Toward A Policy-Relevant Analysis Of Geographic And Racial/Ethnic Disparities In Child Health

Chronic psychological stress and racial disparities in body mass index change between Black and White girls aged 10-19

BACKGROUND

One of the largest health disparities in the USA is in obesity rates between Black and White females.

PURPOSE

The objective of this study was to test the hypothesis that the stress-obesity link is stronger in Black females than in White females aged 10-19.

METHODS

Multilevel modeling captured the dynamic of acute (1 month) and chronic (10 years) stress and body mass index (BMI; weight in kilograms divided by height in meters squared) change in the National Heart, Lung, and Blood Institute Growth and Health Study, which consists of 2,379 Black and White girls across a span of socioeconomic status. The girls were assessed longitudinally from ages 10 to 19.

RESULTS

Higher levels of stress during the 10 years predicted significantly greater increases in BMI over time compared to lower levels of stress. This relationship was significantly stronger for Black compared to White girls.

CONCLUSION

Psychological stress is a modifiable risk factor that may moderate early racial disparities in BMI.

Differential mental health effects of neighborhood relocation among youth in vulnerable families: results from a randomized trial

CONTEXT Extensive observational evidence indicates that youth in high-poverty neighborhoods exhibit poor mental health, although not all children may be affected similarly. OBJECTIVE To use experimental evidence to assess whether gender and family health problems modify the mental health effects of moving from high- to low-poverty neighborhoods. DESIGN Randomized controlled trial. SETTING Volunteer low-income families in public housing in 5 US cities between 1994-1997. PARTICIPANTS We analyze 4- to 7-year outcomes in youth aged 12 to 19 years (n = 2829, 89% effective response rate) in the Moving to Opportunity Study. INTERVENTION Families were randomized to remain in public housing (control group) or to receive government-funded rental subsidies to move into private apartments (experimental group). Intention-to-treat analyses included intervention interactions by gender and health vulnerability (defined as prerandomization health/developmental limitations or disabilities in family members). MAIN OUTCOME MEASURES Past-year psychological distress (Kessler 6 scale [K6]) and the Behavioral Problems Index (BPI). Supplemental analyses used past-year major depressive disorder (MDD). RESULTS Male gender (P = .02) and family health vulnerability (P = .002) significantly adversely modified the intervention effect on K6 scores; male gender (P = .01), but not health vulnerability (P = .17), significantly adversely modified the intervention effect on the BPI. Girls without baseline health vulnerabilities were the only subgroup to benefit on any outcome (K6: β = -0.21; 95% CI, -0.34 to -0.07; P = .003; MDD: odds ratio = 0.42; 95% CI, 0.20 to 0.85; P = .02). For boys with health vulnerabilities, intervention was associated with worse K6 (β = 0.26; 95% CI, 0.09 to 0.44; P = .003) and BPI (β = 0.24; 95% CI, 0.09 to 0.40; P = .002) values. Neither girls with health vulnerability nor boys without health vulnerability experienced intervention benefits. Adherence-adjusted instrumental variable analysis found intervention effects twice as large. Patterns were similar for MDD, but estimates were imprecise owing to low prevalence. CONCLUSIONS Although some girls benefited, boys and adolescents from families with baseline health problems did not experience mental health benefits from housing mobility policies and may need additional program supports.

Residential segregation and the health of African-American infants: does the effect vary by prevalence?

Segregation effects may vary between areas (e.g., counties) of low and high low birth weight (LBW; <2,500 g) and preterm birth (PTB; <37 weeks of gestation) rates due to interactions with area differences in risks and resources. We assess whether the effects of residential segregation on county-level LBW and PTB rates for African-American infants vary by the prevalence of these conditions. The study sample includes 368 counties of 100,000 or more residents and at least 50 African-American live births in 2000. Residentially segregated counties are identified alternatively by county-level dissimilarity and isolation indices. Quantile regression is used to assess how residential segregation affects the entire distributions of county-level LBW and PTB rates (i.e. by prevalence). Residential segregation increases LBW and PTB rates significantly in areas of low prevalence, but has no such effects for areas of high prevalence. As a sensitivity analysis, we use metropolitan statistical area level data and obtain similar results. Our findings suggest that residential segregation has adverse effects mainly in areas of low prevalence of LBW and preterm birth, which are expected overall to have fewer risk factors and more resources for infant health, but not in high prevalence areas, which are expected to have more risk factors and fewer resources. Residential policies aimed at area resource improvements may be more effective.

Racial/ethnic disparities in health and health care among U.S. adolescents

OBJECTIVE

To examine racial/ethnic disparities in medical and oral health status, access to care, and use of services in U.S. adolescents.

DATA SOURCE

Secondary data analysis of the 2003 National Survey of Children's Health. The survey focus was children 0-17 years old.

STUDY DESIGN

Bivariate and multivariable analyses were conducted for white, African American, Latino, Asian/Pacific Islander, American Indian/Alaskan Native, and multiracial adolescents 10-17 years old (n = 48,742) to identify disparities in 40 measures of health and health care.

PRINCIPAL FINDINGS

Certain disparities were especially marked for specific racial/ethnic groups and multiracial youth. These disparities included suboptimal health status and lack of a personal doctor or nurse for Latinos; suboptimal oral health and not receiving all needed medications in the past year for African Americans; no physician visit or mental health care in the past year for Asian/Pacific Islanders; overweight/obesity, uninsurance, problems getting specialty care, and no routine preventive visit in the past year for American Indian/Alaska Natives; and not receiving all needed dental care in multiracial youth.

CONCLUSIONS

U.S. adolescents experience many racial/ethnic disparities in health and health care. These findings indicate a need for ongoing identification and monitoring of and interventions for disparities for all five major racial/ethnic groups and multiracial adolescents.

Miles to go before we sleep: racial inequities in health

Large, pervasive, and persistent racial inequalities exist in the onset, courses, and outcomes of illness. A comprehensive understanding of the patterning of racial disparities indicates that racism in both its institutional and individual forms remains an important determinant. There is an urgent need to build the science base that would identify how to trigger the conditions that would facilitate needed societal change and to identify the optimal interventions that would confront and dismantle the societal conditions that create and sustain health inequalities.

Physical education policy compliance and children's physical fitness

BACKGROUND

Physical education policies have received increased attention as a means for improving physical activity levels, enhancing physical fitness, and contributing to childhood obesity prevention. Although compliance at the school and district levels is likely to be critical for the success of physical education policies, few published studies have focused on this issue.

PURPOSE

This study investigated whether school district-level compliance with California physical education policies was associated with physical fitness among 5th-grade public-school students in California.

METHODS

Cross-sectional data from FITNESSGRAM(®) 2004-2006, district-level compliance with state physical education requirements for 2004-2006, school- and district-level information, and 2000 U.S. Census data were combined to examine the association between district-level compliance with physical education policies and children's fitness levels. The analysis was completed in 2010.

RESULTS

Of the 55 districts with compliance data, 28 (50%) were in compliance with state physical education mandates; these districts represented 21% (216) of schools and 18% (n=16,571) of students in the overall study sample. Controlling for other student-, school-, and district-level characteristics, students in policy-compliant districts were more likely than students in noncompliant districts to meet or exceed physical fitness standards (AOR=1.29, 95% CI=1.03, 1.61).

CONCLUSIONS

Policy mandates for physical education in schools may contribute to improvements in children's fitness levels, but their success is likely to depend on mechanisms to ensure compliance.

Integrating multiple social statuses in health disparities research: the case of lung cancer

OBJECTIVE

To illustrate the complex patterns that emerge when race/ethnicity, socioeconomic status (SES), and gender are considered simultaneously in health care disparities research and to outline the needed research to understand them by using disparities in lung cancer risks, treatment, and outcomes as an example.

PRINCIPAL FINDINGS

SES, gender, and race/ethnicity are social categories that are robust predictors of variations in health and health services utilization. These are usually considered separately, but intersectionality theory indicates that the impact of each depends on the others. Each reflects historically and culturally contingent variations in social, economic, and political status. Distinct patterns of risk and resilience emerge at the intersections of multiple social categories and shape the experience of health, health care access, utilization, quality, and outcomes where these categories intersect. Intersectional approaches call for greater attention to understand social processes at multiple levels of society and require the collection of relevant data and utilization of appropriate analytic approaches to understand how multiple risk factors and resources combine to affect the distribution of disease and its management.

CONCLUSIONS

Understanding how race/ethnicity, gender, and SES are interactive, interdependent, and social identities can provide new knowledge to enhance our efforts to effectively address health disparities.

The Impact of Household Investments on Early Child Neurodevelopment and on Racial and Socioeconomic Developmental Gaps - Evidence from South America

This paper assesses the effects of household investments through child educating activities on child neurodevelopment between the ages of 3 and 24 months, and evaluates whether investments explain racial and socioeconomic developmental gaps in South America. Quantile regression is used to evaluate the heterogeneity in investment effects by unobserved developmental endowments. The study finds large positive investment effects on early child neurodevelopment, with generally larger effects among children with low developmental endowments (children at the left margin of the development distribution). Investments explain part of the observed racial gaps and the whole socioeconomic developmental gap. Investments may compensate for low endowments and policy interventions to increase investments may reduce early development gaps and result in high social and economic returns.

Preconceptional stress and racial disparities in preterm birth: an overview

OBJECTIVE

We reviewed the evidence for three theories of how preconceptional psychosocial stress could act as a contributing determinant of excess preterm birth risk among African American women: early life developmental plasticity and epigenetic programming of adult neuroendocrine systems; blunting, weathering, or dysfunction of neuroendocrine and immune function in response to chronic stress activation through the life course; individuals' adoption of risky behaviors such as smoking as a response to stressful stimuli.

METHODS

Basic science, clinical, and epidemiologic studies indexed in MEDLINE and Web of Science databases on preconceptional psychosocial stress, preterm birth and race were reviewed.

RESULTS

Mixed evidence leans towards modest associations between preconceptional chronic stress and preterm birth (for example common odds ratios of 1.2-1.4), particularly in African American women, but it is unclear whether this association is causal or explains a substantial portion of the Black-White racial disparity in preterm birth. The stress-preterm birth association may be mediated by hypothalamic-pituitary-adrenal axis dysfunction and susceptibility to bacterial vaginosis, although these mechanisms are incompletely understood. Evidence for the role of epigenetic or early life programming as a determinant of racial disparities in preterm birth risk is more circumstantial.

CONCLUSIONS

Preconceptional stress, directly or in interaction with host genetic susceptibility or infection, remains an important hypothesized risk factor for understanding and reducing racial disparities in preterm birth. Future studies that integrate adequately sized epidemiologic samples with measures of stress, infection, and gene expression, will advance our knowledge and allow development of targeted interventions.

Racial Diversity and Change in Metropolitan Neighborhoods

This study investigates the changing racial diversity and structure of metropolitan neighborhoods. We consider three alternative perspectives about localized racial change: that neighborhoods are bifurcating along a white/nonwhite color line, fragmenting into homogeneous enclaves, or integrating white, black, Latino, and Asian residents into diverse residential environments. To assess hypotheses drawn from these perspectives, we develop a hybrid methodology (incorporating the entropy index and majority-rule criteria) that offers advantages over previous typological efforts. Our analysis of 1990-2000 census tract data for the 100 largest U.S. metropolitan areas finds that most neighborhoods are becoming more diverse and that members of all groups have experienced increasing exposure to neighborhood diversity. However, white populations tend to diminish rapidly in the presence of multiple minority groups and there has been concomitant white growth in low-diversity neighborhoods. Latino population dynamics have emerged as a primary force driving neighborhood change in a multi-group context.

Access to health and health care: how race and ethnicity matter

Racial and ethnic disparities in health are multifactorial; they reflect differences in biological vulnerability to disease as well as differences in social resources, environmental factors, and health care interventions. Understanding and intervening in health inequity require an understanding of the disparate access to all of the personal resources and environmental conditions that are needed to generate and sustain health, a set of circumstances that constitute access to health. These include access to health information, participation in health promotion and disease prevention activities, safe housing, nutritious foods, convenient exercise spaces, freedom from ambient violence, adequate social support, communities with social capital, and access to quality health care. Access to health care is facilitated by health insurance, a regular source of care, and a usual primary care provider. Various mechanisms through which access to health and access to health care are mediated by race and ethnicity are discussed; these include the built environment, social environment, residential segregation, stress, racism, and discrimination. Empirical evidence supporting the association between these factors and health inequities is also reviewed.

The co-occurrence of obesity, elevated blood pressure, and acanthosis nigricans among American Indian school children: identifying individual heritage and environment-level correlates

OBJECTIVE

To estimate the prevalence and explore the social and cultural etiologic roots of weight status, blood pressure, and acanthosis nigricans among American Indian children on a reservation in South Dakota.

METHODS

This observational study was conducted in 26 schools from 1998 to 2002 and included 5,422 observations representing 3,841 children, ages 3 to 19. Trained staff measured height, weight, blood pressure, and assessed the presence of acanthosis nigricans (AN). Percent Indian heritage (PIH) was abstracted from tribal records. Sociodemographic environment (SDE) was calculated using the 2000 Census at the city/town level. Descriptive analyses were conducted using one measurement time point, including tests for trend and co-occurrence of risk factors using the [kappa] statistic. Hierarchical, multivariate logistic regression estimated associations with overweight/obesity status, accounting for multiple measures on individuals and SDE.

RESULTS

The overall prevalence of overweight/obesity was 46%, of hypertension 9%, and of AN 14%. The co-occurrence of risk factors was moderate to high. PIH and AN were positively associated in unadjusted analysis. Controlling for sex, age, and SDE, higher PIH was a significant correlate of overweight/obesity, although when hypertension (OR = 5.92, CI = 3.27-10.72), prehypertension (OR = 3.80, CI = 1.99-7.26), and AN (OR = 16.20, CI = 8.08-32.48) were included in the model PIH was no longer significant. SDE was not significantly associated with overweight/obesity.

CONCLUSION

PIH appeared to be an important correlate of overweight and obesity, except when adjusted for the co-occurrence of high blood pressure and AN. Overall, the prevalence and co-occurrence of various risk factors in this population was high. Obesity prevention initiatives targeting families and communities are needed, as well as access to screening and treatment services.

Environmental victims: environmental injustice issues that threaten the health of children living in poverty

Children living in poverty are disproportionately at risk from and affected by environmental hazards. According to the National Center for Children in Poverty, 13 million children in America live in poverty. Thus, not only are millions of children living in poverty but are also living in environments that are hazardous to their health. Impoverished children are more likely to live in environments with heavily polluting industries, hazardous waste sites, contaminated water and soil, in old housing with deteriorating lead-based paint, in areas with limited access to healthy food, and more. Poor children residing in these toxic environments are either at risk or suffer from a myriad of health disparities, such as asthma, cancer, lead poisoning, obesity, and hyperactivity. This unfortunate reality is better known as environmental injustice. Environmental injustice recognizes that economically disadvantaged groups are adversely affected by environmental hazards more than other groups. To remedy this dilemma, environmental justice seeks to address these unfair burdens of environmental health hazards on poor communities. The purpose of this article is to (a) examine the environmental living conditions of children living in poverty, (b) examine the environmental health disparities of children living in poverty, (c) discuss environmental justice legislation, (d) describe government initiatives to improve environmental health, and (e) propose recommendations that executes measures to protect the health of children.

Early life adversity and inflammation in African Americans and whites in the midlife in the United States survey

OBJECTIVES

To determine whether early life adversity (ELA) was predictive of inflammatory markers and to determine the consistency of these associations across racial groups.

METHODS

We analyzed data from 177 African Americans and 822 whites aged 35 to 86 years from two preliminary subsamples of the Midlife in the United States biomarker study. ELA was measured via retrospective self-report. We used multivariate linear regression models to examine the associations between ELA and C-reactive protein, interleukin-6, fibrinogen, endothelial leukocyte adhesion molecule-1, and soluble intercellular adhesion molecule-1, independent of age, gender, and medications. We extended race-stratified models to test three potential mechanisms for the observed associations.

RESULTS

Significant interactions between ELA and race were observed for all five biomarkers. Models stratified by race revealed that ELA predicted higher levels of log interleukin-6, fibrinogen, endothelial leukocyte adhesion molecule-1, and soluble intercellular adhesion molecule-1 among African Americans (p < .05), but not among whites. Some, but not all, of these associations were attenuated after adjustment for health behaviors and body mass index, adult stressors, and depressive symptoms.

CONCLUSIONS

ELA was predictive of high concentrations of inflammatory markers at midlife for African Americans, but not whites. This pattern may be explained by an accelerated course of age-related disease development for African Americans.

Is neighborhood racial/ethnic composition associated with depressive symptoms? The multi-ethnic study of atherosclerosis

The racial/ethnic composition of a neighborhood may be related to residents' depressive symptoms through differential levels of neighborhood social support and/or stressors. We used the Multi-Ethnic Study of Atherosclerosis to investigate cross-sectional associations of neighborhood racial/ethnic composition with the Center for Epidemiologic Studies-Depression (CES-D) scale in adults aged 45-84. The key exposure was a census-derived measure of the percentage of residents of the same racial/ethnic background in each participant's census tract. Two-level multilevel models were used to estimate associations of neighborhood racial/ethnic composition with CES-D scores after controlling for age, income, marital status, education and nativity. We found that living in a neighborhood with a higher percentage of residents of the same race/ethnicity was associated with increased CES-D scores in African American men (p < 0.05), and decreased CES-D scores in Hispanic men and women and Chinese women, although these differences were not statistically significant. Models were further adjusted for neighborhood-level covariates (social cohesion, safety, problems, aesthetic quality and socioeconomic factors) derived from survey responses and census data. Adjusting for other neighborhood characteristics strengthened protective associations amongst Hispanics, but did not change the significant associations in African American men. These results demonstrate heterogeneity in the associations of race/ethnic composition with mental health and the need for further exploration of which aspects of neighborhood environments may contribute to these associations.

Beyond individual neighborhoods: a geography of opportunity perspective for understanding racial/ethnic health disparities

There has been insufficient attention to how and why place and neighborhood context contribute to racial/ethnic health disparities, as well as to policies that can eliminate racial/ethnic health disparities. This article uses a geography of opportunity framework to highlight methodological issues specific for quantitative research examining neighborhoods and racial/ethnic health disparities, including study design, measurement, causation, interpretation, and implications for policy. We argue that failure to consider regional, racialized housing market processes given high US racial residential segregation may introduce bias, restrict generalizability, and/or limit the policy relevance of study findings. We conclude that policies must address the larger geography of opportunity within the region in addition to improving deprived neighborhoods.

Investigating health disparities and disproportionality in child maltreatment reporting: 2002-2006

OBJECTIVES

We examined health disparities and disproportionality in child protective services (CPS) reporting at a regional academic health center.

METHODS

We computed disproportionate representation and disparity indices from archived CPS reports for pediatric patients (N = 1,020) from 2002 to 2006.

RESULTS

Findings indicated that medical personnel reported African American and Hispanic pediatric patients to CPS (1) at higher rates than their representation in the general pediatric patient population and (2) at a rate approximately four times that of White pediatric patients. However, White pediatric patients were reported to CPS at lower rates than their general pediatric patient representation. Additional examination of socioeconomic factors demonstrated that pediatric patients from poor neighborhoods were reported to CPS (1) at higher rates than their numbers in the patient population and (2) five times more often than pediatric patients from prosperous neighborhoods.

CONCLUSIONS

We found significant racial/ethnic and socioeconomic disproportionality and disparities in medical personnel's CPS reporting practices. These findings augment the limited literature investigating disparities and disproportionality in medical personnel's CPS reporting practices. The inclusion of pediatric and general departments allows for increased generalizability of study results. However, more rigorous empirical examination is needed to identify the causal factors responsible for noted differences. Consequently, healthcare systems' collection and examination of patients' racial/ethnic data are imperative to effectively address the multifaceted, social welfare issues of health disparities and disproportionality.

Neighborhood-level risk and resilience factors: an emerging issue in childhood asthma epidemiology

Evaluation of: Gupta RS, Zhang X, Sharp LK, Shannon JJ, Weiss KB. The protective effect of community factors on childhood asthma. J. Allergy Clin. Immunol. 123(6), 1297-1304.e2 (2009). The recent increase in the prevalence of asthma in children is now recognized as the result of a complex interplay of genetic, sociodemographic and environmental factors. Multilevel models simultaneously account for neighborhood characteristics that may be related to childhood asthma, independently of individual-level attributes. Most research that focuses on the physical and social characteristics of neighborhoods to explain disparities in childhood asthma assess such factors as persistent poverty, residential racial segregation and environmental degradation. Researchers have only begun to test models that specifically focus on risk and protective factors at the community/neighborhood level in relation to asthma. Social capital, which measures norms of reciprocity, social ties between neighborhood residents and civic engagement has the potential to buffer the effects of neighborhood risk factors on childhood asthma. Further research, specifically longitudinal studies, needs to be carried out to determine whether findings on neighborhood-level risk and protective factors can guide the development of preventive interventions for childhood asthma.

Race, socioeconomic status, and health: complexities, ongoing challenges, and research opportunities

This paper provides an overview of racial variations in health and shows that differences in socioeconomic status (SES) across racial groups are a major contributor to racial disparities in health. However, race reflects multiple dimensions of social inequality and individual and household indicators of SES capture relevant but limited aspects of this phenomenon. Research is needed that will comprehensively characterize the critical pathogenic features of social environments and identify how they combine with each other to affect health over the life course. Migration history and status are also important predictors of health and research is needed that will enhance understanding of the complex ways in which race, SES, and immigrant status combine to affect health. Fully capturing the role of race in health also requires rigorous examination of the conditions under which medical care and genetic factors can contribute to racial and SES differences in health. The paper identifies research priorities in all of these areas.

Promoting Racial Equality, Parental Involvement, and Youth Engagement: An Interview With Dr. Gail Christopher

With each passing decade, the United States has become a more racially and ethnically diverse nation. Many consider children our world’s greatest resource. Addressing unequal health outcomes and educational achievement in children of different races and economic backgrounds is paramount. Dismal projections on the increased rates of obesity chronic disease and HIV/AIDS among adults may become a reality if more actions are not taken to help curb their current growing trends among youth, particularly youth of color. Health, education, and supportive and safe living environments are necessary to appropriately develop the world’s future adults and leaders. Greater efforts must be made to ensure that the world’s future leaders are a true racial and ethnic representation of the world they serve.

Contextual stress and health risk behaviors among African American adolescents

This study examined the longitudinal association between contextual stress and health risk behaviors and the role of protective factors in a community epidemiologically-defined sample of urban African American adolescents (N = 500; 46.4% female). Structural equation modeling was used to create a latent variable measuring contextual stress (community violence, neighborhood disorder, and experiences with racial discrimination). Contextual stress in 8th grade was associated with aggressive behavior and substance use 2 years later for boys. For girls, contextual stress predicted later substance use, but not aggressive behavior. High academic competence and self-worth reduced the impact of contextual stress on substance use for boys. Implications for intervention and directions for future research on health risk behaviors among African American adolescents are discussed.

Contextual stress and health risk behaviors among African American adolescents

This study examined the longitudinal association between contextual stress and health risk behaviors and the role of protective factors in a community epidemiologically-defined sample of urban African American adolescents (N = 500; 46.4% female). Structural equation modeling was used to create a latent variable measuring contextual stress (community violence, neighborhood disorder, and experiences with racial discrimination). Contextual stress in 8th grade was associated with aggressive behavior and substance use 2 years later for boys. For girls, contextual stress predicted later substance use, but not aggressive behavior. High academic competence and self-worth reduced the impact of contextual stress on substance use for boys. Implications for intervention and directions for future research on health risk behaviors among African American adolescents are discussed.

Regional differences in walking frequency and BMI: what role does the built environment play for Blacks and Whites?

Studies have found that urban sprawl explains many regional differences in BMI and walking behavior. Yet, African Americans, who often live in dense, urban neighborhoods with exemplar street connectivity, suffer disproportionately from obesity. This study analyzed walking and BMI among 1124 Whites and 691 Blacks in Los Angeles County and southern Louisiana in relation to neighborhood safety, street connectivity, and walking destinations. While the built environment partly explains regional differences in walking and BMI among Whites, the magnitude of effect was modest. There were no regional differences in outcomes for African Americans; individual rather than neighborhood characteristics served as the best predictors.

Health disparities in the Latino population

In this review, the authors provide an approach to the study of health disparities in the US Latino population and evaluate the evidence, using mortality rates for discrete medical conditions and the total US population as a standard for comparison. They examine the demographic structure of the Latino population and how nativity, age, income, and education are related to observed patterns of health and mortality. A key issue discussed is how to interpret the superior mortality indices of Latino immigrants and the subsequent declining health status of later generations. Explanations for differences in mortality include selection, reverse selection, death record inconsistencies, inequalities in health status, transnational migration, social marginality, and adaptation to environmental conditions in the United States. The utility of the public health social inequality framework and the status syndrome for explaining Latino disparities is discussed. The authors examine excess mortality from 8 causes: diabetes, stomach cancer, liver cancer, cervical cancer, human immunodeficiency virus/acquired immunodeficiency syndrome, liver disease, homicide, and work-related injuries. The impact of intergenerational changes in health behavior within the Latino population and the contributory role of suboptimal health care are interpreted in the context of implications for future research, public health programs, and policies.

Is segregation bad for your health?

For decades, racial residential segregation has been observed to vary with health outcomes for African Americans, although only recently has interest increased in the public health literature. Utilizing a systematic review of the health and social science literature, the authors consider the segregation-health association through the lens of 4 questions of interest to epidemiologists: How is segregation best measured? Is the segregation-health association socially or biologically plausible? What evidence is there of segregation-health associations? Is segregation a modifiable risk factor? Thirty-nine identified studies test an association between segregation and health outcomes. The health effects of segregation are relatively consistent, but complex. Isolation segregation is associated with poor pregnancy outcomes and increased mortality for blacks, but several studies report health-protective effects of living in clustered black neighborhoods net of social and economic isolation. The majority of reviewed studies are cross-sectional and use coarse measures of segregation. Future work should extend recent developments in measuring and conceptualizing segregation in a multilevel framework, build upon the findings and challenges in the neighborhood-effects literature, and utilize longitudinal data sources to illuminate opportunities for public health action to reduce racial disparities in disease.

The dynamics of income and neighborhood context for population health: do long-term measures of socioeconomic status explain more of the black/white health disparity than single-point-in-time measures?

Socioeconomic status, though a robust and strong predictor of health, has generally been unable to fully explain the health gap between blacks and whites in the United States. However, at both the individual and neighborhood levels, socioeconomic status is often treated as a static factor with only single-point-in-time measurements. These cross-sectional measures fail to account for possible heterogeneous histories within groups who may share similar characteristics at a given point in time. As such, ignoring the dynamic nature of socioeconomic status may lead to the underestimation of its importance in explaining health and racial health disparities. In this study, I use national longitudinal data to investigate the relationship between neighborhood poverty and respondent-rated health, focusing on whether the addition of a temporal dimension reveals a stronger relationship between neighborhood poverty and health, and a greater explanatory power for the health gap between blacks and whites. Results indicate that long-term neighborhood measures are stronger predictors of health outcomes and explain a greater amount of the black/white health gap than single-point measures.

State of childhood asthma and future directions conference: overview and commentary

The Merck Childhood Asthma Network, Inc conference titled "State of Childhood Asthma and Future Directions: Strategies for Implementing Best Practices" was held December 13 to 14, 2006. Here we summarize the presentations and recommendations for systems approaches from that conference and discuss current asthma care.

Role of the social milieu in health and wellness

Can "we" be modified? The impact of the social milieu on health and wellness is not a new concept. Before the invention of an effective pharmacopoeia, manipulation of the social environment was one of the few tools available to physicians. Modern medicine continues to focus on individual rather than community efforts at risk reduction. To understand health and wellness, we must look not only at bodies and illnesses but also at communities and social structure. This article discusses the impact of spirituality and religion, education, economics, and politics on health and wellness. The impact of these issues on health will drive system-level change in global health.

Discrimination and racial disparities in health: evidence and needed research

This paper provides a review and critique of empirical research on perceived discrimination and health. The patterns of racial disparities in health suggest that there are multiple ways by which racism can affect health. Perceived discrimination is one such pathway and the paper reviews the published research on discrimination and health that appeared in PubMed between 2005 and 2007. This recent research continues to document an inverse association between discrimination and health. This pattern is now evident in a wider range of contexts and for a broader array of outcomes. Advancing our understanding of the relationship between perceived discrimination and health will require more attention to situating discrimination within the context of other health-relevant aspects of racism, measuring it comprehensively and accurately, assessing its stressful dimensions, and identifying the mechanisms that link discrimination to health.

Discrimination and racial disparities in health: evidence and needed research

This paper provides a review and critique of empirical research on perceived discrimination and health. The patterns of racial disparities in health suggest that there are multiple ways by which racism can affect health. Perceived discrimination is one such pathway and the paper reviews the published research on discrimination and health that appeared in PubMed between 2005 and 2007. This recent research continues to document an inverse association between discrimination and health. This pattern is now evident in a wider range of contexts and for a broader array of outcomes. Advancing our understanding of the relationship between perceived discrimination and health will require more attention to situating discrimination within the context of other health-relevant aspects of racism, measuring it comprehensively and accurately, assessing its stressful dimensions, and identifying the mechanisms that link discrimination to health.

Linking equitability to quality: the development of a pediatric nursing e-quality measure

Over the past decade, many initiatives have been directed toward eliminating racial and ethnic disparities in healthcare. Despite these efforts, the 2007 National Healthcare Disparities Report revealed that overall disparities in healthcare quality and access have not decreased. Although the disparities described vary in magnitude by category and population, they were identified in almost every aspect of healthcare. Improving the quality of care may not reduce disparities; therefore, ensuring the collection of better patient reported race and ethnicity data, whereas linking it to clinical performance may be one of the first challenges to overcome. Eliminating disparities in healthcare is particularly important in the provision of pediatric care because children of immigrant families are the fastest growing sector of the pediatric population in the United States. This article describes an approach to the stratification of nursing-sensitive measures by race, ethnicity, and insurance group, which integrally links cultural competence to quality of care, identifies disparities in patient outcomes related to nursing care, and informs the development of tailored interventions to meet the needs of diverse patients and their families.

Challenges to using a business case for addressing health disparities

The authors consider the challenges to quantifying both the business case and the social case for addressing disparities, which is central to achieving equity in the U.S. health care system. They describe the practical and methodological challenges faced by health plans exploring the business and social cases for undertaking disparity-reducing interventions. Despite these challenges, sound business and quality improvement principles can guide health care organizations seeking to reduce disparities. Place-based interventions may help focus resources and engage health care and community partners who can share in the costs of-and gains from-such efforts.

Invited commentary: residential segregation and health--the complexity of modeling separate social contexts

When researching racial disparities in health, residential segregation cannot be ignored. Because of segregation, contextual differences by race are so pronounced that ignoring them may lead to mis-estimating the effect of individual-level factors. However, given the stark racial separation of social contexts, researching how residential segregation and neighborhood inequality contribute to racial health disparities remains methodologically challenging. Estimating the contribution of neighborhood effects to health disparities would require overlap in the racial distributions of neighborhood environment, for example, in the distributions of neighborhood poverty. Because of segregation, though, the extent of such overlap is extremely restricted. Previous analyses of the 2000 US Census found, on average, only a 24% overlap between the distribution of neighborhood poverty for black children and that for white children in metropolitan areas. Propensity score methods may be 1 useful tool for addressing limited overlap or exchangeability. However, as shown by their application to the segregation and health relation, their use should be informed by a sound conceptualization of the scale of the social exposure of interest, the hypothesized pathways between the exposure and the health outcome, and possible unmeasured confounders.

Discrimination and racial disparities in health: evidence and needed research

This paper provides a review and critique of empirical research on perceived discrimination and health. The patterns of racial disparities in health suggest that there are multiple ways by which racism can affect health. Perceived discrimination is one such pathway and the paper reviews the published research on discrimination and health that appeared in PubMed between 2005 and 2007. This recent research continues to document an inverse association between discrimination and health. This pattern is now evident in a wider range of contexts and for a broader array of outcomes. Advancing our understanding of the relationship between perceived discrimination and health will require more attention to situating discrimination within the context of other health-relevant aspects of racism, measuring it comprehensively and accurately, assessing its stressful dimensions, and identifying the mechanisms that link discrimination to health.

Place matters: variation in the black/white very preterm birth rate across U.S. metropolitan areas, 2002-2004

OBJECTIVE

We reported on the distribution of very preterm (VPT) birth rates by race across metropolitan statistical areas (MSAs).

METHODS

Rates of singleton VPT birth for non-Hispanic white, non-Hispanic black, and Hispanic women were calculated with National Center for Health Statistics 2002-2004 natality files for infants in 168 MSAs. Subanalysis included stratification by parity, age, smoking, maternal education, metropolitan size, region, proportion of MSA that was black, proportion of black population living below the poverty line, and indices of residential segregation.

RESULTS

The mean metropolitan-level VPT birth rate was 12.3, 34.8, and 15.7 per 1,000 live births for white, black, and Hispanic women, respectively. There was virtually no overlap in the white and black distributions. The variation in mean risk across cities was three times greater for black women compared with white women. The threefold disparity in mean rate, and two- to threefold increased variation as indicated by standard deviation, was maintained in all subanalyses.

CONCLUSION

Compared with white women, black women have three times the mean VPT birth risk, as well as three times the variance in city-level rates. The racial disparity in VPT birth rates was composed of characteristics that were constant across MSAs, as well as factors that varied by MSA. The increased sensitivity to place for black women was unexplained by measured maternal and metropolitan factors. Understanding determinants of differences in both the mean risk and the variation of risk among black and white women may contribute to reducing the disparity in risk between races.

Neighborhood socioeconomic status and fruit and vegetable intake among whites, blacks, and Mexican Americans in the United States

BACKGROUND

Socioeconomic and racial-ethnic disparities in health status across the United States are large and persistent. Obesity rates are rising faster in black and Hispanic populations than in white populations, and they foreshadow even greater disparities in chronic illnesses such as diabetes and cardiovascular disease in years to come. Factors that influence dietary intake of fruit and vegetables in these populations are only partly understood.

OBJECTIVES

We examined associations between fruit and vegetable intake and neighborhood socioeconomic status (SES), analyzed whether neighborhood SES explains racial differences in intake, and explored the extent to which neighborhood SES has differential effects by race-ethnicity of US adults.

DESIGN

Using geocoded residential addresses from the Third National Health and Nutrition Examination Survey, we merged individual-level data with county and census tract-level US Census data. We estimated 3-level hierarchical models predicting fruit and vegetable intake with individual characteristics and an index of neighborhood SES as explanatory variables.

RESULTS

Neighborhood SES was positively associated with fruit and vegetable intake: a 1-SD increase in the neighborhood SES index was associated with consumption of nearly 2 additional servings of fruit and vegetables per week. Neighborhood SES explained some of the black-white disparity in fruit and vegetable intake and was differentially associated with fruit and vegetable intake among whites, blacks, and Mexican Americans.

CONCLUSIONS

The positive association of neighborhood SES with fruit and vegetable intake is one important pathway through which the social environment of neighborhoods affects population health and nutrition for whites, blacks, and Hispanics in the United States.