Policies and Indicators to Operationalize Structural Racism for Quantitative Health Research.

The field of structural racism is developing rapidly, with researchers moving from commentaries and review papers toward empirical research that aims to quantify the impact of exposure to structural racism on racial and ethnic inequities in health. Despite the increasing recognition of the impact of structural racism on health outcomes, its measurement in the empirical literature has focused on a limited set of area-based measures. This paper proposes two ways to expand the measurement of structural racism in public health research. First, by situating indicators of structural racism within the broader context of discriminatory policies that gave rise to racial and ethnic inequities, and second, by broadening the range of area-level indicators of structural racism beyond what has been used in the extant literature. The paper provides practical tools, including an extensive list of discriminatory federal policies, a list of common and novel indicators of structural racism across multiple domains, and an applied example showing how to connect policies and indicators of structural racism. These tools will aid researchers in developing a robust empirical evidence base to examine the role of structural racism in long-standing health inequities and advance quantitative research on the impact of structural racism on health inequities.

Exposure to structural racism-related state laws is associated with worse cardiovascular health among US adults, BRFSS 2011 and 2013.

The objective of this study was to determine whether exposure to structural racism-related state laws is associated with cardiovascular health among a racially and ethnically diverse sample of US adults. Data were from the Database of Structural Racism-Related State Laws and the Behavioral Risk Factor Surveillance System (BRFSS). The sample included 958,019 BRFSS 2011 and 2013 respondents aged 18+ from all 50 US states. The exposure was a summary index of 22 state laws related to the criminal legal system, economics and labor, education, healthcare, housing, immigration, and political participation. The outcome was the American Heart Association's Life's Simple 7 (LS7), a summary index of seven cardiovascular health indicators. Linear regression models included fixed effects for year and state to control for time trends and unmeasured time-invariant state-level contextual factors. In the full sample, a one standard deviation increase in the structural racism state legal index was associated with a 0.06-unit decrease in the LS7 (b=-0.06; 95% CI:-0.09, 0.02; p=0.001), controlling for individual- and state-level covariates. Contrary to expectations, stratified models revealed no statistically significant differences by race and ethnicity in the association between the structural racism state legal index and the LS7.

Social vulnerability and new mobility disability among adults with polymerase chain reaction (PCR)-confirmed SARS-CoV-2: Michigan COVID-19 Recovery Surveillance Study.

OBJECTIVE: Understanding the relationship between social factors and persistent COVID-19 health outcomes, such as onset of a disability after a SARS-CoV-2 (the virus that causes COVID-19) infection, is an increasingly important public health issue. The purpose of this paper is to examine associations between social vulnerability and new onset of a mobility disability post-COVID-19 diagnosis. METHODS: We used data from the Michigan COVID-19 Recovery Surveillance Study, a population-based probability survey of adults with PCR-confirmed SARS-CoV-2 infection in Michigan between January 2020-May 2022 (n = 4295). We used the Minority Health Social Vulnerability Index (MHSVI), with high county-level social vulnerability defined at or above the 75th percentile. Mobility disability was defined as new difficulty walking or climbing stairs. We regressed mobility disability on the overall MHSVI, as well as sub-themes of the index (socioeconomic status, household composition/disability, minority and language, housing type, healthcare access, and medical vulnerability), using multivariable logistic regression, adjusting for age, race, sex, education, employment, and income. RESULTS: Living in a county with high (vs. low) social vulnerability was associated with 1.38 times higher odds (95% confidence interval [CI]:1.18-1.61) of reporting a new mobility disability after a COVID-19 diagnosis after adjustment. Similar results were observed for the socioeconomic status and household composition/disability sub-themes. In contrast, residents of highly racially diverse counties had lower odds (odds ratio 0.74, 95% CI: 0.61, 0.89) of reporting a new mobility disability compared to low diversity counties. CONCLUSIONS: Mitigating the effects of social vulnerabilities requires additional resources and attention to support affected individuals.

Leveraging an Implementation Science Framework to Adapt and Scale a Patient Navigator Intervention to Improve Mammography Screening Outreach in a New Community.

Helping Her Live (HHL) is a community health worker-led outreach model that navigates women from vulnerable communities to mammography screening and diagnostic follow-up. The objective of this study was to evaluate HHL implementation on the southwest side of Chicago. HHL has been implemented on the west side of Chicago since 2008, where it has increased mammogram completion and diagnostic follow-up rates among Black and Hispanic women from resource poor communities. In 2014, HHL was translated to the southwest side of Chicago; implementation success was evaluated by comparing outreach, navigation request, and mammogram completion metrics with the west side. During January 2014-December 2015, outreach was less extensive in the southwest setting (SW) compared to the benchmark west setting (W); however, the proportion of women who completed mammograms in SW was 50%, which compared favorably to the proportion observed in the benchmark setting W (42%). The distribution of insurance status and the racial and ethnic makeup of individuals met on outreach in the W and SW were significantly different (p < 0.0005). This successful expansion of HHL in terms of both geographic and demographic reach justifies further studies leveraging these results and tailoring HHL to additional underserved communities.

Evaluation of Mammogram Parties as an Effective Community Navigation Method.

Women of color do not have the same level of access to mammography services as their White counterparts, and this inequity may be one of the contributing factors to the documented racial disparity in breast cancer mortality in the US. The present study sought to assess the effectiveness of the mammogram party, a promising, but under-studied approach to increasing mammography uptake, particularly among under-served populations. The program targeted mammogram-eligible women in community settings on the west and southwest sides of Chicago, gathering basic demographic information, mammography history, and interest in assistance obtaining a mammogram. Women were navigated either through traditional one-on-one navigation or to a mammogram party. Seven outcome metrics were calculated for each type of navigation. We compared navigation outcomes for those who attended to those who did not attend a mammogram party using two-tailed t tests and chi-square tests. We found that the mammography completion rate for mammogram parties was comparable to that for standard one-on-one navigation (65.8 vs. 63.7%), which is more labor-intensive as evidenced by the number of contacts needed to successfully navigate a woman to mammography (10.9 vs. 15.0). Mammogram parties offer a unique opportunity for fellowship and support for clients who are particularly fearful of mammograms or identifying breast cancer. Programmatically, mammogram parties are an efficient way to complete several mammograms in 1 day. Having the option to both navigate women to mammogram parties or one-on-one navigation allows for more flexibility for scheduling and may ensure a completed a mammogram.

Keys to the Successful Implementation of Community-Based Outreach and Navigation: Lessons from a Breast Health Navigation Program.

The well-documented racial disparities in breast cancer mortality have prompted an aggressive response from the public health community, including the development and implementation of breast health education and breast cancer navigation programs. Many programs are successfully reaching women and providing education and motivation to get screened, and separately, many programs are successfully navigating women who have received abnormal results from a screening mammogram and need follow-up. However, a crucial gap in services remains, where women in the community are not receiving systematic navigation to their initial screening mammogram. This paper describes a community-based, community health worker-led breast health education and screening navigation program, details the metrics used to measure navigation outcomes, and discusses unique features of this project which could be adapted within other settings to initiate similar programming.

Do Police Encounters Increase the Risk for Cardiovascular Disease? Police Encounters and Framingham 30-Year Cardiovascular Risk Score.

INTRODUCTION: Despite increased attention to the societal consequences of aggressive policing, the focus on rarer instances of deaths/severe injuries fails to fully capture the day-to-day experiences that racially minoritized groups face during police encounters (PEs). We explored differential vulnerability by race/ethnicity in the relationship between PEs and cardiovascular disease (CVD) risk. METHODS: Using data from the National Longitudinal Study of Adolescent to Adult Health, we regressed the Framingham 30-Year CVD risk score on a high number of lifetime PEs (6 + among men and 2 + among women). To explore differential vulnerability by race, we added an interaction between PEs and race/ethnicity. We also examined sex- and race and sex-stratified models. RESULTS: We observed no association between PEs and CVD risk in the sample overall, but the interaction between PEs and race/ethnicity was statistically significant. In race stratified models, we found that higher PEs were associated with a lower CVD risk among Black respondents, whereas among White respondents there was no relationship. In the sex-stratified analysis, reporting higher PEs was associated with lower CVD risk among men, while among women there was no relationship. In sex- and race-stratified models, higher PEs was associated with lower CVD risk among Black men and higher CVD risk among White women, while there was no association among Black women and White men. CONCLUSION: The association between PEs and CVD risk depends on race/ethnicity and sex. More work is needed to understand the counterintuitive finding that high PEs are associated with lower CVD risk among Black men.

Cross-sectional population-based estimates of a rural-urban disparity in prevalence of long COVID among Michigan adults with polymerase chain reaction-confirmed COVID-19, 2020-2022.

PURPOSE: To (1) assess whether residential rurality/urbanicity was associated with the prevalence of 30- or 90-day long COVID, and (2) evaluate whether differences in long COVID risk factors might explain this potential disparity. METHODS: We used data from the Michigan COVID-19 Recovery Surveillance Study, a population-based probability sample of adults with COVID-19 (n = 4,937). We measured residential rurality/urbanicity using dichotomized Rural-Urban Commuting Area codes (metropolitan, nonmetropolitan). We considered outcomes of 30-day long COVID (illness duration ≥30 days) and 90-day long COVID (illness duration ≥90 days). Using Poisson regression, we estimated unadjusted prevalence ratios (PRs) to compare 30- and 90-day long COVID between metropolitan and nonmetropolitan respondents. Then, we adjusted our model to account for differences between groups in long COVID risk factors (age, sex, acute COVID-19 severity, vaccination status, race and ethnicity, socioeconomic status, health care access, SARS-CoV-2 variant, and pre-existing conditions). We estimated associations for the full study period (Jan 1, 2020-May 31, 2022), the pre-vaccine era (before April 5, 2021), and the vaccine era (after April 5, 2021). FINDINGS: Compared to metropolitan adults, the prevalence of 30-day long COVID was 15% higher (PR = 1.15 [95% CI: 1.03, 1.29]), and the prevalence of 90-day long COVID was 27% higher (PR = 1.27 [95% CI: 1.09, 1.49]) among nonmetropolitan adults. Adjusting for long COVID risk factors did not reduce disparity estimates in the pre-vaccine era but halved estimates in the vaccine era. CONCLUSIONS: Our findings provide evidence of a rural-urban disparity in long COVID and suggest that the factors contributing to this disparity changed over time as the sociopolitical context of the pandemic evolved and COVID-19 vaccines were introduced.

Institutional Racism and Health: a Framework for Conceptualization, Measurement, and Analysis.

Despite growing interest in the health-related consequences of racially discriminatory institutional policies and practices, public health scholars have yet to reach a consensus on how to measure and analyze exposure to institutional racism. The purpose of this paper is to provide an overview of the conceptualization, measurement, and analysis of institutional racism in the context of quantitative research on minority health and health disparities in the United States. We begin by providing definitions of key concepts (e.g., racialization, racism, racial inequity) and describing linkages between these ideas. Next, we discuss the hypothesized mechanisms that link exposure to institutional racism with health. We then provide a framework to advance empirical research on institutional racism and health, informed by a literature review that summarizes measures and analytic approaches used in previous studies. The framework addresses six considerations: (1) policy identification, (2) population of interest, (3) exposure measurement, (4) outcome measurement, (5) study design, and (6) analytic approach. Research utilizing the proposed framework will help inform structural interventions to promote minority health and reduce racial and ethnic health disparities.

Racial discrimination in healthcare settings and mental health among a population-based sample of racial and ethnic minoritized adults with COVID-19 in Michigan.

The COVID-19 pandemic has worsened existing racial health disparities and racial discrimination in healthcare; however, little is known about how racial discrimination in healthcare settings is related to mental health during the pandemic. Using a population-based probability sample of racial and ethnic minoritized adults with a polymerase chain reaction (PCR)-confirmed SARS-CoV-2 infection in Michigan, we examined how measures of perceived racial discrimination in (1) seeking healthcare for COVID-19 (n = 1,210) and (2) receiving testing/treatment for COVID-19 (n = 1,364) were associated with binary variables of depressive and anxiety symptoms. We conducted a modified Poisson regression analysis with robust standard errors to estimate associations between each measure of racial discrimination and each mental health outcome separately, adjusting for demographic and socio-economic variables, health insurance, and pre-existing physical and psychiatric conditions. 7.3 % and 8.7 % of adults reported racial discrimination in seeking healthcare for COVID-19 and in getting testing/treatment for COVID-19, respectively. Although the overall prevalence of racial discrimination in healthcare settings was low, experiences of racial discrimination were associated with depressive symptoms. Adults who experienced racial discrimination in seeking healthcare had 1.74 times higher prevalence of reporting depressive symptoms (95 % CI:1.21-2.52) than those who did not. Moreover, adults who experienced racial discrimination in getting testing/treatment had 1.86 times higher prevalence of reporting depressive symptoms (95 % CI:1.36-2.53) than those who did not. Neither measure of racial discrimination was associated with anxiety symptoms in the adjusted models. There is a need for promoting anti-racial discrimination policies, educational programs, and awareness efforts in healthcare settings.

Experiences of the Flint Water Crisis Among Reproductive-Age Michigan Women in Communities Outside of Flint: Differences by Race and Ethnicity.

We sought to understand how women in Michigan communities outside of Flint experienced the Flint water crisis, an avoidable public health disaster widely attributed to structural racism. Using survey data from 950 Michigan women aged 18-45 from communities outside of Flint, we examined racial and ethnic differences in personal connections to Flint, perceived knowledge about the water crisis, and beliefs about the role of anti-Black racism in the water crisis factors that could contribute to poor health via increased psychological stress. We found that White (OR = 0.32; 95% CI: 0.22, 0.46) and Hispanic (OR = 0.21; 95% CI: 0.09, 0.49) women had lower odds than Black women of having family or friends who lived in Flint during the water crisis. Compared to Black women, White women were less likely to be moderately or very knowledgeable about the water crisis (OR = 0.58; 95% CI: 0.41, 0.80). White women (OR = 0.26; 95% CI: 0.18, 0.37), Hispanic women (OR = 0.38; 95% CI: 0.21, 0.68), and women of other races (OR = 0.28; 95% CI: 0.15, 0.54) were less likely than Black women to agree that the water crisis happened because government officials wanted to hurt Flint residents. Among those who agreed, White women (OR = 0.47; 95% CI: 0.30, 0.74) and women of other races (OR = 0.33; 95% CI: 0.12, 0.90) were less likely than Black women to agree that government officials wanted to hurt people in Flint because most residents are Black. We conclude that the Flint water crisis was a racialized stressor, with potential implications for the health of reproductive-age Black women.

Heart Disease Self-management for African American Older Adults: Outcomes of an Adapted Evidence-Based Intervention.

Background and Objectives: To assess the impact of an evidence-based self-management intervention adapted through a community-engaged process for African American midlife and older adults with heart disease and/or cardiovascular risk factors. Research Design and Methods: Adults 50 years and over, living in or near Detroit, MI, with diagnosed heart disease or greater or equal to two major risk factors for heart disease, were randomized to a 7-week group-format program called Take Heart, or a usual-care control group. Take Heart included education about heart disease and support for behavioral lifestyle change, using a goal-setting process based on self-regulation theory. Outcome data were collected via telephone surveys at baseline and 1 year from baseline. Primary outcomes were self-reported emergency department visits and hospitalizations in the last year. Secondary outcomes were health-related quality of life (PROMIS-29 Adult Profile) and cardiac symptom burden. Results: A total of 453 participants enrolled (74% female, 84% African American, mean age 65.4 years; 55% with diagnosed heart disease and 45% with risk factors only); 362 provided baseline and follow-up data. Using generalized linear and binomial regression models, at 12-month follow-up, there were no significant differences between intervention and control groups in ED visits or hospitalizations. Intervention versus control participants had greater improvements in PROMIS fatigue (p = .003) and sleep (p = .04) subscales as well as cardiac symptom burden (p = .04). Discussion and Implications: The Take Heart intervention was associated with modest improvements in sleep, fatigue, and cardiac symptom burden. Take Heart was well received and has potential for dissemination by agencies serving older adults.Clinical Trial Registration Number: https://www.clinicaltrials.gov/ct2/show/NCT02950818.

Vicarious structural racism and infant health disparities in Michigan: The Flint Water Crisis.

Building on nascent literature examining the health-related effects of vicarious structural racism, we examined indirect exposure to the Flint Water Crisis (FWC) as a predictor of birth outcomes in Michigan communities outside of Flint, where residents were not directly exposed to lead-contaminated water. Using linear regression models, we analyzed records for all singleton live births in Michigan from 2013 to 2016, excluding Flint, to determine whether birth weight (BW), gestational age (GA), and size-for-gestational-age (SzGA) decreased among babies born to Black people, but not among babies born to White people, following the highly publicized January 2016 emergency declaration in Flint. In adjusted regression models, BW and SzGA were lower for babies born to both Black and White people in the 37 weeks following the emergency declaration compared to the same 37-week periods in the previous 3 years. There were no racial differences in the association of exposure to the emergency declaration with BW or SzGA. Among infants born to Black people, GA was 0.05 weeks lower in the 37-week period following the emergency declaration versus the same 37-week periods in the previous 3 years (95% CI: -0.09, -0.01; p = 0.0177), while there was no change in GA for infants born to White people following the emergency declaration (95% CI: -0.01, 0.03; p = 0.6962). The FWC, which was widely attributed to structural racism, appears to have had a greater impact, overall, on outcomes for babies born to Black people. However, given the frequency of highly publicized examples of anti-Black racism over the study period, it is difficult to disentangle the effects of the FWC from the effects of other racialized stressors.

Comparison of Recruitment Strategies for Engaging Older Minority Adults: Results From Take Heart.

BACKGROUND: Few published studies report lessons learned for recruiting older adults from racial/ethnic minority, low SES communities for behavioral interventions. In this article, we describe recruitment processes and results for Take Heart, a randomized controlled trial testing the effectiveness of an adapted heart disease self-management program for primarily African American, urban, low SES adults 50 years or older living in Detroit. METHODS: Older adults were recruited via community-based (CB), electronic medical record (EMR), and in-person hospital clinic (HC) methods. Recruitment processes, demographic characteristics of enrolled participants, yield and cost, lessons learned, and best practices for each method are described. RESULTS: Within 22 months, 1,478 potential participants were identified, 1,223 were contacted and 453 enrolled, resulting in an overall recruitment yield of 37%. The CB method had the highest yield at 49%, followed by HC at 36% and EMR at 16%. Of six CB approaches, information sessions and flyers had the highest yields at 60% and 59%, respectively. The average cost of recruiting and enrolling one participant was $142. CONCLUSIONS: CB, EMR, and HC methods each made important contributions to reaching our recruitment goal. The CB method resulted in the highest recruitment yield, while EMR had the lowest. Face-to-face interaction with community members and hiring a community health worker were particularly useful in engaging this population. Further research is needed to confirm these findings in urban, minority, low SES populations of older adults.

HIV testing practices and attitudes on prevention efforts in six diverse Chicago communities.

Data describing local level HIV testing practices and attitudes regarding HIV prevention are rarely available, yet would be useful for HIV policy and evaluation. A comprehensive health survey was conducted in six community areas of Chicago (n = 1,699) in 2002-2003. The HIV prevention module of this survey was used for this analysis. The proportion that ever tested for HIV ranged from 40 to 75% and 11 to 38% were tested in the past 12 months. Residents favored: needle exchange programs (59-77%), HIV information in high schools (95-100%) and elementary schools (85-94%), and condom distribution in high schools (74-93%). Attitudes were less favorable regarding pharmacies selling clean needles (37-58%) and condom distribution in elementary schools (22-66%). Adults in these areas are over three times more likely to have been tested recently than adults nationally. Residents strongly favor community based HIV prevention initiatives such as needle exchange programs, condom distribution in high schools, and HIV prevention taught in schools. These evidence-based observations may be valuable in planning HIV prevention programs and in shaping policy.

Do black/white differences in telomere length depend on socioeconomic status?

Social and economic disadvantage are hypothesized to increase the risk of disease and death via accelerated biological aging. Given that US blacks are socially and economically disadvantaged relative to whites, health disparities scholars expected that blacks would have shorter telomere length-a biomarker of cell aging-than whites. Yet the majority of studies have found that blacks have longer telomere length than whites. Using data from the National Health and Nutrition Examination Survey (n = 3,761; 28.3% non-Hispanic black, 71.7% non-Hispanic white), we found that leukocyte telomere length was 4.00% (95% CI: 1.12%, 6.87%) longer among blacks compared to whites in the full sample, but differences were greatest among those with lower SES (5.66%; 95% CI: 0.10%, 10.32%), intermediate among those with middle SES (4.14%; 95% CI: 0.05%, 8.24%), and smallest among those with higher SES (2.33%; 95% CI: -3.02%, 7.67%). These results challenge purely genetic explanations for race differences in telomere length and point to a potential social-environmental cause of longer telomere length in US blacks.

Black:White Disparities in HIV Mortality in the United States: 1990-2009.

OBJECTIVES: The aim of this study was to assess whether racial disparities in human immunodeficiency virus (HIV) mortality in the USA have changed over time. METHODS: Using vital records from the National Center for Health Statistics and census data from the US Census Bureau, we calculated the race- and gender-specific HIV mortality rates and corresponding racial rate ratios for non-Hispanic Blacks and non-Hispanic Whites in the USA for four 5-year increments from 1990-2009. Rates were age-adjusted using the 2000 USA standard population. Additionally, we calculated excess Black deaths for 2005-2009. RESULTS: For the total, male, and female populations, we observed a statistically significant increase in the Black:White HIV mortality disparity between T1 (1990-1994) and T4 (2005-2009). The increasing disparity was due to the fact that the decrease in mortality rates from T1 to T4 was greater among Whites than Blacks. This disparity led to 5603 excess Black deaths in the USA at T4. CONCLUSIONS: Previous research suggests that as HIV becomes more treatable, racial disparities widen, as observed in this study for both men and women. Existing disparities could be ameliorated if access to care were equal among these groups. Equal access would enable more individuals to achieve viral suppression, the final step of the HIV Care Continuum.

Implementing Routine HIV Screening in Three Chicago Hospitals: Lessons Learned.

OBJECTIVE: This study describes routine HIV screening implementation and outcomes in three hospitals in Chicago, Illinois. METHODS: Retrospective data from three hospitals were examined, and routine testing procedures, testing volume, reactive test results, and linkage-to-care outcomes were documented. RESULTS: From January 2012 through March 2014, 40,788 HIV tests were administered at the three hospitals: 18,603 (46%) in the emergency department (ED), 7,546 (19%) in the inpatient departments, and 14,639 (36%) in outpatient clinics. The screened patients varied from 1% to 22% of the total eligible patient population across hospitals. A total of 297 patients tested positive for HIV for a seropositivity rate of 0.7%; 129 (43%) were newly diagnosed and 168 (57%) were previously diagnosed, with 64% of those previously diagnosed out of care at the time of screening. The inpatient areas had the highest seropositivity rate (0.6%). The percentage of newly diagnosed patients overall who were linked to care was 77%. Of newly diagnosed patients, 51% had ≥ 1 missed opportunity for testing (with a mean of 3.8 visits since 2006), and 30% of patients with missed opportunities were late testers (baseline CD4+ counts <200 cells per cubic millimeter). CONCLUSION: Routine screening is an essential tool for identifying new infections and patients with known infection who are out of care. Hospitals need to provide HIV screening in inpatient and outpatient settings--not just EDs--to decrease missed opportunities. Routine screening success will be driven by how notification and testing are incorporated into the normal medical flow, the level of leadership buy-in, the ability to conduct quality assurance, and local testing laws.

Validating self-reported mammography use in vulnerable communities: findings and recommendations.

BACKGROUND: Most health surveys ask women whether they have had a recent mammogram, all of which report mammography use (past 2 years) at about 70% to 80% regardless of race or residence. We examined the potential extent of overreporting of mammography use in low income African-American and Latina women, and whether self-report inaccuracies might bias estimated associations between patient characteristics and mammography use. METHODS: Using venue-based sampling in two poor communities on the west side of Chicago, we asked eligible women living in two west side communities of Chicago to complete a survey about breast health (n = 2,200) and to provide consent to view their medical record. Of the 1,909 women who screened eligible for medical record review, 1,566 consented (82%). We obtained medical records of all women who provided both permission and a valid local mammography facility (n = 1,221). We compared the self-reported responses from the survey with the imaging reports found in the medical record (documented). To account for missing data, we conducted multiple imputations for key demographic variables and report standard measures of accuracy. RESULTS: Although 73% of women self-reported a mammogram in the last 2 years, only 44% of self-reports were documented. Overreporting of mammography use was observed for all three ethnic groups. CONCLUSIONS: These results suggest considerable overestimation of prevalence of use in these vulnerable populations. IMPACT: Relying on known faulty self-reported mammography data as a measure of mammography use provides an overly optimistic picture of utilization, a problem that may be exacerbated in vulnerable minority communities.

Disparities in screening mammography services by race/ethnicity and health insurance.

BACKGROUND: Black and Hispanic women are diagnosed at a later stage of breast cancer than white women. Differential access to specialists, diffusion of technology, and affiliation with an academic medical center may be related to this stage disparity. METHODS: We analyzed data from a mammography facility survey for the metropolitan region of Chicago, Illinois, to assess in part whether quality breast imaging services were equally accessed by non-Hispanic white, non-Hispanic black, and Hispanic women and by women with and without private insurance. Of 49 screening facilities within the city of Chicago, 43 facilities completed the survey, and 40 facilities representing about 149,000 mammograms, including all major academic facilities, provided data on patient race/ethnicity. RESULTS: Among women receiving mammograms at the facilities we studied, white women were more likely than black or Hispanic women to have mammograms at academic facilities, at facilities that relied exclusively on breast imaging specialists to read mammograms, and at facilities where digital mammography was available (p<0.001). Women with private insurance were similarly more likely than women without private insurance to have mammograms at facilities with these characteristics (p<0.001). CONCLUSIONS: Black and Hispanic women and women without private insurance are more likely than white women and women with private insurance to obtain mammography screening at facilities with less favorable characteristics. A disparity in use of high-quality mammography may be contributing to disparities in breast cancer mortality.