Ethnicity & Health: Evidence,

Issues & Models

Hector F. Myers, Ph.D.ProfessorDepartment of Psychology, UCLA

Outline

Summary of Evidence of Ethnic Health Disparities.Why the Differences? Proposed Conceptual Model of Risk.Methodological Challenges. Future Directions.

Challenge - Limitations in available data

Limited data for the 5 major ethnic groups for the major health/disease categoriesLimited data on ethnic sub-groups. Available data suggest substantial diversity in health status within each ethnic groupTherefore, impressions of overall health differences between groups may underestimate within-group differences.Inadequate & inconsistent consideration of SES x Ethnicity interaction.

WHAT DO WE KNOW ABOUTETHNIC HEALTH DISPARITIES?

Cardiovascular DiseaseCancerOther Chronic DiseasesBirth OutcomesHIV/AIDSSelf-Rated Overall Health

Ethnic differences in excess deaths (< age 70)

Africa Americans = 42.3%Native Americans = 25%Hispanics/Latinos = 14%No excess deaths among Asian/Pacific IslandersHowever, Native Hawaiians & South East Asian refugees have rates comparable to Hispanics.

Heart Disease Mortality by Race & Sex

Men WomenNon-Hispanic Whites 329.5 218.1Blacks 398.9 290.5American Indians 211.7 138.3Asian/Pacific Islanders 196.7 121.5Hispanics 212.7 146.5

Percent Population with CVD Risk Factors

Whites Blacks Hispanics

M W M W M W% HBP 25.6 19.7 36.5 36.4 25.9 22.3% Diabetes 5.4 4.7 7.6 9.5 8.1 11.4% High Chol 18.7 20.7 16.4 19.9 18.7 17.7% Obese 20.7 23.3 21.3 39.1 24.4 36.1% Exercise 31.7 25.8 24.3 17.8 26.1 16.7 Source: Health, United States, 2001

Cancer (% by type, U.S., 2004)

Cancer Breast Cervical Prostate

White 7.5 1.3 1.1 1.9

Black 4.2 0.8 0.6 2.5Am. Indian 8.0 ---- ---- ---Asian 2.8 0.9 ---- ---- Pac. Isl. 8.1 ---- ---- ----Hispanic 3.6 0.6 0.7 2.1

Source: National Health Interview Survey, 2004

Other Chronic Diseases (%, U.S., 2004)

Diabetes Ulcers Kidney Liver White 6.5 7.1 1.6 1.3 Black 11.2 5.7 2.3 1.4 Am. Indian 15.8 9.6 2.9 ---- Asian 7.5 3.8 1.7 1.2* Pac. Isl. 20.9 ---- ---- ---- Hispanic 10.4 5.8 3.0 1.9 Source: National Health Interview Survey, 2004

Disparities in Birth Outcomes

(Percent live births, 2003)

Low birthweight(< 2,500 grams)

White 6.94Black 13.37Am. Indian 7.37Asian/Pac Isl. 7.78Latino 6.69 Source: Health, United States, 2005

Birth Outcomes….Cont….

Very Low Birthweight (<1,500 grams)

White 1.17 Black 3.07 Am. Indian 1.30

Asian/Pac Isl. 1.09Latino 1.16

Source: Health, United States, 2005

Percent of those with HIV by Ethnicity (CDC, 2001)

African Americans 49% Whites 31% Latino 19% API/ AI < 1% ea.

AIDS Rates by Ethnicity & Gender

(per 100,000)

Men Women Whites 14 2 Blacks 109 48 Hispanics 43 13 Asian/PI 9 1 Nat. Ame. 19 5

Self-Rated Overall Health(%, U.S., 2004)

Excellent/ Fair/

Very Good Good PoorWhite 63.2 25.5 11.4Black 52.7 28.2 19.2 Am. Indian 44.1 33.0 22.9Asian 63.6 27.7 8.7 Pac. Isl. 42.6 38.3 19.1Hispanic 53.4 29.6 17.0

Source: National Health Interview Survey, 2004

Reasons for health disparities

Disproportionate representation among the poor.Chronic Stress BurdenBurden of health compromising behaviors.Health care access, utilization & quality

PROPOSED INTEGRATIVE EXPLANATORY MODEL

Social Status Factors

Race/Ethnicity. Socio-economic status & social

mobility. Gender. Age.

Debate over Race vs. Ethnicity

Despite obvious phenotypic differences between groups, “racial groups” are social constructions and not distinct genetic groups.However, there are measurable differences in the distribution of gene mutations that have implications for health.“Ethnicity”, which includes consideration of cultural differences and lived experiences, is the more accurate descriptor.

Chronic Stress Burden

Generic Life Stresses.Social Status-Related Stresses Racism/discrimination Intra-group biases/prejudices Gender-related stresses Poverty-related stresses Expectations related to higher social

status(See Myers et al., 2003 for review)

Effects of Exposure to Racism & Discrimination

Higher CV reactivity to discrimnation in laboratory studies (See Anderson, McNeilly & Myers, 1991; Harrell et al, 2003; Clark et al, 1999).

Ambulatory studies show that exposure to discrimination is common, affect future appraisal of experiences, associated with greater CV reactivity, and no evidence of physiologic adaptation (See Brondolo et al., 2003, 2005).

Evidence from the SWAN Heart Study found more coronary artery calcification in African American women exposed to chronic “everyday discrimination”, but not in Caucasian women (Lewis et al., in press).

Chronic Stress Burden …Cont…

Social Status Stresses:Poverty-related stressesAcculturative stressesGender-related stressesIntra-group biases/prejudicesExpectations related to higher

social status

Psychosocial Processes

Health compromising behaviors Perceived control & self-efficacy (e.g.

health locus of control). Coping style & resources. Socio-ecological risk & resources (e.g.

noise, pollution, violence). Health care access & utilization.

Health Compromising Behaviors

%Current %Current %Overweight/ % Never

Smokers Drinkers Obese Exercize

White 21.2 49.7 58.6 60.3Black 19.6 33.0 68.5 69.6 Am. Ind. 28.8 35.2 66.1 72.2Asian 11.2 31.9 34.9 65.3 Pac. Isl. 30.2 36.6 68.5

64.9Hispanic 14.1 36.1 67.0

72.0

Source: National Health Interview Survey, 2004

BIOLOGICAL RISKS & RESISTANCES

Genetic & acquired risks & resistances.

Culturally-mediated risks & resistances.

Socio-ecologically mediated risks.

Biological mechanisms – e.g. allostatic load.

Allostatic Load as biological pathway of cumulative risk

(McEwen, 1998)

Allostatic Load – wear and tear on the system from prolonged exposure over time to stress hormones.Frequent stress exposure.Inadequate habituation.Inability to recover.Inadequate response due to system fatigue.

Cumulative Vulnerability Hypothesis

Lifespan perspective would allow us to assess the relative balance between risk and resources over time as predictor of health outcomes.The Cumulative vulnerability hypothesis (e.g. Geronimus’ “weathering” hypothesis of Black women’s health).

Methodological Challenges & Future Directions

Increase sample size, representativeness & diversity (e.g. including multiple ethnic groups, higher SES)More sophisticated assessment of SES & its interaction with ethnicity to identify their joint effects on healthMore comprehensive assessment of life stresses, including discrimination

Future Directions… Cont…

Careful exploration of ethnic differences in psychosocial moderators & mediatorsExploration of group differences in resistance resources Comprehensive longitudinal studies of cumulative vulnerability (e.g. childhood obesity)