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Critical Perspectives on Racial and Ethnic Differences in Health in Late Life 3 Racial and Ethnic Disparities in Health and Mortality Among the U.S. Elderly Population Robert A. Hummer, Maureen R. Benjamins, and Richard G. Rogers Racial/ethnic differences in health and mortality stand at the heart of the public health agenda of the United States (Kington and Nickens, 2001; Martin and Soldo, 1997; Williams, 2001; Williams and Collins, 1995). One of the three main goals of the Healthy People 2000 initiative was to reduce health disparities among Americans (U.S. Department of Health and Human Services [DHHS], 1991). Now, one of the two primary goals of Healthy People 2010 is to eliminate health disparities (DHHS, 2000). Although racial/ethnic health disparities have been the focus of much previous research, the rapidly changing age, racial/ethnic, and health landscape of the country makes it critical to continually update and assess such disparities. The goals of this chapter are to document racial/ethnic health and mortality disparities among the elderly population of the United States and to examine some simple models of health and mortality that take into account basic demographic and socioeconomic factors. We focus on the five major racial/ethnic subpopulations in the United States: non-Hispanic blacks, non-Hispanic whites, the Hispanic origin population, Asian and Pacific Islanders (APIs), and Native Americans. In several portions of the chapter, the health and mortality patterns of Mexican Americans, the nation’s largest Hispanic subpopulation, are discussed. We recognize there is substantial ethnic, cultural, geographic, and socioeconomic heterogeneity within the five main racial/ethnic categories here. Nevertheless, key limitations with population-based data sets, particularly for the elderly, limit the comparative analyses that are possible even across these five broad groups.
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Critical Perspectives on Racial and Ethnic Differences in Health in Late Life The chapter is organized into six sections. First, we outline overall mortality and cause-specific mortality disparities by race/ethnicity among the elderly population (ages 65+) in the United States. Second, we describe racial/ethnic disparities across general indicators of health for the U.S. elderly population. Third, we briefly compare current racial/ethnic health and mortality disparities among the elderly with those observed for younger age groups. Fourth, we examine whether health and mortality disparities among the elderly correspond with racial/ethnic differences in some key sociodemographic characteristics. Fifth, we present some simple models of health and mortality disparities among the elderly to assess the impact of those sociodemographic factors on the observed differentials. Our concluding section summarizes the findings from the chapter, notes some important data limitations in understanding the national picture of racial/ethnic health disparities among the elderly, and briefly notes future research needs. RACIAL/ETHNIC MORTALITY DISPARITIES AMONG THE ELDERLY Overall Mortality Disparities Using Vital Statistics and Census Data We begin by examining racial/ethnic disparities in older adult mortality. The National Center for Health Statistics (NCHS) constructs official mortality rates based on U.S. Vital Statistics (numerator) and Census (denominator) data. The advantages of these data sources are that they are large and cover the entire population, including individuals in nursing homes, long-term care institutions, and prisons. Although important and informative, there are some well-known limitations with the quality and reliability of the official death rates by race/ethnicity, especially among the elderly (Coale and Kisker, 1986; Elo and Preston, 1997; Kestenbaum, 1992; Lauderdale and Kestenbaum, 2002; Preston, Elo, Rosenwaike, and Hill, 1996; Rosenberg et al., 1999; Rosenwaike and Hill, 1996). One problem is reporting disparities between the two data sources. Disparities may occur because racial/ethnic identification on the Census is completed most often by a household member, while identification at the time of death is assigned most often by a funeral director (Rosenberg et al., 1999). Another problem is that a number of recent studies have shown significant levels of age misreporting among the elderly, which can seriously bias old-age mortality estimates (e.g., Preston et al., 1996). Third, Census undercount, particularly of racial and ethnic minority populations, can artificially bias mortality estimates for these groups upward, although adjustments can be made for the estimated undercount (Rosenberg et al., 1999). Despite these limitations, these official data remain a key source for describing racial/ethnic mortality disparities by age, sex, and geographic area.
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Critical Perspectives on Racial and Ethnic Differences in Health in Late Life Panel A of Table 3-1 presents official death rates per 100,000 by race/ ethnicity and sex for 5-year age groups among the U.S. elderly population in 1999 (Hoyert, Arias, Smith, Murphy, and Kochanek, 2001); Panel B presents rate ratios for the specific racial/ethnic, age, and sex groups vis-à-vis non-Hispanic white elders. As the ratios in Panel B demonstrate, the reported mortality rates of most of the racial/ethnic minority groups (e.g., persons of Hispanic, API, and Native American origin) are lower than or roughly equal to those of non-Hispanic whites at ages 65 to 69 and tend to become comparatively more advantaged at the advanced ages. Among non-Hispanic blacks, the mortality rates are 30 to 50 percent higher than non-Hispanic whites at ages 65 to 79, converge quite rapidly at ages 80 to 84, and eventually cross over among persons ages 85+. Although levels of mortality are higher among men than women for each racial/ethnic and age group, the relative disparities by race/ethnicity vary little by sex. Thus, these official rates depict non-Hispanic blacks to have the highest mortality among most of the elderly age groups, while rates for APIs, Hispanics, and Native Americans are generally lower than non-Hispanic whites. Recent demographic work has been undertaken to evaluate and reestimate black, white, and Asian-American mortality estimates among the elderly for the various sources of bias mentioned (e.g., Elo, 2001; Hill, Preston, and Rosenwaike, 2000; Lauderdale and Kestenbaum, 2002; Preston et al., 1996). The reestimates suggest that the general mortality patterns for these three population groups described remain consistent; that is, black mortality remains significantly higher than that of whites for most elderly age groups, with the greatest disparities occurring among the young-old (ages 65-74), and then convergence and crossover at the oldest ages (Hill et al., 2000). Likewise, new estimates of Asian-American older adult mortality were shown to be lower than whites, although the advantage may not be as great as demonstrated in the official data (Lauderdale and Kestenbaum, 2002). However, a debate continues about whether a real black-white mortality crossover occurs among the oldest-old (Nam, 1995). Although researchers for many years have documented such a mortality crossover using a number of different data sets and have concluded that it appears to be real (Johnson, 2000; Kestenbaum, 1992, 1997; Manton, Poss, and Wing, 1979; Manton and Stallard, 1997; Nam, Weatherby, and Ockay, 1978; Parnell and Owens, 1999), others have been more skeptical because of the data quality concerns (Coale and Kisker, 1986; Preston et al., 1996). The most recent, carefully produced evidence by a research team from the latter group continues to find a racial mortality crossover occurring at ages 90 to 94 for females and 95+ for males (Hill et al., 2000). Although the crossover is identified at an older age than a number of other researchers have found, the weight of the evidence, using a number of nationally based U.S. data sources, is strong that a black-white crossover exists. Probably more important, the evidence from
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Critical Perspectives on Racial and Ethnic Differences in Health in Late Life TABLE 3-1 Death Rates per 100,000 by Race/Ethnicity and Death Rate Ratios Compared with Non-Hispanic Whites for the Elderly Population of the United States, Official U.S. Mortality Data, 1999 Sex and Age Group Non-Hispanic Black Hispanic Origin Asian/Pacific Islander Native American Non-Hispanic White Panel A: Death Rates Females 65-69 2,231.3 1,125.8 862.7 1,743.5 1,515.0 70-74 3,516.5 1,662.1 1,403.9 2,410.1 2,372.3 75-79 5,123.2 2,591.2 2,273.1 3,145.7 3,802.6 80-84 7,714.4 4,300.9 4,261.6 4,502.8 6,492.2 85+ 14,474.3 8,838.7 8,396.6 6,395.1 15,284.6 Males 65-69 3,567.2 1,841.1 1,358.4 2,471.2 2,433.4 70-74 5,236.8 2,704.7 2,394.6 3,246.0 3,780.8 75-79 7,455.4 3,913.0 3,828.0 4,358.5 5,712.0 80-84 10,546.4 5,696.6 5,957.6 5,165.3 9,286.8 85+ 16,321.0 9,842.3 11,343.5 6,946.2 17,539.1 Panel B: Death Rate Ratios vis-à-vis Non-Hispanic Whites Females 65-69 1.47 0.74 0.57 1.15 1.00 70-74 1.48 0.70 0.59 1.02 1.00 75-79 1.35 0.68 0.60 0.83 1.00 80-84 1.19 0.66 0.66 0.69 1.00 85+ 0.95 0.58 0.55 0.42 1.00 Males 65-69 1.47 0.76 0.56 1.02 1.00 70-74 1.39 0.72 0.63 0.86 1.00 75-79 1.31 0.69 0.67 0.76 1.00 80-84 1.14 0.61 0.64 0.56 1.00 85+ 0.93 0.56 0.65 0.40 1.00 SOURCE: Derived from Hoyert et al. (2001).
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Critical Perspectives on Racial and Ethnic Differences in Health in Late Life Hill et al. (2000) shows that mortality rates among aged 80+ U.S. whites (and, given their similarity to white rates, black rates as well) are lower than reports in other low-mortality countries with good data, as originally documented for the U.S. white population by Manton and Vaupel (1995). Notably, and in contrast to the in-depth work devoted to investigating data quality and refining old-age black and white mortality estimates, relatively few researchers have examined data quality or corrected for age misreports among other racial/ethnic groups (see Lauderdale and Kestenbaum, 2002, for an excellent exception that examines Asian-American mortality). Among the studies that have examined death rates across the life course, Rosenberg et al. (1999, p. 9) find that for population groups other than non-Hispanic whites and blacks, “levels of mortality are seriously biased from mis-reporting in the numerator and under-coverage in the denominator of the death rates.” Their findings suggest that officially reported death rates for Native Americans may be more than 20 percent too low, while those reported for APIs and Hispanics may be about 11 percent and 2 percent too low, respectively. On the other hand, Rosenberg et al. (1999) found that officially reported rates for non-Hispanic whites and non-Hispanic blacks were most likely 1 percent and 5 percent too high, respectively. Their refined estimates of age-adjusted death rates across the life course suggest that API and Hispanic death rates still remain the lowest (in that order), while Native American adjusted rates are higher than those of non-Hispanic whites but lower than those of non-Hispanic blacks. How these adjustments for known sources of error specifically influence elderly adult death rates is unknown, although one recent report found that Native American adult decedents were most likely to be misclassified at older adult ages (Stehr-Green, Bettles, and Robertson, 2002). Thus, the officially reported mortality disparities shown in Table 3-1 should be interpreted with great caution, with the low mortality levels for Native Americans, especially at the oldest ages, particularly suspect. We will present alternative estimates of racial/ethnic mortality disparities among the elderly, based on survey data linked to mortality follow-up information below. Cause-Specific Mortality Disparities Using Vital Statistics and Census Data Following up on the documentation of overall mortality by race/ ethnicity, Table 3-2 (also see Figure 3-1) presents cause-specific mortality rates (per 100,000 population) by race/ethnicity for the leading causes of death among the elderly population by gender. These rates are standardized to the gender-specific age distributions of the non-Hispanic white population. Similar to the overall mortality rates, substantial caution is warranted again, particularly for Hispanics, APIs, and Native Americans, because of
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Critical Perspectives on Racial and Ethnic Differences in Health in Late Life problems of racial/ethnic misclassification of decedents, age misreporting, and Census undercount (Rosenberg et al., 1999). For women (Panel A, Table 3-2), diseases of the heart, malignant neoplasms, and cerebrovascular diseases are the three leading causes of death for most racial/ethnic groups and account for 61 to 66 percent of deaths among all groups except Native Americans. For the two leading causes, non-Hispanic black rates are roughly twice as high as those reported for TABLE 3-2 Racial/Ethnic Disparities in Cause-Specific Mortality Rates (per 100,000 population) for the Top 10 Causes of Death Among the U.S. Elderly Population, 1999 Underlying Cause of Death Non-Hispanic Black Hispanic Origin Asian/ Pacific Islander Native American Non-Hispanic White Panel A: Females Heart diseases 1,861.9 974.7 735.4 894.7 1,715.2 Malignant neoplasms 1,029.3 513.9 513.9 547.3 955.4 Cerebrovascular diseases 506.3 233.4 278.1 248.4 481.1 Chronic lower respiratory diseases 140.9 99.6 75.5 169.9 294.9 Influenza and pneumonia 140.1 90.6 72.5 133.3 173.3 Alzheimer’s disease 95.7 61.3 * 65.6 167.4 Diabetes mellitus 298.6 200.0 109.6 292.5 129.0 Accidents * 41.6 40.6 82.8 85.3 Nephritis, nephrotic syndrome, and nephrosis 160.3 54.3 49.0 92.5 72.8 Septicemia 140.0 42.7 31.9 52.7 67.5 Residual (all other causes) 984.2 508.0 399.6 628.0 903.0 TOTAL 5,357.4 2,820.1 2,306.0 3,207.7 5,044.8 Panel B: Males Heart diseases 2,045.5 1,178.6 1,114.3 1,164.7 1,929.9 Malignant neoplasms 1,797.1 816.9 840.7 831.5 1,428.9 Cerebrovascular diseases 473.7 247.8 333.9 244.0 380.4 Chronic lower respiratory diseases 295.7 165.2 186.4 223.6 403.5 Influenza and pneumonia 172.0 103.6 119.6 133.0 172.2 Alzheimer’s disease * * * * 99.8 Diabetes mellitus 247.2 191.4 111.6 241.1 142.4 Accidents 123.1 75.9 68.6 131.5 112.2 Nephritis, nephrotic syndrome, and nephrosis 177.5 70.2 69.4 62.8 92.6 Septicemia 149.6 46.6 43.6 57.0 65.6 Residual (all other causes) 1,048.9 622.6 552.0 686.8 902.9 TOTAL 6,530.3 3,518.7 3,440.1 3,776.0 5,730.3 *This cause of death was not listed in the top 10 for this particular racial/ethnic group and therefore is included in the residual category. SOURCE: Anderson (2001).
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Critical Perspectives on Racial and Ethnic Differences in Health in Late Life FIGURE 3-1 Cause-specific age-standardized mortality rates by race/ethnicity for the five leading causes of death among the elderly, U.S. population, 1999.
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Critical Perspectives on Racial and Ethnic Differences in Health in Late Life Hispanics, APIs, and Native Americans. For Native Americans, diabetes is the third leading cause of death and the three aforementioned causes account for just 53 percent of all deaths. High cause-specific rates of respiratory disease and Alzheimer’s disease stand out among non-Hispanic whites, while non-Hispanic blacks have the highest rates for diseases of the heart, malignant neoplasms, cerebrovascular diseases, influenza/pneumonia, diabetes mellitus, nephritis, septicemia, and the residual category. API women stand out for having the lowest rate for several of the causes, exhibiting especially low rates of respiratory diseases, influenza/pneumonia, Alzheimer’s disease, diabetes mellitus, and septicemia. For example, the age-standardized rate of respiratory disease mortality for API women (75.5) is roughly 69 percent lower than among non-Hispanic white women (294.9), and the rate of septicemia mortality for API women (31.9) is about 85 percent lower than exhibited by non-Hispanic black women (140.0). For elderly men (Panel B, Table 3-2), non-Hispanic blacks and non-Hispanic whites, in that order, also exhibit by far the highest rates of heart disease and malignant neoplasm mortality. For all groups except non-Hispanic whites, cerebrovascular disease is the third leading cause, while for non-Hispanic whites, respiratory disease is the third leading cause. Indeed, similar to the rates for women, non-Hispanic white elderly men exhibit, by far, the highest reported mortality rate for chronic lower respiratory diseases. Non-Hispanic white men (like their counterpart women) are also characterized by the highest reported rates of Alzheimer’s disease mortality. For most causes, however, rates are highest among non-Hispanic black male elders. For example, death rates for nephritis and related causes, septicemia, and diabetes mellitus are highest, by far, among non-Hispanic black men in comparison to all other groups. Relatively high rates of diabetes mellitus also stand out for Native American and Hispanic males, while accident mortality is the highest among Native American male elders. As with women, the API male population is characterized by the lowest overall rates of mortality and lowest rates for several specific causes of death Overall Mortality Disparities Using a Survey-Based Data Set Large, population-based survey data sets, with links to follow-up mortality information, provide another important source of information regarding mortality disparities among the elderly. Using survey-based data sets linked to follow-up death records (i.e., the National Death Index) to analyze adult mortality patterns in the United States offers some important advantages and disadvantages. Key advantages include the fact that the racial/ethnic identifying information is provided by the individual or a coresident of the individual, while, in contrast, official U.S. mortality data are based on reports of race/ethnicity provided by the funeral director that
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Critical Perspectives on Racial and Ethnic Differences in Health in Late Life may or may not match the individual’s own racial/ethnic identity reported in the Census (Rosenberg et al., 1999). Second, and perhaps most important, survey-based data sets provide an array of covariates measured at the time of the survey from which the racial/ethnic patterns of mortality can be understood more thoroughly (e.g., Rogers, Hummer, and Nam, 2000), an enormous advantage over the more limited vital statistics-based data. On the other hand, the survey-based data sets do not cover the complete population: They are samples of the U.S. population and most often exclude the noninstitutionalized population (i.e., persons in nursing homes and prisons) by design. The matched data sets are also believed to miss between 2 and 5 percent of decedents during the mortality follow-up period (e.g., NCHS, 2000). This may particularly influence the findings for racial/ ethnic groups that have high percentages of immigrants. Because the identification of deaths is heavily influenced by matching Social Security numbers from the death file to the original survey report, the quality of matches has been shown to be lesser among heavily immigrant populations (Hummer, Rogers, Amir, Forbes, and Frisbie, 2000; Liao et al., 1998). Third, again for some racial/ethnic groups composed of a large percentage of immigrants (e.g., Mexican Americans), return migration to the country of origin, after their original inclusion in the survey, may also bias survey-based follow-up estimates of mortality downward, although one recent study suggests that return migration effects cannot account for the relatively low adult mortality rates that have been demonstrated for the U.S. Hispanic population (Abraido-Lanza, Dohrenwend, Ng-Mak, and Turner, 1999). However, this hypothesis has never been tested directly using mortality records from out-migration countries such as Mexico. Finally, sample sizes among the oldest-old population in most nationally based survey data sets tend to be quite small, particularly for mortality follow-up purposes, thus providing unstable estimates at the oldest ages and making detailed cause-specific and sex-specific analyses for relatively small racial/ethnic populations unstable. The National Health Interview Survey—Multiple Cause of Death (NHIS-MCD) linked data set (NCHS, 2000) is perhaps the finest of this kind for the study of mortality patterns within the U.S. population. The National Health Interview Survey (NHIS) conducted by the National Center for Health Statistics is an annual health interview of a nationally representative sample of individuals. It is the primary source of information on the health of individuals in the United States. The annual survey includes information from approximately 100,000 people (encompassing nearly 40,000 households annually) regarding central items such as age, sex, race/ ethnicity, nativity, income, education, and self-reported health and activity limitation status. Moreover, its link to the National Death Index provides a unique opportunity to examine mortality patterns among racial/ethnic groups with a large prospective data set.
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Critical Perspectives on Racial and Ethnic Differences in Health in Late Life TABLE 3-3 Predicted Racial/Ethnic Mortality Disparities by Age for the Elderly Population of the United States, NHIS-MCD, 1989-1997 Age Non-Hispanic Blacka Mexican Origina,b Other Hispanica,b Asian/ Pacific Islandera Native American Non-Hispanic Whitea 65 1.40 0.84 0.87 0.36 1.19 1.00 70 1.27 0.84 0.87 0.46 1.13 1.00 75 1.15 0.84 0.87 0.59 1.07 1.00 80 1.04 0.84 0.87 0.76 1.02 1.00 85 0.94 0.84 0.87 0.97 0.97 1.00 aMain effect of race/ethnicity was statistically different (p < .05) from non-Hispanic whites. bRace/ethnicity by age interaction term was not statistically significant. Thus, disparities vis-à-vis non-Hispanic whites are constant across ages. SOURCE: Derived from NCHS (2000). Table 3-3 and Figure 3-2 show estimated racial/ethnic disparities in older adult (65+) mortality for men and women combined at several specific ages. Non-Hispanic whites are specified as the reference group, as is the case in most studies of U.S. mortality. The disparities are estimated using results from a proportional hazards model of mortality risk applied to the NHIS-MCD linked data set (NCHS, 2000). The equations specified mortality risk as a function of race/ethnicity, sex, age, and race/ethnicity by age interaction terms (which account for the possible widening or narrowing of mortality disparities vis-à-vis non-Hispanic whites with increasing age). The race/ ethnicity by age interaction effects proved to be statistically significant for non-Hispanic blacks, APIs, and Native Americans and, thus, the racial/ethnic disparities in comparison to non-Hispanic whites for these groups are shown to vary by age. Data in Table 3-3 include 82,868 individuals aged 65 and older at the time of the baseline interviews, which were conducted in six different NHIS survey years, 1989 through 1994. Mortality follow-up was assessed through the end of 1997, which resulted in 20,145 deaths. These survey-based, follow-up mortality results show non-Hispanic black mortality to be 40 percent higher than non-Hispanic white mortality at age 65, with convergence and eventual crossover at the oldest ages. This disparity is modestly smaller than what was shown in Table 3-1, where for adults aged 65 to 69, non-Hispanic black females and males were each shown to exhibit 47 percent higher mortality than their non-Hispanic white counterparts. The results in Table 3-3 also show 19 percent higher Native American mortality compared to non-Hispanic whites at age 65 (although the small number of Native American deaths yielded a statistically nonsignificant overall difference in comparison to non-Hispanic whites). Perhaps more important, the survey-based results in Table 3-3 for Native Americans do not show substantially lower mortality among Native Americans at the oldest ages, as exhibited in the official mortality data in Table 3-1. The survey-based data in Table
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Critical Perspectives on Racial and Ethnic Differences in Health in Late Life FIGURE 3-2 Predicted racial/ethnic mortality disparities by age, United States, 1989-1997. 3-3 continue to demonstrate lower Hispanic than non-Hispanic white mortality among the elderly. However, the Hispanic mortality advantage using these data is not nearly as wide as evidenced in the officially reported data seen in Table 3-1. Finally, API elderly mortality is significantly lower than non-Hispanic whites throughout the age range, with evidence of convergence to non-Hispanic white levels among the oldest-old. These disparities are quite similar to those reported by Elo and Preston (1997), who used survey-based (Current Population Surveys) follow-up mortality data from the 1979-1985 National Longitudinal Mortality Study data set. Perhaps the only difference of note is that the Hispanic groups presented in Table 3-3 exhibit only moderately (e.g., 13 to 16 percent) lower mortality than non-Hispanic whites, as opposed to the larger advantages (e.g., 21 to 37 percent) reported by Elo and Preston from the earlier time period. In sum, the mortality results show that racial/ethnic disparities remain relatively unchanged in comparison to the results of Elo and Preston (1997), who used data from approximately a decade earlier. Non-Hispanic black
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Critical Perspectives on Racial and Ethnic Differences in Health in Late Life there remain important, unmeasured components of socioeconomic inequality in this set of models (also see Kaufman, Cooper, and McGee, 1997, for a critique of socioeconomic measurement in studies of racial/ethnic health disparities). Furthermore, caution is warranted in interpreting the effects of income as fully causal; indeed, substantial literature points to the effects of health status on income as well as income on health (e.g., Mulatu and Schooler, 2002; Smith and Kington, 1997b). The results for income are consistent with those for education in that a strong, graded association is evident, with individuals in the lowest family income category more than twice as likely to be in poor/fair health compared to individuals in the highest income category. Racial/ethnic disparities in self-reported health are further reduced with the addition of income, although significant differences remain between non-Hispanic blacks and non-Hispanic whites and between Mexican Americans and non-Hispanic whites. Nevertheless, it is clear that socioeconomic factors are instrumental in helping to account for the relatively poor self-reported health for non-Hispanic black, Mexican American, other Hispanic, and Native American elders in comparison to non-Hispanic whites. In contrast, API elders display marginally favorable self-reported health compared to non-Hispanic white elders, with education and family income differences between the API and non-Hispanic white groups having little impact. Table 3-10 turns to racial/ethnic disparities in activity limitations for the elderly. Model 1 shows that API adults exhibit the most favorable patterns, with more than 40 percent lower odds of limitation compared with non-Hispanic whites. This baseline advantage is relatively unaffected by controls for nativity/duration and socioeconomic factors. On the other hand, Native Americans, non-Hispanic blacks, and Mexican Americans exhibit significantly higher levels of activity limitations than non-Hispanic whites that are, again, largely unaffected by controlling for nativity/duration, but substantially reduced with controls for education and income. In fact, the Mexican American difference with non-Hispanic whites is reduced to nonsignificance after controlling for education and income differences across groups, while the higher odds for non-Hispanic blacks and Native Americans are substantially reduced. Again, the important role of socioeconomic variables for poorer health outcomes among elderly Native Americans, non-Hispanic blacks, and Mexican Americans is demonstrated. Finally, Table 3-11 displays results from proportional hazard models of racial/ethnic disparities in elder mortality risk. As exhibited in the descriptive portion of this chapter earlier, mortality disparities display somewhat different patterns than health disparities among the elderly. Model 1, for example, shows that non-Hispanic blacks exhibit just a 13 percent higher overall risk of mortality than non-Hispanic whites, controlling for age and sex, while Mexican Americans, other Hispanics, and, especially, APIs ex-
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Critical Perspectives on Racial and Ethnic Differences in Health in Late Life TABLE 3-10 Odds Ratios for Racial/Ethnic Differences in Elderly Activity Limitations, United States, 1989-1994 Odds Ratios for Activity Limitationsa Model 1 Model 2 Model 3 Model 4 Race/ethnicity [non-Hispanic white]b Non-Hispanic black 1.44*** 1.44*** 1.32*** 1.24*** Mexican American 1.22** 1.27*** 1.13* 1.08 Other Hispanic 1.09 1.17* 1.13 1.09 Asian/Pacific Islander 0.56*** 0.58*** 0.57*** 0.61*** Native American 1.54** 1.53** 1.42* 1.36* Gender [female] Male 0.99 0.99 0.99 1.03 Age, continuous in years 1.04*** 1.04*** 1.04*** 1.03*** Nativity/duration [U.S. born] Foreign born, <10 years in U.S. 1.10 1.07 1.10 Foreign born, 10+ years in U.S. 0.87** * 0.86*** 0.86*** Education [16+ years] 0-8 years 1.58*** 1.34*** 9-11 years 1.44*** 1.21*** 12 years 1.15*** 1.02 13-15 years 1.14*** 1.06 Income [$45,000+] Low ($0-$15,999) 1.81*** Medium ($16,000-$29,999) 1.30*** High ($30,000-$44,999) 1.15*** Missing 1.35*** –2 * log-likelihood 107,766.1 107,740.6 107,222.5 106,597.9 Degrees of freedom 7 9 13 17 N 82,040 82,040 82,040 82,040 aWeighted data. bReference categories are in brackets. NOTE: *** = p < 0.001, ** = p < 0.01, * = p < 0.05. SOURCE: Pooled National Health Interview Surveys, 1989-1994. hibit lower elderly mortality than non-Hispanic whites. The age by racial/ ethnicity interactions shown in Model 2 reconfirm the converging black-white and API-white mortality disparities with age and demonstrate the substantial mortality disadvantage for blacks and mortality advantage for APIs, relative to non-Hispanic whites, at age 65. For example, at age 65, Model 2 demonstrates that non-Hispanic blacks exhibit a 41 percent higher risk of mortality compared to non-Hispanic whites. The nativity/duration association with mortality risk, exhibited in Model 3, is moderately strong and maintains that strength through the complete set of models. The foreign born of less than 10 years of duration in the United States exhibit a 26 percent lower risk of mortality compared to the native born, while the foreign born of 10 or more years of duration display an 18 percent lower risk compared to the native born. Again, the interpretation of these differ-
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Critical Perspectives on Racial and Ethnic Differences in Health in Late Life TABLE 3-11 Hazard Ratios for Racial/Ethnic Differences in Elderly Mortality Risk, United States, 1989-1997 Hazard Ratios of Mortalitya Model 1 Model 2 Model 3 Model 4 Model 5 Race/ethnicity [non-Hispanic white]b Non-Hispanic black 1.13*** 1.41*** 1.41*** 1.34*** 1.30*** Mexican American 0.83** 0.85 0.88 0.83 0.80 Other Hispanic 0.85*** 0.87 0.97 0.96 0.93 Asian/Pacific Islander 0.63*** 0.36*** 0.41*** 0.41*** 0.43*** Native American 1.00 1.19 1.19 1.15 1.11 Gender [female] Male 1.72*** 1.72*** 1.72*** 1.73*** 1.76*** Age, continuous in years 1.09*** 1.09*** 1.09*** 1.09*** 1.09*** Age * race/ethnicity Age * non-Hispanic black 0.98*** 0.98*** 0.98*** 0.98*** Age * Mexican American 1.00 1.00 1.00 1.00 Age * other Hispanic 1.00 1.00 1.00 1.00 Age * Asian/Pacific Islander 1.05*** 1.05*** 1.05*** 1.05***
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Critical Perspectives on Racial and Ethnic Differences in Health in Late Life Age * Native American 0.99 0.99 0.98 0.99 Nativity/duration [U.S. born] Foreign born, <10 years in U.S. 0.74* 0.73** 0.74* Foreign born, 10+ years in U.S. 0.82*** 0.82*** 0.82*** Education [16+ years] 0-8 years 1.35*** 1.24*** 9-11 years 1.29*** 1.18*** 12 years 1.20*** 1.13*** 13-15 years 1.10* 1.05 Income [$45,000+] Low ($0-$15,999) 1.36*** Medium ($16,000-$29,999) 1.18*** High ($30,000-$44,999) 1.11* Missing 1.17*** −2 * log-likelihood 727,370.4 727,315.6 727,263.8 727,092.5 726,941.7 Degrees of freedom 7 12 14 18 22 N 82,040 82,040 82,040 82,040 82,040 aWeighted data. bReference categories are in brackets. NOTES: *** = p < 0.001, ** = p < 0.01, * = p < 0.05. SOURCE: National Health Interview Survey—Multiple Cause of Death linked file (NCHS, 2000).
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Critical Perspectives on Racial and Ethnic Differences in Health in Late Life entials is difficult because of immigrant and emigrant migration selectivity as well as the generally higher quality of death matches among the native-born population in comparison to the foreign born. Interestingly, though, the racial/ethnic disparities are only modestly influenced with the control for nativity/duration, demonstrating that the observed, rather favorable, elder mortality patterns for Mexican Americans, other Hispanics, and APIs are not solely due to the substantial foreign-born composition of these groups. Models 4 and 5 further include education and family income, respectively. Although each of these factors exhibits a graded association with mortality risk in the expected direction, the socioeconomic differences are moderate in size and of weaker magnitude than for the health outcomes examined earlier. The somewhat weaker association of socioeconomic factors with older adult mortality has been noted in a number of national studies (e.g., Kitagawa and Hauser, 1973; Rogers et al., 2000), although the explanation for this phenomenon remains elusive. Moreover, although controlling for education and income in Models 4 and 5 works to help reduce the black-white mortality gap, differences between these two groups remain. Moreover, the relative mortality disparities between the other racial/ethnic populations and whites change only slightly with the introduction of the socioeconomic factors. CONCLUSION Despite the national-level priority on understanding and eliminating health disparities, we know far less about racial/ethnic differences in older adult health, activity limitations, and mortality than is the case among infants, children, and younger adults. It is imperative that the research community push for a greater understanding of these disparities, particularly given the continuing documentation of disparities across groups, the changing racial/ethnic composition of the nation, and an aging population. This chapter set out to document racial/ethnic disparities in older adult health and mortality using large, recent, nationally based data sets; to compare the disparities to earlier portions of the life course; to document how the health and mortality disparities correspond with racial/ethnic differences in sociodemographic factors; and to demonstrate how health and mortality disparities are influenced by controlling for those basic demographic and social factors. To briefly summarize the findings, we have documented continuing racial/ethnic disparities in health, activity limitations, and active life among U.S. elders. Non-Hispanic black, Native American, and, to a lesser degree, Mexican American and other Hispanic elders were shown to have overall worse health across a number of indicators compared to non-Hispanic
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Critical Perspectives on Racial and Ethnic Differences in Health in Late Life whites, while API elders displayed more favorable patterns across a number of the indicators. Mortality disparities were found to be less pronounced than health disparities among the elderly, although non-Hispanic blacks were clearly found to have the highest mortality risks using several different data sources. Excess black mortality, in comparison to whites, is concentrated among the younger elderly population, with negligible differences beyond age 80. Nevertheless, a comparison of the present mortality differentials with those of Elo and Preston (1997) from roughly a decade previous show no evidence of closure of the black-white mortality gap among the younger elderly population, even in the recent context of declining mortality for all groups. Racial/ethnic disparities in elderly health and mortality were also found to be generally of smaller magnitude than the disparities shown for younger U.S. adults, although levels of poor health, activity limitations, and mortality risks increase for all racial/ethnic groups with age. This chapter also documented wide socioeconomic differences between racial/ethnic groups in old age. Our models also showed that education and income differences across groups continue to play an important part in the overall worse health of non-Hispanic blacks, Native Americans, and to a lesser degree, Hispanics in comparison to non-Hispanic whites and the API population. Other demographic and social factors were shown to differ quite markedly across groups. The widely varying immigration experiences across racial/ethnic groups will continue to differentiate Hispanic and API elders from blacks, whites, and Native Americans. Further nativity/duration differences were noted even within the highly concentrated immigrant populations; for example, API foreign-born elders are much more likely to have recently migrated to the United States in comparison to Hispanic foreign-born elders. In our discussion and analyses, we have focused on the associations between sociodemographic factors, including age, sex, nativity, education, and income, and racial/ethnic disparities in health and mortality. But we must not overlook other important factors that may be associated with these disparities, such as health behaviors—tobacco use, alcohol consumption, diet, and exercise; health conditions—such as obesity and diabetes; mental and addictive disorders—such as drug abuse; and environmental and neighborhood factors—including crime and safety (Rogers, Hummer, and Krueger, 2004). Thus, although we have identified some of the major social and demographic factors that influence racial/ethnic health and mortality patterns, there are surely other areas of research that can further clarify the mechanisms that contribute to these patterns. Importantly, untangling the causal associations between socioeconomic factors and health outcomes, and understanding these associations within each racial/ethnic subgroup, should be a major research priority in the coming years.
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Critical Perspectives on Racial and Ethnic Differences in Health in Late Life Important data availability and reliability issues continue to hinder the more complete understanding of racial/ethnic health and mortality disparities among the elderly at the national level. Indeed, much of what is known about mortality among the elderly is based on vital statistics data, which have well-known limitations (e.g., very limited range of covariates, some mismatches of racial/ethnic reports between numerator and denominator data, and undercounts of minority groups in the denominator data), particularly for understanding minority group mortality levels and patterns. Matches between large survey-based data sets and mortality follow-up records (e.g., the NHIS-MCD, the National Longitudinal Mortality Study) have vastly improved our understanding in this area, but even those data sources have limited sets of variables to allow for the full comprehension of mortality patterns across racial/ethnic groups, as well as coverage gaps and matching problems. Nevertheless, such large survey-based data sources currently present the greatest opportunities for most thoroughly documenting and modeling racial/ethnic patterns of mortality across a wide variety of racial/ethnic groups. Longitudinal studies of health among the elderly have been limited, with a major recent improvement made by the Health and Retirement Study (HRS) data collection program. Still, even the HRS surveys offer very limited numbers of Hispanics, Asian Americans, and Native Americans, undermining their utility for understanding the full spectrum of racial/ ethnic disparities in older adult health. Understanding Hispanic and API older adult health and mortality will be a substantial future challenge, particularly with continued large-scale migration and the possibility of circular and/or return migration to Mexico, other countries of Latin America, and Asia. The diverse ethnic, cultural, and geographic factors that characterize all of these broad racial/ethnic groups, but perhaps especially the Hispanic and API populations, will pose a real challenge to the understanding of elderly health and mortality patterns in the United States. Racial/ethnic groups are characterized by internal variation by language, religion, geographic dispersion, immigration patterns, socioeconomic status, health behaviors, and other factors. Indeed, Hispanics include Mexican Americans, Cubans, Puerto Ricans, Central and South Americans, and other persons of Spanish descent. APIs include Chinese, Japanese, Filipinos, Indians and Pakistanis, Vietnamese, Koreans, Hawaiians, and many other individuals from varying backgrounds. Currently, we know relatively little about the health and mortality patterns of most of the component ethnic populations of the broad racial/ethnic groups, and documenting and understanding such patterns will be an important research challenge in the coming decades. Perhaps most important, racial/ethnic disparities in health and mortality among U.S. elders cannot be fully understood without placing such
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Critical Perspectives on Racial and Ethnic Differences in Health in Late Life patterns in a life-course context. The research community will need much better data to understand how life-course factors (e.g., migration experiences, socioeconomic fluctuations, childhood and early adult health and illness, family backgrounds, discriminatory histories) impact older adult health and mortality across various racial/ethnic groups. Disparate patterns of older adult health and mortality among racial/ethnic groups come about because of the varying demographic, social, economic, behavioral, and health and health care experiences of these groups over many years; thus, our more complete understanding of old-age health consequences relies on better tapping this differential accumulation of experiences. In conclusion, the United States experienced a remarkable mortality decline and great improvements in health across the 20th century. All racial/ethnic groups participated in and contributed to these substantial changes, although some important health and mortality disparities remain. With further improvements in standards of living, safety and security, nutrition, and medicine, we can anticipate further health gains and longer lives among all racial/ethnic groups in the coming decades as well, and we can hope that Healthy People 2010’s goal of eliminating health disparities among racial/ethnic groups becomes a reality. REFERENCES Abraido-Lanza, A.F., Dohrenwend, B.P., Ng-Mak, D.S., and Turner, J.B. (1999). The Latino mortality paradox: A test of the “salmon bias” and healthy migrant hypotheses. American Journal of Public Health, 89, 1543-1548. Anderson, R.N. (2001). Deaths: Leading causes for 1999. National Vital Statistics Reports, 49(11). Angel, R., and Guarnaccia, P.J. (1989). Mind, body, and culture: Somatization among Hispanics. Social Science and Medicine, 23, 1229-1238. Cho, Y., Frisbie, W.P., Hummer, R.A., and Rogers, R.G. (in press). Nativity, duration of residence, and the health of Hispanic adults in the United States. International Migration Review. Christenson, B.A., and Johnson, N.E. (1995). Educational inequality in adult mortality: An assessment with death certificate data from Michigan. Demography, 32, 215-230. Coale, A.J., and Kisker, E.E. (1986). Mortality crossover: Reality or bad data? Population Studies, 40, 389-401. Elo, I.T. (2001). New African American life tables from 1935-1940 to 1985-1990. Demography, 38, 97-114. Elo, I.T., and Preston, S.H. (1996). Educational differentials in mortality: United States, 1979-1985. Social Science and Medicine, 42, 47-57. Elo, I.T., and Preston, S.H. (1997). Racial and ethnic differences in mortality at older ages. In L.G. Martin and B.J. Soldo (Eds.), Racial and ethnic differences in the health of older Americans (pp. 10-42). Committee on Population, Commission on Behavioral and Social Sciences and Education, National Research Council. Washington, DC: National Academy Press. Feldman, J., Makuc, D., Kleinman, J., and Cornoni-Huntley, J. (1989). National trends in educational differences in mortality. American Journal of Epidemiology, 129, 919-933.
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Representative terms from entire chapter: