Race, Ethnicity, Social Class and Race, Ethnicity, Social Class and Conceptual FrameworksConceptual Frameworks

EPI 222

Health Disparities Research Methods

Eliseo J. Pérez -Stable, M.D.Eliseo J. Pérez -Stable, M.D.Professor of Medicine, Professor of Medicine,

Division of General Internal Medicine, Department Division of General Internal Medicine, Department of Medicine, Medical Effectiveness Research of Medicine, Medical Effectiveness Research

Center for Diverse PopulationsCenter for Diverse Populations

April 4, 2013April 4, 2013

Summary of PresentationSummary of Presentation

• Definition of disparities

• Measuring Race and Ethnicity

• Genetics: Ancestral Markers

• Social Class and Wealth

• Other social determinants

• Conceptual Frameworks

Definitions of DisparitiesDefinitions of Disparities

• Disparities refers to a difference that Disparities refers to a difference that is a disadvantage for a traditionally is a disadvantage for a traditionally disenfranchiseddisenfranchised groupgroup

• Some differences may not be Some differences may not be classified as disparities–White men classified as disparities–White men have more CADhave more CAD

• Some disadvantaged groups may Some disadvantaged groups may have better outcomes––migrationhave better outcomes––migration

• Difference is a disparity when there Difference is a disparity when there is differential effect on an outcomeis differential effect on an outcome

Definition of RaceDefinition 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

Why is it Important to Measure Why is it Important to Measure Race as a Variable in Research?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

Meaning of Race CategoriesMeaning of Race Categories

• Race is a social construct• Geographic origin of racially

classified groups• Contrast of White and Black–simple• One-drop rule (1/16th Black = Black)• Am Indian Tribal membership• Gradations of pigmentation• Mixed race

EthnicityEthnicity

• Ethnicity refers to self-identity with group defined by racial admixture, geographic origin, culture, religion and/or language

• Characterized by sharing non-phenotypic characteristics

Latin American Population StructureLatin American Population Structure

Race in Colonial Spanish AmericaRace in Colonial Spanish America

• Spanish + Indian = Mestizo

• Spanish + Mestizo = Castizo

• Spanish + African = Mulato

• Spanish + Mulata = Morisca

• African + Indian = Lobo

• Spanish from Spain or America

• Colonialists included Africans, Arabs, and converted Sefardics (marranos)

Latinos in the AmericasLatinos 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

Implications for Research Implications for Research MethodsMethods

• In human research, always consider In human research, always consider asking about race and/or ethnicityasking 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

Office of Management and Office of Management and Budget (OMB) Directive 15Budget (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.”

2010 U.S. Census 2010 U.S. Census OMB OMB Standards set in 2000Standards set in 2000

• Allow for reporting 2 or more race categories––multi-racial

• 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

2010 U.S. Census Questions2010 U.S. Census Questions

Ethnicity question preceding race question

Is this person Spanish/Hispanic Latino?

Ethnicity response options:o No, not Spanish/Hispanic/Latinoo Yes, Mexican, Mexican-Am, Chicanoo Yes, Puerto Ricano Yes, Cubano Yes, other Spanish/Hispanic/Latino

2010 U.S. Census Questions2010 U.S. Census QuestionsRace question: What is this person’s race?

Race response optionsRace response options::•White, Caucasian, (European American)•Black, African American, (African)•American Indian or Alaska Native – tribe

•Asian: Asian Indian, Korean, Chinese,Vietnamese, Japanese, Filipino, Other Asian

•Pacific Islander: Native Hawaiian, SamoanGuamanian or Chamorro, Other PI

• Some other race: ___________

Lack of Heterogeneity in RaceLack of Heterogeneity in Race

• Categories are too simpleCategories are too simple

• African American, Caribbean Black, African American, Caribbean Black, African immigrant not the sameAfrican immigrant not the same

• South AsianSouth Asian, East Asian, SE Asian, East Asian, SE Asian

• American Indian tribal affiliationsAmerican Indian tribal affiliations

• Indigenous groups in the AmericasIndigenous groups in the Americas

• Lump or Split?Lump or Split?

• Lose political leverage if too smallLose political leverage if too small

2010 US Census Latinos by Race 2010 US Census Latinos by Race

Race Category Percent National

White 53 76.2

Black 2.5 14.6

American Indian 1.4 0.9

Asian 0.4 5.6

Pacific Islander 0.1 0.2

Some Other Race 36.7 0.2

Mixed Race 6 2.3

DHHS Standards: 2011DHHS Standards: 2011• Same question on ethnicity

• List 14 race categories: W, B, Am Ind, plus the 11 Asian and PI national origins as race categories

• Primary language –– define LEP

• Disability Status: hearing, vision, mental health, walking, ADL, IDL

Race and GeneticsRace and Genetics• More genetic variance within than More genetic variance within than

between racial groupsbetween racial groups• No genetic basis for raceNo genetic basis for race• Race/ethnicity identifies group more Race/ethnicity identifies group more

likely to share specific alleleslikely to share specific alleles• Interaction with environment – gene Interaction with environment – gene

expressionexpression• Ancestral Informative MarkersAncestral Informative Markers

Ancestral Informative MarkersAncestral Informative Markers• Single Nucleotide Polymorphisms Single Nucleotide Polymorphisms

(SNPs): 25% are identical across races(SNPs): 25% are identical across races• 21% of SNPs are unique to a racial 21% of SNPs are unique to a racial

group defined by geographic origingroup defined by geographic origin• Africans have the greatest Africans have the greatest

heterogeneity given the originheterogeneity given the origin• Founder populations traced to Founder populations traced to

mitochondrial DNAmitochondrial DNA• Interaction with environment – gene Interaction with environment – gene

expressionexpression

3,899 SNPs in 313 genes in 4 U.S. racial 3,899 SNPs in 313 genes in 4 U.S. racial

groupsgroups

Stephens, et al Science 2001

# S

NP

s

Common to:

25% of SNPs are Pan Racial25% of SNPs are Pan Racial

21% of SNPs are racially specific21% of SNPs are racially specific

Genetic vs. Geographical Distance

Jakobssen et al Nature 2008

Race, Genetics and DiseaseRace, 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

Contribution

45%

52% 24%

61%

15%3.0%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

MexicanAmerican

Puerto Rican

Percent

Ancestral

Admixture

Native AmericanAfrican

European

Genetic Origins of 2 Latino GroupsGenetic Origins of 2 Latino Groups

Ancestry Informative Markers Ancestry Informative Markers in Mexican Latinosin Mexican Latinos

Ancestry Informative Markers Ancestry Informative Markers in Puerto Rican Latinosin Puerto Rican Latinos

Racially Admixed PopulationsRacially Admixed Populations

• Latin America has been the admixture laboratory for 500 y with three major groups

• South Asian admixture for 20,000 y –– White and African

• Hawaii 200 y: PI, White, Asian• African Americans in the US

have moderate admixture

Implications of racial AdmixtureImplications of racial Admixture

• Admixture will lead to racial categories Admixture will lead to racial categories becoming less valid and meaningfulbecoming less valid and meaningful

• • Will be more prevalent with time

• • Social construct of race overwhelms any Social construct of race overwhelms any categorization, orcategorization, or

• • Phenotype always trumps genotypePhenotype always trumps genotype

• • What is the clinical relevance?• What are the risks? Fear of genetics

What About Social Class?What About Social Class?

Dominant factor among racially homogeneous

populations

Social Class MeasuresSocial 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

Social Class Measures 2Social Class Measures 2

• Class measure over the life course––childhood exposure

• Parental occupation and education

• Self-perceived ‘standing’ on a ladder ranging from 1 to 10

• How do others perceive your class?

• Simple questions are probably insufficient measures of social class

Wealth or Total AssetsWealth or Total Assets

• Wealth defines social class but not simple to measure total assets

• Stocks, accounts, insurance, retirement, property

• Generation of “class”–1st in family to attend college

• Household income vs. property

• Remember how the 1% make money

Social Class and Race/EthnicitySocial 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 vs. Whites

• Latinos and Asians are more complex

• Income gradient less clear in Latinos

Race/Ethnicity and Social ClassRace/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 even if outcomes are good

• Paradox of good health despite adverse social class status

Other Factors to ConsiderOther Factors to Consider• • Immigration and generation Immigration and generation

• • National origin/backgroundNational origin/background

• • Urban/rural or regionUrban/rural or region

• • Cultural identity Cultural identity

• • English language proficiency English language proficiency

• • Religion, documentation status, sexual Religion, documentation status, sexual orientation, genderorientation, gender

Definition of Epidemiologic Definition of Epidemiologic Paradox in LatinosParadox in Latinos

• Outcomes are better than Outcomes are better than expected based on the known or expected based on the known or standard predictive risk factorsstandard predictive risk factors

• Low SES does not always Low SES does not always translate to worse outcomestranslate to worse outcomes

Proposed Explanations of Proposed Explanations of ParadoxParadox

• Healthy immigrant effect: 40%Healthy immigrant effect: 40%

• Salmon hypothesis–return to die at Salmon hypothesis–return to die at home and deaths not recordedhome and deaths not recorded

• Misclassification of ethnicity in Misclassification of ethnicity in diagnosis and deathsdiagnosis and deaths

• Latinos classified as Whites – 30%?Latinos classified as Whites – 30%?

• Census undercounts (increase)Census undercounts (increase)

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

Perceptions and AttitudesPerceptions and Attitudes

Percent Percent agreeagree

In past 5 years, you, family, In past 5 years, you, family, or close friend discriminatedor close friend discriminateddue to racedue to race

LatinosLatinos 40%40%

African AmericansAfrican Americans 54%54%

WhitesWhites 14%14%Henry J. Kaiser National Survey on Latinos in America, 2000.Henry J. Kaiser National Survey on Latinos in America, 2000.

Perceptions and AttitudesPerceptions and Attitudes

Percent Percent agreeagree

In past year, you, family, In past year, you, family, or close friend discriminatedor close friend discriminateddue to race in health settingdue to race in health setting

LatinosLatinos 12%12%

African AmericansAfrican Americans 17%17%

WhitesWhites 5%5%Henry J. Kaiser National Survey on Latinos in America, 2000.Henry J. Kaiser National Survey on Latinos in America, 2000.

Perception of DiscriminationPerception of DiscriminationDoes It Affect Health?Does It Affect Health?

• Perceived discrimination is commonPerceived discrimination is common• Affects physical and mental health status Affects physical and mental health status

of African Americans in cohort studyof African Americans in cohort study• Administering analgesics to Latinos with Administering analgesics to Latinos with

long bone fractures–UCLAlong bone fractures–UCLA• Referral of patients with chest pain to a Referral of patients with chest pain to a

cardiologist for evaluation varied by racecardiologist for evaluation varied by race• Referral for obtaining technical Referral for obtaining technical

procedures--surgery for lung cancer, renal procedures--surgery for lung cancer, renal transplantation, coronary artery surgerytransplantation, coronary artery surgery

Understanding Race/Ethnic Understanding Race/Ethnic and SES Disparitiesand 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…

Recommendations on Use of Recommendations on Use of Race/EthnicityRace/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

Conceptual FrameworksConceptual Frameworks

How does it all fit into my research question?

ProportionsProportions(Premature Mortality)(Premature Mortality)

GeneticGenetic

30%30%

Health Health carecare

10%10%

Determinants Determinants of Healthof Health

BehaviorBehavior

40%40%

• GeneticGenetic

• Behavioral Behavioral

• EnvironmentalEnvironmental

• Social SettingSocial Setting

• Health careHealth care

SocialSocial15%15%

EnvironmentEnvironment5%5%

Source: McGinnis JM, Russo PG, Knickman, JR. Health Affairs, April 2002.

Understanding Disparities: Role of Understanding Disparities: Role of Conceptual FrameworksConceptual 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

One Ecological Model of One Ecological Model of Determinants of HealthDeterminants of Health

Bio-behavioralmechanisms,

genetics

Individual behavior

Macro social, Macro social, environmental conditions environmental conditions

and policyand policy

Living and working conditions

Social, family, community networks

Over the lifespan

NationalAcademy ofSciences, 2002

Three Broad Types of Conceptual Three Broad Types of Conceptual Frameworks: InteractionsFrameworks: Interactions

• Population sciencePopulation science– Determinants of health in a population – Samples are populations or subgroups

• Health services researchHealth services research– How health care affects outcomes– Samples are patients or health plan

members• Biology/physiologyBiology/physiology

– Biological and genetic pathways

Population-Based Determinants: Population-Based Determinants: Multiple Levels of Influence on HealthMultiple Levels of Influence on Health

• IndividualIndividual– biological, behaviors, attitudes, age, biological, behaviors, attitudes, age,

education, occupationeducation, occupation

• Family and Social NetworkFamily and Social Network– size, structure, support, beliefssize, structure, support, beliefs

• Neighborhood or communityNeighborhood or community– resources, toxins, aesthetics, resources, toxins, aesthetics,

crime/poverty, housing, transportationcrime/poverty, housing, transportation

Population-Based Determinants: Population-Based Determinants: Multiple Levels of Influence on HealthMultiple Levels of Influence on Health

• Cultural group, ethnic identity– shared beliefs, values, behaviors

• Occupation or workplace – toxins, safety, working conditions

• Organizational and Institutional structures– educational system, health care, parks

• Societal, political, economic

Life Course IssuesLife Course 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

Societal Approaches to Health Societal Approaches to Health Improvement-Structural InterventionsImprovement-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

Framework: Socioeconomic Status Framework: Socioeconomic Status Over the Life course and HealthOver the Life course and Health

Lynch J and Kaplan G, Social Epidemiology, Oxford, 2000 (Ch 2, p. 28)

Socioeconomic Position

Birth Childhood Adulthood Old Age

Low birth weightGrowth retardation

Smoking,diet, exercise

Job stressInadequate

medical care

Intrauterineconditions

Education,environment

Work conditions,income

Income,assets

Atherosclerosis CVD Reducedfunction

Bio-psychosocial Effects of Bio-psychosocial Effects of Perceived Racism on HealthPerceived Racism on Health

Environmental stimulus

Perception

Perception of racism

Perception of different

stressor

No perception of racism or other stressor

Coping responses

Psychological and physiological stress responses

Health outcomes

Blunted psychological and

physiological stress responses

Sociodemographic,Sociodemographic,Psychological, Psychological, Behavioral factorsBehavioral factors

Structure-Process-Outcome Structure-Process-Outcome ParadigmParadigm

Ultimate outcomes

-health status-Clinical events

Structure of care

Process of care:-technical care-interpersonal

care

Intermediateoutcomes-adherence-Knowledge

-BP, A1C

Patient characteristics

Cliniciancharacteristics

Summary: Conceptual FrameworksSummary: Conceptual Frameworks

• Numerous frameworks – Health services– Population science– Biological/physiological

• Reflect theories and research from many disciplines

• Frameworks can integrate 3 approaches • Review in designing all research

Conceptual Framework: Multi-level Conceptual Framework: Multi-level Determinants of Health DisparitiesDeterminants of Health Disparities

Psychosocial - beliefs, attitudes, adherence, coping, personality

Behavior - exercise, diet, alcohol, smoking, sexual behavior, substance use

Health care system

Demographics - age, gender, race, ethnicity, education, income

Physical environment

Social environment

HealthHealth& health care& health care

disparitiesdisparities

Biological – genetics -stress, allostatic load, opiate receptors, metabolism, telomeres

Contextual Individual-level

Technical aspects of health care

Communication with clinicians

Economic resources

TICR Professional Conduct StatementTICR Professional Conduct StatementClarifications for this classClarifications for this class

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• I will not use answer keys from prior years• I will write answers in my own words, and, when

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