Health Disparities
The elimination of health disparities by race/ethnicity and socioeconomic status is a key public health priority in the United States. Over the last fifteen years, the PRC has become a major center of activity for the social demographic study of health, aging, and mortality in the US. Much of this work focuses on health disparities across race/ethnic, socioeconomic, and gender lines. Indeed, four recent faculty additions from the Department of Sociology (Chiquita Collins, John Mirowsky, Marc Musick, Catherine Ross) focus their research programs on health disparities, as do a number of established faculty members. With the nationwide importance of the area, and the policy relevance of the questions being addressed, the PRC is at the forefront of a key area of the national health agenda.
Area Projects
Conference Series on Aging in the Americas: United States and Mexico
Principle Investigator: Jacqueline Angel
Funded by: National Institute on Aging
This series of Conference workshops aims at increasing the visibility of research on aging Mexican- origin people and comes at a time when the topic is emerging as a crucial national budget and policy issue. The strength of the proposal is that the Conference Series and accompanying set of workshops bring together, for the first time, emerging research that demonstrates how social, psychological, and biological factors profoundly impact the health and long-term care of Mexican-origin people in late life. An important objective of the Conference Series is to identify disparities in Hispanic health, disability, and illness behavior. It is a relatively well-accepted tenet that health disparities are complex and multifaceted, and to understand them means grasping the intersection between biology and behavior. Thus, we hope to begin an interdisciplinary discussion of the unique situational factors and cultural behaviors that interact to impact the health and functioning of aging Mexican Americans. Research along these interdisciplinary lines will inform specific public health interventions related to disease prevention and identify improvements to public health systems that will protect the health of aging Hispanics. The ultimate objective of the Conference Series is to develop a consensus on the best means of insuring healthful aging of individuals of Mexican ancestry in the United States. Hispanics, especially those of Mexican ancestry, are re-shaping the demographic composition of the U.S. Hispanics are the fastest growing demographic group in the country, due to high immigration from Mexico and other Latin American countries, as well as higher fertility rates compared with non-Hispanic Whites and African-Americans (Tienda and Mitchell, 2006). In 2000, Hispanics became the nation's largest minority category. The Hispanic population has reached 36 million people, representing nearly 13 percent of the U.S. population. Mexican-origin Hispanics represent over half of that 36 million (U.S. Census Bureau, 2003). Moreover, the Hispanic population is aging, and as a result of their health issues and long-term medical needs, the health and wellbeing of this group is fast becoming a critical public policy concern (Angel and Hogan, 2004). A Conference Series focused specifically on increasing scholarly research into the aging process of the Mexican-origin population is vital. We believe this Conference Series will make a substantive contribution to the knowledge base, filling a significant vacuum of information on an understudied group of aging Americans. The consensus objective of the Series will inform the NIH Healthy People 2010 initiative to create national health objectives designed to identify the most significant preventable threats to health and to establish national goals to reduce these threats.
Longitudinal Study of Mexican American Elderly Health
Principal Investigator: Ronald Angel
Additional Investigators: Kyriakos Markides, parent project PI
Jacqueline Angel, Co-Investigator, UT-Austin subcontract
Funded by: National Institute on Aging
This project will conduct two in-person follow-ups of the Hispanic EPESE (Established Population for the Epidemiological Study of Elderly) during 2009-2010 and 2011-2012. The study's baseline was conducted during 1993-1994 when a representative sample of 3,050 Mexican Americans age 65 and over residing in the five Southwestern states - Texas, New Mexico, Colorado, Arizona, and California - were interviewed and followed up four times. By 2004-2005 (Wave 5) 1,167 of the original subjects now aged 75 and over were re-interviewed. An additional representative sample of 902 Mexican Americans also aged 75 and over was added at Wave 5 giving us a combined sample of 2069 subjects aged 75 and over. Of these, 1542 were re-interviewed in 2007 (data still being processed), approximately 2 1/2 years later. The study thus far has generated over 170 publications and has provided valuable information related to the health and health care needs of older Mexican Americans. Wave 7 is proposed to take place in 2009-2010 and we estimate interviewing slightly over 1,000 surviving subjects aged 80 and over. We also propose to interview a "focal relative", most likely a child, who will supply information on the subjects' health, family, and financial situation. Both will be followed up two years later in 2011-2012. We expect that we will re-interview 700 subjects aged 82 and over and 800 of the focal relatives. Family members of deceased subjects will provide information on circumstances surrounding the subjects' death, which we have done over the years by using a proxy death questionnaire. Our first and new aim will be accomplished primarily by interviewing the focal relatives who will provide assessments of the older subjects' financial, family, and health situation. We will assess the nature and extent of any caregiving arrangements in very old Mexican Americans and the physical, psychological, and financial burdens of advanced age on the extended family. Given the advanced age of the sample, we expect to have sufficient numbers of subjects entering nursing homes and assisted living facilities to learn about factors leading to institutionalization. Although the rate of institutionalization among Mexican Americans is lower than that in the general population, our data thus far have suggested that it may be rising. We will have the opportunity to assess the influence of psychosocial and medical factors leading to institutionalization. We continue to assess trajectories of change in physical function, depressive symptomology, and cognitive function. We also propose to do a more extensive assessment of cognitive function including assessments made by the focal relatives. As we have done in the past, we plan to rapidly archive the data and to encourage others to use them. The Mexican American population is experiencing rapid rates of aging, and very little is known about the health, health care needs, and financial situation of the very old. Our findings thus far suggest that this is a population characterized by rising life expectancy which is accompanied by increased disease burden and increasing disabilityrates.
Race/Ethnicity, Poverty, and the Connection between Child Health and Early Education
Principal Investigator: Robert L. Crosnoe
Additional Investigators: Shannon E. Cavanagh, Cynthia Osborne, Co-Investigator
Funded by: Eunice Kennedy Shriver National Institute of Child Health and Human Development
This project investigates the degree to which higher rates of health problems among race/ethnic minority children of all economic strata and among poor children from all race/ethnic populations prior to the start of elementary school put them at an academic disadvantage once elementary school has begun. Because health is a policy amenable developmental factor and the transition to elementary school is a critical intervention point in the educational career, such research provides leverage in attempts to address the persistent, overlapping race/ethnic and economic gaps in educational attainment in the early life course that forecast increasing inequalities in social mobility, morbidity, and mortality in adulthood. Drawing on a classic theoretical perspective that targets the development processes surrounding the transition into elementary school as fundamental to demographic disparities in educational attainment, this project puts forward and tests a conceptual model positing that the poorer physical and mental health of African-American and Latino/a children (controlling for economic status) and of economically disadvantaged children (controlling for race/ethnicity) in the pre-school years contribute to their lower rates of academic achievement in school. Importantly, this project will also explore the mechanisms underlying the academic risks of early health problems and identify aspects of family organization, pre-school programs, elementary school classrooms, and home-school partnerships that protect against these academic risks in general and in traditionally disadvantaged populations in particular. A team of population scientists working with senior consultants from medicine, developmental psychology, and social work will conduct this research. Specifically, this team will apply multi-level, growth curve, and propensity score techniques to two NIH-funded data sets the Fragile Families and Child Well-Being Study, which oversamples the disadvantaged side of the socioeconomic spectrum of American families, and the NICHD Study of Early Child Care and Youth Development, which oversamples the more advantaged side and then supplement this quantitative investigation with analysis of qualitative data to be collected from teachers and parents in a low-income, racially diverse elementary school. This interdisciplinary, theoretically grounded, mixed-methods investigation is specifically designed to elucidate the role of child health in the reproduction of overlapping systems of race/ethnic and economic stratification in ways that directly inform social policy.This project delves into a timely and significant public health issue: the contribution of the connection between health problems and academic struggles in early childhood to the race/ethnic and economic stratification of American society. The main goals are to determine a means by which demographic inequalities are transmitted across generations in ways that affect population rates of morbidity and mortality and then to identify potential policy-amenable remedies to this process.
Measuring Wealth in Health Disparities Research: Practical Recommendations
Principal Investigator: Catherine Cubbin
Funded by: American Legacy Foundation
Wealth is a complex construct, referring not only to material resources, but also to potential access to different lifestyles, and a sense of security, power and control. In survey research, the standard method to measure wealth is by accumulated economic resources offset by accumulated debt, or “net worth.” Strong empirical and conceptual grounds exist for measuring wealth in health disparities studies (Braveman et al, 2005). A given level of income or education reflects dramatically different levels of wealth for people in different racial/ethnic groups. Thus, controlling for income and/or education in health disparities studies is not the same as controlling for wealth.
Failure to measure wealth, then, may under-estimate the contribution of SES/position (SES) to health, such as when studying the etiology of racial/ethnic disparities. Further, wealth may be more relevant for health than income because it can buffer against effects of temporary low income (e.g., due to unemployment, illness) and it reflects power and influence over others more so than does income. However, wealth measures are rarely included in health research, in part because questions on net worth are considered to be intrusive and burdensome (collecting acceptable measures involves a lengthy set of questions and advanced preparation by participants). A recent systematic review of studies that examined relationship between wealth and health found that wealth was significantly associated with health after adjusting for at least one other SES measure, but that more consistent associations between wealth and health were observed when using multiple, detailed questions rather than simple measures, e.g., home ownership (Pollack et al, 2007). In addition, racial/ethnic disparities generally decreased when wealth was included in models compared with models without wealth; however, few studies investigated how wealth was related to health within social groups, defined by race/ethnicity, SES, or gender. The study’s main recommendation called for validation of simpler approaches to measuring wealth that are feasible in health studies. Also of note is that no studies were identified that examined tobacco-related indicators.
Another important reason to measure wealth is to more fully evaluate the downstream consequences of health disparities. Research has shown that health problems can disrupt employment, diminish earnings, affect family relations – factors which in turn feedback to exacerbate health disparities. Very little research has examined how smoking and its disease consequences affect social and economic trajectories of well-being. Yet, it is plausible to expect that smoking potentially diminishes earnings and thereby wealth with substantial consequences for increasing the risk of stress-related conditions, managing health care needs, and so on. Assessment of wealth, therefore, is fundamentally important in the articulation of both the causes and consequences of health and health behaviors.
Validation of simpler approaches could involve developing entirely new measures, and/or evaluating measures that currently exist. We have opted for the latter approach, given that population-based datasets are available with both wealth and health measures, including tobacco-related ones, and sample sizes that allow investigation of subgroup analyses (e.g., by racial/ethnic and SES group). Although we agree that
developing new measures is a sound alternative approach and should be pursued, we are confident that useful, more rapid recommendations will result from assessing existing data sources.
Changing Race/Ethnic Disparities in Infant Mortality
Principal Investigator: W. Parker Frisbie
Additional Investigators: Robert A. Hummer, Daniel A. Powers, Co-Investigators
Funded by: Eunice Kennedy Shriver National Institute of Child Health and Human Development
Although substantial absolute declines in infant mortality have occurred across race/ethnic groups, the relative disparity between blacks and whites has not only persisted, but has actually increased. Analyzing data from the National Center for Health Statistics linked birth/infant death cohort files for the period from 1983 through 2000, Dr. Frisbie aims to document and compare the magnitude and trajectory of changes in the rates of leading specific causes of infant mortality across race/ethnic/nativity populations from 1989 to 2000, modelling the extent to which risk factors are associated with relative and absolute disparities. He will determine if, and why, the direction and magnitude of change by specific cause is different for different race/ethnic/nativity groups, conducting an indirect test of the hypothesis that growing race/ethnic disparities follow in the wake of notable advances in perinatal care and technology because social inequalities result in differential access.
Educational Differences in U.S. Adult Mortality
Principal Investigator: Robert A. Hummer
Additional Investigators: Mark D. Hayward, John Mirowsky, Catherine E. Ross, Co-Investigators UT-Austin
Richard Rogers, Co-Investigator, University of Colorado at Boulder
Consultants: Patrick M. Krueger, University of Colorado at Boulder
Funded by: Eunice Kennedy Shriver National Institute of Child Health and Human Development
The goal of this research is to improve understanding of the linkage between educational attainment and overall and cause-specific adult mortality within the population as a whole and among various subgroups of adults. Analyzing data from the National Health Interview Survey-Multiple Cause of Death (NHIS-MCD) linked files, Dr. Hummer will identify the key mechanisms that lead to low mortality among the highly educated and higher mortality among the less educated, contributing to more sound policy recommendations for dealing with mortality inequalities.
Testing Differences: The Transfer and Transformation of HIV Testing from the West to Sub-Saharan Africa
Principal Investigator: Mark Regnerus
Additional Investigators: Nicole Angotti, Co-Investigator
Funded by: National Science Foundation
This research aims to map and understand how—and with what success—Western public health interventions and the norms upon which they rest are incorporated in non-Western societies. We focus specifically on HIV voluntary counseling and testing (VCT or “HIV testing”), a key prevention strategy in efforts to address the spread of HIV in the West. We are particularly interested in how three Western social norms around HIV testing—that testing include counseling, that testing is volitional, and that the results are confidential—became a global standard. Employing a mixed methods research design consisting of historical and field-based research methods, we consider how HIV testing was exported from the West and what happens when it is transplanted in sub-Saharan Africa, a poor, high-prevalence setting. Our African study site is Malawi, where HIV prevalence is the 8th highest in the world. Fundamental differences between the West and sub-Saharan Africa (SSA) form the basis of our inquiry as to how imported approaches to AIDS prevention fare outside of their context of origin: the demographic profile of the AIDS epidemic, health and resource capacities to respond to the crisis, and social and cultural practices. While several studies have questioned the wisdom of implementing solely Western solutions to the problem of HIV/AIDS, most research on HIV testing evaluates it solely as a public health intervention. Thus there are studies on the hypothetical acceptability of HIV testing in Africa, on the actual use of testing services, and on behavioral change as a consequence of HIV—but little specifically on the provision of HIV testing programs or on how testing is incorporated locally. Toward this end, the proposed project aims to enhance our understanding of the origins, evolution, and social dynamics of HIV testing. In so doing, we conceptualize HIV testing as a dynamic social practice, and take both a historical and an “actor-oriented” approach to consider what happens to imported institutions in the process of their cultural diffusion.
Informed by theories of AIDS and globalization, institutional theories in the sociology of development, ethnographic research on African social life, and preliminary fieldwork conducted by the Co-PI in Malawi, we hypothesize the following: 1) that the standards of practice around HIV testing became embedded in global policy without much adaptation to place, context, or culture; 2) that the various receptors of global HIV testing policy (national elites, HIV trainers, HIV counselors, actual clients, and their neighbors) display divergent perceptions about—and enactment of—the norms of HIV testing practice; and ultimately that 3) there is simply less cultural, institutional, and practical support in Malawi for counseling, and for voluntary and confidential encounters. Hence, the central premise of this research is that the standards of practice that lie at the heart of HIV testing – the Western notions of individualism and respect for privacy – are transformed from their Western design in how the practice of HIV testing itself is interpreted and enacted among various local actors.
Broader Impacts: The proposed project addresses questions with broad significance for social science theory and health policy. First, by examining the origins, historical evolution, and social dynamics of the standards of practice around HIV testing, this research is the first sociological study to consider the cultural diffusion of HIV testing. In so doing, this work will provide a thorough understanding of how the normative perspectives and policy agendas of various social actors and institutions shape the implementation of a key HIV prevention strategy. While much research has been devoted to the practical efficacy of HIV testing, its “success” hinges on shared understandings of its guiding principles and importance among key local enactors. Second, this project will demonstrate how community norms and practices alter HIV testing norms in the highest prevalence region of the world. Finally, this research will contribute to the construction of a theory about what happens to imported institutions in the process of their diffusion—why Western health policy agendas are reinterpreted and altered in new socio-cultural settings. Indeed, prevention strategies may not work well in distinctive contexts. Findings from this research will be broadly disseminated to the academic community via professional conferences and publications, as well as to Malawian health officials, providers, and the local, national and international organizations that assist them.
Validation and Evaluation of a Portable Body Scanner for Determination of Obesity
Principal Investigator: Bugao Xu
Additional Investigators: Jeanne Freeland-Graves
Funded by: National Institute of Diabetes, Digestive and Kidney Diseases, NIH
Obesity has reached epidemic levels in the U.S., with nearly two in three overweight and one in three obese in adults. Besides it is a major health problem in itself, obesity is also a strong risk factor for such serious diseases as type 2 diabetes, heart disease, and certain cancers.
Obesity refers specially to having an abnormally high proportion of body fat. It is usually assessed by body mass index (BMI); however, the relationship between BMI and fatness varies with muscularity, age, gender and ethnicity. To improve the screening of obesity, more direct measurements of the amount and distribution of body fat are needed. Many techniques for fatness assessment are available, but they are either inconvenient, expensive, or with questionable accuracy. Considering the prevalence of obesity, a convenient, reliable, and less expensive device is necessary for timely assessing and monitoring fatness in public health.
It has been validated by densitometry and anthropometry that body fatness can be assessed from outer measures including body size and shape along with weight. In the proposed study, a system for automatic body size and shape characterization will be developed. The system takes advantage of current development in computer vision which has made possible the capture of three-dimensional (3D) surface model of the human body. The amount and distribution of body fat will be assessed from comprehensive measures including lengths, circumferences, volumes, and surface areas. This technique alone will provide a new tool to assess obesity and monitor changes in body fatness, and the obtained anthropometric data can also be integrated into other techniques such as bioelectrical impedance analysis to improve their performance.
Economic Restructuring and the Social Mobility in Japan
Principal Investigator: Wei-hsin Yu
Funded by: Eunice Kennedy Shriver National Institute of Child Health and Human Development
Since the burst of its "bubble" economy in 1989, Japan has experienced an astonishingly long and severe economic recession, featuring just 1.3% average real growth per year between 1990 and 2005. This decade and a half of economic stagnation is thought to have compelled Japanese corporations to abandon their well- known "permanent employment" practices, adopt downsizing, and increase their use of contingent employment contracts. Such changes are likely to fundamentally reshape Japan's system of social protection and hence affect its citizens' lifetime economic conditions. The overall goal of this research project is to estimate the consequences of Japan's transformation on individuals' economic mobility and wellbeing. Japan presents a unique opportunity to study how variations in national labor market characteristics affect individuals' life chances in a single-country setting, where the findings are unlikely to be confounded by the cultural traits that are difficult to measure in multi-country studies. Yu will investigate whether industrial restructuring has increased economic inequality in the Japanese population by analyzing changes in employment stability and income distribution with data from the Social Stratification and Social Mobility Survey (SSM). The SSM was the first to collect detailed work and life history information from a nationally representative sample of Japanese men and women for the entire period of economic stagnation. Because individuals' long-term job prospects affect their rates of marriage, divorce, and childbearing, as well as their health, results of this study will have important implications for future research on these topics. In particular, the study will contribute to understanding Japan's rapidly changing demographic conditions, including the increasing postponement of marriage, declining fertility, the rising divorce rate, and the growing prevalence of psychological depression, as well as the relation between economic and social changes in postindustrial societies in general. More specifically, first, this project will provide evidence for whether and how Japan's permanent employment system has been dismantled by systematically analyzing changes in workers' rates of intrafirm job shifts, employer changes, and employment exits. Second, event history models based on Japanese adults' work and life histories through 2005 will be used to investigate whether economic downturns have increased individuals' risks of financial instability over the life course. Yu will also compare the consequences of Japan's recession for individuals of different gender, age, educational, and occupational groups. In doing so, this research will be the first to demonstrate the impact of economic restructuring on social inequality in Japan. Finally, Yu will use information on current income from the SSM conducted in 1985, 1995, and 2005 to identify the effect of Japan's labor market changes on the economic returns to men's and women's human capital, life-course stages, and job characteristics. The overall goal of this project is to estimate the consequences of Japan's economic stagnation and restructuring on the social mobility and long-term well being of its population. Because individuals' lifetime economic prospects affect their rates of marriage, divorce, and childbearing, as well as their health, results of this study will contribute to understanding Japan's rapidly changing demographic conditions, including the increasing postponement of marriage, declining fertility, the rising divorce rate, and the growing prevalence of psychological depression. By identifying the macro-institutional processes that shape individuals' risks of economic instability, this project will also have important implications for research on the well being of families and children in postindustrial societies in general.
