Theory-guided selection of discrimination measures for racial/ ethnic health disparities research among older adults

Race/ethnic differences in the association of anxiety, depression, and discrimination with subsequent nicotine and cannabis use among young adults: A prospective longitudinal study

INTRODUCTION

The shifting patterns in nicotine and cannabis use among young adults is taking place at a time when there is also increased reports of psychosocial stressors such as anxiety, depression, and everyday discrimination. Although race/ethnicity has been found to moderate the impact of psychosocial stressors, there is limited research examining the association of anxiety, depression, and discrimination with patterns of nicotine and/or cannabis product use among diverse young adults.

METHODS

Data were from a longitudinal study of 2478 US young adults surveyed between 2019 and 2021. General estimating equation models were used to examine associations of self-reported psychological symptoms (depression, anxiety) and social stressors (discrimination) with substance use (any nicotine and cannabis product use; nicotine and cannabis vaping).

RESULTS

Young adults from different racial/ethnic groups differed significantly in their depression and discrimination scores with young adults of color having higher mean scores. Overall, higher depression and everyday discrimination score was associated with increased odds of past 6-month use of any nicotine/tobacco and cannabis products. Higher generalized anxiety score increased odds of any nicotine/tobacco and dual nicotine and cannabis product use. Higher everyday discrimination score was associated with increased odds nicotine and cannabis vaping overall. Stratified models showed variation in associations among different racial/ethnic groups.

CONCLUSIONS

Psychosocial stressors are associated with increased substance use odds among young adults. However, these stressors have a differential impact on substance use odds among young adults from different racial/ethnic contexts.

The measurement of racism in health inequities research

There is limited literature on the measures and metrics used to examine racism in the health inequities literature. Health inequities research is continuously evolving, with the number of publications increasing over time. However, there is limited knowledge on the best measures and methods to examine the impact of different levels of racism (institutionalized, personally mediated, and internalized) on health inequities. Advanced statistical methods have the potential to be used in new ways to examine the relationship between racism and health inequities. In this review, we conduct a descriptive examination of the measurement of racism in the health inequities epidemiologic literature. We examine the study design, methods used for analysis, types of measures used (e.g., composite, absolute, relative), number of measures used, phase of research (detect, understand, solutions), viewpoint (oppressor, oppressed), and components of structural racism measures (historical context, geographical context, multifaceted nature). We discuss methods (e.g., Peters-Belson, latent class analysis, difference in differences) that have demonstrated potential for future work. The articles reviewed were limited to the detect (25%) and understand (75%) phases, with no studies in the solutions phase. Although the majority (56%) of studies had cross-sectional designs, many authors pointed to the need for longitudinal and multilevel data for further exploration. We examined study design features as mutually exclusive elements. However, racism is a multifaceted system and the measurement of racism in many studies does not fit into a single category. As the literature grows, the significance of methodological and measurement triangulation to assess racism should be investigated.

The role of structural racism and geographical inequity in diabetes outcomes

Diabetes is pervasive, exponentially growing in prevalence, and outpacing most diseases globally. In this Series paper, we use new theoretical frameworks and a narrative review of existing literature to show how structural inequity (structural racism and geographical inequity) has accelerated rates of diabetes disease, morbidity, and mortality globally. We discuss how structural inequity leads to large, fixed differences in key, upstream social determinants of health, which influence downstream social determinants of health and resultant diabetes outcomes in a cascade of widening inequity. We review categories of social determinants of health with known effects on diabetes outcomes, including public awareness and policy, economic development, access to high-quality care, innovations in diabetes management, and sociocultural norms. We also provide regional perspectives, grounded in our theoretical framework, to highlight prominent, real-world challenges.

Perceived discrimination among Syrian refugees in Germany and its associations with mental health

Discrimination is a crucial post migratory stressor but there is little research on perceived discrimination by Syrian refugees. This study aims to assess self-reported discrimination by Syrian refugees with a residence permit in Germany, determine its forms, places, and predictors, and explore its possible relation with mental health. Sociodemographics, migration-specific characteristics, traumatic life events, quality of life, perceived discrimination, depression, generalised anxiety disorder, post-traumatic symptoms, and somatic distress were assessed among 116 participants. More than one-third of the participants perceived discrimination in low frequency, and in general, perceived discrimination was confined to treatment with less courtesy or respect. Unfair treatment was perceived mostly while searching for accommodation and in the neighbourhood. Refugees attributed their experiences to their lack of language skills prior to national, religious, and racial causes. Lower age, higher number of completed years of education, and symptoms of posttraumatic stress disorder were significantly and substantially associated with perceived discrimination. Anxiety symptoms, number of traumatic experiences and gender may also be regarded as relevant predictors of perceived discrimination. Health care professionals must be aware of the links between discrimination and symptoms of mental disorders. Policymakers should address discrimination as a key refugee issue and risk to mental health.

Congruence and discrepancy in Asian American women's perception and stress appraisal of gendered racial microaggressions: Relationships with depressive symptoms and internalized racism

Prior research demonstrates significant links between discrimination and mental health by assessing either encounters with or stress appraisal of discrimination. However, research has yet to examine the dynamic interplay between frequency and stress appraisal (e.g., high frequency-low stress appraisal) and their linkage to depressive symptoms. Using a sample of 309 Asian American women (M _age = 22.81, SD = 0.26), we used a polynomial regression and response surface analysis to model the congruence and discrepancy between frequency and stress appraisal of gendered racial microaggressions experienced by Asian American women and how they are related to depressive symptoms and internalized racism. The dynamics between frequency and stress in relation to depressive symptoms were further probed at low, mean, and high levels of internalized racism. Greater congruence between frequency and stress was significantly associated with depressive symptoms (medium to large effect) and internalized racism (small effect). A discrepancy between higher frequency and lower stress was significantly associated with greater internalized racism. Further, when looking across levels of internalized racism, greater congruence between frequency and stress was significantly associated with greater depressive symptoms at low and mean levels of internalized racism but not at high levels. Gendered racial microaggressions are associated with adverse mental health outcomes among Asian American women, contributing to greater depressive symptoms and internalized racism. Further consideration should be given toward how internalized racism shapes differences in the perceptions and stress appraisal of gendered racial microaggressions, and subsequent mental health outcomes among Asian American women.

How Do We Define and Measure Health Equity? The State of Current Practice and Tools to Advance Health Equity

INTRODUCTION

Healthy People establishes national goals and specific measurable objectives to improve the health and well-being of the nation. An overarching goal of Healthy People 2030 is to "eliminate health disparities, achieve health equity, and attain health literacy to improve the health and well-being of all." To inform Healthy People 2030 health equity and health disparities content and products, the US Department of Health and Human Services (HHS) Office of Disease Prevention and Health Promotion (ODPHP), in collaboration with NORC at the University of Chicago, conducted a review of peer-reviewed and gray literature to examine how health equity is defined, conceptualized, and measured by public health professionals.

METHODS

We reviewed (1) peer-reviewed literature, (2) HHS and other public health organization Web sites, and (3) state and territorial health department plans. We also conducted targeted searches of the gray literature to identify tools and recommendations for measuring health equity.

RESULTS

While definitions of health equity identified in the scan varied, they often addressed similar concepts, including "highest level of health for all people," "opportunity for all," and "absence of disparities." Measuring health equity is challenging; however, strategies to measure and track progress toward health equity have emerged. There are a range of tools and resources that have the potential to help decision makers address health equity, such as health impact assessments, community health improvement plans, and adapting a Health in All Policies approach. Tools that visualize health equity data also support data-driven decision making.

DISCUSSION

Using similar language when discussing health equity will help align and advance efforts to improve health and well-being for all. Healthy People objectives, measures, and targets can help public health professionals advance health equity in their work. HHS ODPHP continues to develop Healthy People tools and resources to support public health professionals as they work with cross-sector partners to achieve health equity.

Multiple Reasons for Perceived Everyday Discrimination and All-Cause Mortality Risk Among Older Black Adults

BACKGROUND

This study assessed whether reporting multiple reasons for perceived everyday discrimination was associated with an increased risk for all-cause mortality risk among older Black adults.

METHODS

This study utilized data from a subsample of older Black adults from the Health and Retirement Study (HRS), a nationally representative panel study of older adults in the United States. Our measure of multiple reasons for perceived everyday discrimination was based on self-reports from the 2006/2008 HRS waves. Respondents' vital status was obtained from the National Death Index and reports from key household informants (spanning 2006-2019). Cox proportional hazard models, which accounted for covariates linked to mortality, were used to estimate the risk of all-cause mortality.

RESULTS

During the observation period, 563 deaths occurred. Twenty percent of Black adults attributed perceived everyday discrimination to 3 or more sources. In demographic adjusted models, attributing perceived everyday discrimination to 3 or more sources was a statistically significant predictor of all-cause mortality risk (hazard ratio = 1.45; 95% confidence interval = 1.12-1.87). The association remained significant (hazard ratio = 1.49; 95% confidence interval = 1.15-1.93) after further adjustments for health, behavioral, and economic characteristics.

CONCLUSIONS

Examining how multiple reasons for perceived everyday discrimination relate to all-cause mortality risk has considerable utility in clarifying the unique contributions of perceived discrimination to mortality risk among older Black adults. Our findings suggest that multiple reasons for perceived everyday discrimination are a particularly salient risk factor for mortality among older Black adults.

Addressing Racism in Preventive Services: Methods Report to Support the US Preventive Services Task Force

IMPORTANCE

In January 2021, the US Preventive Services Task Force (USPSTF) issued a values statement that acknowledged systemic racism and included a commitment to address racism and health equity in recommendations for clinical preventive services.

OBJECTIVES

To articulate the definitional and conceptual issues around racism and health inequity and to describe how racism and health inequities are currently addressed in preventive health.

METHODS

An audit was conducted assessing (1) published literature on frameworks or policy and position statements addressing racism, (2) a subset of cancer and cardiovascular topics in USPSTF reports, (3) recent systematic reviews on interventions to reduce health inequities in preventive health or to prevent racism in health care, and (4) health care-relevant professional societies, guideline-making organizations, agencies, and funding bodies to gather information about how they are addressing racism and health equity.

FINDINGS

Race as a social category does not have biological underpinnings but has biological consequences through racism. Racism is complex and pervasive, operates at multiple interrelated levels, and exerts negative effects on other social determinants and health and well-being through multiple pathways. In its reports, the USPSTF has addressed racial and ethnic disparities, but not racism explicitly. The systematic reviews to support the USPSTF include interventions that may mitigate health disparities through cultural tailoring of behavioral interventions, but reviews have not explicitly addressed other commonly studied interventions to increase the uptake of preventive services or foster the implementation of preventive services. Many organizations have issued recent statements and commitments around racism in health care, but few have provided substantive guidance on operational steps to address the effects of racism. Where guidance is unavailable regarding the proposed actions, it is principally because work to achieve them is in very early stages. The most directly relevant and immediately useful guidance identified is that from the GRADE working group.

CONCLUSIONS AND RELEVANCE

This methods report provides a summary of issues around racism and health inequity, including the status of how these are being addressed in preventive health.

Racism and Cancer Screening among Low-Income, African American Women: A Multilevel, Longitudinal Analysis of 2-1-1 Texas Callers

Although racism is increasingly being studied as an important contributor to racial health disparities, its relation to cancer-related outcomes among African Americans remains unclear. The purpose of this study was to help clarify the relation between two indicators of racism-perceived racial discrimination and racial residential segregation-and cancer screening. We conducted a multilevel, longitudinal study among a medically underserved population of African Americans in Texas. We assessed discrimination using the Experiences of Discrimination Scale and segregation using the Location Quotient for Racial Residential Segregation. The outcome examined was "any cancer screening completion" (Pap test, mammography, and/or colorectal cancer screening) at follow-up (3-10 months post-baseline). We tested hypothesized relations using multilevel logistic regression. We also conducted interaction and stratified analyses to explore whether discrimination modified the relation between segregation and screening completion. We found a significant positive relation between discrimination and screening and a non-significant negative relation between segregation and screening. Preliminary evidence suggests that discrimination modifies the relation between segregation and screening. Racism has a nuanced association with cancer screening among African Americans. Perceived racial discrimination and racial residential segregation should be considered jointly, rather than independently, to better understand their influence on cancer screening behavior.

Maternal Experiences of Racial Discrimination, Child Indicators of Toxic Stress, and the Minding the Baby Early Home Visiting Intervention

BACKGROUND

Racism is a significant source of toxic stress and a root cause of health inequities. Emerging evidence suggests that exposure to vicarious racism (i.e., racism experienced by a caregiver) is associated with poor child health and development, but associations with biological indicators of toxic stress have not been well studied. It is also unknown whether two-generation interventions, such as early home visiting programs, may help to mitigate the harmful effects of vicarious racism.

OBJECTIVE

The purpose of this study was to examine associations between maternal experiences of racial discrimination and child indicators of toxic stress and to test whether relationships are moderated by prior participation in Minding the Baby (MTB), an attachment-based early home visiting intervention.

METHODS

Ninety-seven maternal-child dyads (n = 43 intervention dyads, n = 54 control dyads) enrolled in the MTB Early School Age follow-up study. Mothers reported on racial discrimination using the Experiences of Discrimination Scale. Child indicators of toxic stress included salivary biomarkers of inflammation (e.g., C-reactive protein, panel of pro-inflammatory cytokines), body mass index, and maternally reported child behavioral problems. We used linear regression to examine associations between maternal experiences of racial discrimination and child indicators of toxic stress and included an interaction term between experiences of discrimination and MTB group assignment (intervention vs. control) to test moderating effects of the MTB intervention.

RESULTS

Mothers identified as Black/African American (33%) and Hispanic/Latina (64%). In adjusted models, maternal experiences of racial discrimination were associated with elevated salivary interleukin-6 and tumor necrosis factor-α levels in children, but not child body mass index or behavior. Prior participation in the MTB intervention moderated the relationship between maternal experiences of discrimination and child interleukin-6 levels.

DISCUSSION

Results of this study suggest that racism may contribute to the biological embedding of early adversity through influences on inflammation, but additional research with serum markers is needed to better understand this relationship. Improved understanding of the relationships among vicarious racism, protective factors, and childhood toxic stress is necessary to inform family and systemic-level intervention.

Perceived Discrimination Trajectories and Depressive Symptoms Among Middle-Aged and Older Black Adults

BACKGROUND AND OBJECTIVES

Perceived discrimination is a risk factor for poor mental health. However, most studies measure discrimination at one time point, which does not account for heterogeneity in the cumulative patterning of exposure to discrimination. To address this gap, we examine the association between discrimination trajectories and depressive symptoms among black middle-aged and older adults.

RESEARCH DESIGN AND METHODS

Data were analyzed from a subsample of black Health and Retirement Study respondents (2006-2018, N = 2926, older than 50 years). General discrimination and racial discrimination trajectories were constructed based on the Everyday Discrimination Scale using repeated measures latent profile analyses. We examined the extent to which the association between discrimination trajectories are differentially associated with depressive symptoms (8-item Center for Epidemiological Studies-Depression scale) using negative binomial regression models adjusted for potential confounders. Effect modification by age and gender was tested.

RESULTS

Individuals in the persistently high (incident rate ratio [IRR]: 1.70; 95% confidence interval [CI]: 1.49-1.95) and moderate general discrimination trajectories (IRR: 1.19; 95% CI: 1.06-1.33) were more likely to have elevated depressive symptoms in comparison to those in the persistently low trajectory. This relationship was strongest among older adults aged older than 65 years. Respondents in the persistently high racial discrimination trajectory (IRR: 1.50; 95% CI: 1.29-1.73) had a higher risk of elevated depressive symptoms in comparison to respondents in the persistently low trajectory. Sensitivity analyses indicated that there was an independent association between persistently high racial discrimination trajectory class and elevated depressive symptoms, after adjusting for racial discrimination measured at a single time point.

DISCUSSION AND IMPLICATIONS

Characterizing longitudinal patterns of perceived discrimination may facilitate the stratification of mental health risk and vulnerability among black middle-aged and older adults. Trajectories of racial discrimination may inform risk of worse depressive symptoms more accurately than a single assessment of discrimination.

On the prevalence of racial discrimination in the United States

Boutwell, Nedelec, Winegard, Shackelford, Beaver, Vaughn, Barnes, & Wright (2017) published an article in this journal that interprets data from the Add Health dataset as showing that only one-quarter of individuals in the United States experience discrimination. In Study 1, we attempted to replicate Boutwell et al.'s findings using a more direct measure of discrimination. Using data from the Pew Research Center, we examined a large sample of American respondents (N = 3,716) and explored the prevalence of discrimination experiences among various racial groups. Our findings stand in contrast to Boutwell et al.'s estimates, revealing that between 50% and 75% of Black, Hispanic, and Asian respondents (depending on the group and analytic approach) reported discriminatory treatment. In Study 2, we explored whether question framing affected how participants responded to Boutwell's question about experiencing less respect and courtesy. Regardless of question framing, non-White participants reported more experiences than White participants. Further, there was an interaction of participant race and question framing such that when participants were asked about experiences of less respect or courtesy broadly, there were no differences between non-White participants and White participants, but when they were asked about experiences that were specifically race-based, non-White participants reported more experiences than White participants. The current research provides a counterweight to the claim that discrimination is not a prevalent feature of the lives of minority groups and the serious implications this claim poses for research and public policy.

A multi-group path analysis of the relationship between perceived racial discrimination and self-rated stress: how does it vary across racial/ethnic groups?

OBJECTIVE

The objective of this study was to answer three questions: (1) Is perceived discrimination adversely related to self-rated stress via the social capital and health care system distrust pathways? (2) Does the relationship between perceived discrimination and self-rated stress vary across race/ethnicity groups? and (3) Do the two pathways differ by one's race/ethnicity background?

DESIGN

Using the Philadelphia Health Management Corporation's Southeastern Pennsylvania Household Survey, we classified 9831 respondents into 4 race/ethnicity groups: non-Hispanic White (n = 6621), non-Hispanic Black (n = 2359), Hispanic (n = 505), and non-Hispanic other races (n = 346). Structural equation modeling was employed to simultaneously estimate five sets of equations, including the confirmatory factor analysis for both social capital and health care distrust and both direct and indirect effects from perceived discrimination to self-rated stress.

RESULTS

The key findings drawn from the analysis include the following: (1) in general, people who experienced racial discrimination have higher distrust and weaker social capital than those without perceived discrimination and both distrust and social capital are ultimately related to self-rated stress. (2) The direct relationship between perceived discrimination and self-rated stress is found for all race/ethnicity groups (except non-Hispanic other races) and it does not vary across groups. (3) The two pathways can be applied to non-Hispanic White and Black, but for Hispanic and non-Hispanic other races, we found little evidence for the social capital pathway.

CONCLUSIONS

For non-Hispanic White, non-Hispanic Black, and Hispanic, perceived discrimination is negatively related to self-rated stress. This finding highlights the importance of reducing interpersonal discriminatory behavior even for non-Hispanic White. The health care system distrust pathway can be used to address the racial health disparity in stress as it holds true for all four race/ethnicity groups. On the other hand, the social capital pathway seems to better help non-Hispanic White and Black to mediate the adverse effect of perceived discrimination on stress.

Perceived racial/ethnic discrimination, marketing, and substance use among young adults

Perceived experiences of discrimination have been linked to negative health behaviors including tobacco, alcohol, and marijuana use across various racial/ethnic groups. Tobacco and alcohol marketing exposure have also been linked with substance use. This study examined the independent and interacting effects of perceived experiences of discrimination and exposure to alcohol and tobacco marketing, and receptivity to marijuana marketing on substance use in an online survey of a multiethnic sample of young adults in 6 metropolitan areas (n = 505). African Americans (mean (M) = 1.96, 9% 5CI [1.84, 2.09]) and Hispanics (M = 1.98, 95% CI [1.87, 2.09]) reported higher levels of perceived discrimination than Whites (M = 1.52, 95% CI [1.40, 1.64]), p <  .001. African Americans had higher levels of exposure to tobacco and alcohol marketing; Hispanics reported higher levels of exposure to alcohol marketing and receptivity to marijuana promotion. Discrimination and marketing exposure were independently associated with higher odds of all 3 outcomes, controlling for covariates (AOR from 2.1 to 3.4 for discrimination; AOR from 1.4 to 13.8 for marketing). Models showed a significant interaction of discrimination and tobacco marketing on past 30-day cigarette use (F = 5.5; p = .02). Individuals with high levels of tobacco marketing exposure were likely to report high past 30-day cigarette use regardless of level of discrimination, while those with low exposure were only at increased risk of reporting cigarette use at higher levels of discrimination. Both perceived discrimination and marketing exposure play a role in substance use. Interventions should consider discrimination as a significant risk factor underlying vulnerability to substance use among young adults.

Geographic Region Matters in the Relation Between Perceived Racial Discrimination and Psychiatric Disorders Among Black Older Adults

Purpose of the Study

This study examined whether the relation between perceived racial discrimination and psychiatric disorders varied by large geographic region among Black older adults in the United States.

Design and Methods

Black adults aged 55 or older who had experienced racial/ethnic-specific discrimination were drawn from the National Survey of American Life (NSAL). Logistic regression analysis was used to examine main and interaction effects.

Results

Results show that there was a significant main effect of perceived racial discrimination, indicating that greater perceived discrimination was significantly associated with increased odds of having any past-year psychiatric disorder. The interaction of region by perceived racial discrimination was significant: The effect of perceived racial discrimination on any past-year psychiatric disorder was stronger among Blacks in the West than those in the South.

Implications

Findings suggest that whereas, in general, perceived racial discrimination is a risk factor for poor mental health among older Blacks, this association may differ by geographic region. Additional research examining reasons for this variation is needed.

A Question of Trust: Does Mistrust or Perceived Discrimination Account for Race Disparities in Advance Directive Completion?

Background and Objectives

Advance directive completion is associated with end-of-life quality indicators such as dying at home and receiving hospice care. Black older adults are less likely to complete advance directives than their white counterparts. The underlying reasons for these race disparities are not well understood.

Research Design and Methods

In two related studies, data from the Health and Retirement Study were used to examine whether mistrust in health care providers and/or perceived discrimination accounted for lower rates of advance directive completion by black older adults in the United States. Odds of advance directive completion were modeled using logistic regression and multiple measures of trust in health care providers and both medical and nonmedical perceived discriminatory treatment.

Results

In Study 1 (n = 699), controlling for medical mistrust did not reduce the gap between black and white participants’ odds of possessing advance directives. In Study 2 (n = 2,736), higher percentages of black participants reported experiencing medical and nonmedical discriminatory treatment. However, none of the measures of discrimination accounted for black participants’ lower odds of possessing advance directives.

Discussion and Implications

These results call into question the common assertion that mistrust in medical providers or the health care system contributes to lower rates of advance care planning by black older adults. Future research should examine the potential relationships between advance directive completion and other dimensions of discrimination.

Transgender Individuals and Osteoporosis Prevention

BACKGROUND

Risk behaviors and hormone use place transgender individuals (TIs) in jeopardy for osteoporosis.

PURPOSE

The purpose of this study was to expand the science about the knowledge, health beliefs, and osteoporosis (OP) preventing behaviors of TIs.

METHODS

This was a mixed-methods pilot study of a convenience sample of 31 TIs 30 years and older. Participants completed an online Osteoporosis Bone Health Survey. Fifteen participants were randomly selected for an interview to describe their perceptions of bone health.

RESULTS

Transgender individuals performed poorly on the knowledge measure. There were no significant findings for osteoporosis health beliefs. Participants' daily dietary dairy calcium intake was 800 mg and daily walking activity was 17 minutes. Perceptions of bone health revealed two essential elements, knowing and doing.

CONCLUSION

Determining TIs' bone health perception is important because of their unique healthcare issues. Healthcare providers need to be aware of TIs' bone health needs to help enhance TIs' OP knowledge, health beliefs, and preventing behaviors.

Workplace Discrimination Is Associated With Alcohol Abuse Among Ethnically Diverse Hospital Staff

Research suggests that workplace discrimination plays a role in absenteeism, productivity, and turnover. A link among workplace discrimination, mental health, and health disparities may also exist. The purpose of this study was to determine whether self-reported workplace discrimination is associated with alcohol abuse among hospital workers. Cross-sectional analysis of baseline data collected from a prospective cohort study of workers in two healthcare institutions ( n = 664) was conducted. Workplace discrimination in the previous 12 months was reported by 14% ( n = 91) of participants who were four times more likely to score higher on likely alcohol abuse than their peers. White participants who reported any discrimination were more likely to score higher on likely alcohol abuse than racial/ethnic minority participants who reported any discrimination. Given a diversifying workforce, further research is needed on how workplace discrimination contributes to stress and maladaptive coping, and ultimately health disparities.

Assessing the Everyday Discrimination Scale among American Indians and Alaska Natives

The Everyday Discrimination Scale (EDS) has been used widely as a measure of subjective experiences of discrimination. The usefulness of this measure for assessments of perceived experiences of discrimination by American Indian and Alaska Native (AI/AN) peoples has not been explored. Data derived from the Special Diabetes Program for Indians--Healthy Heart Demonstration Project (SDPI-HH), a large-scale initiative to reduce cardiovascular risk among AI/ANs with Type 2 diabetes. Participants (N = 3,039) completed a self-report survey that included the EDS and measures of convergent and divergent validity. Missing data were estimated by multiple imputation techniques. Reliability estimates for the EDS were calculated, yielding a single factor with high internal consistency (α = .92). Younger, more educated respondents reported greater perceived discrimination; retired or widowed respondents reported less. Convergent validity was evidenced by levels of distress, anger, and hostility, which increased as the level of perceived discrimination increased (all p < .001). Divergent validity was evidenced by the absence of an association between EDS and resilient coping. Resilient coping and insulin-specific diabetes knowledge were not significantly associated with perceived discrimination (p = .61 and 0.16, respectively). However, general diabetes-related health knowledge was significantly associated with perceived discrimination (p = .02). The EDS is a promising measure for assessing perceived experiences of discrimination among those AI/ANs who participated in the SDPI-HH.

Discrimination in Healthcare Settings is Associated with Disability in Older Adults: Health and Retirement Study, 2008-2012

BACKGROUND

As our society ages, improving medical care for an older population will be crucial. Discrimination in healthcare may contribute to substandard experiences with the healthcare system, increasing the burden of poor health in older adults. Few studies have focused on the presence of healthcare discrimination and its effects on older adults.

OBJECTIVE

We aimed to examine the relationship between healthcare discrimination and new or worsened disability.

DESIGN

This was a longitudinal analysis of data from the nationally representative Health and Retirement Study administered in 2008 with follow-up through 2012.

PARTICIPANTS

Six thousand and seventeen adults over the age of 50 years (mean age 67 years, 56.3 % female, 83.1 % white) were included in this study.

MAIN MEASURES

Healthcare discrimination assessed by a 2008 report of receiving poorer service or treatment than other people by doctors or hospitals (never, less than a year=infrequent; more than once a year=frequent). Outcome was self-report of new or worsened disability by 2012 (difficulty or dependence in any of six activities of daily living). We used a Cox proportional hazards model adjusting for age, race/ethnicity, gender, net worth, education, depression, high blood pressure, diabetes, cancer, lung disease, heart disease, stroke, and healthcare utilization in the past 2 years.

KEY RESULTS

In all, 12.6 % experienced discrimination infrequently and 5.9 % frequently. Almost one-third of participants (29 %) reporting frequent healthcare discrimination developed new or worsened disability over 4 years, compared to 16.8 % of those who infrequently and 14.7 % of those who never experienced healthcare discrimination (p < 0.001). In multivariate analyses, compared to no discrimination, frequent healthcare discrimination was associated with new or worsened disability over 4 years (aHR = 1.63, 95 % CI 1.16-2.27).

CONCLUSIONS

One out of five adults over the age of 50 years experiences discrimination in healthcare settings. One in 17 experience frequent healthcare discrimination, and this is associated with new or worsened disability by 4 years. Future research should focus on the mechanisms by which healthcare discrimination influences disability in older adults to promote better health outcomes for an aging population.

The association between discrimination and depressive symptoms among older African Americans: the role of psychological and social factors

BACKGROUND/STUDY CONTEXT: Several studies have demonstrated a link between perceived discrimination and depression in ethnic minority groups, yet most have focused on younger or middle-aged African Americans and little is known about factors that may moderate the relationship.

METHODS

Participants were 487 older African Americans (60-98 years old) enrolled in the Minority Aging Research Study. Discrimination, depressive symptoms, and psychological and social resources were assessed via interview using validated measures. Ordinal logistic regression models were used to assess (1) the main relationship between discrimination and depression and (2) resilience, purpose in life, social isolation, and social networks as potential moderators of this relationship.

RESULTS

In models adjusted for age, sex, education, and income, perceived discrimination was positively associated with depressive symptoms (odds ratio [OR]: 1.20, 95% confidence interval [CI]: 1.10-1.31; p < .001). However, there was no evidence of effect modification by resilience, purpose in life, social isolation, or social networks (all ps ≤ .05).

CONCLUSION

Findings provide support for accumulating evidence on the adverse mental health effects of discrimination among older African Americans. Because the association was not modified by psychological or social factors, these findings do not support a role for a buffering effect of resources on discrimination and depressive symptoms. Further studies are needed to examine a wider range of coping resources among older adults.

An Examination of Lower Extremity Function and its Correlates in Older African American and White Men

OBJECTIVE

Maintaining functional status and reducing/eliminating health disparities in late life are key priorities. Older African Americans have been found to have worse lower extremity functioning than Whites, but little is known about potential differences in correlates between African American and White men. The goal of this investigation was to examine measures that could explain this racial difference and to identify race-specific correlates of lower extremity function.

METHODS

Data were analyzed for a sample of community-dwelling men. Linear regression models examined demographics, medical conditions, health behaviors, and perceived discrimination and mental health as correlates of an objective measure of lower extremity function, the Short Physical Performance Battery (SPPB). Scores on the SPPB have a potential range of 0 to 12 with higher scores corresponding to better functioning.

RESULTS

The mean age of all men was 74.9 years (SD=6.5), and the sample was 50% African American and 53% rural. African American men had scores on the SPPB that were significantly lower than White men after adjusting for age, rural residence, marital status, education, and income difficulty (P<.01). Racial differences in cognitive functioning accounted for approximately 41% of the race effect on physical function. Additional models stratified by race revealed a pattern of similar correlates of the SPPB among African American and White men.

CONCLUSIONS

The results of this investigation can be helpful for researchers and clinicians to aid in identifying older men who are at-risk for poor lower extremity function and in planning targeted interventions to help reduce disparities.

Listening to the voices of native Hawaiian elders and ‘ohana caregivers: discussions on aging, health, and care preferences

Native Hawaiians, the indigenous people of Hawai’i, are affected by varying social and health disparities that result in high prevalence of chronic disease, early onset of disability, and shorter life expectancy compared to other ethnic groups in Hawai’i. Six listening meetings were conducted, involving 41 community-dwelling kūpuna (Native Hawaiian elders) and ‘ohana (family) caregivers to investigate health and care preferences that offer the potential for improving well-being in later life for Native Hawaiian elders. As background, we provide three explanatory perspectives and theories—life course perspective, minority stress theory, and historical trauma—that guided the design of this study and provided the study’s context. A number of overarching themes and subthemes were identified, some of which point to universal concerns with age and caregiving (such as challenges and costs associated with growing old and caregiving) and others that are culturally specific (such as influence of culture and social stressors, including discrimination, on health needs and care preferences). Results give further support to the urgency of affordable, accessible, and acceptable programs and policies that can respond to the growing health and care needs of native elders and family caregivers.

Health behaviors and all-cause mortality in African American men

Because of the excess burden of preventable chronic diseases and premature death among African American men, identifying health behaviors to enhance longevity is needed. We used data from the Third National Health and Nutrition Examination Survey 1988-1994 (NHANES III) and the NHANES III Linked Mortality Public-use File to determine the association between health behaviors and all-cause mortality and if these behaviors varied by age in 2029 African American men. Health behaviors included smoking, drinking, physical inactivity, obesity, and a healthy eating index score. Age was categorized as 25-44 years (n = 1,045), 45-64 years (n = 544), and 65 years and older (n = 440). Cox regression analyses were used to estimate the relationship between health behaviors and mortality within each age-group. All models were adjusted for marital status, education, poverty-to-income ratio, insurance status, and number of health conditions. Being a current smoker was associated with an increased risk of mortality in the 25- to 44-year age-group, whereas being physically inactive was associated with an increased risk of mortality in the 45- to 64-year age-group. For the 65 years and older age-group, being overweight or obese was associated with decreased mortality risk. Efforts to improve longevity should focus on developing age-tailored health promoting strategies and interventions aimed at smoking cessation and increasing physical activity in young and middle-aged African American men.