Race, Ethnicity, Social Class and Conceptual Frameworks

1. Race, Ethnicity, Social Class and Conceptual Frameworks EPI 222: Health Disparities Research Methods Eliseo J. Pérez -Stable, M.D. Professor of Medicine, Division of General Internal Medicine, Department of Medicine, Medical Effectiveness Research Center for Diverse Populations March 31, 2011

2. Summary of Presentation • Definition of disparities • Race and ethnicity • US Census Questions and OMB 15 • Race and Genetics • Social Class • Perceived Discrimination • Conceptual Frameworks

3. Definition of Disparities • Disparities implies a difference that demonstrates a disadvantage for a group that has been traditionally disenfranchised • Some differences may not be classified as disparities–White men have more CAD • Some disadvantaged groups may have better outcomes––migration

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 Measure Race as a Variable in Research? • Predictor variable accounting for variance on many clinical 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) • Am Indian Tribal membership • Gradations of pigmentation • Colonial Spanish America table

7. Ethnicity • Ethnicity refers to self-identity with group defined 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 • Mix of culture and themes unify • Central role of Spanish language • Racial admixture – 500+ years of Europe, Indigenous peoples, Africa • Shared heritage: Catholic Church, US dominance

9. 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

10. 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.”

11. 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

12. 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

13. 2010 U.S. Census Questions Race question: What is this person’s race? Race response options: •White, Caucasian, (European American) •Black, African American, (African) •American Indian or Alaska Native - tribe •Asian: Asian Indian, Korean, Samoan, Chinese Vietnamese, Japanese, Filipino Other Asian •Pacific Islander: Native Hawaiian, Guam,Chamorro or Other PI • Some other race

14. 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?

15. 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 • Interaction with environment – gene expression • Ancestral Informative Markers

16. 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

17. 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

18. 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

19. Ancestry Informative Markers in Mexican Latinos

20. Ancestry Informative Markers in Puerto Rican Latinos

21. 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

22. Other Factors to Consider • Admixture will lead to racial categoriesbecoming less valid and meaningful • Social construct of race overwhelms or Phenotype always trumps genotype • Immigration and generation are critical factors in determining health • National origin/background, cultural identity, English language proficiency, religion, documentation status, sexual orientation, …

23. What About Social Class? Dominant factor 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 for African Americans and Whites • Latinos and Asians are more complex • Income gradient less clear in Latinos

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: 40% • 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. Perceptions and Attitudes Percent agree In past year, you, family, or close friend discriminated due to race in health setting Latinos 12% African Americans 17% Whites 5% Henry J. Kaiser National Survey on Latinos in America, 2000.

34. 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

35. Understanding Race/Ethnic and SES Disparities • What is it about being in a minority group or being poor that leads to worse health? • What does race/ethnicity or low SES “stand for” • Deconstruct “race/ethnic group membership” into underlying variables: Behaviors, attitudes, values, beliefs, ethnic identity, acculturation, discrimination, educational experiences, literacy, language proficiency, social class, culture, genetics…

36. Recommendations on Use of Race/Ethnicity • This is a critical construct • Essential in clinical research • Self-report category is gold standard • Variance explained overlaps but is distinct from SES measures • Contributes and predicts a lot • Measure in standard way

37. Conceptual Frameworks How does it all fit into my research question?

38. 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.

39. Understanding Disparities: Role of Conceptual Frameworks • Ground research in theory and knowledge • Help identify and organize key variables addressing objectives • On the pathway to disparities • Help develop specific research questions • Guide selection of measures

40. Three Broad Types of Conceptual Frameworks: Interactions • Population science • Determinants of health in a population • Samples are populations or subgroups • Health services research • How health care affects outcomes • Samples are patients or health plan members • Biology/physiology • Biological and genetic pathways

41. Population-Based Determinants: Multiple Levels of Influence on Health • Individual • biological, behaviors, attitudes, age, education, occupation • Family and Social Network • size, structure, support, beliefs • Neighborhood or community • resources, toxins, aesthetics, crime/poverty, housing, transportation

42. Population-Based Determinants: Multiple Levels of Influence on Health • Cultural group, ethnic identity • shared beliefs, values, behaviors • Occupation or workplace • toxins, safety, working conditions • Organizational/institutional structures • educational system, health care, parks • Societal, political

43. Individual Embedded in Ecological Context Society Community Family Family Individual

44. One Ecological Model of Determinants of Health Living and working conditions Individual behavior Bio-behavioralmechanisms, genetics Over the lifespan Social, family, community networks NationalAcademy ofSciences, 2002 Macro social, environmental conditions and policy

45. Conceptual Framework: Multi-level Determinants of Health Disparities Contextual Individual-level Physical environment Demographics - age, gender, race, ethnicity, education, income Social environment Psychosocial - beliefs, attitudes, adherence, coping, personality Health & health care disparities Health care system Technical aspects of health care Behavior - exercise, diet, alcohol, smoking, sexual behavior, substance use Communication with clinicians Biological - genetics,stress, allostatic load, opiate receptors, metabolism, telomeres Economic resources

46. Neighborhood safety, appearance Housing quality Transportation Segregation Hazardous materials Occupational hazards liquor stores full service grocery stores Availability of fresh fruits and vegetables areas for walking Bicycling paths, parks Physical Environment

47. Social Environment • Social opportunities • Family environment • Social support • Discrimination or racism • Neighborhood cohesiveness • Community meeting places

48. Societal Approaches to Health Improvement-Structural Interventions • Prevention strategies that target population health by changing social and community environments • “No indoor smoking” ordinances • Taxation policies • Smog control legislation (lead in gas) • Food labeling (nutrients) – Signage to use stairs (not elevators) Singer BH et al. New Horizons in Health, 2001

49. Cumulative Pathways or Lifecourse Issues • Health disparities due to lifetime of adverse conditions: Cumulative exposure • Childhood levels of SES and cumulative disadvantageous economic circumstances associated with poor health in mid-life • Lifetime experiences of discrimination due to race/ethnicity adversely affect health

50. Framework: Socioeconomic Status Over the Lifecourse and Health Socioeconomic Position Intrauterineconditions Education,environment Work conditions, income Income, assets Birth Childhood Adulthood Old Age Inadequate medical care Low birth weight Growth retardation Smoking,diet, exercise Job stress Atherosclerosis CVD Reducedfunction Lynch J and Kaplan G, Social Epidemiology, Oxford, 2000 (Ch 2, p. 28)