Racial Differences in the Predictors of Interest in Bariatric Surgery in the Rural, Southeastern USA.

BACKGROUND: Although African-Americans have a higher prevalence of severe obesity than Whites, they are less likely to have bariatric surgery. Demographic, healthcare, and knowledge variables contribute to this racial disparity but have not been examined separately by race. OBJECTIVES: Examine the role of demographic, healthcare, and knowledge variables in African-Americans' versus Whites' interest in bariatric surgery. METHODS: A random sample of 293 African-American and 259 White adults were surveyed door-to-door in the rural south. The survey assessed weight, height, demographics, access to healthcare, and knowledge of and interest in bariatric surgery. RESULTS: African-Americans had significantly lower knowledge of bariatric surgery than Whites but there were no racial differences in interest in the surgery. The logistic regression predicting African-Americans' interest in the surgery from demographic, healthcare, obesity, and knowledge variables revealed that obesity (OR = 4.7) and the health benefits (OR = 3.3) were the only predictors. The same regression for Whites found that knowing someone who had the surgery (OR = 3.7) was the sole predictor. CONCLUSIONS: Knowledge variables may be stronger than healthcare and demographic variables as predictors of interest in bariatric surgery among rural, southern, African-Americans and Whites. Whites' willingness to consider the surgery might be enhanced by favorable stories/blogs by those who had the surgery, whereas African-Americans' interest might be increased by information on the additional health benefits of the surgery. These culturally tailored messages from healthcare providers might increase utilization of and reduce racial disparities in bariatric surgery.

Assessment of the US Federal Retailer Violation Rate as an Estimate of the Proportion of Retailers That Illegally Sell Tobacco to Adolescents.

Importance: Despite progress against tobacco sales to minors, retailers continue to violate state and federal laws and supply adolescent smokers with tobacco products. Government-sanctioned surveys underestimate the extent of the problem, and retailer associations use these data to block stricter enforcement policies. Objectives: To assess the validity of the US federal retailer violation rate (RVR) as an estimate of the proportion of retailers that sell tobacco to minors and to investigate what proportion always or almost always sells vs refuses to sell cigarettes to minors. Design, Setting, and Participants: This survey study was conducted October 6, 2012, to September 8, 2013; data were analyzed between September 28, 2017, and March 21, 2018. The setting was a suburban county adjacent to Denver, Colorado. Participants were a systematically selected, population-based cluster sample of retailers that stock cigarettes for sale. Retailers were masked to the survey. Main Outcomes and Measures: Each retailer was visited 6 times by supervised minors who attempted to purchase cigarettes at each visit. The main outcome was whether cigarettes were sold. Other measures included whether government-issued photo identification (ID) was requested as required by law, how ID was examined, and what the demographic characteristics of study minors and clerks were. Results: The sample of 201 retailers (44.8% of the 449 listed population) included convenience stores (n = 77), liquor stores (n = 63), grocery stores/supermarkets (n = 33), pharmacies (n = 17), tobacco stores (n = 7), and stand-alone gas stations (n = 4). Bars, clubs, and adult establishments were excluded. A total of 1181 purchase attempts were analyzed; 25 (2.1%) were excluded for missing data. The mean RVR across 6 rounds of checks was 18.0% (95% CI, 14.7%-21.2%) and ranged from 13.7% to 28.0% per round. Most retailers (54.7% [110 of 201]) violated at least once in 6 visits, 26.4% (53 of 201) violated at least twice, and 11.9% (24 of 201) violated half or more times. How retailers examined proof of age largely determined whether violations occurred. Conclusions and Relevance: The proportion of retailers that sold cigarettes to a minor at least once in 6 attempts was 3 times higher than the mean RVR based on a single inspection per retailer. Larger replication studies are needed. Enforcement protocols should reflect the fact that each retailer does not respond consistently when adolescents try to buy tobacco products, and many retailers are not properly validating ID that shows proof of age.

Racial disparities in healthcare provider advice to quit smoking.

African-American/Black smokers are less likely than White smokers to be told to quit smoking by healthcare providers. This preliminary study examined the predictors of being told to quit separately by race for the first time to potentially highlight the source of this racial disparity. A random, household sample of 1670 Black and White adults from a southeastern county of the United States completed a brief survey on their demographics, smoking, access to healthcare, health status, and receipt of healthcare provider advice to quit smoking. Analyses are based on the 512 Black and White smokers in that sample. The logistic regression for all smokers revealed that after controlling for demographic, healthcare, and health status variables, White smokers were 2.39 times more likely than Black smokers to have ever been told to quit smoking. The regression for Black smokers revealed that women and older people were more likely to be told to quit, and that healthcare and health status did not contribute. In the regression for White smokers, no predictor was statistically significant. These findings suggest that one possible reason that African-Americans receive cessation advice less often than Whites is that such advice varies with their age and gender, whereas for Whites this is not the case.

Residential Segregation and Racial Cancer Disparities: A Systematic Review.

BACKGROUND: This paper provides the first review of empirical studies of segregation and black-white cancer disparities. METHODS: We searched all years of PubMed (through May 2016) using these terms: racial segregation, residential segregation, neighborhood racial composition (first terms) and (second terms) cancer incidence, mortality, survival, stage at diagnosis, screening. The 17 (of 668) articles that measured both segregation and a cancer outcome were retained. RESULTS: Segregation contributed significantly to cancer and to racial cancer disparities in 70% of analyses, even after controlling for socioeconomic status and health insurance. Residing in segregated African-American areas was associated with higher odds of later-stage diagnosis of breast and lung cancers, higher mortality rates and lower survival rates from breast and lung cancers, and higher cumulative cancer risks associated with exposure to ambient air toxics. There were no studies of many types of cancer (e.g., cervical). Studies differed in their measure of segregation, and 40% used an invalid measure. Possible mediators of the segregation effect usually were not tested. CONCLUSIONS: Empirical analysis of segregation and racial cancer disparities is a recent area of research. The literature is limited to 17 studies that focused primarily on breast cancer. Studies differed in their measure of segregation, yet segregation nonetheless contributed to cancer and to racial cancer disparities in 70% of analyses. This suggests the need for further research that uses valid measures of segregation, examines a variety of types of cancers, and explores the variables that may mediate the segregation effect.

Perioperative Inotrope Therapy and Atrial Fibrillation Following Coronary Artery Bypass Graft Surgery: Evidence of a Racial Disparity.

BACKGROUND AND OBJECTIVE: Following coronary artery bypass graft (CABG) surgery, mortality rates are significantly higher among black patients who experience postoperative atrial fibrillation (POAF). Perioperative inotropic therapy (PINOT) was associated with POAF in previous reports, but the extent to which race influences this association is unknown. In the present study, the relationship between PINOT, race, and POAF was examined in patients undergoing CABG surgery. METHODS AND SETTING: Clinical records were examined from a prospectively maintained cohort of 11,855 patients (median age 64 yrs; 70% male; 16% black) undergoing primary isolated CABG at a large cardiovascular institute in the southeastern region of the United States. Relative risk (RR) and 95% confidence intervals (CIs) were computed using log-binomial regression. MAIN RESULTS: The association between PINOT and POAF was significantly increased among black patients (adjusted RR 1.7, CI 1.4-2.0) compared with white patients (adjusted RR 1.3, CI 1.2-1.4) (pinteraction  = 0.013). CONCLUSIONS: These findings suggest that PINOT may be disproportionately associated with POAF among black patients undergoing CABG surgery. Additional studies are needed to examine further the potential underlying mechanisms of this association.

Rural Shop-Based Health Program Planning: a Formative Research Approach Among Owners.

African American barbershops and beauty salons are settings that have been identified as a significant and culturally relevant venue to reach minority populations for health promotion activities. By being located in almost every town in the USA, this setting is a viable means to promote healthy lifestyles among African Americans. The purpose of this formative research project was to assess African American barbershop and beauty salon owners' perceptions of providing health promotion programming in their shops, as well as to obtain information on health topics of interest and strategies for implementation. Interviewees were recruited using snowballing among clientele and owner referrals, between November 2014 and August 2015. A total of 20 barbershop and salon owners, across 11 counties in eastern North Carolina, completed face-to-face interviews. Responses were stratified by barbershops and beauty salons. Across both groups, all owners stated it would be a good idea to have health programs/interventions within the shop setting. Most noted topics of interest included diet and nutrition, hypertension, and (wo)men's reproductive health. When asked further about these desired topics, both benefits and relevance to customers and the African American community were the reasons for their selections. In addition, across barbershops and salons, 90 % of owners stated interest in having a program implemented in their shop. This information will be used to guide the development of shop-based interventions, with the aid of a community advisory board composed of shop owners, individual barbers and stylists and customers.

Inequities in tobacco retailer sales to minors by neighbourhood racial/ethnic composition, poverty and segregation, USA, 2015.

OBJECTIVE: Tobacco retailers are an important source of tobacco products for minors. Previous research shows racial discrimination in sales to minors, but no national study has examined neighbourhood correlates of retailer under-age sales. METHODS: We accessed publicly available results of 2015 US Food and Drug Administration (FDA) inspections of tobacco retailers (n=108 614). In this cross-sectional study, we used multilevel logistic regression to predict the likelihood of retailer sale to a minor based on tract characteristics. We assessed the proportion of residents identifying as American Indian, Asian, Black, Latino and White; Isolation Index scores for each racial/ethnic group; the proportion of people less than age 65 living in poverty; and the proportion of residents age 10-17 in relation to retailer inspection results. RESULTS: The proportion of American Indian residents, Black residents, Latino residents and residents less than age 65 under the poverty line in a neighbourhood are independently, positively associated with the likelihood that a retailer in that neighbourhood will fail an under-age buy inspection. The proportion of White residents and residents age 10-17 are independently, negatively associated with the likelihood of sale of tobacco products to a minor. Isolation Index scores show a similar pattern. In multivariable models holding neighbourhood characteristics constant, higher proportions of Black (+), Latino (+) and age 10-17 (-) residents remained significant predictors of the likelihood of under-age sale. DISCUSSION: Regulatory agencies should consider oversampling retailers in areas with higher likelihood of sales to minors for inspection. Interventions with tobacco retailers to reduce inequities in youth access should be implemented.

Sociocultural correlates of cigarette smoking among African-American men versus women: Implications for culturally specific cessation interventions.

Low socioeconomic status, racial discrimination, and low acculturation are the major sociocultural correlates of smoking among African-American adults. This study is the first to examine all three variables simultaneously and to analyze gender differences in their association with smoking. Results for the sample revealed that low education and low acculturation predicted smoking but racial discrimination did not. For women, low acculturation was the sole predictor of smoking, whereas for men, socioeconomic status variables were the sole predictors. This suggests that low acculturation may be associated with smoking among African-American women only. Hence, culturally specific smoking cessation programs designed for low-acculturated African-Americans might be effective for African-American women alone.

Targeting cancer information to African Americans: the trouble with talking about disparities.

Cancer messages that are designed for African Americans often include information on Black-White cancer disparities to raise Black adults' perceived cancer risk and increase cancer screening. Whether disparities messages achieve this, and how Blacks feel about hearing that they are worse off than are Whites, largely remain unknown. This study examined Blacks' responses to two mock newspaper articles on colorectal cancer: a disparities article and a nondisparities article. A random sample of 400 Black adults read the articles and answered questions on their reactions to both. Results revealed that readers of the disparities article felt significantly more insulted, discouraged, and angry about it than did readers of the nondisparities article. Article type played no role in desires or intentions to have colon cancer screening among participants of screening age, and no role in perceived cancer risk or intentions to suggest colon cancer screening to family among participants of any age. These findings suggest that disparities messages might not increase perceived cancer risk or increase interest in cancer screening as widely theorized and intended; instead, they simply may elicit anger and discouragement among African Americans.

Advancing research on racial-ethnic health disparities: improving measurement equivalence in studies with diverse samples.

To conduct meaningful, epidemiologic research on racial-ethnic health disparities, racial-ethnic samples must be rendered equivalent on other social status and contextual variables via statistical controls of those extraneous factors. The racial-ethnic groups must also be equally familiar with and have similar responses to the methods and measures used to collect health data, must have equal opportunity to participate in the research, and must be equally representative of their respective populations. In the absence of such measurement equivalence, studies of racial-ethnic health disparities are confounded by a plethora of unmeasured, uncontrolled correlates of race-ethnicity. Those correlates render the samples, methods, and measures incomparable across racial-ethnic groups, and diminish the ability to attribute health differences discovered to race-ethnicity vs. to its correlates. This paper reviews the non-equivalent yet normative samples, methodologies and measures used in epidemiologic studies of racial-ethnic health disparities, and provides concrete suggestions for improving sample, method, and scalar measurement equivalence.

Telephone Surveys Underestimate Cigarette Smoking among African-Americans.

BACKGROUND: This study tested the hypothesis that data from random digit-dial telephone surveys underestimate the prevalence of cigarette smoking among African-American adults. METHOD: A novel, community-sampling method was used to obtain a statewide, random sample of N = 2118 California (CA) African-American/Black adults, surveyed door-to-door. This Black community sample was compared to the Blacks in the CA Health Interview Survey (N = 2315), a statewide, random digit-dial telephone survey conducted simultaneously. RESULTS: Smoking prevalence was significantly higher among community (33%) than among telephone survey (19%) Blacks, even after controlling for sample differences in demographics. CONCLUSION: Telephone surveys underestimate smoking among African-Americans and probably underestimate other health risk behaviors as well. Alternative methods are needed to obtain accurate data on African-American health behaviors and on the magnitude of racial disparities in them.

The relation of race and type of health insurance to long-term risk of mortality among lung cancer patients in rural Eastern North Carolina.

BACKGROUND: Black patients with lung cancer have a higher mortality rate than do their white counterparts. Differences in insurance coverage, demographic characteristics, and treatment profiles may explain this disparity. The purpose of this study was to compare the longterm risk of mortality of black lung cancer patients with that of white lung cancer patients, by insurance type. METHODS: Patients who were diagnosed with lung cancer in Eastern North Carolina and treated at the Leo Jenkins Cancer Center between 2001 and 2010 were included in this study. A Cox regression model was used to compare the risk of mortality of black patients with that of white patients. RESULTS: A total of 2,351 lung cancer patients (717 black and 1,634 white) were treated at the Leo Jenkins Cancer Center during the study period. Independent of age and sex, black patients with lung cancer were observed to die sooner than their white counterparts (hazard ratio = 1.2; 95% confidence interval, 1.04-1.3; P = .0070). However, this difference was not statistically significant after controlling for and stratifying by insurance type. LIMITATIONS: Residual confounding and the misclassification of some variables could have biased estimated study effects. CONCLUSION: The racial disparity in lung cancer mortality observed in Eastern North Carolina is no longer apparent after health insurance type is accounted for.

Racial discrimination and health-promoting vs damaging behaviors among African-American adults.

Studies have found relationships between racial discrimination and increased health-damaging behaviors among African-Americans, but have not examined possible concomitant decreased health-promoting behaviors. We explored the role of discrimination in two health-promoting behaviors, consuming ≥ 5 fruits/vegetables daily (FVC) and physical activity (PA), for the first time, and likewise examined discrimination's contribution to cigarette smoking, among a sample of N = 2118 African-American adults. Results revealed that discrimination contributed positively to smoking and to PA but was unrelated to FVC. These findings suggest that both adaptive and maladaptive health behaviors might be used to cope with the stress of discrimination.

Residential segregation and disparities in health-related quality of life among Black and White cancer survivors.

OBJECTIVE: Studies of health-related quality of life (HRQOL) among Black and White cancer survivors have been based on small convenience samples and yielded inconsistent results. We examined Black-White disparities in survivors' HRQOL with a population-based sample, and tested the hypothesis that area-level segregation accounts for those disparities. DESIGN: A sample of survivors of 10 types of cancer was drawn from 11 U.S. state cancer registries and surveyed 12-15 months after diagnosis. The current sample consisted of 5195 survivors (415 Black, 4780 White) who resided in 584 counties. MAIN OUTCOME MEASURES: SF-36 General Health subscale scores were used as the measure of HRQOL. RESULTS: Bivariate results revealed that Black survivors had significantly poorer HRQOL than did White survivors. Multilevel regression including individual-level (gender, age, marital status, education, cancer type, stage at diagnosis, cancer progression, comorbidities, race/ethnicity) and area-level (county segregation and poverty) variables found that HRQOL was poorer among survivors who resided in high-Black-segregated counties, whereas race/ethnicity was no longer significant. CONCLUSION: These findings indicate that Black-White disparities in HRQOL among cancer survivors might be a function, not of race/ethnicity, but of area-level variables associated with race/ethnicity. The strong role of segregation highlights the need for interventions to target Black-segregated areas.

MEASURING EVERYDAY RACIAL/ETHNIC DISCRIMINATION IN HEALTH SURVEYS: How Best to Ask the Questions, in One or Two Stages, Across Multiple Racial/Ethnic Groups?

While it is clear that self-reported racial/ethnic discrimination is related to illness, there are challenges in measuring self-reported discrimination or unfair treatment. In the present study, we evaluate the psychometric properties of a self-reported instrument across racial/ ethnic groups in a population-based sample, and we test and interpret findings from applying two different widely-used approaches to asking about discrimination and unfair treatment. Even though we found that the subset of items we tested tap into a single underlying concept, we also found that different groups are more likely to report on different aspects of discrimination. Whether race is mentioned in the survey question affects both frequency and mean scores of reports of racial/ethnic discrimination. Our findings suggest caution to researchers when comparing studies that have used different approaches to measure racial/ethnic discrimination and allow us to suggest practical empirical guidelines for measuring and analyzing racial/ethnic discrimination. No less important, we have developed a self-reported measure of recent racial/ethnic discrimination that functions well in a range of different racial/ethnic groups and makes it possible to compare how racial/ethnic discrimination is associated with health disparities among multiple racial/ethnic groups.

Sun-protection behaviors among African Americans.

BACKGROUND: Data suggest that the prevalence of sun-protection behaviors is low (44%) among African Americans; the samples in such studies, however, tended to be small or nonrepresentative. PURPOSE: This article aims to examine the prevalence and correlates of sun-protection behaviors among a large, random, statewide sample of African-American adults living in California to ascertain behavioral patterns and highlight directions for targeted interventions. METHODS: From September 2006 through May 2008, an anonymous health survey collected data on sunscreen, sunglasses, and wide-brim hat use among a random sample of 2187 African-American adults, and assessed demographic, regional, skin type, and other potential correlates of these behaviors. The analysis was conducted in 2009. RESULTS: Only 31% engaged in at least one sun-protection behavior; of the three behaviors, sunscreen use was the least prevalent, with 63% never using sunscreen. Multivariate logistic regressions revealed that gender, SES, and skin type were significant predictors of sun-protection behaviors. CONCLUSIONS: Tailored interventions to increase sun-protection behaviors among African Americans (men in particular) are needed.

Residential segregation and exercise among a national sample of Hispanic adults.

We examined the role of residential segregation in exercise among American Hispanics for the first time. Data on the 8785 Hispanic adults in the 2000 Behavioral Risk Factor Surveillance System (BRFSS) were linked to 2000 census data on the segregation of metropolitan statistical areas (MSAs). Multi-level modeling revealed that after adjusting for individual-level variables, the odds of exercise among Hispanics residing in high-segregated MSAs were 18% lower than those residing in low-segregated MSAs. This suggests that segregation contributes to lack of exercise among Hispanics; this effect might be mediated by the relative lack of recreational resources in segregated-Hispanic neighborhoods.

Ethnic disparities in youth access to tobacco: California statewide results, 1999-2003.

The authors examined the role of youth ethnicity in youth access to tobacco with large, random samples of stores and large samples of ethnically diverse youths for the first time. From 1999 through 2003, White, Black, Latino, and Asian youths made 3,361 cigarette purchase attempts (approximately 700 per year) statewide. Analyses revealed that Black youths had significantly higher access than other youths and that access rates for Black and Asian (but not Latino or White) youths exceeded the Synar-mandated < or = 20%. Clerks who failed to demand youth proof of age identification (ID) sold 95% of the tobacco that youths received and sold significantly more often to minorities and to girls, whereas clerks who demanded youth ID sold equally infrequently to all youths. These findings highlight significant ethnic disparities in youth access to tobacco and imply that those might be eliminated by policies and interventions that increase clerk demands for youth ID.

Separate and unequal: residential segregation and black health disparities.

There are well-known Black-White disparities in adverse birth outcomes, health behaviors, and chronic diseases such as asthma, diabetes, and hypertension. These disparities hold across socioeconomic status and have remained stable for the past 50 years despite efforts to reduce them. This theoretical review argues that such disparities may be largely a function of residential segregation, ie, the separate and unequal neighborhoods in which most Blacks and Whites reside irrespective of their socioeconomic status. We review evidence that Black neighborhoods have significantly poorer healthcare facilities staffed by less competent physicians, higher environmental exposures, and poorer built environments than do White neighborhoods, and we argue that these neighborhood disparities are 3 pathways through which segregation contributes to health disparities. We summarize the research needed on the role of segregation in health disparities and emphasize the hypothesis that these may be differences between Whites and segregated Blacks alone.