Despite population trends, little research on the health of diverse groups has focused on the elderly. In this update of its 1997 report, Racial and Ethic Differences in the Health of Older Americans, a National Research Council panel explores factors affecting the health status of various groups. Members address methodological issues including the social construct of race. Based on some unexpected findings, they identify 18 research needs including longitudinal study of the health effects of stress and discrimination, and the use of alternative therapies by group. Annotation ©2004 Book News, Inc., Portland, OR (booknews.com)
Understanding Racial and Ethnic Differences in Health in Late Life
A Research AgendaNational Academies Press
Copyright © 2004 National Academy of Sciences
All right reserved.ISBN: 978-0-309-09247-0Contents
EXECUTIVE SUMMARY....................................................11 THE NATURE OF RACIAL AND ETHNIC DIFFERENCES.......................7Racial and Ethnic Groups.............................................9Definitions..........................................................9Disparate Treatment..................................................11How Group Membership May Affect Health...............................13Differences in Mortality and Health in Late Life.....................14Mortality............................................................15Causes of Death......................................................18Health and Disability................................................20Diseases and Conditions..............................................21Needed Research......................................................25Why Health Differences Matter........................................282 PERSPECTIVES ON RACIAL AND ETHNIC DIFFERENCES.....................32Major Factors........................................................32Nature of the Evidence...............................................36Selection Processes..................................................39Selection Through Accession to Social Groups.........................39Selection Through Survival...........................................40Reciprocal Causation.................................................41Implications.........................................................42Needed Research......................................................443 GENETIC INFLUENCES................................................46Race in Genetic Perspective..........................................46The Nature of Genetic Influence......................................48Gene Interactions....................................................49Some Racial and Ethnic Differences...................................52Needed Research......................................................534 SOCIOECONOMIC FACTORS.............................................54The Health Gradient and Reciprocal Causation.........................54Status, Race, and Ethnicity..........................................56Mechanisms...........................................................58Needed Research......................................................595 BEHAVIOR RISK FACTORS.............................................61Behavioral Variation.................................................61Reasons for Variation................................................62Effects of Variation and Trends......................................64Other Behaviors......................................................66Needed Research......................................................676 SOCIAL AND PERSONAL RESOURCES.....................................70Social Resources.....................................................70Personal Resources...................................................73Racial and Ethnic Variation..........................................74Needed Research......................................................747 PREJUDICE AND DISCRIMINATION......................................76Correlational Studies................................................78Experimental and Physiological Studies...............................78Needed Research......................................................798 STRESS............................................................82Stress and Health....................................................82Race, Ethnicity, and Stress..........................................83Needed Research......................................................859 BIOPSYCHOSOCIAL INTERACTIONS......................................86Physiological Reactivity.............................................87Allostatic Load......................................................88Psychoneuroimmunology................................................88The Metabolic Syndrome and Psychosocial Factors......................89Neurovisceral Integration............................................89Needed Research......................................................9010 HEALTH CARE.......................................................92Insurance Coverage...................................................92Quality of Care......................................................95Geographic and Institutional Variation...............................98Stereotyping by Providers............................................99Patient Behavior.....................................................101Needed Research......................................................10211 THE LIFE COURSE...................................................104Early Health Disadvantage............................................105Pathways to Disadvantage.............................................106Needed Research......................................................10812 INTERVENTIONS.....................................................111Changing Individual Behavior.........................................111Health Promotion at Older Ages.......................................112Possible Effects on Differentials....................................113Needed Research......................................................114Social Policy........................................................115Effectiveness of Interventions.......................................115Targeted Interventions...............................................117Indirect Effects of Policy...........................................119Needed Research......................................................120REFERENCES...........................................................122APPENDIX.............................................................153BIOGRAPHICAL SKETCHES................................................156INDEX................................................................161
Chapter One
Executive Summary
An enormous amount of research has confirmed the existence of large and persistent differences in health status between various racial and ethnic groups in the United States. Most of this research has focused on black-white differences: it consistently shows that despite rising life expectancy and general improvements in the health status of the U.S. population, blacks continue to experience significantly lower life expectancy than whites.
Over the last 20 years, research on these issues has largely shifted away from straightforward descriptive studies to attempts to identify the underlying determinants of the observed differences in health status by race as a step towards developing an integrated model of causal processes. Many different disciplines have made broad theoretical and empirical contributions to the debate, but, to date, scholars have not been able to integrate these diverse contributions into a unifying model of causal processes. Interdisciplinary dialogue in this area has sometimes been difficult. A major problem is that each discipline makes contributions that focus on their particular domains of interest, uses different underlying assumptions, and applies different standards of evidence when analyzing data. Thus, it is perhaps not surprising that after decades of research in this area, there are still large and persistent differences in health by racial and ethnic groups that have not been fully explained.
Making general statements about the importance of particular factors becomes much harder when racial and ethnic groups other than whites and blacks are included in the discussion. Although some minority older adults, particularly blacks and, generally, American Indians and Alaska Natives, are considerably less healthy than older whites, others, particularly Hispanics and Asians, are generally healthier. Yet these broad observations require qualifications: subgroups of each of these racial or ethnic groups vary in health status, and different indicators of health status also give different results. For example, age-adjusted mortality rates reinforce the general conclusions that Hispanics are healthier, on average, than whites, but from self-reported measures of health, Hispanics appear less healthy than whites.
Specific causes of death and specific morbidities lead to somewhat different rankings of racial and ethnic groups. For example, although blacks die more often than whites from most causes, their death rates from respiratory infections and pneumonia are lower than those for whites. Similarly, although Hispanics die less often than whites from most causes, they experience higher mortality from diabetes. Furthermore, looking across age groups, the contrasts are not consistent: most notably, the black disadvantage in old age is reversed at the oldest ages, when black mortality rates converge with those of whites and apparently fall below them.
Further complicating the study of racial and ethnic differences in health is the fluid nature of the social construct of race. Both academic and popular understandings of racial and ethnic identities have not been fixed and the picture of racial and ethnic differences in health has been heavily influenced by how these understandings have changed over time and how data on race and ethnicity have been collected.
To date, little of the research on racial and ethnic differences in health has been directed specifically towards the elderly, despite population projections that show that the population aged 65 and over is becoming increasingly diverse. Current projections suggest that, by 2050, while the total number of non-Hispanic whites aged 65 and over will double, the number of blacks aged 65 and over will more than triple, and the number of Hispanics will increase eleven-fold.
Recognizing the need for continuing research on racial and ethnic differences in health, as well as the increasing diversity of the U.S. population, the National Institutes of Aging asked the National Academies to (a) organize a 2-day workshop to bring together leading researchers from a variety of disciplines and professional orientations to summarize current research and to identify future direction for research in these areas and (b) to prepare a summary of the state of knowledge incorporating this information and providing recommendations for further work.
FINDINGS
Health differences involve a complexity of factors, including various processes of selection. Some racial and ethnic groups have high proportions of immigrants, some of whom are self-selected to be healthier than the native-born population. When older cohorts are compared, the groups reflect both selection from the original birth cohorts and differences in survival. Socioeconomic factors-education, income, wealth, occupational status, even residential neighborhood-are also important. Not only does low socioeconomic status impair health, but illness can in turn impose costs and reduce earnings and wealth. Yet the processes by which socioeconomic status affects health are not well understood. Furthermore, socioeconomic status is not always the dominant factor: for example, despite higher poverty rates, Hispanics have lower age-adjusted mortality rates than whites, and relatively low-income Vietnamese have lower mortality rates than relatively high-income Asian Indians.
Behavior risk factors-such as smoking, overeating, lack of exercise, and excessive alcohol use-clearly impair health, but their contribution to racial and ethnic differences is not always what one might expect. These risk factors are less common among Asians than whites (except for less exercise), which is consistent with better Asian health. However, they are more common among Hispanics than whites, despite lower Hispanic mortality. And because blacks generally smoke less than whites, this critical risk factor for several causes of death and illness serves to reduce differences between blacks and whites rather than increase them.
Cumulative prejudice and discrimination have been hypothesized to contribute to health differences among groups, but the processes by which they might do so are not well understood. Some evidence suggests that being discriminated against leads to psychological distress, with such negative health effects as elevated blood pressure, but not all studies support this finding.
Levels of stress, not only from experiencing discrimination but also from other pressures of life, are hypothesized to contribute to poor health, and they may vary across racial and ethnic groups. Models of the effects of stress on health such as allostatic load, cardiovascular reactivity, psychoneuroimmunology, metabolic syndrome, and neurovisceral integration may have different predictive value among older persons of different racial and ethnic groups.
Differences in health care access and quality are well documented, and they may affect health, but how much of the racial and ethnic health differences may be accounted for by such differences in health care is unclear. Quality of health care varies geographically, and some of this variation may be related to the racial and ethnic composition of an area. Stereotypes held by providers have been hypothesized to be important, but the effects of such stereotypes on health differences in older ages is unclear. Patient compliance may account for some of the observed differences, and compliance varies by socioeconomic status, yet the patterns across racial and ethnic groups are not consistent.
The influence of each of these factors can cumulate over the life course, so that the health status of older cohorts reflects their entire life experiences. Research increasingly suggests that even early life experiences can contribute to late-life morbidity and age at mortality. Understanding health differences in old age therefore requires understanding influences across the life course.
Although deliberate interventions can affect individual health behaviors, interventions aimed at improving population health may exacerbate racial and ethnic differences, at least initially. For example, people with the most education and income may to be the first to quit smoking, lose weight, or start exercising in response to population-level interventions or when physicians recommend these changes, so that interventions targeted to particular groups may be needed to effect changes.
RESEARCH QUESTIONS AND NEEDS
Understanding the various factors that produce racial and ethnic group health differences in late life is important in the development of health policy. To date, what is known about the origins of racial and ethnic differences in health points in many directions, with findings coming from a variety of disciplines. And much of the research on particular determinants comes from work that does not focus specifically on older people. Consequently, researchers are still a long way from being able to construct a model that integrates all potential factors.
To advance the field, research is needed in each of the areas touched on above. The panel's list of research needs starts with the need to partition differences in morbidity and mortality in older populations to determine how much can be attributed to particular diseases or conditions and in turn how much of the differences in diseases and conditions can be assigned to major risk factors. Such analysis has been done to some extent for the general population, but not specifically for the elderly. If such partitioning can be accomplished, it should be possible to refine the research agenda to focus on the most critical areas. The list of research needs then focuses on verifying apparent health differences in cases where there are uncertainties, and on improving our understanding of the operation of and interaction among the major factors that contribute to racial and ethnic differences in health.
Three main themes underlie the panel's recommended research:
The roots of health differences have to be examined across the life course, taking a longitudinal view and integrated account of the effects of such factors as socioeconomic status, behavior risk factors, and prejudice and discrimination, as well as the effects across cohorts and periods of selection processes and social policy.
All factors should be investigated in terms of their links to stress and biopsychosocial mechanisms that lead to impaired health.
Interventions designed to reduce health differences should be evaluated, along with determining the role of health care quality in racial and ethnic differences, which may range from possible geographic variability to differences in patient compliance and the use of alternative therapies.
Cutting across these themes is the need to investigate variability across and within multiple racial and ethnic groups.
The health disadvantages of a racial or ethnic group are a particular concern when that group is of low socioeconomic status or has experienced a history of prejudice or discrimination. Research is needed to identify the reasons for particular disadvantages and to understand mechanisms of influence. An additional challenge for public health is to achieve a balance between efforts to ameliorate racial and ethnic differences in health and efforts to improve population health in general. The panel recommends work on 18 research needs:
Research Need 1: Attempt a systematic decomposition of racial and ethnic differences in mortality and morbidity among older people to determine the relative contribution of particular diseases or conditions. Try to assign differences in the prevalence of specific diseases and conditions to differences in the prevalence of major risk factors.
Research Need 2: Clarify the contrasts between mortality rankings and morbidity rankings, particularly between older whites and Hispanics, and assess the relative contributions of diseases and conditions to differences in mortality and overall health.
Research Need 3: When particular diseases are especially prevalent for specific racial and ethnic groups, collect more indicators of biological and functional performance in order to identify possibilities for intervention.
Research Need 4: Identify and quantify the various selection processes that affect health differences among racial and ethnic groups.
Research Need 5: Assess genetic and environmental factors in racial and ethnic differences in health simultaneously, in designs that permit identification of both main effects and interactions.
Research Need 6: Clarify the degree to which socioeconomic status accounts for racial and ethnic differences in health outcomes over the life course.
Research Need 7: Identify the mechanisms through which socioeconomic status produces racial and ethnic health differences in health among the elderly, and identify other factors that complicate its effects.
Research Need 8: Study how behavior risk factors act over the life course in different racial and ethnic groups.
Research Need 9: Characterize the distribution of social and psychological resources in different older populations and investigate whether their effects on health vary by race and ethnicity.
Research Need 10: Determine the lifetime effects of prejudice and discrimination on health using longitudinal data and a framework that centers on stress and its effects.
Research Need 11: Evaluate the effects of prejudice and discrimination on the health of minorities other than blacks.
Research Need 12: Study populations of different racial and ethnic groups to assess the connection between health and the stresses that accumulate over a lifetime.
Research Need 13: Clarify how biopsychosocial factors affect health outcomes over time in racial and ethnic groups of middle-aged and older adults.
Research Need 14: Identify differences in health care-access, use, and quality-for racial and ethnic minority populations other than blacks.
Research Need 15: Determine the reasons for differences in health care quality, focusing on the contributions of geographic variation, characteristics of health care institutions, provider behavior and stereotyping, and patient adherence to recommendations for care.
Research Need 16: Place particular emphasis on panel studies that follow cohorts in order to study differences in health among racial and ethnic groups over the life course.
Research Need 17: Measure the use of complementary and alternative therapies by racial and ethnic groups.
Research Need 18: Characterize long-term trends (and possible lags) in the effects of changing social policy-federal, state, and local-on health differences and on public health.
(Continues...)
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