Toward improved health: disaggregating Asian American and Native Hawaiian/Pacific Islander data

Race, ethnicity, and linguistic isolation as determinants of participation in public health surveillance surveys

INTRODUCTION

To plan, implement, and evaluate programs designed to improve health conditions among racial and ethnic minority populations in the United States, public health officials and researchers require valid and reliable health surveillance data. Monitoring chronic disease and behavioral risk factors among such populations, however, is challenging. This study assesses the effects of race, ethnicity, and linguistic isolation on rates of participation in the Behavioral Risk Factor Surveillance System (BRFSS).

METHODS

County-level data from the 2003 BRFSS survey and 2000 U.S. census were used to examine the effects of race, ethnicity, and linguistic isolation on six measures of survey participation (i.e., rates of resolution, screening, cooperation, response, language barriers, and refusal).

RESULTS

Participation rates were significantly lower in counties with higher percentages of black people and people who did not speak English. Response rates decreased by 4.6% in counties with the highest concentration of black residents compared with counties with few black residents. Likewise, response rates decreased by approximately 7% in counties in which a larger percentage of the population spoke only Spanish or another Indo-European language compared with counties in which all residents spoke English.

CONCLUSION

The negative relationship between the percentage of Spanish-only-speaking households and participation rates is troubling given that the BRFSS is conducted in both Spanish and English. The findings also indicate that more needs to be done to improve participation among other minorities. Researchers are investigating several ways of addressing disparities in participation rates, such as using postsurvey adjustments, developing more culturally appropriate data-collection procedures, and offering surveys in multiple languages.

Differential mortality and transplantation rates among Asians and Pacific Islanders with ESRD

Few studies in patients with ESRD have examined outcomes in Asian or Pacific Islander subgroups compared with white individuals. The objective of this study was to assess ethnic disparities in mortality and kidney transplantation among a multiethnic cohort of incident dialysis patients. A total of 24,963 patients who initiated dialysis within the TransPacific Renal Network (Network 17) between April 1, 1995, and September 30, 2001, were studied to ascertain death and kidney transplantation through September 30, 2002. Overall, 12,902 deaths and 2258 kidney transplantations were observed during 59,075 person-years of follow-up. Mortality on dialysis among Asians and Pacific Islanders (except Chamorros) was lower than that of white individuals after controlling for differences in sociodemographic characteristics, comorbid conditions, and other risk factors for death (adjusted hazard ratio [95% confidence interval] versus white individuals: Japanese 0.64 [0.57 to 0.72], Chinese 0.64 [0.52 to 0.78], Filipino 0.64 [0.57 to 0.72], Native Hawaiian 0.84 [0.72 to 0.96], Samoan 0.62 [0.48 to 0.82], and Chamorro 0.96 [0.84 to 1.20]). In contrast, Asians and Pacific Islanders were much less likely to undergo kidney transplantation (adjusted rate ratio [95% confidence interval] versus white individuals: Japanese 0.34 [0.24 to 0.46], Chinese 0.54 [0.30 to 0.88], Filipino 0.32 [0.26 to 0.47], Native Hawaiian 0.17 [0.10 to 0.30], Samoan 0.17 [0.07 to 0.38], and Chamorro 0.04 [0.01 to 0.14]). Despite wide variations in primary cause of ESRD, clinical characteristics, and body size at dialysis initiation, Asians and Pacific Islanders experience better survival but substantially lower transplantation rates compared with white individuals. Strategies that are aimed at improving access to transplantation in Asian and Pacific Islander communities may further enhance survival among Asians and Pacific Islanders with ESRD.

Differences in the health care needs and service utilization of women in nursing homes: comparison by race/ethnicity

The purpose of this study is to describe health care needs and service utilization among institutionalized women of color. The sample was dichotomized by length of stay to determine how African American, Native American, Asian/Pacific Islander, and Hispanic/Latino women differed at two points in time. Data for this study came from the Current Resident Survey of the 1999 National Nursing Home Survey. The data were analyzed using GLM. The findings suggest that Native American women are the most impaired and Asian/Pacific Islander women are the least impaired. Additionally, very few women received mental health services despite their extensive need.

Leisure time, non-leisure time, and occupational physical activity in Asian Americans

PURPOSE

Asian American immigrants' risk of heart disease, diabetes, and obesity increase with duration of residence in the United States (US). Regular physical activity reduces the risk of these diseases, yet little is known about physical activity in Asian Americans and how it changes after immigration.

METHODS

Data from the 2001 California Health Interview Survey, which oversampled Asian Americans, were analyzed to investigate the effects of ethnicity, nativity, and years in the US on leisure time physical activity (LTPA), non-leisure time physical activity (NLTPA), and occupational physical activity. A total of 4226 Asian Americans and 29,473 US-born non-Asians were included.

RESULTS

Asian Americans were much less likely to meet recommended levels of LTPA than US-born non-Asians (odds ratio [OR], men=0.51, 95% confidence interval [CI], 0.42, 0.61, OR, women = 0.48, 95% CI, 0.40, 0.57). Foreign-born Asians were least likely to participate in LTPA; LTPA increased as years in the US increased. After accounting for NLTPA, Asian Americans had significantly lower estimated weekly energy expenditure than US-born non-Asians.

CONCLUSIONS

Asian Americans, especially immigrants, are at risk for low levels of LTPA and high levels of physical inactivity. NLTPA does not offset these lower levels of LTPA. Increasing physical activity is key to protecting the health of this rapidly growing population.

Mental health care for ethnic minority individuals and communities in the aftermath of disasters and mass violence

Findings from research on psychiatric epidemiology, disaster effects, discrepancies in service use, and cross-cultural psychology are reviewed to generate guidelines for culturally responsive postdisaster interventions. Ethnicity and culture influence mental health care at various points: on need for help; on availability and accessibility of help; on help-seeking comfort (stigma, mistrust), and on the probability that help is provided appropriately. There are aspects of disaster mental health practice that may ameliorate many of barriers that contribute to ethnic disparities in service use. It is proposed that interventions should give greater attention to socially engaged emotions and functioning. To promote disaster recovery, practitioners are advised to: assess community needs early and often; provide easily accessible services; work collaboratively and proactively to reduce stigma and mistrust and engage minorities in care; validate and normalize distress and help-seeking; value interdependence as well as independence as an appropriate developmental goal; promote community action; and advocate for, facilitate, or conduct treatment and evaluation research. Notwithstanding the pain and stress they cause, disasters create opportunities to de-stigmatize mental health needs and build trust between providers and minority communities.

Inconsistencies between self-reported ethnicity and ethnicity recorded in a health maintenance organization

PURPOSE

Information on patient ethnicity in hospital admissions databases is often used in epidemiologic and health services research. However, the extent of consistency of these data with self-reported ethnicity is not well studied, particularly for specific Asian subgroups. We examined agreement between ethnicity in records of a sample of members of five Northern California Kaiser Permanente medical centers with self-reported ethnicity.

METHODS

Subjects were 3168 cases and 2413 controls aged 45 years and older from a study of fractures. Ethnicity recorded in the Kaiser admissions database (primarily inpatient) was compared with self-reported ethnicity from the study interviews.

RESULTS

Among study subjects with available Kaiser ethnicity, sensitivities and positive predictive values of the Kaiser classification were high among blacks (0.95 for both measures) and whites (0.98 and 0.94, respectively), slightly lower among Asians (0.88 and 0.95, respectively), and considerably lower among Hispanics (0.55 and 0.81, respectively) and American Indians (0.47 and 0.50, respectively). Among Asian subgroups, the proportion classified as Asian was high among Chinese (0.94) and Japanese (0.99) but lower among Filipinos (0.79) and other Asians (0.74). Among the 228 (4%) subjects who self-identified with multiple ethnicities, 13 of 18 white + Hispanic subjects were classified as being white, and of the 77 subjects identifying as part American Indian, only one was classified as being American Indian in the Kaiser database.

CONCLUSIONS

Given the importance of ethnicity information, medical facilities should be encouraged to adopt policies toward collecting high quality data.

Health status of Cambodians and Vietnamese--selected communities, United States, 2001-2002

National health data often are reported for Asians in the aggregate and do not monitor the health of specific Asian subpopulations (e.g., Cambodians and Vietnamese) in the United States. In addition, surveys conducted in English exclude Cambodians and Vietnamese with limited English proficiency. This report summarizes and compares health data from 1) a survey of one Cambodian and three Vietnamese communities conducted during 2001-2002 for the Racial and Ethnic Approaches to Community Health (REACH) 2010 project and 2) a survey of Asians in the aggregate and the general U.S. population conducted by the 2002 Behavioral Risk Factor Surveillance System (BRFSS). The questions were identical on both surveys. The results of this analysis indicated that Cambodians and Vietnamese had lower levels of education and household income and substantially different health-risk profiles than both the aggregate Asian population and the general U.S. population. Public health agencies should examine the health status of racial/ethnic subpopulations and prioritize interventions that address disparities.

Inclusion of immigrant status in smoking prevalence statistics

OBJECTIVES

Data from the 1995-1996 and 1998-1999 Current Population Survey tobacco use supplements were used to examine smoking prevalence statistics by race/ethnicity and immigrant status.

METHODS

Smoking prevalence statistics were calculated, and these data were decomposed by country of birth for Asian immigrants to illustrate the heterogeneity in smoking rates present within racial/ethnic groups.

RESULTS

Except in the case of male Asian/Pacific Islanders, immigrants exhibited significantly lower smoking prevalence rates than nonimmigrants. However, rates varied according to country of birth.

CONCLUSIONS

This research highlights the need to disaggregate health statistics by race/ethnicity, sex, immigrant status, and, among immigrants, country of birth. Data on immigrants' health behaviors enhance the development of targeted and culturally sensitive public health smoking prevention programs.

Racial and ethnic identification practices in public health data systems in New England

OBJECTIVE

Efforts are underway to standardize "racial" and "ethnic" identification in public health data systems under the Revised Minimum Standards for the Classification of Federal Data on Race and Ethnicity issued in 1997. This study analyzed the racial and ethnic constructs and labels used in public health data systems maintained by the six New England states in light of these standards.

METHODS

The authors surveyed public health officials responsible for ongoing individual-level data systems and reviewed relevant documents.

RESULTS

Information was obtained on 169 of 170 identified data systems. Ninety-one systems (54%) conformed to the federal standard in having separate "race" and "ethnicity" fields, yet many of these did not conform to the standard in other respects. Fifty-five systems had only a race field; of these, 20 included no identifiers corresponding to Hispanic and/or Latino ethnicity. Three systems used only an ethnicity field. The systems used various lists of racial and/or ethnic categories, and overlapping but not fully comparable labels. Few systems allowed for identification of ancestry groups not included in the revised federal guidelines but with large populations in New England, such as Brazilians. Some definitions and coding instructions seemed inconsistent with social and geographic reality.

CONCLUSIONS

These public health data systems used inconsistent methods for classifying people by race and ethnicity. Standardization according to federal standards would improve comparability, but would limit options for defining and including some ethnic groups while forcing other groups to be aggregated in single race categories, perhaps inappropriately. Fundamental reconsideration of racial and ethnic categorization is called for.

Classification of race and ethnicity: implications for public health

Emerging methods in the measurement of race and ethnicity have important implications for the field of public health. Traditionally, information on race and/or ethnicity has been integral to our understanding of the health issues affecting the U.S. population. We review some of the complexities created by new classification approaches made possible by the inclusion of multiple-race assessment in the U.S. Census and large health surveys. We discuss the importance of these classification decisions in understanding racial/ethnic health and health care access disparities. The trend toward increasing racial and ethnic diversity in the United States will put further pressure on the public health industry to develop consistent and useful approaches to racial/ethnic classifications.

Racial and ethnic disparity in blood pressure and cholesterol measurement

OBJECTIVE

To evaluate racial and ethnic disparity in blood pressure and cholesterol measurement and to analyze factors associated with any observed disparity.

DESIGN

Cross-sectional analysis of the household component of the 1996 Medical Expenditure Panel Survey.

PARTICIPANTS

Representative sample of the U.S. non-institutionalized population age 21 or older.

MEASUREMENTS

Prevalence of self-reported blood pressure measurement within 2 years and cholesterol measurement within 5 years were calculated by race/ethnicity. Logistic regression was used to adjust for health insurance status, having a usual source of care, health status, and socioeconomic and demographic factors. Odds ratios and 95% confidence intervals (95% CIs) from the logistic regression were converted to prevalence ratios to estimate relative risk (RR).

MAIN RESULTS

Mexican Americans compared to non-Hispanic whites were less likely to have a blood pressure measurement (RR, 0.85; 95% CI, 0.81 to 0.89) or a cholesterol measurement (RR, 0.72; 95% CI, 0.65 to 0.78). Non-Hispanic blacks had blood pressure and cholesterol measurements similar to non-Hispanic whites. In a multivariate analysis, Mexican Americans had similar blood pressure measurements (RR, 0.97; 95% CI, 0.94 to 1.00) and cholesterol measurements (RR, 1.04; 95% CI, 0.99 to 1.08). The factors associated with the largest disparity were lack of health insurance, not having a usual source of care, and low education.

CONCLUSIONS

No disparity was found between non-Hispanic blacks and non-Hispanic whites in undergoing blood pressure and cholesterol measurement. Disparities in cardiovascular preventive services for Mexican Americans were associated with lack of health insurance and a usual source of care, but other demographic and socioeconomic factors were also important.

Racial/ethnic variations in women's health: the social embeddedness of health

This article provides an overview of the magnitude of and trends in racial/ethnic disparities in health for women in the United States. It emphasizes the importance of attending to diversity in the health profiles and populations of minority women. Socioeconomic status is a central determinant of racial/ethnic disparities in health, but several other factors, including medical care, geographic location, migration and acculturation, racism, and exposure to stress and resources also play a role. There is a need for renewed attention to monitoring, understanding, and actively seeking to eliminate racial/ethnic disparities in health.

Moving forward: addressing the health of Asian American and Pacific Islander women

Little is known about the health of Asian American and Pacific Islander (AAPI) women, a rapidly growing population marked by diverse sociodemographic characteristics, health needs, and access to and use of health services. This commentary provides broad recommendations for research, program development, and policy development based on the first-ever White House Initiative report on AAPIs. These recommendations address the issues of data, access, civil rights, community capacity, and the need to recognize ethnic subgroups among the AAPI population. Reflecting on the events of the past year, the recommendations provide direction for public health to address the health and well-being of AAPI women.

Risk behaviors of Filipino methamphetamine users in San Francisco: implications for prevention and treatment of drug use and HIV

OBJECTIVE

This study describes the demographics, HIV risk and drug use behaviors, and psychosocial status of Filipino American methamphetamine users in the San Francisco Bay area.

METHODS

Individual interviews were conducted with 83 Filipino American methamphetamine users, recruited through snowball sampling methods. A structured survey questionnaire included measures of drug use behaviors, HIV-related sexual behaviors, psychosocial factors, and demographics.

RESULTS

Filipino methamphetamine users tended to be male, to have low levels of perceived personal control in their lives, and to report low levels of shame about their drug use. Methamphetamine use was strongly associated with HIV-related risk behaviors. Frequent methamphetamine users tended to engage in drug use before or during sex and to use condoms infrequently. Commercial sex activity was associated with frequency of methamphetamine use. About one-third of the study participants had never been tested for HIV.

CONCLUSION

HIV/STD and drug abuse prevention programs that target Filipino Americans are needed. These programs should be tailored to meet clients' needs on the basis of gender, employment status, acculturation, and psychosocial variables that affect drug use and sexual behaviors.