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Use of Race and Ethnicity In Epidemiological Research

Unit 16:. Use of Race and Ethnicity In Epidemiological Research. Traditionally used definitions of race and ethnicity in the U.S. Race, Ethnicity, and Culture in the Sociology of Mental Health. Definitions:

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Use of Race and Ethnicity In Epidemiological Research

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  1. Unit 16: Use of Race and Ethnicity In Epidemiological Research

  2. Traditionally used definitions of race and ethnicity in the U.S.

  3. Race, Ethnicity, and Culture in the Sociology of Mental Health • Definitions: • Race: a socially constructed category based on observed phenotypic manifestations of presumed, underlying genetic differences. • Ethnicity: a grouping of persons according to a shared geographic, national, or cultural heritage. Encompasses both biological and non-biological differences.

  4. Research-based Definitions • Federal Definitions of Race (5 minimum categories): • White/Caucasian • Black or African-American • Asian • Native Hawaiian or Other Pacific Islander • American Indian or Alaska Native • Federal Definitions of Ethnicity: • Hispanic or Latino • Not Hispanic or Latino • Census 2000 Revision: Persons can report more than one race

  5. Commentary: White, European, Western Caucasian, or What? Inappropriate labeling in research on race, ethnicity, and health (Bhopal R, Donaldson L. AJPH 1998;88:1303-7). • Historically, much of the debate has been on proper labeling of minority populations • Substantial variation in disease rates occurs by racial and ethnic groups • Thus, studying race/ethnicity in epi research may allow better understanding of causes of disease, particularly relative contribution of genetic and environmental factors.

  6. Commentary: White, European, Western Caucasian, or What? Inappropriate labeling in research on race, ethnicity, and health (Bhopal R, Donaldson L. AJPH 1998;88:1303-7) The terms “White” and Caucasian” are probably too heterogeneous to be of any scientific value (e.g. for comparisons) • Ethnicity is slowly replacing race, although the terms are still often used interchangeably.

  7. Racial differences: Psychiatry • Initial problem with defining race/ethnicity • In addition, biases in exposure and outcome classification by race/ethnicity -- Problems with raters -- Problems with diagnostic criteria -- Problems with assessing cultural differences

  8. Problems with Diagnostic Criteria: -- Patterns of referral and treatment of psychosis vary among white and non-white patients -- Black patients are more likely to be diagnosed with the following: • Severe first-rank psychotic symptomatology • Schizo-affective disorders, specifically schizophrenia -- Black patients are more likely to be hospitalized

  9. Thought insertion r=.32 Thought withdrawal .44 Being controlled .32 Voices commenting .57 Auditory hallucination .48 Visual hallucination .39 Grandiose incoherence .35 Aggressive behavior .30 Racial differences: ResultsSymptomatology IndexFirst Rank Symptoms(exhibiting a correlation of .30 or higher only)

  10. Problems w/Assessing Cultural Differences: --For many Western medicine diagnoses, cultural factors are not considered (exception – psychiatry) “Susto” (“fright” or “soul loss”): A folk illness prevalent among some Latinos in the U.S. and among people in Mexico and Central/South America. Susto is an illness attributed to a frightening event that causes the soul to leave the body and results in unhappiness and sickness. Symptoms may occur from days to years after the fright is experienced, and include appetite and sleep disturbances, low motivation and self-worth, muscle aches and pains, headache, diarrhea. Ritual healings are focused on calling the soul back to the body and cleansing the person to restore bodily and spiritual balance.

  11. Do Races Exist?

  12. Ethnicity in Psychiatric Epidemiology: Need for Precision • Do races exist? • Populations do differ biologically in the distribution of traits of simple inheritance such as blood groups, abnormal hemoglobin, human lymphocyte antigen system, taste sensitivity. • However, there are no racial typologies in grouping such traits. • It is now accepted that racial classification based on traits such as skin color are scientifically invalid. Singh, SP. Ethnicity in psychiatric epidemiology: need for precision. Brit J of Psych. 1997;171:305-8.

  13. Scientific American, December 2003 • Do races exist? ---If races are defined as “genetically discrete groups”, then the answer is NO. ---However, researchers can use some genetic information to group individuals into clusters with “medical relevance”.

  14. Scientific American, December 2003 Outward signs of which definitions of race are based (i.e. skin color and hair texture) are dictated by a handful of genes: -- “Other” genes of 2 people of the same “race” can be very different. -- Conversely, 2 people of different “races” can share more genetic similarity than 2 individuals of the same “race”.

  15. Scientific American, December 2003 The medical implications of racial genetic differences are still under debate: -- The FDA (as well as NIH) advocate collection of race and ethnicity data in all clinical trials. -- Some investigators assert that genomic data, rather than self-reported race, should be collected on each study participant. -- The extent to which different “races” respond differently to treatment regimens, and vary in disease susceptibility remains a matter of scientific debate.

  16. “Commentary on Why National Epidemiological Estimates of Substance Abuse by Race Should Not be Used”…Kip KE, Peters RH, Morrison-Rodriguez B.Am J Drug & Alcohol Abuse, 2002; 28(3): 545-56

  17. BACKGROUND • In the U.S., 3 large scale epidemiological studies have estimated prevalence of substance use, abuse, and/or dependence: --Epidemiologic Catchment Area (ECA): 1980-84: 5 community-based sites (n>20,000): structured DIS. --National Comorbidity Survey (NCS): 1990-92: National sample of 8,098 non-institutionalized persons ages 15 to 54: structured CIDI. --National Longitudinal Alcohol Epidemiologic Survey (NLAES): 1992: National sample of 42,862 non-institutionalized adults: structured AUDADIS.

  18. BACKGROUND Epidemiologic Catchment Area (ECA): •Prevalence rates of alcoholism similar between Blacks and Whites, except in age group 18 to 29 (50% lower rates in Blacks). •Lifetime prevalence of drug dependence 50% lower in Black women ages 18-29 vs. White women •Indicators of SES (education, income) generally inversely associated with prevalence of alcoholism and drug abuse/dependence.

  19. BACKGROUND National Comorbidity Survey (NCS): •Blacks estimated to have 65% lower odds of substance use disorder in their lifetime vs. Whites, and 53% lower odds in the past 12 months. •Among persons with lifetime drug dependence, Blacks 3 times more likely to be dependent in the past 12 months vs. Whites. •Education and income inversely associated with 1-year prevalence of substance use disorder, and in particular, lifetime drug dependence.

  20. BACKGROUND National Longitudinal Alcohol Epidemiologic Survey (NLEAS): •Odds of drinking >12 drinks on >12 occasions in the previous year were 53% lower in Blacks vs. Whites. •Among persons with lifetime alcohol dependence, Blacks 61% more likely than Whites to be dependent in the past 12 months. •Education and income inversely associated with 1-year prevalence of alcohol and drug dependence.

  21. Discussion Question What are some of the possible explanations for epidemiological differences in substance abuse disorders by race (i.e. other than valid, true differences)?

  22. Explanation #1 Social and Family Support Systems: • Religiosity is inversely associated with range of substance use/abuse/dependence.

  23. Explanation #2 Inadequate Sampling in Non-Civilian Settings: • NCS and NLAES conducted among civilian populations only; possible bias if Blacks are over-represented in institutionalized settings (prisons, nursing homes, mental hospitals).

  24. Explanation #3 Ethnic and Diagnostic Instrument Bias: • Perhaps the structured instruments used have differential reliability and validity among Black vs. White individuals.

  25. Explanation #4 Possible Reporting Bias: • Perhaps the instruments per se are not invalid, but self-reporting of substance use is biased.

  26. Explanation #4 Possible Reporting Bias: • Several studies have noted that Blacks tend to be more likely than other racial groups to underreport drug use (e.g. heightened suspicion or fear of possible adverse consequence from admitting illicit drug use).

  27. Explanation #4 Possible Reporting Bias: • In NCS, no difference by race for anxiety of affective disorders – perhaps greater stigma and social disapproval for reporting substance use problems (particularly among Black women).

  28. Explanation #4 Possible Reporting Bias: • Indicators of SES are generally inversely associated with substance use disorders – given overall lower SES of Blacks in U.S., results are counter-intuitive.

  29. Explanation #4 Possible Reporting Bias: • In all 3 studies, no apparent attempt to match race/ethnicity between interviewer and interviewee.

  30. Explanation #4 Possible Reporting Bias: • Unclear (not intuitive) as to why Blacks would be at lower risk of developing a substance use disorder, but once dependent, become more persistently dependent.

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