UNDERSTANDING RACIAL AND ETHNIC DIFFERENCES IN HEALTH IN LATE LIFE

A RESEARCH AGENDA

Panel on Race, Ethnicity, and Health in Later Life

Rodolfo A. Bulatao and Norman B. Anderson, Editors

Committee on Population

Division of Behavioral and Social Sciences and Education

NATIONAL RESEARCH COUNCIL OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS
Washington, D.C. www.nap.edu



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Understanding Racial and Ethnic Differences in Health in Late Life: A Research Agenda UNDERSTANDING RACIAL AND ETHNIC DIFFERENCES IN HEALTH IN LATE LIFE A RESEARCH AGENDA Panel on Race, Ethnicity, and Health in Later Life Rodolfo A. Bulatao and Norman B. Anderson, Editors Committee on Population Division of Behavioral and Social Sciences and Education NATIONAL RESEARCH COUNCIL OF THE NATIONAL ACADEMIES THE NATIONAL ACADEMIES PRESS Washington, D.C. www.nap.edu

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Understanding Racial and Ethnic Differences in Health in Late Life: A Research Agenda THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, D.C. 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This study was supported by Contract No. N01-OD-4-2139, TO #78 between the National Academies and the National Institute of Aging and by a grant from the Andrew W. Mellon Foundation. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the authors and do not necessarily reflect the views of the organizations or agencies that provided support for the project. Library of Congress Cataloging-in-Publication Data Understanding racial and ethnic differences in health in late life : a research agenda / Panel on Race, Ethnicity, and Health in Later Life, Committee on Population, Division of Behavioral and Social Sciences and Education ; Rodolfo A. Bulatao and Norman B. Anderson, editors. p. ; cm. “This volume is the Panel”s final report. The workshop papers are available in a companion volume, Critical perspectives on racial and ethnic differences in health in late life”—Pref. Updates work from: Racial and ethnic differences in the health of older Americans. 1997. Includes bibliographical references and index. ISBN 0-309-09247-7 (pbk.) 1. Minorities—Health and hygiene—United States. 2. Ethnic groups—Health and hygiene—United States. 3. Older people—Health and hygiene—United States. 4. Health services accessibility—United States. 5. Discrimination in medical care—United States. 6. Health status indicators—United States. 7. Health and race—United States. 8. Social medicine—United States. [DNLM: 1. Continental Population Groups—United States. 2. Geriatric Assessment—United States. 3. Ethnic Groups—United States. 4. Health Services Accessibility—Aged—United States. 5. Socioeconomic Factors—Aged—United States. WT 30 U45 2004] I. Bulatao, Rodolfo A., 1944- II. Anderson, Norman B. III. National Research Council (U.S.). Panel on Race, Ethnicity, and Health in Later Life. IV. Racial and ethnic differences in the health of older Americans. RA448.4.U52 2004 362.1’089’00973—dc22 2004016831 Additional copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, D.C. 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); http://www.nap.edu. Printed in the United States of America. Copyright 2004 by the National Academies. All rights reserved. Suggested citation: National Research Council. (2004). Understanding Racial and Ethnic Differences in Health in Late Life: A Research Agenda. Panel on Race, Ethnicity, and Health in Later Life. Roldolfo A. Bulatao and Norman B. Anderson, editors. Committee on Population, Division of Behavioral and Social Sciences and Education. Washington, DC: The National Academies Press.

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Understanding Racial and Ethnic Differences in Health in Late Life: A Research Agenda THE NATIONAL ACADEMIES Advisers to the Nation on Science, Engineering, and Medicine The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Bruce M. Alberts is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Wm. A. Wulf is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’ s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Bruce M. Alberts and Dr. Wm. A. Wulf are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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Understanding Racial and Ethnic Differences in Health in Late Life: A Research Agenda PANEL ON RACE, ETHNICITY, AND HEALTH IN LATER LIFE NORMAN B. ANDERSON (Chair), American Psychological Association, Washington, DC EILEEN M. CRIMMINS, Andrus Gerontology Center, University of Southern California ANGUS S. DEATON,* Woodrow Wilson School of Public and International Affairs, Princeton University DAVID V. ESPINO, Department of Family and Community Medicine, University of Texas Health Science Center, San Antonio JAMES S. HOUSE, Institute of Gerontology, University of Michigan Ann Arbor JAMES S. JACKSON, Department of Psychology, University of Michigan Ann Arbor CHRISTOPHER JENCKS, John F. Kennedy School of Government, Harvard University GERALD E. MCCLEARN, Center for Developmental and Health Genetics, Pennsylvania State University ALBERTO PALLONI, Department of Sociology, University of Wisconsin–Madison TERESA E. SEEMAN, School of Medicine, University of California, Los Angeles JAMES P. SMITH, RAND Corporation, Santa Monica, CA EUGENIA Y.-H. WANG, School of Medicine, University of Louisville DAVID R. WILLIAMS, Department of Sociology, University of Michigan Ann Arbor RODOLFO A. BULATAO, Study Director BARNEY COHEN, Director, Committee on Population BANGHWA LEE CASADO, Research Intern CHRISTINE COVINGTON CHEN, Senior Program Assistant ANTHONY S. MANN, Senior Program Assistant *   Until October 2002.

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Understanding Racial and Ethnic Differences in Health in Late Life: A Research Agenda COMMITTEE ON POPULATION KENNETH W. WACHTER (Chair), Department of Demography, University of California, Berkeley ELLEN BRENNAN-GALVIN, School of Forestry and Environmental Studies, Yale University JANET CURRIE, Department of Economics, University of California, Los Angeles JOHN N. HOBCRAFT, Department of Social Policy, London School of Economics CHARLES B. KEELY, Walsh School of Foreign Service, Georgetown University DAVID I. KERTZER, Department of Anthropology, Brown University DAVID LAM, Population Studies Center, University of Michigan, Ann Arbor CYNTHIA B. LLOYD, Population Council, New York DOUGLAS S. MASSEY, Department of Sociology and Woodrow Wilson School of Public and International Affairs, Princeton University RUBEN G. RUMBAUT, Center for Research on Immigration, Population and Public Policy and Department of Sociology, University of California, Irvine JAMES W. VAUPEL, Max Planck Institute for Demographic Research, Rostock, Germany LINDA J. WAITE, Department of Sociology, University of Chicago ROBERT J. WILLIS, Institute for Social Research, University of Michigan, Ann Arbor BARNEY COHEN, Director

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Understanding Racial and Ethnic Differences in Health in Late Life: A Research Agenda Preface The Panel on Race, Ethnicity, and Health in Later Life was established in 2001 under the auspices of the Committee on Population of the National Research Council (NRC). The panel’s task was to inform the National Institute on Aging about recent research findings on racial and ethnic disparities in later life and to help in developing a future research agenda for reducing them. This project was a follow-up to a 1994 Committee on Population workshop, which resulted in a volume of papers published by the National Academy Press, Racial and Ethnic Differences in the Health of Older Americans. The panel was asked, first to organize a 2-day workshop bringing together leading researchers from a variety of disciplines and professional orientations to summarize current research and to identify research priorities. That workshop was held in March 2002 in Washington, DC. The panel was also asked to produce a summary of the state of knowledge, based on the workshop, and to provide recommendations for further work. The initial plan called for the papers and the panel report to be published in a single volume, but ultimately it was decided to publish the papers and the panel report separately. This volume is the panel’s final report. The workshop papers are available in a companion volume, Critical Perspectives on Racial and Ethnic Differences in Health in Late Life. The panel benefited greatly from the workshop papers and thanks the following individuals for their contribution to the workshop and the resulting volume: Gary D. Sandefur, Mary E. Campbell, Jennifer Eggerling-Boeck, Robert A. Hummer, Maureen R. Benjamins, Richard G. Rogers, Jennifer J.

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Understanding Racial and Ethnic Differences in Health in Late Life: A Research Agenda Manly, Richard Mayeux, Clyde Hertzman, Alberto Palloni, Douglas Ewbank, Guillermina Jasso, Douglas S. Massey, Mark E. Rosenzweig, James P. Smith, Richard S. Cooper, Eileen M. Crimmins, Mark D. Hayward, Teresa E. Seeman, Carlos Mendes de Leon, Thomas A. Glass, Jeffrey D. Morenoff, John Lynch, Marilyn A. Winkleby, Catherine Cubbin, Hector F. Myers, Wei-Chin Hwang, Rodney Clark, Julian F. Thayer, Bruce H. Friedman, Amitabh Chandra, Jonathan S. Skinner, David M. Cutler, James Y. Nazroo, Debbie Bradshaw, Rosana Norman, Ria Laubscher, Michelle Schneider, Nolwazi Mbananga, and Krisela Steyn. The panel met multiple times over the course of the project to plan and hold the workshop and to digest and interpret the presentations. This report reflects the intense deliberations of the full panel, based on the papers and the members’ own expertise. This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the NRC’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We thank the following individuals for their review of this report: Stuart H. Altman, National Health Policy, Heller Graduate School, Brandeis University; Lisa Berkman, School of Public Health, Harvard University; Janet Currie, Department of Economics, University of California, Los Angeles; Mark D. Hayward, Social Science Research Institute, Pennsylvania State University; Judith R. Lave, Health Policy and Management, Graduate School of Public Health, University of Pittsburgh; Spero Manson, American Indian and Alaska Native Programs, University of Colorado Health Sciences Center, Aurora, CO; Kyriakos S. Markides, Division of Sociomedical Sciences, Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston, TX; Thomas G. McGuire, Department of Health Care Policy, Harvard Medical School; Gary D. Sandefur, Department of Sociology, Institute of Poverty, University of Wisconsin–Madison; and Kenneth W. Wachter, Department of Demography, University of California, Berkeley. Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by Larry Bumpass, Center for Demography and Ecology, University of Wisconsin–Madison, and Harold C. Sox, Annals of Internal Medicine, American College of Physicians of Internal Medicine, Philadelphia, PA. Appointed by the NRC, they were

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Understanding Racial and Ethnic Differences in Health in Late Life: A Research Agenda responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution. The panel is grateful to the sponsors of the project, the National Institute of Aging and the Andrew W. Mellon Foundation. Besides providing funding, the representatives of these organizations were a valuable source of information and advice to the panel. The panel was fortunate to have the services of the study director, Randy Bulatao, who worked closely with panel members to draft and edit the report. Barney Cohen, director of the Committee on Population, oversaw the work and managed the final stages of the process. Special thanks are due to Christine Covington Chen for her superb administrative and logistic support, to Eugenia Grohman for skillfully editing the manuscript, to Kirsten Sampson Snyder for navigating the report through review, and to Anthony Mann and Yvonne Wise for preparing the final manuscript for publication. Norman B. Anderson, Chair Panel on Race, Ethnicity, and Health in Later Life

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Understanding Racial and Ethnic Differences in Health in Late Life: A Research Agenda Contents     EXECUTIVE SUMMARY   1 1   THE NATURE OF RACIAL AND ETHNIC DIFFERENCES   7      Racial and Ethnic Groups,   9      Definitions,   9      Disparate Treatment,   11      How Group Membership May Affect Health,   13      Differences in Mortality and Health in Late Life,   14      Mortality,   15      Causes of Death,   18      Health and Disability,   20      Diseases and Conditions,   21      Needed Research,   25      Why Health Differences Matter,   28 2   PERSPECTIVES ON RACIAL AND ETHNIC DIFFERENCES   32      Major Factors,   32      Nature of the Evidence,   36      Selection Processes,   39      Selection Through Accession to Social Groups,   39      Selection Through Survival,   40      Reciprocal Causation,   41      Implications,   42      Needed Research,   44

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Understanding Racial and Ethnic Differences in Health in Late Life: A Research Agenda 3   GENETIC INFLUENCES   46      Race in Genetic Perspective,   46      The Nature of Genetic Influence,   48      Gene Interactions,   49      Some Racial and Ethnic Differences,   52      Needed Research,   53 4   SOCIOECONOMIC FACTORS   54      The Health Gradient and Reciprocal Causation,   54      Status, Race, and Ethnicity,   56      Mechanisms,   58      Needed Research,   59 5   BEHAVIOR RISK FACTORS   61      Behavioral Variation,   61      Reasons for Variation,   62      Effects of Variation and Trends,   64      Other Behaviors,   66      Needed Research,   67 6   SOCIAL AND PERSONAL RESOURCES   70      Social Resources,   70      Personal Resources,   73      Racial and Ethnic Variation,   74      Needed Research,   74 7   PREJUDICE AND DISCRIMINATION   76      Correlational Studies,   78      Experimental and Physiological Studies,   78      Needed Research,   79 8   STRESS   82      Stress and Health,   82      Race, Ethnicity, and Stress,   83      Needed Research,   85 9   BIOPSYCHOSOCIAL INTERACTIONS   86      Physiological Reactivity,   87      Allostatic Load,   88      Psychoneuroimmunology,   88      The Metabolic Syndrome and Psychosocial Factors,   89      Neurovisceral Integration,   89      Needed Research,   90

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Understanding Racial and Ethnic Differences in Health in Late Life: A Research Agenda 10   HEALTH CARE   92      Insurance Coverage,   92      Quality of Care,   95      Geographic and Institutional Variation,   98      Stereotyping by Providers,   99      Patient Behavior,   101      Needed Research,   102 11   THE LIFE COURSE   104      Early Health Disadvantage,   105      Pathways to Disadvantage,   106      Needed Research,   108 12   INTERVENTIONS   111      Changing Individual Behavior,   111      Health Promotion at Older Ages,   112      Possible Effects on Differentials,   113      Needed Research,   114      Social Policy,   115      Effectiveness of Interventions,   115      Targeted Interventions,   117      Indirect Effects of Policy,   119      Needed Research,   120     REFERENCES   122     APPENDIX   153     BIOGRAPHICAL SKETCHES   156     INDEX   161

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