Disaggregating Heterogeneity among Non-Hispanic Whites: Evidence and Implications for U.S. Racial/Ethnic Health Disparities.

Research has made strides in disaggregating health data among racial/ethnic minorities, but less is known about the extent of diversity among Whites. Using logistic regression modeling applied to data on respondents aged 40+ from the 2008 to 2016 American Community Survey, we disaggregated the non-Hispanic White population by ancestry and other racial/ethnic groups (non-Hispanic Black, non-Hispanic Asian, and Hispanic) by common subgroupings and examined heterogeneity in disability. Using logistic regression models predicting six health outcome measures, we compared the spread of coefficients for each of the large racial/ethnic groups and all subgroupings within these large categories. The results revealed that health disparities within the White population are almost as large as disparities within other racial groups. In fact, when Whites were disaggregated by ancestry, mean health appeared to be more varied among Whites than between Whites and members of other racial/ethnic groups in many cases. Compositional changes in the ancestry of Whites, particularly declines in Whites of western European ancestry and increases in Whites of eastern European and Middle Eastern ancestry, contribute to this diversity. Together, these findings challenge the oft-assumed notion that Whites are a homogeneous group and indicate that the aggregate White category obscures substantial intra-ethnic heterogeneity in health.

The Critical Role of Racial/Ethnic Data Disaggregation for Health Equity.

Population-level health outcomes and measures of well-being are often described relative to broad racial/ethnic categories such as White or Caucasian; Black or African American; Latino or Hispanic; Asian American; Native Hawaiian and Pacific Islander; or American Indian and Alaska Native. However, the aggregation of data into these groups masks critical within-group differences and disparities, limiting the health and social services fields' abilities to target their resources where most needed. While researchers and policymakers have recognized the importance of disaggregating racial/ethnic data-and many organizations have advocated for it over the years-progress has been slow and disparate. The ongoing lack of racial/ethnic data disaggregation perpetuates existing inequities in access to much-needed resources that can ensure health and well-being. In its efforts to help build a Culture of Health and promote health equity, the Robert Wood Johnson Foundation has supported activities aimed to advance the meaningful disaggregation of racial/ethnic data-at the collection, analysis, and reporting phases. This special issue presents further evidence for the importance of disaggregation, the technical and policy challenges to creating change in practice, and the implications of improving the use of race and ethnicity data to identify and address gaps in health.

Immigration and health among non-Hispanic whites: The impact of arrival cohort and region of birth.

Immigration is central to our understanding of U.S. racial and ethnic health disparities, yet relatively little is known about the health of white immigrants - a group whose ethnic origins have become increasingly diverse. To the extent that whites are included in social stratification research, they are typically used as the reference category for gauging health inequities, with little attention to diversity among them. This study addresses this question using nationally representative data from the American Community Survey (2008-2017). We disaggregate non-Hispanic whites by nativity, region of birth, and period of arrival in the U.S. and examine differences in physical disability among adults aged 40 and older (n = 12, 075, 638). The analysis finds that foreign-born whites have a slightly lower prevalence of disability than U.S.-born whites, and this varies by arrival cohort. Immigrants who arrived in the 1981-1990 and 1991-2000 cohorts have a smaller advantage over U.S.-born whites than immigrants in the earlier and later cohorts. Compositional changes in the region of birth of white immigrants, especially the influx of eastern Europeans and Middle Easterners during the 1980s and 1990s, explained this variation. These findings challenge the oft-assumed notion that whites are a monolithic group and highlight growing intra-ethnic heterogeneity that is obscured by the aggregate category. Our findings also suggest that the standard practice of using whites as the reference for benchmarking health inequities may mask health inequities not only among them, but also between whites and other racial and ethnic populations.

Gender and national origin differences in healthcare utilization among U.S. Immigrants from Mexico, China, and India.

OBJECTIVES: To examine gender and national origin differences in the healthcare utilization of immigrants from the three largest populations in the U.S. today (Mexico, China, and India) and to determine if barriers to utilization operate similarly across groups. METHODS: The analysis uses nationally-representative data from the 2003 New Immigrant Survey (NIS) to compare utilization behaviors among legal permanent residents from Mexico, China, and India (n = 2244). Conceptually, the study draws on Andersen's Behavioral Model to hypothesize gender and national origin differences in utilization based on factors that might predispose, enable, or necessitate healthcare. Multivariate logistic regression models are used to predict the odds of having seen a doctor in the past year and to test whether obstacles to utilization differ across immigrant groups. RESULTS: Chinese immigrants are less likely than Mexican and Indian immigrants to have seen a doctor in the past year, a finding that is largely driven by a lack of health insurance. Female immigrants are more likely than males to have done so, despite having fewer resources that enable access to care (e.g. income, English proficiency). Moreover, the relationship between gender and utilization is moderated by English language proficiency: among immigrants with low levels of proficiency, women are significantly more likely than men to have seen a doctor in the past year, while no difference exists between men and women who are proficient in English. This pattern is most evident among Mexican, and to a lesser extent, Indian immigrants. CONCLUSIONS: Barriers to immigrant healthcare utilization vary by gender and national origin. Research will need to continue documenting such variation in order to better inform policy makers and health practitioners of potential solutions for improving health outcomes in increasingly diverse immigrant communities.

Region of origin diversity in immigrant health: Moving beyond the Mexican case.

Research suggests that Mexican immigrants arrive in the United States with equivalent or better health than native-born whites but lose their advantage over time. We seek to examine systematically how well the patterns of initial advantage and deteriorating health apply to immigrants originating from other regions of the world - regions that represent a growing proportion of U.S. immigrants. We begin by identifying which of the groups in our study have a health advantage compared to U.S.-born whites and to Mexican immigrants. We then we assess changes in health over time, controlling for variation in the health profiles of cohorts upon arrival. We use logistic regression of self-rated health and heart conditions with data from the 2004-2013 National Health Interview Survey. The results reveal diversity and similarity in health outcomes across world regions of origin, both on arrival and over time. By comparing and contrasting cases previously examined in isolation, we clarify and qualify theories of the immigrant health paradox and health deterioration.

Determinants of non-urgent Emergency Department attendance among females in Qatar.

BACKGROUND: The use of emergency department (ED) services for non-urgent conditions is well-studied in many Western countries but much less so in the Middle East and Gulf region. While the consequences are universal-a drain on ED resources and poor patient outcomes-the causes and solutions are likely to be region and country specific. Unique social and economic circumstances also create gender-specific motivations for patient attendance. Alleviating demand on ED services requires understanding these circumstances, as past studies have shown. We undertook this study to understand why female patients with low-acuity conditions choose the emergency department in Qatar over other healthcare options. SETTING AND DESIGN: Prospective study at Hamad General Hospital's (HGH) emergency department female "see-and-treat" unit that treats low-acuity cases. One hundred female patients were purposively recruited to participate in the study. Three trained physicians conducted semi-structured interviews with patients over a three-month period after they had been treated and given informed consent. RESULTS: The study found that motivations for ED attendance were systematically influenced by employment status as an expatriate worker. Forty percent of the sample had been directed to the ED by their employers, and the vast majority (89%) of this group cited employer preference as the primary reason for choosing the ED. The interviews revealed that a major obstacle to workers using alternative facilities was the lack of a government-issued health card, which is available to all citizens and residents at a nominal rate. CONCLUSION: Reducing the number of low-acuity cases in the emergency department at HGH will require interventions aimed at encouraging patients with non-urgent conditions to use alternative healthcare facilities. Potential interventions include policy changes that require employers to either provide workers with a health card or compel employees to acquire one for themselves.

Gender differences in immigrant health: the case of Mexican and Middle Eastern immigrants.

This article draws on theories of gender inequality and immigrant health to hypothesize differences among the largest immigrant population, Mexicans, and a lesser known population of Middle Easterners. Using data from the 2000-2007 National Health Interview Surveys, we compare health outcomes among immigrants to those among U.S.-born whites and assess gender differences within each group. We find an immigrant story and a gender story. Mexican and Middle Eastern immigrants are healthier than U.S.-born whites, and men report better health than women regardless of nativity or ethnicity. We identify utilization of health care as a primary mechanism that contributes to both patterns. Immigrants are less likely than U.S.-born whites to interact with the health care system, and women are more likely to do so than men. Thus, immigrant and gender health disparities may partly reflect knowledge of health status rather than actual health.

Gender, acculturation, and health among Mexican Americans.

This study examines whether the relationship between acculturation and physical health varies by gender among Mexican Americans, and if the mechanisms that mediate the acculturation-health relationship operate differently by gender. Using the 1998-2007 National Health Interview Study, we construct a composite measure of acculturation and estimate regression models for the total number of health conditions, hypertension, heart disease, and diabetes. Immigrants with the lowest levels of acculturation are the healthiest, but this association is stronger for men. Medical care plays a central role in accounting for gender and acculturation differences across health outcomes-increased access to and utilization of medical care is associated with worse health, which suggests that better health among recent arrivals (particularly men) partially results from their lack of knowledge about their own poor health.

Racial/ethnic differences in hypertension and depression among US adult women.

OBJECTIVES: This study assesses racial/ethnic differences in the odds of hypertension among US adult women and examines the degree to which depression, in addition to demographic, socioeconomic status, and health lifestyle characteristics, account for observed differences. METHODS: The most recent iterations of the National Health Interview Survey (2001-2003) were used to examine the odds of hypertension among adult women aged > or =18. The sample consisted of non-Hispanic Whites (n=34,698), non-Hispanic Blacks (n=8,077), and Hispanics (n=9,055). RESULTS: Age-adjusted hypertension rates were significantly higher for Black and Hispanic women than for White women. Sequential logistic regression models demonstrated that health lifestyle accounted for the largest portion of the racial/ethnic gap in hypertension, and depression had little mediating influence. Adjusting for all covariates reduced the gap between Black and White women somewhat, but Black women retained their elevated odds of hypertension (odds ratio [OR] 1.74, 95% confidence interval [CI] 1.60-1.90), while the gap between Hispanic and White women was reduced to nonsignificance (OR .99, 95% CI .90-1.11). Interaction tests revealed that the relationship between depression and hypertension differed across racial/ethnic groups; depression had a much stronger association with hypertension among Black and Hispanic women than among Whites. CONCLUSIONS: After adjusting for age, Black and Hispanic women were more hypertensive than their White counterparts, and depression disproportionately increased their risk. Efforts to improve hypertension treatment and control would benefit from a better understanding of the link between mental and physical health among US minority groups.

Gender inequalities in US adult health: the interplay of race and ethnicity.

Gender differences in adult health are well documented, but only recently has research begun to investigate how race and ethnicity condition gendered health disparities. This paper contributes to this line of inquiry by assessing gender differences in morbidity across five major US racial and ethnic populations. Using data from the 1997-2001 waves of the National Health Interview Survey, the analysis examines differences in men and women's self-rated health, functional limitations, and life-threatening medical conditions for whites, blacks, Mexicans, Puerto Ricans, and Cubans. For each health outcome, we investigate the utility of socioeconomic factors in accounting for observed disparities. Contrary to finding universal excess in female morbidity, the results show that the magnitude of gender difference varies considerably by racial/ethnic group, health outcome, and comparison category. The most striking findings are the consistently higher levels of functional limitations for all women compared to men in their same racial/ethnic group and the poorer health of black women relative to both white and black men for all health measures, after adjustment for socioeconomic and background factors. The gender gap for all other health measures is more variable, and for Mexican women a difference is only evident for functional limitations and only when compared to Mexican men. Our results underscore the need for more research on the role of race and ethnicity in shaping gendered health inequalities and the mechanisms that lead to such variable patterns of difference across and within US racial and ethnic populations.

Implications of black immigrant health for U.S. racial disparities in health.

This paper contributes to a growing understanding of U.S. black-white health disparities by using national-level data to disaggregate the health status of black Americans into the following subgroups: U.S.-born blacks, black immigrants from Africa, black immigrants from the West Indies, and black immigrants from Europe. Using new data on the 2000 and 2001 National Health Interview Surveys (NHIS), the authors compare the status of U.S.- and foreign-born blacks to that of U.S.-born whites on three measures of health. The analysis finds that U.S.-born and European-born blacks have worse self-rated health, higher odds of activity limitation, and higher odds of limitation due to hypertension compared to U.S.-born whites. In contrast, African-born blacks have better health than U.S.-born whites on all three measures, while West Indian-born blacks have poorer self-rated health and higher odds of limitation due to hypertension but lower odds of activity limitation. These findings suggest that grouping together foreign-born blacks misses important variations within this population. Rather than being uniform, the black immigrant health advantage varies by region of birth and by health status measure. The authors conclude by exploring the implications of these findings for researchers, health professionals, and public policy.

Arab immigrants: a new case for ethnicity and health?

Community-based studies of Arab Americans point to significant health problems among the immigrants, a finding that runs contrary to theories of immigrant selectivity. This study is the first to use nationally representative data to test this question. Using new questions that identify region of birth in the 2000 and 2001 National Health Interview Surveys, we compare the self-rated health and activity limitation of Arab immigrants to US-born white Americans and test the extent to which social, demographic, and immigrant characteristics account for observed disparities. The results find that Arab immigrants do not significantly differ from US-born whites in their self-rated health and are less likely to report limitations in activity. Length of time in the US has no composite effect on health; however, US citizenship does. Compared to the most recent immigrant arrivals, Arab immigrants who are citizens report worse health while their peers who are not officially American (non-citizens) do not, regardless of their duration of US residency. Contrary to prior studies on Arab health, we find that Arab immigrants are not uniformly disadvantaged in their health outcomes and that their health profile is more diverse than currently documented. The results also suggest that controlling for years of US residency may be insufficient for capturing the cumulative effects of acculturation on immigrant health. We conclude by suggesting avenues of future research for capturing heterogeneity among emergent ethnic populations such as Arab Americans.