Measurement of Race, Ethnicity and Social Class

1. Measurement of Race, Ethnicity and Social Class Research in Diverse Communities Eliseo J. Pérez-Stable, M.D. Professor of Medicine, Division of General Internal Medicine, Department of Medicine, Medical Effectiveness Research Center for Diverse Populations (MERC) April 1, 2010

2. Proportions (Premature Mortality) Determinants of Health Social15% • Genetic • Behavioral • Environmental • Social Setting • Health care Genetic 30% Environment5% Health care 10% Behavior 40% Source: McGinnis JM, Russo PG, Knickman, JR. Health Affairs, April 2002.

3. Summary of Presentation • Race ––Why bother? • Ethnicity • US Census Questions and OMB 15 • Race and Genetics • Social Class • Perceived Discrimination/Racism • Clinical Research Examples

4. Definition of Race Societal constructed taxonomy that reflects intersection of particular historical conditions with economic, political, legal, social and cultural factors, as well as racism. David Williams, PhD, 1994

5. Why is it Important to Include Race as a Variable in Research? • Reason to measure: Predictor variable accounting for variance on outcomes • Assess the impact of organizational changes in the health care system on quality of care for vulnerable groups • Due to treatment disparities: track processes and outcomes of care • Advance knowledge in understanding mechanisms of disease and behavior

6. Meaning of Race Categories • Race is a social construct • Geographic origin of racially classified groups–data compelling • Contrast of White and Black–simple • One-drop rule (1/16th Black = Black) • Gradations of pigmentation • Colonial Spanish America table

7. Ethnicity • Ethnicity refers to self-identity with a group defined in part by racial admixture, geographic origin, culture, religion and/or language • Characterized by sharing non-phenotypic characteristics

8. Latinos in the Americas • More similarities than differences despite 20 different national origins • Unique mix of culture and genetics • Central role of Spanish language • Cultural themes unify • Racial admixture – 500+ years • Common cultural heritage: Catholic Church, Spain, Indigenous peoples

9. Other Factors to Consider • Admixture will lead to racial categoriesbecoming less valid and meaningful • Social construct of race overwhelms • Phenotype always trumps genotype • National background, cultural identity, language proficiency, religious background, documentation status, sexual orientation, …

10. Implications for Research Methods • In human research, always consider asking about race and/or ethnicity • Method used: Self-identification should be the “gold standard” • Administrative data has limitations with up to 30% misclassification • Need to over sample ethnic groups or stratify by or focus on ethnicity

11. Office of Management and Budget (OMB) Directive 15 • Sets guidelines for the collection of racial and ethnic categories to “provide for the collection and use of compatible, non-duplicated, exchangeable racial and ethnic data by Federal agencies.”

12. 2000 U.S. Census OMB Standards Continued in 2010 • Allow for reporting more than 1 race • Separate Asian/Pacific Islander into 2 categories: Asian and Native Hawaiian or Other Pacific Islander • Change to Hispanic or Latino • Change to black or African American • Strongly endorse self-identification

13. 2010 U.S. Census Questions Ethnicity question preceding race question Is this person Spanish/Hispanic Latino? Ethnicity response options: o No, not Spanish/Hispanic/Latino o Yes, Mexican, Mexican-Am, Chicano o Yes, Puerto Rican o Yes, Cuban o Yes, other Spanish/Hispanic/Latino

14. 2010 U.S. Census Questions Race question: What is this person’s race? Race response options: •White, Caucasian, (European American) •Black, African American, or Negro •American Indian or Alaska Native - tribe •Asian: Asian Indian, Korean, Samoan, Chinese Vietnamese, Japanese, Other A •Pacific Islander: Filipino, Native Hawaiian, Guam,Chamorro or Other PI • Some other race

15. Lack of Heterogeneity in Race • Categories are too simple • African American, Caribbean Black, African immigrant • South Asian, East Asian, SE Asian • American Indian tribal affiliations • Indigenous groups in the Americas • Lump or Split?

16. Race and Genetics • More genetic variance within than between racial groups–no genetic basis for race • Race/ethnicity identifies group more likely to share specific alleles • Random coupling will eliminate race––ever? • Interaction with environment – gene expression • Ancestral Informative Markers

17. 21% of SNPs are racially specific 25% of SNPs are Pan Racial 3,899 SNPs in 313 genes in 4 U.S. racial groups Common to: # SNPs Stephens, et al Science 2001

18. Race, Genetics and Disease • Racial categories emphasize geographic region of origin of a person’s ancestry • Most diseases are multi-factorial • Gene pool predisposition often confused with “racial” characteristic • Prevalence of hypertension in Caribbean Blacks less than US Whites < Southern AA • International variation in effect size of SBP on rate of stroke and heart attack

19. 100% 3.0% 90% 15% 80% 70% 52% 24% African 60% Native American 50% European 40% 30% 61% 45% 20% 10% 0% Mexican Puerto Rican American Genetic Origins of 2 Latino Groups Percent Ancestral Contribution Admixture

20. Ancestry Informative Markers in Mexican Latinos

21. Ancestry Informative Markers in Puerto Rican Latinos

22. Role of Admixture • America has been the modern laboratory––South Asia older, Hawaii • Will be more prevalent with time in all populations • Does self-report correlate with ancestry admixture? • What is the clinical relevance of this? • What are the risks? Fear of genetics

23. What About Social Class? Dominant among racially homogeneous populations

24. Social Class Measures • Education – years of formal or establish ordinal categories • Income defined in terms of annual household and factor number of dependents. Frequently decline to report or inaccurate • Occupation– laborer, technical, professional, business

25. Social Class Measures 2 • Class measure over the life course––childhood exposure • Parental occupation and education • Self-perceived ‘standing’ on a ladder • How do others perceive your class? • Simple questions are probably insufficient measuresof social class

26. Wealth or Total Assets • Wealth defines social class but not simple to measure • Measure total assets, property • Home ownership • Generation of “class”–1st in family to attend college • Household income vs. property

27. Social Class and Race/Ethnicity • Race been a substitute for defining social class in the U.S. • Gradient of health outcomes at all levels by race--especially true for comparing African Americans and Whites • Latinos and Asians are more complex

28. Race/Ethnicity and Social Class • Explain often independent variance in outcomes • Strong association between the two constructs • Gradient of health exists across all levels of social class • Paradox of good health despite adverse social class status

29. Definition of Epidemiologic Paradox in Latinos • Outcomes are better than expected based on the known or standard predictive risk factors • Low SES does not always translate to worse outcomes

30. Proposed Explanations of Paradox • Healthy immigrant effect • Salmon hypothesis–return to die at home and deaths not recorded • Misclassification of ethnicity in diagnosis and deaths • Latinos classified as Whites – 30%? • Census undercounts (increase)

31. “Let’s just forget for a moment that you’re black.”

32. Perceptions and Attitudes Percent agree In past 5 years, you, family, or close friend discriminated due to race Latinos 40% African Americans 54% Whites 14% Henry J. Kaiser National Survey on Latinos in America, 2000.

33. Perception of DiscriminationDoes It Affect Health? • Perceived discrimination is common • Affects physical and mental health status of African Americans in cohort study • Administering analgesics to Latinos with long bone fractures–UCLA • Referral of patients with chest pain to a cardiologist for evaluation varied by race • Referral for obtaining technical procedures--surgery for lung cancer, renal transplantation, coronary artery surgery

34. Measurement Issues: Race, Ethnicity and Social Class Examples from Clinical Research

35. Cancer Incidence by Site and Ethnicity in Women, U.S. 2000(per 100,000 age-adjusted)

36. Cancer Incidence by Site and Ethnicity in Men, U.S. 2000(per 100,000 age-adjusted)

37. Genetic Ancestry & Breast CA • 106 ancestry markers genotyped in 440 cases and 597 controls • Immigrants + less accult protects • European ancestry associated with higher risk of breast CA: OR = 1.79 • After adjustment, association was attenuated to OR = 1.39 (1.06 – 2.11) Fejerman L, Cancer Res 2008; 68:9723-28

38. Cancer Mortality and Poverty in Latino Men, 1990-94/1995-00 Chu K, et al. JNMA 2007; 1092-1104

39. Cigarette Smoking in the U.S. – 2007National Health Interview Survey

40. Multiethnic Cohort Study: Lung Cancer by Smoking Intensity • 183,813 Af Ams, Japanese-Am, Latino, Native Hawaiian, Whites; age 45 - 75, in California and Hawaii • 1979 cases lung cancer, identified through SEER, from 1993-2001; 1135 in men • African Americans as referent group • Stratify by smoking intensity • Relative risk of Lung Cancer by race/ethnicity within smoking level Haiman CA, et al. N Engl J Med. 2006;354(4):333-42

41. Relative Risk of Lung Cancer by Ethnicity and Smoking Intensity Haiman CA, et al. N Engl J Med. 2006;354(4):333-42

42. Cigarette Smoking in the U.S. – 2002National Health Interview Survey

43. Nicotine Metabolism and Intake in African Americans • African Americans have 50% more lung cancer and higher cotinine levels per cigarette despite fewer cigarettes/day • Total and renal clearance of cotinine were 20% lower in African Americans • Nicotine intake per cigarette was 30% greater in African Americans JAMA 1999;280:152-56

44. Nicotine Metabolism in Chinese and Latinos • Metabolic clearance of nicotine and cotinine in Latinos was similar to Whites and lower among Chinese • Intake of nicotine per cigarette: • Chinese: 0.73 mg (0.53 to 0.94) • Latinos: 1.05 mg (0.85 to 1.25) • Whites 1.10 (0.91 to 1.30) • Nicotine intake = tobacco smoke

45. TB Rate Ratio by EthnicityDemographics and SES

46. CHD Prediction Scores By EthnicityColor in Framingham? • Applied sex specific CHD functions to 6 ethnically diverse cohorts • White and Black men and women prediction of CHD events works well • Japanese & Latino men and American Indian men & women–risk is overestimated • Adjust for different rates of risk factors and underlying rate of CHD • JAMA 2001; 286:180-7

47. Ethnic Disparities in Diabetic Complications at KPMCP • Observational study: 62 432 patients • 10% Lat, 64% W, 14% AA, 12% API • Latinos had less MI (0.68), CHF (0.61) and stroke (0.72) compared to Whites • More ESRD among Latinos–1.46 • Setting of uniform access • Genetics and environment?

48. Access to Markets with Healthy Foods for Diabetics in New York City • Food targets: Fruit, vegetables, 1% fat milk, diet drinks, high fiber bread • 173 stores in East Harlem and 152 stores in Upper East Side • Had all 5 categories: 9% vs. 48% • More likely to live on a block with no store selling foods in E Harlem–50% vs. 24% • Example of disparities in environmental justice issues complicating behavior AJPH 2004; 94: 1549-54

49. Ethnicity in Patient-Doctor Relationship • Refusal: whose issue? • DNR discussions–Race of clinician is an independent predictor • Cultural competence • Language factors • Racism may affect behavior: • Fewer cardiology referrals in Blacks

50. Ethnicity and Attitudes toward Patient Autonomy among Persons ≥ 65 yrs