Number of Chronic Medical Conditions Fully Mediates the Effects of Race on Mortality; 25-Year Follow-Up of a Nationally Representative Sample of Americans

General Anxiety Disorder-7 Questionnaire as a marker of low socioeconomic status and inequity

BACKGROUND

The General Anxiety Disorder-7 (GAD-7) questionnaire is a standard tool used for screening and follow-up of patients with Generalized Anxiety Disorder (GAD). Although it is generally accepted that anxiety correlates with clinical and psychosocial stressors, precise quantitative data is limited on the relations among GAD-7, traditional biomarkers, and other measures of health. Further research is needed about how GAD-7 relates to race, ethnicity, and socioeconomic status (SES) as an assembly. We determined how multiple demographic and socioeconomic data correlate with the participants' GAD-7 results when compared with laboratory, physical function, clinical, and other biological markers.

METHODS

The Project Baseline Health Study (BHS) is a prospective cohort of adults representing several populations in the USA. We analyzed a deeply phenotyped group of 2502 participants from that study. Measures of interest included: clinical markers or history of medical diagnoses; physical function markers including gait, grip strength, balance time, daily steps, and echocardiographic parameters; psychometric measurements; activities of daily living; socioeconomic characteristics; and laboratory results.

RESULTS

Higher GAD-7 scores were associated with female sex, younger age, and Hispanic ethnicity. Measures of low SES were also associated with higher scores, including unemployment, income ≤$25,000, and ≤12 years of education. After adjustment for 158 demographic, clinical, laboratory, and symptom characteristics, unemployment and overall higher SES risk scores were highly correlated with anxiety scores. Protective factors included Black race and older age.

LIMITATIONS

Correlations identified in this cross-sectional study cannot be used to infer causal relationships; further, we were not able to account for possible use of anxiety treatments by study participants.

CONCLUSIONS

These findings highlight the importance of understanding anxiety as a biopsychosocial entity. Clinicians and provider organizations need to consider both the physical manifestations of the disorder and their patients' social determinants of health when considering treatment pathways and designing interventions.

Family's Subjective Economic Status and Children's Matrix Reasoning: Blacks' Diminished Returns

BACKGROUND

Due to a pattern known as Marginalization-related Diminished Returns (MDRs), historically oppressed non-Hispanic Black Americans show weaker effects of economic status on health and development, when compared to socially privileged non-Hispanic White Americans. Such MDRs are also documented for the effects of economic status on the school performance of non-Hispanic Black children. However, the existing knowledge is minimal on similar diminished returns on children's intelligence.

AIM

To compare racial and ethnic groups for the effect of subjective economic status on children's cognitive performance, we compared non-Hispanic White and non-Hispanic Black children for the effects of subjective economic status on children's matrix reasoning.

METHODS

This cross-sectional study included 7898 children from the Adolescent Brain Cognitive Development (ABCD) study. The predictor variable was subjective economic status, which was treated as a continuous measure. The primary outcome was children's matrix reasoning, a domain of cognitive performance, measured by the Wechsler Intelligence Scales for Children-IV (WISC-V) matrix reasoning total score.

RESULTS

Overall, high subjective economic status was associated with higher matrix reasoning score. Race showed a statistically significant interaction with subjective economic status on children's matrix reasoning score. This interaction suggested that high subjective economic status has a smaller boosting effect on increasing matrix reasoning score for non-Hispanic Black children relative to non-Hispanic White children.

CONCLUSION

The degree by which subjective economic status correlates with matrix reasoning score, an important domain of cognitive performance, depends on race and racialization. Non-Hispanic Black children may show weaker gains in matrix reasoning from their subjective economic status than their non-Hispanic White counterparts. To minimize the racial gap in cognitive performance, we need to address diminished returns that occur as a result of the racialization of racial and ethnic minority children. Not only should we equalize economic status, but also increase the marginal returns of economic status for racial minorities, particularly non-Hispanic Black families. Such efforts require public policies that go beyond access and also consider how we can empower non-Hispanic Black communities and families so they can more effectively leverage and utilize their economic resources to secure measurable and tangible outcomes. Structural and societal barriers such as residential and school segregation may hinder non-Hispanic Black children from receiving the full effects of their family-level economic status on a variety of outcomes, including their cognitive performance.

Impact of paternal education on epigenetic ageing in adolescence and mid-adulthood: a multi-cohort study in the USA and Mexico

BACKGROUND

Both parental and neighbourhood socio-economic status (SES) are linked to poorer health independently of personal SES measures, but the biological mechanisms are unclear. Our objective was to examine these influences via epigenetic age acceleration (EAA)-the discrepancy between chronological and epigenetic ages.

METHODS

We examined three USA-based [Coronary Artery Risk Disease in Adults (CARDIA) study, Fragile Families and Child Wellbeing Study (FFCWS) and Programming Research in Obesity, Growth, Environment and Social Stressors (PROGRESS)] and one Mexico-based (Project Viva) cohort. DNA methylation was measured using Illumina arrays, personal/parental SES by questionnaire and neighbourhood disadvantage from geocoded address. In CARDIA, we examined the most strongly associated personal, parental and neighbourhood SES measures with EAA (Hannum's method) at study years 15 and 20 separately and combined using a generalized estimating equation (GEE) and compared with other EAA measures (Horvath's EAA, PhenoAge and GrimAge calculators, and DunedinPoAm).

RESULTS

EAA was associated with paternal education in CARDIA [GEEs: βsome college = -1.01 years (-1.91, -0.11) and β<high school = 1.05 (0.09, 2.01) vs college graduates] and FFCWS [GEEs: β<high school = 0.62 (0.00, 1.24)]. We found stronger associations for some paternal education categories among White adults (for GEE, βsome college = -1.39 (-2.41, -0.38)], men (βsome college = -1.76 (-3.16, -0.35)] and women [β<high school = 1.77 (0.42, 3.11)].

CONCLUSIONS

These findings suggest that EAA captures epigenetic impacts of paternal education independently of personal SES later in life. Longitudinal studies should explore these associations at different life stages and link them to health outcomes. EAA could be a useful biomarker of SES-associated health and provide important insight into the pathogenesis and prevention of chronic disease.

Racial Disparities in COVID-19 Testing and Outcomes : Retrospective Cohort Study in an Integrated Health System

BACKGROUND

Racial disparities exist in outcomes after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection.

OBJECTIVE

To evaluate the contribution of race/ethnicity in SARS-CoV-2 testing, infection, and outcomes.

DESIGN

Retrospective cohort study (1 February 2020 to 31 May 2020).

SETTING

Integrated health care delivery system in Northern California.

PARTICIPANTS

Adult health plan members.

MEASUREMENTS

Age, sex, neighborhood deprivation index, comorbid conditions, acute physiology indices, and race/ethnicity; SARS-CoV-2 testing and incidence of positive test results; and hospitalization, illness severity, and mortality.

RESULTS

Among 3 481 716 eligible members, 42.0% were White, 6.4% African American, 19.9% Hispanic, and 18.6% Asian; 13.0% were of other or unknown race. Of eligible members, 91 212 (2.6%) were tested for SARS-CoV-2 infection and 3686 had positive results (overall incidence, 105.9 per 100 000 persons; by racial group, White, 55.1; African American, 123.1; Hispanic, 219.6; Asian, 111.7; other/unknown, 79.3). African American persons had the highest unadjusted testing and mortality rates, White persons had the lowest testing rates, and those with other or unknown race had the lowest mortality rates. Compared with White persons, adjusted testing rates among non-White persons were marginally higher, but infection rates were significantly higher; adjusted odds ratios [aORs] for African American persons, Hispanic persons, Asian persons, and persons of other/unknown race were 2.01 (95% CI, 1.75 to 2.31), 3.93 (CI, 3.59 to 4.30), 2.19 (CI, 1.98 to 2.42), and 1.57 (CI, 1.38 to 1.78), respectively. Geographic analyses showed that infections clustered in areas with higher proportions of non-White persons. Compared with White persons, adjusted hospitalization rates for African American persons, Hispanic persons, Asian persons, and persons of other/unknown race were 1.47 (CI, 1.03 to 2.09), 1.42 (CI, 1.11 to 1.82), 1.47 (CI, 1.13 to 1.92), and 1.03 (CI, 0.72 to 1.46), respectively. Adjusted analyses showed no racial differences in inpatient mortality or total mortality during the study period. For testing, comorbid conditions made the greatest relative contribution to model explanatory power (77.9%); race only accounted for 8.1%. Likelihood of infection was largely due to race (80.3%). For other outcomes, age was most important; race only contributed 4.5% for hospitalization, 12.8% for admission illness severity, 2.3% for in-hospital death, and 0.4% for any death.

LIMITATION

The study involved an insured population in a highly integrated health system.

CONCLUSION

Race was the most important predictor of SARS-CoV-2 infection. After infection, race was associated with increased hospitalization risk but not mortality.

PRIMARY FUNDING SOURCE

The Permanente Medical Group, Inc.

Resilient Leadership: A Phenomenological Exploration Into How Black Women in Higher Education Leadership Navigate Cultural Adversity

This article explores adversity and the lived experiences of Black women in higher education leadership. Using phenomenology, this study specifically explores how Black women in higher education leadership navigate the adverse challenges of intersectionality, stereotype threat, and tokenism. Black women in leadership undergo adversity including limited role models, the concrete ceiling, and the intersectionality of racism, sexism, and ageism, as well as tokenism. The current findings validate that Black women in higher education leadership experience adversity. Some of the more salient codes that emerged were discrimination such as racism, sexism, ageism, and the intersection of these challenges with identity, cultural diversity and belonging, resilience, and leadership callings. Referred to as “superwomen,” Black women are resilient and strong. The results of this study reveal that Black women use adversity as fuel, thus helping them develop the necessary skills to prepare them for leadership. Their strength through adversity is driven by the resilience that has manifested as motivation factors such as family and relationships, mentorship and sponsorship, as well as the support of cultural identity and diversity. The current findings support the notion that adversity shapes Black women into leaders with an emphasis on higher education leadership.

Not Race or Age but Their Interaction Predicts Pre-Adolescents' Inhibitory Control

Background

African American pre-adolescents are at a higher risk of risky behaviors such as aggression, drug use, alcohol use, and subsequent poor outcomes compared to Caucasian pre-adolescents. All these high-risk behaviors are connected to low levels of inhibitory control (IC).

Aim

We used the Adolescent Brain Cognitive Development (ABCD) data to compare Caucasian and African American pre-adolescents for the effect of age on pre-adolescents IC, a driver of high-risk behaviors.

Methods

This cross-sectional analysis included 4,626 pre-adolescents between ages 9 and 10 from the ABCD study. Regression was used to analyze the data. The predictor variable was age measured in months. The main outcome was IC measured by a stop-signal task (SST). Race was the effect modifier.

Results

Overall, age was associated with IC. Race also showed a statistically significant interaction with age on pre-adolescents' IC, indicating weaker effects of age on IC for African American than Caucasian pre-adolescents.

Conclusion

Age-related changes in IC are more pronounced for Caucasian than African American pre-adolescents. To eliminate the racial gap in brain development between African American and Caucasian pre-adolescents, we should address structural and societal barriers that alter age-related development for racial minority pre-adolescents. Social and public policies, rather than health policies, are needed to address structural and societal barriers that hinder African American adolescents' brain development. Interventions should add resources to the urban areas that many African American families live in so their children can have better age-related brain development. Such changes would be essential given IC in pre-adolescents is a predictor of a wide range of behaviors.

Parental Human Capital and Adolescents' Executive Function: Immigrants' Diminished Returns

Racial minorities, particularly non-Hispanic Blacks in the US, experience weaker effects of family socioeconomic position (SEP) on tangible outcomes, a pattern called Minorities' Diminished Returns (MDRs). These MDRs are frequently shown for the effects of family SEP on immigrant adolescents' school performance. As a result of these MDRs, immigrant adolescents from high SEP families show worse than expected cognitive outcomes, including but not limited to poor school performance. However, the existing knowledge is minimal about the role of executive function in explaining diminished returns of family SEP on adolescents' outcomes. To investigate racial differences in the effects of parental human capital on adolescents' executive function, we compared non-Hispanic White non-immigrant and immigrant adolescents for the effect of parental human capital on adolescents' executive function. This was a cross-sectional analysis that included 2,723 non-twin non-Hispanic White adolescents from the Adolescent Brain Cognitive Development (ABCD) study. The independent variable was parental human capital (parental educational attainment), treated as a continuous measure with a higher score reflecting higher subjective socioeconomic status. The primary outcome was adolescents' executive function measured by the stop-signal task (SST). Age, sex, parental marital status, parental employment, family income, and financial difficulties. Immigration status was the effect modifier. Overall, high parental human capital was associated with higher task-based executive function. Immigration status showed statistically significant interactions with parental human capital on adolescents' executive function outcomes. This interaction term suggested that high parental human capital has a smaller effect on increasing immigrants' executive function compared to non-immigrant adolescents. The boosting effect of parental human capital on executive function is diminished for immigrants compared to non-immigrant adolescents. To minimize the inequalities in executive function-related outcomes such as school performance, we need to address the diminishing returns of existing resources for immigrants. Not only should we equalize groups based on their SEP but also equalize the marginal returns of their existing SEP. Such efforts require public policies that aim for equal processes. As such, social policies should address structural and societal barriers such as xenophobia, segregation, racism, and discrimination that hinder immigrant families' ability to effectively utilize their resources. In a fair society, immigrant and non-immigrant families should be equally able to leverage their SEP resources and turn them into tangible outcomes.

Subjective Family Socioeconomic Status and Adolescents' Attention: Blacks' Diminished Returns

Background: Racial minorities, particularly non-Hispanic blacks (NHBs) in the US, experience weaker effects from their families' socioeconomic status on tangible outcomes, a pattern called the Minorities' Diminished Returns (MDRs) theory. These MDRs are frequently shown in the effects of the families' socioeconomic status (SES) on NHB adolescents' school performance. As a result of these MDRs, NHB adolescents from high SES families show a worse than expected school performance. The existing knowledge is, however, minimal about the role of attention in explaining the diminished returns of the families' SES with regard to the adolescents' outcomes. Aim: To investigate the racial differences in the effects of the subjective family SES on adolescents' attention, we compared non-Hispanic white (NHW) and NHB adolescents to assess the effect of the subjective family SES on adolescents' attention. Methods: This was a cross-sectional analysis that included 4188 adolescents from the Adolescent Brain Cognitive Development (ABCD) Study. The independent variable was the subjective family SES. The primary outcome was the adolescents' attention to be measured by the stop-signal task (SST). The attention domain of the Child Behavior Checklist (CBCL) was also measured. Results: Overall, a high subjective family SES was associated with a higher task-based and CBCL-based attention. Race showed statistically significant interactions with subjective family SES in terms of adolescents' attention outcomes. These interactions suggested that a high subjective family SES has smaller tangible effects on increasing the attention of NHB than NHW adolescents. Conclusion: The boosting effect of subjective family SES on attention is diminished for NHB rather than NHW adolescents. To minimize the racial gap in attention-related behaviors, such as school performance, we need to address the diminished returns of resources in the lives of NHB families. Not only should we equalize SES, but also increase the marginal returns of SES for racial minorities, particularly NHB families. Such efforts require public policies that empower NHB families to better leverage their SES resources and turn them into tangible outcomes. In addition, social policies should directly aim to alter the societal barriers that limit NHB families' ability to effectively utilize their resources. Discrimination, segregation, and racism should be targets of our policy solutions.

African American Children's Diminished Returns of Subjective Family Socioeconomic Status on Fun Seeking

Background: Reward sensitivity (fun-seeking) is a risk factor for a wide range of high-risk behaviors. While high socioeconomic status (SES) is known to reduce reward sensitivity and associated high-risk behaviors, less is known about the differential effects of SES on reward sensitivity. It is plausible to expect weaker protective effects of family SES on reward sensitivity in racial minorities, a pattern called Minorities' Diminished Returns (MDRs). Aim: We compared Caucasian and African American (AA) children for the effects of subjective family SES on children's fun-seeking. Methods: This was a cross-sectional analysis of 7061 children from the Adolescent Brain Cognitive Development (ABCD) study. The independent variable was subjective family SES. The main outcome was children's fun-seeking measured by the behavioral approach system (BAS) and behavioral avoidance system (BIS). Age, gender, marital status, and household size were the covariates. Results: In the overall sample, high subjective family SES was associated with lower levels of fun-seeking. We also found a statistically significant interaction between race and subjective family SES on children's fun-seeking in the overall sample, suggesting that high subjective family SES is associated with a weaker effect on reducing fun-seeking among AA than Caucasian children. In race-stratified models, high subjective family SES was protective against fun-seeking of Caucasian but not AA children. Conclusion: Subjective family SES reduces the fun-seeking for Caucasian but not AA children.

Reward Responsiveness in the Adolescent Brain Cognitive Development (ABCD) Study: African Americans' Diminished Returns of Parental Education

(1) Background: Reward responsiveness (RR) is a risk factor for high-risk behaviors such as aggressive behaviors and early sexual initiation, which are all reported to be higher in African American and low socioeconomic status adolescents. At the same time, parental education is one of the main drivers of reward responsiveness among adolescents. It is still unknown if some of this racial and economic gap is attributed to weaker effects of parental education for African Americans, a pattern also called minorities' diminished returns (MDRs). (2) Aim: We compared non-Hispanic White and African American adolescents for the effects of parent education on adolescents RR, a psychological and cognitive construct that is closely associated with high-risk behaviors such as the use of drugs, alcohol, and tobacco. (3) Methods: This was a cross-sectional analysis that included 7072 adolescents from the adolescent brain cognitive development (ABCD) study. The independent variable was parent education. The main outcome as adolescents' RR measured by the behavioral inhibition system (BIS) and behavioral activation system (BAS) measure. (4) Results: In the overall sample, high parent education was associated with lower levels of RR. In the overall sample, we found a statistically significant interaction between race and parent education on adolescents' RR. The observed statistical interaction term suggested that high parent education is associated with a weaker effect on RR for African American than non-Hispanic White adolescents. In race-stratified models, high parent education was only associated with lower RR for non-Hispanic White but not African American adolescents. (5) Conclusion: Parent education reduces RR for non-Hispanic White but not African American adolescents. To minimize the racial gap in brain development and risk-taking behaviors, we need to address societal barriers that diminish the returns of parent education and resources in African American families. We need public and social policies that target structural and societal barriers, such as the unequal distribution of opportunities and resources. To meet such an aim, we need to reduce the negative effects of social stratification, segregation, racism, and discrimination in the daily lives of African American parents and families. Through an approach like this, African American families and parents can effectively mobilize their resources and utilize their human capital to secure the best possible tangible outcomes for their adolescents.

Parental Education on Youth Inhibitory Control in the Adolescent Brain Cognitive Development (ABCD) Study: Blacks' Diminished Returns

BACKGROUND

Non-Hispanic Black (NHB) youth are at a higher risk of high-risk behaviors compared to non-Hispanic White (NHW) youth. Some of this racial gap is shown to be due to weaker effects of parental educational attainment on reducing the prevalence of behavioral risk factors such as impulsivity, substance use, aggression, obesity, and poor school performance for NHBs, a pattern called Minorities' Diminished Returns. These diminishing returns may be due to lower than expected effects of parental education on inhibitory control.

AIM

We compared NHW and NHB youth for the effect of parental educational attainment on youth inhibitory control, a psychological and cognitive construct that closely predicts high-risk behaviors such as the use of drugs, alcohol, and tobacco.

METHODS

This was a cross-sectional analysis that included 4188 youth from the Adolescent Brain Cognitive Development (ABCD) study. The independent variable was parental educational attainment. The main outcome was youth inhibitory control measured by the stop-signal task (SST), which was validated by parent reports on the Child Behavior Checklist (CBCL).

RESULTS

In race/ethnicity-stratified models, high parental educational attainment was associated with a higher level of inhibitory control for NHB than NHW youth. In the pooled sample, race/ethnicity showed a statistically significant interaction with parental educational attainment on youth inhibitory control suggesting that high parental educational attainment has a smaller boosting effect on inhibitory control for NHB than NHW youth.

CONCLUSION

Parental educational attainment boosts inhibitory control for NHW but not NHB youth. To minimize the racial gap in youth brain development, we need to address societal barriers that diminish the returns of family economic and human resources, particularly parental educational attainment, for racial and ethnic minority youth. Social and public policies should address structural and societal barriers such as social stratification, segregation, racism, and discrimination that hinder NHB parents' abilities to effectively mobilize their human resources and secure tangible outcomes for their developing youth.

General practice (GP) level analysis shows that patients' own perceptions of support within primary care as reported in the GP patient survey (GPPS) are as important as medication and services in improving glycaemic control

BACKGROUND

The way that GP practices organize their services impacts as much on glycaemia in type 2 diabetes as does prescribing.

AIM

Our aim was to evaluate the link between patients' own perception of support within primary care and the % patients at each GP practice at target glycaemic control (TGC) and at high glycaemic risk (HGR).

DESIGN AND SETTING

Utilisation of National Diabetes Audit (NDA) available data combined with the General practitioner patient survey (GPPS).

METHOD

The NDA 2016_17 published data on numbers of type 2 patients, levels of local diabetes services and the target glycaemic control (TGC) % and high glycaemic risk (HGR) % achieved. The GPPS 2017 published % "No" responses from long term condition (LTC) patients to the question "In the last 6 months, had you enough support from local services or organisations to help manage LTCs?". Multivariate regression was used on the set of indicators capturing patients' demographics and services provided.

RESULTS

6498 practices were included (with more than 2.5 million T2DM patients) and median values with band limits that included 95% practices for % "No" response to the question above was 12% (2%-30%), for TGC 67% (54%-78%) and for HGR 6% (2%-13%). The model accounted for 25% TGC variance and 26% HGR variance. The standardised β values shown as (TGC/HGR) (+=more people; -=less people) for older age (+0.24/-0.25), sulphonylurea use (-0.21/+0.14), greater social disadvantage (-0.09/+0.21), GPPS Support %No (-0.08/+0.12), %Completion 8 checks (+0.09/-0.12) and metformin use (+0.11/-0.05).

CONCLUSION

The relation between the person with diabetes and clinician in primary care is shown to be quantitatively potentially as important in influencing glycaemic outcome as the services provided and medication prescribed. We suggest that all of us in who work in the health care system can bear this in mind in our everyday work.

Understanding America: Unequal Economic Returns of Years of Schooling in Whites and Blacks

BACKGROUND

Higher schooling is associated with higher economic wellbeing. Marginalization-related Diminished Returns (MDRs) framework, however, refers to smaller returns of schooling for non-Hispanic Blacks (NHBs) compared to non-Hispanic Whites (NHWs).

AIM

Using a national sample of American adults, the current study compared NHBs and NHWs for the effects of each incremental increase in the years of schooling (gradient of educational level) on economic wellbeing of American adults.

METHODS

Data came from the Understanding America Study (UAS), a national online survey with a nationally representative sample. A total of 5715 adults (18+ years old) were included. From this number, 4,826 (84.4%) were NHWs, and 889 (15.6%) were NHBs. Years of schooling was the independent variable. Economic wellbeing was the main outcome. Age and gender were the covariates. Race was the moderator.

RESULTS

Overall, each additional year of schooling was associated with higher economic wellbeing, net of age, and gender. A statistically significant interaction was found between race and years of schooling on the outcome, indicating a smaller boosting effect of any incremental increase in the years of education on the economic wellbeing of NHBs compared to NHWs.

CONCLUSION

In line with MDRs, highly educated Black people experience low economic wellbeing. The MDRs of education on economic wellbeing may be why highly educated, and middle-class Black Americans still report poor health. Policy solutions should address multi-level causes of MDR-related health disparities.

Insomnia Symptoms among African-American Older Adults in Economically Disadvantaged Areas of South Los Angeles

BACKGROUND

Although psychosocial and health factors impact insomnia symptoms, less is known about these effects in economically disadvantaged African-American older adults.

AIMS

This study investigated social and health determinants of insomnia symptoms among economically disadvantaged African-American older adults.

METHODS

This survey enrolled 398 African-American older adults (age ≥ 65 years) from economically disadvantaged areas of South Los Angeles. Gender, age, educational attainment, financial difficulty, number of chronic diseases, self-rated health, pain intensity, and depression were covariates. Total insomnia, insomnia symptoms, and insomnia impact were our outcomes. Linear regression was applied for data analysis.

RESULTS

Based on linear regression, higher financial difficulty (B = 0.48, 95% CI = 0.35-0.61), smoking status (B = 1.64, 95% CI = 0.13-3.16), higher pain intensity (B = 0.39, 95% CI = 0.11-0.67), higher number of chronic diseases (B = 0.34, 95% CI = 0.05-0.64), and more depressive symptoms (B = 0.35, 95% CI = 0.12-0.57) were associated with a higher frequency of insomnia symptoms. Based on a logistic regression model, lower age (B = 0.91, 95% CI = 0.91-1.00) and high financial difficulty (OR = 1.15, 95% CI = 1.08-1.24), pain (OR = 2.08, 95% CI = 1.14-3.80), chronic disease (OR = 1.27, 95% CI = 1.07-1.51) and depression (OR = 2.38, 95% CI = 1.22-4.65) were associated with higher odds of possible clinical insomnia. We also found specific predictors for insomnia symptoms and insomnia impact.

CONCLUSIONS

Among African-American older adults in economically disadvantaged areas of South Los Angeles, insomnia symptoms co-occur with other economic, physical, and mental health challenges such as financial difficulty, smoking, multimorbidity, pain, and depression. There is a need to address sleep as a component of care of economically disadvantaged African-American older adults who have multiple social and health challenges.

Higher Educational Attainment is Associated with Lower Risk of a Future Suicide Attempt Among Non-Hispanic Whites but not Non-Hispanic Blacks

PURPOSE

In a sample of patients presenting to the emergency department (ED), the current study was conducted with two aims: (1) to investigate the protective effects of educational attainment (i.e., completing college) on subsequent risk of suicide attempt/death among patients presenting to the ED and (2) to compare this effect between non-Hispanic Black and non-Hispanic White ED patients.

METHODS

The current study analyzed data from the Emergency Department Safety Assessment and Follow-Up Evaluation (ED-SAFE) study, a quasi-experimental, eight-center study of universal suicide screening and follow-up of ED patients presenting for suicidal ideation and behavior. Our sample included 937 non-Hispanic White and 211 non-Hispanic Blacks. The dependent variable was suicide attempt/death during the 52-week follow-up. The independent variable was completing college. Age, gender, lesbian/gay/bisexual status, psychiatric history, and previous suicide attempts at baseline were covariates. Race/ethnicity was the focal effect modifier. Logistic regression models were used to test the protective effects of educational attainment on suicide risk in the overall sample and by race/ethnicity.

RESULTS

In the overall sample, educational attainment was not associated with suicide risk over the follow-up period. A significant interaction was found between race/ethnicity and educational attainment on suicide risk, suggesting a larger protective effect for non-Hispanic Whites compared with non-Hispanic Blacks. In race/ethnicity-specific models, completing college was associated with decreased future suicide risk for non-Hispanic Whites but not Blacks.

CONCLUSIONS

Consistent with the Minorities' Diminished Return theory, educational attainment better protected non-Hispanic White than non-Hispanic Blacks against future suicide attempt/death. While Whites who have not completed college may be at an increased risk of suicide, risk of suicide seems to be independent of educational attainment for non-Hispanic Blacks.

Minorities' Diminished Returns of Educational Attainment on Hospitalization Risk: National Health Interview Survey (NHIS)

BACKGROUND

As suggested by the Minorities' Diminished Returns (MDRs) theory, educational attainment shows a weaker protective effect for racial and ethnic minority groups compared to non-Hispanic Whites. This pattern, however, is never shown for hospitalization risk.

OBJECTIVES

This cross-sectional explored racial and ethnic variation in the association between educational attainment and hospitalization in the US.

METHODS

Data came from the National Health Interview Survey (NHIS 2015). The total sample was 28,959 American adults. Independent variables were educational attainment and hospitalization. The main outcome was hospitalization during the last 12 months. Age, gender, employment, marital status, region, obesity, and the number of cardiovascular conditions were covariates. Race and ethnicity were the effect modifiers. Logistic regression models were utilized to analyze the data.

RESULTS

From all participants, 16.2% were Black and 11.6 were Hispanic, with a mean age of 51 years old. Overall, higher education levels were associated with lower odds of hospitalization, independent of all confounders. Educational attainment showed significant interactions with race (OR =1.04, 95% CI = 1.01 - 1.08) and ethnicity (OR = 1.04, 95% CI =1.01 -1.07) on hospitalization, indicating smaller protective effects of educational attainment on hospitalization of Hispanics and Blacks than non-Hispanic Whites.

CONCLUSION

The protective effect of educational attainment on population health is smaller for Blacks and Hispanics compared to non-Hispanic Whites. To prevent health disparities, there is a need to minimize diminished returns of educational attainment for racial and ethnic minorities. To do so, there is a need for innovative and bold economic, public, and social policies that do not limit themselves to equalizing socioeconomic status but also help minorities leverage their available resources and gain tangible outcomes.

Binge Drinking among Economically Disadvantaged African American Older Adults with Diabetes

Purpose. This study investigated the effect of demographic, socioeconomic, and psychological factors as well as the role of health determinants on alcohol consumption and binge drinking among economically disadvantaged African American older adults with type 2 diabetes mellites (T2DM). Methods. This survey recruited 231 African Americans who were older adults (age 65+ years) and had T2DM. Participants were selected from economically disadvantaged areas of South Los Angeles. A structured face-to-face interview was conducted to collect data on demographic factors, objective and subjective socioeconomic status (SES) including education and financial difficulty, living arrangement, marital status, health, and drinking behaviors (drinking and binge drinking). Results. Age, gender, living alone, pain, comorbid conditions, and smoking were associated with drinking/binge drinking. Male gender, pain, and being a smoker were associated with higher odds of drinking/binge drinking, while individuals with more comorbid medical conditions had lower odds of binge drinking. Conclusion. In economically constrained urban environments, gender, pain, and smoking but not age, SES, depression, and health may predict binge drinking for African American older adults with T2DM. African Americans older adult men with T2DM with comorbid pain should be screened for binge drinking.

Being Married Increases Life Expectancy of White but Not Black Americans

Objective: The positive effect of high socioeconomic position (SEP) on health is well established. According Minorities' Diminished Returns (MDRs) theory, however, the SEP-health link is smaller for Blacks compared to Whites. Using a 25-year follow up data of a national sample, this study tested racial differences in the effects of marital status on life expectancy among American adults. Materials and methods: The data of Americans' Changing Lives (ACL, 1986 - 2011) were used. The ACL is a nationally representative longitudinal cohort study followed 3,361 White or Blacks adults from 1986 to 2011. The predictor of interest was marital status in 1986. Confounders included demographic factors (age and gender), SEP (education and employment), health behaviors (drinking, smoking, and physical activity), and health status (depressive symptoms, chronic disease, and self-rated health) all measured at baseline. Race was the moderator variable. All-cause mortality was the main dependent variable (outcome). Cox proportional hazard modeling was applied for data analysis. Results: In the overall sample, individuals who were married at baseline had a lower risk of mortality during the 25 years of follow up. Race altered the effect of marital status on life expectancy, indicating smaller protective effect for Blacks relative to Whites. Race -specific Cox regression models showed an association between marital status and life expectancy for White but not Black Americans. Conclusion: In line with the MDRs theory, the health gain that follows marital status is diminished for Black Americans compared to White Americans. Only equalizing SEP across racial groups may not be adequate for eliminating racial/ethnic health inequalities. Policies should go beyond SEP and reduce societal and structural barriers that disproportionately hinder Blacks from translating their SEP indicators to desirable health outcomes.

Educational Attainment Better Reduces Disability for Non-Hispanic than Hispanic Americans

Objectives: Minorities’ Diminished Returns (MDRs) refers to the weaker protective health effects of socioeconomic status (SES) for minorities, particularly educational attainment for racial and ethnic minorities, compared to the general population. This pattern has been documented among African-Americans compared to Whites, however, we know very little about MDRs for educational attainment on disability among Hispanics compared to Non-Hispanic Whites. Aims: This cross-sectional study explored ethnic variation in the effects of educational attainment on severity of disability in the United States of America (USA). Materials and Methods: The 2015 National Health Interview Survey (NHIS) was a national survey of the general population in the USA. The total sample was 1021 American adults that reported some disability. Of the 1021 participants, 855 identified as Non-Hispanic and 165 identified as Hispanic. The independent variable was educational attainment. The main outcome was severity of disability measured using self-reported data. Age, gender, and race were covariates. Ethnicity was the effect modifier. Results: Among individuals with a disability, higher levels of educational attainment were associated with fewer disabilities, independent of all confounders. When ethnicity and educational attainment were interacted on severity of disability, the results indicated a smaller protective effect for Hispanics than for Non-Hispanics with a disability. Ethnicity-stratified models showed an effect for Non-Hispanics but not for Hispanics. Conclusions: The protective effects of educational attainment against severity of disability are smaller for Hispanics than for Non-Hispanics. To prevent health disparities, there is a need to minimize MDRs of SES for ethnic minorities. To do so, there is a need for innovative economic, public, and social policies that are not limited to equalizing educational attainment but that also help minorities leverage their resources and gain tangible outcomes.

High Education Level Protects European Americans but Not African Americans Against Chronic Obstructive Pulmonary Disease: National Health Interview Survey

BACKGROUND

Education level reduces the risk of chronic diseases (CDs), including Chronic Obstructive Pulmonary Disease (COPD). Minorities' Diminished Returns, however, refer to smaller health benefits of socioeconomic position (SEP) improvement for racial and ethnic minorities compared to majority groups. It is not known if MDRs exist for the effects of education level on COPD for African Americans (AAs), relative to European Americans (EAs).

AIMS

Using a nationally representative sample, the current study explored racial and ethnic variation in the association between education level and COPD among American adults.

METHODS

Data came from the National Health Interview Survey (NHIS 2015), a national survey. A total of 25,488 adults (18+ years old) were included in the study. From this number, 4,533 (17.8%) were AAs and 20,955 (82.2%) were EAs. Education level was the independent variable. Outcome was COPD. Age, gender, and income were the covariates. Race/ethnicity was the moderator.

RESULTS

Overall, education level was inversely associated with the odds of COPD. A statistically significant interaction was found between race/ethnicity and education level on odds of COPD, indicating smaller effect of education for AAs compared to EAs.

CONCLUSIONS

In line with the Minorities' Diminished Returns (MDRs), highly educated AAs remained at high risk for COPD, a pattern which is not observed for EAs. Policies that exclusively address racial/ethnic inequalities in SEP may not be enough for eliminating racial/ethnic inequalities in COPD in the US. Public policies must go beyond equalizing SEP and address structural and environmental barriers that disproportionately increase risk of COPD in AAs across SEP levels. Future research should test if residential segregation and exposure to air pollutants contributes to high prevalence of COPD in highly educated AAs. Research is needed on multi-level interventions that may minimize MDR-related health disparities.

Race/Ethnicity, Socioeconomic Status, and Polypharmacy among Older Americans

Background: Very few studies with nationally representative samples have investigated the combined effects of race/ethnicity and socioeconomic position (SEP) on polypharmacy (PP) among older Americans. For instance, we do not know if prevalence of PP differs between African Americans (AA) and white older adults, whether this difference is due to a racial gap in SEP, or whether racial and ethnic differences exist in the effects of SEP indicators on PP. Aims: We investigated joint effects of race/ethnicity and SEP on PP in a national household sample of American older adults. Methods: The first wave of the University of Michigan National Poll on Healthy Aging included a total of 906 older adults who were 65 years or older (80 AA and 826 white). Race/ethnicity, SEP (income, education attainment, marital status, and employment), age, gender, and PP (using 5+ medications) were measured. Logistic regression was applied for data analysis. Results: Race/ethnicity, age, marital status, and employment did not correlate with PP; however, female gender, low education attainment, and low income were associated with higher odds of PP among participants. Race/ethnicity interacted with low income on odds of PP, suggesting that low income might be more strongly associated with PP in AA than white older adults. Conclusions: While SEP indicators influence the risk of PP, such effects may not be identical across diverse racial and ethnic groups. That is, race/ethnicity and SEP have combined/interdependent rather than separate/independent effects on PP. Low-income AA older adults particularly need to be evaluated for PP. Given that race and SEP have intertwined effects on PP, racially and ethnically tailored interventions that address PP among low-income AA older adults may be superior to universal interventions and programs that ignore the specific needs of diverse populations. The results are preliminary and require replication in larger sample sizes, with PP measured directly without relying on individuals’ self-reports, and with joint data collected on chronic disease.

Diminished Return of Employment on Ever Smoking Among Hispanic Whites in Los Angeles

Purpose: According to the Minorities' Diminished Return (MDR) theory, socioeconomic status (SES) indicators such as employment status produce smaller tangible outcomes for racial and ethnic minority groups, however, very limited information exists on such diminished returns for Hispanics. To test whether MDR also holds for the social patterning of smoking behaviors among white adults, this study explored ethnic differences in the association between employment status and ever smoking in a representative sample of adults in Los Angeles. Methods: Los Angeles Family and Neighborhood Survey 2001 included 907 non-Hispanic white and 2117 Hispanic white adults (ages 18 or older). Ethnicity, gender, age, employment status, marital status, immigration status, and ever smoking were measured. Logistic regression models were used for data analysis. Results: In the pooled sample that included both non-Hispanic whites and Hispanic whites, being employed was associated with lower odds of ever smoking, net of covariates. A significant interaction was found between ethnicity and employment status on odds of ever smoking, suggesting a stronger inverse association between employment status and ever smoking for non-Hispanic whites than Hispanic whites. Ethnic specific models showed an inverse association between being employed and ever smoking status for non-Hispanic whites, but not for Hispanic whites. Conclusion: Even among whites, whether or not employment reduces the risk of ever smoking may depend on ethnicity, with Hispanics being at a disadvantage relative to non-Hispanic whites in terms of lower odds of ever smoking from their employment status.

Cigarette Smoking among Economically Disadvantaged African-American Older Adults in South Los Angeles: Gender Differences

The current study aims to explore gender differences in the risk of cigarette smoking among African-American (AA) older adults who live in economically disadvantaged urban areas of southern Los Angeles. This cross-sectional study enrolled 576 older AA adults (age range between 65 and 96 years) who were residing in Service Planning Area 6 (SPA 6), one of the most economically challenged areas in southern Los Angeles. All participants had cardiometabolic disease (CMD). Data were collected using structured face-to-face interviews. Demographic factors (age and gender), socioeconomic status (educational attainment and financial difficulty), health (number of comorbid medical conditions and depressive symptoms), and health behaviors (current alcohol drinking and current smoking) were measured. Logistic regressions were used to analyze the data without and with interaction terms between gender and current drinking, depressive symptoms, and financial difficulty. AA men reported more smoking than AA women (25.3% versus 9.3%; p < 0.05). Drinking showed a stronger association with smoking for AA men than AA women. Depressive symptoms, however, showed stronger effects on smoking for AA women than AA men. Gender did not interact with financial difficulty with regard to current smoking. As AA older men and women differ in psychological and behavioral determinants of cigarette smoking, gender-specific smoking cessation interventions for AA older adults who live in economically deprived urban areas may be more successful than interventions and programs that do not consider gender differences in determinants of smoking. Gender-tailored smoking cessation programs that address drinking for AA men and depression for AA women may help reduce the burden of smoking in AA older adults in economically disadvantaged urban areas. Given the non-random sampling, there is a need for replication of these findings in future studies.

Polypharmacy in African American Adults: A National Epidemiological Study

Background: Despite the association between polypharmacy and undesired health outcomes being well established, very little is known about epidemiology of polypharmacy in the African American community. We are not aware of any nationally representative studies that have described the socioeconomic, behavioral, and health determinants of polypharmacy among African Americans. Aims: We aimed to investigate the socioeconomic and health correlates of polypharmacy in a national sample of African American adults in the US. Methods: The National Survey of American Life (NSAL, 2003⁻2004) included 3,570 African American adults. Gender, age, socioeconomic status (SES; education attainment, poverty index, and marital status), access to the healthcare system (health insurance and having a usual source of care), and health (self-rated health [SRH], chronic medical disease, and psychiatric disorders) in addition to polypharmacy (5 + medications) as well as hyper-polypharmacy (10 + medications) were measured. Logistic regressions were applied for statistical analysis. Results: that About 9% and 1% of all African American adults had polypharmacy and hyper-polypharmacy, respectively. Overall, higher age, higher SES (education and poverty index), and worse health (poor SRH, more chronic medical disease, and psychiatric disorders) were associated with polypharmacy and hyper-polypharmacy. Individuals with insurance and those with a routine place for healthcare also had higher odds of polypharmacy and hyper-polypharmacy. Conclusions: Given the health risks associated with polypharmacy, there is a need for systemic evaluation of medication use in older African Americans with multiple chronic conditions. Such policies may prevent medication errors and harmful drug interactions, however, they require effective strategies that are tailored to African Americans.

Combined Effects of Race and Socioeconomic Status on Cancer Beliefs, Cognitions, and Emotions

AIM

To determine whether socioeconomic status (SES; educational attainment and income) explains the racial gap in cancer beliefs, cognitions, and emotions in a national sample of American adults.

METHODS

For this cross-sectional study, data came from the Health Information National Trends Survey (HINTS) 2017, which included a nationally representative sample of American adults. The study enrolled 2277 adults who were either non-Hispanic Black (n = 409) or non-Hispanic White (n = 1868). Race, demographic factors (age and gender), SES (i.e., educational attainment and income), health access (insurance status, usual source of care), family history of cancer, fatalistic cancer beliefs, perceived risk of cancer, and cancer worries were measured. We ran structural equation models (SEMs) for data analysis.

RESULTS

Race and SES were associated with perceived risk of cancer, cancer worries, and fatalistic cancer beliefs, suggesting that non-Hispanic Blacks, low educational attainment and low income were associated with higher fatalistic cancer beliefs, lower perceived risk of cancer, and less cancer worries. Educational attainment and income only partially mediated the effects of race on cancer beliefs, emotions, and cognitions. Race was directly associated with fatalistic cancer beliefs, perceived risk of cancer, and cancer worries, net of SES.

CONCLUSIONS

Racial gap in SES is not the only reason behind racial gap in cancer beliefs, cognitions, and emotions. Racial gap in cancer related beliefs, emotions, and cognitions is the result of race and SES rather than race or SES. Elimination of racial gap in socioeconomic status will not be enough for elimination of racial disparities in cancer beliefs, cognitions, and emotions in the United States.

Polypharmacy and Psychological Distress May Be Associated in African American Adults

Background: Compared to Whites, African Americans are at a higher risk of multiple chronic conditions, which places them at a higher risk of polypharmacy. Few national studies, however, have tested whether polypharmacy is associated with psychological distress—the net of socioeconomic status, health status, and stress—in African Americans. Aims: In a national sample of African Americans in the US, this study investigated the association between polypharmacy and psychological distress. Methods: The National Survey of American Life (NSAL, 2003) included 3570 African American adults who were 18 years or over. This number was composed of 2299 women and 1271 men. Polypharmacy (using ≥ 5 medications) and hyper-polypharmacy (using ≥ 10 medications) were the independent variables. Psychological distress was the dependent variable. Age, gender, socioeconomic status (education attainment, income, employment, and marital status), health care access (insurance status and usual place of care), and health status (multimorbidity and psychiatric disorders) were the covariates. Linear multivariable regression was applied to perform the data analysis. Results: Both polypharmacy and hyper-polypharmacy were associated with psychological distress. This association was significant after controlling for all the covariates. Conclusions: African Americans with polypharmacy, particularly those with hyper-polypharmacy, are experiencing higher levels of psychological distress, which itself is a known risk factor for poor adherence to medications. There is a need for a comprehensive evaluation of medications as well as screening for psychopathology in African Americans with multiple medical conditions.

Subjective financial status and suicidal ideation among American college students: Racial differences

PURPOSE

The current study aimed to compare American Black and White college students for the protective effect of subjective socioeconomic status (SES) on suicidal ideation.

METHODS

This study used data from the Healthy Mind Study (HMS 2015-2017). This study included 2,983 undergraduate college students who were at least 18 years of old. These participants were either White (n=2,704) or Black (n=279). The dependent variable was suicidal ideation. The independent variable was subjective SES. Age, gender, transition status, first generation status, and social isolation were covariates. Race/ethnicity was the moderator. Logistic regressions were applied to test the effect of subjective SES on suicidal ideation in the overall sample and by race/ ethnicity.

RESULTS

In the overall sample, high subjective SES was associated with less suicidal ideation in the pooled sample of college students. A significant interaction was found between race and subjective SES on suicide risk, suggesting a larger protective effect of high subjective SES for Whites than Blacks. In race-stratified models, high subjective SES was associated with less suicidal ideation for White college students but not for Black college students.

CONCLUSIONS

Consistent with the Minorities' Diminished Returns theory and in line with previous research that has documented worse mental health of high SES Blacks particularly Black men, this study showed that high SES protects White college students but not Black college students against suicidal ideation. While Whites with low SES are protected against risk of suicide, risk of suicidal ideation seems to be constant regardless of SES among Black college students.

The association between the number of chronic health conditions and advance care planning varies by race/ethnicity

Objectives: Although a national consensus exists on the need to increase the rates of advance care planning (ACP) for all adults, racial/ethnic differences in ACP have been consistently observed. This study investigated the intersection of racial/ethnic differences and the number of chronic health conditions on ACP among middle-aged and older adults in the United States.Method: Responses from 8,926 adults from the 2014 wave of the Health and Retirement Study were entered into multilevel hierarchical logistic regression analyses with generalized linear mixed models to predict ACP focused on assigning a durable power of attorney for healthcare (DPOAHC) and having a written living will after adjusting for covariates.Results: We found a significant positive relationship between the number of chronic health conditions and ACP. Non-Hispanic Blacks/African Americans and Hispanics were less likely to engage in ACP than non-Hispanic Whites/Caucasians. Racial/ethnic disparities were even starker for completing a living will. The number of chronic health conditions had a greater effect for Hispanics than non-Hispanic Whites/Caucasians on ACP through assigning a DPOAHC and having a living will. The initial disparity in ACP among Hispanics with no chronic health conditions decreased as the number of chronic health conditions increased.Conclusion: Our findings suggest that more chronic health conditions increase the likelihood that Hispanics will complete ACP documents. These ACP differences should be highlighted to researchers, policymakers, and healthcare professionals to reduce stark racial/ethnic disparities in ACP. A comprehensive and culturally caring decision-making approach should be considered when individuals and families engage in ACP.

High Income Protects Whites but Not African Americans against Risk of Depression

Background: Built on the Blacks’ diminished return theory, defined as smaller effects of socioeconomic status (SES) on a wide range of health outcomes for African Americans compared to Whites, the current study compared African Americans and Whites for the association between household income and risk of lifetime, 12-month, and 30-day major depressive disorder (MDD). Methods: For the current cross-sectional study, we used data from the Collaborative Psychiatric Epidemiology Surveys (CPES), 2001–2003. With a nationally representative sampling, CPES included 4746 non-Hispanic African Americans and 7587 non-Hispanic Whites. The dependent variables were lifetime, 12-month, and 30-day MDD, measured using Composite International Diagnostic Interview (CIDI). The independent variable was household income. Age, gender, education, chronic medical conditions, and obesity were covariates. Race was the focal moderator. Logistic regression models were used to test the protective effects of household income against MDD in the overall sample and also by race. Results: In the overall sample, household income was inversely associated with the risk of 12-month and 30-day MDD. We found a significant interaction between race and household income on 12-month and 30-day MDD, suggesting a smaller protective effect of household income against MDD for African Americans compared to Whites. Conclusion: In line with the Blacks’ diminished return theory, household income better protects Whites than African Americans against MDD. The contribution of diminished return of SES as an underlying mechanism behind racial disparities in health in the United States is often overlooked. Additional research is needed on why and how SES resources generate smaller health gain among minority groups.

The Benefits of Higher Income in Protecting against Chronic Medical Conditions Are Smaller for African Americans than Whites

Background: Blacks’ diminished return is defined as smaller protective effects of socioeconomic status (SES) on health of African Americans compared to Whites. Aim: Using a nationally representative sample, the current study aimed to examine if the protective effect of income on chronic medical conditions (CMC) differs for African Americans compared to Whites. Methods: With a cross-sectional design, the National Survey of American Life (NSAL), 2003, included 3570 non-Hispanic African Americans and 891 non-Hispanic Whites. The dependent variable was CMC, treated as a continuous measure. The independent variable was income. Race was the focal moderator. Age, education, and marital status were covariates. Linear regressions were used to test if the protective effect of income against CMC varies by race. Results: High income was associated with a lower number of CMC in the pooled sample. We found a significant interaction between race and income, suggesting that income has a smaller protective effect against CMC for African Americans than it does for Whites. Conclusion: Blacks’ diminished return also holds for the effects of income on CMC. Blacks’ diminished return is a contributing mechanism to the racial disparities in health in the United States that is often overlooked. More research is needed on the role of diminished health return of SES resources among other minority groups.

Chronic Conditions May Be More Important Than Race or Ethnicity in Relation to Health Information Seeking and Use

OBJECTIVE

This research examines health information (HI) seeking and use among middle-aged and older adults with chronic health conditions.

METHOD

We used logistic regression models to analyze HI seeking ( N = 7,822) and use (N = 4,541-4,547) among participants (aged 45+ years) with chronic conditions from the nationally-representative Health Tracking Household Survey.

RESULTS

Adults aged 45+ years with chronic conditions were significantly more likely to seek and use HI; however, these results varied based on the age and education. Compared with Whites, Latinos were less likely to seek HI but more likely to use HI to treat illness, and African Americans were more likely to use HI to maintain health.

CONCLUSION

Middle-aged and older adults with chronic conditions are prominent HI seekers and users. Proficient HI seeking and use may have the potential to enhance control over one's own health, maintain independence in the community, and reduce the impact of negative health consequences on the health care system.

Income Gradient in Renal Disease Mortality in the United States

Background

Non-communicable diseases and associated mortality follow a social gradient and chronic kidney disease is not an exception to this rule. Intermediate behavioral and medical factors that may explain such social gradients are, however, still unknown.

Objectives

Using nationally representative data in the United States, this study was conducted to investigate the mediating effect of medical and behavioral risk factors on the association between socioeconomic status (SES) and renal disease mortality.

Patients and methods

Americans’ Changing Lives Study (ACL), 1986–2011, is a 25-year nationally representative prospective cohort study. ACL followed 3,361 adults for up to 25 years. Income, education, and unemployment were the main predictors of interest. Death due to renal disease was the main outcome. Health behaviors (smoking, drinking, and exercise) and medical risk factors (diabetes, hypertension, and obesity) were the mediators. Cox proportional hazards models were used for data analysis.

Results

Higher income (HR = 0.75; 95% CI = 0.62–0.89) was associated with lower risk of death due to renal disease over the 25-year follow-up period. Although health behaviors and medical risk factors at baseline were also predictors of the outcome, they failed to explain the effect of income on death due to renal disease. That is, income was associated with death due to renal disease above and beyond all potential mediators including behavioral and medical risk factors.

Conclusion

Socioeconomic inequalities in the United States cause disparities in renal disease mortality; however, such differences are not due to health behaviors (smoking and drinking) and medical risk factors (hypertension and diabetes). To reduce disparities in renal disease mortality in the United States, policies should go beyond health behaviors and medical risk factors. While programs should help low-income individuals maintain exercise and avoid smoking, reduction of income disparities should be regarded as a strategy for reduction of disparities in renal disease mortality. By increasing minimum pay and minimizing the income gap, we may reduce disparities in renal disease mortality.

Socioeconomic Status and Glycemic Control in Type 2 Diabetes; Race by Gender Differences

Background: This study aimed to investigate differences in the association between socioeconomic status (SES) and glycemic control in type 2 diabetes mellitus (DM) across race by gender groups. Methods: Using a convenient sampling strategy, participants were 112 patients with type 2 DM who were prescribed insulin (ns = 38 Black women, 34 Black men, 14 White women, and 26 White men, respectively). Linear regression was used to test the associations between sociodemographic variables (race, gender, SES, governmental insurance) and Hemoglobin A1c (HbA1c) in the pooled sample and within subgroups defined by race and gender. Results: In the pooled sample, neither SES nor governmental insurance were associated with HbA1c. However, the race by gender interaction approached statistical significance (B = 0.34, 95% CI = −0.24–3.00, p =0.094), suggesting higher HbA1c in Black women, compared to other race by gender groups. In stratified models, SES (B = −0.33, 95% CI = −0.10–0.00, p = 0.050), and governmental insurance (B = 0.35, 95% CI = 0.05–2.42, p = 0.042) were associated with HbA1c for Black men, but not for any of the other race by gender subgroups. Conclusion: Socioeconomic factors may relate to health outcomes differently across race by gender subgroups. In particular, SES may be uniquely important for glycemic control of Black men. Due to lack of generalizability of the findings, additional research is needed.

Diabetes, hypertension, obesity, and long-term risk of renal disease mortality: Racial and socioeconomic differences

AIMS/INTRODUCTION

Diabetes, hypertension, and obesity increase the risk of chronic kidney disease and associated mortality. Race and socioeconomic status (SES) differences in the effects of these risk factors are, however, still unknown. The current study aimed to investigate whether or not race and SES alter the effects of diabetes, hypertension, and obesity on mortality due to renal disease.

MATERIALS AND METHODS

Data came from the Americans' Changing Lives Study, 1986-2011, a nationally representative prospective cohort of adults with 25 years of follow up. The study included 3,361 adults aged 25 years and older who were followed for up to 25 years. The outcome was death from renal disease. Diabetes, hypertension, and obesity were the main predictors. Race and SES (education, income, and employment) were moderators. Health behaviors and health status at baseline were covariates. We used Cox proportional hazards models for data analysis.

RESULTS

In separate models, diabetes, hypertension, and obesity at baseline were associated with a higher risk of death from renal disease. From our SES indicators, education and income interacted with diabetes, hypertension, and obesity on death from renal disease. In a consistent pattern, diabetes, hypertension, and obesity showed stronger effects on the risk of death from renal disease among high-SES groups compared with low-SES individuals. Race and employment did not alter the effects of diabetes, hypertension and obesity on the risk of death from renal disease.

CONCLUSIONS

Social groups differ in how diabetes, hypertension, and obesity influence health outcomes over long-term periods. Elimination of disparities in renal disease mortality in the USA requires understanding of the complex and non-linear effects of socioeconomic and medical risk factors on health outcomes. Multidisciplinary programs and policies are required to reduce social inequality in renal disease burden caused by diabetes, hypertension, and obesity.