Educational health disparities in hypertension and diabetes mellitus among African descent populations in the Caribbean and the USA: a comparative analysis from the Spanish town cohort (Jamaica) and the Jackson heart study (USA).

BACKGROUND: Studies have suggested that social inequalities in chronic disease outcomes differ between industrialized and developing countries, but few have directly compared these effects. We explored inequalities in hypertension and diabetes prevalence between African-descent populations with different levels of educational attainment in Jamaica and in the United States of America (USA), comparing disparities within each location, and between countries. METHODS: We analyzed baseline data from the Jackson Heart Study (JHS) in the USA and Spanish Town Cohort (STC) in Jamaica. Participants reported their highest level of educational attainment, which was categorized as 'less than high school' (HS). Educational disparities in the prevalence of hypertension and diabetes were examined using prevalence ratios (PR), controlling for age, sex and body mass index (BMI). RESULTS: Analyses included 7248 participants, 2382 from STC and 4866 from JHS, with mean age of 47 and 54 years, respectively (p < 0.001). Prevalence for both hypertension and diabetes was significantly higher in the JHS compared to STC, 62% vs. 25% (p < 0.001) and 18% vs. 13% (p < 0.001), respectively. In bivariate analyses there were significant disparities by education level for both hypertension and diabetes in both studies; however, after accounting for confounding or interaction by age, sex and BMI these effects were attenuated. For hypertension, after adjusting for age and BMI, a significant education disparity was found only for women in JHS, with PR of 1.10 (95% CI 1.04-1.16) for < HS vs > HS and 1.07 (95% CI 1.01-1.13) for HS vs > HS. For diabetes; when considering age-group and sex specific estimates adjusted for BMI, among men: significant associations were seen only in the 45-59 years age-group in JHS with PR 1.84 (95% CI 1.16-2.91) for < HS vs > HS. Among women, significant PR comparing < HS to > HS was seen for all three age-groups for JHS, but not in STC; PR were 3.95 (95% CI 1.94-8.05), 1.53 (95% CI 1.10-2.11) and 1.32 (95% CI 1.06-1.64) for 25-44, 45-59 and 60-74 age-groups, respectively. CONCLUSION: In Jamaica, educational disparities were largely explained by age, sex and BMI, while in the USA these disparities were larger and persisted after accounting these variables.

Cause-of-death disparities in the African diaspora: exploring differences among shared-heritage populations.

OBJECTIVES: We investigated changes in life expectancy (LE) and cause-specific mortality over time, directly comparing African-descent populations in the United States and the Caribbean. METHODS: We compared LE at birth and cause-specific mortality in 6 disease groups between Caribbean countries with a majority (> 90%) African-descent population and US African Americans. RESULTS: The LE improvement among African Americans exceeded that of Afro-Caribbeans so that the LE gap, which favored the Caribbean population by 1.5 years in 1990, had been reversed by 2009. This relative improvement among African Americans was mainly the result of the improving mortality experience of African American men. Between 2000 and 2009, Caribbean mortality rates in 5 of the 6 disease groups increased relative to those of African Americans. By 2009, mortality from cerebrovascular diseases, cancers, and diabetes was higher in Afro-Caribbeans relative to African Americans, with a diabetes mortality rate twice that of African Americans and 4 times that of White Americans. CONCLUSIONS: The Caribbean community made important mortality reductions between 2000 and 2009, but this progress fell short of African American health improvements in the same period, especially among men.

Disparities in hypertension among black Caribbean populations: a scoping review by the U.S. Caribbean Alliance for Health Disparities Research Group (USCAHDR).

BACKGROUND: Despite the large body of research on racial/ethnic disparities in health, there are limited data on health disparities in Caribbean-origin populations. This scoping review aimed to analyze and synthesize published and unpublished literature on the disparities in hypertension and its complications among Afro-Caribbean populations. METHODS: A comprehensive protocol, including a thorough search strategy, was developed and used to identify potentially relevant studies. Identified studies were then screened for eligibility using pre-specified inclusion/exclusion criteria. An extraction form was developed to chart data and collate study characteristics including methods and main findings. Charted information was tagged by disparity indicators and thematic analysis performed. Disparity indicators evaluated include ethnicity, sex, socioeconomic status, disability, sexual orientation and geographic location. Gaps in the literature were identified and extrapolated into a gap map. RESULTS: A total of 455 hypertension related records, published between 1972 and 2012, were identified and screened. Twenty-one studies met inclusion criteria for detailed analysis. The majority of studies were conducted in the United Kingdom and utilized a cross-sectional study design. Overall, studies reported a higher prevalence of hypertension among Caribbean blacks compared to West African blacks and Caucasians. Hypertension and its related complications were highest in persons with low socioeconomic status. Gap analysis showed limited research data reporting hypertension incidence by sex and socioeconomic status. No literature was found on disability status or sexual orientation as it relates to hypertension. Prevalence and morbidity were the most frequently reported outcomes. CONCLUSION: The literature on hypertension health disparities in Caribbean origin populations is limited. Future research should address these knowledge gaps and develop approaches to reduce them.

Disparities in diabetes mellitus among Caribbean populations: a scoping review.

BACKGROUND: Despite the large body of research on racial/ethnic disparities in health, there are limited data on health disparities in Caribbean origin populations. This review aims to analyze and synthesize published literature on the disparities in diabetes mellitus (DM) and its complications among Afro-Caribbean populations. METHODS: A detailed protocol, including a comprehensive search strategy, was developed and used to identify potentially relevant studies. Identified studies were then screened for eligibility using pre-specified inclusion and exclusion criteria. An extraction form was developed to chart data and collate study characteristics including methods and main findings. Charted information was tagged by disparity indicators and thematic analysis performed. Disparity indicators evaluated include ethnicity, sex, age, socioeconomic status, disability and geographic location. Gaps in the literature were identified and extrapolated into a gap map. RESULTS: A total of 1009 diabetes related articles/manuscripts, published between 1972 and 2013, were identified and screened. Forty-three studies met inclusion criteria for detailed analysis. Most studies were conducted in the United Kingdom, Trinidad and Tobago and Jamaica, and used a cross-sectional study design. Overall, studies reported a higher prevalence of DM among Caribbean Blacks compared to West African Blacks and Caucasians but lower when compared to South Asian origin groups. Morbidity from diabetes-related complications was highest in persons with low socioeconomic status. Gap analysis showed limited research data reporting diabetes incidence by sex and socioeconomic status. No published literature was found on disability status or sexual orientation as it relates to diabetes burden or complications. Prevalence and morbidity were the most frequently reported outcomes. CONCLUSION: Literature on diabetes health disparities in Caribbean origin populations is limited. Future research should address these knowledge gaps and develop approaches to reduce them.

Disparities in cardiovascular disease among Caribbean populations: a systematic literature review.

BACKGROUND: Cardiovascular diseases (CVD) are the predominant cause of death globally. The large health disparities in the distribution of the burden of disease seen in developed and developing countries are of growing concern. Central to this concern is the poor outcome which is seen disproportionately in socially disadvantaged groups and racial/ethnic minorities. The aim of the study was to conduct a systematic literature review to investigate the nature of cardiovascular disease health disparities among Afro-Caribbean origin populations and identify current knowledge gaps. METHODS: A systematic literature review including a detailed search strategy was developed to search MEDLINE and other research databases. Using an a priori protocol peer-reviewed publications and grey literature articles were retrieved and screened and relevant data extracted by two independent review authors. Thematic analysis was done according to CVD outcomes and measures of disparity including age, sex, ethnicity and socioeconomic status. RESULTS: The search retrieved 665 articles of which 22 met the inclusion criteria. Most studies were conducted in the United Kingdom and centered on the prevalence of CVD by ethnicity, age and sex. An important sub-theme identified was the disparities in health service utilization/hospital admission. Coronary Heart Disease (CHD) and Peripheral Arterial Disease (PAD) were less prevalent among Afro-Caribbeans compared to Caucasian and South East Asian ethnic groups. The prevalence of CHD ranged from 0-7% in Afro-Caribbean to 2-22% in Caucasians. Strokes were more common among Afro-Caribbeans. There are inadequate data on morbidity and mortality from CVD, particularly across the socio-economic gradient, in Afro-Caribbean populations. CONCLUSIONS: There are important differences in morbidity and mortality from CVD across ethnic groups. Important knowledge gaps remain in understanding the social determinants of these disparities in CVD. More research exploring these gaps by varying disparity indicators needs to be undertaken.

Forming state collaborations to diversify the nation's health workforce: the experience of the sullivan alliance to transform the health professions.

Diversifying the nation's health professions is essential in order to maintain a vigorous health workforce, able to respond to the needs of all Americans. The inability of the health workforce to keep pace with the changing demographics of the nation is a major cause of the persistent inequities in access to quality health care for ethnic and racial minorities in the U.S. Ethnic and racial minorities have been underrepresented in the genetic counseling profession since its inception, despite vigorous professional initiatives to remedy this situation. Mittman and Downs published a critical review of these initiatives detailing recommendations for change in this journal in 2008. One of their major recommendations was the need to learn from, and join, efforts with other health professions in seeking to increase professional diversity in genetic counseling. This paper reviews new findings on issues impacting health workforce diversity in the nation, presents a case study of a national best practice to diversify the health workforce and illuminates actions that can be taken by the genetic counseling profession. The Sullivan Alliance to Diversify the Health Professions is a culmination of two historic initiatives for addressing the dearth of minority health professionals and is a national catalyst for increasing diversity within the health professions by forging state collaborations among institutions of higher education, health professions schools and other key stakeholders.

Keynote address: The need for greater racial and ethnic diversity in orthopaedic surgery.

BACKGROUND: Advances in medicine in the past century have resulted in substantial reductions in morbidity and mortality in the United States. However, despite these improvements, ethnic and racial minorities continue to experience health status and healthcare disparities. There is inadequate national awareness of musculoskeletal health disparities, which results in greater chronic pain and disability for members of ethnic and racial minority groups. The Sullivan Commission concluded in 2004 the inability of the health professions to keep pace with the US population is a greater contributor to health disparities than lack of insurance. WHERE ARE WE NOW?: While African Americans, Hispanic Americans, and Native Americans constitute more than one-third of the US population, they make up less than 10% of physicians, dentists, and nurses and less than 4% of orthopaedists in the United States. WHERE DO WE NEED TO GO?: Increasing the representation of women and ethnic and racial minorities in orthopaedics will help to increase trust between patients and their providers and will improve the quality of these interactions by enhancing culturally and linguistically appropriate orthopaedic care. HOW DO WE GET THERE?: Pipeline enrichment programs along the educational spectrum are important in the academic preparation of underrepresented minorities. Collaborations between health professions schools and postsecondary educational institutions will increase awareness about careers in the health professions. Ongoing mentorships and career counseling by orthopaedists should enhance the interest of underrepresented minority students in careers as orthopaedists.

Workforce diversity in dentistry - current status and future challenges.

The racial and ethnic diversity of the US oral health care workforce remains insufficient to meet the needs of an increasingly diverse population and to address persistent health disparities. The findings from a recent national survey of underrepresented minority dentists are reviewed and recommendations are made for enhancing diversity in the dental profession.

Educational Health Disparities in Cardiovascular Disease Risk Factors: Findings from Jamaica Health and Lifestyle Survey 2007-2008.

OBJECTIVES: Socioeconomic disparities in health have emerged as an important area in public health, but studies from Afro-Caribbean populations are uncommon. In this study, we report on educational health disparities in cardiovascular disease (CVD) risk factors (hypertension, diabetes mellitus, hypercholesterolemia, and obesity), among Jamaican adults. METHODS: We analyzed data from the Jamaica Health and Lifestyle Survey 2007-2008. Trained research staff administered questionnaires and obtained measurements of blood pressure, anthropometrics, glucose and cholesterol. CVD risk factors were defined by internationally accepted cut-points. Educational level was classified as primary or lower, junior secondary, full secondary, and post-secondary. Educational disparities were assessed using age-adjusted or age-specific prevalence ratios and prevalence differences obtained from Poisson regression models. Post-secondary education was used as the reference category for all comparisons. Analyses were weighted for complex survey design to yield nationally representative estimates. RESULTS: The sample included 678 men and 1,553 women with mean age of 39.4 years. The effect of education on CVD risk factors differed between men and women and by age group among women. Age-adjusted prevalence of diabetes mellitus was higher among men with less education, with prevalence differences ranging from 6.9 to 7.4 percentage points (p < 0.05 for each group). Prevalence ratios for diabetes among men ranged from 3.3 to 3.5 but were not statistically significant. Age-specific prevalence of hypertension was generally higher among the less educated women, with statistically significant prevalence differences ranging from 6.0 to 45.6 percentage points and prevalence ratios ranging from 2.5 to 4.3. Similarly, estimates for obesity and hypercholesterolemia suggested that prevalence was higher among the less educated younger women (25-39 years) and among more educated older women (40-59 and 60-74 years). There were no statistically significant associations for diabetes among women, or for hypertension, high cholesterol, or obesity among men. CONCLUSION: Educational health disparities were demonstrated for diabetes mellitus among men, and for obesity, hypertension, and hypercholesterolemia among women in Jamaica. Prevalence of diabetes was higher among less educated men, while among younger women the prevalence of hypertension, hypercholesterolemia, and obesity was higher among those with less education.

Hospice and palliative care: an expert interview with Louis W. Sullivan, MD. Interview by Perry G. Fine.

At the National Hospice and Palliative Care Organization's 6th Clinical Team Conference on Hospice and Palliative Care, held April 21-23, 2005, in Atlanta, Georgia, Perry G. Fine, MD, Professor in the Department of Anesthesiology at the University of Utah in Salt Lake City and Vice President of Medical Affairs for the National Hospice and Palliative Care Organization interviewed Louis W. Sullivan, MD, former Secretary of the US Department of Health and Human Services and currently President Emeritus of Morehouse School of Medicine, Chair of the Sullivan Commission-a commission to increase diversity among health professionals, Chair of the National Health Museum, Cochair of the President's Commission on HIV/AIDS, and Chair of the President's Commission on Black Colleges and Universities, as well as Chair of Medical Education for South African Blacks. Dr. Fine and Dr. Sullivan discussed the importance of hospice and palliative care, along with some of the practical issues facing clinicians who wish to use the hospice care system.

Grasping At The Moon: Enhancing Access To Careers In The Health Professions.

A former HHS secretary reflects on what's needed to enable more minorities to become doctors and other health professionals.

"Managing the unmanageable" the U.S. Department of Health and Human Services, 1989-1993.

The author served as the 17th U.S. Secretary of Health and Human Services, from March 1, 1989 until January 20, 1993. The department had 250 programs and 38 percent of the expenditures of the federal government ($600.0 billion), the fourth largest budget in the world. The history of the department included the fact that the tenure of previous Secretaries had ranged from only eight months up to 37 months, and had averaged 27.5 months, resulting in the view that the department was unmanageable. The author's tenure as Secretary was 47 months, and, in the author's view, the department was indeed manageable. The United States Department of Health, Education and Welfare (DHEW) was created as a cabinet agency in 1953, during the administration of President Dwight D. Eisenhower. The Department was formed by bringing together the Social Security Administration (founded in 1935), the United States Commissioner of Education, and the United States Public Health Service (founded in 1798) to serve the United States Merchant Marines). This new cabinet department contained the nation's major domestic programs concerned with income security, public health and education. Oveta Culp Hobby of Texas was the first Secretary of the Department. By 1989, the department's programs had increased to more than 250, including Medicare, Medicaid, Headstart, Welfare, and others. During the administration of President Jimmy Carter, the Education programs were separated into a new cabinet agency, the U.S. Department of Education, and the name of the U.S. Department of Health, Education and Welfare became the U.S. Department of Health and Human Services (DHHS).

Managing pain: The Challenge in Underserved Populations: Appropriate Use Versus Abuse and Diversion.

ISSUE: Inadequate pain management is a serious public health problem that affects a wide cross-section of Americans. Patients are often denied sufficient medication, because physicians lack training and fear scrutiny from federal and state regulatory agencies. In addition, even the state-financed system of care, Medicaid, has been increasingly denying payment for the best treatment for pain management. These factors are complicated by physician bias about various subgroups and poor physician-patient communication. Comprehensive patient assessment plays a crucial role in determining appropriate treatment and identifying potential abuse problems. Physicians must routinely document medications analgesic effects and screen for potential ill effects and drug abuse. OBJECTIVE: To examine the prevalence of the undertreatment of pain, particularly among African Americans, and to recommend relevant proactive policy and practice changes to aid in eliminating this health problem. CONSENSUS PROCESS: In July 2002, the NMA convened the "Managing Pain: The Challenge in Underserved Populations: Appropriate Use versus Abuse and Diversion" Consensus Meeting in Washington, DC. The country's most renowned experts in the area of pain management and substance abuse reviewed substantial information regarding pain management and substance abuse including the following: --A draft summary paper on pain management and substance abuse that served as briefing material for consensus members; --Annotated bibliographies; --Articles on pain management and substance abuse; and --Key presentations on pain management and substance abuse.