The use of race variables in genetic studies of complex traits and the goal of reducing health disparities: A transdisciplinary perspective

Conflating race and ancestry: Tracing decision points about population descriptors over the precision medicine research life course

Responding to calls for human genomics to shift away from the use of race, genomic investigators are coalescing around the possibility of using genetic ancestry. This shift has renewed questions about the use of social and genetic concepts of difference in precision medicine research (PMR). Drawing from qualitative data on five PMR projects, we illustrate negotiations within and between research teams as genomic investigators deliberate on the relevance of race and genetic ancestry for different analyses and contexts. We highlight how concepts of both social and genetic difference are embedded within and travel through research practices, and identify multiple points across the research life course at which conceptual slippage and conflation between race and genetic ancestry occur. We argue that moving beyond race will require PMR investigators to confront the entrenched ways in which race is built into research practices and biomedical infrastructures.

Genetic ancestry, differential gene expression, and survival in pediatric B-cell acute lymphoblastic leukemia

BACKGROUND

Black children have lower incidence yet worse survival than White and Latinx children with B-cell acute lymphoblastic leukemia (B-ALL). It is unclear how reported race/ethnicity (RRE) is associated with death in B-ALL after accounting for differentially expressed genes associated with genetic ancestry.

METHODS

Using Phase 1 and 2 NCI TARGET B-ALL cases (N = 273; RRE-Black = 21, RRE-White = 162, RRE-Latinx = 69, RRE-Other = 9, RRE-Unknown = 12), we estimated proportions of African (AFR), European (EUR), and Amerindian (AMR) genetic ancestry. We estimated hazard ratios (HR) and 95% confidence intervals (95% CI) between ancestry and death while adjusting for RRE and clinical measures. We identified genes associated with genetic ancestry and adjusted for them in RRE and death associations.

RESULTS

Genetic ancestry varied within RRE (RRE-Black, AFR proportion: Mean: 78.5%, Range: 38.2%-93.6%; RRE-White, EUR proportion: Mean: 94%, Range: 1.6%-99.9%; RRE-Latinx, AMR proportion: Mean: 52.0%, Range: 1.2%-98.7%). We identified 10, 1, and 6 differentially expressed genes (p_adjusted  <0.05) associated with AFR, AMR, and EUR ancestry proportion, respectively. We found AMR and AFR ancestry were statistically significantly associated with death (AMR each 10% HR: 1.05, 95% CI: 1.03-1.17, AFR each 10% increase HR: 1.03, 95% CI:1.01-1.19). RRE differences in the risk of death were larger in magnitude upon adjustment for genes associated with genetic ancestry for RRE-Black, but not RRE-Latinx children (RRE-Black HR: 3.35, 95% CI: 1.31, 8.53; RRE-Latinx HR: 1.47, 0.88-2.45).

CONCLUSIONS

Our work highlights B-ALL survival differences by RRE after adjusting for ancestry differentially expressed genes suggesting other factors impacting survival are important.

A scoping review of guidelines for the use of race, ethnicity, and ancestry reveals widespread consensus but also points of ongoing disagreement

The use of population descriptors such as race, ethnicity, and ancestry in science, medicine, and public health has a long, complicated, and at times dark history, particularly for genetics, given the field's perceived importance for understanding between-group differences. The historical and potential harms that come with irresponsible use of these categories suggests a clear need for definitive guidance about when and how they can be used appropriately. However, while many prior authors have provided such guidance, no established consensus exists, and the extant literature has not been examined for implied consensus and sources of disagreement. Here, we present the results of a scoping review of published normative recommendations regarding the use of population categories, particularly in genetics research. Following PRISMA guidelines, we extracted recommendations from n = 121 articles matching inclusion criteria. Articles were published consistently throughout the time period examined and in a broad range of journals, demonstrating an ongoing and interdisciplinary perceived need for guidance. Examined recommendations fall under one of eight themes identified during analysis. Seven are characterized by broad agreement across articles; one, "appropriate definitions of population categories and contexts for use," revealed substantial fundamental disagreement among articles. Additionally, while many articles focus on the inappropriate use of race, none fundamentally problematize ancestry. This work can be a resource to researchers looking for normative guidance on the use of population descriptors and can orient authors of future guidelines to this complex field, thereby contributing to the development of more effective future guidelines for genetics research.

Autism presentation in female and Black populations: Examining the roles of identity, theory, and systemic inequalities

LAY ABSTRACT

Although the prevalence of autism has been rising in recent years, disparities in diagnosis still remain. Female and Black populations in the United States are diagnosed later, are more likely to have an intellectual disability, and are excluded from research as well as services designed for autistic individuals. Autistic Black girls are effectively invisible in the current scientific literature. Intersectional theory, which looks at a person as a whole, examines models that are inclusive toward diverse gender, ability, and racial/ethnic backgrounds. This theory may be a useful approach to clinical and research work with autism so that practitioners may be most effective for the whole population of autistic people. The authors recommend research focusing on inclusion of autistic populations with intellectual disability and research studies that include evaluations as part of the procedure. Clinically, the authors recommend a focus on screening all young children for autism and improving provider knowledge in working with diverse autistic populations.

Challenges in Diversity, Equity, and Inclusion in Research and Clinical Oncology

Disparities are common and well-known in the field of clinical oncology and cancer research. In patient care, poor access and a number of other factors disadvantage patients and this can lead to inadequate screening, prevention or treatment of cancer and poor patient outcomes. World-wide, socioeconomic status, health care expenditures and a number of other challenges contribute to disparities in cancer care and patient outcomes. Access to cancer clinical trials remains inadequate for underrepresented minorities as well as non-white racial and ethnic groups. There are also disparities and many challenges in the biomedical research enterprise that can limit innovation and that must be addressed as part of active interventions.

Evaluating and sharing global genetic ancestry in biomedical datasets

Genetic ancestry is a critical co-factor to study phenotype-genotype associations using cohorts of human subjects. Most publicly available molecular datasets are, however, missing this information or only share self-reported race and ethnicity, representing a limitation to identify and repurpose datasets to investigate the contribution of ancestry to diseases and traits. We propose an analytical framework to enrich the metadata from publicly available cohorts with genetic ancestry information and a resulting diversity score at continental resolution, calculated directly from the data. We illustrate this framework using The Cancer Genome Atlas datasets searched through the DataMed Data Discovery Index. Data repositories and contributors can use this framework to provide genetic diversity measurements for controlled access datasets, minimizing the work involved in requesting a dataset that may ultimately prove inadequate for a researcher's purpose. With the increasing global scale of human genetics research, studies on disease risk and susceptibility would benefit greatly from the adequate estimation and sharing of genetic diversity in publicly available datasets following a framework such as the one presented.

Essential(ist) medicine: promoting social explanations for racial variation in biomedical research

Biomedical research has a long and complicated history as a tool of oppression, exemplary of the racial science used to legitimise and maintain racial hierarchies in the USA and abroad. While the explicit racism and racial inferiority supported by this research has dissipated and modern methods of inquiry have increased in sophistication and rigor, contemporary biomedical research continues to essentialise race by distilling racial differences and disparities in health to an underlying, biogenetic source. Focusing on the persistence of essentialism in an era of genomic medicine, this paper examines the deep social origins and social implications of the essentialist viewpoint in biomedicine and how it relates to the broader construction of social and scientific knowledge. Invoking Hacking's 'looping effects' as a useful conceptual tool, I then demonstrate how sociohistorical forces influence scientific and medical research in producing evidence that favours and legitimises a biological construction of race. I extend the looping framework to consider a parallel 'louping' process whereby applying a socially rooted meaning to race in biomedical research results becomes magnified to influence social norms and ideas about race. As many biomedical researchers are motivated by a desire to eliminate racial disparities in outcomes, I argue that greater social acuity allows scientists to avoid individualising and racialising health, challenge preconceived assumptions about the meaning of racial variation in health and medicine and thus promote and strengthen a socioenvironmental focus on how to best improve individuals' and population health. Concluding with a call for structural competency in biomedical research, I suggest that empowering scientists to more freely discuss sociostructural factors in their work allows for the continued use of race in biological and medical research, while social scientists and medical humanities scholars stand to benefit from seeing their work imbued with the cultural authority currently granted to biomedicine.

A content analysis of the views of genetics professionals on race, ancestry, and genetics

Over the past decade, the proliferation of genetic studies on human health and disease has reinvigorated debates about the appropriate role of race and ancestry in research and clinical care. Here we report on the responses of genetics professionals to a survey about their views on race, genetics, and ancestry across the domains of science, medicine, and society. Through a qualitative content analysis of free-text comments from 515 survey respondents, we identified key themes pertaining to multiple meanings of race, the use of race as a proxy for genetic ancestry, and the relevance of race and ancestry to health. Our findings suggest that for many genetics professionals the questions of what race is and what race means remain both professionally and personally contentious. Looking ahead as genomics is translated into the practice of precision medicine and as learning health care systems offer continued improvements in care through integrated research, we argue for nuanced considerations of both race and genetic ancestry across research and care settings.

Some basic questions about (a) decolonizing Africa(n)-centred psychology considered

Conceptual disagreement remains rife with regard to African psychology with some scholars mistakenly equating it to, for example, ethnotheorizing and traditional healing, while others confound African psychology with Africanization and racialization. Using writing as inquiry, this article aims to clear up some of the conceptual confusion on African psychology while engaging with the issue of a decolonizing African psychology. Accordingly, questions such as ‘What is the main dispute between Africa(n)-centred psychology and Euro-American-centric psychology in Africa?’; ‘Does Africa(n)-centred psychology not homogenize Africans?’; ‘What can be gained from imbricating decolonizing perspectives and feminist Africa(n)-centred psychology?’; and ‘What would a decolonizing Africa(n)-centred community psychology look like?’ are pertinent in the clarification of the conceptual confusion. Arising from an inventive dialogical and collaborative method, the aim of this article is not only to illuminate some basic misunderstandings on (a) decolonizing African psychology but also to generate further dialogue on how to work towards African psychology as situated decolonizing practice and knowledge.

Prioritizing diversity in human genomics research

Recent studies have highlighted the imperatives of including diverse and under-represented individuals in human genomics research and the striking gaps in attaining that inclusion. With its multidecade experience in supporting research and policy efforts in human genomics, the National Human Genome Research Institute is committed to establishing foundational approaches to study the role of genomic variation in health and disease that include diverse populations. Large-scale efforts to understand biology and health have yielded key scientific findings, lessons and recommendations on how to increase diversity in genomic research studies and the genomic research workforce. Increased attention to diversity will increase the accuracy, utility and acceptability of using genomic information for clinical care.

Ethnic groups' knowledge, attitude and practices and Rift Valley fever exposure in Isiolo County of Kenya

Rift Valley fever (RVF) is an emerging mosquito-borne viral hemorrhagic fever in Africa and the Arabian Peninsula, affecting humans and livestock. For spread of infectious diseases, including RVF, knowledge, attitude and practices play an important role, and the understanding of the influence of behavior is crucial to improve prevention and control efforts. The objective of the study was to assess RVF exposure, in a multiethnic region in Kenya known to experience RVF outbreaks, from the behavior perspective. We investigated how communities in Isiolo County, Kenya were affected, in relation to their knowledge, attitude and practices, by the RVF outbreak of 2006/2007. A cross-sectional study was conducted involving 698 households selected randomly from three different ethnic communities. Data were collected using a structured questionnaire regarding knowledge, attitudes and practices that could affect the spread of RVF. In addition, information was collected from the communities regarding the number of humans and livestock affected during the RVF outbreak. This study found that better knowledge about a specific disease does not always translate to better practices to avoid exposure to the disease. However, the high knowledge, attitude and practice score measured as a single index of the Maasai community may explain why they were less affected, compared to other investigated communities (Borana and Turkana), by RVF during the 2006/2007 outbreak. We conclude that RVF exposure in Isiolo County, Kenya during the outbreak was likely determined by the behavioral differences of different resident community groups. We then recommend that strategies to combat RVF should take into consideration behavioral differences among communities.

Understanding and effectively addressing breast cancer in African American women: Unpacking the social context

Black women have a higher incidence of breast cancer before the age of 40 years, more severe disease at all ages, and an elevated mortality risk in comparison with white women. There is limited understanding of the contribution of social factors to these patterns. Elucidating the role of the social determinants of health in breast cancer disparities requires greater attention to how risk factors for breast cancer unfold over the lifecourse and to the complex ways in which socioeconomic status and racism shape exposure to psychosocial, physical, chemical, and other individual and community-level assaults that increase the risk of breast cancer. Research that takes seriously the social context in which black women live is also needed to maximize the opportunities to prevent breast cancer in this underserved group. Cancer 2016;122:2138-49. © 2016 American Cancer Society.

Contributions of Public Health to Genetics Education for Health Care Professionals

With growing knowledge about the role of genetics in health, genetics education for health care professionals has taken on increasing importance. Many efforts are under way to develop new genetics curricula. Although such efforts are primarily the responsibility of health professional schools and professional societies, the public health system is an important stakeholder, and different sectors of public health have opportunities to enhance educational efforts. These include the development of authoritative information sources about the clinical utility of genetic susceptibility and pharmacogenetic tests, creation of networks that link professionals in underserved regions to educational materials and consultative backup, and sponsorship of forums for multidisciplinary discussion of controversial issues. Public health input can help to ensure an appropriate emphasis on health outcomes as new genomic tests and technologies come into use, thus helping to protect society from the social and medical costs of genetic tests with limited clinical value.

The Roles of Counseling Psychologists in Reducing Health Disparities

This article presents an overview of the health disparities problem that exists among individuals from ethnic minority and low-income backgrounds and their majority counterparts. The argument is made that the involvement of counseling psychologists in addressing this health disparities problem presents an opportunity for the field to remain true to its commitment to prevention, multiculturalism, and social justice while becoming more competitive in the health care and health promotion fields. This article highlights the prevalence of health disparities and identifies the primary factors contributing to these disparities. In addition, the roles and approaches that counseling psychologists can adopt to help alleviate this problem are specified.

Between (Racial) Groups and a Hard Place: An Exploration of Social Science Approaches to Race and Genetics, 2000-2014

As the social sciences expand their involvement in genetic and genomic research, more information is needed to understand how theoretical concepts are applied to genetic data found in social surveys. Given the layers of complexity of studying race in relation to genetics and genomics, it is important to identify the varying approaches used to discuss and operationalize race and identity by social scientists. The present study explores how social scientists have used race, ethnicity, and ancestry in studies published in four social science journals from 2000 to 2014. We identify not only how race, ethnicity, and ancestry are classified and conceptualized in this growing area of research, but also how these concepts are incorporated into the methodology and presentation of results, all of which structure the discussion of race, identity, and inequality. This research indicates the slippage between concepts, classifications, and their use by social scientists in their genetics-related research. The current study can assist social scientists with clarifying their use and interpretations of race and ethnicity with the incorporation of genetic data, while limiting possible misinterpretations of the complexities of the connection between genetics and the social world.

A reconsideration of the role of self-identified races in epidemiology and biomedical research

A considerable number of studies in epidemiology and biomedicine investigate the etiology of complex diseases by considering (self-identified) race as a relevant variable and focusing on the differences in risk among racial groups in the United States; they extensively draw on a genetic hypothesis--viz. the hypothesis that differences in the risk of complex diseases among racial groups are largely due to genetic differences covarying with genetic ancestry--that appears highly problematic in the light of both current biological evidence and the theory of human genome evolution. Is this reason for dismissing self-identified races? No. An alternative promising use of self-identified races exists, and ironically is suggested by those studies that investigate the etiology of complex diseases without focusing on racial differences. These studies provide a large amount of empirical evidence supporting the primacy of the contribution of non-genetic as opposed to genetic factors to the risk of complex diseases. We show that differences in race--or, better, in racial self-identification--may be critically used as proxies for differences in risk-related exposomes and epigenomes in the context of the United States. Self-identified race is what we need to capture the complexity of the effects of present and past racism on people's health and investigate risk-related external and internal exposures, gene-environment interactions, and epigenetic events. In fact patterns of racial self-identifications on one side, and patterns of risk-related exposomes and epigenomes on the other side, constantly coevolve and tend to match each other. However, there is no guarantee that using self-identified races in epidemiology and biomedical research will be beneficial all things considered: special attention must be paid at balancing positive and negative consequences.

Culture as a variable in neuroscience and clinical neuropsychology: A comprehensive review

Culture is a dynamic system of bidirectional influences among individuals and their environment, including psychological and biological processes, which facilitate adaptation and social interaction. One of the main challenges in clinical neuropsychology involves cognitive, behavioral and functional assessment of people with different sociocultural backgrounds. In this review essay, examining culture from a historical perspective to ethical issues in cross-cultural research, including the latest significant and publications, the authors sought to explore the main features related to cultural variables in neuropsychological practice and to debate the challenges found regarding the operational methods currently in use. Literature findings suggest a more comprehensive approach in cognitive and behavioral neuroscience, including an interface between elementary disciplines and applied neuropsychology. Thus, as a basis for discussion on this issue, the authors analyzed key-topics related to the study of new trends in sociocultural neuroscience and the application of their concepts from a clinical perspective.

Genetic ancestry is associated with measures of subclinical atherosclerosis in African Americans: the Jackson Heart Study

OBJECTIVE

To determine whether genetic ancestry was associated with subclinical atherosclerosis measures after adjustment for traditional cardiovascular disease risk factors, inflammatory marker, socioeconomic status, and psychosocial factors in a large admixed African American population.

APPROACH AND RESULTS

Participants were drawn from the Jackson Heart Study. Participant's percent of European ancestry (PEA) was estimated based on 1747 genetic markers using HAPMIX. Association of PEA with peripheral arterial disease and common carotid intima-media thickness were investigated among 2168 participants and with coronary artery calcification >0 and abdominal aortic calcification >0 among 1139 participants. The associations were evaluated using multivariable regression models. Our results showed that a 1 SD increase in PEA was associated with a lower peripheral arterial disease prevalence after adjusting for age and sex (prevalence ratio=0.90 [95% CI, 0.82-0.99]; P=0.036). Adjustments for traditional cardiovascular disease risk factors, socioeconomic status, and psychosocial factors attenuated this association (prevalence ratio=0.91 [0.82-1.00]; P=0.046). There was also a nonlinear association between PEA and coronary artery calcification and abdominal aortic calcification. The lowest PEA was associated with a lower coronary artery calcification (prevalence ratio=0.75 [0.58-0.96]; P=0.022) and a lower abdominal aortic calcification [prevalence ratio=0.80 [0.67-0.96]; P=0.016) compared with the reference group (10th-90th percentile) after adjusting for traditional cardiovascular disease risk factors, inflammatory marker, socioeconomic status, and psychosocial factors. However, we found no significant association between PEA and common carotid intima-media thickness.

CONCLUSIONS

Overall, our findings indicate that genetic ancestry was associated with subclinical atherosclerosis, suggesting unmeasured risk factors and interactions with genetic factors might contribute to the distribution of subclinical atherosclerosis among African Americans.

Biogeographical ancestry and race

The use of racial and ethnic categories in biological and biomedical research is controversial-for example, in the comparison of disease risk in different groups or as a means of making use of or controlling for population structure in the mapping of genes to chromosomes. Biogeographical ancestry (BGA) has been recommended as a more accurate and appropriate category. BGA is a product of the collaboration between biological anthropologist Mark Shriver from Pennsylvania State University and molecular biologist Tony Frudakis from the now-defunct biotechnology start-up company DNAPrint genomics, Inc. Shriver and Frudakis portray BGA as a measure of the 'biological', 'genetic', 'natural', and 'objective' components of race and ethnicity, what philosophers of science would call a natural kind. This paper argues that BGA is not a natural kind that escapes social and political connotations of race and ethnicity, as Shriver and Frudakis and other proponents believe, but a construction that is built upon race-as race has been socially constructed in the European scientific and philosophical traditions. More specifically, BGA is not a global category of biological and anthropological classification but a local category shaped by the U.S. context of its production, especially the forensic aim of being able to predict the race or ethnicity of an unknown suspect based on DNA found at the crime scene. Therefore, caution needs to be exercised in the embrace of BGA as an alternative to the use of racial and ethnic categories in biological and biomedical research.

Race and laboratory norms. The critical insights of Julian Herman Lewis (1891-1989)

The work of Julian Herman Lewis helps to expose the underlying racial organization of laboratory normality in early twentieth-century medicine. In the 1920s and 1930s, Lewis launched a critique of prevailing racial theory, as he established an academic career in pathology at the University of Chicago. As one of the small number of black research physicians at the time, Lewis met barriers to his work that eventually derailed his career. Although his research fell short of its goals, his work continues to provide a key insight into medical laboratory standards as they became institutionalized in Lewis's field of clinical pathology. By avoiding attributions of race and following prevailing practices of racial exclusion, medical laboratories quietly reasserted social norms in the formation of laboratory normality. An examination of Lewis's critiques and his research sharpens questions about the development of the concept of "normal" in the human sciences and a related tendency in twentieth-century medicine to conflate difference with pathology.

Homogeneity and heterogeneity as situational properties: producing--and moving beyond?--race in post-genomic science

In this article, we explore current thinking and practices around the logics of difference in gene-environment interaction research in the post-genomic era. We find that scientists conducting gene-environment interaction research continue to invoke well-worn notions of racial difference and diversity, but use them strategically to try to examine other kinds of etiologically significant differences among populations. Scientists do this by seeing populations not as inherently homogeneous or heterogeneous, but rather by actively working to produce homogeneity along some dimensions and heterogeneity along others in their study populations. Thus we argue that homogeneity and heterogeneity are situational properties--properties that scientists seek to achieve in their study populations, the available data, and other aspects of the research situation they are confronting, and then leverage to advance post-genomic science. Pointing to the situatedness of homogeneity and heterogeneity in gene-environment interaction research underscores the work that these properties do and the contingencies that shape decisions about research procedures. Through a focus on the situational production of homogeneity and heterogeneity more broadly, we find that gene-environment interaction research attempts to shift the logic of difference from solely racial terms as explanatory ends unto themselves, to racial and other dimensions of difference that may be important clues to the causes of complex diseases.

Discussing race-related limitations of genomic testing for colon cancer risk: implications for education and counseling

This study examines communication about limitations of genomic results interpretation for colon cancer risk during education and counseling of minority participants. As part of a larger study conducted from 2010 to 2012, participants recruited from a large primary care clinic were offered testing for a research panel of 3 genomic markers (single nucleotide polymorphisms or SNPs) for colorectal cancer risk. Genetic counselors conducted pre- and post-test sessions which included discussion of limitations of result interpretation due to the lack of racial/ethnic diversity in research populations from which risk data are derived. Sessions were audio-recorded, transcribed and thematically analyzed. Many participants did not respond directly to this limitation. Among the participants that responded directly to this race-related limitation, many responses were negative. However, a few participants connected the limited minority information about SNPs with the importance of their current research participation. Genetic counselor discussions of this limitation were biomedically focused with limited explanations for the lacking data. The communication process themes identified included: low immediacy (infrequent use of language directly involving a participant), verbal dominance (greater speaking ratio of the counselor to the patient) and wide variation in the degree of interactivity (or the amount of turn-taking during the discussion). Placed within the larger literature on patient-provider communication, these present results provide insight into the dynamics surrounding race-related educational content for genomic testing and other emerging technologies. Clinicians may be better able to engage patients in the use of new genomic technology by increasing their awareness of specific communication processes and patterns during education or counseling sessions.

Troubling "environments": postgenomics, Bajan wheezing, and Lévi-Strauss

Postgenomics is intended to move beyond the search for genes to explore disease as a result of genes interacting with their environment, revealing how they have relevance for health. This addition of environment confers genomic research with new cultural life, making it relevant to public health discourse, government interventions, and health disparities. Drawing on ethnographic research following an American genetics of asthma study conducted in Barbados, I explore the ways environment gets construed by the multiple communities involved-U.S. researchers, Bajan officials, medical practitioners, and patient participants. I draw on Lévi-Strauss to argue that plural competing environments give mana to the American postgenomic project as intervention on racial injustice, household practices, pollution, and other aspects of asthma.

Gene-environment interactions and health inequalities: views of underserved communities

This article examines the beliefs and experiences of individuals living in underserved ethnically diverse communities in Cleveland, Ohio, regarding the influence of genetic, social, and environmental factors on health and health inequalities. Using a community-engaged methodological approach, 13 focus groups were conducted with African American, Hispanic, and White individuals residing in the Cleveland area to explore attitudes and beliefs about genetics, genetic research, and health disparities and inequalities. Results of this study highlight the range of meanings that individuals attach to genetic variation, genomic research, and gene-environment interactions, and their implications for addressing health inequalities. The majority of participants in all focus groups reported that social and environmental factors were more important than genetics in contributing to health inequalities. Most participants were unfamiliar with genetic research. These data have implications for how genetic information and research might be applied in conjunction with addressing social determinants of health to improve prevention strategies in underserved communities and ultimately reduce health inequalities.

Practice parameter for cultural competence in child and adolescent psychiatric practice

The United States faces a rapidly changing demographic and cultural landscape, with its population becoming increasingly multiracial and multicultural. In consequence, cultural and racial factors relating to mental illness and emotional disturbances deserve closer attention and consideration. This Practice Parameter outlines clinical applications of the principle of cultural competence that will enable child and adolescent mental health clinicians to better serve diverse children, adolescents, and their families.

Genes, race, and culture in clinical care: racial profiling in the management of chronic illness

Race, although an unscientific concept, remains prominent in health research and clinical guidelines, and is routinely invoked in clinical practice. In interviews with 58 primary care clinicians we explored how they understand and apply concepts of racial difference. We found wide agreement that race is important to consider in clinical care. They explained the effect of race on health, drawing on common assumptions about the biological, class, and cultural characteristics of racial minorities. They identified specific race-based clinical strategies for only a handful of conditions and were inconsistent in the details of what they said should be done for minority patients. We conclude that using race in clinical medicine promotes and maintains the illusion of inherent racial differences and may result in minority patients receiving care aimed at presumed racial group characteristics, rather than care selected as specifically appropriate for them as individuals.

Pharmacogenetics in primary care: the promise of personalized medicine and the reality of racial profiling

Many anticipate that expanding knowledge of genetic variations associated with disease risk and medication response will revolutionize clinical medicine, making possible genetically based Personalized Medicine where health care can be tailored to individuals, based on their genome scans. Pharmacogenetics has received especially strong interest, with many pharmaceutical developers avidly working to identify genetic variations associated with individual differences in drug response. While clinical applications of emerging genetic knowledge are becoming increasingly available, genetic tests for drug selection are not as yet widely accessible, and many primary care clinicians are unprepared to interpret genetic information. We conducted interviews with 58 primary care clinicians, exploring how they integrate emerging pharmacogenetic concepts into their practices. We found that in their current practices, pharmacogenetic innovations have not led to individually tailored treatment, but instead have encouraged use of essentialized racial/ethnic identity as a proxy for genetic heritage. Current manifestations of Personalized Medicine appear to be reinforcing entrenched notions of inherent biological differences between racial groups, and promoting the belief that racial profiling in health care is supported by cutting-edge scientific authority. Our findings raise concern for how pharmacogenetic innovations will actually affect diverse populations, and how unbiased treatment can be assured.

Cultural Neuroscience: Progress and Promise

The nature and origin of human diversity has been a source of intellectual curiosity since the beginning of human history. Contemporary advances in cultural and biological sciences provide unique opportunities for the emerging field of cultural neuroscience. Research in cultural neuroscience examines how cultural and genetic diversity shape the human mind, brain and behavior across multiple time scales: situation, ontogeny and phylogeny. Recent progress in cultural neuroscience provides novel theoretical frameworks for understanding the complex interaction of environmental, cultural and genetic factors in the production of adaptive human behavior. Here, we provide a brief history of cultural neuroscience, theoretical and methodological advances, as well as empirical evidence of the promise of and progress in the field. Implications of this research for population health disparities and public policy are discussed.

Looking to the future: incorporating genomic information into disparities research to reduce measurement error and selection bias

OBJECTIVE

To extend recent conceptual and methodological advances in disparities research to include the incorporation of genomic information in analyses of racial/ethnic disparities in health care and health outcomes.

DATA SOURCES

Published literature on human genetic variation, the role of genetics in disease and response to treatment, and methodological developments in disparities research.

STUDY DESIGN

We present a conceptual framework for incorporating genomic information into the Institute of Medicine definition of racial/ethnic disparities in health care, identify key concepts used in disparities research that can be informed by genomics research, and illustrate the incorporation of genomic information into current methods using the example of HER-2 mutations guiding care for breast cancer.

PRINCIPAL FINDINGS

Genomic information has not yet been incorporated into disparities research, though it has direct relevance to concepts of race/ethnicity, health status, appropriate care, and socioeconomic status. The HER-2 example demonstrates how available genetic information can be incorporated into current disparities methods to reduce selection bias and measurement error. Advances in health information infrastructure may soon make standardized genetic information more available to health services researchers.

CONCLUSION

Genomic information can refine measurement of racial/ethnic disparities in health care and health outcomes and should be included wherever possible in disparities research.

Making sense of skin color in clinical care

The background of this article is that assessment and quantification of skin color is important to health care; color is one indicator of overall health and is linked to oxygenation, tissue perfusion, nutritional status, and injury. The purpose is to describe how skin color varies across racial/ethnic groups so that the information can be applied to clinical practice. The method used is cross-sectional, descriptive design (n = 257). We recorded self-defined race/ethnicity and used a spectrophotometer to measure skin color at two anatomic sites. Skin color variables included L* (light/dark), a* (red/green), and b* (yellow/blue). As regards results, we found significant differences in L*, a*, and b* values by site and race/ethnicity in White, Asian, and Biracial participants. L*: F(3, 233) = 139.04, p < .01 and F(3, 233) = 118.47, p < .01. Black participants had significantly lower mean L* values and wider ranges of L*, a*, and b* as compared with other groups. In regard to application, these findings suggest that clinicians and researchers should plan and provide care based on skin color, rather than race/ethnicity.

Finding a place for genomics in health disparities research

The existence of pronounced differences in health outcomes between US populations is a problem of moral significance and public health urgency. Pursuing research on genetic contributors to such disparities, despite striking data on the fundamental role of social factors, has been controversial. Still, advances in genomic science are providing an understanding of disease biology at a level of precision not previously possible. The potential for genomic strategies to help in addressing population-level disparities therefore needs to be carefully evaluated. Using 3 examples from current research, we argue that the best way to maximize the benefits of population-based genomic investigations, and mitigate potential harms, is to direct research away from the identification of genetic causes of disparities and instead focus on applying genomic methodologies to the development of clinical and public health tools with the potential to ameliorate healthcare inequities, direct population-level health interventions or inform public policy. Such a transformation will require close collaboration between transdisciplinary teams and community members as well as a reorientation of current research objectives to better align genomic discovery efforts with public health priorities and well-recognized barriers to fair health care delivery.

Conceptual approaches to the study of health disparities

Scientific and policy interest in health disparities, defined as systematic, plausibly avoidable health differences adversely affecting socially disadvantaged groups, has increased markedly over the past few decades. Like other research, research in health disparities is strongly influenced by the underlying conceptual model of the hypothetical causes of disparities. Conceptual models are important and a major source of debate because multiple types of factors and processes may be involved in generating disparities, because different disciplines emphasize different types of factors, and because the conceptual model often drives what is studied, how results are interpreted, and which interventions are identified as most promising. This article reviews common conceptual approaches to health disparities including the genetic model, the fundamental cause model, the pathways model, and the interaction model. Strengths and limitations of the approaches are highlighted. The article concludes by outlining key elements and implications of an integrative systems-based conceptual model.

What are our AIMs? Interdisciplinary Perspectives on the Use of Ancestry Estimation in Disease Research

BACKGROUND

Ancestry estimation serves as a tool to identify genetic contributions to disease but may contribute to racial discrimination and stigmatization. We sought to understand user perspectives on the benefits and harms of ancestry estimation to inform research practice and contribute to debates about the use of race and ancestry in genetics.

METHODS

Key informant interviews with 22 scientists were conducted to examine scientists' understandings of the benefits and harms of ancestry estimation.

RESULTS

Three main perspectives were observed among key informant scientists who use ancestry estimation in genetic epidemiology research. Population geneticists self identified as educators who controlled the meaning and application of ancestry estimation in research. Clinician-researchers were optimistic about the application of ancestry estimation to individualized risk assessment and personalized medicine. Epidemiologists remained ambivalent toward ancestry estimation and suggested a continued role for race in their research.

CONCLUSIONS

We observed an imbalance of control over the meaning and application of ancestry estimation among disciplines that may result in unwarranted or premature translation of ancestry estimation into medicine and public health. Differences in disciplinary perspectives need to be addressed if translational benefits of genetic ancestry estimation are to be realized.

Feminist intersectionality: bringing social justice to health disparities research

The principles of autonomy, beneficence, non-maleficence, and justice are well established ethical principles in health research. Of these principles, justice has received less attention by health researchers. The purpose of this article is to broaden the discussion of health research ethics, particularly the ethical principle of justice, to include societal considerations--who and what are studied and why?--and to critique current applications of ethical principles within this broader view. We will use a feminist intersectional approach in the context of health disparities research to firmly establish inseparable links between health research ethics, social action, and social justice. The aim is to provide an ethical approach to health disparities research that simultaneously describes and seeks to eliminate health disparities.

Complex systems thinking and current impasses in health disparities research

Complex systems approaches have received increasing attention in public health because reductionist approaches yield limited insights in the context of dynamic systems. Most discussions have been highly abstract. There is a need to consider the application of complex systems approaches to specific research questions. I review the features of population health problems for which complex systems approaches are most likely to yield new insights, and discuss possible applications of complex systems to health disparities research. I provide illustrative examples of how complex systems approaches may help address unanswered and persistent questions regarding genetic factors, life course processes, place effects, and the impact of upstream policies. The concepts and methods of complex systems may help researchers move beyond current impasse points in health disparities research.

Complex systems thinking and current impasses in health disparities research

Complex systems approaches have received increasing attention in public health because reductionist approaches yield limited insights in the context of dynamic systems. Most discussions have been highly abstract. There is a need to consider the application of complex systems approaches to specific research questions. I review the features of population health problems for which complex systems approaches are most likely to yield new insights, and discuss possible applications of complex systems to health disparities research. I provide illustrative examples of how complex systems approaches may help address unanswered and persistent questions regarding genetic factors, life course processes, place effects, and the impact of upstream policies. The concepts and methods of complex systems may help researchers move beyond current impasse points in health disparities research.

Ethnic disparities in the perception of ethical risks from psychiatric genetic studies

To examine if ethnic differences in concerns about unfavorable consequences from psychiatric genetic studies, existing between non-Hispanic Black and White populations, persist among participants in an actual genetic study of bipolar disorder. Historically, minority subjects have been less willing to participate in such studies. Participants in the US Bipolar Genome Study (BIGS) were assessed on six items of concerns in the Questionnaire on Genetic Risk (QGR). Each item had five response categories, ranging from "not at all" concerned to "very concerned." Responses from Black (N = 188) and White participants (N = 1,065) formed the base for this analysis. Concerns about unfavorable consequences of conducting psychiatric genetic studies were prevalent in the whole sample. Concern for medical insurance was most prevalent (63.4%), followed by job concern (58.8%) and stigma (57.4%). Racial discrimination was less prevalent (28.1%). Blacks endorsed significantly stronger concerns for all consequences except the medical insurance item (P < 0.008). The most significant ethnic disparity in concerns was for racial discrimination (P < 0.0001). Associations between levels of concern and ethnicity remained significant after adjustments for other factors in multivariate models. Ethnic differences (Blacks vs. Whites) in perceived concerns about unfavorable consequences from participation persist among participants in an actual psychiatric genetic study. This suggests that other factors may play a more critical role in the decision not to participate. Future studies should investigate more comprehensive sources of barriers to consenting for ongoing psychiatric genetic studies in representative samples, incorporating assessments from non-participants as well as participants.

Pharmacogenetics of alcohol, nicotine and drug addiction treatments

The numerous premature deaths, medical complications and socio-economic repercussions of drug and alcohol addiction suggest that improvements in treatment strategies for addictive disorders are warranted. The use of pharmacogenetics to predict response to medication, side effects and appropriate dosages is relatively new in the field of drug addiction. However, increasing our understanding of the genetic factors influencing these processes may improve the treatment of addiction in the future. We examined the available scientific literature on pharmacogenetic advancements in the field of drug addiction with a focus on alcohol and tobacco to provide a summary of genes implicated in the effectiveness of pharmacotherapy for addiction. In addition, we reviewed pharmacogenetic research on cocaine and heroin dependence. Thus far, the most promising results were obtained for polymorphisms in the OPRM1 and CYP2A6 genes, which have been effective in predicting clinical response to naltrexone in alcoholism and nicotine replacement therapy in smoking, respectively. Opinions differ as to whether pharmacogenetic testing should be implemented in the clinic at this time because clinical utility and cost-effectiveness require further investigation. However, the data summarized in this review demonstrate that pharmacogenetic factors play a role in response to addiction pharmacotherapy and have the potential to aid in the personalization of addiction treatments. Such data may lead to improved cessation rates by allowing physicians to select medications for individuals based, at least in part, on genetic factors that predispose to treatment success or failure rather than on a trial and error basis.

Different differences: the use of 'genetic ancestry' versus race in biomedical human genetic research

This article presents findings from our ethnographic research on biomedical scientists' studies of human genetic variation and common complex disease. We examine the socio-material work involved in genome-wide association studies (GWAS) and discuss whether, how, and when notions of race and ethnicity are or are not used. We analyze how researchers produce simultaneously different kinds of populations and population differences. Although many geneticists use race in their analyses, we find some who have invented a statistical genetics method and associated software that they use specifically to avoid using categories of race in their genetic analysis. Their method allows them to operationalize their concept of 'genetic ancestry' without resorting to notions of race and ethnicity. We focus on the construction and implementation of the software's algorithms, and discuss the consequences and implications of the software technology for debates and policies around the use of race in genetics research. We also demonstrate that the production and use of their method involves a dynamic and fluid assemblage of actors in various disciplines responding to disciplinary and sociopolitical contexts and concerns. This assemblage also includes particular discourses on human history and geography as they become entangled with research on genetic markers and disease.We introduce the concept of'genome geography' to analyze how some researchers studying human genetic variation'locate' stretches of DNA in different places and times. The concept of genetic ancestry and the practice of genome geography rely on old discourses, but they also incorporate new technologies, infrastructures, and political and scientific commitments. Some of these new technologies provide opportunities to change some of our institutional and cultural forms and frames around notions of difference and similarity. Nevertheless, we also highlight the slipperiness of genome geography and the tenacity of race and race concepts.

Human genomics: challenges for African Americans and policy implications for direct social work practice

Recent advancements in the scientific study of the human genome may benefit African Americans through increased knowledge of the causes and cures for diseases that disproportionately affect them. Other potential benefits are far reaching and include legal and socioeconomic importance for the African American community. Although these benefits have tremendous appeal, advancements in genomic science pose significant social issues for African Americans. Disparities in access, insensitive and discriminatory programming, a lack of appreciation of environmental factors, and misuse of genetic databases are among the challenges for African Americans. This article identifies the major benefits and challenges of human genomics cited in literature from various disciplines and discusses policy implications for direct social work practice. The author explains the importance of social work involvement in shaping genetic policies and outlines traditional roles social workers may play in establishing ethnic-sensitive public policies and agency practices to protect the interests of African Americans who interface with the rapidly expanding field of human genomics.

The confluence of human genomics, environment, and determinants of health-related quality of life among African American hemodialysis patients

The intersection of human genome sequencing, environmental factors that lend to further understanding of the etiology of complex diseases, and components that constitute the health-related quality of life for African American hemodialysis patients are explored in this article. There are many renal diseases that have genetic components. Even though genetic polymorphisms and allelic variations can explain some of the etiology and disparities in disease susceptibility for African Americans, the role of the environment must also be considered. For African American hemodialysis patients, the environmental influences of religiosity and social support, along with genetic factors, affect their health-related quality of life. A study of 176 African American hemodialysis patients revealed that religiosity and social support had a significant impact on patient's health-related quality of life. Implications of the study mandate that social and behavioral researchers, who tend to focus on environmental issues, be given more freedom and latitude, along with genetic researchers, in designing and implementing studies involving genomic sequencing and the influence on health disparities among persons of African descent.

African Americans' responses to genetic explanations of lung cancer disparities and their willingness to participate in clinical genetics research

PURPOSE

To assess whether reactions to genetic explanations for disparities in lung cancer incidence among family members of African American patients with lung cancer are associated with willingness to participate in clinical genetics research.

METHODS

Data are reported for 67 self-identified African Americans aged 18 to 55 years who completed a telephone survey assessing reactions to explanations (i.e., genetics, toxin exposure, menthol cigarettes, and race-related stress) for lung cancer disparities. Majority were female (70%), current smokers (57%), and patients' biological relatives (70%).

RESULTS

Family members rated the four explanations similarly, each as believable, fair, and not too worrisome. Participants also indicated a high level of willingness to participate in genetics research (M = 4.1 +/- 1.0; scale: 1-5). Endorsements of genetics explanations for disparities as believable and fair, and toxin exposure as believable were associated significantly with willingness to participate in genetics research.

CONCLUSION

These results suggest that strategies to encourage African Americans' participation in genetics research would do well to inform potential participants of how their involvement might be used to better understand important environmental factors that affect health disparities.

Hyperdiagnostics: postcolonial utopics of race-based biomedicine

The expansion of biomedical research into countries outside the United States and Western Europe is positing new biological links between populations based on race. This expansion includes six international projects occurring in Barbados, premised on the idea that the population is genetically representative of other black people. Based on ethnographic research tracking one such study, a genetics of asthma project, this article explores the ways Caribbean meanings of ethnicity and illness are reworked as Barbadian state medical practitioners become involved in facilitating the international genetics research on race and disease. As the state attempts to participate in an imagined future of genetic medicine, the hyperspecificity of genetic technologies create new medical meanings of race and disease. These changes rely on a paradoxical response by medical practitioners toward the high technology American genetic research as both authoritative and inapplicable, creating unexpected etiologies of illness and ethnicity.

Theory and methods in cultural neuroscience

Cultural neuroscience is an emerging research discipline that investigates cultural variation in psychological, neural and genomic processes as a means of articulating the bidirectional relationship of these processes and their emergent properties. Research in cultural neuroscience integrates theory and methods from anthropology, cultural psychology, neuroscience and neurogenetics. Here, we review a set of core theoretical and methodological challenges facing researchers when planning and conducting cultural neuroscience studies, and provide suggestions for overcoming these challenges. In particular, we focus on the problems of defining culture and culturally appropriate experimental tasks, comparing neuroimaging data acquired from different populations and scanner sites and identifying functional genetic polymorphisms relevant to culture. Implications of cultural neuroscience research for addressing current issues in population health disparities are discussed.

The public health utility of genome-wide association study results for smoking behavior

New approaches to improve smoking cessation rates are needed. In recent years, substantial progress has been made in understanding the genetics of smoking behavior, and this knowledge may eventually be used to personalize treatment for smokers. Although there are highly significant and reproducible genetic associations, none are yet ready for clinical applications. We suggest that translational research from several disciplines, including behavioral science, ethics and economics, should be performed in parallel with ongoing genome-wide association studies for smoking behavior and pharmacogenetic trials. The coordinated effort of multidisciplinary research teams will help reveal the circumstances under which we can translate genetic insights into clinical practice in the hope of reducing the burden of smoking in society.

Population description and its role in the interpretation of genetic association

Despite calls for greater clarity and precision of population description, studies have documented persistent ambiguity in the use of race/ethnicity terms in genetic research. It is unclear why investigators tolerate such ambiguity, or what effect these practices have on the evaluation of reported associations. To explore the way that population description is used to replicate and/or extend previously reported genetic observations, we examined articles describing the association of the peroxisome proliferator-activated receptor-gamma-gamma Pro12Ala polymorphism with type 2 diabetes mellitus and related phenotypes, published between 1997 and 2005. The 80 articles identified were subjected to a detailed content analysis to determine (1) how sampled populations were described, (2) whether and how the choice of sample was explained, and (3) how the allele frequency and genetic association findings identified were contextualized and interpreted. In common with previous reports, we observed a variety of sample descriptions and little explanation for the choice of population investigated. Samples of European origin were typically described with greater specificity than samples of other origin. However, findings from European samples were nearly always compared to samples described as "Caucasian" and sometimes generalized to all Caucasians or to all humans. These findings suggest that care with population description, while important, may not fully address analytical concerns regarding the interpretation of variable study outcomes or ethical concerns regarding the attribution of genetic observations to broad social groups. Instead, criteria which help investigators better distinguish justified and unjustified forms of population generalization may be required.

Racial and ethnic differences in willingness to participate in psychiatric genetic research

OBJECTIVE

The National Institute of Mental Health's effort to rectify the underrepresentation of American Blacks in the genetic studies of psychiatric disorders has met with mixed success. This study was designed to understand some of the barriers to recruitment.

METHODS

Men and women, who were of Black, White or Hispanic race/ethnicity, aged 18-79 years (N= 353), were recruited from clinical and community settings in New York City. Participants responded to a survey that was designed to measure willingness to participate and attitudes toward genetic research. Principal components analyses generated eight factors including perceived benefits, concerns about, and drawbacks of genetic research, and beliefs about genetic or environmental contributions to psychopathology. Analysis of variance assessed within-ethnic group differences on factor scores, as they related to willingness to participate in genetic research.

RESULTS

Ethnic groups did not differ significantly in stated willingness to participate in genetic research; more than 70% in each group were willing to participate. Among Blacks and Hispanics, mistrust and wariness, and stigma were significantly increased in those unwilling to participate; for Whites, perceived benefit to society and perceived importance for knowledge/education were associated with willingness to participate. For Blacks and Hispanics, youth (aged 18-29 years) and college education reduced, but did not eliminate the association between wariness and mistrust and willingness to participate.

CONCLUSION

Findings suggest that recruitment efforts aimed at increasing the representation of Blacks should be aware of the barriers among those who are less educated, and involve interactive community collaborations, to fully address the mistrust in this population.