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Racial and Ethnic Disparities in Women’s Health Status

Racial and Ethnic Disparities in Women’s Health Status. An Epidemiologic Framework Carol Hogue 16 th Annual MCH Leadership Conference April 29, 2003. DRAFT 3/31/03—MAY BE DIFFERENT FROM FINAL PRESENTATION. Infant Mortality by Birthweight, Maternal Education, and Color, NIMS*, 1980.

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Racial and Ethnic Disparities in Women’s Health Status

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  1. Racial and Ethnic Disparities in Women’s Health Status An Epidemiologic Framework Carol Hogue 16th Annual MCH Leadership Conference April 29, 2003 DRAFT 3/31/03—MAY BE DIFFERENT FROM FINAL PRESENTATION

  2. Infant Mortality by Birthweight, Maternal Education, and Color, NIMS*, 1980 *National Infant Mortality Surveillance Source: Hogue CJ, et al., Public Health Reports 1987;102:125-138.

  3. Black/White Infant Mortality Ratio by Education, NIMS*, 1980 *National Infant Mortality Surveillance Source: Hogue CJ, et al. Public Health Reports 1987;102:126-138.

  4. Black/White Infant Mortality Ratios, Babies Born to College-educated Parents, U.S., 1983-85(from Schoendorf K, et al., NEJM, 1991) • Crude odds ratio: 1.9 • Odds ratio adjusted for prenatal care entry, parity, age, marital status: 1.8 • Very low birthweight (<1,500g) differential: 3-fold • What is causing VLBW (or preterm) deliveries among well-educated African American women?

  5. Source: Chang J, et al. Pregnancy-related mortality surveillance— United States, 1991-1999. MMWR Surveillance Summaries 2003;52:ss-2.

  6. Source: Chang J, et al. Pregnancy-related mortality surveillance— United States, 1991-1999. MMWR Surveillance Summaries 2003;52:ss-2.

  7. Source: Chang J, et al. Pregnancy-related mortality surveillance— United States, 1991-1999. MMWR Surveillance Summaries 2003;52:ss-2.

  8. What explains this? • One or more phenomena that cause the disparity, either singly or in combination • Phenomena that occur more frequently among African American than among White women • Phenomena that are not uniformly distributed, or whose effects are not uniformly distributed, among African American women. The majority of African American pregnant women are healthy and deliver healthy, full term infants.

  9. Criteria for Causal Hypothesis Development: Example of Preterm Delivery • Risk Factor Specificity: Is X a risk factor for preterm delivery? • Race Specificity: Does X occur more frequently among African American women of reproductive age? • Within-race Specificity: What behaviors increase/decrease the frequency of X among African American women (or, mitigate the effects of X in some, but not all, African American women?

  10. Risk Factors Currently Under Investigation* • Stress – Including effect of racism • Personally mediated • Institutional • Internalized • Infection • Bacterial vaginosis • Periodontal disease • [Diet • Obesity • Micro nutrient imbalance] • Gene-environment interactions *See Paediatric and Perinatal Epidemiology 2001;14 (suppl 2):1-158.

  11. Behavior and Current Causal Hypotheses

  12. Operational Definition of Racism(adapted from CP Jones AJE 2001;154;299-304) • Personally mediated racism - an acute stressor, including individual insults and discriminatory acts • Institutionalized racism - discriminatory, race- or class-based policies and practices (informal and formal). • Internalized racism - “acceptance by members of the stigmatized races of negative messages about their own abilities and intrinsic worth”

  13. Is Personally Mediated Racism a Risk Factor for Ill Health?* • 53 published, population-based studies (24 published 2000-2002) • Of 86 comparisons: • 59 (69%) were positive for an association • 12 (14%) were positive for certain subgroup(s) • 14 (17%) had no statistical association • 0 (0%) had a reverse association *Williams DR, Neighbors HW, Jackson JS. AJPH 2003;93:200-208.

  14. Is Personally Mediated Racism a Risk Factor for Ill Health?* • Mental health was most studied • 25 Psychological distress (80% +) • 22 Other mental health issues (73% +) • Physical health studies • 17 Self report (including self-rated health) (71% +) • 11 Blood pressure and 3 CHD (64% +) • 1 Mortality (+) • 5 Health behavior studies (3 smoking, 2 alcohol, all +) *Williams DR, Neighbors HW, Jackson JS. AJPH 2003;93:200-208.

  15. Unfair Treatment by Race and Neighborhood Poverty, Detroit, 1995 *African American, White **Census tracts: poor (20% or more households in poverty), middle class (remainder) Source: Schulz A, et al. J Health Soc Behav 2000;41:314-332.

  16. Is Personally Mediated Racism A Risk Factor for Preterm Delivery?* • Of 53 published studies of perceived discrimination and health, only 2 examined VLBW. • One found increased risk for women with other risk factors (Collins JW Jr, et al. Epidemiol 2000;11:337-339) • One found no statistical association (Murrell NL. J Natl Black Nurses Assoc 1996;8:45-53. *Williams DR, Neighbors HW, Jackson JS. AJPH 2003;93:200-208.

  17. Percent Reporting Discrimination:African American mothers, Cook County Hospital Crude OR 1.9 (0.5-6.6) Adjusted OR 3.2 (0.9-11.3) Collins, Epidemiology 2000

  18. Is Personally Mediated Racism A Risk Factor for Preterm Delivery Differentials? • Risk factor specificity? Not yet sufficiently studied • More frequent among African American women? Yes • Behaviors that increase/decrease risk? • Not yet studied • Indication that social status does not protect against personally mediated racism

  19. Is Institutionalized Racism A Risk Factor for Racial/Ethnic Disparities in Women’s Health? • Strong evidence that poverty (the result of historical racism) is associated with poor health. Also, weathering (see Geronimus). • African American women are more likely to be poor and to be weathered. • Health system behaviors may mitigate institutional racism (for an example of a conceptual framework, see Van Ryn M and Fu SS. AJPH 2003;93:248-255).

  20. Percent of Women Aged 16 Expected to Live to Selected Ages, 1990: Effect of Weathering? Source: Geronimus JAMWA 2001;56:133-136.

  21. Selected Diseases Where Survival is Related to Race for Women, NLMS*, 1979-1985 *National Longitudinal Mortality Study Source: Howard G, et al. Ann Epidemiol 2000;10:214-223.

  22. Is Internalized Racism a Risk Factor for Racial/Ethnic Women’s Health Differentials? • Internalized racism has been associated with some ill health indicators

  23. Association of Internalized Racism with Prevalence of Obesity, Abdominal Obesity,* and Hypertension, Afro-Caribbean Women, Barbados, 1996 *Waist-to-hip circumference (WHR) Source: Tull ES, et al. J Natl Med Assoc 1999;91:447-452.

  24. Survival Probability by Racism/Attribution Pattern Variables, National Survey of Black Americans, 1979-1992 Source: LaVeist TA, Sellers R, Neighbors HW. Ethn Dis 2001;11:711-721).

  25. Is Internalized Racism a Risk Factor for Preterm Delivery Differentials? • Meets criterion of race specificity • Some evidence that personality traits interact with experience to mitigate impact of internalized racism

  26. Stress Reactivity:level of physiologic response to a set level of stressor • Associated with both poor health outcomes and the psychosocial stress of experienced discrimination (Evans, et al., 1994) • Blood Pressure (BP) rises in experimental racist settings (Armstead et al, 1989) • Differentials in BP rise among African Americans not associated with familial hypertension (Harrell, et al., 1998) • Stress reactivity “set” by age 2-3

  27. Risk Factors Currently Under Investigation for Preterm Delivery* • Stress – Including effect of racism • Personally mediated • Institutional • Internalized • Infection • Bacterial vaginosis • Periodontal disease • [Diet • Obesity • Micro nutrient imbalance] • Gene-environment interactions *See Paediatric and Perinatal Epidemiology 2001;14 (suppl 2):1-158.

  28. Infection/Individual Behavior • Sexually transmitted diseases • Age of sexual debut • Number of sexual partners • Douching • Timing • Reason • Type

  29. Infection/Interpersonal Behavior • Sexually Transmitted Disease – partner’s role • Negotiation around condoms • Partner’s partners

  30. Infection/Social-Cultural • Differential exposure to infection • Differential access to health care • Differential cultural attitudes • Sexuality as example • “Community load” • Male/female roles • Alternatives to child-adult transition • Availability/acceptability of contraception • Pregnancy wantedness?

  31. Bacterial Vaginosis in Pregnant Women: B/W Odds Ratios(Culhane JF, et al. AJOG 2002;187:1272-1276) • Crude OR: 3.3 (2.4-4.6) • Adj for sociodemo.: 3.3 (2.4-4.5) • + behav&perceiv. stress: 3.4 (2.7-4.7) • Plus obj. stress: 2.9 (2.1-4.2) • Housing, conflict, material hardship, danger • Plus neighborhood stress: 2.4 (1.6-3.5) • Emergency shelters, assault

  32. Social-environmental risk factors Maternal and fetal genes Mat & fetal HPA axis activation Susceptibility to environmental toxins Decidual chorioamniotic inflammation Uteroplacental vasculopathy Preterm labor, PROM, medical induction From Wang, et al. PPE 2001;15 (suppl):64. Preterm delivery

  33. Possible Unifying Framework:Prenatal Stress(Wadhwa PD, et al., PPE 2001;15 (suppl 2):17-29) • Maternal-placental-fetal neuroendocrine pathophysiology (of largely unknown origin) and maternal-placental-fetal infections and related immune pathophysiology are the current leading candidates for etiologic investigation • Maternal stress (both prenatal and pre-conception) are plausible causal factors in producing/increasing endocrine &/or immune pathophysiology during gestation

  34. Racism-Associated Host Factors for Racial/ethnic Women’s Health Disparities Host Personality trait-environment interactions (includes behavioral risk factors) Internalized racism Gene-environment interactions Stressreactivity Weathering Environment Agent (Racism)

  35. SUMMARY • IF the Maternal Stress Framework provides an accurate framework for the causes of preterm delivery • Then effects of the stresses associated with being a member of a minority group may explain much of the excess PTD delivery risk for African Americans

  36. Mobilizing to Eliminate Health Disparities • Research with a comprehensive approach to studying effect of racism on disparities • Action now: • Identify and root out personally mediated racism in health care settings • “Vaccinate” individuals against stress • Improve social supports for women, infants & children in poverty, including improved family planning

  37. Is Attitude Towards Pregnancy a Risk Factor for Preterm Delivery Differentials? • Risk Factor Specificity: No, if unintended; Yes, if unwanted (interrupts causal pathway) (see Hogue CJR. IN The Best Intentions, IOM, 1995, chapter 3) • Race Specificity: Yes • Within-race Specificity:

  38. Percentage of Women Unhappy with Their Pregnancy by Pregnancy Intendedness,NSFG 1995* Source: Vital and Health Statistics, Series 23, No. 19, Table 16. Unhappy defined as scoring 1-3 on 10-point scale (10 being happiest to be pregnant.

  39. Percentage Reduction in VLBW Deliveries if No Pregnancies were Unwanted Source for percentage of deliveries that were unwanted: Vital and Health Statistics, Series 23, No. 19, Table 14.

  40. Directions for Unintended Pregnancy Research • In depth research into public health relevancy of unwanted conceptions that lead to birth among all women • In depth research into racial and ethnic differentials among the public health-relevant, unwanted conceptions • Based on findings, targeted interventions

  41. Recommendations for All Research into Racial/Ethnic Health Disparities • When studying PTD differentials, include measures of • acute and chronic stressors associated with discrimination as well as poverty • estimate of chronic stress-associated age • stress reactivity • internalized racism • personality traits (e.g. anger and anxiety traits) • and (when available) relevant genetic distributions

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