Medical Sociology Exam 5!!!!

Basic Patterns of Racial Disparities

• Found from birth to death

• Disparities in mortality are found for a variety of specific causes of death

• Disparities are dynamic: some have grown over time, but a few have declined or disappeared

Suspected Mechanisms of Racial Disparities

Socioeconomic advantages

Differences in the effects of these advantages

Institutions that perpetuate disadvantage

Treatment Disparities

Life Expectancy At Birth

Women live longer than men, white men and women live longer than their black counterparts, disparities were much greater in 1900s

Survival Curves

Asian females live the longest

Hispanic females live the second longest

Asian males

White females

Hispanic males

Black females

White males

American Indian females

Black males

American Indian males

Mortality Crossover

Survival of the fittest or poorer vital registration data among older African Americans

Blacks have high mortality in middle ages but as population ages it reverses

Intersect around 80

For men, the crossover happens slightly earlier and the gap between groups at younger ages is even wider, reflecting the generally higher mortality rates for men across the board.

Survival of the fittest

It suggests that because members of a disadvantaged group face harsher conditions and higher mortality earlier in life, only the most "robust" or biologically resilient individuals survive into extreme old age. By the time they reach 85, they are "hardier" on average than the survivors of a group that didn't face those same early-life pressures.

Poorer vital registration data for older African Americans

Some researchers argue the crossover is an illusion caused by "age misreporting." Historically, in census and death records, older individuals in certain populations (particularly those born in eras or regions with less formal record-keeping) might have their ages exaggerated, making it appear as though they are dying at a later age than they actually are.

Sources of Disparities

many conditions contribute to racial disparities in health, but some are more important: CVD, HIV, trauma, diabetes

Leading Causes of Deaths for Males by Race US 2018

White: heart disease, cancer, unintentional injuries

Black: heart disease, cancer, alzheimer’s

Asian: cancer, heart disease, stroke

American Indian: heart disease, cancer, unintentional injuries

Native Hawaiian: heart disease, cancer, unintentional injuries

Hispanic: heart disease, cancer, unintentional injuries

Dynamic Patterns

Large disparities: some leading causes of death

Small disparities: the virtual elimination of flu and pneumonia disparities

The application of a widely diffused technology can eliminate a large disparity in health because variations in motivation, knowledge, and resources play a smaller role in such cases

Blacks more likely to have homicides (5.7:1), heart disease (1.3:1), cancer (1.3), flu/pneumonia (1.1:1), and suicide (0.5:1)

Morbidity

Blacks suffer significantly higher morbidity overall

Black men: hbp, diabetes, lung diseases, heart condition, stroke, arthritis, asthma, kidney, stomach ulcers

Black women: hbp, diabetes, heart condition, heart attack in last 5 years, heart surgery, stroke, arthritis, asthma, kidney, stomach ulcers

Distribution of Self-Assessed Health Status

Both men most likely to rate good (51-61)

White women most likely to rate very good, Black women most likely to rate good (51-61)

White men most likely to rate good, black men most likely to rate fair (70+)

White women most likely to rate good and black women most likely to rate fair (70+)

High risk for Covid

Ranking: whites, black, hispanic, asian

Blacks: BMI, smoker, diabetes, hpb, asthma

Whites: age 65+. cancer, CHD

Paradox of Mental Health

both minority groups had lower risk for common internalizing disorders

presence of protective factors that originate in childhood

but greater persistence

Hispanic Health Paradox

US Latinos have very low mortality rates, whereas US African Americans have high

the epidemiological observation that Latino immigrants in the U.S. often have better health outcomes—such as lower mortality rates and longer life expectancy—than non-Latino whites, despite generally having lower socioeconomic status, less education, and lower access to healthcare.

Explaining Race Differences in Morbidity

Results regarding SES and mortality

Behavior vs SES

Whites exercise more often, have higher incomes, higher prob of health insurance and job demands, lower depression scale, less satisfied by finances and friendships, more likely to be educated and married, less likely to live in metropolitan area, more likely to be born in North and living in the North, and less likely to have be smoking (past smoker), less likely to be in Q4/5 for obesity, higher moderate alcohol consumption

SES is important

Diabetes, ADLs, vision impairment, stroke, hypertension all big ones Blacks have compared to Whites

Explaining Mortality Differences

Difference at all levels of education (whites always more likely to be educated)

Double jeopardy of low SES and racial/ethnic minority status

Minorities have fewer returns to SES

Discrimination

Some weaknesses: many use primitive measures of discrimination, more research on mental health than physical health (and even more research on non-specific distress), and little contextual information: other kinds of stress and coping

Some results: generally has a deleterious effect consistent with that of other stressors, non-linear responses (U-shaped relationship w bp)

Results from MIDUS: lifetime discrimination

major discrimination 25-44, females (males pretty close), other race (black close behind)

Day-to-Day Discrimination

age 25-44, males, non-hispanic blacks

Reasons for Discrimination

race then gender, appearance, age, religion, SES, sexual orientation, physical/mental disability, other

Other Ways of Studying Discrimination

Study of CA birth certificate data

Arabic named women had a much higher risk of a LBW baby after 9/11

No other group of women had an elevated risk

Other Institutions Related to Health

The prison system as potential determinant of population health

Growth of Prisoners and Former Prisoners has increased tremendously

Some Prison Estimates

large percent African American currently and formerly in prison

Racial Inequality in Lifetime Risk of Incarceration

Black men have higher prison incarceration, military service

White men have higher bachelor’s degree and marriage

Non-college Men: Black men higher prison incarceration and military service, White men have higher high school diploma and marriage

Health Effects of Incarceration

Immediate Effects: infectious disease, trauma, prison health care

Long-term effects: marital instability, unemployment and slow wage growth, uninsurance, and discrimination

What are the effects of a prison record on employment?

Audit study: pair of whites, pair of blacks

Randomly exchange who has a criminal conviction on a weekly basis: possession of cocaine with intent to distribute 18 months in prison, conviction was conveyed directly (checkbox) or indirectly (parole officer as reference or work experience in prison)

Reduction in likelihood of a callback is ~50%, 40% larger for blacks

Many blacks asked upfront about a criminal conviction

The wage difference between those with and without a record is large and grows with age (cumulative disadvantage)

Effects of Current Incarceration

Mortality in prisons is low for African Americans, medical treatment often improves during incarceration

Basic Access and Utilization

federal inmates less likely to have condition examined by professional, more likely to not continue on same or any meds during incarceration, no blood test since admission despite problems, not examined after serious injury

Mental health: federal more likely to have diagnosed mental condition, taking meds or therapy during arrest or ever took them and taking or receiving since admission

Prison Effects on Later Mortality

Binswanger et al 2007: follow up between 1999-2003

Risk of mortality among released inmates is 3.5x higher than state average, particularly high 1-2 weeks after release, leading causes were drug overdose, CVD, homicide, and suicide

Prison Effects on Morbidity

incarceration is linked with stress-related disorders and infectious disease but not other conditions

Effects emerge only after release

Status Loss of Contact post prison, crime, or arrest

• The "Penalty" of Incarceration: There is a clear downward trend. As the severity of legal involvement increases (from "Arrest" to "Long Incarceration"), the ladder scores drop significantly.

• Short vs. Long Term: "Long incarceration" (30+ days) shows the most dramatic negative coefficients (e.g., -1.596 for Whites and -2.138 for African Americans), meaning these individuals feel significantly "lower" in society.

• Racial Disparities: The data compares Non-Hispanic Whites and African Americans. While both groups show lower subjective status following incarceration, the coefficients for African Americans are often larger, suggesting a more profound impact on their perceived standing in the U.S. and their local communities.

Treatment Disparities

across a wide range of disease areas and clinical services and settings (public and private hospitals, teaching and non-teaching hospitals) although some hospitals are clearly better than others

difference: clinical appropriateness and need patient preferences, discrimination, ecology of health care systems and environmental factors

among medicare beneficiaries enrolled in managed care plans, African Americans receive poorer quality of care (beta blockers, follow-up, eye exams, breast screenings)

Treatment Disparities Basic Explanations

differences in access or quality

different underlying disease severity

physician bias

different patient preferences

Patient Preferences

• Overall High Willingness: For most physical limitations—like pain interfering with work or being unable to perform moderate activities—over 70% of respondents across both groups expressed a desire to seek treatment.

• Mental vs. Physical Health: There is a noticeable drop in the "Percent that Would Seek Treatment" when the conditions are emotional rather than physical. For instance, only about 50% would seek help for emotional problems affecting their work, compared to over 80% for physical pain.

Racial Comparisons:

• For the majority of the conditions listed, the differences between White and Black respondents are not statistically significant

• Significant Disparities: There are two specific areas where Black respondents showed a significantly higher predisposition to seek treatment than White respondents: "Not feeling calm and peaceful" and "Not having lots of energy"

• The Scoring System: The "Means" column uses a 4-point scale where 1 is "Definitely not go" and 4 is "Definitely go." Most averages hover around 2.5 to 3.2, suggesting a general inclination toward seeking care rather than avoiding it.

An experiment

physician predispositions vs clinical features in the treatment of chest pain

a 2×2×2×2×3×3 study: race, gender, age, level of coronary risk, type of chest pain, results of stress test

physicians recruited at national meeting, administered the experiment through a computer, featuring scripted interviews with actors

Estimates of the Probability of Coronary Artery Disease

estimates before stress test are consistent with known prevalences

no race differences

This table shows that while physicians initially used factors like sex, age, risk level, and chest pain type to estimate the probability of Coronary Artery Disease, the stress test results eventually became the dominant factor in their final assessments, significantly narrowing the gaps between different patient categories.

A stress test (often called a cardiac stress test) is a diagnostic tool used to determine how well your heart handles physical exertion - acts as a leveler

Referral for Cardiac Catheterization

race and sex matter even after need is eliminated

type of chest pain is only other experimental factor that matters

not due to assessed personality of character

This table demonstrates that even when medical need is the same, physicians are significantly less likely to refer women and Black patients for cardiac catheterization compared to men and White patients.

Race and Pain Evaluations

Sample of med students and residents

Two mock medical cases (ankle fracture and kidney stones)

Outcomes: pain rating 0 to 10, accurate treatment = recommend narcotics

False Beliefs: blacks’ nerve endings are less sensitive than whites’, blacks’ skin is thicker, etc.

Biological Beliefs: assorted beliefs that blacks/whites differ biologically

The Clinical Encounter: Four General Mechanisms

Unobserved heterogeneity

Prejudice: being less willing to interact with minorities, a negative attitude or affect

Clinical Uncertainty: interpreting a symptom of illness as less reliable

Stereotyping: holding a belief that minorities are less likely to comply

Gender Paradox

Mortality: women have lower mortality

• women have had advantage since 1900

• sex differences small in low-income countries

• gap in LE between males and females narrowed from 7 years in 1990 to 5.2 years in 2004

Morbidity: women have higher morbidity

• chronic diseases (20-30%)

• short-term disability: 25% more days

• long-term disability: 40% more whole days in bed

LE at birth and 65 years

while life expectancy at birth has increased dramatically since 1900 due to improved public health and lower infant mortality, life expectancy for those who have already reached age 65 has grown much more slowly and modestly.

Male to Female Death Ratio

males will die more frequently than women for most conditions except alzheimer’s

Self-Rated Health Patterns by Age

Average SRHS: gap then converge around 70, 0 to 10 overlap, women higher

Fraction in Fair/Poor Health: around 55 merge, smaller gap, 0 to 10 overlap, women higher during mid years then men surpass

Fraction Who Died Within 24 Months: 25-40 about the same then large gap 55 on with men higher

Average Annual Hospital Episodes: women higher and large gap from 20-50 then sporadic changes

Conditions by Age

women experience more headaches, arthritis, depression, asthma, hypertension at old age

men experience more CVD at old age, emphysema at older ages, diabetes spikes

reproductive cancer crosses about 70 where women got it more then switches to men

Expected Years with Disease

Women are expected to live more years with hypertension and CVD in part because men have an earlier onset and higher mortality

Physicians still maintain intuition that CVD is a disease of men

LE with and without disease

This table quantifies the "burden of disease" by showing how many years of a person's total life expectancy are spent living either with or without specific chronic conditions, highlighting that women generally live more years with disabilities and diseases like arthritis and hypertension compared to men.

Pharmaceutical Use

at age 40, most Americans are taking at least one prescription drug

a child born in 2019 can expect to take drugs for roughly half their lifetime (48 years for a girl and 37 for a boy)

Depression and Anxiety

major depression is leading cause of disease-related disability among women in world

higher prevalence due to higher risk of first onset, not differential persistence or recurrence

risk emerges in adolescence

World Mental Health

Across various countries, this data shows a consistent gender pattern in mental health where women have a significantly higher risk for mood and anxiety disorders, while men are much more likely to experience externalizing and substance use disorders.

Summary Gender

very large sex differences in disabling and painful conditions (women face higher)

fatal conditions more common among men

Potential Origins of Sex Differences

innate biological factors: reproductive problems account for a small percent

reporting differences: self-rated health

acquired risks: different occupations, income, education, health behaviors, and psychosocial risks

Reporting of Physical Health Problems

men and women generally weigh chronic conditions similarly when evaluating their own health, as most conditions fall along the 45-degree line of equality, though certain issues like depression and hypertension have a slightly stronger negative impact on women's self-rated health than on men's.

Reporting of Mental Health Problems

men are 1.36x more likely than women to say they keep their emotions to themselves

those who report that they keep their emotions to themselves also tend to report more depression

recall bias is still a possibility

Health Behaviors

men workout more than women at all ages

Diet and Cholesterol

women more likely to have higher cholesterol than men at all ages but 20-44

Gender Gap in Smoking

Decline of gender differences in smoking has diminished sex differences in LE

men still higher then women then mothers during pregnancy

Some Counterfactuals

probability of surviving from age 50 to 85: increasing with no smoking for both men and women

Gender Differences in Stress

Women’s choices are more constrained than men’s:

• work family balance

• caregiving expectations

• women in high demand and low control occupations

• women’s health behavior gets worse with long hours

What is stressful for men and women?

social rejection challenge: confederates gradually excluded and socially rejected participants

achievement challenge: participants told that researchers were studying intelligence then given math and verbal tests

Women react more to social rejection challenge, men react more to achievement challenge

Sex, Gender and Nonconformity

• Masculinity is associated with better self-rated health for cisgender men, whereas femininity is associated with better self-rated health for cisgender women.

• People who report that they are seen as gender nonconforming report worse health, but only when this perception does not match their own gender identification.

Gender and Health Care System

epidemiologists regularly disregard system-level, yet physician behavior is important and reflects systemic factors

Physician Bias in CHD

one in two women will die of heart disease, one in nine will die of breast cancer

the protective effects of estrogen are accepted as fact, but the risk of heart disease, expressed as mortality, does not exhibit a bump

Myocardial Infarctions Go Unrecognized

more silent cases of MI among women

especially pronounced disjuncture at younger ages, when estrogen is presumed to be protective

An Experiment

Even when all symptoms are exactly the same, physicians see cardiac conditions less in younger women

Another Experiment

studies 256 doctors who watched videotapes of patient who presents all symptoms of CHD

men are given more tests, even though physicians are less confident about diagnosis among women

Women getting one less test than men - men given more tests