Cover Image

PAPERBACK
$51.75



View/Hide Left Panel

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,



The National Academies | 500 Fifth St. N.W. | Washington, D.C. 20001
Copyright © National Academy of Sciences. All rights reserved.
Terms of Use and Privacy Statement



Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
Intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text on the opening pages of each chapter. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

Do not use for reproduction, copying, pasting, or reading; exclusively for search engines.

OCR for page 450
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,

OCR for page 450
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/

OCR for page 450
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).

OCR for page 450
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.

OCR for page 450
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

OCR for page 450
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).

OCR for page 450
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.

OCR for page 450
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,

OCR for page 450
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

OCR for page 450
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).

OCR for page 450
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).

OCR for page 450
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);

OCR for page 450
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

OCR for page 450
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.

OCR for page 450
Critical Perspectives on Racial and Ethnic Differences in Health in Late Life REFERENCES Adler, N.E., Boyce, T., Chesney, M., Folkman, S., and Syme, L. (1993). Socioeconomic inequalities in health: No easy solution. Journal of the American Medical Association, 269, 3140-3145. Aguirre-Molina, M., Molina, C.W., and Zambrana, R.E. (2001). Health issues in the Latin community. San Francisco: Jossey-Bass. Anderson, N.B. (1995). Behavioral and sociocultural perspectives on ethnicity and health. Health Psychology, 14, 589-591. Anderson, R.E., Crespo, C.J., Bartlett, S.J., Cheskin, L.J., and Pratt, M. (1998). Relationship of physical activity and television watching with body weight and level of fatness among children: Results from the Third National Health and Nutrition Examination Survey. Journal of the American Medical Association, 279, 938-942. Balcazar, H., and Cobas, J.A. (1993). Overweight among Mexican-Americans and its relationship to life style behavioral risk factors. Journal of Community Health, 18, 55-67. Belcher, J.D., Ellison, R.C., Shepard, W.E., Bigelow, C., Webber, C.S., Wilmore, J.H., Parcel, G.S., Zucker, D.M., and Luepker, R.V. (1993). Lipid and lipoprotein distributions in children by ethnic group, gender, and geographic location: Preliminary findings of the Child and Adolescent Trial for Cardiovascular Health (CATCH). Preventive Medicine, 22, 143-153. Berenson, G.S., Srinivasan, S.R., Bao, W., Newman, W.P., III, Tracy, R.E., and Wattigney, W.A. (1998). Association between multiple cardiovascular risk factors and atherosclerosis in children and young adults. New England Journal of Medicine, 338, 1650-1656. Black, S.A., and Markides, K.S. (1993). Acculturation and alcohol consumption in Puerto Rican, Cuban-American, and Mexican-American women in the United States. American Journal of Public Health, 83, 890-893. The Bogalusa Heart Study 20th Anniversary Symposium. (1995). American Journal of the Medical Sciences, 310, S1-S138. Braveman, P., Cubbin, C., Marchi, K., Egerter, S., and Chavez, G. (2001). Measuring socioeconomic status/position in studies of racial/ethnic disparities: Maternal and infant health. Public Health Reports, 116, 449-463. Burke, G.L., Savage, P.J., Manolio, T.A., Sprafka, J.M., Wagenknecht, L.E., Sidney, S., Perkins, L.L., Liu, K., and Jacobs, D.R., Jr. (1992). Correlates of obesity in young black and white women: The CARDIA Study. American Journal of Public Health, 82, 1621-1625. Conference of Socioeconomic Status and Cardiovascular Health and Disease. (1995). Report of the Conference of Socioeconomic Status and Cardiovascular Health and Disease, November 6-7, 1995. Washington, DC: National Heart, Lung, and Blood Institute. Cooper, R., Cutler, J., Desvigne-Nickens, P., Fortmann, S.P., Friedman, L., Havlik, R., Hogelin, G., Marler, J., McGovern, P., Morosco, G., Mosca, L., Pearson, T., Stamler, J., Stryer, D., and Thom, T. (2000). Trends and disparities in coronary heart disease, stroke, and other cardiovascular diseases in the United States. Findings of the National Conference on Cardiovascular Disease Prevention. Circulation, 102, 3137-3147. Corti, M.C., Guralnik, J.M., Ferrucci, L., Izmirlian, G., Leveille, S.G., Pahor, M., Cohen, H.J., Pieper, C., and Havlik, R.J. (1999). Evidence for a black-white crossover in all-cause and coronary heart disease mortality in an older population: The North Carolina EPESE. American Journal of Public Health, 89, 308-314. Cubbin, C., Hadden, W.C., and Winkleby, M.A. (2001). Neighborhood context and cardiovascular disease risk factors: The contribution of material deprivation. Ethnicity and Disease, 11, 687-700.

OCR for page 450
Critical Perspectives on Racial and Ethnic Differences in Health in Late Life Davis, R.M. (1987). Current trends in cigarette advertising and marketing. New England Journal of Medicine, 316, 725-732. Diehl, A.K., and Stern, M.P. (1989). Special health problems of Mexican Americans: Obesity, gallbladder disease, diabetes mellitus, and cardiovascular disease. Advances in Internal Medicine, 34, 79-96. Diez-Roux, A.V. (1998). Bringing context back into epidemiology: Variables and fallacies in multi-level analysis. American Journal of Public Health, 88, 216-222. Diez-Roux, A.V., Nieto, F.J., Muntaner, C., Tyroler, H.A., Comstock, G.W., Shahar, E., Cooper, L.S., Watson, R.L., and Szklo, M. (1997). Neighborhood environments and coronary heart disease: A multilevel analysis. American Journal of Epidemiology, 146, 48-63. Diez-Roux, A.V., Nieto, F.J., Caulfield, L., Tyroler, H.A., Watson, R.L., and Szklo, M. (1999). Neighbourhood differences in diet: The Atherosclerosis Risk in Communities (ARIC) Study. Journal of Epidemiology and Community Health, 53, 55-63. Diez-Roux, A.V., Merkin, S.S., Arnett, D., Chambless, L., Massing, M., Nieto, F.J., Sorlie, P., Szklo, M., Tyroler, H.A., and Watson, R.L. (2001). Neighborhood of residence and incidence of coronary heart disease. New England Journal of Medicine, 345, 99-106. DiPietro, L., Williamson, D.F., Caspersen, C.J., and Eaker, E. (1993). The descriptive epidemiology of selected physical activities and body weight among adults trying to lose weight: The Behavioral Risk Factor Surveillance System survey, 1989. International Journal of Obesity and Related Metabolic Disorders, 17, 69-76. Duelberg, S.I. (1992). Preventive health behavior among black and white women in urban and rural areas. Social Science and Medicine, 34, 191-198. Duncan, C., Jones, K., and Moon, G. (1996). Health-related behaviour in context: A multilevel modelling approach. Social Science and Medicine, 42, 817-830. Dwyer, J.T., Stone, E.J., Yang, M., Feldman, H., Webber, L.S., Must, A., Perry, C.L., Nader, P.R., and Parcel, G.S. (1998). Predictors of overweight and overfatness in a multiethnic pediatric population. Child and Adolescent Trial for Cardiovascular Health Collaborative Research Group. American Journal of Clinical Nutrition, 67, 602-610. Elder, J.P., Castro, F.G., de Moor, C., Mayer, J., Candelaria, J.I., Campbell, N., Talavera, G., and Ware, L.M. (1991). Differences in cancer-risk-related behaviors in Latino and Anglo adults. Preventive Medicine, 20, 751-763. Ellaway, A., Anderson, A., and Macintyre, S. (1997). Does area of residence affect body size and shape? International Journal of Obesity and Related Metabolic Disorders, 21, 304-308. Eller, T.J. (1994). Household wealth and asset ownership: 1991 (Current Population Reports No. P70-34. Washington, DC: U.S. Bureau of the Census. Elo, I.T., and Preston, S.H. (1997). Racial and ethnic differences in mortality at older ages. In L.G. Martin and B.J. Soldo (Eds.), Racial and ethnic differences in the health of older Americans (pp. 10-42). Committee on Population, Commission on Behavioral and Social Sciences and Education, National Research Council. Washington, DC: National Academy Press. Englander, T.J. (1986). Cigarette makers shift and strategies. United States Tobacco and Candy Journal, 213, 1-46. Ernster, V. (1991). How tobacco companies target women. World Smoking and Health, 16, 8-11. Espino, D.V., Burge, S.K., and Moreno, C.A. (1991). The prevalence of selected chronic diseases among the Mexican-American elderly: Data from the 1982-1984 Hispanic Health and Nutrition Examination Survey. Journal of the American Board of Family Practice, 4, 217-222.

OCR for page 450
Critical Perspectives on Racial and Ethnic Differences in Health in Late Life Flegal, K.M., Carroll, M.D., Kuczmarski, R.J., and Johnson, C.L. (1998). Overweight and obesity in the United States: Prevalence and trends, 1960-1994. International Journal of Obesity and Related Metabolic Disorders, 22, 39-47. Folsom, A.R., Burke, G.L., Ballew, C., Jacobs, D.R., Jr., Haskell, W.L., Donahue, R.P., Liu, K.A., and Hilner, J.E. (1989). Relation of body fatness and its distribution to cardiovascular risk factors in young blacks and whites. The role of insulin. American Journal of Epidemiology, 130, 911-924. Folsom, A.R., Cook, T.C., Sprafka, J.M., Burke, G.L., Norsted, S.W., and Jacobs, D.R., Jr. (1991). Differences in leisure-time physical activity levels between blacks and whites in population-based samples: The Minnesota Heart Survey. Journal of Behavioral Medicine, 14, 1-9. Franzini, L., Ribble, J.C., and Keddie, A.M. (2001). Understanding the Hispanic paradox. Ethnicity and Disease, 11, 496-518. French, S.A., Story, M., and Jeffery, R.W. (2001). Environmental influences on eating and physical activity. Annual Review of Public Health, 22, 309-335. Geronimus, A.T. (1992). The weathering hypothesis and the health of African-American women and infants: Evidence and speculations. Ethnicity and Disease, 2, 207-221. Gidding, S.S., Liu, K., Bild, D.E., Flack, J., Gardin, J., Ruth, K.J., and Oberman, A. (1996). Prevalence and identification of abnormal lipoprotein levels in a biracial population aged 23 to 35 years: The CARDIA Study. American Journal of Cardiology, 78, 304-308. Goff, D.C., Nichaman, M.Z., Chan, W., Ramsey, D.J., Labarthe, D.R., and Ortiz, C. (1997). Greater incidence of hospitalized myocardial infarction among Mexican Americans than non-Hispanic whites: The Corpus Christi Heart Project 1988-1992. Circulation, 95, 1433-1440. Green, L.W., and Kreuter, M.W. (1991). Health promotion planning: An educational and environmental approach, (2nd ed.). Mountain View, CA: Mayfield. Gutierrez-Ramirez, A., Valdez, R.B., and Carter-Pokras, O. (1994). Cancer. In C.W. Molina and M. Aguirre-Molina (Eds.), Latino health in the U.S.: A growing challenge (pp. 211-246). Washington, DC: American Public Health Association. Haffner, S.M., Stern, M.P., Hazuda, H.P., Pugh, J.A., Patterson, J.K., and Malina, R. (1986). Upper body and centralized adiposity in Mexican-Americans and non-Hispanic whites: Relationship to body mass index and other behavioral and demographic variables. International Journal of Obesity, 10, 493-502. Hart, C., Ecob, R., and Smith, G.D. (1997). People, places and coronary heart disease risk factors: A multilevel analysis of the Scottish Heart Health Study archive. Social Science and Medicine, 45, 893-902. Haynes, S.G., Harvey, C., Montes, H., Nickens, H., and Cohen, B.H. (1990). Patterns of cigarette smoking among Hispanics in the United States: Results from HHANES 1982-84. American Journal of Public Health, 80(Suppl.), 47-53. Hazuda, H.P., Stern, M.P., and Haffner, S.M. (1988). Acculturation and assimilation among Mexican Americans: Scales and population-based data. Social Science Quarterly, 69, 687-706. Hewitt, M., Devesa, S., and Breen, N. (2002). Papanicolaou test use among reproductive-age women at high risk for cervical cancer: Analyses of the 1995 National Survey of Family Growth. American Journal of Public Health, 92, 666-669. Hollman, F. (1993). U.S. population estimates by age, sex, race, and Hispanic origin: 1980 to 1991 (Current Population Reports, Series P-25, No. 1095). Washington, DC: U.S. Bureau of the Census. Howard-Pitney, B., Winkleby, M.A., Albright, C.L., Bruce, B., and Fortmann, S.P. (1997). The Stanford Nutrition Action Program: A dietary fat intervention for low literate adults. American Journal of Public Health, 87, 1971-1976.

OCR for page 450
Critical Perspectives on Racial and Ethnic Differences in Health in Late Life Hunt, K.J., Resendez, R.G., Williams, K., Haffner, S.M., Stern, M.P., and Hazuda H.P. (2003). All-cause and cardiovascular mortality among Mexican-American and non-Hispanic white older participants in the San Antonio Heart Study—evidence against the “Hispanic paradox”. American Journal of Epidemiology, 158, 1048-1057. Institute of Medicine. (1991). Disability in America: Toward a national agenda for prevention. Washington, DC: National Academy Press. Jasso, G., Massey, D.S., Rosenzweig, M.R., and Smith, J.P. (2000). The New Immigrant Survey Pilot (NIS-P): Overview and new findings about U.S. legal immigrants at admission. Demography, 37, 127-138. Jeffery, R.W., Drewnowski, A., Epstein, L.H., Stunkard, A.J., Wilson, G.T., and Wing, R.R. (2000). Long-term maintenance of weight loss: Current status. Health Psychology, 19, 5-16. Jemal, A., Thomas, A., Murray, T., and Thun, M. (2002). Cancer statistics, 2002. A Cancer Journal for Clinicians, 52, 23-47. Jones, C.P. (2000). Levels of racism: a theoretic framework and a gardener’s tale. American Journal of Public Health, 90, 1212-1215. Kaplan, G.A., and Keil, J.E. (1993). Socioeconomic factors and cardiovascular disease: A review of the literature. Circulation, 88, 1973-1998. Kaufman, J.S., Cooper, R.S., and McGee, D.L. (1997). Socioeconomic status and health in blacks and whites: The problem of residual confounding and the resiliency of race. Epidemiology, 8, 621-628. Krieger, N. (1999). Embodying inequality: A review of concepts, measures, and methods for studying health consequences of discrimination. International Journal of Health Services, 29, 295-352. Krieger, N. (2001). A glossary for social epidemiology. Journal of Epidemiology and Community Health, 55, 693-700. Krieger, N., Williams, D.R., and Moss, N.E. (1997). Measuring social class in U.S. public health research: Concepts, methodologies, and guidelines. Annual Review of Public Health, 18, 341-378. Kuczmarski, R.J., Flegal, K.M., Campbell, S.M., and Johnson, C.L. (1994). Increasing prevalence of overweight among U.S. adults: The National Health and Nutrition Examination Surveys, 1960 to 1991. Journal of the American Medical Association, 272, 205-211. Kumanyika, S., Wilson, J.F., and Guilford-Davenport, M. (1993). Weight-related attitudes and behaviors of black women. Journal of the American Dietetic Association, 93, 416-422. Kumanyika, S.K. (1993). Special issues regarding obesity in minority populations. Annals of Internal Medicine, 119, 650-654. LeClere, F.B., Rogers, R.G., and Peters, K. (1998). Neighborhood social context and racial differences in women’s heart disease mortality. Journal of Health and Social Behavior, 39, 91-107. Lee, R.E., and Cubbin, C. (2002). Neighborhood context and youth cardiovascular health behaviors. American Journal of Public Health, 92, 428-436. Link, B.G., and Phelan, J. (1995). Social conditions as fundamental causes of disease. Journal of Health and Social Behavior, 35(Suppl.), 80-94. Lowry, R., Kann, L., Collins, J.L., and Kolbe, L.J. (1996). The effect of socioeconomic status on chronic disease risk behaviors among US adolescents. Journal of the American Medical Association, 276, 792-797. Lynch, J.W., Kaplan, G.A., Cohen, R.D., Tuomilehto, J., and Salonen, J.T. (1996). Do cardiovascular risk factors explain the relation between socioeconomic status, risk of all-cause mortality, and acute myocardial infarction? American Journal of Epidemiology, 144, 934-942.

OCR for page 450
Critical Perspectives on Racial and Ethnic Differences in Health in Late Life Lynch, J.W., Kaplan, G.A., and Shema, S.J. (1997). Cumulative impact of sustained economic hardship on physical, cognitive, psychological, and social functioning. New England Journal of Medicine, 337, 1889-1895. Macintyre, S., Maciver, S., and Sooman, A. (1993). Area, class and health: Should we be focusing on places or people? Journal of Society and Politics, 22, 213-234. Macintyre, S., Ellaway, A., and Cummins, S. (2002). Place effects on health: How can we conceptualise, operationalise, and measure them? Social Science and Medicine, 55, 125-139. Markides, K.S., and Coreil, J. (1986). The health of Hispanics in the southwestern United States: An epidemiologic paradox. Public Health Reports, 101, 253-265. Markides, K.S., Ray, L.A., Stroup-Benham, C.A., and Trevino, F. (1990). Acculturation and alcohol consumption in the Mexican American population of the southwestern United States: Findings from HHANES 1982-84. American Journal of Public Health, 80(Suppl.), 42-46. Marmot, M., and Elliot, P. (1992). Coronary heart disease epidemiology from aetiology to public health. New York: Oxford University Press. Martin, L.G., and Soldo, B.J. (1997). Racial and ethnic differences in the health of older Americans. Washington, DC: National Academy Press. McNutt, S.W., Hu, Y., Schreiber, G.B., Crawford, P.B., Obarzanek, E., and Mellin, L. (1997). A longitudinal study of the dietary practices of black and white girls 9 and 10 years old at enrollment: The NHLBI Growth and Health Study. Journal of Adolescent Health, 20, 27-37. Miller, B.A., Kolonel, L.N., Bernstein, L., Young Jr., J.L., Swanson, G.M., West, D.W., Key, C.R., Liff, J.M., Glover, C.S., Alexander, G.A., Coyle, L., Hankey, B.F., Gloeckler Ries, L.A., Kosary, C.L., Harras, A., Percy, C., and Edwards, B.K. (1996). Racial/ethnic patterns of cancer in the United States 1988-1992 (NIH Pub. No. 96-4104). Bethesda, MD: National Cancer Institute. Minkler, M. (1990). Improving health through community organization, In K. Glanz, F.M. Lewis, and B.K. Rimer (Eds.), Health behavior and health education: Theory, research and practice (pp. 257-287). San Francisco: Jossey-Bass. Mitchell, B.D., Stern, M.P., Haffner, S.M., Hazuda, H.P., and Patterson, J.K. (1990). Risk factors for cardiovascular mortality in Mexican Americans and non-Hispanic whites: The San Antonio Heart Study. American Journal of Epidemiology, 131, 423-433. Muntaner, C., Nieto, F.J., and O’Campo, P. (1996). The Bell Curve: On race, social class, and epidemiologic research. American Journal of Epidemiology, 144, 531-535. National Cancer Institute. (2001). SEER program public-use data tapes 1973-1998, August 2000 submission. Bethesda, MD: National Institutes of Health. National Center for Health Statistics. (1994a). National Health Interview Survey/Multiple Cause of Death Public Use Data 1986-1990. Diskette and documentation. Hyattsville, MD: Centers for Disease Control and Prevention. National Center for Health Statistics. (1994b). Plan and operation of the Third National Health and Nutrition Examination Survey, 1988-1994, series 1: Programs and collection procedures. Vital Health Statistics, 32, 1-407. National Heart, Lung, and Blood Institute. (1998). Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults: The evidence report (Rep. No. 98-4083). Bethesda, MD: National Institutes of Health. National Research Council (1997). Racial and ethnic differences in the health of older Americans. L.G. Martin and B.J. Soldo (Eds.), Committee on Population, Commission on Behavioral and Social Sciences and Education . Washington, DC: National Academy Press.

OCR for page 450
Critical Perspectives on Racial and Ethnic Differences in Health in Late Life Otten, M.W., Jr., Teutsch, S.M., Williamson, D.F., and Marks, J.S. (1990). The effect of known risk factors on the excess mortality of black adults in the United States. Journal of the American Medical Association, 263, 845-850. Padilla, A.M. (Ed.). (1980). Acculturation: Theory, models, and some new findings (AAAS Pub. No. SS(NS)-39 ed.). American Association for the Advancement of Science Boulder, CO: Westview Press. Pamuk, E., Makuc, D., Heck, K., Reuben, C., and Lochner, K. (1998). Socioeconomic status and health chartbook: Health, United States, 1998 (Rep. No. 71-641496). Hyattsville, MD: National Center for Health Statistics. Pappas, G., Queen, S., Hadden, W., and Fisher, G. (1993). The increasing disparity in mortality between socioeconomic groups in the United States, 1960 and 1986. New England Journal of Medicine, 329, 103-109. Pérez-Stable, E.J., Otero-Sabogal, R., Sabogal, F., McPhee, S.J., and Hiatt, R.A. (1994). Self-reported use of cancer screening tests among Latinos and Anglos in a prepaid health plan. Archives of Internal Medicine, 154, 1073-1081. Pi-Sunyer, F.X. (1993). Medical hazards of obesity. Annals of Internal Medicine, 119, 655-660. Pickett, K.E., and Pearl, M. (2001). Multilevel analyses of neighborhood socioeconomic context and health outcomes: A critical review. Journal of Epidemiology and Community Health, 55, 111-122. Pierce, J.P., Choi, W.S., Gilpin, E.A., Farkas, A.J., and Berry, C.C. (1998). Tobacco industry promotion of cigarettes and adolescent smoking. Journal of the American Medical Association, 279, 511-515. Ragland, K., Selvin, S., and Merrill, D. (1991). Black-white differences in stage-specific cancer survival: Analysis of seven selected sites. American Journal of Epidemiology, 133, 672-682. Rogers, R.G. (1991). Health-related lifestyles among Mexican Americans, Puerto Ricans, and Cubans in the United States. In I. Rapsenwaike (Ed.), Mortality of Hispanic patients (pp. 145-167). New York: Greenwood Press. Runciman, W.G. (Ed.). (1978). Weber: Selections in translation. Cambridge, England: Cambridge University Press. Shah, B.V., Barnwell, B.G., Hunt, P.N., Nileen, P., and LaVange, L.M. (1991). SUDAAN user’s manual, release 5.50. Research Triangle Park, NC: Research Triangle Institute. Singh, G.K., Kochanek, K.D., and McDonan, M.F. (1996). Advance report of final mortality statistics, 1994. Hyattsville, MD: National Center for Health Statistics. Smith, J.P., and Kington, R.S. (1997). Race, socioeconomic status, and health in late life. In L.G. Martin and B.J. Soldo (Eds.), Racial and ethnic differences in the health of older Americans (pp. 106-162). Committee on Population, Commission on Behavioral and Social Sciences and Education, National Research Council. Washington, DC: National Academy Press. Smith, G.D., Neaton, J.D., Wentworth, D., Stamler, R., and Stamler, J. (1996). Socioeconomic differentials in mortality risk among men screened for the Multiple Risk Factor Intervention Trial: I. White men. American Journal of Public Health, 86, 486-496. Smith, G.D., Hart, C., Watt, G., Hole, D., and Hawthorne, V. (1998). Individual social class, area-based deprivation, cardiovascular disease risk factors, and mortality: The Renfrew and Paisley Study. Journal of Epidemiology and Community Health, 52, 399-405. Sorlie, P.D., Backlund, E., Johnson, N.J., and Rogot, E. (1993). Mortality by Hispanic status in the United States. Journal of the American Medical Association, 270, 2464-2468. Srinivasan, S.R., Bao, W., Wattigney, W.A., and Berenson, G.S. (1996). Adolescent overweight is associated with adult overweight and related multiple cardiovascular risk factors: The Bogalusa Heart Study. Metabolism: Clinical and Experimental, 45, 235-240.

OCR for page 450
Critical Perspectives on Racial and Ethnic Differences in Health in Late Life Stephen, E.H., Foote, K., Hendershot, G.E., and Schoenborn, C.A. (1994). Health of the foreign-born population: United States, 1989-90. Advance data. Vital Health Statistics, 241, 1-12. Sundquist, J., and Winkleby, M.A. (1999). Cardiovascular risk factors in Mexican American adults: A transcultural analysis of NHANES III, 1988-1994. American Journal of Public Health, 89, 723-730. Sundquist, J., Malmstrom, M., and Johansson, S.E. (1999). Cardiovascular risk factors and the neighbourhood environment: A multilevel analysis. International Journal of Epidemiology, 28, 841-845. Sundquist, J., Winkleby, M.A., and Pudaric, S. (2001). Cardiovascular disease risk factors among older black, Mexican American, and white women and men: An analysis of NHANES III, 1988-1994. Journal of the American Geriatrics Society, 49, 109-116. Syme, S.L. (2004). Social determinants of health: The community as an empowered partner. Available: http://www.cdc.gov/pcd/issues/2004/jan/syme.htm. Tortolero, S.R., Goff, D.C., Jr., Nichaman, M.Z., Labarthe, D.R., Grunbaum, J.A., and Hanis, C.L. (1997). Cardiovascular risk factors in Mexican-American and non-Hispanic white children: The Corpus Christi Child Heart Study. Circulation, 96, 418-423. Tyroler, H.A., Wing, S., and Knowles, M.G. (1993). Increasing inequality in coronary heart disease mortality in relation to educational achievement: Profile of places of residence, United States, 1962 to 1987. Annals of Epidemiology, 3(Suppl.), S51-54. U.S. Census Bureau. (2001). Population Projections of the United States by Age, Sex, Race, Hispanic Origin, and Nativity: 1999 to 2100. Available: http://www.census.gov/population/projections/nation/detail/np-d1-a.txt [Accessed January 26, 2002]. U.S. Department of Health and Human Services. (2001). Women and smoking: Report of the Surgeon General. Washington, DC: National Center for Chronic Disease Prevention and Health Promotion. Vega, W.A., and Amaro, H. (1994). Latino outlook: Good health, uncertain prognosis. Annual Reviews in Public Health, 15, 39-67. Ventura, S.J., Peters, K.D., Martin, J.A., and Maurer, J.D. (1997). Births and deaths: United States, 1996. Monthly Vital Statistics Report, 46, 1-40. Villarejo, D., Lighthall, D., Williams, D., III, Souter, A., Mines, R., Bade, B., Samuels, S., and McCurdy, S. (2000). Suffering in silence: A report on the health of California’s agricultural workers. Davis, CA: California Institute for Rural Studies. Wallack, L., and Winkleby, M. (1987). Primary prevention: A new look at basic concepts. Social Science and Medicine, 25, 923-930. Wallerstein, N., and Bernstein, E. (1994). Introduction to community empowerment, participatory education, and health. Health Education Quarterly, 21, 141-148. Williams, D.R. (1996). Race/ethnicity and socioeconomic status: Measurement and methodological issues. International Journal of Health Services, 26, 483-505. Williams, D.R., and Collins, C. (1995). U.S. socioeconomic and racial differences in health: Patterns and explanations. Annual Review of Sociology, 21, 349-386. Winkleby, M.A., and Cubbin, C. (2003). Influence of individual and neighborhood socioeconomic status on mortality among Black, Mexican-American, and White women and men in the U.S. Journal of Epidemiology and Community Health, 57, 444-452. Winkleby, M.A., Fortmann, S.P., and Rockhill, B. (1993). Health-related risk factors in a sample of Hispanics and whites matched on sociodemographic characteristics: The Stanford Five-City Project. American Journal of Epidemiology, 137, 1365-1375. Winkleby, M.A., Schooler, C., Kraemer, H.C., Lin, J., and Fortmann, S.P. (1995). Hispanic versus white smoking patterns by sex and level of education. American Journal of Epidemiology, 142, 410-418.

OCR for page 450
Critical Perspectives on Racial and Ethnic Differences in Health in Late Life Winkleby, M.A., Kraemer, H.C., Ahn, D.K., and Varady, A.N. (1998). Ethnic and socioeconomic differences in cardiovascular disease risk factors: Findings for women from the Third National Health and Nutrition Examination Survey, 1988-1994. Journal of the American Medical Association, 280, 356-362. Winkleby, M.A., Cubbin, C., Ahn, D.K., and Kraemer, H.C. (1999a). Pathways by which SES and ethnicity influence cardiovascular disease risk factors. Annals of the New York Academy of Sciences , 896, 191-209. Winkleby, M.A., Robinson, T.N., Sundquist, J., and Kraemer, H.C. (1999b). Ethnic variation in cardiovascular risk factors among children and young adults: Findings from the Third National Health and Nutrition Examination Survey, 1988-1994. Journal of the American Medical Association, 281, 1006-1013. Winkleby, M.A., Feighery, E., Dunn, M., Kole, S., Ahn, D., Killen, J. (2004). Effects of an advocacy intervention to reduce smoking among teenagers. Archives of Pediatrics and Adolescent Medicine, 158, 269-275. Yen, I.H., and Kaplan, G.A. (1998). Poverty area residence and changes in physical activity level: Evidence from the Alameda County Study. American Journal of Public Health, 88, 1709-1712. Young, L.R., and Nestle, M. (2002). The contribution of expanding portion sizes to the U.S. obesity epidemic. American Journal of Public Health, 92, 246-249. Young, R.C. (2002). Cancer statistics, 2002: Progress or cause for concern? CA: A Cancer Journal for Clinicians, 52, 6-7.