Patricia Y. Miranda

Relational pathways between socioeconomic position and cardiovascular risk in a multiethnic urban sample: complexities and their implications for improving health in economically disadvantaged populations

Background: The study was designed to provide evidence of a cascade effect linking socioeconomic position to anthropometric indicators of cardiovascular disease (CVD) risk through effects on psychosocial stress, psychological distress and health-related behaviours, and consider implications for disease prevention and health promotion. Methods: A cross-sectional stratified two-stage probability sample of occupied housing units in three areas of Detroit, Michigan, was used in the study. 919 adults aged ⩾25 years completed the survey (mean age 46.3; 53% annual household income <

A Review of Cancer in U.S. Hispanic Populations

20 000; 57% non-Hispanic black, 22% Latino, 19% non-Hispanic white). Variables included self-report (eg, psychosocial stress, depressive symptoms, health behaviours) and anthropometric measurements (eg, waist circumference, height, weight). The main outcome variables were depressive symptoms, smoking status, physical activity, body mass index and waist circumference. Results: Income was inversely associated with depressive symptoms, likelihood of current smoking, physical inactivity and waist circumference. These relationships were partly or fully mediated by psychosocial stress. A suppressor effect of current smoking on the relationship between depressive symptoms and waist circumference was found. Independent effects of psychosocial stress and psychological distress on current smoking and waist circumference were found, above and beyond the mediated pathways. Conclusions: The results suggest that relatively modest improvements in the income of economically disadvantaged people can set in motion a cascade of effects, simultaneously reducing exposure to stressful life conditions, improving mental well-being, increasing health-promoting behaviours and reducing anthropometric risks associated with CVD. Such interventions offer important opportunities to improve population health and reduce health disparities.

Breast cancer screening and ethnicity in the United States: implications for health disparities research

There are compelling reasons to conduct studies of cancer in Hispanics, the fastest growing major demographic group in the United States (from 15% to 30% of the U.S. population by 2050). The genetically admixed Hispanic population coupled with secular trends in environmental exposures and lifestyle/behavioral practices that are associated with immigration and acculturation offer opportunities for elucidating the effects of genetics, environment, and lifestyle on cancer risk and identifying novel risk factors. For example, traditional breast cancer risk factors explain less of the breast cancer risk in Hispanics than in non-Hispanic whites (NHW), and there is a substantially greater proportion of never-smokers with lung cancer in Hispanics than in NHW. Hispanics have higher incidence rates for cancers of the cervix, stomach, liver, and gall bladder than NHW. With respect to these cancers, there are intriguing patterns that warrant study (e.g., depending on country of origin, the five-fold difference in gastric cancer rates for Hispanic men but not Hispanic women). Also, despite a substantially higher incidence rate and increasing secular trend for liver cancer in Hispanics, there have been no studies of Hispanics reported to date. We review the literature and discuss study design options and features that should be considered in future studies. Cancer Prev Res; 5(2); 150–63. ©2012 AACR.

Mammography Use After the 2009 Debate

Ethnic and racial minority women within the U.S. are less likely to use breast cancer screening (BCS) procedures than non-Latina White women, and are more likely to be diagnosed with cancer at later stages of disease. Previous studies examining Latina rates of screening and disease have used aggregated populations for comparison, possibly attenuating important ethnic healthcare disparities and yielding misleading findings. The purpose of this study was to examine if ethnicity matters in understanding current estimates of BCS patterns among U.S. women; to test if healthcare disparities in BCS are present, and if any ethnic/racial groups are primarily affected. The authors used multivariate multinomial regression to examine self-reported mammogram and clinical breast exam in the 2007 full-year U.S. Medical Expenditure Panel Survey. Mexican origin women reported the lowest rates of past-year mammograms and clinical breast examination. Factors enabling healthcare moderated the group’s lower likelihood of mammograms and clinical breast examination. Some breast cancer screening parity appears to have been achieved in 2007 for Black and some Latina groups; however, those rates lag behind for the largest Latino ethnic group, Mexican. Factors enabling healthcare access, such as education, income and insurance, attenuated the BCS inequalities found for Mexican origin women. Findings suggest that successful efforts to reduce BCS disparities be strategically redirected to include women of Mexican origin in addition to other underserved populations.

Protective Neighborhoods: Neighborhood Proportion of Mexican Americans and Depressive Symptoms in Very Old Mexican Americans

In November 2009, the United States Preventive Services Task Force (USPSTF) updated their guidelines to recommend against routine screening mammography for women aged 40 to 49 years and recommended biennial instead of annual mammography for women aged 50 to 74 years for women of average risk.1,2 The Task Force also concluded that “current evidence is insufficient to assess the additional benefits and harms of screening mammography in women age 75 years or older (p.716).”1 The guideline update invoked many medical societies to release their own guidelines to support annual mammogram in women age 40 years and older.3 Most private and public insurers continued to cover annual mammography for women age 40 years and older.4-7 Moreover, breast cancer screening is the only preventive procedure that the Patient Protection and Affordable Care Act (ACA) coverage did not match the 2009 USPSTF recommendations and instead, covers annual mammography without co-pay or co-insurance for women starting at age 40 years of average risk.8 The National Breast and Cervical Cancer Early Detection Program continues to pay for annual mammography for underserved women aged 40 to 64 years of average risk.9 We used the Medical Expenditure Panel Survey-National Health Interview Survey (MEPS-NHIS) linked data to identify women aged 41 years and older. We obtained person-level data covering three calendar years (2008-2010). Women aged 41 years or older were asked about mammography use in the past year three times during the study period. We stratified women into three age groups: 41 to 49, 51 to 74, and 76 years and older. We reported trends of the percentage of women who reported a mammogram in the past year by age group. We estimated logistic multivariate regression models with person-specific fixed effects to compare self-reported mammography screening in each of the three years. Variables in the regression analyses include survey year, household income compared to federal poverty line, insurance status, whether the respondent has a usual source of care, and self-rated health status measure. Because we stratify by age, we do not further control for it in the regression models. Insurance status was not controlled in the analyses of the age group 75 years of older because they are by and large Medicare beneficiaries. The model included person-specific fixed effects to account for unobservable characteristics that could bias estimates of mammography utilization. In the 41 to 49 age group, the percentage of women reporting a past-year mammogram rose from 46% in 2008 to 56% in 2010 (p<0.05). We have observed The mammography rates in older women were virtually unchanged (Figure 1). Table 1 confirms the patterns observed. Women aged 41 to 49 years (odds ratio=2.00, 95% CI: 1.26-3.17) were more likely to report a past-year mammogram in 2010 than in 2008. For women aged 51 to 74 and 76 or older, the past-year mammograms were unchanged from 2008 to 2010 in the multivariate analyses. Women aged 51 to 74 years who had a usual source of care were more likely to report mammography in the past year (odds ratio =2.84, 95% CI: 1.60-5.04). Figure 1 Percentage of women reporting a past-year mammogram Table 1 The Odds Ratio (95% CI) By following a cohort of women from 2008 to 2010, we found that mammography screening rates did not decrease in any age group after the 2009 issuance of guideline changes. Contrasting to a downward trend in mammography rates between 2000 and 2008,10 the percentage of women who reported a past-year mammogram was higher in 2010 than in 2008 in women aged 41 to 49 years. Although aging may explain some of the increase in mammography use in this age group, it probably safe to conclude that there was very little response to the new USPSTF guideline recommendations for younger women. Mammography rates were unchanged over time in other age groups. The vigorous debate following the USPTF new guidelines may have raised the awareness of breast cancer screening. Continued analysis of mammography rates with more years of longitudinal data will inform whether there is a long-term impact of the 2009 guidelines on screening rates. The next USPSTF breast cancer screening recommendations are due in the near future. We should be prepared for an ongoing debate about balance of benefit and harms, the age at which screening should begin and end, and issues of over-diagnosis/over-treatment.

Policy implications of early onset breast cancer among Mexican-origin women

Research indicates that neighborhood context can have a significant effect on the health of older adults. The evidence suggests that there may be physical health benefits afforded to Mexican Americans living in ethnically homogenous neighborhoods, despite the relatively high economic risk in such neighborhoods, but few studies have considered the effect of neighborhood ethnic density on mental health outcomes in older adults. This study evaluated the association between neighborhoods with a high proportion of Mexican Americans and depressive symptoms in very old Mexican Americans. Hierarchical linear modeling was used to examine data from Wave 5 (2004/05) of the Hispanic Established Populations for the Epidemiologic Study of the Elderly. Subjects included 1,875 community‐dwelling Mexican Americans aged 75 and older living in 386 neighborhoods in five states in the southwestern United States (Arizona, California, Colorado, New Mexico, Texas). Depressive symptoms were measured using the Center for Epidemiologic Studies Depression Scale (α=0.88). Results showed that, in very old men, there was a significant negative association between percentage of Mexican Americans in the neighborhood and depressive symptoms (P=.01). In women, the direction of the association was the same, but the effect was not significant. These findings suggest that the proportion of Mexican Americans in the neighborhood matter more for very old Mexican American men than women. Further research may inform screening and treatment for depressive symptoms based on differences in neighborhood composition. Recommendations include culturally customized programs that offer older Mexican Americans greater mobility and access to programs and opportunities in culturally identifiable neighborhoods.

Medical expenditures among immigrant and nonimmigrant groups in the United States: Findings from the medical expenditures panel survey (2000-2008)

Overall, Latinas are more likely to be diagnosed with a more advanced stage of breast cancer and are 20% more likely to die of breast cancer than non‐Hispanic white women. It is estimated that from 2003 to 2006,

Strategies for Recruitment of Healthy Premenopausal Women into the African American Nutrition for Life (A NULIFE) Study.

82.0 billion in direct medical care expenditures, in addition to 100,000 lives annually, could be saved by eliminating health disparities experienced by Latinos and increasing the use of up to 5 preventive services in the United States. An additional 3700 lives could be saved if 90% of women aged ≥40 years were recently screened for breast cancer.

Antidepressant use among Asians in the United States

Objective:The objective of the study was to examine time trends and differences in medical expenditures between noncitizens, foreign-born, and US-born citizens. Methods:We used multi-year Medical Expenditures Panel Survey (2000–2008) data on noninstitutionalized adults in the United States (N=190,965). Source specific and total medical expenditures were analyzed using regression models, bootstrap prediction techniques, and linear and nonlinear decomposition methods to evaluate the relationship between immigration status and expenditures, controlling for confounding effects. Results:We found that the average health expenditures between 2000 and 2008 for noncitizens immigrants (

Addressing cancer health disparities using a global biopsychosocial approach.

1836) were substantially lower compared with both foreign-born (