All dollars are not created equal: Health disparities persist even among the highest income Americans

Investigating the Intersections of Racial Identity and Perceived Income Adequacy in Relation to Dietary Quality Among Adults in Canada

BACKGROUND

Structural racism and economic marginalization shape dietary patterns in complex ways. Most research examining race and income inequities discount their interactions in shaping dietary intakes. An intersectional approach is needed to identify interconnected sources of social inequities and to more precisely locate dietary inequities.

OBJECTIVES

We examined whether racial identity and perceived income adequacy independently and jointly shape dietary quality, defined using the Healthy Eating Index (HEI) 2015, among a large sample of adults in Canada.

METHODS

Cross-sectional data from 2540 adults (≥18 years of age) in Canada who participated in the 2019 International Food Policy Study were analyzed. Multivariable linear regression models were executed to test the independent associations and interactions between racial identity and perceived income adequacy with HEI-2015 scores. Models were constructed to examine HEI-2015 total and component scores, adjusting for age, gender, and education.

RESULTS

Perceived income adequacy, but not racial identity, was independently associated with HEI-2015 total scores. The interaction between racial identity and perceived income adequacy was significantly associated with HEI-2015 scores. Compared to the reference group (individuals identifying as White and reporting income adequacy), those identifying as Black and reporting income adequacy were associated with lower HEI-2015 scores (β, -7.30; 95% CI, -13.07 to -1.54) and those identifying as Black and reporting income inadequacy were associated with lower HEI-2015 scores (β, -6.37; 95% CI, -12.13 to -0.60). Individuals who identified as indigenous and reported neither income adequacy nor inadequacy had lower HEI-2015 scores (β, -8.50; 95% CI, -13.82 to -3.18) compared to the reference group.

CONCLUSIONS

Findings suggest that racial identity and perceived income adequacy jointly shape dietary quality. Inequities in dietary quality may be missed when intersecting racial identities and socioeconomic positions are not explicitly investigated. To support healthier dietary patterns, strategies must reduce socioeconomic barriers that impose dietary constraints on some racialized groups.

Greater financial toxicity relates to greater distress and worse quality of life among breast and gynecologic cancer survivors

BACKGROUND

Financial toxicity includes distress and burden from cancer-related costs. Women are more likely to experience worse cancer-related financial outcomes than men. This study evaluated breast and gynecologic cancer patients' subjective experiences of financial toxicity and associations with distress and quality of life (QOL).

METHODS

A cross-sectional survey study included measures of financial toxicity (Comprehensive Score for Financial Toxicity [COST] Version 2), distress (Patient Health Questionnaire), and QOL (Functional Assessment of Cancer Therapy). Chi-square, t-tests, and ANOVAs examined bivariate relationships. Two regression models tested associations between financial toxicity and distress and QOL, controlling for covariates. Financial toxicity subgroups were compared based on a validated grading system.

RESULTS

Participants (N = 273; 74% breast cancer) averaged 54.65 years (SD = 12.08), were 3.42 years (SD = 4.20) post-diagnosis, and 33% reported cancer-related change in employment status. Financial toxicity was "mild" overall (COST M = 26.11, SD = 11.14); 32% worried about cancer-related financial problems (quite a bit/very much; item-level analysis). Worse financial toxicity related to younger age (p < 0.001), identifying as a non-Asian minority (p = 0.03) or Hispanic (p = 0.01), being single (p < 0.001), lower education (p = 0.004), lower income (p < 0.001), late-stage disease (p = 0.001), recurrent disease (p = 0.004), and active treatment (p < 0.001). In separate multivariable models, greater financial toxicity related to greater distress (β = -0.45 p < 0.001) and worse QOL (β = 0.58, p < 0.001). Financial toxicity subgroups reported clinically significant differences in distress and QOL (p's < 0.05).

CONCLUSIONS

Cancer-related financial burden is associated with pervasive negative effects and may impact subgroups differently. Future research should explore financial experiences across subgroups, aiming to better identify those at risk and build targeted interventions.

Cost-Related Non-Utilization of Health Services and Self-Perceived Reactions to Race

Purpose

There is limited information regarding the prevalence and predictors of cost-related non-utilization (CRNU), while there is increasing attention to the rising out-of-pocket cost of health services including prescription medications. Prior studies have not quantified the role of perceived racism despite its documented relationship with health services utilization. We examine perceptions of reactions to race and quantify their relationship with CRNU.

Methods

This retrospective cross-sectional study utilized data from the 2014 Behavioral Risk Factor Surveillance System (BRFSS) public use file, an annual, state-based telephone survey of US adults aged 18 and older. We utilized data for four states that provided responses to five Reactions to Race items, including information about the self-perceived quality of the respondent's health care experience compared with people of other races (worse vs same or better) and whether the respondent experienced physical symptoms because of treatment due to their race. The three binary outcomes were: 1) did not visit a physician; 2) did not visit a physician due to cost; 3) did not fill a prescription due to cost. We estimated covariate-adjusted odds ratios associated with each outcome using logistic regression models.

Results

The BRFSS sample consisted of 20,366 respondents of whom 8% were African American non-Hispanic, 12% were Hispanic and 73% were White. Three percent of respondents considered their experience to be worse than people of other races. Three percent of individuals reported physical symptoms because of treatment due to their race while 5% of respondents reported becoming emotionally upset because of treatment due to their race. The proportions for the three study outcomes were 11%, 13% and 7%, respectively. In covariate-adjusted models, a worse experience with the health care system was statistically significantly associated with CRNU (physician visit: 2.6 [95% CI: 1.6 - 4.3]). The experience of physical symptoms because of treatment due to race was statistically significantly associated with CRNU (physician visit: 2.6 [95% CI: 1.7 - 4]; prescription fills: 2.1 [1.2 - 3.6]). No Reactions to Race items were associated with general non-utilization.

Conclusions

Negative perceptions of reactions to race during the time of health services utilization is positively associated with CRNU, ie, foregoing physician visits and prescription fills due to cost.

Differences in Stage of Cancer at Diagnosis, Treatment, and Survival by Race and Ethnicity Among Leading Cancer Types

IMPORTANCE

Information about stage of cancer at diagnosis, use of therapy, and survival among patients from different racial/ethnic groups with 1 of the most common cancers is lacking.

OBJECTIVE

To assess stage of cancer at diagnosis, use of therapy, overall survival (OS), and cancer-specific survival (CSS) in patients with cancer from different racial/ethnic groups.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study included 950 377 Asian, black, white, and Hispanic patients who were diagnosed with prostate, ovarian, breast, stomach, pancreatic, lung, liver, esophageal, or colorectal cancers from January 2004 to December 2010. Data were collected using the Surveillance, Epidemiology, and End Results (SEER) database, and patients were observed for more than 5 years. Data analysis was conducted in July 2018.

MAIN OUTCOMES AND MEASURES

Multivariable logistic and Cox regression were used to evaluate the differences in stage of cancer at diagnosis, treatment, and survival among patients from different racial/ethnic groups.

RESULTS

A total of 950 377 patients (499 070 [52.5%] men) were included in the study, with 681 251 white patients (71.7%; mean [SD] age, 65 [12] years), 116 015 black patients (12.2%; mean [SD] age, 62 [12] years), 65 718 Asian patients (6.9%; mean [SD] age, 63 [13] years), and 87 393 Hispanic patients (9.2%; mean [SD] age, 61 [13] years). Compared with Asian patients, black patients were more likely to have metastatic disease at diagnosis (odds ratio [OR], 1.144; 95% CI, 1.109-1.180; P < .001). Black and Hispanic patients were less likely to receive definitive treatment than Asian patients (black: adjusted OR, 0.630; 95% CI, 0.609-0.653; P < .001; Hispanic: adjusted OR, 0.751; 95% CI, 0.724-0.780; P < .001). White, black, and Hispanic patients were more likely to have poorer CSS and OS than Asian patients (CSS, white: adjusted HR, 1.310; 95% CI, 1.283-1.338; P < .001; black: adjusted HR, 1.645; 95% CI, 1.605-1.685; P < .001; Hispanic: adjusted HR, 1.300; 95% CI, 1.266-1.334; P < .001; OS, white: adjusted HR, 1.333; 95% CI, 1.310-1.357; P < .001; black: adjusted HR, 1.754; 95% CI, 1.719-1.789; P < .001; Hispanic: adjusted HR, 1.279; 95% CI, 1.269-1.326; P < .001).

CONCLUSIONS AND RELEVANCE

In this study of patients with 1 of 9 leading cancers, stage at diagnosis, treatment, and survival were different by race and ethnicity. These findings may help to optimize treatment and improve outcomes.

Parental Education Attainment and Educational Upward Mobility; Role of Race and Gender

Background. The Minorities' Diminished Return theory suggests that education attainment and other socioeconomic resources have smaller effects on the health and well-being of African Americans and other racial and ethnic minorities compared to Whites. Racial and ethnic differences in the processes involved with educational upward mobility may contribute to the diminished returns of education attainment for African Americans compared to Whites. Aim: This study compared African Americans and non-Hispanic Whites for the effect of parental education attainment on educational upward mobility and explored gender differences in these effects. Methods. The National Survey of American Life (NSAL 2003) is a nationally representative survey of American adults. Participants included 891 non-Hispanic White and 3570 African American adults. Gender, race/ethnicity, age, highest parental education attainment, and respondents' educational attainment were measured. Data were analyzed using linear regression models. Results. Overall, higher parental education attainment was associated with higher educational upward mobility (b = 0.34, p < 0.001), however, this boosting effect was significantly smaller for African Americans compared to Whites (b = -0.13, p = 0.003). Our further analysis showed that race by parental education attainment can be found for females (b = -0.14, p = 0.013) but not males (p > 0.05). Conclusion. African American females are at a disadvantage compared to White females regarding the effect of parental education attainment on their educational upward mobility, a phenomenon which could not be observed when comparing African American and White males. These results advocate for taking intersectionality frameworks to study the effects of race, gender, and class in the US.