Does study subject diversity influence cardiology research site performance?: Insights from 2 U.S. National Coronary Stent Registries.

BACKGROUND: Minorities and women are underrepresented in cardiovascular research. Whether their higher enrollment can be predicted or influences research site performance is unclear. METHODS: We evaluated 104 sites that enrolled 4,184 patients in the U.S. Platinum Diversity (PD) and Promus Element Plus (PE Plus) studies (2012 to 2016). Research sites were ranked from lowest to highest minority and female enrollment, respectively. United States Census Bureau division and core-based statistical area (CBSA) populations were determined for each site and the following study performance metrics compared across quartiles of minority and female enrollment, respectively: (1) study subject enrollment rate (SER), (2) time to first patient enrolled, (3) rate of follow-up visits not done, (4) rate of follow-up visits out of window, and (5) protocol deviation rate (PDR). Multivariable regression was used to predict SER and PDR. RESULTS: Minority enrollment varied by region (P = .025) and population (P = .024) with highest recruitment noted in the Pacific, West South Central, South Atlantic, Mid-Atlantic and East North Central divisions. Female enrollment bore no relationship to region (P = .67) or population (P = .40). Median SER was similar in sites withi the highest vs lowest quartile of minority enrollment (SER of 4 vs 5 patients per month, respectively, P =0.78) and highest vs. lowest female enrollment (SER of 4 vs 4, respectively, P = .21). Median PDR was lower in sites within the highest vs lowest minority enrollment (0.23 vs 0.50 PDs per patient per month, respectively, P = .01) and highest vs. lowest female enrollment (0.28 vs. 0.37 PDs per patient per month, respectively, P = .04). However, this relationship did not persist after multivariable adjustment. All other site performance metrics were comparable across quartiles of minority and female enrollment. CONCLUSIONS: Minority, but not female enrollment, correlated with research site geographic region and surrounding population. High enrollment of minorities and women did not influence study performance metrics. These findings help inform future strategies aimed at increasing clinical trial diversity. TRIAL REGISTRATION: The PD and PE Plus studies are registered at www.clinicaltrials.gov under identifiers NCT02240810 and NCT01589978, respectively. KEY POINTS: Question: Does the enrollment of more Blacks, Hispanics and women in US cardiovascular research studies influence the overall rate of study subject enrollment and/or other key study site performance metrics and can diverse enrollment be predicted? FINDINGS: In this pooled analysis of 104 sites that enrolled 4,184 patients in the Platinum Diversity and Promus Element Plus Post-Approval Studies, we found that the enrollment of higher proportions of underrepresented minorities and women was univariately associated with lower protocol deviation rates while having no effect on other site performance metrics. A site's geographic location and surrounding population predicted minority, but not female enrollment. Meaning: These findings suggest that cardiovascular research subject diversity may be predicted from site characteristics and enhanced without compromising key study performance metrics. These insights help inform future strategies aimed at improving clinical trial diversity.

The Contested Whiteness of Arab Identity in the United States: Implications for Health Disparities Research.

In response to the Institute on Minority Health and Health Disparities' (NIMHD) new health disparities research framework, we call on the National Institutes of Health (NIH) to acknowledge Arabs in the United States as a health disparity population. Arab classification as White leads to their cultural invisibility and perpetuates a cycle of undocumented health disparities.We provide examples of how this contested identity reinforces challenges associated with identifying this population and contributes to enactments of structural violence and undocumented health disparities. Decades of research with Arabs in the United States provides consistent evidence that their health does not fit the health profile of White Americans and that Arabs do not benefit from Whiteness and White privilege associated with their White racial categorization. On the contrary, Arabs in the United States experience discrimination and health disparities that require urgent attention; this can be achieved only by identifying the population with a racial category other than White.We conclude with recommendations to NIH and NIMHD to revise their definition of health disparity populations to include Arabs in the United States.

"I thought you were Japanese": Ethnic miscategorization and identity assertion.

Across 2 studies we examined how ethnic minorities respond to ethnic miscategorization. Using a 21-day experience sampling procedure (Study 1), we found that ethnic minorities exhibited greater ethnic identity assertion when they had reported being ethnically miscategorized the previous day. Similarly, we found that ethnic minorities who were ethnically miscategorized (vs. not) by a White partner in the laboratory exhibited greater ethnic identity assertion and expressed greater dislike of their partner (Study 2). In both studies, these effects were stronger for individuals whose ethnic identity was central to their self-concept. The implications of these findings for ethnic identity development and intergroup relations are discussed. (PsycINFO Database Record

Sources of self-categorization as minority for mixed-race individuals: Implications for affirmative action entitlement.

Multiracial individuals are in the unique position of being able to categorize themselves as members of multiple racial groups. Drawing on self-categorization theory, we suggest that similarity to the minority ingroup depends on self-perceptions of physical appearance and connectedness to the minority ingroup. Moreover, we argue that similarity to the ingroup determines self-categorization as minority, which predicts category-based entitlements such as perceived eligibility for minority resources (e.g., affirmative action). Using path analysis, we found support for this model on a convenience sample of 107 mixed-race minority-White participants. The results suggest that affective processes rather than observable characteristics such as prototypical physical appearance better predict self-categorization among mixed-race individuals.

A meta-analysis of the hepatitis C virus distribution in diverse racial/ethnic drug injector groups.

Hepatitis C virus (HCV) is mostly transmitted through blood-to-blood contact during injection drug use via shared contaminated syringes/needles or injection paraphernalia. This paper used meta-analytic methods to assess whether HCV prevalence and incidence varied across different racial/ethnic groups of injection drug users (IDUs) sampled internationally. The 29 prevalence and 11 incidence studies identified as part of the HCV Synthesis Project were categorized into subgroups based on similar racial/ethnic comparisons. The effect estimate used was the odds or risk ratio comparing HCV prevalence or incidence rates in racial/ethnic minority groups versus those of majority status. For prevalence studies, the clearest disparity in HCV status was observed in the Canadian and Australian Aboriginal versus White comparison, followed by the US non-White versus White categories. Overall, Hispanic IDUs had greater HCV prevalence, and HCV prevalence in African-Americans was not significantly greater than that of Whites in the US. Aboriginal groups showed higher HCV seroconversion rates when compared to others, and African-Americans had lower seroconversion rates compared to other IDUs in the US. The findings suggest that certain minority groups have elevated HCV rates in comparison to other IDUs, which may be a consequence of stigma, discrimination, different risk behaviors or decreased access to health care, services and preventive education. Future research should seek to explicitly explore and explain racial/ethnic variations in HCV prevalence and incidence, and define the groups more precisely to allow for more accurate detection of possible racial/ethnic differences in HCV rates.

Racial disparities in Medicaid enrollment and prenatal care initiation among pregnant teens in Florida: comparisons between 1995 and 2001.

BACKGROUND: Teens and racial and ethnic minority women are less likely to initiate prenatal care (PNC) in the first trimester of pregnancy than their counterparts. OBJECTIVE: This study examines the impact of Medicaid program changes in the late 1990s on the timing of Medicaid enrollment and PNC initiation among pregnant teens by race and ethnicity. RESEARCH DESIGN: Using Medicaid enrollment and claims data and a difference-in-differences method, we examine how the patterns of prepregnancy Medicaid enrollment, PNC initiation, and racial and ethnic disparities in PNC changed over time after controlling for person- and county-level characteristics. SUBJECTS: We included 14,089 teens in Florida with a Medicaid-covered delivery in fiscal years 1995 and 2001. MEASURES: Prepregnancy enrollment was defined as enrollment 9 or more months before delivery; late or no PNC was defined as initiation of PNC within 3 months of delivery or not at all. RESULTS: For teens enrolled in traditional welfare-related categories, the proportion with prepregnancy Medicaid enrollment increased and the proportion with late or no PNC declined from 1995 to 2001. Teens enrolled under the Omnibus Budget Reconciliation Act (OBRA) expansion category in 2001 were less likely than welfare-related teen enrollees to have prepregnancy coverage but were more likely to initiate PNC early. Racial disparities were found in PNC initiation among the 1995 welfare-related group and the 2001 expansion group but were eliminated or greatly reduced among the 2001 welfare-related group. CONCLUSIONS: Providing public insurance coverage improves access to care but is not sufficient to meet Healthy People 2010 goals or eliminate racial and ethnic disparities in PNC initiation.

The ambiguous meanings of the racial/ethnic categories routinely used in human genetics research.

Many researchers are currently studying the distribution of genetic variations among diverse groups, with particular interest in explaining racial/ethnic health disparities. However, the use of racial/ethnic categories as variables in biological research is controversial. Just how racial/ethnic categories are conceptualized, operationalized, and interpreted is a key consideration in determining the legitimacy of their use, but has received little attention. We conducted semi-structured, open-ended interviews with 30 human genetics scientists from the US and Canada who use racial/ethnic variables in their research. They discussed the types of classifications they use, the criteria upon which they are based, and their methods for classifying individual samples and subjects. We found definitions of racial/ethnic variables were often lacking or unclear, the specific categories they used were inconsistent and context specific, and classification practices were often implicit and unexamined. We conclude that such conceptual and practical problems are inherent to routinely used racial/ethnic categories themselves, and that they lack sufficient rigor to be used as key variables in biological research. It is our position that it is unacceptable to persist in the constructing of scientific arguments based on these highly ambiguous variables.

Ethnogenetic layering (EL): an alternative to the traditional race model in human variation and health disparity studies.

BACKGROUND: Traditionally, studies in human biodiversity, disease risk, and health disparities have defined populations in the context of typological racial models. However, such racial models are often imprecise generalizations that fail to capture important local patterns of human biodiversity. AIM: More explicit, detailed, and integrated information on relevant geographic, environmental, cultural, genetic, historical, and demographic variables are needed to understand local group expressions of disease inequities. This paper details the methods used in ethnogenetic layering (EL), a non-typological alternative to the current reliance of the biological racial paradigm in public health, epidemiology, and biomedicine. SUBJECTS AND METHODS: EL is focused on geographically identified microethnic groups or MEGs, a more nuanced and sensitive level of analysis than race. Using the MEG level of analysis, EL reveals clinical variations, details the causes of health disparities, and provides a foundation for bioculturally effective intervention strategies. EL relies on computational approaches by using GIS-facilitated maps to produce horizontally stratified geographical regional profiles which are then stacked and evaluated vertically. Each horizontal digital map details local geographic variation in the attributes of a particular database; usually this includes data on local historical demography, genetic diversity, cultural patterns, and specific chronic disease risks (e.g. dietary and toxicological exposures). Horizontal visual display of these layered maps permits vertical analysis at various geographic hot spots. RESULTS AND CONCLUSIONS: From these analyses, geographical areas and their associated MEGs with highly correlated chronic disease risk factors can be identified and targeted for further study.

The association between perceived discrimination and underutilization of needed medical and mental health care in a multi-ethnic community sample.

This study examines the association between perceived discrimination and underutilization of needed medical and mental health care, in a representative, multi-ethnic community sample. Data were derived from a cross sectional survey of 10,098 White, U.S.-born Black, African-born Black, American Indian, Hispanic, and Southeast Asian adults in Hennepin County, Minnesota. Even after controlling for socio-demographic characteristics, health care access, and physical and mental health, perceived discrimination was associated with underutilization of medical care among Whites, U.S.-born Blacks, and American Indians and was associated with underutilization of mental health care among Whites, U.S.-born Blacks, Southeast Asians, and American Indians. Correlates of different types of discrimination (major, everyday, health care) on underutilization of care varied among ethnic groups. The higher prevalence of discrimination among racial and ethnic minorities may contribute to their underutilization of health care services. Future research is needed to understand the impacts of different types of discrimination on different groups.

The educational background and qualifications of UK medical students from ethnic minorities.

BACKGROUND: UK medical students and doctors from ethnic minorities underperform in undergraduate and postgraduate examinations. Although it is assumed that white (W) and non-white (NW) students enter medical school with similar qualifications, neither the qualifications of NW students, nor their educational background have been looked at in detail. This study uses two large-scale databases to examine the educational attainment of W and NW students. METHODS: Attainment at GCSE and A level, and selection for medical school in relation to ethnicity, were analysed in two separate databases. The 10th cohort of the Youth Cohort Study provided data on 13,698 students taking GCSEs in 1999 in England and Wales, and their subsequent progression to A level. UCAS provided data for 1,484,650 applicants applying for admission to UK universities and colleges in 2003, 2004 and 2005, of whom 52,557 applied to medical school, and 23,443 were accepted. RESULTS: NW students achieve lower grades at GCSE overall, although achievement at the highest grades was similar to that of W students. NW students have higher educational aspirations, being more likely to go on to take A levels, especially in science and particularly chemistry, despite relatively lower achievement at GCSE. As a result, NW students perform less well at A level than W students, and hence NW students applying to university also have lower A-level grades than W students, both generally, and for medical school applicants. NW medical school entrants have lower A level grades than W entrants, with an effect size of about -0.10. CONCLUSION: The effect size for the difference between white and non-white medical school entrants is about B0.10, which would mean that for a typical medical school examination there might be about 5 NW failures for each 4 W failures. However, this effect can only explain a portion of the overall effect size found in undergraduate and postgraduate examinations of about -0.32.

Changes in medical care experiences of racial and ethnic groups in the United States, 1996-2002.

The authors examined changes in medical care experiences of racial/ethnic groups (non-Hispanic white, Asian and Pacific Islander, Hispanic, and non-Hispanic black) between 1996 and 2002, using data from the Household Component of Medical Expenditure Panel Surveys. Proportions and adjusted odds ratios for each group's primary care experience are presented. Comparisons are made between groups at each time period and within groups between the two time periods. Multivariable analyses control for demographic and socioeconomic characteristics, health care needs and source of care, and health insurance. Racial/ethnic minorities experienced worse medical care than non-Hispanic whites, but results differed among groups. Non-Hispanic blacks were no different from non-Hispanic whites and showed a slight improvement over time, except for lower odds of having a usual source of care and worse sociodemographic and health indicators. Hispanics had worse experiences than whites in 5 of 8 indicators in 2002 (vs. 3 in 1996). Asians assessed their experience as worse than that of whites in 6 of 8 indicators in 2002 (vs. 3 in 1996), yet had higher self-rated health and education than non-Hispanic whites. Disparities in medical care experience have increased for some groups, and efforts must be made to reduce financial and nonfinancial barriers to care for racial/ethnic minority populations.

Ethnicity and mental health treatment utilization by patients with personality disorders.

The authors examined the relationship between ethnicity and treatment utilization by individuals with personality disorders (PDs). Lifetime and prospectively determined rates and amounts of mental health treatments received were compared in over 500 White, African American, and Hispanic participants with PDs in a naturalistic longitudinal study. Minority, especially Hispanic, participants were significantly less likely than White participants to receive a range of outpatient and inpatient psychosocial treatments and psychotropic medications. This pattern was especially pronounced for minority participants with more severe PDs. A positive support alliance factor significantly predicted the amount of individual psychotherapy used by African American and Hispanic but not White participants, underscoring the importance of special attention to the treatment relationship with minority patients. These treatment use differences raise complex questions about treatment assessment and delivery, cultural biases of the current diagnostic system, and possible variation in PD manifestation across racial/ethnic groups. Future studies need to assess specific barriers to adequate and appropriate treatments for minority individuals with PDs.

Challenges faced by minority children in obtaining dental care.

Deaths of children due to neglected dental diseases have put the issue of access to care by minorities at the forefront of dental public health discussions. We evaluated the trends in dental service utilization in relation to racial disparities and other factors using Medicaid enrollment and claims data from 1990 to 1997 for Alabama children 19 years of age and younger (N=512,049). Alabama Medicaid children visited the dentist at a low and declining rate. The number of participating providers gradually declined over time and the racial disparities in service utilization were related to the availability of a local provider. Lower service utilization, however, was not a simple function of race, but a complex interaction of race with age and gender. Identification of these complex interactions and removal of barriers to service utilization in race, age, and gender sub-groups will help the U.S. meet the year 2010 oral health objectives.

Cognitions and depressive symptoms among ethnic minority adolescents.

Cognitive models have guided effective intervention strategies in the treatment of depression. However, little is known about the cognitive model's relevance in different cultural ethnic groups in the United States. This study examines the cross-sectional and longitudinal associations among cognitive variables and depressive symptoms among African American, Caucasian, and Hispanic adolescents in the United States. Community adolescents (N = 450) ages 14-18 years (African American n = 79; Caucasian n = 273; Hispanic n = 98) provided information regarding their depressive symptoms and cognitions at two surveys, 6 months apart. Self-efficacy, cognitive errors, and hopelessness were associated with concurrent depressive symptoms at baseline. In addition, cognitive errors at baseline, controlling for baseline depressive symptoms and the occurrence of stressful events, predicted depressive symptoms at follow-up. Ethnic differences disappeared when parent education level was controlled. Our findings demonstrate support for the cognitive model of depression across ethnic groups. The importance of controlling for social class when examining ethnic differences in psychological variables is highlighted by our findings.

Racial and ethnic disparities in access to physicians with HIV-related expertise.

OBJECTIVE: Professional medical associations recommend that physicians who treat patients with human immunodeficiency virus (HIV) have a measurable form of disease-specific expertise, such as high HIV patient volume or infectious diseases certification. Although it is known that racial/ethnic minorities generally have worse access to care than do whites, previous work has not examined disparities in the use of physicians with HIV-related expertise. DESIGN, SETTING, AND PARTICIPANTS: We linked data from a prospective cohort study of 2,207 persons with HIV receiving care in the United States with a cross-sectional survey of 404 physicians caring for them. Using multivariate analysis, we estimated the association of patient race/ethnicity with the experience and training of their physicians, controlling for health status, socioeconomic status, demographic characteristics, and geographic variation in provider supply. RESULTS: Compared with white patients, African Americans were less likely to have an infectious diseases specialist as a regular source of care (odds ratio [OR], 0.60; 95% confidence interval [CI], 0.37 to 0.95). Persons of Alaskan Native, American Indian, Asian, Pacific Islander, or mixed racial background were also less likely than whites to have an infectious diseases specialist (OR, 0.44; 95% CI, 0.23 to 0.83). Conversely, Latino patients had physicians whose HIV patient volume was, on average, 24% higher than the physicians of white patients (incident rate ratio, 1.24; 95% CI, 1.03 to 1.50). CONCLUSIONS: Some groups of racial/ethnic minorities are less likely than are whites to have infectious diseases specialists as a regular source of care. The finding that the physicians of Latino patients had relatively higher HIV caseloads suggests that this particular patient subpopulation has access to HIV expertise. Further work to explain racial/ethnic differences in access to physicians will help in the design of programs and policies to eliminate them.

Racial and ethnic disparities and perceptions of health care: does health plan type matter?

OBJECTIVE: To examine whether racial and ethnic differences in the distribution of individuals across types of health plans explain differences in satisfaction and trust with their physicians. DATA SOURCES: Data were derived from the 1998-1999 Community Tracking Household and Followback Studies and consisted of a nationwide sample of adults (18 years and older). DATA COLLECTION: The data were collected by telephone survey. Surveys were administered in English and Spanish. The response rate for the Household Survey was 63 percent, and the match rate for the Followback Survey was 59 percent. STUDY DESIGN: Multivariate analyses used regression methods to detect independent effects of respondent race and ethnicity on satisfaction and trust with physician, while controlling for enrollment in different types of health plans. PRINCIPAL FINDINGS: Racial and ethnic minorities are more likely than whites to have lower levels of trust and satisfaction with their physician. The most prominent differences occurred within the Latino and Native American/Asian American/Pacific Islander/Other ("Other") populations. Plan type does not mitigate the relationship between race/ethnicity and trust and satisfaction for the overall adult population. CONCLUSIONS: Disparate levels of trust and satisfaction exist within ethnic and minority populations, even when controlling for the distribution of individuals across types of health plans. The results demonstrate a need to better understand the health care-related factors that drive disparate trust and satisfaction.

The Imam's role in meeting the counseling needs of Muslim communities in the United States.

OBJECTIVE: Muslims are one of the most rapidly growing minority groups in the United States and have experienced increased stress since September 11, 2001. The purpose of this study was to elucidate the roles of imams, Islamic clergy, in meeting the counseling needs of their communities. METHODS: An anonymous self-report questionnaire was mailed to 730 mosques across the United States. RESULTS: Sixty-two responses were received from a diverse group of imams, few of whom had received formal counseling training. Imams reported that their congregants came to them most often for religious or spiritual guidance and relationship or marital concerns. Imams reported that since September 11, 2001, there has been an increased need to counsel persons for discrimination. An increased need to counsel persons who were discriminated against was reported by all imams with congregations in which a majority are Arab American, 60 percent of imams with congregations in which a majority are South Asian American, and 50 percent of imams with congregations in which a majority are African American. CONCLUSIONS: Although imams have little formal training in counseling, they are asked to help congregants who come to them with mental health and social service issues. Imams need more support from mental health professionals to fulfill a potentially vital role in improving access to services for minority Muslim communities in which there currently appear to be unmet psychosocial needs.

Racial and ethnic disparities in breast cancer stage, treatment, and survival in the United States.

Several studies indicate that African-American, Hispanic White, and Native American women with breast cancer present with more advanced stages and have poorer survival rates than non-Hispanic Whites, while Asians/Pacific Islanders do not. However, Asians/Pacific Islanders and Hispanic Whites are heterogeneous populations, and recent data indicate that certain subgroups of these populations have poorer breast cancer outcomes compared to non-Hispanic Whites, while others have better outcomes. Many of these disparities have persisted for decades, but until recently, detailed studies exploring the reasons behind these disparities have been limited. The results of these studies point to the effect of differences in socioeconomic status, access to health care (including both breast cancer screening and treatment services), lifestyle factors, and tumor characteristics on these disparities. Thus, these studies indicate that these disparities are multifactorial, and therefore strategies aimed at reducing them must involve advocacy, research, education, and healthcare services. A key component to the success of these strategies is not only support for them on the federal and state levels, but also the involvement of local communities in developing programs and policies that are culturally and linguistically appropriate for their communities in order to ensure not only the utility, but also the longevity, of these efforts.

Testing the interaction between parent-child relationship factors and parent smoking to predict youth smoking.

PURPOSE: To examine if parental smoking modifies the association between parent-child connectedness and parental disapproval of youth smoking with smoking behavior among minority youth. METHODS: Baseline data from an urban Seattle, Washington neighborhood-based intervention trial to reduce risk behaviors among minority males and females aged 11-15 years were used to identify 428 minority youth-parent/guardian pairs. Parental smoking status, assessed by telephone interview, and youth reports of connectedness and parental disapproval, assessed by questionnaire, were tested in Chi-squared stratified analysis and logistic regression to predict youth smoking. RESULTS: The majority (86%) of the parents/guardians were the natural parent of the surveyed child (67% mother; 19% father). Parental mean age was 41 years, 54% reported household incomes less than $30K, and 26% were current smokers. Youth had a mean age of 13 years, 28% self-identified as African-American, 37% as Asian, and 35% as "Multiethnic"; 41% reported ever smoking, and 9% reported smoking within the past 30 days. Perceived parental disapproval of smoking was not associated with youth smoking behavior. Among youth whose parent did not smoke, those who reported low level of parent-child connectedness were two times more likely to report ever having smoked than those who reported high levels of connectedness. Among youth whose parent smoked, connectedness was not associated with youth smoking. The interaction between connectedness and parental smoking status and its relationship to youth smoking remained significant after controlling for covariates. CONCLUSION: Overall, high levels of parent-child connectedness are protective against youth smoking. However, family connectedness may not protect children from becoming smokers when parents smoke.