1. Ethnicity & Health: Evidence, Issues & Models Hector F. Myers, Ph.D. Professor Department of Psychology, UCLA

2. Outline Summary of Evidence of Ethnic Health Disparities. Why the Differences? Proposed Conceptual Model of Risk. Methodological Challenges. Future Directions.

3. Challenge - Limitations in available data Limited data for the 5 major ethnic groups for the major health/disease categories Limited data on ethnic sub-groups. Available data suggest substantial diversity in health status within each ethnic group Therefore, impressions of overall health differences between groups may underestimate within-group differences. Inadequate & inconsistent consideration of SES x Ethnicity interaction.

4. WHAT DO WE KNOW ABOUT ETHNIC HEALTH DISPARITIES? Cardiovascular Disease Cancer Other Chronic Diseases Birth Outcomes HIV/AIDS Self-Rated Overall Health

5. Ethnic differences in excess deaths (< age 70) Africa Americans = 42.3% Native Americans = 25% Hispanics/Latinos = 14% No excess deaths among Asian/Pacific Islanders However, Native Hawaiians & South East Asian refugees have rates comparable to Hispanics.

6. Heart Disease Mortality by Race & Sex Men Women Non-Hispanic Whites 329.5 218.1 Blacks 398.9 290.5 American Indians 211.7 138.3 Asian/Pacific Islanders 196.7 121.5 Hispanics 212.7 146.5

7. Percent Population with CVD Risk Factors Whites Blacks Hispanics M W M W M W % HBP 25.6 19.7 36.5 36.4 25.9 22.3 % Diabetes 5.4 4.7 7.6 9.5 8.1 11.4 % High Chol 18.7 20.7 16.4 19.9 18.7 17.7 % Obese 20.7 23.3 21.3 39.1 24.4 36.1 % Exercise 31.7 25.8 24.3 17.8 26.1 16.7 Source: Health, United States, 2001

8. Cancer (% by type, U.S., 2004) Cancer Breast Cervical Prostate White 7.5 1.3 1.1 1.9 Black 4.2 0.8 0.6 2.5 Am. Indian 8.0 ---- ---- --- Asian 2.8 0.9 ---- ---- Pac. Isl. 8.1 ---- ---- ---- Hispanic 3.6 0.6 0.7 2.1 Source: National Health Interview Survey, 2004

9. Other Chronic Diseases (%, U.S., 2004) Diabetes Ulcers Kidney Liver White 6.5 7.1 1.6 1.3 Black 11.2 5.7 2.3 1.4 Am. Indian 15.8 9.6 2.9 ---- Asian 7.5 3.8 1.7 1.2* Pac. Isl. 20.9 ---- ---- ---- Hispanic 10.4 5.8 3.0 1.9 Source: National Health Interview Survey, 2004

10. Disparities in Birth Outcomes (Percent live births, 2003) Low birthweight (< 2,500 grams) White 6.94 Black 13.37 Am. Indian 7.37 Asian/Pac Isl. 7.78 Latino 6.69 Source: Health, United States, 2005

11. Birth Outcomes….Cont…. Very Low Birthweight (<1,500 grams) White1.17 Black3.07 Am. Indian1.30 Asian/Pac Isl.1.09 Latino1.16 Source: Health, United States, 2005

12. Percent of those with HIV by Ethnicity (CDC, 2001) African Americans 49% Whites 31% Latino 19% API/ AI < 1% ea.

13. AIDS Rates by Ethnicity & Gender (per 100,000) MenWomen Whites 14 2 Blacks 109 48 Hispanics 43 13 Asian/PI 9 1 Nat. Ame. 19 5

14. Self-Rated Overall Health (%, U.S., 2004) Excellent/ Fair/ Very Good Good Poor White 63.2 25.5 11.4 Black 52.7 28.2 19.2 Am. Indian 44.1 33.0 22.9 Asian 63.6 27.7 8.7 Pac. Isl. 42.6 38.3 19.1 Hispanic 53.4 29.6 17.0 Source: National Health Interview Survey, 2004

15. Reasons for health disparities Disproportionate representation among the poor. Chronic Stress Burden Burden of health compromising behaviors. Health care access, utilization & quality

16. PROPOSED INTEGRATIVE EXPLANATORY MODEL

18. Social Status Factors  Race/Ethnicity.  Socio-economic status & social mobility.  Gender.  Age.

19. Debate over Race vs. Ethnicity Despite obvious phenotypic differences between groups, “racial groups” are social constructions and not distinct genetic groups. However, there are measurable differences in the distribution of gene mutations that have implications for health. “Ethnicity”, which includes consideration of cultural differences and lived experiences, is the more accurate descriptor.

21. Chronic Stress Burden Generic Life Stresses. Social Status-Related Stresses Racism/discrimination Intra-group biases/prejudices Gender-related stresses Poverty-related stresses Expectations related to higher social status (See Myers et al., 2003 for review)

22. Effects of Exposure to Racism & Discrimination Higher CV reactivity to discrimnation in laboratory studies (See Anderson, McNeilly & Myers, 1991; Harrell et al, 2003; Clark et al, 1999). Ambulatory studies show that exposure to discrimination is common, affect future appraisal of experiences, associated with greater CV reactivity, and no evidence of physiologic adaptation (See Brondolo et al., 2003, 2005). Evidence from the SWAN Heart Study found more coronary artery calcification in African American women exposed to chronic “everyday discrimination”, but not in Caucasian women (Lewis et al., in press).

23. Chronic Stress Burden …Cont… Social Status Stresses:  Poverty-related stresses  Acculturative stresses  Gender-related stresses  Intra-group biases/prejudices  Expectations related to higher social status

25. Psychosocial Processes Health compromising behaviors Perceived control & self-efficacy (e.g. health locus of control). Coping style & resources. Socio-ecological risk & resources (e.g. noise, pollution, violence). Health care access & utilization.

26. Health Compromising Behaviors %Current %Current %Overweight/ % Never Smokers Drinkers Obese Exercize White 21.2 49.7 58.6 60.3 Black19.6 33.0 68.5 69.6 Am. Ind. 28.8 35.2 66.1 72.2 Asian 11.2 31.9 34.9 65.3 Pac. Isl. 30.2 36.6 68.5 64.9 Hispanic 14.1 36.1 67.0 72.0 Source: National Health Interview Survey, 2004

28. BIOLOGICAL RISKS & RESISTANCES Genetic & acquired risks & resistances. Culturally-mediated risks & resistances. Socio-ecologically mediated risks. Biological mechanisms – e.g. allostatic load.

29. Allostatic Load as biological pathway of cumulative risk (McEwen, 1998) Allostatic Load – wear and tear on the system from prolonged exposure over time to stress hormones. Frequent stress exposure. Inadequate habituation. Inability to recover. Inadequate response due to system fatigue.

30. Cumulative Vulnerability Hypothesis Lifespan perspective would allow us to assess the relative balance between risk and resources over time as predictor of health outcomes. The Cumulative vulnerability hypothesis (e.g. Geronimus’ “weathering” hypothesis of Black women’s health).

32. Methodological Challenges & Future Directions Increase sample size, representativeness & diversity (e.g. including multiple ethnic groups, higher SES) More sophisticated assessment of SES & its interaction with ethnicity to identify their joint effects on health More comprehensive assessment of life stresses, including discrimination

33. Future Directions… Cont… Careful exploration of ethnic differences in psychosocial moderators & mediators Exploration of group differences in resistance resources Comprehensive longitudinal studies of cumulative vulnerability (e.g. childhood obesity)