1. Racial/Ethnic and Gender Disparities in Health Outcomes of Persons with Spinal Cord Injury James S. Krause, PhD Karla Reed, MA (8-15-08) Jennifer Coker, MPH Randy Smith, MA © 2008 Medical University of South Carolina A Webcast Sponsored by the NCDDR July 30, 2008 - 3:00 PM EDT National Center for the Dissemination of Disability Research National Center for the Dissemination of Disability Research Funded by NIDRR, US Department of Education, PR# H133A060028

2. Funding This research was supported by the following field-initiated grants from NIDRR of OSERS of the US DOE – #H133G020218 – #H133G030151 – #H133G20200-93 – #H133G050165 Support from NIH – # 1R01 NS 48117-01 A Support from the Model Spinal Cord Injury Systems Grant – #H133N000005 Data were collected at: – Shepherd Center, Atlanta, GA; – Craig Hospital, Englewood, CO; and – Rancho Los Amigo National Rehabilitation Center, Downey, CA. – Model Spinal Cord Injury Systems 2

3. Nature of Spinal Cord Injury Annual incidence in the United States is about 40 cases per million. Permanent sensory and motor loss Associated with early mortality May adversely affect function and may significantly affect quality of life. Majority of individuals with SCI are Caucasian (63%). Studies of racial-ethnic minorities with SCI are rare. Existing studies have primarily focused on African- Americans with SCI. 3

4. Purpose The purpose of this presentation is to: Describe multiple studies we have conducted related to outcomes after SCI Highlight comparisons as a function of race- ethnicity and gender Discuss the practical implications of these findings for underrepresented populations Discuss needs for future research. 4

5. Sources of Data 1.Model spinal cord injury systems 2.Minnesota/Georgia Aging study 3.Shepherd Health study 4.Collaborative study of gender, race, aging 5

6. Format of Presentation Based on topic rather than data source/study 1.Participation (employment) 2.Subjective well-being/Depression 3.Health 4.Cross-cutting 6

7. Participation (Employment) 7

8. Overview of Employment Racial-ethnic minorities, with a possible exception of Asian Americans, have consistently reported lower employment rates than Caucasians. Data to be discussed – Model Systems (MSCIS) – 30 year Aging – Earnings 8

9. Model Systems Study Krause, J. S., Kewman, D., DeVivo, M. J., Maynard, F., Coker, J. L., Roach, M. J., & Ducharme, S. (1999). Employment after spinal cord injury: An analysis of cases from the model spinal cord injury systems. Archives of Physical Medicine and Rehabilitation, 80, 1492-1500. 9

10. Model SCI Systems Federally funded centers of excellence in care and research in SCI Currently 14 centers All contribute data to the National Spinal Cord Injury Statistical Center (NSCISC) at the University of Alabama Birmingham We have analyzed some data from the NSCISC as related to minorities. 10

11. Percentage Employed as a Function of Gender and Race-Ethnicity 11

12. Race-Ethnicity and Current Employment SCI Model Systems Data Gender Caucasian (n = 2072) African American (n = 596) Hispanic (n = 231) Other Minority (n = 75) Male (n = 2396) 36.3 (n = 1627) 7.3 (n = 520) 12.9 (n = 194) 17.6 (n =51) Female (n = 587) 28.3 (n = 447) 11.7 (n = 77) 8.1 (n = 37) 12.5 (n = 24) The n values in parentheses are total of number of cases that fell within the cell, not the number of cases working in that cell (i.e., for Caucasian males, there are 1,627 cases of which 36.3% are working). 12

13. Percentage Employed as a Function of Years of Education and Injury Severity 13

14. Minnesota-Georgia Studies As related to Employment/Earnings 14

15. Minnesota/Georgia Aging Study 35-year longitudinal study Started in Minnesota with 3 preliminary samples drawn in 1974, 1985, and 1993 Southeastern samples from the Shepherd Center in Atlanta, GA were added in 1993 and 2002 to increase racial-ethnic diversity (21.8% were minority, 19.1% African-American). A total of 2,208 participated over the years All participants were adults with traumatic onset SCI of at least one year duration 15

16. Racial Breakdown for Minnesota- Georgia Study 16

17. Study 1 - Earnings Two stage model: Part 1 – Predictors of employment status Part 2 – Predictors of conditional earnings Combined – Predictors of unconditional earnings Conditional earnings = Earnings among those employed Unconditional earnings = Earnings of all people, with those who are unemployed - 0 – earnings Krause, J.S., & Terza, J.V. (2006) Injury and demographic factors predictive of disparities in earnings after spinal cord injury. Archives of Physical Medicine and Rehabilitation, 87(10), 1318-1326. 17

18. 2 Types of Predictors Attributable differences = factors that cannot be directly manipulated as a function of changes in policy (e.g. gender, race, age, injury severity) Policy factors = those factors that can become the focus of policy changes to affect change in outcomes (e.g. education) 18

19. Earnings – Study 1 Minnesota-Georgia: 25 year Part 1: Attributable Differences for Binary Variables using Probit Results VariableAttributable Differencet-statp-value Gender - Male0.105.32.00 Race – non African American0.228.96.00 Age at study (35-49y)-0.06-2.54.01 Age (≥ 50)-0.12-4.69.00 Years since injury (11-20)0.020.87.39 Years since injury (≥ 21)0.124.67.00 Severity – non Cervical0.116.05.00 Ambulatory0.218.04.00 Some education beyond high school (13-15y)0.125.90.00 College0.4018.69.00 19

20. Earnings – Study 1 Part 2: Attributable Differences for Binary Variables using Exponential Regression Results VariableAttributable Differencet-statp-value Gender - Male15,9465.40.00 Race – non African American19,4024.77.00 Age at study (35-49y)81091.89.06 Age (≥ 50)-421-0.08.93 Years since injury (11-20)-3824-0.94.35 Years since injury (≥ 21)4480.10.92 Severity – non Cervical5920.20.84 Ambulatory2960.07.94 Some education beyond high school (13-15y)73561.47.14 College35,9287.61.00 20

21. Study 1: Conditional Earnings 21

22. Earnings – Study 1 Part 3: Attributable Differences for Binary Variables using 2-Part Model Results VariableAttributable Differencet-statp-value Gender - Male12,2465.73.00 Race – non African American16,3927.59.00 Age at study (35-49y)16940.55.58 Age (≥ 50)-5660-1.70.09 Years since injury (11-20)-1202-0.41.68 Years since injury (≥ 21)56221.64.10 Severity – non Cervical50252.22.02 Ambulatory88232.58.01 Some education beyond high school (13-15y)97072.67.01 College37,8519.82.00 22

23. Unconditional Earnings 23

24. Study 2 - Earnings Similar methodology to Study 1 Uses 30-year follow-up data (Study 1 used 25-year follow-up data) Larger sample (Study 1 = 615; Study 2 = 1,296) Greater diversity of policy variables Krause, J.S., Terza, J.V., & Dismuke, C. (in press). Earnings among people with spinal cord injury. Archives of Physical Medicine and Rehabilitation, 89. 24

25. Earnings – Study 2 Minnesota-Georgia: 30 year Part 1: AD (for disparities variables) and PE (for policy variables) using Probit results. Disparities VariableAttributable Differencet-statp-value Gender - Male 0.093.79<0.01 Race - Caucasian 0.176.23<0.01 Age at the Study (35-49)0.010.240.81 Age (>50)-0.10-3.77<0.01 Severity – non Cervical0.062.610.01 Ambulatory0.113.81<0.01 Policy VariablePolicy Effectt-statp-value Some Education Beyond HS (13-15 years)0.186.21<0.01 College0.226.36<0.01 Working at injury-0.01-0.300.77 25

26. Earnings – Study 2 Part 2: AD and PE using Exponential Regression results Disparities VariableAttributable Differencet-stat p-value Gender - Male 110313.08<0.01 Race - Caucasian 126012.66 0.01 Age at the Study (35-49)57521.36 0.17 Age (>50)-7177-1.64 0.10 Severity – non Cervical58341.72 0.09 Ambulatory48291.13 0.26 Policy VariablePolicy Effectt-stat p-value Some Education Beyond HS (13-15 years) 62231.38 0.17 College218825.41<0.01 Working at injury-2987-0.66 0.51 Return to same job59231.01 0.31 Return to diff job, same company-1501-0.24 0.81 Number of Jobs since SCI16641.75 0.08 Total years worked since SCI8512.70 0.01 Percentage time since SCI Working13342.59<0.01 Employed by the government250363.17<0.01 Employed by private company149893.10<0.01 Employed by other161461.82 0.07 26

27. Study 2: Conditional Earnings 27

28. Earnings – Study 2 Part 3: AD and PE using Two-Part Model results Disparities VariableAttributable Differencet-stat p-value Gender - Male 66263.58<0.01 Race - Caucasian 92804.79<0.01 Age at the Study (35-49) 20260.94 0.35 Age (>50) -5738-2.76 0.01 Severity – non Cervical40802.19 0.03 Ambulatory 58232.36 0.02 Policy VariablePolicy Effectt-stat p-value Some Education Beyond HS (13-15 years) 83953.86<0.01 College158465.52<0.01 Working at injury-1244-0.53 0.59 Return to same job123953.13<0.01 Return to diff job, same company 64841.58 0.11 Number of Jobs since SCI 5163.02<0.01 Total years worked since SCI 2694.58<0.01 Percentage time since SCI Working 4174.37<0.01 Employed by the government 78085.37<0.01 Employed by private company 46325.29<0.01 Employed by other 50153.13<0.01 28

29. Study 2: Unconditional Earnings 29

30. Summary - Employment Studies Employment rates are lower among minorities. Although, men typically are more likely to be employed than women, the reverse trend is observed for African-Americans. Education is key to both return to employment and conditional earnings. The disparities in employment rates between men and women and between Caucasians and African-Americans are accentuated by further differences in earnings (i.e. women and minorities are not only less likely to work, when they do they make less money). Multiple policy variables are related to earnings. 30

31. References - Employment Studies 1.Krause, J.S. (1992). Employment after spinal cord injury. Archives of Physical Medicine and Rehabilitation, 73, 163 ‑ 169. 2.Krause, J. S. & Anson, C. A. (1996). Employment after spinal cord injury: Relationship to selected participant characteristics. Archives of Physical Medicine and Rehabilitation, 77, 737-743. 3.Krause, J. S., Sternberg, M., Maides, J., & Lottes, S. (1998). Employment after spinal cord injury: Differences related to geographic region, gender, and race. Archives of Physical Medicine and Rehabilitation, 79, 615-624. 4.Krause, J. S., Kewman, D., DeVivo, M. J., Maynard, F., Coker, J. L., Roach, M. J., & Ducharme, S. (1999). Employment after spinal cord injury: An analysis of cases from the model spinal cord injury systems. Archives of Physical Medicine and Rehabilitation, 80, 1492-1500. 5.Krause, J.S., & Terza, J.V. (2006) Injury and demographic factors predictive of disparities in earnings after spinal cord injury. Archives of Physical Medicine and Rehabilitation, 87(10), 1318-1326. 6.Krause, J.S., Terza, J.V., & Dismuke, C. (in press). Earnings among people with spinal cord injury. Archives of Physical Medicine and Rehabilitation, 89. 31

32. Subjective Well-being 32

33. Minnesota-Georgia Study (cont.) Definition: One of two components of quality of life. It reflects the individual’s subjective appraisal of her/his life, rather than their actual activity patterns (their satisfaction with finances, as opposed to how much they make). Krause, J. S. (1998). Dimensions of subjective well being after spinal cord injury: An empirical analysis by gender and race/ethnicity. Archives of Physical Medicine and Rehabilitation, 79, 900-909. Krause, J. S. (1998). Subjective well being after spinal cord injury: Relationship to gender, race/ethnicity, and chronologic age. Rehabilitation Psychology, 43, 282-296. 33

34. Subjective Well-being Scale Scores as a Function of Race ScaleCaucasianMinority Race Fdfs Satisfaction 49.9047.026.63**3, 443 Problems 50.4052.062.643, 498 Engagement 49.5548.750.483, 537 Negative Affect 51.0950.600.053, 571 Health Problems 50.5651.060.183, 570 Finances 50.3546.2525.72***3, 578 Career Opportunities 50.8344.9236.41***3, 475 Living Circumstances 49.9147.468.35**3, 576 Interpersonal Relations 50.0549.910.283, 543 **p <.01 ; ***p <.001 Note: Normative scale scores are T-scores with a mean of 50 and standard deviation of 10. 34

35. Subjective Well-being Scale as a Function of Race 35

36. Satisfaction Items with Largest Disparities and Those that Favor Minorities ItemCaucasianMinority Race Fdfs Items favoring Caucasians (most prominent) Employment2.783.5937.79***3, 490 Finances3.003.5221.37***3, 587 Job Opportunities3.103.5813.91***3, 547 Items favoring Minorities Sex life3.213.064.59*3, 554 Physical Appearance2.442.224.33*3, 583 * p <.05; *** p <.001 36

37. Satisfaction Items ItemCaucasianMinority Race Fdfs Living arrangements1.872.169.00**3, 589 Employment2.783.5937.79***3, 490 Finances3.003.5221.37***3, 587 Job Opportunities3.103.5813.91***3, 547 Social Life2.512.590.603, 584 General health2.412.551.073, 587 Family relationships1.932.134.87*3, 585 Recreational opportunities2.672.915.46*3, 574 Life opportunities2.602.853.583, 576 Emotional adjustment2.212.474.28*3, 581 Accomplishments2.412.571.653, 583 Relationships with friends1.922.093.86*3, 582 Activity level2.582.630.203, 580 How spend time2.61 0.003, 582 Availability of health care2.272.391.043, 587 Home life2.012.234.12*3, 586 Relationship status2.362.699.68**3, 576 Control over life2.492.420.503, 582 Sex life3.213.064.59*3, 554 Physical Appearance2.442.224.33*3, 583 *p <.05; **p<.01; ***p<.001 Note: Items highlighted in bold/green are NOT statistically significant. 37

38. Problems Items ItemCaucasianMinority Race Fdfs Items favoring Caucasians (most prominent) Income2.813.3518.78***3, 584 Transportation1.742.4637.24***3, 584 Adequate job2.313.0727.47***3, 562 Money2.826.4627.62***3, 550 Lack of job skills2.012.6623.74***3, 563 No chance to learn1.962.5220.81***3, 579 Items favoring Minorities Making friends1.831.595.46*3, 586 *p <.05; ***p<.001 38

39. Collaborative Study of Gender, Race, & Aging Participating institutions: Shepherd Center in Atlanta, GA; Rancho Los Amigos National Rehabilitation Center in Downey, CA; Craig Hospital in Englewood, CO; Santa Clara Valley Medical Center in San Jose, CA. Specifically designed to over sample racial-ethnic minorities and women. 39

40. Racial-Ethnic Breakdown for Collaborative Study: Time 1 40

41. Subjective Well-being Scales as a Function of Race-Ethnicity Caucasian African- American American Indian, Alaskan NativeHispanic Race F (df) MaleFemaleMaleFemaleMaleFemaleMaleFemale Engagement 53.0 (9.9) 52.1 (9.1) 52.9 (9.1) 50.1 (10.4) 49.4 (8.5) 50.9 (8.0) 47.9 (9.8) 49.3 (9.5) 3.606 (3, 455)* Negative Affect 47.8 (8.5) 48.8 (8.1) 47.5 (8.5) 50.6 (12.3) 52.4 (10.9) 51.2 (10.2) 49.0 (9.4) 52.0 (10.0) 2.641 (3, 458)* Health Problems 48.1 (8.5) 50.2 (8.3) 49.6 (8.5) 53.0 (10.3) 52.0 (9.7) 49.9 (9.5) 48.4 (9.3) 47.5 (11.3) 1.196 (3, 449) Finances 53.5 (10.8) 54.1 (9.7) 47.0 (10.0) 48.0 (10.2) 47.7 (9.0) 49.7 (10.5) 48.4 (8.4) 47.5 (6.7) 11.489 (3, 457)*** Career Opportunities 52.0 (10.3) 54.2 (8.4) 48.6 (9.3) 46.6 (10.3) 43.7 (10.0) 47.5 (8.4) 44.4 (7.7) 46.6 (8.1) 17.888 (3, 425)*** Living Circumstances 54.5 (7.7) 52.0 (8.7) 51.9 (9.8) 49.9 (9.7) 50.3 (8.4) 47.2 (10.3) 49.8 (9.1) 48.3 (8.8) 5.566 (3, 456)*** Interpersonal Relations 50.7 (9.9) 52.9 (9.2) 52.2 (9.5) 55.8 (9.1) 49.0 (10.0) 51.6 (8.4) 49.9 (9.1) 49.3 (9.7) 3.731 (3, 397)** *p<.05; **p<.01; ***p<.001 41

42. Scores on Finance Scale by Race- Ethnicity and Gender 42

43. Career Opportunities Scale Scores by Race-Ethnicity and Gender 43

44. Summary – Subjective Well-being From Minnesota-Georgia Largest differences are in areas related to employment, finances, and career opportunities Not all significant differences favor Caucasians Many areas of life and problems that are not related to race- ethnicity From Health Study The same basic pattern is observed for multiple racial-ethnic groups, with African Americans fairing no worse, and sometime better on these outcomes. Conclusion: Areas of dissatisfaction are consistent with the general population and disparities in opportunities. 44

45. References – Subjective Well-being 1.Krause, J. S. & Anson, C. A. (1997). Adjustment after spinal cord injury: Relationship to gender and race. Rehabilitation Psychology, 42(1), 31-46. 2.Krause, J. S. (1998). Community reintegration after SCI: Relationship to gender and race. Topics in Spinal Cord Injury Rehabilitation, 4, 31-41. 3.Krause, J. S. (1998). Dimensions of subjective well being after spinal cord injury: An empirical analysis by gender and race/ethnicity. Archives of Physical Medicine and Rehabilitation, 79, 900-909. 4.Krause, J. S. (1998). Subjective well being after spinal cord injury: Relationship to gender, race/ethnicity, and chronologic age. Rehabilitation Psychology, 43, 282-296. 5.Krause, J. S., Coker, J. L., Charlifue, S., & Whiteneck, G. G. (1999). Depression and subjective well being among 97 American Indians with spinal cord injury. Rehabilitation Psychology, 44, 354-372. 6.Krause, J. S., Broderick, L. E. & Broyles, J. (2004). Subjective Well-Being Among African- Americans with Spinal Cord Injury: An Exploratory Study Between Men and Women. Neurorehabilitation, 19, 81-89. 45

46. Depression Shepherd Health Study Krause, J. S., Kemp, B. J., & Coker, J. L. (2000). Depression after spinal cord injury: Relation to gender, ethnicity, aging, and socioeconomic indicators. Archives of Physical Medicine and Rehabilitation, 81, 1099-1109. 46

47. Shepherd Health Study Started in 1997 – 1998 N = 1391 Are currently performing a 10-year longitudinal follow-up Inclusion criteria are the same as MN-GA study (adults with traumatic onset SCI of at least one year duration) 25.2 % were minority, most of which were African American (22.2%) 47

48. Racial-Ethnic Breakdown for Health Study 48

49. Study Design: Mediational Model Hypothesis: African Americans would have a greater likelihood of a depressive disorder, but this would disappear after accounting for socioeconomic status (SES; education and income). Requirements for mediation: 1.Race must be significantly related to mediators (SES) and the depressive diagnosis. 2.Mediators (SES) must be related to the depressive diagnosis. 3.When accounting for mediators (SES), the relationship between race and the diagnosis must disappear. 49

50. Mediational model of depressive symptomatology Aging Factors Income Years of Education Gender Race/Ethnicity Depressive Symptomatology 50

51. 3 Stage Logistic Regression Analysis of Diagnosis of Clinically Significant Symptoms Stage 1 Odds Ratio Confidence Intervals Race/Sex Caucasian male Caucasian female Minority male Minority female -- 1.15 1.85*** 3.37*** -- 0.84, 1.55 1.35, 2.53 1.90, 5.99 ***p <.001 Key point: Race is related to the depressive diagnosis. 51

52. 3 Stage Logistic Regression Analysis of Diagnosis of Clinically Significant Symptoms Stage 2 __________________________________________________________ Odds RatioConfidence Intervals Race/Sex Caucasian male-- Caucasian female 1.310.96, 1.79 Minority male 1.54**1.12, 2.14 Minority female 3.02***1.66, 5.35 Years of education More than 16-- Less than 125.14***3.10, 8.58 122.32***1.46, 3.67 13-151.80*1.13, 2.89 161.640.98, 2.75 *p <.05; **p<.01; ***p<.001 Key point: After introducing years of education into the equation, race continues to be significantly related to the depressive disorder. 52

53. 3 Stage Logistic Regression Analysis of Diagnosis of Clinically Significant Symptoms Stage 3 Odds RatioConfidence Intervals Race/Sex Caucasian male-- Caucasian female1.290.94, 2.27 Minority male1.300.93, 1.82 Minority female 2.64**1.45, 4.86 Years of education More than 16-- Less than 12 3.28***1.90, 5.64 12 1.67*1.03, 2.69 13-151.460.90, 2.36 161.600.95, 2.66 Income $75,000 and higher-- Less than $15,000 2.84***1.70, 4.76 $15,000 - $24,9991.680.98, 2.86 $25,000-$49,999 1.70*1.02, 2.83 $50,000-$74,9991.060.59, 1.92 *p <.05; **p<.01; ***p<.001 Key point: After introducing income, race is no longer associated with a depressive diagnosis for men, although it is still significant for minority women. 53

54. Depression Comprehensive Study Multi-group Collaborative (cont.) Krause, J. S. & Broderick, L. E. (2004) Outcomes after spinal cord injury: Comparisons as a function of gender and race ethnicity. Archives of Physical Medicine and Rehabilitation, 85, 355-362. 54

55. Depression Scores (OAHMQ) as a Function of Race-Ethnicity and Gender 55

56. Summary - Depression From Shepherd Health Race appears to be related to a depressive disorder. Socioeconomic factors mediate this relationship for minority men, such that the relationship is no longer significant when accounting for SES. Income appears more important than education. No mediational relationship for women. Note: Nearly all minority participants were African American, so the results may or may not apply to other groups. From Comprehensive-Collaborative Study Women have higher depression scores, with the exception of American Indians, although sample size was small for that group. 56

57. References - Depression 1.Kemp, B. J., Krause, J. S., & Adkins, R. A. (1999). Depressive symptomatology among African-American, Latino, and Caucasian participants with spinal cord injury. Rehabilitation Psychology, 44, 235-247. 2.Krause, J. S., Kemp, B. J., & Coker, J. L. (2000). Depression after spinal cord injury: Relation to gender, ethnicity, aging, and socioeconomic indicators. Archives of Physical Medicine and Rehabilitation, 81, 1099-1109. 57

58. Health Outcomes Comprehensive Multi-Group Collaborative Study Krause, J. S. & Broderick, L. E. (2004) Outcomes after spinal cord injury: Comparisons as a function of gender and race ethnicity. Archives of Physical Medicine and Rehabilitation, 85, 355-362. 58

59. Univariate analysis of variance for health as a function of race-ethnicity CaucasianAfrican-American American Indian, Alaskan NativeHispanic Race F (df) MaleFemaleMaleFemaleMaleFemaleMaleFemale Rate Health 3.5 (0.9) 3.3 (1.0) 3.2 (0.9) 2.9 (1.0) 3.0 (1.0) 3.2 (0.8) 3.0 (1.1) 2.8 (0.9) 4.089 (3, 463)** Health compared to 1 year ago 3.2 (0.8) 3.2 (0.8) 3.4 (0.8) 3.2 (0.9) 3.5 (0.9) 3.5 (0.8) 3.3 (0.8) 3.0 (0.9) 2.432 (3, 462) Days in poor health 4.1 (7.5) 5.8 (7.4) 4.9 (8.5) 6.2 (9.7) 4.3 (7.3) 6.1 (7.7) 5.0 (7.7) 4.9 (7.1).395 (3, 462) Days in poor mental health 3.5 (6.2) 4.1 (6.0) 2.5 (4.6) 5.9 (9.4) 5.0 (8.5) 4.3 (5.0) 2.3 (4.4) 4.1 (5.8).858 (3, 458) Satisfaction with health 3.5 (1.0) 3.4 (0.9) 3.3 (0.9) 3.0 (1.0) 3.2 (1.1) 2.8 (1.0) 3.3 (0.9) 3.0 (0.9) 3.682 (3, 459)** Days stopped normal activities 2.2 (5.5) 3.7 (7.0) 2.5 (5.8) 3.5 (7.7) 4.7 (8.2) 3.0 (4.3) 2.6 (5.8) 3.4 (6.0).337 (3, 455) **p<.01 59

60. Self-rated Health as a Function of Race-Ethnicity and Gender 60

61. Pressure Ulcer Analysis In order to identify differences in an objective outcome, as opposed to overall evaluations of health, we compared: The odds of a pressure ulcer as a function of race- ethnicity (controlling for other factors) Barriers to staying in bed to heal a pressure ulcer Barriers to seeing a physician to treat a pressure ulcer Saladin, L.K., & Krause, J.S. (under review). Pressure ulcer incidence and prevention strategies after spinal cord injury: Comparisons of four racial- ethnic groups. NeuroRehabilitation. 61

62. Odds of a Current Pressure Ulcer Exp(B)95% CISig. Caucasian 2.46[.84, 7.20].101 African-American 4.59[1.79, 11.83].002 American-Indian 4.54[1.68, 12.30].003 Hispanic 1.00 Note: Race was significant at p<.005 while controlling for biographic and injury factors. Important point: Compared with Hispanics, who had the lowest odds of a current pressure ulcer, African-American and American Indian participants had significantly higher odds of a current pressure ulcer. 62

63. Odds of a Pressure Ulcer Within Last Year Exp(B)95% CISig. Caucasian 1.120[.55, 2.29].757 African-American 1.700[.90, 3.21].102 American-Indian 3.652[1.86, 7.18].000 Hispanic 1.00 Note: Race was significant at p<.001 while controlling for biographic and injury factors. Important point: Compared with Hispanics, who had the lowest odds, American Indian participants had significantly higher odds of a pressure ulcer within the last year. 63

64. Percentage reporting barriers to staying in bed to heal a pressure ulcer Caucasian African- American IndianHispanic Sig. Needing to go to work42.733.044.230.5 0.125 Needing somebody to stay with you43.525.533.028.1 p<.05 Not having enough $ to pay for extra attendant help 50.559.449.035.1 p<.01 Boredom65.441.658.240.0p<.001 Placing a strain on your relationship with a spouse or significant other 30.338.841.925.5 0.081 64

65. Percentage reporting barriers to seeing a physician to heal a pressure ulcer Caucasian African- American IndianHispanic Sig. Not having enough money or insurance 23.139.640.424.3 p<.01 Not having transportation23.145.543.627.0p<.001 Not trusting that a doctor…30.626.723.424.3 0.65 Not having a good doctor you can see close to where you live 38.037.644.830.4 0.20 65

66. Summary – Health Outcomes The disparities were not great for the self-reported evaluations of overall health. However, this may simply be a reflection on the nature of the outcomes investigated, as they were self ratings, rather than secondary conditions or hospitalizations. At least for pressure ulcers, Hispanics reported better outcomes in terms of both the prevalence or odds of getting a pressure ulcer, as well as fewer barriers to treatment. Barriers to treatment clearly varied by race-ethnicity, and this should be a topic for future research. 66

67. References – Comprehensive Study 1.Krause, J. S., Coker, J. L., Charlifue, S., & Whiteneck, G. G. (1999). Depression and subjective well being among 97 American Indians with spinal cord injury. Rehabilitation Psychology, 44, 354-372. 2.Krause, J. S., Coker, J. L., Charlifue, S., & Whiteneck, G. G. (1999). Selected health behaviors among American Indians with spinal cord injury: Comparison to 1996 data from the Behavioral Risk Factor Surveillance System. Archives of Physical Medicine and Rehabilitation, 80, 1435-1440. 3.Krause, J. S., Coker, J. L., Charlifue, S., & Whiteneck, G. G. (2000). Health outcomes among American Indians with spinal cord injury. Archives of Physical Medicine and Rehabilitation, 81, 924-931. 4.Broderick, L. E. & Krause, J. S. (2003). Breast and gynecologic screening behaviors among 191 women with spinal cord injuries. Journal of Spinal Cord Medicine, 26 (2), 145-9. 5.Krause, J. S. & Broderick, L. E. (2004) Outcomes after spinal cord injury: Comparisons as a function of gender and race ethnicity. Archives of Physical Medicine and Rehabilitation, 85, 355-362. 6.Saladin, L.K., & Krause, J.S. (under review). Pressure ulcer incidence and prevention strategies after spinal cord injury: Comparisons of four racial-ethnic groups. NeuroRehabilitation. 7.Krause, J.S. & Saladin, L.K. (under review). Disparities in subjective well-being, participation and health after spinal cord injury: A 6-year longitudinal study. NeuroRehabilitation. 67

68. Future Research 1.Must have greater involvement of institutions that have access to and serve large minority populations that have been typically underserved in SCI research. 2.Need to utilize population based participants to avoid selective participation and bias. 3.Need to better understand differences in health behaviors and disparities in healthcare practices and their relationship with health outcomes among minorities. 4.Need to go beyond simply focusing on SCI specific health issues (e.g., pressure ulcers) to investigating disparities in the prevalence of chronic diseases (e.g. diabetes, cardiovascular disease) and the contributing health behaviors among minorities with disabling conditions (Do they parallel differences in the general population? Or, are they accentuated?). 68

69. Ongoing Collaborations If you are representing a historically black college or university, Hispanic serving institution of higher education, American Indian tribal college or university, or another institution of higher education whose minority student enrollment is at least 50% and interested in additional webcasts on developing disparities research, please contact us. 69

70. Contact Information cokerj@musc.edu For more information on future dissemination, contact Jennifer Coker: cokerj@musc.eduhttp://www.musc.edu/chp/sciorg Principal Investigator: James S. Krausekrause@musc.edu 70

71. THANK YOU!