Amani Nuru-Jeter

Is doctor-patient race concordance associated with greater satisfaction with care?

We examined a national sample of African American, white, Hispanic, and Asian American respondents to test the hypothesis that doctor-patient race concordance is predictive of patient satisfaction. Our analysis examined racial/ethnic differences in patient satisfaction among patients in multiple combinations of doctor-patient race/ethnicity pairs. Additionally, we outline the determinants of doctor-patient race concordance. The analysis used the 1994 Commonwealth Fund Minority Health Survey to construct a series of multivariate models. We found that for respondents in each race/ethnic group, patients who had a choice in the selection of their physician were more likely to be race concordant. Whites were more likely to be race concordant with their physician compared to African American, Hispanic, and Asian American respondents. Among each race/ethnic group, respondents who were race concordant reported greater satisfaction with their physician compared with respondents who were not race concordant. These findings suggest support for the continuation of efforts to increase the number of minority physicians, while placing greater emphasis on improving the ability of physicians to interact with patients who are not of their own race.

Family Socioeconomic Status and Child Executive Functions: The Roles of Language, Home Environment, and Single Parenthood

The association between family socioeconomic status (SES) and child executive functions is well-documented. However, few studies have examined the role of potential mediators and moderators. We studied the independent and interactive associations between family SES and single parenthood to predict child executive functions of inhibitory control, cognitive flexibility, and working memory and examined child expressive language abilities and family home environment as potential mediators of these associations. Sixty families from diverse SES backgrounds with a school-age target child (mean [SD] age = 9.9 [0.96] years) were evaluated. Child executive functioning was measured using a brief battery. The quality of the home environment was evaluated using the Home Observation for the Measurement of the Environment inventory. Family SES predicted the three child executive functions under study. Single parent and family SES were interactively associated with childrens inhibitory control and cognitive flexibility; such that children from low SES families who were living with one parent performed less well on executive function tests than children from similarly low SES who were living with two parents. Parental responsivity, enrichment activities and family companionship mediated the association between family SES and child inhibitory control and working memory. This study demonstrates that family SES inequalities are associated with inequalities in home environments and with inequalities in child executive functions. The impact of these disparities as they unfold in the lives of typically developing children merits further investigation and understanding.

The Association of Doctor-Patient Race Concordance with Health Services Utilization

We examined a national sample of African-American, white, Hispanic, and Asian-American respondents to test the hypothesis that when patients are race concordant with their physicians, they are more likely to utilize health services. The analysis used the 1994 Commonwealth Fund Minority Health Survey to construct a series of multivariate models. Using three dimensions of health services utilization, we found support for the hypothesis. Compared to patients whose regular doctors are of a different race, patients who are of the same racial or ethnic group as their physicians were more likely to use needed health services (OR=.62; 95% CI .46, .81); were less likely to postpone or delay seeking care (OR=.78; 95% CI .65,.94); and reported a higher volume of use of health services (OR=2.68; 95% CI 2.07, 3.45). Analysis within race-specific sub-samples found this pattern to be most consistent among white and African-Americans and less prevalent among Hispanic and Asian-Americans. Adjusting the models for health status and a variety of other known predictors of health care utilization did not substantially affect the relationship between doctor-patient race concordance and health services use.

‘‘It’s The Skin You’re In’’: African-American Women Talk About Their Experiences of Racism. An Exploratory Study to Develop Measures of Racism for Birth Outcome Studies

Objectives Stress due to experiences of racism could contribute to African-American women’s adverse birth outcomes, but systematic efforts to measure relevant experiences among childbearing women have been limited. We explored the racism experiences of childbearing African-American women to inform subsequent development of improved measures for birth outcomes research. Methods Six focus groups were conducted with a total of 40 socioeconomically diverse African-American women of childbearing age in four northern California cities. Results Women reported experiencing racism (1) throughout the lifecourse, with childhood experiences seeming particularly salient and to have especially enduring effects (2) directly and vicariously, particularly in relation to their children; (3) in interpersonal, institutional, and internalized forms; (4) across different life domains; (5) with active and passive responses; and (6) with pervasive vigilance, anticipating threats to themselves and their children. Conclusions This exploratory study’s findings support the need for measures reflecting the complexity of childbearing African-American women’s racism experiences. In addition to discrete, interpersonal experiences across multiple domains and active/passive responses, which have been measured, birth outcomes research should also measure women’s childhood experiences and their potentially enduring impact, perceptions of institutionalized racism and internalized negative stereotypes, vicarious experiences related to their children, vigilance in anticipating future racism events, as well as the pervasiveness and chronicity of racism exposure, all of which could be sources of ongoing stress with potentially serious implications for birth outcomes. Measures of racism addressing these issues should be developed and formally tested.

Discrimination, Racial Bias, and Telomere Length in African-American Men

BACKGROUND Leukocyte telomere length (LTL) is an indicator of general systemic aging, with shorter LTL being associated with several chronic diseases of aging and earlier mortality. Identifying factors related to LTL among African Americans may yield insights into mechanisms underlying racial disparities in health. PURPOSE To test whether the combination of more frequent reports of racial discrimination and holding a greater implicit anti-black racial bias is associated with shorter LTL among African-American men. METHODS Cross-sectional study of a community sample of 92 African-American men aged between 30 and 50 years. Participants were recruited from February to May 2010. Ordinary least squares regressions were used to examine LTL in kilobase pairs in relation to racial discrimination and implicit racial bias. Data analysis was completed in July 2013. RESULTS After controlling for chronologic age and socioeconomic and health-related characteristics, the interaction between racial discrimination and implicit racial bias was significantly associated with LTL (b=-0.10, SE=0.04, p=0.02). Those demonstrating a stronger implicit anti-black bias and reporting higher levels of racial discrimination had the shortest LTL. Household income-to-poverty threshold ratio was also associated with LTL (b=0.05, SE=0.02, p<0.01). CONCLUSIONS Results suggest that multiple levels of racism, including interpersonal experiences of racial discrimination and the internalization of negative racial bias, operate jointly to accelerate biological aging among African-American men. Societal efforts to address racial discrimination in concert with efforts to promote positive in-group racial attitudes may protect against premature biological aging in this population.

Basic ADL Disability and Functional Limitation Rates Among Older Americans From 2000–2005: The End of the Decline?

BACKGROUND This study sought to determine whether the rates of basic activities of daily living (ADL) disabilities and functional limitations declined, remained the same, or increased between 2000 and 2005 when (a) only community-dwelling Americans aged 65 and older were examined and (b) when institutionalized older adults were included. METHOD Using data from the American Community Survey and the National Nursing Home Survey, we calculated annual prevalence rates of basic ADL disabilities and functional limitations and fitted regression lines to examine trends over time. RESULTS The rates of basic ADL disabilities among community-dwelling adults aged 65 and older increased 9% between 2000 and 2005. When institutionalized elders were included, basic ADL disability rates were stable among men but increased among women. Functional limitation rates did not significantly change between 2000 and 2005. CONCLUSION These findings suggest an end of the decline in disability rates among older Americans, which, if confirmed, could have important implications for health care.

Black—White Disparities in Disability Among Older Americans: Further Untangling the Role of Race and Socioeconomic Status

Objectives: To explore the impact of adjusting for income and education on disparities in functional limitations and limitations in activities of daily living (ADLs) between Black and White older Americans. Method: Data from the 2003 American Community Survey were used to examine the associations of education and income, stratified by race and gender, with functional limitations and ADLs, in a sample of 16,870 non-Hispanic Blacks and 186,086 non-Hispanic Whites aged 55 to 74. Sequential logistic regressions were used to examine the relative contribution of income and education to racial disparities. Results: Ninety percent of the Black—White difference in disability rates for men and 75% of the difference for women aged 55 to 64 were explained by income and education. Discussion: The greatly elevated risk of disability among Blacks aged 55 to 74 is largely explained by differences in socioeconomic status. Reductions in Black—White health disparities require a better understanding of the mechanisms whereby lower income and education are associated with functional outcomes in older persons.

Racial discrimination and depressive symptoms among African-American men: The mediating and moderating roles of masculine self-reliance and John Henryism

Despite well-documented associations between everyday racial discrimination and depression, mechanisms underlying this association among African-American men are poorly understood. Guided by the Transactional Model of Stress and Coping, we frame masculine self-reliance and John Henryism as appraisal mechanisms that influence the relationship between racial discrimination, a source of significant psychosocial stress, and depressive symptoms among African-American men. We also investigate whether the proposed relationships vary by reported discrimination-specific coping responses. Participants were 478 African-American men recruited primarily from barbershops in the West and South regions of the United States. Multiple linear regression and Sobel-Goodman mediation analyses were used to examine direct and mediated associations between our study variables. Racial discrimination and masculine self-reliance were positively associated with depressive symptoms, though the latter only among active responders. John Henryism was negatively associated with depressive symptoms, mediated the masculine self-reliance-depressive symptom relationship, and among active responders moderated the racial discrimination-depressive symptoms relationship. Though structural interventions are essential, clinical interventions designed to mitigate the mental health consequences of racial discrimination among African-American men should leverage masculine self-reliance and active coping mechanisms.

Experiences and Perceptions of Medical Discrimination Among a Multiethnic Sample of Breast Cancer Patients in the Greater San Francisco Bay Area, California

OBJECTIVES We conducted qualitative interviews with breast cancer survivors to identify themes related to institutional, personally mediated, and internalized discrimination in the medical setting. METHODS We conducted 7 focus groups and 23 one-on-one interviews with a multiethnic sample of breast cancer survivors randomly selected from a population-based registry covering the Greater San Francisco Bay Area, California. RESULTS Participants reported experiencing different forms of medical discrimination related to class, race, and language. Among African Americans, participants reported experiencing internalized discrimination and personal or group discrimination discrepancy-perceiving discrimination against them as a racial/ethnic group, yet not perceiving or discussing personal experiences of discrimination. Among Asian immigrants, participants reported experiencing institutional and personally mediated overt types of discrimination, including lack of access to quality and readily available translation services. Our results also indicated well-established coping mechanisms in response to discrimination experiences in both groups. CONCLUSIONS Participants reported experiencing medical discrimination at all 3 levels, which may have deleterious health effects through the biopsychosocial stress pathway and through active coping mechanisms that could lead to delayed- or underutilization of the health care system to avoid discrimination.

Implicit racial bias as a moderator of the association between racial discrimination and hypertension: a study of Midlife African American men.

Objectives Empirical findings on racial discrimination and hypertension risk have been inconsistent. Some studies have found no association between self-reported experiences of discrimination and cardiovascular health outcomes, whereas others have found moderated or curvilinear relationships. The current cross-sectional study examined whether the association between racial discrimination and hypertension is moderated by implicit racial bias among African American midlife men. Methods This study examined the data on 91 African American men between 30 and 50 years of age. Primary variables were self-reported experiences of racial discrimination and unconscious racial bias as measured by the Black-White Implicit Association Test. Modified Poisson regression models were specified, examining hypertension, defined as a mean resting systolic level of at least 140 mm Hg or diastolic level of at least 90 mm Hg, or self-reported history of cardiovascular medication use with a physician diagnosis of hypertension. Results No main effects for discrimination or implicit racial bias were found, but the interaction of the two variables was significantly related to hypertension (&khgr;2(1) = 4.89, p < .05). Among participants with an implicit antiblack bias, more frequent reports of discrimination were associated with a higher probability of hypertension, whereas among those with an implicit problack bias, it was associated with lower risk. Conclusions The combination of experiencing racial discrimination and holding an antiblack bias may have particularly detrimental consequences on hypertension among African American midlife men, whereas holding an implicit problack bias may buffer the effects of racial discrimination. Efforts to address both internalized racial bias and racial discrimination may lower cardiovascular risk in this population.