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 April 4, 2013

2. Summary of Presentation • Definition of disparities • Measuring Race and Ethnicity • Genetics: Ancestral Markers • Social Class and Wealth • Other social determinants • Conceptual Frameworks

3. Definitions of Disparities • Disparities refers to a difference that is a disadvantage for a traditionally disenfranchisedgroup • Some differences may not be classified as disparities–White men have more CAD • Some disadvantaged groups may have better outcomes––migration • Difference is a disparity when there is differential effect on an outcome

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

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. Latin American Population Structure

9. Race 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)

10. 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

11. 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

12. 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.”

13. 2010 U.S. Census OMB Standards 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

14. 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

15. 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, Chinese, Vietnamese, Japanese, Filipino, Other Asian •Pacific Islander: Native Hawaiian, Samoan Guamanian or Chamorro, Other PI • Some other race: ___________

16. Lack of Heterogeneity in Race • Categories are too simple • African American, Caribbean Black, African immigrant not the same • South Asian, East Asian, SE Asian • American Indian tribal affiliations • Indigenous groups in the Americas • Lump or Split? • Lose political leverage if too small

17. 2010 US Census Latinos by Race

18. DHHS 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

19. 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

20. Ancestral Informative Markers • Single Nucleotide Polymorphisms (SNPs): 25% are identical across races • 21% of SNPs are unique to a racial group defined by geographic origin • Africans have the greatest heterogeneity given the origin • Founder populations traced to mitochondrial DNA • Interaction with environment – gene expression

21. 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

22. Genetic vs. Geographical Distance Jakobssen et al Nature 2008

23. 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

24. 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

25. Ancestry Informative Markers in Mexican Latinos

26. Ancestry Informative Markers in Puerto Rican Latinos

27. Racially 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

28. Implications of racial Admixture • Admixture will lead to racial categories becoming less valid and meaningful • Will be more prevalent with time • Social construct of race overwhelms any categorization, or • Phenotype always trumps genotype • What is the clinical relevance? • What are the risks? Fear of genetics

29. What About Social Class? Dominant factor among racially homogeneous populations

30. 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

31. Social 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 measuresof social class

32. Wealth 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

33. 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 vs. Whites • Latinos and Asians are more complex • Income gradient less clear in Latinos

34. 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 even if outcomes are good • Paradox of good health despite adverse social class status

35. Other Factors to Consider • Immigration and generation • National origin/background • Urban/rural or region • Cultural identity • English language proficiency • Religion, documentation status, sexual orientation, gender

36. 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

37. 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)

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

39. 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.

40. 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.

41. 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

42. 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…

43. 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

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

45. 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.

46. 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

47. 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

48. 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

49. 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

50. 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 and Institutional structures • educational system, health care, parks • Societal, political, economic