African American Mortality Rates Research Articles

Addressing Disparities and Inequalities in Healthcare: Disproportionate Representation of Minorities in COVID-19 Deaths as a Health and Social Injustice

Social inequalities exist around the world limiting a group's social, health, and economic advancement. These unfavorable conditions inhibit people from having access to essential resources such as healthcare, housing, education, employment, and transportation. Consequently, inequalities in accessing indispensable social goods generally affects diets and overall health and wellness of individuals negatively. Unfortunately, this systemic problem tends to inflict greater harm to lower-income groups disproportionately. These limitations usually result in poorer health and higher rates of health problems. Historically, existing inequalities in society are manifested in moments of crisis, and the COVID-19 pandemic (2019-2021) revealed overwhelming manifestation of this fact. The mortality rates for African Americans are more than triple the rates for whites after correcting for age, and the rates for Hispanic/Latinos are almost double the rates for non-Hispanic whites. According to the CDC’s racial demographic information on COVID-19 cases and deaths, almost 23% of reported COVID-19 deaths in the U.S. are African Americans, even though blacks make up approximately only 13% of the U.S. population. This glaring revelation of the health inequities that exist in our society must be addressed. This paper examines the documented cases of significant health inequities in the U.S. including the underlying social determinants and implications that make minority groups vulnerable, contributing to their higher risk of morbidity and mortalities, and argued that healthcare is a fundamental human rights issue as stated in a 2017 WHO press release. This author contends that health inequity due to social inequity is unsustainable, and a detriment to sustainable development and provide recommendations to address the health inequities.

Symptomatic, clinical and biomarker associations for mortality in hospitalized COVID-19 patients enriched for African Americans

Background and AimsInitial reports on US COVID-19 showed different outcomes in different races. In this study we use a diverse large cohort of hospitalized COVID-19 patients to determine predictors of mortality.MethodsWe analyzed data from hospitalized COVID-19 patients (n = 5852) between March 2020- August 2020 from 8 hospitals across the US. Demographics, comorbidities, symptoms and laboratory data were collected.ResultsThe cohort contained 3,662 (61.7%) African Americans (AA), 286 (5%) American Latinx (LAT), 1,407 (23.9%), European Americans (EA), and 93 (1.5%) American Asians (AS). Survivors and non-survivors mean ages in years were 58 and 68 for AA, 58 and 77 for EA, 44 and 61 for LAT, and 51 and 63 for AS. Mortality rates for AA, LAT, EA and AS were 14.8, 7.3, 16.3 and 2.2%. Mortality increased among patients with the following characteristics: age, male gender, New York region, cardiac disease, COPD, diabetes mellitus, hypertension, history of cancer, immunosuppression, elevated lymphocytes, CRP, ferritin, D-Dimer, creatinine, troponin, and procalcitonin. Use of mechanical ventilation (p = 0.001), shortness of breath (SOB) (p < 0.01), fatigue (p = 0.04), diarrhea (p = 0.02), and increased AST (p < 0.01), significantly correlated with death in multivariate analysis. Male sex and EA and AA race/ethnicity had higher frequency of death. Diarrhea was among the most common GI symptom amongst AAs (6.8%). When adjusting for comorbidities, significant variables among the demographics of study population were age (over 45 years old), male sex, EA, and patients hospitalized in New York. When adjusting for disease severity, significant variables were age over 65 years old, male sex, EA as well as having SOB, elevated CRP and D-dimer. Glucocorticoid usage was associated with an increased risk of COVID-19 death in our cohort.ConclusionAmong this large cohort of hospitalized COVID-19 patients enriched for African Americans, our study findings may reflect the extent of systemic organ involvement by SARS-CoV-2 and subsequent progression to multi-system organ failure. High mortality in AA in comparison with LAT is likely related to high frequency of comorbidities and older age among AA. Glucocorticoids should be used carefully considering the poor outcomes associated with it. Special focus in treating patients with elevated liver enzymes and other inflammatory biomarkers such as CRP, troponin, ferritin, procalcitonin, and D-dimer are required to prevent poor outcomes.

Optimism and risk of mortality among African-Americans: The Jackson heart study

Optimism is associated with reduced mortality risk among Whites, but evidence for this relationship is limited among African-Americans, whose life expectancy is shorter than Whites. This study examined the association between optimism and mortality rate in African-Americans. Data were from African-American women (n = 2652) and men (n = 1444) in the United States from the Jackson Heart Study. Optimism was measured using the Life Orientation Test-Revised at the baseline period (2000–2004), and mortality data were obtained until 2018. Using Cox proportional hazards models, we estimated hazard ratios (HRs) of mortality by optimism level, controlling for sociodemographic factors, depressive symptoms, health conditions, and health behaviors. In secondary analyses, we evaluated potential effect modification by sex, age, income, and education. Higher optimism was related to lower mortality rates (HR = 0.85, 95% confidence interval [CI] = 0.74, 0.99), controlling for sociodemographic factors and depressive symptoms. After further adjusting for health conditions and health behaviors, associations were slightly attenuated (HR = 0.89; 95%CI = 0.77, 1.02). Stronger associations between optimism and mortality were observed in men, among those with higher income or education, and with age ≤ 55 (all p's for interaction terms <0.06). In summary, optimism was associated with lower mortality rates among African-Americans in the Jackson Heart Study. Effect modification by sociodemographic factors should be further explored in additional research considering optimism and mortality in diverse populations. Positive factors, such as optimism, may provide important health assets that can complement ongoing public health efforts to reduce health disparities, which have traditionally focused primarily on risk factors.

Differences in RAAS/vitamin D linked to genetics and socioeconomic factors could explain the higher mortality rate in African Americans with COVID-19.

COVID-19 is said to be a pandemic that does not distinguish between skin color or ethnic origin. However, data in many parts of the world, especially in the United States, begin to show that there is a sector of society suffering a more significant impact from this pandemic. The Black population is more vulnerable than the White population to infection and death by COVID-19, with hypertension and diabetes mellitus as probable predisposing factors. Over time, multiple disparities have been observed between the health of Black and White populations, associated mainly with socioeconomic inequalities. However, some mechanisms and pathophysiological susceptibilities begin to be elucidated that are related directly to the higher prevalence of multiple diseases in the Black population, including infection and death by COVID-19. Plasma vitamin D levels and evolutionary adaptations of the renin-angiotensin-aldosterone system (RAAS) in Black people differ considerably from those of other races. The role of these factors in the development and progression of hypertension and multiple lung diseases, among them SARS-CoV-2 infection, is well established. In this sense, the present review attempts to elucidate the link between vitamin D and RAAS ethnic disparities and susceptibility to infection and death by COVID-19 in Black people, and suggests possible mechanisms for this susceptibility.

Convergence of Mortality Among African Americans

The purpose of this study is to explore any possible convergence in African American mortality rates in the United States. Using county-level data of the United States over a period of nearly five decades (1968-2015), the findings indicate that β-convergence has occurred in mortality rates of African American population implying that their mortality rates are getting closer to their means. The results are particularly stronger for females and the elderly. The findings reflect lower cost of implementation and dissemination of strategies that would target the health of such population. JEL Classifications: II0, I30, R10

Impact of Race on Outcomes in Intermediate Risk Acute Myeloid Leukemia

Introduction:A 2012 retrospective review of acute myeloid leukemia (AML) patient outcomes in the SEER national database showed higher mortality rates for African Americans and Hispanics despite lower rates of incidence and more favorable genetics at presentation compared to non-Hispanic whites (Patel. Cancer Causes & Control, 2011). While age is a known negative prognostic factor, it has been difficult to analyze the contribution of additional demographic factors predicting outcomes in AML. The purpose of this study was to investigate the impact of race on disease outcome in a diverse patient cohort of intermediate risk AML treated at two urban academic centers in Chicago.Methods:We retrospectively analyzed patients with intermediate risk AML cytogenetics treated with intensive chemotherapy with or without allogeneic stem cell transplant from 2003-2018 at Northwestern Memorial and the University of Illinois Hospital. Baseline clinical and molecular characteristics and treatment response were compared across racial groups. Categorical variables were compared using Pearson's chi square or the Fisher's exact test while overall survival (OS) was estimated by the Kaplan-Meier analysis and compared by the log-rank test. Risk factors for OS were assessed by the Cox regression model.Results:A total of 111 intermediate risk AML patients were included with the 3 major groups being Caucasian (non-Hispanic white), African American (AA) and Hispanic patients (Figure 1). Nearly half of each group was> 60 years of age at presentation. At the time of diagnosis, AA had a significantly higher body mass index (BMI) with a mean of 33.7 kg/m2 compared to 28.1 kg/m2 in the Caucasian group and 27.7 kg/m2 of Hispanic/others (p = 0.0047). There was no statistically significant difference in presenting labs including LDH, WBC count, blast percentage or molecular characteristics including FLT3-ITD or NPM1 mutation status (Figure 2).In log-rank analysis, Caucasians had significantly improved median OS compared to AA and Hispanics/others (31.6 vs. 16.7 vs.18.1 mos; p=0.026) (Figure 3). Multivariate analysis indicated that non-Caucasian patients had a 1.8 times higher risk of death compared to Caucasians (p = 0.059) even when adjusted for age and NPM1 and FLT3-ITD mutational status.We sought to examine whether this outcome disparity could be explained by chemotherapy resistance. The predominantly Hispanic group had a decreased response to induction chemotherapy compared to other groups (52% complete response (CR) vs. 70.6% of Caucasians and 68.8% of AA ; p=NS). In multivariate analysis, age (p = 0.046) and NPM1 status (p = 0.0006) predicted response to therapy while race did not. The favorable risk NPM1 mutation was enriched in Caucasians while the unfavorable FLT3 mutation was more commonly found in the primarily Hispanic group of patients (p = NS).Transplant emerged as a significant predictor of overall survival (p = 0.03). There was a difference approaching statistical significance in transplant utilization between the groups with only 36.8% of AA transplanted compared to 58.1% of non-African Americans (p = 0.09). Underrepresentation of minorities in the transplant registry was reflected in the significantly higher utilization of alternate donor sources in the AA and Hispanic patients. The proportion of patients receiving haploidentical and cord blood transplants was 5.7% of Caucasians vs. 57.1% of AA and 40% of Hispanic/others (p = 0.0006).Conclusion:In a cytogenetically homogenous cohort of AML patients we show that Caucasian patients had significantly superior overall survival compared to other racial groups. We found a statistically significant difference in BMI between racial groups, which may be reflective of comorbidities and chronic illnesses that affect clinical outcome. Our data also showed there was increased utilization of transplant in Caucasian patients likely related to donor availability and insurance coverage. We will next use Geographic Information Systems and payer source data to dissect the contribution of socioeconomic status and health care access to these disparities in disease outcome. Identifying health service gaps in these populations will enable healthcare providers to provide personalized and equitable care to an increasingly diverse patient population. [Display omitted] DisclosuresFrankfurt:Celgene, Jazz, Agios: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; AbbVie: Membership on an entity's Board of Directors or advisory committees. Khan:Teva: Speakers Bureau.

Mortality Inequality: The Good News from a County-Level Approach

Analysts who have concluded that inequality in life expectancy is increasing have generally focused on life expectancy at age 40 to 50. However, we show that among infants, children, and young adults, mortality has been falling more quickly in poorer areas with the result that inequality in mortality has fallen substantially over time. This is an important result given the growing literature showing that good health in childhood predicts better health in adulthood and suggests that today's children are likely to face considerably less inequality in mortality as they age than current adults. We also show that there have been stunning declines in mortality rates for African-Americans between 1990 and 2010, especially for black men. The fact that inequality in mortality has been moving in opposite directions for the young and the old, as well as for some segments of the African-American and non-African-American populations argues against a single driver of trends in mortality inequality, such as rising income inequality. Rather, there are likely to be multiple specific causes affecting different segments of the population. We show that the differential timing of smoking reductions among the rich and the poor can explain a significant fraction of the current increase in mortality inequality in older cohorts.

Abstract A75: Ten-year retrospective cross racial and ethnic prostate cancer incidence and mortality in the Florida Department of Corrections

Abstract To establish a novel environment for elucidating the relative socioenvironmental and biological etiologies of racial and ethnic disparities in prostate cancer, we are conducting a 10-year retrospective cross-racial and ethnic analysis of prostate cancer incidence and mortality within the Florida Department of Corrections (FDOC). Prostate Cancer is the most common cancer in men and exhibits the most profound racial and ethnic disparity of all cancers, with a 60% higher incidence rate and an astonishing 140% higher mortality rate in African Americans than in Caucasians. Successful efforts to thwart prostate cancer health disparities depend understanding the relative contributions of biological and socio-behavioral factors on prostate cancer disparities; however, the inherent heterogeneity of a of unlinked factors within and among racial and ethnic groups precludes the effectual determination of the relative contributions of prostate cancer health disparities. We propose that the etiologies of health disparities can be defined within the context of large, racially and ethnically diverse settings in which several variables thought to contribute to prostate cancer health disparities are normalized across racial and ethnic groups. Correctional facilities are vast congregate settings, inherently unique due to the remarkably similar socio-behavioral environments between and within racial and ethnic groups relative to non-incarcerated communities. Prisons are home to over 1.6 million people, primarily African American, Caucasian, and Hispanic men. The FDOC offices of Health Care, Food Services, and Wellness and Recreation provide services that may circuitously reduce racial and ethnic cancer disparities. Prisoners of all races and ethnicities have equal access to free and identical health care services including prostate cancer education, routine prostate cancer screening, and prostate cancer treatment. Inmates are all provided the same nutritionally balanced diets, meeting or exceeding the National Academy of Sciences’ standards, including nutritional supplements, soy-rich products, and nearly 3 million pounds of fresh produce cultivated on FDOC farms; reflecting diets thought to decrease prostate cancer risk. Physical activity in the form of exercise is a regular component of approximately 95% of prisoner's lifestyles. Cigarette smoking is common across racial and ethnic groups in the FDOC; however, alcohol consumption and drug use are prohibited. The FDOC's wellness efforts, and similar efforts by the majority of United States correctional facilities, inadvertently address several conjectural bases of health disparities, thereby providing an environment ripe for distinguishing the factors that contribute to prostate cancer and it vast racial and ethnic disparities. With support and approval by the FDOC, we have begun to elucidate the complex etiologies of racial and ethnic disparities in prostate cancer incidence and mortality by conducting a 10-year, cross-racial and ethnic retrospective analysis of prostate cancer incidence and mortality within the FDOC. The data from this study will provide the foundation for further studies to better understand the socio-environmental and biological factors that contribute to racial and ethnic disparities in prostate cancer incidence and mortality. Citation Information: Cancer Epidemiol Biomarkers Prev 2010;19(10 Suppl):A75.

Abstract A15: Increasing participation in therapeutic clinical trials among African Americans with cancer

Abstract Background: A study of patients enrolled in NCI-sponsored cooperative group nonsurgical treatment trials for breast, lung, colorectal, or prostate cancers reported an enrollment rate of only 1.8% among Caucasian patients. The comparable rate for African Americans was even lower at 1.3%. Recent statistics confirm markedly higher cancer-specific mortality rates for African Americans than members of other racial/ethnic groups. The recognition of cultural beliefs and attitudes towards clinical trials has been acknowledged as critical to ameliorating disparities in cancer outcomes. Our study thus focuses on the need to develop patient-level interventions to increase the representation of African Americans in cancer clinical trials. To date there have been qualitative studies to determine the nature of attitudes preventing participation but to our knowledge no actual intervention in the African American population. Aims and Focus: With active community involvement, we have developed a 15-minute narrative-based video for African American men and women with cancer. Using positive messaging the video addresses six cultural and attitudinal barriers to African American participation that have been documented in literature. We aim to assess whether African American patients are more likely to participate in trials after viewing the video and evaluate whether attitudes on the six trial barriers are impacted. We will also determine if the trial enrollment rate is higher than the national average after viewing the video. Methods: We are in the process of enrolling 114 African American patients at Washington Cancer Institute (WCI), a large urban cancer institute serving a predominantly African American patient population. We will use a mixed-methods approach including a pre-post test analysis with a survey instrument developed specifically to assess attitudes on the six study barriers. Semistructured interviews for participants consenting to follow-up will also be conducted and analyzed to provide additional context to inform our findings. Research Implications: This study has a potential national impact as it addresses the sociodemographic context and culturally rooted beliefs and preferences that may further hinder African American enrollment on therapeutic trials. The study and its products should have particular benefit for National Cancer Institute (NCI) cooperative groups as well as utility in community-based settings. The video we have developed will be an important tool to stimulate dialogue in African American community settings. Acknowledgement of Funding: National Center on Minority Health and Health Disparities: 1RC1MD004185-01. Citation Information: Cancer Epidemiol Biomarkers Prev 2010;19(10 Suppl):A15.

Prostate cancer characteristics and survival in males of African Ancestry according to place of birth: Data from Brooklyn—New York, Guyana, Tobago and Trinidad

Prostate cancer mortality rates for African-Americans are much higher than Caucasians and a similar trend is observed for prostate cancer survival. Data on recently immigrated African-descent men are lacking. Using cancer registry data from Brooklyn, NY and two countries in the Caribbean (Guyana and Trinidad and Tobago), survival rates were estimated. We also examined whether Black race or Caribbean birthplace predict prostate cancer survival among males living in the United States (US). The Caribbean cases were diagnosed at a later age than those in the US (Guyana: 74.5 years, Trinidad and Tobago: 72.4 years, Brooklyn: 65.8 years). Patients in the Caribbean had a worse 5-year survival rate compared to those in the US (41.6% vs. 84.4%) but for immigrant Caribbean-born males living in the US the 5-year survival rate was not significantly different from African-Americans (78.1%, 95% CI: 70.9-83.7% vs. 81.4%, 95% CI: 69.5-89.1%, P = 0.792). The risk of death for Caribbean-born was more than three times higher than US-born men (HR: 3.43, 95% CI: 2.17-5.44, adjusted for ethnicity, stage, and mean age of diagnosis). A mean age of diagnosis >65 years old and stage IV disease, but not ethnicity, were found to be independently associated with the risk of death. The survival disadvantage for Caribbean-born patients may be partly due to later diagnosis. Interventions focused on screening, education about the disease and early detection could potentially reduce cancer mortality in this population.

Community-Driven Approaches for Reducing Health Disparities in Cancer

SINCE 1990, OVERALL CANCER MORTALITY RATES HAVE declined at a rate of approximately 1% per year, with mortality from breast, colorectal, prostate, and lung cancer declining at about 2% per year. These declines have largely been attributed to favorable trends in some risk factors for cancer, increased use of methods to detect cancer earlier, and more effective means to treat the disease. However, cancer-related mortality rates for African Americans continue to be considerably higher than those for non-Hispanic whites in the United States. Although the mortality gap has decreased somewhat, mostly secondary to tobacco-related cancers and reflecting declining tobacco use by African Americans, the mortality gap has not diminished for cancers with rates affected by early detection or effective treatment. Differences in mortality and prevalence of risk factors are related to social class as defined by level of educational achievement. The decline in cancer mortality is greater for college graduates than for high school graduates, and no decline has occurred among those with less than a high school education. Other causes of cancer health disparities involve limited access to care, including prevention and early detection; unequal treatment when cancer is diagnosed; differences in behaviors that increase cancer risk, such as tobacco use, unhealthful diet, and lack of physical activity; differences in behaviors that decrease cancer risk, such as screening for breast, colorectal, and cervical cancer; and diverse cultural beliefs that influence the care-seeking behavior of patients. Advances in medical knowledge and technology also widen the disparity gap because technological innovations are differentially delivered to various groups and populations. Elimination of the screening gap between African American and white patients for breast, cervical, and colorectal cancer is perhaps the easiest way to influence cancer health disparity. Screening is at most an annual event, and at least for breast cancer and cervical cancer, most of the population has access to screening either through insurance, Medicare, or the Breast and Cervical Cancer Early Detection Program (colorectal screening is being added to the latter program incrementally). One approach to increase screening involves engaging low-income, low-education, mostly minority communities in a community-based participatory process that leads to “community efficacy,” a willingness on the part of community residents to help for the common good. This approach resulted in elimination of disparities in Medicare mammography screening rates between African American and white women in targeted counties in Alabama and Mississippi. Screening is in many ways the low-hanging fruit that allows programs to demonstrate success, and it also is an effective way to engage the community because the task is clear, achievable, and measurable in the short term. Other interventions, such as those aimed at tobacco cessation, healthful eating, and increased physical activity, require efforts that go beyond the individual behavioral change to a socioecological approach that engages all facets of the community—the individual, family, neighborhood, organizations, and policy makers. Because it is more complex, this approach is more difficult to implement. The first step is to engage the community. However, academic institutions, nongovernmental organizations, cancer volunteer organizations, and public health departments too often attempt health promotion from afar, working through the media, creating culturally relevant literature, and meeting with community members in conference rooms, without establishing an onsite presence in the community. Cancer control from a distance does not work in the geographic areas and demographic populations most at risk for disparities. Organizations and agencies must leave the comfort zone of the home base and begin engaging community members in the community, building mutual trust, offering guidance, sharing expertise, and empowering community volunteers to address the problem locally. Access to care will remain a major impediment to closing the disparity gap in cancer as long as substantial

Abstract B23: Evaluating an intervention to improve perceptions of cancer clinical trials among minority communities in South Carolina

Abstract Objective: Cancer mortality rates for African Americans in South Carolina are among the highest in the nation. However, African Americans are less likely than other groups to participate in cancer clinical trials. Results of previous investigations have shown that their low participation rates are related to negative perceptions of trials. We conducted a community based cancer clinical trials education intervention to improve perceptions of cancer clinical trials in this population. Methods: The study was conducted at eight different sites in six counties in South Carolina. The intervention consisted of a 30-minute cancer clinical trials educational presentation developed by the National Institutes of Health/National Cancer Institute. The intervention was part of a larger 3.5-hour education program aimed at increasing general cancer knowledge, prostate cancer knowledge, and perceived self efficacy in patient-physician interaction among minority populations in South Carolina. Study participants were recruited by community partners in each locale where the training sessions were conducted. A pre- and post-intervention survey was administered immediately before and after the intervention was delivered at each site. The survey instrument included seven items. Sample items include the following: Do you think that patients should be asked to take part in medical research? Would you be prepared to take part in a study comparing different treatments? Would you be prepared to take part in a study where treatment was chosen at random? Results: The study sample consisted of 164 predominantly African American participants. One-hundred and twenty-five (78.6%) of the 159 participants who provided data on race were African American, 19 (12.0%) were Caucasian and 15 (9.4%) were Native American. The majority of the 160 participants who provided data on age were ages 50+ years (62.5%). The majority of the 154 participants who reported their income had an annual household income &amp;gt; = $40,000 (53.8%). For each of the seven survey items assessing perceptions of cancer clinical trials, 74%, 69%, 56%, 49%, 61%, 50% and 58% of the participants, respectively, changed to more favorable responses on the post-test vs. pre-test. All results were statistically significant at the p&amp;lt;0.001 level. Conclusions: Providing cancer clinical trials information to African American community members positively influenced their trial perceptions. Future research could incorporate a longer follow-up assessment period. Citation Information: Cancer Prev Res 2010;3(1 Suppl):B23.

Abstract B24: Evaluating an intervention to increase cancer knowledge in minority communities in South Carolina

Abstract Objective: Cancer mortality rates for African Americans in South Carolina are among the highest in the nation. Lack of knowledge likely contributes to cancer disparities. To address this issue, we conducted a community based cancer education intervention to improve cancer knowledge among African American and other minority communities in South Carolina. Methods: The study was conducted at eight different sites in six counties in South Carolina. The intervention consisted of a 3.5-hour evidence-based cancer education program in which a 3-hour component focused on general cancer knowledge and a 30-minute component focused on prostate cancer knowledge. Pre- and post-intervention surveys were administered immediately before and after the intervention was delivered at each site. The maximum score for the 31-item cancer knowledge instrument was 31. Prostate cancer knowledge was assessed using a 10-item instrument, with a maximum score of 10. Perceived self-efficacy in patient-physician communication about cancer was measured by a 5-item scale with a maximum score of 5. We hypothesized that the intervention would result in increases in general cancer knowledge, prostate cancer knowledge, and perceived self-efficacy in patient-physician interaction. Results: The study sample consisted of 164 predominantly African American participants. One-hundred and twenty-five (78.6%) of the 159 participants who provided data on race were African American, 19 (12.0%) were Caucasian and 15 (9.4%) were Native American. The majority of the 160 participants who provided data on age were ages 50+ years (62.5%). The majority of the 154 participants who reported their income had an annual household income &amp;gt; = $40,000 (53.8%). The general cancer knowledge pre-test score had a mean of 26.2 with a standard deviation (SD) of 3.7 and a mean post-intervention increase of 2.04 points (p&amp;lt;0.01). The mean pre-test prostate cancer knowledge score was 7.3 (SD 2.0). The mean increase in prostate cancer knowledge was 0.48 points (p&amp;lt;0.01). Due to a ceiling effect, most sites showed little increase in perceived self-efficacy in patient-physician interaction (PEPPI). The exception was the Native American site, which had a larger increase in each PEPPI question from pre-test to post-test than the other sites. Conclusions: General cancer knowledge scores and prostate cancer knowledge scores increased following the intervention. Future interventions could incorporate more intensive (i.e., repeated sessions) cancer education programs as well as an assessment of the impact of the interventions on the communication dynamics between patients and their health care providers. Citation Information: Cancer Prev Res 2010;3(1 Suppl):B24.

Regional Differences in African Americans' High Risk for Stroke: The Remarkable Burden of Stroke for Southern African Americans

The stroke mortality rate for African Americans aged 45 to 64 years is 3 to 4 times higher than for whites of the same age, with a decreasing black-to-white mortality ratio with increasing age. There is also a "STROKE BELT" with higher stroke mortality in the southeastern United States. This study assesses if there are also geographic variations in the magnitude of the excess stroke mortality for African Americans. The age- and sex-specific black-to-white mortality ratio was calculated for each of 26 states with a sufficient African American population for stable estimates. The southern excess was calculated as the percentage excess of southern over nonsouthern rates. Across age and sex strata, the black-to-white stroke mortality ratio was consistently higher for southern states, with an average black-to-white stroke mortality ratio that ranged from 6% to 21% higher among southern states than in nonsouthern states. The increase in stroke mortality rates for African Americans in southern states is even larger than expected. That southern states that are not part of the "STROKE BELT" (Virginia and Florida) also have an elevated black-to-white mortality ratio suggests the mechanism of higher risk for African Americans may be independent of the causes contributing to "STROKE BELT."

The relationships among racial identity, self-esteem, sociodemographics, and health-promoting lifestyles.

The purpose of this study was to explore the relationships between racial identity, self-esteem, sociodemographic factors, and health-promoting lifestyles in a sample of African Americans. African American mortality rates are disproportionately high. These rates are associated with health behaviors that are driven by many factors including lifestyle practices. Other factors may be self-esteem and racial identity. Research shows gender differences in health behaviors, but no studies have explored a racial identity and gender interaction. Exploring these relationships may lead to the improved health status of African Americans. A convenience sample of 224 was recruited consisting of 48% males (n = 108). The mean age was 37.2 years (SD = 12.6). Regression analyses demonstrated that the internalization racial identity stage (beta = .12; p < .001) and self-esteem (beta = .50; p < .001) contributed to the variance in health-promoting lifestyles. Self-esteem did not mediate the relationship between immersion and health-promoting lifestyle scores (beta = -.16; p = .03). The full model Beta values show that racial identity remains significant with sociodemographics and interactions controlled, but moderators do not. Racial identity, while not a strong predictor, has some impact on health-promoting lifestyles regardless of sociodemographics.

Public Health and the Public Agenda

Thank you, Mr. McDonough, for that gracious introduction and, of course, for the opportunity to come home to New York. People often remark that New York City is something of a microcosm of our nation as a whole. For that reason, I cannot think of a better place to have this conference. But even more, I cannot think of a better time to have it than now. What today's presentations tell us is something that Secretary Shalala, myself-and our entire Administration-are aware of back in Washington. We are living through a remarkable-perhaps unprecedented-economic expansion: a time in which millions of jobs have been created, productivity is up, and the U.S. economy has firmly reestablished its vitality. I think Chairman Greenspan the other day used the phrase truly phenomenal. But while our economy has brought hope and opportunity to millions, we recognize how much more still needs to be done for many Americans. That is a particular issue for us at the Department of Health and Human Services. Because while many measure low incomes in dollars and cents, we also see them reflected in illnesses and injuries that go untreated-and in diseases, even deaths, that could have been prevented. We have seen these occurrences not only in our cities, but in Appalachia, the Mississippi Delta, and the reservations of Native Americans. I would like to speak with you for a moment about the challenges that we face today-and about the demands they will place on us tomorrow. In the time that I have been at Health and Human Services, one of the things I have learned is that the public health profession has quite a lot to teach policymakers. That is something many New Yorkers learned earlier this decade when Dr. Margaret Hamburg was New York City's health commissioner. Faced with a serious outbreak of tuberculosis, she organized a multipronged effort aimed at prevention, treatment, and long-term care. It was an effort that involved not only mobilizing health care providers in the field, but also policymakers in New York City, Albany, and Washington. And it was a success. Dr. Hamburg's accomplishment was all about making the right diagnoses, and carrying out the right plan of action. Well, when public health professionals examine America's health, they see many, many strengths, but they also recognize some very serious symptoms. The good news, of course, is that Americans are living longer, healthier lives. Thanks in large measure to advances in public health, over the course of this century the average American's life span has increased by twentyfive years. Today, infant mortality is at an all-time low and child immunization is at an all-time high. We have even seen a decline in teen pregnancy. And, over the last several years, we have made dramatic inroads in our fight against AIDS, cancer, and other diseases. But there is also some disturbing news: too many are being left behind. Let me share a few statistics with you: Today, infant mortality rates for African-Americans are twice as high as they are for white Americans. Chinese-Americans are four to five times more likely to have liver cancer than other citizens. Latinos suffer diabetes at a rate twice the national average. The diabetes rate among Native Americans is three times as high as the national average. In fact, one-half of all the adults in the Pima Indian Tribe in Arizona are diabetic. That is the highest known rate in the world. These are the symptoms. What is the diagnosis? We have known for a long time that an individual's risk of an early death rises as his or her standing in the social hierarchy falls. In fact, income is actually one of the strongest single predictors of mortality. This is what it really means when, despite the incredible economic gains we have made over the last six years, we say how much more we still need to achieve. Today, 10.5 percent of Americans over the age of sixty-five are still living in poverty. …

Metropolitan governance, residential segregation, and mortality among African Americans.

This study tested the hypothesis that the degree to which local government is metropolitanized is associated with mortality rates for African Americans and with residential segregation, which has itself previously been shown to be positively associated with mortality among African Americans. One hundred fourteen US standard metropolitan statistical areas were examined. The primary dependent variable was the age-adjusted, race- and sex-specific all-cause mortality rate, averaged for 1990 and 1991. The 2 primary independent variables were residential segregation, as measured by the index of dissimilarity, and metropolitanization of government, as measured by the central city's elasticity score. Mortality rates for male and female African Americans were lower in metropolitan statistical areas with more metropolitanized local governments and lower levels of residential segregation. Mortality for male and female Whites was not associated in either direction with residential segregation. White male mortality showed no association with level of metropolitanization, but lower White female mortality rates were associated with less metropolitanization. This study suggests the need for further research into whether policy changes in areas not traditionally thought of as "health policy" areas can improve the health of urban minorities.

Mortality following lower extremity amputation in minorities with diabetes mellitus

The aim of this study was to identify the age adjusted and level specific mortality rate in African-Americans, Hispanics and non-Hispanic whites (NHW) during the perioperative period following a lower extremity amputation. We identified amputation data obtained from the Office of Statewide Planning and Development in California for 1991 from ICD-9-CM codes 84.11–84.18 and diabetes mellitus from any 250 related code. Amputations were categorized as foot (84.11–84.12), leg (84.13–84.16) or thigh (84.17–84.18). Death was coded under discharge status. Age adjusted and level specific mortality rates per 1000 amputees were calculated for each race/ethnic group. The age adjusted mortality was highest for African-Americans (41.39) compared to Hispanics (19.69) and NHW's (34.98). Mortality was consistently more frequent for proximal amputations. We conclude that mortality rates for persons with diabetes hospitalized for an amputation varied by race, gender and level of amputation. Higher prevalence or severity of risk factors may explain the excess mortality observed in African-Americans.

African-american mortality at older ages: Results of a matching study

In this paper we investigate the quality of age reporting on death certificates of elderly African-Americans. We link a sample of death certificates of persons age 65+ in 1985 to records for the same individuals in U.S. censuses of 1900, 1910, and 1920 and to records of the Social Security Administration. The ages at death reported on death certificates are too young on average. Errors are greater for women than for men. Despite systematic under-reporting of age at death, too many deaths are registered at ages 95+. This excess reflects an age distribution of deaths that declines steeply with age, so that the base for upward transfers into an age category is much larger than the base for the transfers downward and out. When corrected ages at death are used to estimate age-specific death rates, African-American mortality rates increase substantially above age 85 and the racial "crossover" in mortality disappears. Uncertainty about white rates at ages 95+, however, prevents a decisive racial comparison at the very oldest ages.