From genes to social science: impact of the simplistic interpretation of race, ethnicity, and culture on cancer outcome

Cultural Influence on Family Management of Children With Cancer

A family's cultural context directly influences how they define and manage their child's cancer. Knowing this dynamic can guide nurses in delivering holistic, culturally competent care. This literature review examines the international and domestic pediatric oncology research as it relates to the inclusion of family and cultural variables. Most international studies and comparative studies have investigated Asian cultures and found that health beliefs, communication beliefs, religious practice, and family structure are common themes of cultural influences on families. Additional studies within the United States are needed to explore cultural beliefs through carefully tailored family assessments. Implications for practice include the possibility of providing evidence-based culturally competent care to families of children with cancer.

Association of race/ethnicity, socioeconomic status, and breast cancer subtypes in the National Cancer Data Base (2010-2011)

To estimate the odds of breast cancer subtypes in minority populations versus non-Hispanic (NH) whites stratified by socioeconomic status (SES) [a composite of individual-level SES (insurance status) and area-level SES (median household income quartile from 2000 U.S. Census data)] using a large nationwide cancer database. We used the National Cancer Data Base to identify breast cancer cases diagnosed in 2010 and 2011, the only 2 years since U.S. cancer registries uniformly began collecting HER2 results. Breast cancer cases were classified into five subtypes based on hormone receptor (HR) and HER2 status: HR+/HER2-, HR+/HER2+, HR-/HER2+ (HER2-overexpressing), HR-/HER2- (TN), and unknown. A polytomous logistic regression was used to estimate odds ratios (ORs) comparing the odds of non-HR+/HER2-subtypes to HR+/HER2- for racial/ethnic groups controlling for and stratifying by SES, using a composite of insurance status and area-level income. Compared with NH whites, NH blacks and Hispanics were 84 % (OR = 1.84; 95 % CI 1.77-1.92) and 17 % (OR = 1.17; 95 % CI 1.11-1.24) more likely to have TN subtype versus HR+/HER2-, respectively. Asian/Pacific Islanders (API) had 1.45 times greater odds of being diagnosed with HER2-overexpressing subtype versus HR+/HER2- compared with NH whites (OR = 1.45; 95 % CI 1.31-1.61). We found similar ORs for race in high and low strata of SES. In a large nationwide hospital-based dataset, we found higher odds of having TN breast cancer in black women and of HER2-overexpressing in API compared with white women in every level of SES.

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.

Is workplace smoking policy equally prevalent and equally effective among immigrants?

BACKGROUND

This study examined whether immigrants were less likely to be covered by a smoke-free workplace policy and whether workplace smoking policies garnered comparable associations with smoking for immigrants and for those born in the USA.

METHODS

Investigators applied multiple logistic regression to the 2001-2 Current Population Survey Tobacco Use Supplement among US indoor workers (n = 85,784). The study examined first, whether nativity (immigrants vs US born) was independently associated with smoke-free policy coverage, and second, whether the smoke-free policy association with current smoking was differential by nativity (effect modification).

RESULTS

Immigrants were less likely to work in smoke-free workplaces than those born in the USA; however, occupation and industry accounted for these disparities. Employment in a workplace that was not smoke free was associated with higher odds of smoking (vs smoke-free workplaces), both before (OR 1.83, 95% CI 1.74 to 1.92) and after (OR 1.36, CI 1.29 to 1.44) covariate adjustment among the US born, but associations were weaker among immigrants (OR 1.39, CI 1.20 to 1.61, unadjusted; OR 1.15 CI 0.97 to 1.35 adjusted). Worker industry partly explained (16% of) the weaker policy-smoking association among immigrants, while other socioeconomic variables reduced the policy-smoking association without explaining the disparity.

CONCLUSIONS

The patchwork of US workplace smoking restriction policy at different governmental levels, combined with a voluntary regime among some employers, generates coverage inequalities. Workplace smoke-free policies may be less effective for immigrants, and this is related to differential coverage by such policies due to occupational segregation. Understanding the complex patterns of the social context of smoking is important for understanding how policy interventions might have heterogeneous effects for different demographic groups.

The development of a culturally informed, family-focused treatment for schizophrenia

With the changing demographics in the United States, there is an increasing need for psychotherapy interventions that have been tailored for and empirically evaluated with culturally diverse groups. This article discusses the development and evaluation of a family-focused, culturally informed therapy for schizophrenia (CIT-S) that is currently being pilot tested at the University of Miami. Case examples of CIT-S with participating families are provided, along with a discussion of interesting and challenging cultural issues that we have encountered during the pilot phase of this treatment study.

Population science is science only if you know the population

BACKGROUND

Cancer control efforts have had limited effect in reducing the inequities for minorities and the medically underserved. One factor is the lack of theory-based conceptualization of the terms used to define race, ethnicity, and culture.

METHOD

Guidelines are provided to develop more accurate use of the terms race, ethnicity, and culture to determine standards of comparability across studies of cancer incidence, survival, and quality of life in diverse populations rather than stereotypes.

RESULTS AND CONCLUSIONS

Our ability to use theoretically based criteria to differentiate groups of people could increase our ability to more effectively eliminate these disparities.

A strategy to reduce cross-cultural miscommunication and increase the likelihood of improving health outcomes

Encounters between physicians and patients from different cultural backgrounds are becoming commonplace. Physicians strive to improve health outcomes and increase quality of life for every patient, yet these discordant encounters appear to be a significant factor, beyond socioeconomic barriers, in creating the unequal and avoidable excess burden of disease borne by members of ethnic minority populations in the United States. Most clinicians lack the information to understand how culture influences the clinical encounter and the skills to effectively bridge potential differences. New strategies are required to expand medical training to adequately address culturally discordant encounters among the physicians, their patients, and the families, for all three may have different concepts regarding the nature of the disease, expectations about treatment, and modes of appropriate communication beyond language. The authors provide an anthropological perspective of the fundamental relationship between culture and health, and outline systemic changes needed within the social and legal structures of the health care system to reduce the risk of cross-cultural miscommunication and increase the likelihood of improving health outcomes for all populations within the multicultural U.S. society. The authors define the strengths inherent within every culture, provide a guideline for the clinician to evaluate disease and illness within its cultural context, and outline the clinical skills required to negotiate among potential differences to reach mutually desired goals for care. Last, they indicate the structural changes required in the health care setting to enable and support such practice.