Latina and African American women: continuing disparities in health

Elements of Suffering in Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: The Experience of Loss, Grief, Stigma, and Trauma in the Severely and Very Severely Affected

People who are severely and very severely affected by Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) experience profound suffering. This suffering comes from the myriad of losses these patients experience, the grief that comes from these losses, the ongoing stigma that is often experienced as a person with a poorly understood, controversial chronic illness, and the trauma that can result from how other people and the health care community respond to this illness. This review article examines the suffering of patients with ME/CFS through the lens of the Fennell Four-Phase Model of chronic illness. Using a systems approach, this phase framework illustrates the effects of suffering on the patient and can be utilized to help the clinician, patient, family, and caregivers understand and respond to the patient's experiences. We highlight the constructs of severity, uncertainty, ambiguity, and chronicity and their role in the suffering endured by patients with ME/CFS. A composite case example is used to illustrate the lives of severely and very severely affected patients. Recommendations for health care providers treating patients with ME/CFS are given and underscore the importance of providers understanding the intense suffering that the severely and very severely affected patients experience.

Racial and ethnic disparities in chronic health conditions among women with a history of gestational diabetes mellitus

Background: This study aims to examine and determine the role of race/ethnicity in chronic conditions in women diagnosed with gestational diabetes mellitus (GDM) during any of their previous pregnancies. Methods: We used the National Health and Nutrition Examination Survey (NHANES) from2007-2016 to identify women who self-reported prior GDM and chronic disease diagnoses such as cardiovascular disease, hypertension, depression, and type 2 diabetes mellitus (T2DM).We used bivariate analysis using the chi-square test (χ²) and multiple logistic regressions to perform statistical test for associations, taking into consideration design and sample weight. Results: Among participants with prior GDM diagnoses, black women had a 74.4% prevalence of chronic disease, followed by Whites, 58.5% Hispanics, 58.0%, and Asians, 51.9% (P=0.009).Black women with prior GDM diagnoses had 2.4 odds of having chronic conditions compared to Whites (adjusted odds ratio [AOR]=2.40, 95% confidence interval [CI] = 1.28-4.50). In addition, they had higher odds of being former smokers (AOR=1.73, 95% CI=1.01-2.96),current smokers (AOR=1.96, 95% CI=1.06-3.61), having a body mass index (BMI) of 25-29.9(AOR=2.55, 95% CI=1.10-5.87), or a BMI ≥30 (AOR=4.09, 95% CI = 2.05-8.17) compared to their White counterparts. Hispanic women had lower odds of being diagnosed with GDM and associated chronic diseases. Conclusion: Black women with GDM were disproportionally affected and at higher risk to be diagnosed with chronic conditions. Smoking and obesity were strongly associated with chronic disease diagnoses. Our findings also suggest a 'Hispanic Paradox', requiring further study. These findings inform primary care clinicians and Obstetricians, and Gynecologists of at-risk patients who could benefit from lifestyle modification recommendations and counseling.

Healthcare disparities in critical illness

OBJECTIVE

To summarize the current literature on racial and gender disparities in critical care and the mechanisms underlying these disparities in the course of acute critical illness.

DATA SOURCES

MEDLINE search on the published literature addressing racial, ethnic, or gender disparities in acute critical illness, such as sepsis, acute lung injury, pneumonia, venous thromboembolism, and cardiac arrest.

STUDY SELECTION

Clinical studies that evaluated general critically ill patient populations in the United States as well as specific critical care conditions were reviewed with a focus on studies evaluating factors and contributors to health disparities.

DATA EXTRACTION

Study findings are presented according to their association with the prevalence, clinical presentation, management, and outcomes in acute critical illness.

DATA SYNTHESIS

This review presents potential contributors for racial and gender disparities related to genetic susceptibility, comorbidities, preventive health services, socioeconomic factors, cultural differences, and access to care. The data are organized along the course of acute critical illness.

CONCLUSIONS

The literature to date shows that disparities in critical care are most likely multifactorial involving individual, community, and hospital-level factors at several points in the continuum of acute critical illness. The data presented identify potential targets as interventions to reduce disparities in critical care and future avenues for research.

Access to health and health care: how race and ethnicity matter

Racial and ethnic disparities in health are multifactorial; they reflect differences in biological vulnerability to disease as well as differences in social resources, environmental factors, and health care interventions. Understanding and intervening in health inequity require an understanding of the disparate access to all of the personal resources and environmental conditions that are needed to generate and sustain health, a set of circumstances that constitute access to health. These include access to health information, participation in health promotion and disease prevention activities, safe housing, nutritious foods, convenient exercise spaces, freedom from ambient violence, adequate social support, communities with social capital, and access to quality health care. Access to health care is facilitated by health insurance, a regular source of care, and a usual primary care provider. Various mechanisms through which access to health and access to health care are mediated by race and ethnicity are discussed; these include the built environment, social environment, residential segregation, stress, racism, and discrimination. Empirical evidence supporting the association between these factors and health inequities is also reviewed.

Racial/ethnic variations in women's health: the social embeddedness of health

This article provides an overview of the magnitude of and trends in racial/ethnic disparities in health for women in the United States. It emphasizes the importance of attending to diversity in the health profiles and populations of minority women. Socioeconomic status is a central determinant of racial/ethnic disparities in health, but several other factors, including medical care, geographic location, migration and acculturation, racism, and exposure to stress and resources also play a role. There is a need for renewed attention to monitoring, understanding, and actively seeking to eliminate racial/ethnic disparities in health.

The health of men: structured inequalities and opportunities

I have summarized in this article data on the magnitude of health challenges faced by men in the United States. Across a broad range of indicators, men report poorer health than women. Although men in all socioeconomic groups are doing poorly in terms of health, some especially high-risk groups include men of low socioeconomic status (SES) of all racial/ethnic backgrounds, low-SES minority men, and middle-class Black men. Multiple factors contribute to the elevated health risks of men. These include economic marginality, adverse working conditions, and gendered coping responses to stress, each of which can lead to high levels of substance use, other health-damaging behaviors, and an aversion to health-protective behaviors. The forces that adversely affect men's health are interrelated, unfold over the life course, and are amenable to change.

Race/ethnicity, socioeconomic status and the health of pregnant women

We examined how traditional (income, education) and nontraditional (public assistance, material deprivation, subjective social standing) socioeconomic status (SES) indicators were associated with self-rated health, physical functioning, and depression in ethnically diverse pregnant women. Using multiple regression, we estimated the association of race/ethnicity (African American, Latino, Asian/Pacific Islander (PI) and white) and sets of SES measures on each health measure. Education, material deprivation, and subjective social standing were independently associated with all health measures. After adding all SES variables, race/ethnic disparities in depression remained for all minority groups; disparities in self-rated health remained for Asian/Pacific Islanders. Few race/ethnic differences were found in physical functioning. Our results contribute to a small literature on how SES might interact with race/ethnicity in explaining health.

Race/ethnicity, socioeconomic status, and lifetime morbidity burden in the women's health initiative: a cross-sectional analysis

OBJECTIVES

We sought to assess the extent to which race/ethnicity and socioeconomic status (SES) are independently and jointly related to lifetime morbidity burden by comparing the impact of SES on lifetime morbidity among women of different racial/ethnic groups: white, black, Hispanic, American Indian/Alaska Native (AIAN), and Asian/Pacific Islander (API).

METHODS

Using baseline data from the Women's Health Initiative (WHI), a national study of 162,000 postmenopausal women, we measured lifetime morbidity burden using a modified version of the Charlson Index, and measured SES with educational attainment and household income. In multivariable simple polytomous logistic regression models, we first assessed the effect of SES on lifetime morbidity burden among women of each racial/ethnic group, then assessed the combined effect of race/ethnicity and SES.

RESULTS

Five percent of all women in the study population had high lifetime morbidity burden. Women with high lifetime morbidity were more likely to be AIAN or black; poor; less educated; divorced, separated, or widowed; past or current smokers; obese; uninsured or publicly insured. Lower SES was associated with higher morbidity among most women. The extent to which morbidity was higher among lower SES compared to higher SES women was about the same among Hispanic women and white women, but was substantially greater among black and AIAN women compared with white women.

CONCLUSIONS

This study demonstrates the importance of considering race/ethnicity and class together in relation to health outcomes.

The epidemiology of drinking among women of child-bearing age

OBJECTIVES

To estimate the prevalence of drinking, binge drinking (4 or more drinks), and alcohol abuse and dependence and to identify predictors of heavier drinking among women of child-bearing age (18-44 years).

METHODS

Subjects are part of a national multistage random sample from the 2002 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC).

RESULTS

Binge drinking, abuse, and dependence are higher in younger (<30 years) pregnant and nonpregnant women. Among pregnant women, binge drinking is highest among Whites; alcohol abuse and dependence rates are relatively low and similar in all racial/ethnic groups. Among nonpregnant women, Whites and mixed race women have the highest rates of binge drinking. Alcohol abuse and dependence are highest among Native Hawaiian/Pacific Islanders, followed by Native American/Alaska Native women. Women who are White, younger (21-29 years), single, or cohabiting and with a higher income (> 40,000 US dollars) are at a higher risk for heavier drinking.

CONCLUSIONS

Drinking and heavier drinking remain at high levels among women of child-bearing age. Prevention efforts must be comprehensive and should target pregnant women who are drinking and those who could become pregnant and are drinking at high-risk levels.

Measurement Adequacy of Parenting and Children’s Functional Status in African American and Latino Families

To examine the psychometric adequacy of two existing instruments, the Functional Status Questionnaire (FS IIR) and the Parent Behavior Checklist (PBC), in two ethnic minority groups. Age-specific items that were not relevant for children ages 1 to 5 were removed from the FS IIR and PBC. Measures were administered to 196 Latino and African American parents of children aged 1 to 5. Reliability, variability, item-convergence, and factor structure were examined. The results highlight common pitfalls in using existing measures in populations other than those on which they were originally developed. Both measures were modified resulting in all scales having low or acceptable reliability. Construct validity was supported for both the FS IIR and the PBC through confirmation of hypothesized relationships. In both ethnic groups, factor analyses supported the hypothesized factor solutions for the FS IIR and the PBC. Use of measures in minority groups requires researchers to be cognizant of the issues of psychometric adequacy in all groups. The psychometric properties of the FS IIR and the PBC were generally acceptable for Hispanics and African Americans, but each had some problems in at least one psychometric characteristic in one or both groups. Different factor loadings for some items for Hispanics and African Americans suggest different interpretation of items between the two cultural groups.

Advancing health disparities research: can we afford to ignore measurement issues?

BACKGROUND

Research on racial and ethnic health disparities in the United States requires that self-report measures, developed primarily in mainstream samples, are appropriate when applied in diverse groups. To compare groups, mean scores must reflect true scores and have minimal bias, assumptions that have not been tested for many self-report measures used in this research.

OBJECTIVE

To identify conceptual and psychometric issues that need to be addressed to assure the quality of self-report measures being used in health disparities research.

METHODS

We present 2 broad conceptual frameworks for health disparities research and describe the main research questions and measurement issues for 4 key concepts hypothesized as potential mechanisms of health disparities: socioeconomic status, discrimination, acculturation, and quality of care. This article is based on a small conference convened by 6 Resource Centers for Minority Aging Research (RCMAR) measurement cores. We integrate written materials prepared for the conference by quantitative and qualitative measurement specialists and cross-cultural researchers, conference discussions, and current literature.

RESULTS

Problems in the quality of the conceptualizations and measures were found for all 4 concepts, and little is known about the extent to which measures of these concepts can be interpreted similarly across diverse groups. Many problems also apply to other concepts relevant to health disparities. We propose an agenda for accomplishing this challenging measurement research.

CONCLUSIONS

The current national commitment to reduce health disparities may be compromised without more research on measurement quality. Integrated, systematic efforts are needed to move this work forward, including collaborative efforts and special initiatives.

Plasma lipoprotein concentrations in ethnic populations

There is a complex interplay between genetic and environmental factors that influences the expression of plasma lipoprotein levels. It is therefore not surprising that differences in lipid levels have been reported between ethnic groups. There are conflicting data on racial and ethnic variations in lipids, and also limited data on the relationship between lipoprotein levels and coronary heart disease risk in specific populations. This review summarizes available data on ethnic variations in plasma lipoproteins and the potential impact on coronary morbidity and mortality.

The health of men: structured inequalities and opportunities

I have summarized in this article data on the magnitude of health challenges faced by men in the United States. Across a broad range of indicators, men report poorer health than women. Although men in all socioeconomic groups are doing poorly in terms of health, some especially high-risk groups include men of low socioeconomic status (SES) of all racial/ethnic backgrounds, low-SES minority men, and middle-class Black men. Multiple factors contribute to the elevated health risks of men. These include economic marginality, adverse working conditions, and gendered coping responses to stress, each of which can lead to high levels of substance use, other health-damaging behaviors, and an aversion to health-protective behaviors. The forces that adversely affect men's health are interrelated, unfold over the life course, and are amenable to change.

Risk factors for hysterectomy among Mexican-American women in the US southwest

The purpose of this study was to assess risk factors associated with a history of hysterectomy among Mexican-American women living in the United States Southwest. Mexican-American women ages 20-74 at time of interview were defined as a subpopulation among adults in the Hispanic Health and Nutrition Examination Survey (HHANES), 1982-1984. Language preference, reproductive history, level of education, poverty status, generation of immigration, marital status, and insurance coverage were examined in relation to risk of hysterectomy using weighted tabulation and logistic regression for data resulting from complex survey designs. Heretofore, language preference has not been a variable considered in relation to risk of hysterectomy. In the HHANES, over 60% of women who spoke English most often rather than Spanish reported a history of hysterectomy. Women who had previously been pregnant were almost four times as likely (odds ratio 3.972) to have had a hysterectomy compared to women who had never been pregnant. Women who expressed any preference for English were twice as likely (odds ratio 2.050) to have had a hysterectomy than were those who responded that they exclusively preferred Spanish. Age, higher levels of education, and higher economic status also increased the risk of hysterectomy. In contrast, reproductive history, marital status, prior tubal ligation, generation of immigration, and health insurance did not have substantial effects on the risk of hysterectomy. This study suggests that, in the future, the effect of language preference should not be overlooked when considering risk factors for hysterectomy.

Stability and change in health insurance among older Mexican Americans: longitudinal evidence from the Hispanic established populations for epidemiologic study of the elderly

OBJECTIVES

This study examined the association between health insurance coverage, medical care use, limitations in activities of daily living, and mortality among older Mexican-origin individuals.

METHODS

We analyzed longitudinal data from the Hispanic Established Populations for Epidemiologic Study of the Elderly (H-EPESE).

RESULTS

The uninsured tend to be younger, female, poor, and foreign born. They report fewer health care visits, are less likely to have a usual source of care, and more often receive care in Mexico. Conversely, those with private health insurance are economically better off and use more health care services. Over time, the data reveal substantial changes in type of insurance coverage.

CONCLUSIONS

The data reveal serious vulnerabilities among older Mexican Americans that result from a lack of private Medigap supplemental coverage.

Racial/ethnic variations in women's health: the social embeddedness of health

This article provides an overview of the magnitude of and trends in racial/ethnic disparities in health for women in the United States. It emphasizes the importance of attending to diversity in the health profiles and populations of minority women. Socioeconomic status is a central determinant of racial/ethnic disparities in health, but several other factors, including medical care, geographic location, migration and acculturation, racism, and exposure to stress and resources also play a role. There is a need for renewed attention to monitoring, understanding, and actively seeking to eliminate racial/ethnic disparities in health.

Women's health centers and minority women: addressing barriers to care. The National Centers of Excellence in Women's Health

New models of care delivery have been developed to better coordinate and integrate healthcare for women. In the United States, one of the challenges is to incorporate the needs of racial and ethnic minority populations into these newer care paradigms. This paper begins with a brief historical review of the experience of racial and ethnic minorities in the American healthcare system to provide a context for discussing barriers and limitations of more traditional models of women's healthcare. Specific approaches used by National Centers of Excellence in Women's Health are presented as examples of strategies that may be implemented by other communities to address these barriers.

Racial residential segregation: a fundamental cause of racial disparities in health

Racial residential segregation is a fundamental cause of racial disparities in health. The physical separation of the races by enforced residence in certain areas is an institutional mechanism of racism that was designed to protect whites from social interaction with blacks. Despite the absence of supportive legal statutes, the degree of residential segregation remains extremely high for most African Americans in the United States. The authors review evidence that suggests that segregation is a primary cause of racial differences in socioeconomic status (SES) by determining access to education and employment opportunities. SES in turn remains a fundamental cause of racial differences in health. Segregation also creates conditions inimical to health in the social and physical environment. The authors conclude that effective efforts to eliminate racial disparities in health must seriously confront segregation and its pervasive consequences.

Health protecting and health promoting behaviors of African Americans living in Appalachia

The importance of the influence of health protecting and health promoting behaviors on the health of Appalachian African Americans has not been widely published. Review of the literature revealed a paucity of research data describing these behaviors. Therefore, the purpose of this descriptive study was to describe health protecting and health promoting behaviors of Appalachian African Americans. Pender's (1996) health promotion conceptual framework was used as the organizing framework for this study. Data were collected through structured interviews with 204 Appalachian African Americans representing two states and six counties in Appalachia. Quantitative research methodology was used to describe health protecting and health promoting behaviors. Data analysis revealed that these participants actively engaged in health protecting and health promoting behaviors. Morbidity data, mortality data, and family history of diseases were consistent with those reported nationally. Findings from this study support the need for a long-range research study of Appalachian African Americans.

Meanings of community in a community health center

As health care organizations make communities the targets for their interventions, connections between "community" as theory for practice and community as setting for practice require examination. This study s purpose was to explore meanings given to community in a newly formed community health center, with particular emphasis on the relationship among women, community, and health. Using interpretive and emancipatory methodologies, interviews were conducted with clinic administrators and staff, and women who used the clinic. Data analysis revealed discrepancies in meanings of community. Clinic personnel referred to community as the target for their services, while clinic users spoke about community as the process that made feeling connected with others possible. Health center staff and administrators described the community they were serving as having limited economic, educational, physical, and psychological resources and saw little which could be labeled a community strength. Health center users however, spoke primarily of their abilities to support each other. These contradictory understandings of the meaning of community rendered different expectations regarding health care services. Meanings given to community may de-personalize, homogenize, and objectify, and ultimately distance nursing from those intended to be served.

Access to and utilization of primary care services among HIV-infected women

OBJECTIVES

To identify factors associated with the use of medical services, and to test a model of access to care, among HIV-infected women.

METHODS

A cross-sectional telephone survey was administered to 213 HIV-infected women. Outcomes were having a primary care provider, and use of primary care and emergency health services. Predictors included characteristics of the population-at-risk and of the health care system.

RESULTS

Ninety-three percent of respondents had a primary care provider. Linear regression found age >45 years (p = .002), perceiving greater barriers to getting to a clinic (p = .04) and greater benefits from medications (p = .03), lack of problems with appointment times (p = .02), having AIDS (p = .01), shorter appointment waiting times (p = .0003), and greater cost of travel to care (p = .001) were associated with a greater number of primary care visits. Thirty-seven percent missed at least 1 primary care appointment. In logistic regression, lack of insurance (odds ratio [OR] = 2.76), current injection drug use (OR = 2.89) and difficulty remembering appointments (OR = 2.36) were associated with having missed any appointments.

CONCLUSIONS

Characteristics of the population-at-risk and of the health care system both make important contributions to primary care service use.

Mediators of ethnic-associated differences in infant birth weight

PURPOSE

To examine whether ethnic differences in low birth weight babies of low-income women may be explained in part by group differences in prenatal health behaviors and psychosocial factors.

METHODS

A prospective, survey of 1,071 low-income, primiparous African-American and Mexican-origin women was conducted in Los Angeles County, California. In face-to-face interviews, data were obtained on substance use, prenatal stress, social support, attitudes toward pregnancy, initiation of prenatal care, and medical risk. Medical chart data were abstracted regarding medical risk factors and labor, delivery, and neonatal data. Interview data were linked with birth outcome data retrieved from maternal medical records. Structural equation modeling was used to test a hypothesized model in which differences in birth weight were expected to be mediated by ethnic differences in substance use, psychosocial factors, and medical risk.

RESULTS

As expected, African-American women delivered babies of earlier gestational age and lower birth weight than did women of Mexican origin. Direct predictors of low birth weight were use of drugs and cigarettes, prenatal stress, and positive attitudes toward pregnancy; together, these factors accounted for the observed ethnic differences in birth weight.

CONCLUSION

These data contribute to our understanding of the factors that may account for ethnic-associated differences in low birth weight.

Lay health advisors: a strategy for getting the word out about breast cancer

Transforming natural helpers into lay health advisors (LHAs) is a complex undertaking. Using the North Carolina Breast Cancer Screening Program (NC-BCSP) as a case study, this article describes the steps involved in developing, implementing, and evaluating an LHA intervention, considering factors that make the LHA approach appropriate for the NC-BCSP's population, setting, and health focus. The authors review five phases of implementation (start-up, training, LHA activities, follow-up, resource mobilization) and discuss the NC-BCSP's evaluation strategies and tools in light of difficulties involved in assessing natural helping processes and impact. Program challenges related to resource needs, identification of natural helpers, and LHA monitoring and support also are considered. The authors describe ways in which one large group of older, rural, African American LHAs are helping establish countywide partnerships between health care providers, agencies, and local communities that support and sustain individual changes in health behavior.

Race/ethnicity, the social environment, and health

International and national research has documented the relations between socio-economic conditions and health. Nonetheless, racial/ethnic group comparisons of health indices frequently are presented in the United States without stratifying or adjusting for socio-economic conditions that could affect interpretation of the data. This paper examines how racial/ethnic group identifiers have been used in past research. While some studies assume biologic differences; others presume that race/ethnicity is a proxy for socio-economic race factors. One consequence of these presumptions has been an underdevelopment of knowledge about racial/ethnic minority populations that could help shape public policies and preventive interventions to reduce disparities in health. Findings from studies that examine the influence of both race and social class on health are reviewed in an effort to clarify the state-of-knowledge. Although the findings vary for particular health indices, the studies provide considerable evidence that socio-economic conditions are a powerful, although not necessarily exclusive, explanatory variable for racial disparities in health. The findings are used as the basis for encouraging more theoretically grounded and methodologically rigorous research rather than avoiding an assessment of the influence of race/ethnicity on health.

Breast cancer control among the underserved--an overview

This paper explores barriers to the use of standard screening and breast cancer treatment that result in systematic differences in health outcomes. We review available data on individual, socioeconomic, and health system determinants of access to standard breast cancer care, including screening, diagnostic, and treatment services. Based on this review, we discuss the combination of factors which result in underservice. We argue that a broad framework which considers health system and social class as well as individual factors is useful for analyzing how structures of health care delivery tend to provide less than standard care to women who are older, have less income, or are less educated, black, or Hispanic. Data collection efforts which do not include structural and socioeconomic variables may result in an incomplete or misleading understanding of the determinants of underservice. These factors also need to be considered in the design and evaluation of public health policies and interventions meant to ameliorate the effects of underservice.