial/ethnic inequalities. A growing body of work underscores the need to consider multiple dimensions of race - the social construction of race as a function of appearance, societal interactions, institutional dynamics, stereotypes, and social norms. One such multidimensional measure is socially-assigned race, the perception of one's race by others, that may serve as the basis for differential or unfair treatment and subsequently lead to deleterious health outcomes. We conducted a scoping review to systematically appraise the socially-assigned race and health literature. A systematic search of the PubMed, Web of Science, 28 EBSCO databases and 24 Proquest databases up to September 2019 was conducted and supplemented by a manual search of reference lists and grey literature. Quantitative and qualitative studies that examined socially-assigned race and health or health-related outcomes were considered for inclusion. Eighteen articles were included in the narrative synthesis. Self-rated health and mental health were among the most frequent outcomes studied. The majority of studies were conducted in the United States, with fewer studies conducted in New Zealand, Canada, and Latin America. While most studies demonstrate a positive association between social assignment as a disadvantaged racial or ethnic group and poorer health, some studies did not document an association. We describe key conceptual and methodological considerations that should be prioritized in future studies examining socially-assigned race and health. Socially-assigned race can provide additional insight into observed differential health outcomes among racial/ethnic groups in racialized societies based upon their lived experiences. Studies incorporating socially-assigned race warrants further investigation and may be leveraged to examine nuanced patterns of racial health advantage and disadvantage.

Clinical Trials Participation Among African Americans and the Ethics of Trust: Leadership Perspectives

Background

Assuring health equity throughout the U.S. continues to challenge the public and private research enterprise. Even with some progress, racial and ethnic health disparities continue, particularly among African Americans. Health equity for African Americans is improbable unless participation in clinical trials is measurably increased.

Method

To inform efforts to enhance participation, interviews were conducted with three African American leadership groups from across the country to document their perceptions of why the research community is unable to engage African Americans effectively in clinical trials. The results of thirty-five interviews, conducted from three leadership groups, were analyzed and are reported in this article. The leadership groups include health/education, faith, and civic society.

Ethical Considerations

This research was conducted based upon the ethical protocols of the National Center for Bioethics in Research and Health Care, research ethics, and confidentiality.

Results

Findings indicate that trustworthiness must precede trust; both are essential in enhancing African American participation in research, especially in less understood clinical trials.

Conclusion

Respondents agreed that the research community must demonstrate trustworthiness before trust can be established. They also indicated the importance of increasing the number of African American researchers in leadership roles. Also, suggestions were made regarding the need to develop short and long-term positive relationships between the research community and the African American population, at various levels, if increases in participation in clinical trials are expected. With the likely development of new clinical research and the attention to increasing excess deaths among African Americans, there must be representative numbers of African Americans and other underserved populations in leadership roles if health disparities are to be eliminated and health equity is to be achieved.

Health-Related Disparities among Migrant Children at School Entry in Germany. How does the Definition of Migration Status Matter?

Background: Migration background is known to be an important risk factor for a number of medical outcomes. Still, relatively little is known about the epidemiologic relevance of different definitions of migration status. Methods: Data from 5250 school entry examinations spanning three consecutive years (2015-2017) were gathered from the Public Health Department in Halle, Germany. Data were stratified according to six different migration statuses and evaluated for differences in health service utilization and developmental outcomes. Results: Compared to non-migrant children, migrant children have a lower utilization of preventative services, and higher frequencies of developmental delays. Children with first-generation migration background consistently show results worse than all others, while children with one-sided second-generation migration background show results similar to those of their non-migrant peers. These findings are not substantially altered by adjustment for social status. Conclusions: Children with first-generation migration background should receive special attention in school entry examinations, since they constitute a group with consistently higher health risks compared to other groups of preschoolers.

Ethics in Categorizing Ethnicity and Disability in Research with Children

The use of categories is a contested subject in social sciences. The use of social categories allows researchers to explore similarities, differences, and inequalities between groups of people. However, by using social categories, researchers run the risk of essentializing differences. The aim of this article is to problematize the procedural and relational ethics of using categories in research with children. Based on two research projects studying inclusion and exclusion in physical education, we examine the ongoing ethical dilemmas of categorizing children in terms of disability and ethnic background. The reflections are grounded in intersectional and relational ethical perspectives with a focus on how power is manifested in practices and structures throughout the research process. The data consist of field notes, transcripts of interviews with children and their parents, and the authors’ reflective accounts. The results are organized into three main themes: (1) How categories frame the research in its initial phases (informed consent and voluntary participation), (2) power relationships in context (navigating meanings of categories in the interviews and the relational ethics of generational ordering in combined interviews with children and their parents), and (3) (re)constructing stories and ensuring anonymity. In the discussion, we reflect on how singling out groups of children framed the research, how categories and power relations were negotiated and navigated in interviews and fieldwork, and how, in the reporting of the results, understandings of the children and their experiences were constructed. We argue that by not reflecting on the ethics of categorizing children in research, researchers are in danger of reproducing rather than challenging social inequality and discrimination.

Obesity risk factors in American Indians and Alaska Natives: a systematic review

OBJECTIVES

We systematically reviewed the literature on risk factors for obesity in American Indians (AIs) and Alaska Natives (ANs) of all ages.

STUDY DESIGN

We searched titles and abstracts in PubMed with combinations of the following terms: obesity, body mass index (BMI), American Indian, Alaska Native, and Native American.

METHODS

We limited our review to articles that provided an empirically testable claim about a variable associated with obesity, measured obesity as a dependent variable, and provided data specific to AI/ANs.

RESULTS

Our final sample included 31 articles; 20 examined AI/AN youth (<18 years), and 11 examined AI/AN adults (≥18 years). Risk factors for obesity varied by age. In infants, low birth weight, early termination of breastfeeding, and high maternal BMI, and maternal diabetes increased the risk of childhood obesity. In children and adolescents, parental obesity, sedentary behaviors, and limited access to fruits and vegetables were associated with obesity. In adulthood, sedentary behaviors, diets high in fats and carbohydrates, stress, verbal abuse in childhood, and the belief that health cannot be controlled were associated with obesity.

CONCLUSIONS

Extant studies have three limitations: they do not apply a life course perspective, they lack nationally representative data and have limited knowledge of the resilience, resistance and resourcefulness of AI/ANs. Future studies that avoid these shortcomings are needed to inform interventions to reduce the prevalence of obesity in AI/ANs across the life course.

Ethnic differences in acute heart failure outcomes in Ontario

BACKGROUND

Previous studies have identified ethnic differences in outcomes after episodes of acute heart failure in natives of Asia as compared to those of Europe. Whether these ethnic differences in outcomes would still exist, years after migration to a different geographical and cultural setting remain unclear. We investigated the one-year mortality after an episode of acute heart failure admission in Ontario residents of South Asian and Chinese descent as compared to the General Population.

METHODS

We conducted a population-based, retrospective cohort study of adult Ontarions who were hospitalized for AHF between April 1, 2010 and March 31, 2016. Ethnicity was categorized using validated surname-based algorithms. The primary outcome was all-cause one-year mortality. Mortality rates were calculated using the Kaplan-Meier method. The relative hazard of death was assessed using a multivariable Cox proportional hazard model.

RESULTS

Of 82,125 patients, 1287 (1.6%) were Chinese, 1662 (2.0%) were South Asians, and the remaining 79,176 (96.4%) were of the General Population. The risk of mortality was markedly lower amongst South Asians (adjusted HR 0.81, 95% CI [0.73-0.89]) relative to the General Population. There was no statistically significant difference in the risk of mortality between Chinese and the General Population (adjusted HR 1.00 [0.91-1.10]). In addition, guideline-directed medical therapies were associated with similar survival benefit in patients of all three ethnic origins.

CONCLUSIONS

We found a lower risk of one-year mortality after acute heart failure hospitalization amongst South Asians compared to Chinese and the General Population, and similar benefit of medical therapy in all three groups. Further studies are needed to explore the etiologies of these ethnic disparities to truly improve outcomes at the population level.

Emergence of racial/ethnic differences in infant sleep duration in the first six months of life

Objective

Examine the emergence of differences in sleep duration between infants from different racial/ethnic backgrounds and extent to which differences are explained by socioeconomic status (SES) and sleep continuity.

Methods

Sleep duration and continuity (number of night wakings and longest nighttime stretch of sleep) were assessed for 394 infants in the Rise & Sleep Health in Infancy & Early Childhood (SHINE) birth cohort at one- and six-months using the Brief Infant Sleep Questionnaire (BISQ). Multivariable regression was used to estimate associations of race/ethnicity with sleep duration adjusting for individual-level covariates, SES, and sleep continuity.

Results

The sample was 40% non-Hispanic white, 33% Hispanic, 11% Black, and 15% Asian. Mean (SD) durations for daytime, nighttime, and total sleep at one-month were 6.3 (2.0), 8.9 (1.5), and 15.2 (2.7) hours, respectively. Corresponding durations at six-months were 3.0 (1.4), 9.9 (1.3), and 13.0 (1.9) hours. At one-month, Hispanic infants had shorter nighttime sleep than white infants [β: −0.44 h (95% CI: −0.80, −0.08)]. At six-months, Hispanic [β: −0.96 h (−1.28, −0.63)] and Black [β: −0.60 h (−1.07, −0.12)] infants had shorter nighttime sleep than white infants. The near 1-h differential in night sleep among Hispanics resulted in shorter total sleep [β: −0.66 h (−1.16, −0.15)]. Associations across all racial/ethnic groups were attenuated after adjustment for SES at one- and six months. Sleep continuity attenuated associations with nighttime and total sleep duration by 20–60% for Hispanic infants at six-months.

Conclusions

Differences in sleep duration emerge early in life among racial/ethnic groups and are in part explained by SES and sleep continuity.

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At one-month, Hispanic infants slept significantly less at night than white infants.

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At six-months, Hispanic and Black infants slept less at night than white infants.

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The near 1-h differential among Hispanics resulted in shorter total sleep.

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Adjusting for SES attenuated associations across all racial/ethnic groups.

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Sleep continuity attenuated associations for Hispanic infants at six-months.

BEYOND RACE/ETHNICITY: SKIN COLOR, GENDER, AND THE HEALTH OF YOUNG ADULTS IN THE UNITED STATES

Researchers typically identify health disparities using self-reported race/ethnicity, a measure identifying individuals' social and cultural affiliations. In this study, we use data from Waves 1, 3, and 4 of Add Health to examine health disparities by interviewer-ascribed skin color, a measure capturing the perceptions of race/ethnicity ascribed to individuals by others. Individuals with darker skin tones may face greater exposure to serious stressors such as perceived discrimination, poverty, and economic hardship which can accumulate over the lifecourse and increase the likelihood of poor health. We found significant gradients in Body Mass Index (BMI), obesity, self-reported health, and depressive symptoms by interviewer-ascribed skin color but results differed by gender. Associations of BMI, obesity, and fair/poor health among women were only partially mediated by discrimination, self-reported stress, or low socio-economic status and persisted after controlling for race/ethnicity. Among men, initial associations between skin color and both fair/poor health and depressive symptoms did not persist after controlling for race/ethnicity. This study demonstrates the value of considering stratification by skin color and gender in conjunction with race/ethnicity.

Suicide Attempt Resiliency in American Indian, Hispanic, and Anglo Youth in New Mexico: The Influence of Positive Adult Relationships

The purpose of this study was to identify whether positive relationships with adults at home, school, and in the community are protective for suicide among American Indian/Alaska Native, Hispanic, and Anglo adolescents. Using data from the New Mexico version of the 2015 Centers for Disease Control and Prevention Youth Risk Behavior Survey, we found that positive relationships with adults affected past-year suicide attempts differently in youth from the 3 groups. The final multivariable model for American Indian/Alaska Native youth included only positive relationships with adults in the home. Among Hispanic and Anglo youth, adults in the home and also in the community were protective.

Factors Underlying Racial Disparities in Sepsis Management

Sepsis, a syndrome characterized by systemic inflammation during infection, continues to be one of the most common causes of patient mortality in hospitals across the United States. While standardized treatment protocols have been implemented, a wide variability in clinical outcomes persists across racial groups. Specifically, black and Hispanic populations are frequently associated with higher rates of morbidity and mortality in sepsis compared to the white population. While this is often attributed to systemic bias against minority groups, a growing body of literature has found patient, community, and hospital-based factors to be driving racial differences. In this article, we provide a focused review on some of the factors driving racial disparities in sepsis. We also suggest potential interventions aimed at reducing health disparities in the prevention, early identification, and clinical management of sepsis.

Risk factors for pre-diabetes and diabetes in adolescence and their variability by race and ethnicity

Adolescent risk factors for pre-diabetes and diabetes in young adulthood were examined in three minority groups and compared to those in non-Hispanic Whites. Retrospective cohort study with data on 8337 adolescent respondents from Add Health (1994-2008). Participants included 5131 non-Hispanic Whites, 1651 non-Hispanic Blacks, 1223 Hispanics, and 332 American Indians/Alaska Natives. Diabetes was defined as: hemoglobin A1C ≥ 6.5%, glucose > 125 mg/dl, self-reported diabetes, or self-reported diabetes medication use, in Wave 4 data. Pre-diabetes was defined as hemoglobin A1C ≥ 5.7%. Relative risk regression models were used to evaluate the association between risk factors and risk of diabetes and pre-diabetes, controlling for body mass index, sedentary and physical activity habits, fast food consumption, and parental education, parental diabetes status, and financial stability. 484 participants developed diabetes; 2878 developed pre-diabetes between 1994 and 2008. Pre-diabetes and diabetes were more prevalent in non-Hispanic Blacks (55% and 12%, respectively) than in American Indians/Alaska Natives (43% and 11%), Hispanics (37% and 6%), and non-Hispanic Whites (27% and 3%). In all races, higher body mass index and parental diabetes were associated with higher risk of pre-diabetes and diabetes, while female sex was associated with lower risk of pre-diabetes. Efforts to reduce the risk of pre-diabetes and diabetes in adolescents should emphasize parental diabetes and BMI in all races, independent of physical activity, sedentary behaviors, or fast food consumption. Future interventions might be interested in targeting households, rather than individuals, to prevent pre-diabetes and diabetes in adolescents and young adults.

Workplace psychosocial stressors experienced by migrant workers in Australia: A cross-sectional study

OBJECTIVE

To explore work-related psychosocial stressors among people of Chinese, Vietnamese and Arabic-speaking backgrounds currently working in Australia.

METHODS

In 2015, a telephone survey of 585 Vietnamese, Chinese and Arabic-speaking workers asked about workplace bullying, ethnic discrimination, job complexity, degree of control, security and fairness of payment along with demographic and employment information. Estimates of job-related psychosocial stressors were derived and regression analyses used to identify significant associations.

RESULTS

At least one workplace stressor was reported by 83% of the workers in the study. Education was significantly associated with experiencing any psychosocial stressor and also with the total number of stressors. Workers aged 45 years and older were more likely to be bullied or experience racial discrimination compared with younger workers of any ethnicity. There was a greater likelihood of reporting low control over a job when the interview was conducted in a language other than English and the workers were either Chinese or Arabic. Workers on a fixed-term contract, independent of ethnicity were more likely to report a job with low security. Overall psychosocial job quality decreased with education and was associated with occupation type which interacted with ethnicity and gender.

CONCLUSIONS

The results suggest that job-related psychosocial stressors are widespread but not uniform across ethnic groups. Further research into what drives differences in work experience for migrant groups would provide information to guide both employers and migrants in ways to reduce workplace psychosocial stressors.

Demographic and Clinical Correlates of Mucosal Disaccharidase Deficiencies in Children With Functional Dyspepsia

BACKGROUND

A subset of children with functional gastrointestinal disorders (FGIDs), which includes functional dyspepsia, may have duodenal disaccharidase deficiencies.

OBJECTIVES

To determine the frequency, demographics, and clinical characteristics associated with duodenal disaccharidase deficiencies in children with functional dyspepsia.

METHODS

Children ages 4 to 18 years undergoing esophagogastroduodenoscopy (EGD) evaluation for dyspepsia were enrolled in either a retrospective (study 1) or prospective (study 2) evaluation. Those with histologic abnormalities were excluded. Duodenal biopsies were obtained for disaccharidase enzyme analysis. In the retrospective study, both demographic and clinical characteristics were obtained via chart review. In the prospective study, parents completed the Rome II Questionnaire on Gastrointestinal Symptoms before the EGD.

RESULTS

One hundred and twenty-nine children (n = 101, study 1; n = 28, study 2) were included. Mean age was 11.2 ± 3.8 (SD) years in study 1 and 10.6 ± 3.2 years in study 2. Forty-eight (47.5%) of subjects in study 1 and 13 (46.4%) of subjects in study 2 had at least 1 disaccharidase deficiency identified. All of those with a disaccharidase deficiency in both studies had lactase deficiency with 8 (7.9%) and 5 (17.9%) of those in studies 1 and 2, respectively, having an additional disaccharidase deficiency. The second most common disaccharidase deficiency pattern was that of pan-disaccharidase deficiency (PDD) in both studies. In study 1 (where both race and ethnicity were captured), self-identified Hispanic (vs non-Hispanic, P < 0.05) and non-white (vs white, P < 0.01) children were more likely to have lactase deficiency. Age, sex, and type of gastrointestinal symptom were not associated with presence or absence of a disaccharidase deficiency.

CONCLUSIONS

Approximately half of children with functional dyspepsia undergoing EGD were identified as having a disaccharidase deficiency (predominantly lactase deficiency). Race/ethnicity may be associated with the likelihood of identifying a disaccharidase deficiency. Other clinical characteristics were not able to distinguish those with versus without a disaccharidase deficiency.

II. MORE THAN JUST CONVENIENT: THE SCIENTIFIC MERITS OF HOMOGENEOUS CONVENIENCE SAMPLES

Despite their disadvantaged generalizability relative to probability samples, nonprobability convenience samples are the standard within developmental science, and likely will remain so because probability samples are cost-prohibitive and most available probability samples are ill-suited to examine developmental questions. In lieu of focusing on how to eliminate or sharply reduce reliance on convenience samples within developmental science, here we propose how to augment their advantages when it comes to understanding population effects as well as subpopulation differences. Although all convenience samples have less clear generalizability than probability samples, we argue that homogeneous convenience samples have clearer generalizability relative to conventional convenience samples. Therefore, when researchers are limited to convenience samples, they should consider homogeneous convenience samples as a positive alternative to conventional (or heterogeneous) convenience samples. We discuss future directions as well as potential obstacles to expanding the use of homogeneous convenience samples in developmental science.

Relative Roles of Race Versus Socioeconomic Position in Studies of Health Inequalities: A Matter of Interpretation

An abundance of research has documented health inequalities by race and socioeconomic position (SEP) in the United States. However, conceptual and methodological challenges complicate the interpretation of study findings, thereby limiting progress in understanding health inequalities and in achieving health equity. Fundamental to these challenges is a lack of clarity about what race is and the implications of that ambiguity for scientific inquiry. Additionally, there is wide variability in how SEP is conceptualized and measured, resulting in a lack of comparability across studies and significant misclassification of risk. The objectives of this review are to synthesize the literature regarding common approaches to examining race and SEP health inequalities and to discuss the conceptual and methodological challenges associated with how race and SEP have been employed in public health research. Addressing health inequalities has become increasingly important as the United States trends toward becoming a majority-minority nation. Recommendations for future research are presented.

Invited Commentary: Sex and Race Differences in Diabetes and Cardiovascular Disease-Achieving the Promise of Sex and Race Subgroup Analyses in Epidemiologic Research

Diabetes confers a higher risk of cardiovascular disease on women than on men. The reasons for these sex differences, such as poorer cardiovascular risk factor profiles, have received considerable attention. However, a recent report on sex × diabetes interactions on cardiovascular disease identified that few if any prior studies have confirmed these sex differences in black individuals, despite known diabetes-related disparities. In this issue of the Journal, George et al. (Am J Epidemiol. 2018;187(3):403-410.) found marginally significant multiplicative sex × diabetes interactions in black but not white study participants after adjustments for traditional and behavioral risk factors, competing risk, and change in diabetes status over time. This study is notable for its attempt to fill an important literature gap, and it elegantly addressed multiple statistical considerations in assessing sex × diabetes interactions according to race strata. The findings also highlighted several important considerations for conducting race and sex subgroup analyses.

U.S. adolescent alcohol use by race/ethnicity: Consumption and perceived need to reduce/stop use

Understanding racial/ethnic drinking patterns and service provision preferences is critical for deciding how best to use limited alcohol prevention, intervention, and treatment resources. We used nationally representative data from 150,727 U.S. high school seniors from 2005 to 2016 to examine differences in a range of alcohol use behaviors and the felt need to reduce or stop alcohol use based on detailed racial/ethnic categories, both before and after controlling for key risk/protective factors. Native students reported particularly high use but corresponding high felt need to reduce/stop use. White and dual-endorsement students reported high use but low felt need to stop/reduce alcohol use.

Racial/ethnic differences in the association between alcohol use and mortality among men living with HIV

BACKGROUND

Increasing alcohol use is associated with increased risk of mortality among patients living with HIV (PLWH). This association varies by race/ethnicity among general outpatients, but racial/ethnic variation has not been investigated among PLWH, among whom racial/ethnic minorities are disproportionately represented.

METHODS

VA electronic health record data from the Veterans Aging Cohort Study (2008-2012) were used to describe and compare mortality rates across race/ethnicity and levels of alcohol use defined by the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) questionnaire. Within each racial/ethnic group, Cox proportional hazards models, adjusted for age, disease severity, and comorbidities, compared mortality risk for moderate-risk (AUDIT-C = 4-7) and high-risk (AUDIT-C ≥ 8) relative to lower-risk (AUDIT-C = 1-3) alcohol use.

RESULTS

Mean follow-up time among black (n = 8518), Hispanic (n = 1353), and white (n = 7368) male PLWH with documented AUDIT-C screening (n = 17,239) was 4.3 years. Black PLWH had the highest mortality rate among patients reporting lower-risk alcohol use (2.9/100 person-years) relative to Hispanic and white PLWH (1.8 and 2.3, respectively) (p value for overall comparison = 0.011). Mortality risk was increased for patients reporting high-risk relative to lower-risk alcohol use in all racial/ethnic groups [black adjusted hazard ratio (AHR) = 1.36, 95% confidence interval (CI) 1.12-1.66; Hispanic AHR = 2.18, 95% CI 1.30-3.64; and white AHR = 2.04, 95% CI 1.61-2.58]. For only white PLWH, mortality risk was increased for patients reporting moderate-relative to lower-risk alcohol use (black AHR = 1.09, 95% CI 0.93-1.27; Hispanic AHR = 1.36, 95% CI 0.89-2.09; white AHR = 1.51, 95% CI 1.28-1.77).

CONCLUSION

Among all PLWH, mortality risk was increased among patients reporting high-risk alcohol use across all racial/ethnic groups, but mortality risk was only increased among patients reporting moderate-risk relative to lower-risk alcohol use among white PLWH, and black patients appeared to have higher mortality risk relative to white patients at lower-risk levels of alcohol use. Findings of the present study further underscore the need to address unhealthy alcohol use among PLWH, and future research is needed to understand mechanisms underlying observed differences.

How Are Race, Cultural, and Psychosocial Factors Associated With Outcomes in Veterans With Spinal Cord Injury?

OBJECTIVE

To understand the role of cultural and psychosocial factors in the outcomes of veteran wheelchair users with spinal cord injury (SCI) to help clinicians identify unique factors faced by their patients and help researchers identify target variables for interventions to reduce disparities in outcomes.

DESIGN

Cross-sectional cohort study.

SETTING

Three urban Veterans Affairs medical centers affiliated with academic medical centers.

PARTICIPANTS

Of the patients (N=516) who were eligible to participate, 482 completed the interview and 439 had SCI. Because of small numbers in other race groups, analyses were restricted to white and African American participants, resulting in a final sample of 422.

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

Quality of life (QOL, Veterans RAND 12-Item Health Survey); satisfaction (Client Satisfaction Questionnaire); and participation (Craig Handicap Assessment and Reporting Technique Short Form).

RESULTS

African American Veterans reported poorer physical QOL but better mental QOL than did white Veterans. No other significant race differences were found in unadjusted analyses. Multivariable analyses showed that psychosocial factors were predominantly associated with patients' QOL outcomes and satisfaction with service, but demographic and medical factors were predominantly associated with participation outcomes. Interaction analyses showed that there was a stronger negative association between anxiety and mental QOL for African Americans than for whites, and a positive association between higher self-esteem and social integration for whites but not African Americans.

CONCLUSIONS

Findings suggest that attempts to improve the outcomes of Veterans with SCI should focus on a tailored approach that emphasizes patients' demographic, medical, and psychosocial assets (eg, building their sense of self-esteem or increasing their feelings of mastery), while providing services targeted to their specific limitations (eg, reducing depression and anxiety).

Outcomes following percutaneous coronary revascularization among South Asian and Chinese Canadians

Background

Previous data suggest significant ethnic differences in outcomes following percutaneous coronary revascularization (PCI), though previous studies have focused on subgroups of PCI patients or used administrative data only. We sought to compare outcomes in a population-based cohort of men and women of South Asian (SA), Chinese and “Other” ethnicity.

Methods

Using a population-based registry, we identified 41,792 patients who underwent first revascularization via PCI in British Columbia, Canada, between 2001 and 2010. We defined three ethnic groups (SA, 3904 [9.3%]; Chinese, 1345 [3.2%]; and all “Others” 36,543 [87.4%]). Differences in mortality, repeat revascularization (RRV) and target vessel revascularization (TVR), at 30 days and from 31 days to 2 years were examined.

Results

Adjusted mortality from 31 days to 2 years was lower in Chinese patients than in “Others” (hazard ratio [HR] 0.72; 95% confidence interval [CI] 0.53-0.97), but not different between SAs and “Others”. SA patients had higher RRV at 30 days (adjusted odds ratio [OR] 1.30; 95% CI: 1.12-1.51) and from 31 days to 2 years (adjusted hazard ratio [HR] 1.17; 95% CI: 1.06-1.30) compared to “Others”. In contrast, Chinese patients had a lower rate of RRV from 31 days to 2 years (adjusted HR 0.79; 95% CI: 0.64-0.96) versus “Others”. SA patients also had higher rates of TVR at 30 days (adjusted OR 1.35; 95% CI: 1.10-1.66) and from 31 days to 2 years (adjusted HR 1.19; 95% CI: 1.06-1.34) compared to “Others”. Chinese patients had a lower rate of TVR from 31 days to 2 years (adjusted HR 0.76; 95% CI: 0.60-0.96).

Conclusions

SA had higher RRV and TVR rates while Chinese Canadians had lower rates of long-term RRV, compared to those of “Other” ethnicity. Further research to elucidate the reasons for these differences could inform targeted strategies to improve outcomes.

Quality and Equity in Wheelchairs Used by Veterans

OBJECTIVES

To assess in Veterans with spinal cord injury (SCI) or amputated limb (AL) the following: (1) patient demographics, medical factors, cultural and psychosocial characteristic by race; (2) wheelchair quality by race; and (3) the independent associations of patient race and the other factors with wheelchair quality.

DESIGN

Cross-sectional cohort study.

SETTING

Three Department of Veterans Affairs (VA) medical centers affiliated with academic medical centers.

PARTICIPANTS

Eligible participants were Veterans with SCI or ALs (N=516); 482 of them completed the interview. Analyses were restricted to white and African American participants. Because there was no variation in wheelchair quality among AL patients (n=42), they were excluded from all but descriptive analyses, leading to a final sample size of 421.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Wheelchair quality as defined by the Medicare Healthcare Common Procedure Coding System.

RESULTS

We found race differences in many of our variables, but not in quality for manual (odds ratio [OR]=.67; 95% confidence interval [CI], .33-1.36) or power (OR=.82; 95% CI, .51-1.34) wheelchairs. Several factors including age (OR=.96; 95% CI, .93-.99) and income (OR=3.78; 95% CI, 1.43-9.97) were associated with wheelchair quality. There were no significant associations of cultural or psychosocial factors with wheelchair quality.

CONCLUSIONS

Although there were no racial differences in wheelchair quality, we found a significant association of older age and lower income with poorer wheelchair quality among Veterans. Efforts are needed to raise awareness of such disparities among VA wheelchair providers and to take steps to eliminate these disparities in prescription practice across VA sites.