Olivia Carter-Pokras, Ph.D. Associate Professor Department of Epidemiology and Biostatistics University of Maryland College Park School of Public Health 2234G SPH Bldg. College Park, MD 20742 Phone: 301-405-8037 (office) 301-257-6106 (cell) Fax: 301-314-9366 opokras@umd.edu http://sph.umd.edu/epib/cultural_competency/
Olivia Carter-Pokras, Ph.D. is an Associate Professor, Department of Epidemiology and Biostatistics, University of Maryland College Park School of Public Health. She has been recognized by the Surgeon General, Assistant Secretary for Health and Latino Caucus of the American Public Health Association for her career achievements to improve racial and ethnic data and develop national health policy to address health disparities. Her research has played a critical role in national recognition of health disparities experienced by Latin American immigrants. Dr. Carter-Pokras is the Principal Investigator for a NHLBI cultural competency and health disparities academic award, and a NICHD community based participatory research grant on Oral Health of Latino and Ethiopian Children and Their Mothers. Dr. Carter-Pokras is a member of the Board of Directors for the American College of Epidemiology, and the Executive Board of the American Public Health Association.
Abstract: American Indians have the highest prevalence of cigarette use in the United States, but there is a shortage of knowledge about American Indians' own perspectives on smoking and cessation. The purpose of this exploratory qualitative study was to obtain information on American Indians' views that would be useful for subsequent intervention planning and development. Four focus groups were conducted with urban American Indians living in Maryland to explore the sociocultural contexts of tobacco use and their perspectives on various mainstream and culturally-specific smoking cessation strategies and service delivery models. Tobacco interventions targeting American Indians should increase service access, address negative experiences with medications, emphasize empowerment for behavior change, explicitly distinguish ceremonial tobacco from cigarette use, and send culturally-relevant messages. Smoking cessation programs and health promotion efforts may be perceived as more relevant by the target population if they incorporate an understanding of the social and cultural facets of smoking behavior.
Abstract: An impressive body of public health knowledge on health care disparities among Latinos has been produced. However, inconclusive and conflicting results on predictors of health care disparities remain. We examined the theoretical assumptions and methodological limitations of acculturation research in understanding Latino health care disparities, the evidence for socioeconomic position as a predictor of health care disparities, and the effectiveness of cultural competency practice. Persistent use of culture-driven acculturation models decenters social determinants of health as key factors in health disparities and diminishes the effectiveness of cultural competency practice. Social and economic determinants are more important predictors than is culture in understanding health care disparities. Improvements in the material conditions of low-income Latinos can effectively reduce health care disparities.
Abstract: BACKGROUND: The National Consortium for Multicultural Education for Health Professionals (Consortium) comprises educators representing 18 US medical schools, funded by the National Institutes of Health. Collective lessons learned from curriculum implementation by principal investigators (PIs) have the potential to guide similar educational endeavors. OBJECTIVE: Describe Consortium PI's self-reported challenges with curricular development, solutions and their new curricular products. METHODS: Information was collected from PIs over 2 months using a 53-question structured three-part questionnaire. The questionnaire addressed PI demographics, curriculum implementation challenges and solutions, and newly created curricular products. Study participants were 18 Consortium PIs. Descriptive analysis was used for quantitative data. Narrative responses were analyzed and interpreted using qualitative thematic coding. RESULTS: Response rate was 100%. Common barriers and challenges identified by PIs were: finding administrative and leadership support, sustaining the momentum, continued funding, finding curricular space, accessing and engaging communities, and lack of education research methodology skills. Solutions identified included engaging stakeholders, project-sharing across schools, advocacy and active participation in committees and community, and seeking sustainable funding. All Consortium PIs reported new curricular products and extensive dissemination efforts outside their own institutions. CONCLUSION: The Consortium model has added benefits for curricular innovation and dissemination for cultural competence education to address health disparities. Lessons learned may be applicable to other educational innovation efforts.
Abstract: In this paper we present the current state of cultural diversity education for undergraduate medical students in three English-speaking countries: the United Kingdom (U.K.), United States (U.S.) and Canada. We review key documents that have shaped cultural diversity education in each country and compare and contrast current issues. It is beyond the scope of this paper to discuss the varied terminology that is immediately evident. Suffice it to say that there are many terms (e.g. cultural awareness, competence, sensitivity, sensibility, diversity and critical cultural diversity) used in different contexts with different meanings. The major issues that all three countries face include a lack of conceptual clarity, and fragmented and variable programs to teach cultural diversity. Faculty and staff support and development, and ambivalence from both staff and students continue to be a challenge. We suggest that greater international collaboration may help provide some solutions.
Abstract: BACKGROUND: Practice guidelines suggest that immunomodulators (IMs) be given prior to infliximab (IFX) in patients with Crohn's disease (CD). The package insert for IFX recommends that maintenance therapy be prescribed for patients who respond to induction therapy. Our aim was to determine the extent to which gastroenterologists (GIs) are utilizing IM prior to IFX and prescribing maintenance IFX when treating patients with CD. METHODS: An 18-item questionnaire was developed and validated. The survey was sent to 4515 GIs who are members of the American Gastroenterology Association. Bivariate and multivariate analyses were performed. RESULTS: In all, 305 GIs responded; 70% use an IM prior to IFX, 86% prescribe maintenance IFX, and 62% reported both use of IM prior to IFX and use of maintenance IFX. Academic GIs, Midwest GIs, and GIs prescribing IFX a few times per year were more likely to report both use of an IM prior to IFX and use of maintenance IFX (odds ratio [OR] = 4.56, 2.18, and 2.25, respectively). GIs demonstrated awareness of the risk of reactivation of tuberculosis when initiating IFX and appropriately manage infusion reactions. GIs were unable to rank serious adverse reactions associated with IFX. CONCLUSIONS: A total of 38% of GIs did not report the use of IM prior to IFX and/or did not use maintenance IFX. GIs practicing outside the Midwest and those in nonacademic settings may need additional training regarding prescribing IFX.
Abstract: PURPOSE: In the past decade, we have witnessed increasing numbers of individuals entering the field of epidemiology. With the increase also has come a diversity of training and paths by which individuals entered the field. The purpose of this survey was characterization of the epidemiology workforce, its job diversity, and continuing education needs. METHODS: The Minority Affairs and Membership committees of the American College of Epidemiology (ACE) prepared and administered a workforce survey to identify racial/ethnic diversity, demographic background, workplace type, credentials, income, subspecialties, and continuing education needs of epidemiologists. The survey was self-administered to attendees of the Second North American Congress of Epidemiology in June 2006. RESULTS: A sample of 397 respondents of the 1348 registered for the Congress was captured (29.5% response). Epidemiologists who participated were from 36 states and 18 countries; 54.6% were trained at the doctoral level; 19.1% earned $120,001 or more a year. A wide range of epidemiology subspecialties and continuing education needs were identified. CONCLUSIONS: This preliminary snapshot of epidemiologists indicates a wide range of training mechanisms, workplace sites, and subspecialties. Results indicate a need for examination of the core graduate training needs of epidemiologist as well as responding to desired professional development needs through the provision of continuing education efforts.
Abstract: Despite growing recognition of the need to increase cultural diversity undergraduate education in the UK, the US and Canada, there is a lack of cohesion in the development and delivery of cultural diversity teaching in medical schools in these three countries. This article highlights 12 tips for developing cultural diversity education in undergraduate medical programmes by integrating it in institutional policies, curriculum content, faculty development and assessment. These tips can be used to help ensure that students gain needed knowledge, skills and attitudes consistent with a view of patients as complex individuals with unique needs.
Abstract: BACKGROUND: Challenges to recruitment of Latinos in health research may include language, cultural and communication barriers, trust issues, heterogeneity of legal status, and a high percent of uninsured when compared to the US population. This paper highlights the community-based participatory research (CBPR) process and expands on the applicability of these principles to Latino communities. METHODS: We review steps taken and describe lessons learned in using a participatory approach to broadly assess and address the health of urban-dwelling Latinos in Baltimore, Maryland, through the adaptation of CBPR principles. FINDINGS: We identified health priorities, access barriers, and community resources (eg, Latin American trained nurses who were not currently working in the health field, immigrant networks) using a participatory approach. Suggestions for improving trust, research participation, and access to care ranged from not collecting data on legal status, and regular attendance and presentations of ongoing research at community provider meetings, to referral to free or low-cost health care services at screening events. CONCLUSION: Despite growing interest in CBPR, limited guidance exists on how to apply CBPR principles to conduct health research among Latinos. Incorporating a participatory process can help address Latino community concerns, enrich quality and relevance of research, and empower community members.
Abstract: This study seeks the unique perspective of Latin-American-trained nurses on barriers and strategies to improve the health of Baltimore's Latino community. Individual in-depth interviews are conducted in Spanish with one male and seven female nurses recruited by Baltimore's Latino Providers Network. Audiotaped home interview transcripts are manually reviewed for common themes. Strategies include professional medical interpreters, workshops on the U.S. health care system, media campaign on affordable/bilingual care sources, licensing foreign-trained nurses, and outreach clinics linked to trusted community-based organizations. Findings can be used to develop culturally appropriate programs to better administer health care to Latino communities.
Abstract: OBJECTIVES: This paper compares select health status indicators between the U.S. and Mexico, and within the Mexican-origin population using proxy measures of acculturation. METHODS: Statistical data were abstracted and a Medline literature review conducted of English-language epidemiologic articles on Mexican-origin groups published during 1976-2005. RESULTS: U.S.-born Mexican-Americans have higher morbidity and mortality compared to Mexico-born immigrants. Mexico has lower healthcare resources, life expectancy, and circulatory system and cancer mortality rates, but similar infant immunization rates compared to the U.S. Along the U.S.-Mexico border, the population on the U.S. side has better health status than the Mexican side. The longer in the U.S., the more likely Mexican-born immigrants engage in behaviors that are not health promoting. Conclusions Researchers should consider SEP, community norms, behavioral risk and protective factors when studying Mexican-origin groups. It is not spending-time in the U.S. that worsens health outcomes but rather changes in health promoting behaviors.
Abstract: PURPOSE: Adolescent mothers have high rates of repeat pregnancy and sexually transmitted infections (STIs). We sought to identify factors associated with their consistent condom use. METHODS: Data for 107 urban adolescent mothers enrolled in a longitudinal computer-assisted motivational interviewing (CAMI) intervention were analyzed. The intervention aimed to motivate and instill confidence in using condoms consistently. Data sources: 1) structured interviews during the third trimester of pregnancy (baseline), 2) CAMI responses at 9-12 months postpartum. Outcomes were dichotomized as: consistent condom users and inconsistent condom users. RESULTS: At baseline, mean age was 17 (1.1 SD) years, 96% African American, and 26% reported always using condoms. At 9-12 months postpartum, 33 (31%) used condoms consistently. Consistent condom users were less likely to report having sex with their baby's father (61% vs. 81%; p = 0.05). Adolescent mothers who used condoms consistently experienced greater self-efficacy in the prevention of STIs and recognized the importance of preventing STIs with a new boyfriend (p = 0.006). Consistent condom users held the opinion that it was more important to use condoms with a new boyfriend than with their baby's father regardless whether their main partner was the father of their baby or a new boyfriend. CONCLUSIONS: Level of motivation, belief in the importance of condom use and self-efficacy to use condoms with a new boyfriend regardless of actual sexual partner relationship were the strongest predictors of consistent condom use among adolescent mothers. Future interventions aimed at improving condom use should focus on motivation and to different views held by teens regarding their partner-specific condom use.
Abstract: PURPOSE: Older African Americans may be vulnerable to risks due to impaired healthcare access and understudied complementary and alternative medicine (CAM) use and other traditions. We describe CAM use among older African Americans in Baltimore, MD, examining associations among CAM and sociodemographic, health status, healthcare utilization and neighborhood factors. METHODS: Cross-sectional telephone survey of 95 African Americans ages > or =60 on use of CAM modalities (herb/home remedies, prayer, group spiritual practices, meditation/visualization, massage, chiropractic, acupuncture, relaxation/biofeedback) in prior year. RESULTS: A large majority (88.4%) reported CAM use in the previous year: 50.5% reported CAM use excluding individual prayer. The most commonly reported modalities were individual prayer (96.8%), herbs/home remedies (29.5%) and group spiritual practices (17.0%). Most (77.3%) herbal/home remedy users disclosed use to providers. In multivariable logistic regression at the individual level, CAM was associated with higher number of comorbidities (OR = 1.24, 95% CI: 1.06-1.45), older age (OR = 1.09, 95% CI: 1.01-1.17) and more years of education (OR = 1.24, 95% CI: 1.03-1.49). Adding neighborhood variables attenuated effects of comorbidity (OR = 1.17, 95% CI: 0.99-1.39); residence in more racially integrated neighborhoods (OR = 1.03, 95% CI: 1.00-1.06; p = 0.047) was also important. CONCLUSIONS: CAM use was greater than expected. Although disclosure of herb use was high, providers should probe for CAM use.
Abstract: We sought to determine prescribing patterns and awareness of adverse drug reactions to infliximab among gastroenterologists. A questionnaire was developed and mailed to all gastroenterologists in Maryland and Washington, D.C. Ninety-six of 336 (28.6%) gastroenterologists responded; 86% of respondents use infliximab often or sometimes and 48% infuse infliximab on-site. Only 48% of respondents use immunomodulators prior to infusing infliximab. Thirty-three percent of respondents do not prescribe maintenance infliximab. Respondents reported that infusion reactions occur in 12.9% of infliximab infusions. Most respondents order a purified protein derivative prior to starting infliximab. Respondents underestimated the risk of serious infection, death, demyelinating diseases, and malignancy and overestimated the risk of congestive heart failure. We conclude that a substantial number of gastroenterologists underutilize immunomodulators and fail to prescribe maintenance infliximab. Further, respondents were unaware of the frequency of major adverse events associated with infliximab. Education regarding treatment algorithms in CD and infliximab-related side effects is needed.
Abstract: INTRODUCTION AND HYPOTHESIS: Despite higher rates of depression, lower hormone replacement therapy (HRT) use, and inadequate knowledge of factors associated with osteoporosis, Mexican Americans have been understudied with regards to the association between depression, osteoporosis, and fractures. We hypothesized that depression increases the risk for osteoporosis and fractures among older Mexican American women. METHODS: Seven years of prospective data (1993-2001) from the Hispanic Established Populations for Epidemiologic Studies of the Elderly were analyzed for 1,350 women in the Southwest United States who had complete data for at least the first follow-up interview. RESULTS: Respondents (mean age:75) were generally poorly educated, had low income, and reported poor or fair health. High levels of depressive symptoms were reported by 31%, while new diagnosis of osteoporosis and new fractures were reported by 18 and 13%, respectively. Logistic regression analyses showed that predictors of newly diagnosed osteoporosis included age, high school (HS) education, ever having been an alcoholic, early menopause, hormone replacement therapy, and high levels of depressive symptoms. Factors predictive of new fractures included age, HS education, diabetes, early menopause, and high levels of depressive symptoms. CONCLUSIONS: Depressive symptoms were associated with increased risk of osteoporosis and new fractures, even after controlling for other predictive factors.
Abstract: OBJECTIVES: To compare hypertension-related mortality (HRM) age-standardized and age-specific rates for Hispanic subgroup and non-Hispanic White (NHW) women; to identify underlying causes of HRM by Hispanic subgroup and age; and to examine relative percent change in HRM among Hispanic subgroups and NHW women. DESIGN: Secondary data analyses of 1995-1996 and 2001-2002 national vital statistics multiple cause mortality files. SETTING: United States-50 states and District of Columbia. SUBJECTS: Mexican American (MA), Puerto Rican (PR), Cuban (CA) and NHW female decedents ages > or =45 years with hypertension listed as one of up to 20 conditions resulting in death. MAIN OUTCOME MEASURES: Age-standardized death rates (ASDR per 100,000) for HRM and relative percent change to examine trends (2-year intervals). RESULTS: During 1995-1996, the ASDR (per 100,000) for HRM was highest among PR (248.5) followed by NHW (188.7), MA (185.4), and CA women (139.7). During 2001-2002, PR (215.5) and MA (205.5) had higher ASDR for HRM than NHW (171.9) and CA women (104.6). The relative percent increase from 1995-1996 to 2001-2002 was 10.8% (P < .01) among MA, while CA (-25.1%, P < .01), PR (-13.3%, P < .01) and non-Hispanic Whites (-8.5%, P < .01) showed a decrease. CONCLUSIONS: HRM was highest among PR and MA women, increased significantly for MA women between 1995-1996 to 2001-2002, and declined for CA, PR and non-Hispanic White women. Public health efforts should focus on strengthening heart health protection communication and hypertension control programs for PR and MA women and their healthcare providers.
Abstract: The objective of this study was to determine whether neonatal-perinatal fellowship programs (NFTPs) in the United States vary in indomethacin use for the management of patent ductus arteriosus (PDA) in < or =28 week gestational age infants at birth. A 53-item web-based survey was sent to 84 NFTP directors who received prenotification, followed 2 weeks later by a reminder letter. A total of 56 NFTP directors responded (67% maximum response rate). Wide variation exists in the maximum number of indomethacin courses used to close ductus, use of indomethacin for reopened PDA beyond 14 days, ductal closure definition, contraindications before consideration of indomethacin, interventions for contraindications, and reported ductal closer rate after each indomethacin course. Indomethacin therapy for symptomatic PDA and short course of indomethacin are common practices. Indomethacin use for the management of PDA in premature infants varies among NFTP directors. Practice attitudes may explain variations in ductal closure and ligation rates. Because practice variations may have implications for long-term outcome of vulnerable premature infants, studies relevant to the management of PDA in premature infants are needed.
Abstract: BACKGROUND: We compared access to health care, use of services, and health care experiences for Mexicans and other Latinos by citizenship and immigrant authorization status. METHODS: We acquired data from the 2003 California Health Interview Survey, with 42,044 participants representative of noninstitutionalized households. Participants were differentiated by ethnicity/race, national origin, and citizenship/immigration authorization status. Outcome measures included having a usual source of care, problems in obtaining necessary care, use of physician and emergency department care, and 3 experiences with health care. Multivariate analyses measured the associations of citizenship/immigration authorization status with the outcome measures among foreign-born Mexicans and other Latinos vs their US-born counterparts. RESULTS: In multivariate analyses, undocumented Mexicans had 1.6 fewer physician visits (P < .01); compared with US-born Mexicans; other undocumented Latinos had 2.1 fewer visits (P < .01) compared with their US-born counterparts. Both undocumented groups were less likely to report difficulty obtaining necessary health care than US-born Mexicans (odds ratio, 0.68; P < .01) and other US-born Latinos (odds ratio, 0.40; P < .01), respectively. Undocumented Mexicans were less likely to have a usual source of care (odds ratio, 0.70; P < .01) and were more likely to report negative experiences than US-born Mexicans (odds ratio, 1.93; P < .01). Findings were similar for other undocumented Latinos, with the exception of having a usual source of care. Patterns of access to and use of health care services tended to improve with changing legal status. CONCLUSION: In this large sample, undocumented Mexicans and other undocumented Latinos reported less use of health care services and poorer experiences with care compared with their US-born counterparts, after adjustment for confounders in multivariate analyses.
Abstract: This paper describes the level of public emergency knowledge and perceptions of risks among Latin American immigrants, and their preferred and actual sources of emergency preparedness information (including warning signals). Five Latino community member focus groups, and one focus group of community health workers, were conducted in a suburban county of Washington D.C. (N=51). Participants came from 13 Latin American countries, and 64.7% immigrated during the previous five years. Participants had difficulty defining emergency and reported a wide range of perceived personal emergency risks: immigration problems; crime, personal insecurity, gangs; home/traffic accidents; home fires; environmental problems; and snipers. As in previous studies, few participants had received information on emergency preparedness, and most did not have an emergency plan. Findings regarding key messages and motivating factors can be used to develop clear, prioritized messages for communication regarding emergencies and emergency preparedness for Latin American immigrant communities in the U.S.
Abstract: Representing 1 in 6 children in the United States, Latino children incur disproportionate exposures to air pollutants, pesticides, and toxic industrial chemicals, as well as lead and mercury from candy, traditional folk remedies, religious practices, and other sources. Latino children also have higher rates of asthma, lead and mercury poisoning, behavioral and developmental disorders, and certain cancers. Concurrent exposure to multiple pollutants, pre-existing disease, poor nutrition, substandard housing, limited access to health care, and other factors related to their lower socioeconomic status increase Latino children's susceptibility to environmental contaminants. Targeted research, education, prevention and intervention efforts, and economic development initiatives are needed.
Abstract: Surveys are widely used to gather health information from a sample of individuals. This brief report reviews 14 free and low-cost software packages (< dollar 1,000) that can be used when conducting health surveys with a limited budget. Information available on the Internet or directly from the provider in response to inquiry was reviewed for key features used by health survey researchers. Many free or low-cost software options appropriate for questionnaire development are readily available. Questionnaire mode and complexity, data management and analytical needs, and computing environment are all important considerations in selecting survey software.
Abstract: BACKGROUND: Cultural diversity teaching is increasingly present in both undergraduate and postgraduate training programmes. This study explored the views of stakeholders in medical education about the potential outcomes of cultural diversity teaching and how they thought cultural diversity programmes might be effectively evaluated. METHODS: A semi-structured interview was undertaken with 61 stakeholders (including policymakers, diversity teachers, students and users). The data were analysed and themes identified. RESULTS: Many participants felt that clinical practice was improved through 'cultural diversity teaching' and this was mostly as a result of improved doctor-patient communication. There was a strong view that service users need to participate in the evaluation of outcomes of cultural diversity teaching. CONCLUSION: There is a general perception, rather than clear evidence, that cultural diversity teaching can have a positive effect on clinical practice. Cultural diversity teaching needs to be reviewed in undergraduate and postgraduate medicine and better evaluation tools need to be established.
Abstract: OBJECTIVES: This report discusses six issues that affect the measurement of disparities in health between groups in a population: Selecting a reference point from which to measure disparity. Measuring disparity in absolute or in relative terms. Measuring in terms of favorable or adverse events. Measuring in pair-wise or in summary fashion. Choosing whether to weight groups according to group size. Deciding whether to consider any inherent ordering of the groups. These issues represent choices that are made when disparities are measured. METHODS: Examples are used to highlight how these choices affect specific measures of disparity. RESULTS: These choices can affect the size and direction of disparities measured at a point in time and conclusions about the size and direction of changes in disparity over time. Eleven guidelines for measuring disparities are presented. CONCLUSIONS: Choices concerning the measurement of disparity should be made deliberately, recognizing that each choice will affect the results. When results are presented, the choices on which the measurements are based should be described clearly and justified appropriately.
Abstract: OBJECTIVES: To summarize key findings on disparities in health insurance coverage for latino children, to present selected socioeconomic and healthcare access indicators for the nine states with latino populations over 500,000, and to recommend state strategies to increase public health insurance coverage for latino children. METHODS: Literature review performed on latino children and health insurance coverage, key informant interviews with frontline service providers, review of outreach sections of eight state 1115 waiver requests approved by the Secretary of the U.S. Department of Health and Human Services, and national and state data compiled on sociodemographic and healthcare access indicators for nine states with the largest latino populations. RESULTS: Eligibility and enrollment into Medicaid and State Children's Health Insurance Program (SCHIP) are hindered by financial, nonfinancial, and social policy barriers. Disparities in insurance and access indicators show that lack of parental employment-linked benefits, procedural barriers to enrollment, and lack of clarification on eligibility for children of noncitizen parents are associated with low levels of insurance coverage among latino children. CONCLUSION: To state strategies consistent with the overarching goal of Healthy People 2010 to eliminate health disparities can increase health insurance coverage for children of low-wage latino workers.
Abstract: With Healthy People 2010 making the goal of eliminating health disparities a national priority, policymakers, researchers, medical centers, managed care organizations (MCOs), and advocacy organizations have been called on to move beyond the historic documentation of health disparities and proceed with an agenda to translate policy recommendations into practice. Working models that have successfully reduced health disparities in managed care settings were presented at the National Managed Health Care Congress Inaugural Forum on Reducing Racial and Ethnic Disparities in Health Care on March 10-11, 2003, in Washington, DC. These models are being used by federal, state, and municipal governments, as well as private, commercial, and Medicaid MCOs. Successful models and programs at all levels reduce health disparities by forming partnerships based on common goals to provide care, to educate, and to rebuild healthcare systems. Municipal models work in collaboration with state and federal agencies to integrate patient care with technology. Several basic elements of MCOs help to reduce disparities through emphasis on preventive care, community and member health education, case management and disease management tracking, centralized data collection, and use of sophisticated technology to analyze data and coordinate services. At the community level, there are leveraged funds from the Health Resources and Services Administration's Bureau of Primary Health Care. Well-designed models provide seamless monitoring of patient care and outcomes by integrating human and information system resources.
Abstract: We characterized differences in severity, presentation, and treatment compliance in sleep-disordered breathing (SDB) between African Americans (AA) and Caucasians (W). We retrospectively analyzed demographics, proxy measures of socioeconomic position, concurrent illness, presenting complaints, polysomnographic data including respiratory disturbance index (RDI) and time less than 90% O2 saturation (T90), and acceptance of and long-term compliance with CPAP therapy. Over 1 year there were 128 AA, 102 W, and 3 "other." AA were younger (44.9+/-14.1 vs. 49.2+/-14.5 years; P=0.022), had greater body mass index (BMI) (39.7+/-10.7 vs. 33.4+/-9.2 kg/m2; p<0.0001), and reported lower estimated median household income (MHI) than W ($33,365+/-15,236 vs. $52,641+/-20,209; p<0.0001). OSA was more severe among AA: (median RDI: AA 32.9, W 29.1 events/h; p=0.008; median T90: AA 17.6 vs. W 5.3 per minute; P=0.006). However, after adjustment for BMI and MHI, differences between AA and W in RDI were not significant. Equal frequencies of AA and W accepted and were compliant with CPAP. We conclude that while AA present with more severe OSA than W this was accounted for by factors known to influence OSA severity. Further, there were no racial differences in accepting and adhering to therapy with CPAP.
Abstract: Increasing numbers of persons in the United States cannot speak, read, write, or understand the English language at a level that permits them to interact effectively. These limitations can hamper encounters between patients and healthcare providers, often leading to misunderstandings as to diagnosis and treatment, which in turn may result in poor patient compliance, unsatisfactory outcomes, and increased costs. A questionnaire was developed and distributed to clinical practice managers at the University of Maryland School of Medicine to assess the needs for language interpretation services and resources among clinical faculty providing healthcare to persons with limited English proficiency (LEP). Literature review, search of key Web sites, and consultation with national experts on issues pertaining to language access, health services, and reimbursement strategies also were done. Then, recommendations regarding the costs and benefits of language interpretation in healthcare settings were developed. Because recipients of federal financial assistance from the Department of Health and Human Services must provide meaningful access to persons with LEP at no cost to the client, there are clear benefits to providing language interpretation. Providers and managers should be made aware of interpretation service options and cost-saving strategies.
Abstract: Latinos recently became the largest racial/ethnic minority group of US children. The Latino Consortium of the American Academy of Pediatrics Center for Child Health Research, consisting of 13 expert panelists, identified the most important urgent priorities and unanswered questions in Latino child health. Conclusions were drawn when consensus was reached among members, with refinement through multiple iterations. A consensus statement with supporting references was drafted and revised. This article summarizes the key issues, including lack of validated research instruments, frequent unjustified exclusion from studies, and failure to analyze data by pertinent subgroups. Latino children are at high risk for behavioral and developmental disorders, and there are many unanswered questions about their mental health needs and use of services. The prevalence of dental caries is disproportionately higher for Latino children, but the reasons for this disparity are unclear. Culture and language can profoundly affect Latino children's health, but not enough cultural competency training of health care professionals and provision of linguistically appropriate care occur. Latinos are underrepresented at every level of the health care professions. Latino children are at high risk for school dropout, environmental hazards, obesity, diabetes mellitus, asthma, lack of health insurance, nonfinancial barriers to health care access, and impaired quality of care, but many key questions in these areas remain unanswered. This article suggests areas in which more research is needed and ways to improve research and care of Latino children.
Abstract: The limited availability of Hispanic health data has hampered the development of targeted public health policies. Hispanics represent 11.5 percent of the population and are projected to become the largest minority group in the United States by the year 2010. This paper explores current issues in Hispanic health data collection, examines methodological concerns, and presents recommendations for future Hispanic public health data collection. Data are derived from statistical reports of the U.S. Bureau of the Census, National Center for Health Statistics, Bureau of Labor Statistics, and other empirical studies. Recommendations include: collecting both race and ethnic-specific data by Hispanic subgroup, designing appropriate data collection instruments and approaches, and selecting referent groups for comparison purposes. The authors conclude that the renewed national focus on health disparities among underserved populations requires an increased commitment to adequately identify Hispanic subgroups.
Abstract: OBJECTIVES: This study examined the relationship between acculturation and leisure-time physical inactivity among Mexican American adults. METHODS: Using data from the Third National Health and Nutrition Examination Survey, we estimated the prevalence of physical inactivity according to place of birth and language used at home. RESULTS: Spanish-speaking Mexican Americans had a higher prevalence of physical inactivity during leisure time than those who spoke mostly English, independent of place of birth. CONCLUSIONS: Acculturation seems to be positively associated with participation in leisure-time physical activity.
Abstract: BACKGROUND: Physical inactivity is more prevalent among racial and ethnic minorities than among Caucasians. It is not known if differences in participation in leisure time physical activity are due to differences in social class. Thus, this paper provides estimates of the prevalence of physical inactivity during leisure time and its relationship to race/ethnicity and social class. METHODS: This was a national representative cross-sectional survey with an in-person interview and medical examination. Between 1988 and 1994, 18,885 adults aged 20 or older responded to the household adult and family questionnaires as part of the Third National Health and Nutrition Examination Survey . Mexican-Americans and African-Americans were over-sampled to produce reliable estimates for these groups. Multiple assessment of social class included education, family income, occupation, poverty status, employment status, and marital status. RESULTS: The age-adjusted prevalence (per 100) of adults reporting leisure time inactivity is lower among Caucasians (18%) than among African-Americans (35%) and Mexican-Americans (40%). African-American and Mexican-American men and women reported higher prevalence of leisure time inactivity than their Caucasian counterparts across almost every variable, including education, family income, occupation, employment, poverty and marital status. CONCLUSIONS: Current indicators of social class do not seem to explain the higher prevalence of physical inactivity during leisure time among African-American and Mexican-American. More research is needed to examine the effect of other constructs of social class such as acculturation, safety, social support and environmental barriers in promoting successful interventions to increase physical activity in these populations.
Abstract: To prevent posttransfusion viral hepatitis, screening of potential blood donors includes the measurement of serum alanine aminotransferase (ALT) levels. The current use of single system-wide ALT cutoffs to determine acceptability of a blood unit or donor may not be appropriate, since male and Hispanic blood donors have much higher rejection rates than other donors, based solely on ALT level. Serum ALT measurements from the Hispanic Health and Nutrition Examination Survey were used to confirm these ALT elevations within general population samples of Mexican Americans, Cubans, and Puerto Ricans. Until specific tests are available to detect all hepatitis viral infections, testing blood donors for ALT levels will likely continue. Health personnel should be cautious in their interpretation of "elevated" ALT levels in these Hispanic populations.
Abstract: Data from the Hispanic Health and Nutrition Examination Survey (HHANES) (1982 through 1984) and the National Health and Nutrition Examination Survey (NHANES) II (1976 through 1980) were used to examine reported physician-diagnosed asthma among 6-month-old through 11-year-old children. The highest prevalence of active asthma was reported for Puerto Ricans: 11.2% compared with 3.3% for non-Hispanic Whites, 5.9% for non-Hispanic Blacks, 2.7% for Mexican Americans, and 5.2% for Cubans. Health services utilization and severity do not appear to explain the differences between Puerto Ricans and Mexican Americans. Educational programs on asthma should consider focusing on Puerto Ricans.
Abstract: Much of the epidemiologic research in the United States has been based only on the categories of age, sex and race; thus, race has often been used in health statistics as a surrogate for social and economic disadvantage. Few multivariate analyses distinguish effects of components of social class (such as economic level) from the relative, joint, and independent effects of sociocultural identifiers such as race or ethnicity. This paper reviews studies of social class and minority status differentials in health, with a particular emphasis on health status outcomes which are known or suspected to be related to environmental quality and conditions which increase susceptibility to environmental pollutants. Sociodemographic data are presented for the U.S. population, including blacks, Asian American/Pacific Islanders, American Indian/Alaska Natives, and Hispanics. Four areas of health status data are addressed: mortality, health of women of reproductive age, infant and child health, and adult morbidity. Conceptual and methodological issues surrounding various measures of position in the system of social strata are discussed, including the multidimensionality of social class, in the context of the importance of these issues to public health research. Whenever possible, multivariate studies that consider the role of socioeconomic status in explaining racial/ethnic disparities are discussed.
Abstract: Residues of toxic chemicals in human tissues and fluids can be important indicators of exposure. Urine collected from a subsample of the second National Health and Nutrition Examination Survey was analyzed for organochlorine, organophosphorus, and chlorophenoxy pesticides or their metabolites. Urine concentration was also measured. The most frequently occurring residue in urine was pentachlorophenol (PCP), found in quantifiable concentrations in 71.6% of the general population with an estimated geometric mean level of 6.3 ng/ml. Percent quantifiable levels of PCP were found to be highest among males. Quantifiable concentrations of 3,5,6-trichloro-2-pyridinol (5.8%), 2,4,5-trichlorophenol (3.4%), para-nitrophenol (2.4%), dicamba (1.4%), malathion dicarboxylic acid (0.5%), malathion alpha-monocarboxylic acid (1.1%), and 2,4-D (0.3%) were found, but at much lower frequencies. No quantifiable levels of 2,4,5-T or silvex were found. Preliminary analyses showed an apparent relationship between residue concentration and two measures of urine concentration (osmolality and creatinine). A large segment of the general population of the United States experienced exposure to certain pesticides, including some considered biodegradable, during the years 1976-1980.
Abstract: This report presents descriptive data for clinical chemistry profiles by age and sex. This information is from the Hispanic Health and Nutrition Examination Survey, a sample survey of selected groups of civilian noninstitutionalized Hispanic persons residing in the United States. The survey was conducted during 1982-84.
Abstract: Data from the Hispanic Health and Nutrition Examination Survey were used to estimate arithmetic mean blood lead and percent with elevated blood lead [25 micrograms per deciliter (micrograms per dl) or greater] for 4-11-year-old Mexican American, Puerto Rican, and Cuban children. The sample size was 1,390 for Mexican American children, 397 for Puerto Rican children, and 114 for Cuban children. Puerto Rican children had the highest mean blood lead levels (11.5 micrograms per dl), followed by Mexican American children (10.4 micrograms per dl) and Cuban children (8.6 micrograms per dl, P less than .05). Puerto Rican children had the highest percent with elevated blood lead (2.7 percent); 1.6 percent of Mexican American children had elevated blood lead; less than 1 percent (0.9 percent) of the Cuban children had elevated blood lead (P less than .05). Mexican American girls had a lower mean blood lead level than did boys: 9.7 micrograms per dl versus 11.0 micrograms per dl (P less than .05). For both Puerto Rican and Mexican American children, younger age indicated a higher risk of having elevated blood lead levels. Mexican American children who lived in poverty had higher mean blood lead levels than did Mexican American children who did not live in poverty--11.6 micrograms per dl versus 9.6 micrograms per dl (P less than .05). Despite advances in primary prevention of lead toxicity in children during the past 10 years, many Hispanic children are at risk of lead toxicity. Approximately 19,000 Mexican American 4-11-year-old children living in the Southwest and approximately 8,000 Puerto Rican children living in the New York City area had elevated blood lead levels (greater than or equal to 25 micrograms per dl) during 1982-84.
Abstract: National prevalence estimates of scoliosis in adults, based on the reading of 6594 chest X-rays from the first National Health and Nutrition Examination Survey, are presented by age, sex and race. Among US adults aged 25-74 years in 1971-75, the prevalence rate of scoliosis was 8.3%. The prevalence of scoliosis increased across age groups among women (p less than 0.001), but not among men. Women had about twice the prevalence of scoliosis as men; 10.7% versus 5.6% (p less than 0.001). Because scoliosis prevalence rates differed by age and sex, prevalence rates and means for scoliosis status subgroups were adjusted for age and sex. Blacks had a higher rate, although not statistically significant (using alpha = 0.10), of scoliosis than whites: 9.7% versus 8.1%. Bone density of the radius was lower for scoliotics than for non-scoliotics: (287.0 versus 294.0 aluminum equivalency units, p less than 0.001), suggesting a possible association between scoliosis and osteoporosis. The percentage with delayed menarche was higher for scoliotics than non-scoliotics: 37.8 versus 30.8% (p = 0.01). Scoliotic women also had a lower mean age of menstruation termination than non-scoliotic women: 43.4 years versus 44.8 years (p = 0.07). This is the first study to present national prevalence estimates for scoliosis among adults in the US.
