The Continuing Practice and Impact of Discrimination

This chapter provides a detailed discussion of the evidence on housing and mortgage lending discrimination, as well as the potential impacts of such discrimination on minority outcomes like homeownership and neighborhood environment. The paper begins by discussing conceptual issues surrounding empirical analyses of discrimination including explanations for why discrimination takes place, defining different forms of discrimination, and the appropriate interpretation of observed racial and ethnic differences in treatment or outcomes. Next, the paper reviews evidence on housing market discrimination starting with evidence of segregation and price differences in the housing market and followed by direct evidence of discrimination by real estate agents in paired testing studies. Finally, mortgage market discrimination and barriers in access to mortgage credit are discussed. This discussion begins with an assessment of the role credit barriers play in explaining racial and ethnic differences in homeownership and follows with discussions of analyses of underwriting and the price of credit based on administrative and private sector data sources including analyses of the subprime market. The paper concludes that housing discrimination has declined especially in the market for owner-occupied housing and does not appear to play a large role in limiting the neighborhood choices of minority households or the concentration of minorities into central cities. On the other hand, the patterns of racial centralization and lower home ownership rates of African-Americans appear to be related to each other, and lower minority homeownership rates are in part attributable to barriers in the market for mortgage credit. The paper presents considerable evidence of racial and ethnic differences in mortgage underwriting, as well as additional evidence suggesting these differences may be attributable to differential provision of coaching, assistance, and support by loan officers. At this point, innovation in loan products, the shift towards risk based pricing, and growth of the subprime market have not mitigated the role credit barriers play in explaining racial and ethnic differences in homeownership. Further, the growth of the subprime lending industry appears to have segmented the mortgage market in terms of geography leading to increased costs of relying on local/neighborhood sources of mortgage credit and affecting the integrity of many low-income minority neighborhoods through increased foreclosure rates.

Dysregulation of alternative splicing of coagulation factor V results in bleeding disorder, east Texas type and other disorders of hemostasis

The studies completed herein explore different phenotypes related to the genetic defects that predispose individuals to a disruption of normal hemostasis. In the first study, a novel autosomal dominant bleeding disorder, which is characterized by excessive bleeding with trauma or surgery and menorrhagia in affected women, was studied in a large family (16 affected individuals) from east Texas. Affected members had a prolongation of their PT and/or aPTT, but normal clinical coagulation studies. Previous linkage analysis by Kuang et. al. (2001) mapped the defective gene to 1g23-24 (LODmax 7.22), which contains the gene for coagulation factor V (FV). I identified an alteration (A2440G) in the FV gene in exon 13 that segregated with the disease and was not present in 62 controls. Interestingly, this alteration resulted in a 22-fold up-regulation of a novel alternative splicing variant in patients' RNA versus controls. This translated into a similar fold increase in a 250-kDa isoform of FV seen in patients' plasma versus controls. A recombinant of this splicing event exhibited an increased sensitivity to cleavage by activated protein C (APC) that was more striking in the presence of PS. In addition, this novel isoform had increased APC cofactor activity, thus increasing the degradation of FVIIIa. These data indicated that A2440G up-regulates an alternatively spliced transcript of FV, and increases a FV isoform that hinders coagulation as opposed to promoting it like its wild-type counterpart. ^ The second study reports the largest screening to date of African Americans in two independent cohorts for a rare prothrombin variant, C20209T, which is suspected to be associated with thrombotic disease. The Texas Medical Center Genetics Resource (TexGen) Stroke DNA repository revealed 1.67% (Fisher p=0.27) of African American stroke patients were heterozygous for the 20209*T allele. Screening of the Atherosclerosis Risk in Communities Study (ARIC) cohort (n=3470) for the 20209*T allele revealed a population prevalence of 0.58% in individuals of African American descent; however, all associations with thrombotic disease were negative. Analysis of these two independent cohorts revealed that, unlike its neighbor G20210A, the C20209T variant does not increase the risk of thrombotic events in the African American population. ^

Interventions to reduce sexual risk behavior in African American men

The purpose of this review was to describe characteristics of interventions that have been conducted for African American men and identify similarities and differences between interventions for subpopulations of African American men. Of the 473 studies identified through database searching, 8 studies met the eligibility criteria for this review. Target populations within these studies included heterosexual men, homosexual and bisexual men, persons with mental health problems, and injection and non-injection drug users. Little variation was found in the theories and methods used in interventions for different target populations. However, several different behavioral determinants were addressed within these interventions. Although interventions for drug users generally did not exclude individuals based on sexual orientation, these interventions were able to address HIV sexual risk behavior in heterosexual, homosexual, and bisexual-identified men. Given these findings, multi-faceted approaches to HIV prevention are recommended in order to reduce HIV risk in African American men.^

Cultural competence in an HIV dedicated dental clinic: Application of the National Standards for Culturally and Linguistically Appropriate Services in Health Care (CLAS)

This dissertation investigated perspectives on cultural competence among African-American women patients, staff, and the administrator of a dental clinic serving people living with HIV/AIDS; and evaluated the role of the National Standards for Culturally and Linguistically Appropriate Services in Health Care (CLAS) in advancing the provision of culturally competent care in the clinic. ^ The study was qualitative with data collection via focus groups and individual interviews with a sample of African-American women patients, and individual interviews with a sample of staff and the clinic administrator. Transcripts were coded and themes identified using the software program ATLAS.ti. A cultural audit template was developed and applied to evaluate cultural competency. ^ Among attitudes and behaviors that contributed to the provision of culturally competent care at the clinic were respect and empathic communication. Formal cultural competency was not featured strongly in the methods by which the staff learned to work with diverse populations. Instead cultural competence among the staff was based on thoughtful hiring practices, natural aptitude and a climate that encouraged learning through informal sharing of experiences. The staff and administrator felt that an African-American dentist would be an asset in improving culturally competent care at the clinic. Previous research and national policy also promote the provider-patient racial/ethnic concordance to improve care. In this study, however, the patients were happy with the care provided regardless of the race/ethnicity of the staff, probably reflecting the well developed cultural competence skills of clinic staff overall. ^ The clinic administrator was unaware of the CLAS standards although the clinic was implicitly operated under their mandates. This occurred because the clinic is supported by federal funding and the CLAS standards were incorporated into the requirements. Incorporation into and monitoring of the CLAS standards in federally funded programs therefore appears to be an effective means for ensuring that they are implemented. ^ This study illustrates that cultural competence, though not universally understood, can be systematically investigated to identify what constitutes appropriate care and the factors that support or inhibit it. Among important elements of culturally competent care are respect and empathic communication. ^

Exploring parents' memories of their child's death related sensory experiences as a dimension of grieving

Little is known about how dying children and their parents experience death. Dying children have reported death related sensory experiences (DRSEs), defined as seeing or hearing someone or something not visible or audible to others, associated with dying. Although parents report that they and the dying child benefit from these experiences, healthcare providers often unknowingly dismiss them. The aims of this phenomenological inquiry were to describe children's DRSEs and their meaning from the parents' perspectives. Four fathers and six mothers of African American, Caucasian, or Hispanic ethnicity, all Christian, ranging in age from 35 to 59 years, whose child died 23 to 52 months prior and was treated at a children's cancer center, were interviewed in the home or hospital setting of their choice. Children's ages at the time of their death ranged from 4 to 13 years. A modification of van Kaarn's phenomenological method of analysis was used to analyze data. Themes emerging from the data for the first aim were: perceiving someone or something from a spiritual realm others could not, expressing awareness tempered by parental reactions, and embracing transcendence. Themes emerging from the data for the second aim were: spiritual beings prepared child; child revealed reality, preparing parents; and child transcended wholly, easing parents' grief. Post-interview surveys revealed that parents found participating in this study a "very positive" or "positive" experience, particularly being able to tell the story of their child. Children's DRSEs have clinical implications for all who provide care near the end of life. Informing parents of DRSEs, cautioning that not all dying children express them, may help parents to anticipate this phenomenon, which may decrease anxiety when their child expresses them, increasing the opportunity for open dialogue between parent and child about dying and death, and decrease regrets associated with being unreceptive to their child's expressions of death awareness. Validating a child's DRSE can have profound effects on bereaved parents. Examining DRSEs from the child's perspective and the influence of informing parents of DRSEs on the dying experience of the child and the parental grieving process are recommended. ^

Correlation between dental care utilization and oral cavity cancer in a large sample of community-based United States residents

Cancer of the oral cavity and pharynx remains one of the ten leading causes of cancer death in the United States (US). Besides smoking and alcohol consumption, there are no well established risk factors. While poor dental care had been implicated, it is unknown if the lack of dental care, implying poor dental hygiene predisposes to oral cavity cancer. This study aimed to assess the relationship between dental care utilization during the past twelve months and the prevalence of oral cavity cancer. A cross-sectional design of the National Health Interview Survey of adult, non-institutionalized US residents (n=30,475) was used to assess the association between dental care utilization and self reported diagnosis of oral cavity cancer. Chi square statistic was used to examine the crude association between the predictor variable, dental care utilization and other covariates, while unconditional logistic regression was used to assess the relationship between oral cavity cancer and dental care utilization. There were statistically significant differences between those who utilized dental care during the past twelve months and those who did not with respect to education, income, age, marital status, and gender (p < 0.05), but not health insurance coverage (p = 0.53). Also, those who utilized dental care relative to those who did not were 65% less likely to present with oral cavity cancer, prevalence odds ratio (POR), 0.35, 95% Confidence Interval (CI), 0.12–0.98. Further, higher income advanced age, people of African heritage, and unmarried status were statistically significantly associated with oral cavity cancer, (p < 0.05), but health insurance coverage, alcohol use and smoking were not, p > 0.05. However, after simultaneously controlling for the relevant covariates, the association between dental care and oral cavity cancer did not attenuate nor persist. Thus, compared with those who did not use dental care, those who did wee 62% less likely to present with oral cavity cancer adjusted POR, 0.38, 95% CI, 0.13-1.10. Among US adults residing in community settings, use of dental care during the past twelve months did not significantly reduce the predisposition to oral cavity cancer. However, due to the nature of the data used in this study, which restricts temporal sequence, a large sample prospective study that may identify modifiable factors associated with oral cancer development namely poor dental care, is needed. ^

Effectiveness of dietary intervention in children and adolescents with elevated blood pressure

Hypertension is a known risk factor for cardiovascular disease in adults. Essential hypertension in children and adolescents is increasing in prevalence in the United States, and hypertension in children may track into adulthood. This increasing prevalence is attributed to the trends of increasing overweight and obese children and adolescents. Family history and being of African-American/black descent may predispose youth to elevated blood pressure. Interventions targeted to reduce and treat hypertension in youth include non-pharmaceutical interventions such as weight reduction, increased physical activity, and dietary changes and pharmaceutical treatment when indicated. The effectiveness of non-pharmaceutical interventions is well documented in adults, but there are limited studies with regards to children and adolescents, specifically in the arena of dietary interventions. Lifestyle modifications such as dietary interventions are the mainstay of recommended treatment for those children and adolescents with prehypertension or stage 1 hypertension. Given the association of being overweight and hypertension, efficacy of dietary interventions are of interest because of reduced cost, easy implementation and potential for multiple beneficial outcomes such as reduced weight and reduction of other metabolic or cardiovascular derangements. Barriers to dietary interventions often include socioeconomic status, ethnicity, personal, and external factors. The goal of this systematic review of the literature is to identify interventions targeted to children and adolescents that focus on recommended dietary changes related to blood pressure. Dietary interventions found for this review mostly focused on a particular nutrient or food group with the one notable exception that focused on the DASH pattern of eating. The effects of the interventions on blood pressure varied, but overall dietary modifications can be achieved in youth and can serve a role in producing positive outcomes on blood pressure. Increasing potassium and following a DASH diet seemed to provide the most clinically significant results. Further studies are still needed to evaluate long-term effectiveness and to contribute more supporting evidence for particular modifications in these age cohorts.^

Spatial analysis of cardiovascular disease mortality and air pollution in Harris County, Texas

The association between fine particulate matter air pollution (PM2.5) and cardiovascular disease (CVD) mortality was spatially analyzed for Harris County, Texas, at the census tract level. The objective was to assess how increased PM2.5 exposure related to CVD mortality in this area while controlling for race, income, education, and age. An estimated exposure raster was created for Harris County using Kriging to estimate the PM2.5 exposure at the census tract level. The PM2.5 exposure and the CVD mortality rates were analyzed in an Ordinary Least Squares (OLS) regression model and the residuals were subsequently assessed for spatial autocorrelation. Race, median household income, and age were all found to be significant (p<0.05) predictors in the model. This study found that for every one μg/m3 increase in PM2.5 exposure, holding age and education variables constant, an increase of 16.57 CVD deaths per 100,000 would be predicted for increased minimum exposure values and an increase of 14.47 CVD deaths per 100,000 would be predicted for increased maximum exposure values. This finding supports previous studies associating PM2.5 exposure with CVD mortality. This study further identified the areas of greatest PM2.5 exposure in Harris County as being the geographical locations of populations with the highest risk of CVD (i.e., predominantly older, low-income populations with a predominance of African Americans). The magnitude of the effect of PM2.5 exposure on CVD mortality rates in the study region indicates a need for further community-level studies in Harris County, and suggests that reducing excess PM2.5 exposure would reduce CVD mortality.^

Changes in sexual behaviors associated with crack cocaine cessation among African Americans in Houston, Texas

Aim To examine the association between the crack cocaine cessation and risky sexual behaviors. Design and setting Between June 2002 and March 2005, a sample of African-American residents of Houston, Texas who were using crack at the time of enrollment participated in a cohort study to evaluate per outreach interventions to reduce HIV risk behaviors. The sample for this study consisted of 351 women and men who completed structured surveys at baseline and at six months about socio-demographic characteristics, drug use, and sexual behaviors. Multivariate logistic regression was used to analyze the association between crack cessation and risky sexual behaviors at follow-up, while controlling for confounding characteristics. Measurements Crack cessation was defined as reporting no crack use in the 30 days prior to the follow-up interview. Possible associated factors included unprotected sex, having multiple sex partners, trading sex for money/drugs, crack use, and socio-demographic variables. Findings At the six-month follow-up interview, 21% of participants reported that they had not used crack in the previous 30 days. For women, crack cessation was significantly associated with having only one sex partner at follow-up; for men, crack cessation was significantly associated with being single, separated, or divorced at baseline, having only one sex partner at follow-up, and initiating protected sex by follow-up. Conclusion These findings support previous research indicating that crack use is associated with unprotected sex and multiple sexual partners, as men and women who ceased crack use were less likely to engage in these risky sexual behaviors. Findings demonstrate that treatment for crack use could have a meaningful effect on risky sexual behaviors and HIV/STI prevention.^

Preserving Family: Themes from a Qualitative Study of Kin Caregivers

This article presents themes from a qualitative study of 58 African American female kinship caregivers in San Francisco. Core concepts that emerged describe various paths along which children move into kin homes, and caregivers' mixed emotional reactions to becoming surrogate parents. Women also discussed multiple family roles they assumed after taking in children. Responses highlight three primary reasons for becoming caregivers that center on providing for and protecting these children—particularly from the perceived threat of the public foster care system—and ultimately preserving the family unit. Paradoxically, caregivers' reasons mirror the stated goals of the public foster care system, which they view as a threat to family stability. We discuss the problems of implementing practice and policy recommendations for permanency and family preservation and how to bridge the gap between the deeply held negative beliefs of African American caregivers towards the public system and begin to build trust.

Risk and protective factors associated with depression among racial and ethnic mothers of adolescents

The central paradigm linking disadvantaged social status and mental health has been the social stress model (Horwitz, 1999), the assumption being that individuals residing in lower social status groups are subjected to greater levels of stress not experienced by individuals from higher status groups. A further assumption is that such individuals have fewer resources to cope with stress, in turn leading to higher levels of psychological disorder, including depression (Pearlin, 1989). Despite these key assumptions, there is a dearth of literature comparing the social patterning of stress exposure (Hatch & Dohrenwend, 2007; Meyer, Schwartz, & Frost, 2008; Kessler, Mickelson, & Williams, 1999; Turner & Avison, 2003; Turner & Lloyd, 1999; Turner, Wheaton, & Lloyd, 1995), and the distribution and contribution of protective factors, posited to play a role in the low rates of depression found among African- and Latino-Americans (Alegria et al., 2007; Breslau, Aguilar-Gaxiola, Kendler, Su, Williams, & Kessler, 2006; Breslau, Borges, Hagar, Tancredi, Gilman, 2009; Gavin, Walton, Chae, Alegria, Jackson, & Takeuchi, 2010; Williams, & Neighbors, 2006). Thus, this study sought to describe both the distribution and contribution of risk and protective factors in relation to depression among a sample of African-, European-, and Latina-American mothers of adolescents, including testing a hypothesized mechanism through which social support, an important protective factor specific to women and depression, operates. ^ Despite the finding that the levels of depression were not statistically different across all three groups of women, surprising results were found in describing the distribution of both risk and protective factors, in that results reported among all women who were mothers when analyzed masked differences within each ethnic group when SES was assessed, a point made explicit by Williams (2002) regarding racial and ethnic variations in women's health. In the final analysis, while perceived social support was found to partially mediate the effect of social isolation on depression, among African-Americans, the direct effect of social isolation and depression was lower among this group of women, as was the indirect effect of social isolation and perceived social support when compared to European- and Latina-American mothers. Or, put differently, higher levels of social isolation were not found to be as associated with more depression or lower social support among African-American mothers when compared to their European- and Latina-American counterparts. ^ Women in American society occupy a number of roles, i.e., that of being female, married or single, mother, homemaker or employee. In addition, to these roles, ethnicity and SES also come into play, such that the intersection of all these roles and the social contexts that they occupy are equally important and must be taken into consideration when making predictions drawn from the social stress model. Based on these findings, it appears that the assumptions of the social stress model need to be revisited to include the variety of roles that intersect among individuals from differing social groups. More specifically, among women who are mothers and occupy a myriad of other roles, i.e., that of being female, married or single, African- or Latina-American, mother, homemaker or employee, the intersection of all the roles and the social contexts that women occupy are equally important and must be taken into consideration when looking at both the types and distribution of stressors across women. Predictions based on simple, mutually exclusive categories of social groups may lead to erroneous assumptions and misleading results.^

La presencia de Africa en los Diseños Curriculares de Ciencias Sociales e Historia para el nivel secundario bonaerense

Entendiendo que la construcción de identidad es un proceso relacional, la aproximación al "Otro" -en este caso lo africano- es una forma no sólo de conocimiento de las otras identidades sino, sobre todo, de construcción de la propia identidad. Africa, junto a las comunidades originarias, ha tenido muy poca presencia en la educación formal argentina. Tampoco fue sumada al proceso de construcción de lo que se denominó: "identidad argentina". En consecuencia, ante las nuevas situaciones producto de la globalización, el siguiente artículo analizará la presencia de las sociedades africanas en los actuales Diseños Curriculares de Ciencias Sociales e Historia del nivel secundario de la provincia de Buenos Aires

La presencia de Africa en los Diseños Curriculares de Ciencias Sociales e Historia para el nivel secundario bonaerense

Entendiendo que la construcción de identidad es un proceso relacional, la aproximación al "Otro" -en este caso lo africano- es una forma no sólo de conocimiento de las otras identidades sino, sobre todo, de construcción de la propia identidad. Africa, junto a las comunidades originarias, ha tenido muy poca presencia en la educación formal argentina. Tampoco fue sumada al proceso de construcción de lo que se denominó: "identidad argentina". En consecuencia, ante las nuevas situaciones producto de la globalización, el siguiente artículo analizará la presencia de las sociedades africanas en los actuales Diseños Curriculares de Ciencias Sociales e Historia del nivel secundario de la provincia de Buenos Aires

La presencia de Africa en los Diseños Curriculares de Ciencias Sociales e Historia para el nivel secundario bonaerense

Entendiendo que la construcción de identidad es un proceso relacional, la aproximación al "Otro" -en este caso lo africano- es una forma no sólo de conocimiento de las otras identidades sino, sobre todo, de construcción de la propia identidad. Africa, junto a las comunidades originarias, ha tenido muy poca presencia en la educación formal argentina. Tampoco fue sumada al proceso de construcción de lo que se denominó: "identidad argentina". En consecuencia, ante las nuevas situaciones producto de la globalización, el siguiente artículo analizará la presencia de las sociedades africanas en los actuales Diseños Curriculares de Ciencias Sociales e Historia del nivel secundario de la provincia de Buenos Aires