Measurement of Race, Measurement of Race, Ethnicity and Social ClassEthnicity and Social ClassResearch in Diverse CommunitiesEliseo J. Pérez-Stable, M.D.Eliseo J. Pérez-Stable, M.D.

Professor of Medicine, Professor of Medicine, Division of General Internal Medicine, Division of General Internal Medicine,

Department of Medicine, Department of Medicine, Medical Effectiveness Research Center Medical Effectiveness Research Center

for Diverse Populations (MERC) for Diverse Populations (MERC)

March 28, 2006March 28, 2006

ProportionsProportions(Premature Mortality)(Premature Mortality)

GeneticGenetic

30%30%

Health Health carecare

10%10%

Determinants Determinants of Healthof Health

BehaviorBehavior

40%40%

• GeneticGenetic

• Behavioral Behavioral

• EnvironmentalEnvironmental

• Social SettingSocial Setting

• Health careHealth care

SocialSocial15%15%

EnvironmentEnvironment5%5%

Source: McGinnis JM, Russo PG, Knickman, JR. Health Affairs, April 2002.

Summary of PresentationSummary of Presentation•Race ––Why bother?•Ethnicity•US Census Questions and OMB 15•Race and Genetics•Social Class •Perceived Discrimination/Racism•Clinical Research Examples

Definition of RaceDefinition of Race

Societally constructed

taxonomy that reflects

intersection of particular

historical conditions with

economic, political, legal,

social and cultural factors,

as well as racism.

David Williams, PhD, 1994

Why is it Important to Why is it Important to Include Race as a Variable Include Race as a Variable

in Research?in Research?• Reason to measure: Predictor variable accounting for variance on outcomes

• Public health surveillance

• Assess the impact of organizational changes in the health care system on quality of care for vulnerable groups

• Due to treatment disparities: track processes and outcomes of care

• Advance knowledge

Race CategoriesRace Categories

• Race is a social construct

• Geographic origin of racially classified social groups holds

• Contrast of White and Black–simple

• One-drop rule (1/16th)

• Gradations of pigmentation

EthnicityEthnicity

• Ethnicity refers to self-identity with a group defined in part by racial admixture, geographic origin, culture, religion and/or language

• Examples cover a broad spectrum but dictated by sharing non-phenotypic characteristics

• Latinos or Hispanics as example

Ethnicity could be the Ethnicity could be the Preferred TerminologyPreferred Terminology

• Admixture will lead to racial

categories becoming less valid

and should be abandoned

• Social construct of race overwhelms Social construct of race overwhelms

genotypegenotype

• National background, cultural

identity, language proficiency

Implications for Research Implications for Research MethodsMethods

• In human research, always consider In human research, always consider asking about race or ethnicityasking about race or ethnicity

• Method used: Self-identification should be the “gold standard”

• Administrative data has limitations with up to 30% misclassification

• Need to over sample ethnic groups or stratify or focus on ethnicity

OMB Directive 15OMB Directive 15

• Sets guidelines for the collection of racial and ethnic categories to “provide for the collection and use of compatible, non-duplicated, exchangeable racial and ethnic data by Federal agencies.”

2000 U.S. Census: New 2000 U.S. Census: New OMB OMB StandardsStandards

• Allow for reporting more than 1 race

• Separate Asian/Pacific Islander into 2 categories: Asian and Native Hawaiian or Other Pacific Islander

• Change to Hispanic or Latino• Change to black or African American• Strongly endorse self-identification

2000 U.S. Census Questions2000 U.S. Census Questions

Ethnicity question preceding race question

• Is this person Spanish/Hispanic Latino?

Ethnicity response options:o No, not Spanish/Hispanic/Latinoo Yes, Mexican, Mexican-Am, Chicanoo Yes, Puerto Ricano Yes, Cubano Yes, other Spanish/Hispanic/Latino

2000 U.S. Census Questions2000 U.S. Census Questions

Race question: What is this person’s race?

Race response options:o White, Caucasian, (European American)o Black, African American, or Negroo American Indian or Alaska Native - principal tribe

o Asian Indian o Korean o Samoano Chinese o Vietnamese o Other PI

o Filipino o Native Hawaiian o Japanese o Guamanian or Chamorroo Other Asiano Some other race

Lack of Heterogeneity in RaceLack of Heterogeneity in Race

• Categories too simpleCategories too simple

• African American, Caribbean Black, African American, Caribbean Black, AfricanAfrican

• South Asian, East Asian, SE AsianSouth Asian, East Asian, SE Asian

• American Indian tribal affiliationsAmerican Indian tribal affiliations

• Indigenous groups in the Americas

• Lump or Split?

Latinos in the U.S.Latinos in the U.S.

•More similarities than differences

•Central role of Spanish language

•Cultural themes unify

•Racial admixture–500+ years

•Common cultural heritage: Catholic Church, Spain, Indigenous

Race and GeneticsRace and Genetics• More genetic variance within than between More genetic variance within than between

racial groups–no genetic basis for raceracial groups–no genetic basis for race• Race/ethnicity identifies group more likely to Race/ethnicity identifies group more likely to

share specific allelesshare specific alleles• Random coupling will eliminate race––Random coupling will eliminate race––ever?ever?

• Interaction with environment–gene Interaction with environment–gene expressionexpression

• Ancestral Informative MarkersAncestral Informative Markers

0

500

1000

1500

2000

2500

3000

African American

Asian

Caucasian

Latino American

1 group2 groups3 groups4 groups

3,899 SNPs in 313 genes in 4 U.S. racial 3,899 SNPs in 313 genes in 4 U.S. racial

groupsgroups

Stephens, et al Science 2001

# S

NP

s

Common to:

25% of SNPs are Pan Racial25% of SNPs are Pan Racial

21% of SNPs are racially specific21% of SNPs are racially specific

Race, Genetics and DiseaseRace, Genetics and Disease• Racial categories emphasize geographic

region of origin of a person’s ancestry

• Most diseases are multi-factorial

• Gene pool predisposition often confused with “racial” characteristic

• HTN in Caribbean Blacks < Whites < Southern AA

• International variation in effect size of SBP on rate of stroke and heart attack

Contribution

45%

52% 24%

61%

15%3.0%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

MexicanAmerican

Puerto Rican

Percent

Ancestral

Admixture

Native AmericanAfrican

European

Genetic Origins of 2 Latino GroupsGenetic Origins of 2 Latino Groups

Ancestry Informative Markers Ancestry Informative Markers in Mexican Latinosin Mexican Latinos

Individual Admixture (IA) Estimates of Mexican Asthmatic Subjects

0%

20%

40%

60%

80%

100%

1 8 15 22 29 36 43 50 57 64 71 78 85 92 99 106 113 120 127 134 141 148 155 162 169 176

African European Native Amer

Ancestry Informative Markers Ancestry Informative Markers in Puerto Rican Latinosin Puerto Rican Latinos

Individual Admixture (IA) Estimates of Puerto Rican Asthmatic Subjects

0%

20%

40%

60%

80%

100%

1 8 15 22 2936 43 50 57 64 71 78 85 92 99

106 113 120 127 134 141 148 155 162 169 176

African European Native Amer

Role of AdmixtureRole of Admixture

• America is the laboratory• Will be more prevalent with time in all populations

• Can we develop a self-report measure of ancestry admixture?

• What is the clinical relevance of this?

• What are the risks?

What About Social Class?What About Social Class?

Dominant among racially homogeneous populations

Social Class MeasuresSocial Class Measures

• Education – years of formal or establish ordinal categories

• Income defined by annual household and factor number of dependents

• Decline to report or inaccurate• Occupation– laborer, technical, professional, business

Social Class Measures 2Social Class Measures 2

• Class measure over the life course––childhood exposure

• Parental occupation• Self-perceived ‘standing” on a ladder

• How do others perceive your class?• Simple questions are probably insufficient measures of social class

WealthWealth

• Wealth defines social class but not simple to measure

• Measure assets, property• Home ownership • Generation of “class”–1st in family to attend college,

• Household income vs. property

Social Class and Social Class and Race/EthnicityRace/Ethnicity

• Race been a substitute for defining social class in the U.S.

• Gradient of health outcomes at all levels by race--especially true for comparing African Americans and Whites

• Latinos and Asians are more complex

Race and EducationRace and Education

• Charleston Health Study: less education not risk factor for CAD mortality among Blacks

• Correlation of education with life expectancy in patients > 65 y is stronger than race

• Accounts for observed racial difference survival from cancer

Definition of Definition of Epidemiologic ParadoxEpidemiologic Paradox

• Outcomes are better than Outcomes are better than expected based on the known expected based on the known or standard predictive risk or standard predictive risk factorsfactors

• Low SES does not always Low SES does not always translate to worse outcomestranslate to worse outcomes

Proposed Explanations of Proposed Explanations of ParadoxParadox

• Healthy immigrant effectHealthy immigrant effect• Salmon hypothesis–return to die Salmon hypothesis–return to die at home and deaths not recordedat home and deaths not recorded

• Misclassification of ethnicity Misclassification of ethnicity in diagnosis and deathsin diagnosis and deaths

• Latinos classified as Whites – Latinos classified as Whites – 30%?30%?

• Census undercounts (increase)Census undercounts (increase)

“Let’s just forget for a moment that you’re black.”

Perceptions and AttitudesPerceptions and Attitudes

(% agree)(% agree) LATLAT AAAA WHWH

- - In past 5 years, you, family, In past 5 years, you, family, or close friend discriminated or close friend discriminated 4040 5454 1414due to race due to race

- Abortion should be legal in - Abortion should be legal in 4040 5050 4949all or most casesall or most cases

- MD-assisted suicide should - MD-assisted suicide should 3838 3333 5757be legal if terminally illbe legal if terminally ill

Henry J. Kaiser National Survey on Latinos in America, 2000.Henry J. Kaiser National Survey on Latinos in America, 2000.

Perception of Perception of DiscriminationDiscrimination

Does It Affect Health?Does It Affect Health?• Perceived discrimination is commonPerceived discrimination is common• Affects physical and mental health Affects physical and mental health status of African Americans in cohort status of African Americans in cohort studystudy

• Administering analgesics to Latinos with Administering analgesics to Latinos with long bone fractures--UCLAlong bone fractures--UCLA

• Referral of patients with chest pain to Referral of patients with chest pain to a cardiologist for evaluation varied by a cardiologist for evaluation varied by racerace

• Referral for obtaining technical Referral for obtaining technical procedures--surgery for lung cancer, procedures--surgery for lung cancer, renal transplantation, coronary artery renal transplantation, coronary artery surgerysurgery

Measurement Issues: Race, Measurement Issues: Race, Ethnicity and Social Class Ethnicity and Social Class

Examples from Clinical Research

Disparities in Quality of CareDisparities in Quality of CareMedicare Managed CareMedicare Managed Care

• HEDIS–4 measures of quality, Blacks compared to Whites

• Breast Cancer screen: 63% vs. 71%• Eye exams in diabetes: 44% vs. 50%• Beta-blocker after MI: 64% vs. 74%• Follow-up after mental illness hospitalization: 33% vs. 54%

• Schneider E, JAMA 2002; 287: 1288-94

Cancer Incidence by Site and Ethnicity Cancer Incidence by Site and Ethnicity in Women, U.S. 2000in Women, U.S. 2000

(per 100,000 age-adjusted)(per 100,000 age-adjusted)

Af Am API White Latino

Breast 102 78 116 69

Lung 46 23 44 19

Colon 45 31 36 23

Uterus 14 12 22 14

Cervix 11 10 8 14

NCI, SEER,

Cancer Incidence by Site and Ethnicity Cancer Incidence by Site and Ethnicity in Men, U.S. 2000in Men, U.S. 2000

(per 100,000 age-adjusted)(per 100,000 age-adjusted)

Af Am API White Latino

Prostate 234 83 145 103

Lung 117 52 76 42

Colon 61 45 56 38

Stomach 11 15 6 10

Smoking Related Risk of Lung Smoking Related Risk of Lung Cancer by Race and EthnicityCancer by Race and Ethnicity

Cigs AfAm N Haw Latino Japan White

1-9 1.0 0.88 0.210.21 0.250.25 0.450.45

11-20 1.0 0.90 0.360.36 0.390.39 0.570.57

21-30 1.0 0.93 0.610.61 0.610.61 0.730.73

31+ 1.0 0.95 0.79 0.75 0.82

Ethnic Disparities in Diabetic Ethnic Disparities in Diabetic Complications at KPMCPComplications at KPMCP

• Observational study: 62 432 Observational study: 62 432 patientspatients

• 10% Lat, 64% W, 14% AA, 12% API10% Lat, 64% W, 14% AA, 12% API• Latinos had less MI (0.68), CHF Latinos had less MI (0.68), CHF (0.61) and stroke (0.72) compared (0.61) and stroke (0.72) compared to Whitesto Whites

• More ESRD among Latinos–1.46More ESRD among Latinos–1.46• Setting of uniform accessSetting of uniform access• Genetics and environment?Genetics and environment?

TB Rate Ratio by EthnicityTB Rate Ratio by EthnicityDemographics and SESDemographics and SES

Demographic SES+ Crowding

Afr Amer 9.6 4.4 2.1/2.0

Latino 6.5 2.8 1.6/4.1

Asian 3.8 3.5 3.3/4.5

Am Indian 4.6 2.3 1.9/3.6

Catwell MF, AJRCCM 1997; 157:1016

CHD Prediction Scores By EthnicityCHD Prediction Scores By EthnicityColor in Framingham?Color in Framingham?

• Applied sex specific CHD functions to 6 ethnically diverse cohorts

• White and Black men and women prediction of CHD events works well

• Japanese & Latino men and American Indian men & women–risk is overestimated

• Adjust for different rates of risk factors and underlying rate of CHD

JAMA 2001; 286:180-7

Cigarette Smoking in the U.S. – 2002Cigarette Smoking in the U.S. – 2002National Health Interview SurveyNational Health Interview Survey

% Men % Women

WhiteAfrican AmLatinoAsianAm Indian

25.627.021.818.142.8

22.319.211.7 6.839.1

8 years or less9-11 yrs schoolhigh school diplCollege degree

25.438.129.813.6

13.530.922.110.5

Below poverty 36.9 30.1

MMWR 2004;53:427-431

Nicotine Metabolism and Intake in Nicotine Metabolism and Intake in African AmericansAfrican Americans

• African Americans have 50% more lung cancer and higher cotinine levels per cigarette despite fewer cigarettes/day

• Total and renal clearance of cotinine were 20% lower in African Americans

• Nicotine intake per cigarette was 30% greater in African Americans

JAMA 1999;280:152-56

Nicotine Metabolism in Nicotine Metabolism in Chinese and LatinosChinese and Latinos

• Metabolic clearance of nicotine and cotinine in Latinos was similar to Whites and lower among Chinese

• Intake of nicotine per cigarette:– Chinese: 0.73 mg (0.53 to 0.94)– Latinos: 1.05 mg (0.85 to 1.25)– Whites 1.10 (0.91 to 1.30)

• Nicotine intake = tobacco smoke

Ethnicity in Patient-Doctor Ethnicity in Patient-Doctor RelationshipRelationship

• Refusal: whose issue?

• DNR discussions–Race of clinician is an independent predictor

• Cultural competence

• Language factors

• Racism may affect behavior:– Fewer cardiology referrals in Blacks

Ethnicity and Attitudes toward Patient Ethnicity and Attitudes toward Patient Autonomy among Persons ≥ 65 yrsAutonomy among Persons ≥ 65 yrs

Tell Dx%

Tellprognosis

%

Life support%

European Am 87 69 65

Mexican Am 65 48 41

African Am 89 63 60

Korean Am 47 35 28

JAMA 1995; 274:820

Recommendations on Use of Recommendations on Use of Race/EthnicityRace/Ethnicity

• This is a critical construct• Essential in clinical research• Self-report category is gold standard

• Variance explained overlaps but is distinct from SES measures

• Contributes and predicts a lot• Measure in standard way

Homework AssignmentHomework Assignment

• Within your area of interest or study, identify a paper where race, ethnicity and/or class were measured

• How was this analyzed and• Write a brief critique• How are you suing measures of

race/ethnicity and class in your project?• Email responses by Monday AM to

eliseops@medicine.ucsf.edu