The Influence of Patient Race and Activation on Pain Management in Advanced Lung Cancer: a Randomized Field Experiment.

BACKGROUND: Pain management racial disparities exist, yet it is unclear whether disparities exist in pain management in advanced cancer. OBJECTIVE: To examine the effect of race on physicians' pain assessment and treatment in advanced lung cancer and the moderating effect of patient activation. DESIGN: Randomized field experiment. Physicians consented to see two unannounced standardized patients (SPs) over 18 months. SPs portrayed 4 identical roles-a 62-year-old man with advanced lung cancer and uncontrolled pain-differing by race (black or white) and role (activated or typical). Activated SPs asked questions, interrupted when necessary, made requests, and expressed opinions. PARTICIPANTS: Ninety-six primary care physicians (PCPs) and oncologists from small cities, and suburban and rural areas of New York, Indiana, and Michigan. Physicians' mean age was 52 years (SD = 27.17), 59% male, and 64% white. MAIN MEASURES: Opioids prescribed (or not), total daily opioid doses (in oral morphine equivalents), guideline-concordant pain management, and pain assessment. KEY RESULTS: SPs completed 181 covertly audio-recorded visits that had complete data for the model covariates. Physicians detected SPs in 15% of visits. Physicians prescribed opioids in 71% of visits; 38% received guideline-concordant doses. Neither race nor activation was associated with total opioid dose or guideline-concordant pain management, and there were no interaction effects (p > 0.05). Activation, but not race, was associated with improved pain assessment (ẞ, 0.46, 95% CI 0.18, 0.74). In post hoc analyses, oncologists (but not PCPs) were less likely to prescribe opioids to black SPs (OR 0.24, 95% CI 0.07, 0.81). CONCLUSIONS: Neither race nor activation was associated with opioid prescribing; activation was associated with better pain assessment. In post hoc analyses, oncologists were less likely to prescribe opioids to black male SPs than white male SPs; PCPs had no racial disparities. In general, physicians may be under-prescribing opioids for cancer pain. TRIAL REGISTRATION: NCT01501006.

Association Between Discrimination and Objective and Subjective Sleep Measures in the Midlife in the United States Study Adult Sample.

OBJECTIVE: Evidence suggests that sleep quality is worse in nonwhite minorities compared with whites. Poor sleep is associated with higher levels of perceived interpersonal discrimination, which is consistently reported among minorities. However, the literature is limited in exploring discrimination with both objective and subjective sleep outcomes in the same sample. We examined the relationship between discrimination and markers of subjective and objective sleep in a racially diverse sample. METHODS: The analytic sample included 441 participants of the Midlife in the United States II (MIDUS) study (M [SD] age, 46.6 [1.03]; female, 57.9%; male, 42.1%; nonwhite, 31.7%). Complete data were available for 361 participants. Sleep measures included the Pittsburgh Sleep Quality Index, sleep latency, wake after sleep onset, and sleep efficiency derived from 7-day actigraphy. Discrimination was measured with the Williams Everyday Discrimination Scale. Ordinary least squares and logistic regression models were used to assess the relationship between discrimination and the subjective and objective measures of sleep. RESULTS: After adjusting for covariates, respondents with higher discrimination scores were significantly more likely to experience poor sleep efficiency (odds ratio, 1.12; p = .005) and report poorer sleep quality (odds ratio, 1.09; p = .029) on the basis of the Pittsburgh Sleep Quality Index. Higher discrimination scores were also associated with longer wake after sleep onset (b = 0.032, p < .01) and more sleep difficulties (b = 0.049, p = .01). Discrimination attenuated all differences in the sleep measures between whites and nonwhites except for sleep efficiency. CONCLUSIONS: The findings support the model that discrimination acts as a stressor that can disrupt subjective and objective sleep. These results suggest that interpersonal discrimination explains some variance in worse sleep among nonwhites compared with whites.

The social and behavioral influences (SBI) study: study design and rationale for studying the effects of race and activation on cancer pain management.

BACKGROUND: Racial disparities exist in the care provided to advanced cancer patients. This article describes an investigation designed to advance the science of healthcare disparities by isolating the effects of patient race and patient activation on physician behavior using novel standardized patient (SP) methodology. METHODS/DESIGN: The Social and Behavioral Influences (SBI) Study is a National Cancer Institute sponsored trial conducted in Western New York State, Northern/Central Indiana, and lower Michigan. The trial uses an incomplete randomized block design, randomizing physicians to see patients who are either black or white and who are "typical" or "activated" (e.g., ask questions, express opinions, ask for clarification, etc.). The study will enroll 91 physicians. DISCUSSION: The SBI study addresses important gaps in our knowledge about racial disparities and methods to reduce them in patients with advanced cancer by using standardized patient methodology. This study is innovative in aims, design, and methodology and will point the way to interventions that can reduce racial disparities and discrimination and draw links between implicit attitudes and physician behaviors. TRIAL REGISTRATION: https://clinicaltrials.gov/ , #NCT01501006, November 30, 2011.

A Differential Item Functional Analysis by Age of Perceived Interpersonal Discrimination in a Multi-racial/ethnic Sample of Adults.

We investigated whether individual items on the nine item William's Perceived Everyday Discrimination Scale (EDS) functioned differently by age (<45 vs ≥ 45) within five racial groups in the United States: Asians (n=2,017); Hispanics (n=2,688); Black Caribbeans (n=1,377); African Americans (n=3,434); and Whites (n=854). We used data from the 2001-2003 National Survey of American Lives and the 2001-2003 National Latino and Asian Studies. Multiple-indicator, multiple-cause models (MIMIC) were used to examine differential item functioning (DIF) on the EDS by age within each racial/ethnic group. Overall, Asian and Hispanic respondents reported less discrimination than Whites; on the other hand, African Americans and Black Caribbeans reported more discrimination than Whites. Regardless of race/ethnicity, the younger respondents (aged <45 years) reported less discrimination than the older respondents (aged ≥ 45 years). In terms of age by race/ethnicity, the results were mixed for 19 out of 45 tests of DIF (40%). No differences in item function were observed among Black Caribbeans. "Being called names or insulted" and others acting as "if they are afraid" of the respondents were the only two items that did not exhibit differential item functioning by age across all racial/ethnic groups. Overall, our findings suggest that the EDS scale should be used with caution in multi-age multi-racial/ethnic samples.

The relationship between perceived discrimination and psychotherapeutic and illicit drug misuse in Chicago, IL, USA.

Based on several stress-coping frameworks, recent studies have suggested that perceived experiences of discrimination, a psychosocial stressor, may be associated with various risky health behaviors. The 2001 Chicago Community Adult Health Study (n = 3,101), a face-to-face representative probability sample of adults in Chicago, IL, USA, was used to examine the relationship among lifetime everyday discrimination, major discrimination, and the use of illicit and psychotherapeutic drugs for nonmedical reasons. We used negative binomial logistic and multinomial regression analyses controlling for potential confounders. Approximately 17 % of the respondents reported using one or more illicit drugs and/or misusing one or more psychotherapeutic drug. Adjusting for socio-demographic characteristics, other stressors and various personality-related characteristics, results from negative binomial regression suggest that respondents who experienced moderate to high levels of everyday discrimination misused on average 1.5 different kinds of drugs more than respondents that experienced relatively low levels of everyday discrimination (p < 0.05). Similarly, an increase in one lifetime major discrimination event was associated with an increase of misusing 1.3 different drugs on average regardless of experiences of everyday discrimination (p < 0.001). When examining the types of drugs misused, results from multinomial logistic regression suggest that everyday discrimination was only associated with illicit drug use alone; however, lifetime major discrimination was associated with increased odds of using any illicit and both illicit/psychotherapeutic drugs. Mental health and substance use clinical providers should be aware of these potential relationships and consider addressing the harmful effects of perceived discrimination, in all patients not only among racial/ethnic minority patients.

Interpersonal discrimination and depressive symptomatology: examination of several personality-related characteristics as potential confounders in a racial/ethnic heterogeneous adult sample.

BACKGROUND: Research suggests that reports of interpersonal discrimination result in poor mental health. Because personality characteristics may either confound or mediate the link between these reports and mental health, there is a need to disentangle its role in order to better understand the nature of discrimination-mental health association. We examined whether hostility, anger repression and expression, pessimism, optimism, and self-esteem served as confounders in the association between perceived interpersonal discrimination and CESD-based depressive symptoms in a race/ethnic heterogeneous probability-based sample of community-dwelling adults. METHODS: We employed a series of ordinary least squares regression analyses to examine the potential confounding effect of hostility, anger repression and expression, pessimism, optimism, and self-esteem between interpersonal discrimination and depressive symptoms. RESULTS: Hostility, anger repression, pessimism and self-esteem were significant as possible confounders of the relationship between interpersonal discrimination and depressive symptoms, together accounting for approximately 38% of the total association (beta: 0.1892, p < 0.001). However, interpersonal discrimination remained a positive predictor of depressive symptoms (beta: 0.1176, p < 0.001). CONCLUSION: As one of the first empirical attempts to examine the potential confounding role of personality characteristics in the association between reports of interpersonal discrimination and mental health, our results suggest that personality-related characteristics may serve as potential confounders. Nevertheless, our results also suggest that, net of these characteristics, reports of interpersonal discrimination are associated with poor mental health.

Examining the relationship between the endorsement of racial/ethnic stereotypes and excess body fat composition in a national sample of African Americans and black Caribbeans.

Using the National Survey of American Life, a nationally representative household survey of non-institutionalized US Blacks, our study examined whether the endorsement of racial/ ethnic stereotypes was associated with excess body fat composition among African Americans (n = 3,265) and Black Caribbeans (n = 1,332) living in the United States. We used ordinary least squares and multinomial logistic regression analyses controlling for potential confounders. Results from the linear regression suggested that the endorsement of racial/ethnic stereotypes was associated with increased body mass index and weight among African American males (b = .57, P < .05) and females (b = .50 P < .05). Further, results from the adjusted multinomial logistic regression suggested that African American males who endorsed racial/ethnic stereotypes were more likely to be obese (odds ratio = 1.33, P < .05), than African American males who did not endorse racial/ethnic stereotypes. Surprising, a positive relationship was not found among Black Caribbeans. Future studies should examine the relationship between internalized discrimination and endorsements of negative racial/ethnic stereotypes and excess fat accumulation among ethnically heterogeneous samples of Blacks.

Perceived discrimination and DSM-IV-based alcohol and illicit drug use disorders.

OBJECTIVES: We examined the relationship between everyday and major discrimination and alcohol and drug use disorders in a nationally representative sample of African Americans and Black Caribbeans. METHODS: With data from the National Survey of American Life Study, we employed multivariable logistic regression analyses--while controlling for potential confounders--to examine the relationship between everyday and major discrimination and substance use disorders on the basis of Diagnostic and Statistical Manual of Mental Disorders criteria. RESULTS: Every 1 unit increase in the everyday discrimination scale positively predicted alcohol (odds ratio [OR] = 1.02; P < .01) and drug use (OR = 1.02; P < .05) disorders. Similarly, each additional major discrimination event positively predicted alcohol (OR = 1.10; P < .05) and drug use (OR = 1.15; P < .01) disorders. CONCLUSIONS: To our knowledge, this study is the first to examine problematic usage patterns rather than infrequent use of alcohol and drugs in a national sample of African American and Black Caribbean adults and the first to examine this particular relationship in a national sample of Black Caribbeans.

Variations in hypertension-related outcomes among Blacks, Whites and Hispanics in two large urban areas and in the United States.

OBJECTIVE: This study compared the hypertension prevalence, awareness, treatment and control in Chicago, Illinois and Detroit, Michigan to that of the general United States population (aged > or = 25 years) for the period 2001-2003. We examined whether and how much 1) urban populations have less favorable hypertension-related outcomes and 2) the rates of racial/ethnic minorities lag behind those of Whites in order to determine if the national data understate the magnitude of hypertension-related outcomes and racial/ethnic disparities in two large cities in the Midwestern region of the United States and perhaps others. METHODS: Unstandardized and standardized hypertension-related outcome rates were estimated. RESULTS: The hypertension-related outcomes among Chicago and Detroit residents lag behind the United States by 8%-14% and 10%-18% points, respectively. Additionally, this study highlights the complexity of the racial/ethnic differences in hypertension-related outcomes, where within each population, Blacks were more likely to have hypertension and to be aware of their hypertension status than Whites, and no less likely to be treated. Conversely, Hispanics were less likely to have hypertension and also less likely to be aware of their status when they do have hypertension when compared to Whites. CONCLUSION: At a time when efficacious treatment for hypertension has been available for more than 50 years, continued racial/ethnic differences in the prevalence, awareness, treatment and control of hypertension is among public health's greatest challenges. To achieve the proposed national hypertension-related goals, future policies must consider the social context of hypertension within central cities of urban areas.

Association between perceived interpersonal everyday discrimination and waist circumference over a 9-year period in the Midlife Development in the United States cohort study.

The relation between perceived interpersonal experiences of discrimination and measures of obesity is of great interest to many. This study examined the relation between changes in waist circumference and changes in perceived interpersonal everyday discrimination using the 1995-2004 Midlife Development in the United States cohort study (N = 1,452). After controlling for potential confounding variables that assessed behavioral and sociodemographic characteristics, sex-stratified ordinary least squares regression analyses suggested that the waist circumference of adult males who reported consistently high levels of interpersonal everyday discrimination increased 2.39 cm more than that of adult males who consistently reported low levels of interpersonal everyday discrimination (P < 0.05). Similarly, the waist circumference of adult females who reported an increase in interpersonal everyday discrimination increased 1.88 cm more than that of adult females who reported consistently low levels of interpersonal everyday discrimination (P < 0.05). These findings suggest that perceived interpersonal everyday discrimination may be associated with an increase in waist circumference over time among adults in the United States.

The association between perceived discrimination and obesity in a population-based multiracial and multiethnic adult sample.

OBJECTIVES: We examined whether perceived chronic discrimination was related to excess body fat accumulation in a random, multiethnic, population-based sample of US adults. METHODS: We used multivariate multinomial logistic regression and logistic regression analyses to examine the relationship between interpersonal experiences of perceived chronic discrimination and body mass index and high-risk waist circumference. RESULTS: Consistent with other studies, our analyses showed that perceived unfair treatment was associated with increased abdominal obesity. Compared with Irish, Jewish, Polish, and Italian Whites who did not experience perceived chronic discrimination, Irish, Jewish, Polish, and Italian Whites who perceived chronic discrimination were 2 to 6 times more likely to have a high-risk waist circumference. No significant relationship between perceived discrimination and the obesity measures was found among the other Whites, Blacks, or Hispanics. CONCLUSIONS: These findings are not completely unsupported. White ethnic groups including Polish, Italians, Jews, and Irish have historically been discriminated against in the United States, and other recent research suggests that they experience higher levels of perceived discrimination than do other Whites and that these experiences adversely affect their health.

Alcohol Use and Mental Health Conditions Among Black College Males: Do Those Attending Postsecondary Minority Institutions Fare Better Than Those at Primarily White Institutions?

While there is a sizeable body of research examining the association between alcohol use and mental health conditions among college students, there are sparse investigations specifically focusing on these associations among Black college students. This is concerning given Black college students face different stressors compared with their non-Black peers. Black males appear especially at risk, exhibiting increased susceptibility to mental health issues and drinking in greater quantities and more frequently than Black females. This investigation examined the association between alcohol consumption and mental health conditions among Black men attending institutions of higher education in the United States and sought to determine differences between Black men attending predominantly White institutions (PWIs) compared with those attending postsecondary minority institutions. Final sample included 416 Black men, 323 of which attended a PWI. Data were from the National College Health Assessment. Black men attending a PWI reported significantly greater levels of alcohol consumption and significantly more mental health conditions. Attendance at a minority-serving institution was associated with fewer mental health conditions among Black men. Future studies should seek to replicate these findings and conduct culturally sensitive and gender-specific research examining why Black men at PWIs report greater alcohol consumption and more mental health conditions than their peers attending postsecondary minority institutions.

Correlates of past year dental health visits: findings from the Indiana black men's health study.

OBJECTIVES: To examine the role of social support and additional predisposing, enabling and need factors that may be associated with past year dental visits among adult Black men. METHODS: Data came from a 2011 study of 1,444 Black men from 12 Indiana counties. Based on Andersen's Behavioral Model of Health Service Utilization, we conducted multivariable logistic regression analyses examining predisposing (age, sex, marital status, education), enabling (income, employment, health insurance, place of sick care, social support) and need factors (self-reported smoking status, health status, mental health days, and fruit and vegetable consumption). RESULTS: Overall, 42% of African American males sought dental care in the past year. Several predisposing (being married, having a college degree), enabling (being unemployed, having higher income, having health insurance and reporting high levels of social support) and need (increased fruit consumption) factors were found to be positively associated (P < 0.05) with past year dental care utilization in the fully adjusted model. Vegetable consumption was not significantly associated with past year dental use. CONCLUSION: Adult black men in this sample underutilized dental services. Results suggest several factors that can be used to target Black men to increase utilization rates. In particular, social support may be a promising factor that should be explored in further studies.

A birth records analysis of the Maternal Infant Health Advocate Service program: a paraprofessional intervention aimed at addressing infant mortality in African Americans.

Recognizing that no single intervention was likely to eliminate racial disparities, the Genesee County REACH 2010 partnership, utilizing both "bench" science and "trench" knowledge, developed 13 broad-based, multi-faceted interventions to eliminate infant mortality. This article provides highlights from a recent birth records comparison analysis of the Maternal Infant Health Advocate Service (MIHAS) intervention, and is solely based on the records of 111 MIHAS clients, and a random sample of 350 African-American women residing in Flint, Michigan. The MIHAS clients were more likely than the comparison sample not to have graduated from high school (56% vs 35%, respectively, P<.0001). The MIHAS clients were more likely to report at least some smoking during pregnancy (20% vs 15%, respectively, P<.05). However, after controlling for age and education, these results were no longer statistically significant. In terms of birth outcomes, the comparative odds of MIHAS clients delivering a low birth-weight infant are 1.124 (95% CI: 0.620-2.038); the odds of their delivering an infant at 37 weeks or earlier are 1.032 (0.609-1.749). Although the MIHAS clients did not have statistically better birth outcomes than those of the general African-American population in Flint, the MIHAS clients did not demonstrate the outcomes one would expect, given their higher level of risk. Based on this analysis, the MIHAS intervention may have brought its clients "up to par" with the general community on several birth outcomes.