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Critical Perspectives on Racial and Ethnic Differences in Health in Late Life 12 Racial/Ethnic Disparities in Health Behaviors: A Challenge to Current Assumptions Marilyn A. Winkleby and Catherine Cubbin One of the primary goals of Healthy People 2010 is “eliminating health disparities” among all population subgroups. This replaces the policy in earlier Healthy People Objectives of setting differential health goals by race/ ethnicity, age, gender, and indicators of socioeconomic status (SES). These new objectives acknowledge the need to eliminate, rather than merely reduce, social inequalities in order to achieve a parity of health. This chapter has two goals that contribute to our understanding of health disparities. First, we examine racial/ethnic disparities in a comprehensive set of health behaviors related to chronic diseases to evaluate the extent to which disparities differ across health behaviors, age groups, and gender. Second, we assess the extent to which racial/ethnic disparities in health behaviors are related to underlying differences in indicators of SES. In addressing these goals, we challenge conventional assumptions about racial/ethnic disparities in health behaviors, especially the assumptions that populations of color have less healthy behaviors than white populations, and that racial/ethnic groups are internally homogeneous. We conclude that for some health behaviors, white populations have less healthy behaviors than do black and/or Hispanic populations, and for other health behaviors, the opposite is true. Furthermore, we conclude that disparities exist within each racial/ethnic group by important sociodemographic indicators, including age, gender, educational attainment, household income, and for Mexican Americans, country of birth and language spoken. We focus on the following health behaviors and risk factors, all of which are related to chronic diseases: smoking, obesity, physical inactivity,
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Critical Perspectives on Racial and Ethnic Differences in Health in Late Life poor diet, high alcohol consumption, and inadequate cancer screening practices. We selected these factors because of their effect on other chronic disease risk factors (hypertension, high cholesterol, diabetes) and important chronic disease outcomes (heart disease, stroke, cancer). While the underlying causes of these behaviors are not yet fully understood, they are all preventable, and change at any age can result in improved health. In this chapter, we argue that fundamental explanations for racial/ ethnic disparities in health behaviors are largely socioeconomic in nature. Despite a consensus that race and ethnicity are sociopolitical constructs, as opposed to biological categories (Muntaner, Nieto, and O’Campo, 1996; Williams, 1996), some researchers and policy makers have interpreted racial/ethnic disparities in health behaviors, either implicitly or explicitly, as reflecting inherent genetically based differences (for a critique of this approach, see Krieger, 2001). Rather, racial/ethnic disparities may reflect the consequences of a historical pattern of discrimination, by individuals as well as institutions (Geronimus, 1992; Lynch, Kaplan, and Shema, 1997). The consequences of discrimination are expressed through a variety of mechanisms, including differences in population-level SES (Jones, 2000) (e.g., blacks and Hispanics in the United States are far more likely to be poor than whites) and residential environments (e.g., blacks and Hispanics in the United States are far more likely to live in poor communities than whites). Such differences in SES and residential environments have been shown repeatedly to be associated with unhealthy behaviors for whites as well as populations of color (Conference of Socioeconomic Status and Cardiovascular Health and Disease, 1995; Cubbin, Hadden, and Winkleby, 2001; Kaplan and Keil, 1993; Marmot and Elliot, 1992; Winkleby, Kraemer, Ahn, and Varady, 1998). Racial/ethnic disparities in health behaviors may also reflect differences in cultural norms and values. This interpretation may be particularly relevant for groups who have recently immigrated to the United States; for example, foreign-born Mexican Americans may have healthier diets and exercise patterns than those who are born in the United States. We present data for the three largest racial/ethnic groups in the United States: white non-Hispanics, black non-Hispanics, and Hispanics (with a focus on Mexican Americans when possible). We do not present data on other racial/ethnic groups because data are limited from nationally representative samples across broad age groups. We base our main observations on data from two national data sets, the 1988-1994 Third National Health and Nutrition Examination Survey (NHANES III) and the 2000 Behavioral Risk Factor Surveillance System (BRFSS). In the first section of this chapter, we (1) present population projections from Census data for selected racial/ethnic and age groups in the United States for the next 50 years; (2) review selected scientific literature on racial/
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Critical Perspectives on Racial and Ethnic Differences in Health in Late Life ethnic disparities in chronic disease outcomes and health behaviors; and (3) evaluate the importance of considering socioeconomic status, residential environments, and acculturation in studies on racial/ethnic disparities in health behaviors. In the second section of this chapter, we present new findings from analyses of racial/ethnic disparities in health behaviors and practices across a broad range of age groups using data from a national sample of white, black, and Hispanic women and men. In the third section we discuss the implications of our findings, and in the final section, we provide conclusions from our analyses. POPULATION PROJECTIONS Dramatic changes in the racial/ethnic and age distributions of the U.S. population over the next 50 years will have a significant impact on chronic diseases, most which manifest in later life. Figure 12-1 presents population projections from the U.S. Census for the years 2000, 2010, and 2050 for white, black, and Hispanic adult women and men by age group (U.S. Census Bureau, 2001). Population sizes are given in thousands. There will be large increases in the Hispanic total adult population and to a lesser FIGURE 12-1 Population projections in thousands for the years 2000, 2010, and 2050 for white, black, and Hispanic adults, 18 and older, by age group. Population in thousands. SOURCE: U.S. Census Bureau (2001).
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Critical Perspectives on Racial and Ethnic Differences in Health in Late Life degree in the black population. In 2000, Hispanics and blacks accounted for 11 percent and 12 percent, respectively, of the three racial/ethnic groups aged 18 and over shown in Figure 12-1. By 2050, Hispanics and blacks will account for 25 percent and 15 percent, respectively. There will be even larger changes in the elderly population. By 2050, the elderly white population (aged 75 and older) will increase twofold, the elderly black population will increase fivefold, and the elderly Hispanic population will increase ninefold. For example, while the elderly Hispanic population in 2000 numbered under 1 million (792,000), it is projected to increase to more than 7 million people (7,055,000) by 2050. Given these projections, ethnic minority populations will bear an increased share of chronic diseases. RACIAL/ETHNIC DISPARITIES IN CHRONIC DISEASE INCIDENCE AND MORTALITY The leading causes of death for all racial/ethnic groups in the United States are from heart disease (30 percent of all deaths), cancer (23 percent), and stroke (7 percent) (Jemal, Thomas, Murray, and Thun, 2002). These chronic diseases account for nearly three-fourths of all deaths among women and men during some of the most productive years of their lives (25 to 64 years of age). Furthermore, they account for more than $300 billion in direct medical costs each year (Institute of Medicine, 1991). Although the majority of deaths for all racial/ethnic groups occur from chronic diseases, death rates vary considerably across racial/ethnic groups. Black women and men have higher age-standardized death rates from cardiovascular disease (CVD) than white women and men, regardless of income (Singh, Kochanek, and McDonan, 1996). This includes their strikingly higher death rates from stroke. Higher death rates for blacks from CVD begin in early ages and continue until age 65 (Pamuk, Makue, Heck, Reuben, and Lochner, 1998). After age 65, black-white differences in CVD death rates are smaller, with rates converging or crossing over at the oldest ages (Hollman, 1993). Although there have been large declines in U.S. death rates from CVD since the mid-1960s, the declines since the mid-1980s have been slower for blacks than for whites, producing larger black-white disparities (Singh et al., 1996; Tyroler, Wing, and Knowles, 1993). Blacks also have higher incidence rates for cancer and higher death rates following diagnosis than whites or Hispanics (Jemal et al., 2002). Death rates for all cancer sites are approximately 33 percent higher for blacks than for whites, and more than twice as high as for Hispanics. In the past decade, black men have shown the largest declines in cancer incidence and mortality of all racial/ethnic and gender-specific groups (Jemal et al., 2002), a change most likely related to a combination of risk factor reduction and better treatment and access to care.
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Critical Perspectives on Racial and Ethnic Differences in Health in Late Life In contrast to blacks, past studies have shown that Hispanics have lower age-standardized death rates from all causes, CVD, and cancer than whites (Aguirre-Molina, Molina, and Zambrana, 2001; Elo and Preston, 1997; Goff et al., 1997; National Cancer Institute, 2001; Sorlie, Backlund, Johnson, and Rogot, 1993; Vega and Amaro, 1994). These rates are consistent for women and men, and for all Hispanic groups, including Mexican-Americans, Cuban Americans, and mainland Puerto Ricans. There are several exceptions to the cancer rates——Hispanics have higher incidence and/or mortality rates of stomach, liver, cervical, and gallbladder cancer than whites (Gutierrez-Ramirez, Valdez, and Carter-Pokras, 1994; Sorlie et al., 1993). The overall mortality advantage for Hispanics has been termed the “Hispanic paradox” because Hispanics have higher rates of diabetes and obesity and lower socioeconomic status than whites. However, the Hispanic paradox has recently been called into question. Investigators from the Corpus Christi Heart Project reported a greater incidence of hospitalized myocardial infarction among both Mexican-American women and men than among non-Hispanic whites, concluding that the finding was congruent with the risk factor patterns observed in the Mexican-American population (Goff et al., 1997). More recently, investigators from the San Antonio Heart Study reported greater all-cause, CVD, and coronary heart disease mortality among Mexican Americans than non-Hispanic whites (Hunt et al., 2003). These new findings point out the need for studies of larger populations as well as studies that examine possible bias in mortality rates. For example, studies are needed to determine the extent to which Hispanic mortality rates are underestimated because of factors including selective immigration, return of terminally ill persons to their country of birth, age misreporting at older ages, and record linkage issues (Elo and Preston, 1997; Stephen, Foote, Hendershot, and Schoenborn, 1994). Are Disparities in Mortality Explained by Differences in Health Behaviors? Given the racial/ethnic disparities in chronic disease mortality, investigators have explored whether differences in health behaviors and risk factors (e.g., smoking, dietary habits, exercise, alcohol consumption) explain these disparities (Lynch, Kaplan, Cohen, Tuomilehto, and Salonen, 1996; Smith, Neaton, Wentworth, Stamler, and Stamler, 1996). Otten and colleagues, Teutsch, Williamson, and Marks (1990), used data for black and white adults from the NHANES Epidemiologic Follow-Up Survey to evaluate whether black-white differences in all-cause mortality (of which chronic diseases are major contributors) were explained by differences in health behaviors and risk factors (cigarette smoking, systolic blood pressure, cholesterol level, body mass index, alcohol intake, and diabetes mellitus). The
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Critical Perspectives on Racial and Ethnic Differences in Health in Late Life black-white mortality ratio for women and men aged 35 to 54 was 2.3 without adjustment for health behaviors and risk factors. This decreased to 1.9 when the six factors were taken into account, and to 1.4 when family income was also considered. The authors concluded that 31 percent of the black-white differences in all-cause mortality could be accounted for by the six health behaviors and risk factors and an additional 38 percent by family income (Otten et al., 1990). The remaining differences in mortality, unexplained by known health behaviors, risk factors, and/or SES, suggest that other mechanisms contribute to racial/ethnic disparities in mortality. However, in this study, as well as in others, adjustment for SES was most likely incomplete. Racial/Ethnic Disparities in Health Behaviors Among Adults Many studies have examined racial/ethnic disparities in health behaviors among adults, although most have not used representative samples or had adequate sample sizes to assess differences by gender, age, and/or SES. Studies on smoking show that white women, particularly those with lower SES, are more likely to smoke and to smoke more heavily than black or Hispanic women, especially Mexican-American women (U.S. Department of Health and Human Services, 2001). Although some studies show that white men are more likely to smoke than black and Hispanic men, this finding varies according to the age of the study population, the composition of the Hispanic sample, and the consideration of SES in the analysis (Haynes, Harvey, Montes, Nickens, and Cohen, 1990). Studies that have examined smoking among men from the three main Hispanic populations in the United States (Mexican Americans, mainland Puerto Ricans, and Cuban Americans) have found that Cuban-American men smoke the most and Mexican-American men smoke the least (Rogers, 1991). In contrast to studies on smoking, other studies consistently show that black women have higher prevalences of excess weight and physical inactivity and poorer diets than white women; differences between black and white men are less consistent and generally of lower magnitude (Burke et al., 1992; DiPietro, Williamson, Caspersen, and Eaker, 1993; Duelberg, 1992; Folsom et al., 1991; Gidding et al., 1996; Kumanyika, Wilson, Guilford-Davenport, 1993). Other studies, with some inconsistencies, show that Mexican-American women have higher prevalences of excess weight and physical inactivity than white women (Balcazar and Cobas, 1993; Diehl and Stern, 1989; Haffner et al., 1986; Kuczmarski, Flegal, Campbell, and Johnson, 1994; Mitchell, Stern, Haffner, Hazuda, and Patterson, 1990; Winkleby, Fortmann, and Rockhill, 1993; Winkleby et al., 1998). Again, findings are less consistent for men (Winkleby et al., 1993; Winkleby, Cubbin, Ann, and Kraemer, 1999a; Elder et al., 1991).
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Critical Perspectives on Racial and Ethnic Differences in Health in Late Life In general, these studies show much higher prevalences among those with lower SES. Most studies of alcohol consumption show few or no differences between black and white populations. Some groups of Hispanic men show heavier alcohol consumption than white men. Mexican-American and Puerto Rican men show heavy use in younger ages, with decreasing use in older ages (Markides, Ray, Stroup-Benham, and Trevino, 1990; Rogers, 1991). As with smoking, alcohol consumption is low for Hispanic women, especially those of Mexican origin; however, rates appear to increase with level of acculturation (Black and Markides, 1993). Heavy alcohol consumption is much more likely in men than in women for all racial/ethnic groups, and has shown inverse associations with SES. Recent studies of racial/ethnic differences in health behaviors have had the opportunity to include data on representative samples of women and men from the largest racial/ethnic groups in the United States. Given the large sample sizes, these studies have been able to evaluate the influence of SES as well as age. One of the largest national surveys to include multiple racial/ethnic groups, with clinical examination, is NHANES III (National Center for Health Statistics, 1994b). This national survey was conducted from 1988 to 1994 at 89 sites to assess the health and nutrition status of the U.S. population aged 2 months and older. It is noteworthy because it included an oversampling of black and Mexican-American women and men who represent a wide range of SES levels. In a previous analysis, Winkleby and Cubbin used NHANES III data to examine racial/ethnic differences in health behaviors among 3,229 black, 3,025 Mexican-American, and 3,775 white (non-Hispanic) women and men, ages 25 to 64 (Winkleby et al., 1999a). This analysis evaluated differences in three factors related to chronic disease health behaviors: smoking, obesity, and leisure-time physical inactivity. The results showed that race/ethnicity was independently associated with health behaviors after adjustment for educational attainment and family income divided by family size. Black and Mexican-American women had significantly higher odds of obesity and physical inactivity than white women (odds ratios 1.5 to 2.3, p values <0.01). Black men had higher odds of smoking and physical inactivity than white men (odds ratios 1.3 and 1.4 respectively, p values <.05). In contrast, both Mexican-American women and men had lower odds of smoking than white women and men (odds ratios 0.19 and 0.37 respectively, p values <0.001). The magnitude of the racial/ethnic differences was large for many comparisons (Winkleby et al., 1998). For example, black women were, on average, 16.8 pounds heavier than white women of comparable education and age. While these analyses of NHANES III data adjusted for age, differences across age groups were not examined.
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Critical Perspectives on Racial and Ethnic Differences in Health in Late Life Racial/Ethnic Disparities in Health Behavior Among Children and Young Adults A number of studies have examined racial/ethnic differences in health behaviors among children and young adults (Anderson, Crespo, Bartlett, Cheskin, and Pratt, 1998; Belcher et al., 1993; Berenson et al., 1998; The Bogalusa Heart Study, 1995; Dwyer et al., 1998; Folsom et al., 1989; McNutt et al., 1997, Srinivasan, Bao, Wattigney, and Berenson, 1996; Tortolero et al., 1997). Using NHANES III data, Winkleby et al., examined racial/ethnic differences in health behaviors in a sample of 2,769 black, 2,854 Mexican-American, and 2,063 white children and young adults, aged 6 to 24 years (Winkleby, Robinson, Sundquist, and Kraemer, 1999b). The analysis evaluated the age groups at which racial/ethnic differences were first apparent and whether differences remained after accounting for educational attainment of the head of the household and family income divided by family size. Whites, especially those from less educated households, had the highest prevalences of smoking; 77 percent of young white men and 61 percent of young white women, aged 18 to 24 years, from lower educated households were current smokers. In contrast, black and Mexican-American girls had significantly higher levels of body mass index (BMI) and percentages of energy from dietary fat than white girls. The racial/ethnic differences for BMI were evident by 6 to 9 years of age (a difference of approximately 0.5 BMI units) and widened thereafter (a difference of more than 2 BMI units among 18- to 24-year-olds). Black boys had higher levels of dietary fat energy intake than white boys. All racial/ ethnic differences remained significant after adjusting for age and education of the head of the household. Adjusting for family income showed similar results. Racial/Ethnic Disparities in Health Behaviors Among the Elderly Few studies have examined racial/ethnic differences in health behaviors among elderly populations, especially using nationally representative samples. The initial studies in this area show that: (1) older white women and men are more likely to have ever smoked, but are also more likely to have quit smoking than older black women and men; and (2) older black women and men are more obese and physically inactive, but are less likely to have high alcohol consumption than older white women and men (National Research Council, 1997). Sundquist and colleagues used data from NHANES III to examine whether racial/ethnic differences in health behaviors shown for younger women and men in NHANES III persisted for elderly women and men (Sundquist, Winkleby, and Pudaric, 2001). His analysis included 700 black,
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Critical Perspectives on Racial and Ethnic Differences in Health in Late Life 628 Mexican-American, and 2,192 white women and men aged 65 to 84 years. The health behaviors examined were cigarette smoking, abdominal obesity, and leisure-time physical inactivity. No significant racial/ethnic differences were found for smoking. However, black women were significantly more likely to be obese and physically inactive than white women after accounting for age and years of education (odds ratios 1.8 and 2.6 respectively). Black men were significantly more likely to be physically inactive than white men (odds ratio 1.9). No significant differences were found between Mexican Americans and whites for the three health behaviors. The racial/ethnic differences documented by this study may be underestimated because of survival bias. The study population represents an age cohort born between 1904 and 1929 who survived to 1988 to 1994, the dates of the NHANES III assessments. Therefore, people in this age cohort who survived to 1988 to 1994 may represent those with healthier behaviors. Underestimation may be especially true for the black-white differences because of the substantially higher rates of early death from chronic diseases and injuries for black compared with white women and men (Corti et al., 1999; Ventura, Peters, Martin, and Maurer, 1997). Health Behaviors Across Age Groups Despite the strong associations between age and chronic disease outcomes, few studies have examined racial/ethnic disparities in health behaviors across a broad range of age groups. Some studies indicate that disparities in health behaviors are larger for younger and middle-aged adults than for older adults; however, most studies have lacked sufficient sample sizes within racial/ethnic subgroups to provide definitive answers. Because chronic diseases reflect a progressive process that begins early in the life course and initiation of unhealthy behaviors often occurs in early adolescence, it is important to include young populations in analyses of racial/ ethnic disparities in health behaviors. It is also important to include populations across a broad age range to examine when disparities are first apparent and whether disparities differ across age groups. This can provide insight about causal pathways and the timing, focus, and content of primary, secondary, and tertiary prevention programs and policies (Lowry, Kahn, Collins, and Kolbe, 1996; Smith, Hart, Watt, Hole, and Hawthorne, 1998; Winkleby et al., 1999a). The Role of Socioeconomic Status Racial/ethnic disparities in health behaviors most likely result from complex relationships, with SES, residential environments, and cultural characteristics each playing a role. SES, however measured, has shown
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Critical Perspectives on Racial and Ethnic Differences in Health in Late Life strong, consistent associations with chronic disease outcomes and health behaviors for decades (Adler, Boyce, Chesney, Folkman, and Syme, 1993; Conference of Socioeconomic Status and Cardiovascular Health and Disease, 1995; Kaplan and Keil, 1993; Marmot and Elliot, 1992). Studies on racial/ethnic disparities in health that assess SES should ideally measure multiple dimensions of SES (e.g., measuring power, status, and economic class) at multiple levels (individual, household, neighborhood, community). However, because of its complexity, measuring SES fully is exceedingly difficult. In addition, there are issues of bias because SES measures such as education and income may not be commensurate across racial/ ethnic groups. Thus it is likely that residual confounding by SES exists in any study that investigates racial/ethnic disparities even after “adjusting” for multiple measures of SES (Braveman, Cubbin, Marchi, Egerter, and Chavez, 2001; Kaufman, Cooper, and McGee, 1997; Winkleby and Cubbin, 2003). Individual-level education, income, and occupational status have most commonly been used as indicators of SES in studies of health behaviors. Each measure has limitations (Smith and Kington, 1997); some are related to general measurement bias and others are particularly relevant to investigations of how racial/ethnic disparities vary across age groups. The measurement of education in the United States is compromised because measures of educational attainment (e.g., years of education or credentials) do not account for large inequalities in quality of schooling, especially for those from certain racial/ethnic groups and those from the current generation of elderly people. Furthermore, the same level of educational attainment does not convey the same meaning when examining differences in health behaviors across age groups; for example, a high school degree for an elderly population may confer the same status and prestige as a college degree for a younger population. Finally, the measurement of education is difficult to interpret when sample populations include people who have been educated in countries outside the United States. Measurement of income and occupation/employment status present additional challenges in studies of racial/ethnic differences in health behaviors. Current income may not reflect earnings over one’s lifetime and does not reflect wealth (e.g., investment income), especially among the retired. This is particularly problematic in that racial/ethnic differences in wealth are far greater than differences in income (Eller, 1994). Occupational status is also complicated in analyses across age groups because the same occupational category may reflect different exposures, experiences, and/or status across racial/ethnic groups. In addition, standard occupational categories in the United States combine a broad range of occupations and are based on types of work rather than social class theory, limiting their use as a socioeconomic measure (Krieger, Williams, and Moss, 1997).
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Critical Perspectives on Racial and Ethnic Differences in Health in Late Life THE ROLE OF RESIDENTIAL ENVIRONMENTS In recent years there has been an increasing interest in contextual studies that combine characteristics of both individuals and residential environments to investigate their joint association on individual-level health outcomes (Diez-Roux, 1998; Pickett and Pearl, 2001). A number of investigators have proposed that racial/ethnic differences in health behaviors may be explained in part by factors beyond the individual, such as neighborhood-level influences. There is a growing consensus that the residential environment that encompasses the immediate physical surroundings, social relationships, and cultural milieus within which people function and interact may influence both the SES and health of their residents. This includes the built infrastructure; industrial and occupational structure; labor markets; social and economic processes; wealth; social, human, and health services; government; race relations; cultural practices; religious institutions and practices; and beliefs about place and community (Macintyre, Ellaway, and Cummins, 2002; Winkleby and Cubbin, 2003). Differences in these residential environments can translate into differences in access to tobacco, alcohol, healthy food choices, safe places to exercise, and preventive health care, all of which can promote or impede healthy behaviors. Racial/ethnic groups in the United States are highly segregated, resulting in populations of color being far more likely to live in disadvantaged places. Thus, taking into account the characteristics of residential environments may partly explain racial/ethnic disparities in health, after accounting for differences in individual-level demographic and socioeconomic characteristics. A growing body of research supports the independent association of neighborhood socioeconomic characteristics on chronic disease morbidity and mortality, risk factors, and health behaviors. Residence in a socioeconomically disadvantaged area has been found to be independently associated with heart disease morbidity (Diez-Roux et al., 1997, 2001; Jones, 2000; Smith et al., 1998) and mortality (LeClere, Rogers, and Peters, 1998; Smith et al., 1998; Winkleby and Cubbin, 2003), and CVD risk factors and health behaviors (Cubbin et al., 2001; Diez-Roux et al., 1997, 1999; Duncan, Jones, and Moon, 1996; Ellaway, Anderson, and Macintyre, 1997; Hart, Ecob, and Smith, 1997; Lee and Cubbin, 2002; Smith et al., 1998; Sundquist, Malmstrom, and Johansson, 1999; Yen and Kaplan, 1998). For example, living in a low-SES neighborhood has been independently associated with lower physical activity (Yen and Kaplan, 1998), higher body mass index (Cubbin et al., 2001; Ellaway et al., 1997; Smith et al., 1998), higher prevalence of smoking (Cubbin et al., 2001; Diez-Roux et al., 1997; Smith et al., 1998; Sundquist et al., 1999), and less healthy dietary habits in adults (Diez-Roux et al., 1999) as well as youth (Lee and Cubbin, 2002).
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Critical Perspectives on Racial and Ethnic Differences in Health in Late Life would allow for a more accurate assessment of the degree to which racial/ ethnic disparities are explained by SES. For example, income measures could be collected in such a way as to allow for categories of income in relation to the federal poverty level or could include estimates of childhood socioeconomic factors and adult wealth as is done in the National Longitudinal Survey of Youth. Education could include parental education, country of education, and name of the town or city where a person’s highest education was obtained (to provide an indicator of geographic region of education and a surrogate of quality of education). Acculturation measures could include country of birth, language(s) spoken at home, and length of time lived in the United States. The Next Generation of Chronic Disease Prevention Chronic diseases, with heart disease ranking first, cancer ranking second, and stroke ranking third, will remain the leading causes of death in the United States for the next 50 years for all major racial/ethnic groups (Cooper et al., 2000). The National Conference on Cardiovascular Disease Prevention, held in 1999, addressed national trends in health behaviors related to CVD and other chronic diseases (Cooper et al., 2000). The conference leaders concluded that little progress has been made recently in addressing smoking, obesity, and physical inactivity despite widespread efforts to promote a populationwide adoption of healthy lifestyles, primary prevention for high-risk groups, and secondary prevention. Furthermore, the conference leaders stressed that wide racial/ethnic disparities in CVD mortality continue and that SES disparities in CVD mortality may be increasing. Their conclusions are supported by findings from other studies that show that the mortality disparity between lower and higher SES groups has widened (Pappas, Queen, Hadden, and Fisher, 1993). The next generation of chronic disease prevention and control programs and policies must acknowledge and effectively address the social and historical context within which health behaviors are inextricably linked (Green and Kreuter, 1991; Minkler, 1990; Syme, 2004; Wallack and Winkleby, 1987; Wallerstein and Bernstein, 1994). The responsibility for improving health behaviors has been framed too often from an individual perspective that places the main responsibility for change with the individual. The rationale for this approach has been that once individuals are informed of their risk, they will adopt or modify behaviors to lower that risk (Wallack and Winkleby, 1987). Although an individual approach can be effective for addressing health problems (especially at the secondary and tertiary prevention levels), it has had limited success when used in isolation because it (1) places the burden for change on individuals who often are those with the fewest resources (e.g., socioeconomically disadvantaged);
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Critical Perspectives on Racial and Ethnic Differences in Health in Late Life (2) can lead to increases in social disparities in health if those with the most resources and power (i.e., white and higher SES populations) are more able to take advantage of health-promoting programs, information, and policies to change their behaviors; (3) deflects attention away from important factors in the social and physical environment that influence choices regarding health-related behaviors; and (4) does not provide reinforcement of positive health behaviors from the environment in which a person lives and works. In summary, we support a broad health policy agenda for the prevention of chronic diseases that integrates a focus on race/ethnicity, SES, and the social environment (Anderson, 1995; Williams and Collins, 1995). This is critical given that health behaviors are shaped by the communities in which people live (Syme, 2004). A broad focus on socioeconomic inequalities acknowledges the strong influence of SES on chronic disease outcomes, ensures the inclusion of all low-SES populations in health initiatives and guidelines, and achieves more equitable access to resources. Finally, it creates a more valid scientific ground for research on racial/ethnic disparities in health behaviors that goes beyond individual-level measures, and furthers an understanding that social, economic, and political factors are fundamental causes of health (Link and Phelan, 1995). CONCLUSIONS In this chapter we examined racial/ethnic disparities in a comprehensive set of health behaviors to assess the extent to which disparities varied across health behaviors, age groups, and gender, and to evaluate the contribution of indicators of SES to racial/ethnic disparities. We used data from national surveys that have large representative samples that allowed for a stratification of data across a wide range of age groups. We included women and men from the three largest ethnic groups in the United States, delineating Mexican Americans when possible. We focused on smoking, obesity, physical inactivity, poor diet, high alcohol consumption, and cancer screening practices, all of which are related to chronic diseases. Our findings highlight many disparities in health behaviors, none of which are restricted to any gender or age group. Furthermore, the disparities were greatly influenced by education and income. The main conclusions from our BRFSS and NHANES III analyses are: For some health behaviors, white populations have higher levels of unhealthy behaviors than black and/or Hispanic populations (particularly for smoking, secondhand smoke exposure, and inadequate Pap and mammogram screening), and for other health behaviors, the opposite is true
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Critical Perspectives on Racial and Ethnic Differences in Health in Late Life (particularly for physical inactivity and obesity, with disparities being larger for blacks than for Hispanics). These disparities remain after adjustment for education and income. Health behaviors also differ within racial/ethnic groups by important sociodemographic indicators, including age, educational attainment, household income, country of birth, and language spoken. These differences have implications for the timing, focus, and content of primary, secondary, and tertiary prevention programs and policies. In general, racial/ethnic disparities in health behaviors are stronger for women than for men, in large part because of the greater disparities for women than for men for smoking, secondhand smoke exposure, physical inactivity, and obesity. Racial/ethnic disparities in health behaviors tend to be stronger for younger and middle-aged adults than for older adults. This is apparent for smoking, secondhand smoke exposure, physical inactivity, high alcohol consumption, and inadequate mammography screening. Both white and black adults with lower SES (as measured by either educational attainment or household income) have considerably less healthy behaviors than those with higher SES for all seven health behaviors, with the exception of high alcohol consumption. These differences show the importance of considering SES when planning and implementing health promotion and disease prevention programs. Hispanic adults have different patterns of results than white and black adults. Few differences in health behaviors are evident between Hispanics and whites after adjustment for education and income. In addition, few differences are evident for Hispanics when stratified by education or income, except for obesity, physical inactivity, and mammography screening. However, large differences in health behaviors exist for Mexican Americans by country of birth; adults who are born in the United States and/or who speak English have higher predicted prevalences of unhealthy behaviors than those who are born in Mexico and/or who speak Spanish. ACKNOWLEDGMENTS This work was cofunded by the National Institute of Environmental Sciences and the National Heart, Lung, and Blood Institute: Grant RO1 HL67731 to Dr. Marilyn Winkleby. We thank Dr. David Ahn, Dr. Ying-Chih Chuang, and Dr. Michaela Kiernan for their valuable comments on an earlier draft, and Alana Koehler for her technical assistance in preparing the tables and figures.
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