1. Continuity of Change: Where We Have Come From, Where We Are Going New Orleans, LA June 5 th – June 9 th, 2011 Bruce Cohen, Malena Hood, and James K. West Massachusetts Department of Public Health Division of Research and Epidemiology Vitals Ethnicity Data: A New Approach to Disparities Research

2. Continuity of Change: Where We Have Come From, Where We Are Going New Orleans, LA June 5 th – June 9 th, 2011 Outline The added value of ethnicity for understanding disparities Examples from natality data Examples from mortality data Analytic issues Concluding thoughts

3. Continuity of Change: Where We Have Come From, Where We Are Going New Orleans, LA June 5 th – June 9 th, 2011 Race: group or groups that an individual identifies with because they share similar physical characteristics or social and geographic origins. Ethnicity: a person’s background, heritage, culture, ancestry, country of birth Basic concepts

4. Continuity of Change: Where We Have Come From, Where We Are Going New Orleans, LA June 5 th – June 9 th, 2011 OF RACE can be used to monitor discrimination yields more stable rates (has denominators) adheres to OMB standard more routinely collected OF ETHNICITY better understood less context dependent more useful for program targeting and development improved sensitivity to linguistic needs added insight into acculturation Added value of each …

5. Continuity of Change: Where We Have Come From, Where We Are Going New Orleans, LA June 5 th – June 9 th, 2011 WITH RACE changing over time not clearly understood conceptually context dependent heterogeneity within groups used as proxy WITH ETHNICITY lack of denominators for population based rates small numbers for analysis requires more complex data collection geographic variability Concerns …

6. Continuity of Change: Where We Have Come From, Where We Are Going New Orleans, LA June 5 th – June 9 th, 2011 Advantages Client-centered care target interventions monitor demographic change health status monitoring Disadvantages expanded IT efforts moves beyond Federal minimum standards lack of denominator data for calculating rates increases data collector and respondent burden Collecting both …

7. Continuity of Change: Where We Have Come From, Where We Are Going New Orleans, LA June 5 th – June 9 th, 2011 Ethnicity in Births

8. Continuity of Change: Where We Have Come From, Where We Are Going New Orleans, LA June 5 th – June 9 th, 2011 Ethnicity Variables in Massachusetts Birth Data Hispanic ethnicity Mother’s ancestry Father’s ancestry Infant’s ancestry is based on the mother’s race and ethnicity as indicated on the birth certificate

9. Continuity of Change: Where We Have Come From, Where We Are Going New Orleans, LA June 5 th – June 9 th, 2011 Massachusetts Births – Parent Worksheet MOTHER'S RACE (Please mark the one category that best describes the mother's race): 1 □ White 2 □ Black 3 □ Asian/Pacific Islander 4 □ American Indian 5 □ Other (specify):_____________________ Parent’s Worksheet – Race Question

10. Continuity of Change: Where We Have Come From, Where We Are Going New Orleans, LA June 5 th – June 9 th, 2011 Parent’s Worksheet – Ancestry Question MOTHER'S ANCESTRY Please mark the one category that best describes the mother's ancestry or ethnic heritage: HISPANIC/LATINA 1 □ Puerto Rican 2 □ Dominican 3 □ Mexican 4 □ Cuban 5 □ Colombian 6 □ Salvadoran 7 □ Other Central American (specify):_____ 8 □ Other South American (specify):_____ 9 □ Other Hispanic/Latina (specify):______ ASIAN/PACIFIC ISLANDER 10 □ Chinese 11 □ Vietnamese 12 □ Cambodian 13 □ Asian Indian 14 □ Korean 15 □ Filipino 16 □ Japanese 17 □ Laotian 18 □ Pakistani 19 □ Thai 20 □ Hawaiian 21 □ Other Asian/Pacific Islander (specify):____ PORTUGUESE SPEAKING 22 □ Cape Verdean 23 □ Brazilian 24 □ Other Portuguese (specify):_________ WEST INDIAN/CARIBBEAN ISLANDER 25 □ Haitian 26 □ Jamaican 27 □ Barbadian 28 □ Other West Indian/Caribbean Islander (specify):_____ AFRICAN/AFRICAN AMERICAN 29 □ African-American/ Afro-American 30 □ Nigerian 31 □ Other African (specify):__________ MIDDLE EASTERN 32 □ Lebanese 33 □ Iranian 34 □ Israeli 35 □ Other Middle Eastern (specify):_____ AMERICAN ANCESTRY 36 □ Native American/ American Indian (specify tribe/affiliation): ____________________ 37 □ American EUROPEAN and OTHER ancestries 38 □ European (specify):______________ 39 □ Other (specify):_________________

11. Continuity of Change: Where We Have Come From, Where We Are Going New Orleans, LA June 5 th – June 9 th, 2011 Cesarean Delivery by Race and Ethnicity, Massachusetts: 2008 * Statistically different from state rate (p<0.05)

12. Continuity of Change: Where We Have Come From, Where We Are Going New Orleans, LA June 5 th – June 9 th, 2011 Cesarean Delivery by Ethnicity Massachusetts: 2008 * Statistically different from state rate (p<0.05)

13. Continuity of Change: Where We Have Come From, Where We Are Going New Orleans, LA June 5 th – June 9 th, 2011 Gestational Diabetes by Race and Ethnicity, Massachusetts: 2008 * Statistically different from state rate (p<0.05)

14. Continuity of Change: Where We Have Come From, Where We Are Going New Orleans, LA June 5 th – June 9 th, 2011 Gestational Diabetes by Ethnicity Massachusetts: 2008 * Statistically different from state rate (p<0.05)

15. Continuity of Change: Where We Have Come From, Where We Are Going New Orleans, LA June 5 th – June 9 th, 2011 Gestational Diabetes Mellitus (GDM) and Asian Indian Births Massachusetts: 2000-2008

16. Continuity of Change: Where We Have Come From, Where We Are Going New Orleans, LA June 5 th – June 9 th, 2011 Low Birthweight by Race and Ethnicity, Massachusetts: 2008 * Statistically different from state rate (p<0.05)

17. Continuity of Change: Where We Have Come From, Where We Are Going New Orleans, LA June 5 th – June 9 th, 2011 Low Birthweight Infants by Ethnicity Massachusetts: 2008 * Statistically different from state rate (p<0.05)

18. Continuity of Change: Where We Have Come From, Where We Are Going New Orleans, LA June 5 th – June 9 th, 2011 Breastfeeding by Race and Ethnicity Massachusetts: 2008 * Statistically different from state rate (p<0.05)

19. Continuity of Change: Where We Have Come From, Where We Are Going New Orleans, LA June 5 th – June 9 th, 2011 Breastfeeding by Ethnicity Massachusetts: 2008 * Statistically different from state rate (p<0.05)

20. Continuity of Change: Where We Have Come From, Where We Are Going New Orleans, LA June 5 th – June 9 th, 2011 Smoking During Pregnancy by Race and Ethnicity, Massachusetts: 2008 * Statistically different from state rate (p<0.05)

21. Continuity of Change: Where We Have Come From, Where We Are Going New Orleans, LA June 5 th – June 9 th, 2011 Smoking During Pregnancy by Ethnicity, Massachusetts: 2008 * Statistically different from state rate (p<0.05)

22. Continuity of Change: Where We Have Come From, Where We Are Going New Orleans, LA June 5 th – June 9 th, 2011 Ethnicity in Deaths

23. Continuity of Change: Where We Have Come From, Where We Are Going New Orleans, LA June 5 th – June 9 th, 2011 Ethnicity Ascertainment The gold standard, self identification, is not available Ethnicity is supplied by the informant or assumed by the funeral director For research, ethnicity can be ascertained through a combination of variables

24. Continuity of Change: Where We Have Come From, Where We Are Going New Orleans, LA June 5 th – June 9 th, 2011 Variables for Ethnicity Hispanic ethnicity Race Decedent, Father, and Mother’s place of birth

25. Continuity of Change: Where We Have Come From, Where We Are Going New Orleans, LA June 5 th – June 9 th, 2011 Ethnicity - Hispanic ethnicity Hispanic ethnicity codes Puerto Rican Dominican Cuban Other Central American South American Mexican Other and Unknown Hispanic

26. Continuity of Change: Where We Have Come From, Where We Are Going New Orleans, LA June 5 th – June 9 th, 2011 Ethnicity - Race Race codes White Black Indian Chinese Japanese Hawaiian Laotian Vietnamese Thai Cambodian Filipino Other Asian or Pacific Islander Cape Verdean Other Non-White Hispanic N/A

27. Continuity of Change: Where We Have Come From, Where We Are Going New Orleans, LA June 5 th – June 9 th, 2011 Ethnicity – Place of Birth Text fields Country of Birth City of Birth

28. Continuity of Change: Where We Have Come From, Where We Are Going New Orleans, LA June 5 th – June 9 th, 2011 Cape Verdean Deaths (Non-Hispanic) Massachusetts: 2008 Method of Identification (Mutually exclusive)Cape Verdean Deaths Race = 'Cape Verdean'219 Decedent born in CV34 Decedent, Mother, and Father born in CV33 Father born in CV15 Mother born in CV1 Decedent and Father born in CV1 Total303

29. Continuity of Change: Where We Have Come From, Where We Are Going New Orleans, LA June 5 th – June 9 th, 2011 Chinese Deaths Massachusetts: 2008 Method of Identification (Mutually exclusive)Chinese Deaths Race = ‘ Chinese' 303 Decedent, Mother, and Father born in China32 Mother and Father born in China8 Decedent born in China7 Decedent and Mother born in China1 Total351

30. Continuity of Change: Where We Have Come From, Where We Are Going New Orleans, LA June 5 th – June 9 th, 2011 Brazilian Deaths Massachusetts: 2008 Method of Identification (Mutually exclusive)Brazilian Deaths Race/Ethnicity = ‘ Brazilian' 0 Decedent, Mother, and Father born in Brazil58 Mother and Father born in Brazil26 Father born in Brazil8 Mother born in Brazil5 Total97

31. Continuity of Change: Where We Have Come From, Where We Are Going New Orleans, LA June 5 th – June 9 th, 2011 Asian Indian Deaths Massachusetts: 2008 Method of Identification (Mutually exclusive) Asian Indian Deaths Race/Ethnicity = ‘ Asian Indian' 0 Decedent, Mother, and Father born in India87 Mother and Father born in India11 Decedent born in India 6 Mother born in India5 Father born in India3 Decedent and Father born in India 1 1 Total114

32. Continuity of Change: Where We Have Come From, Where We Are Going New Orleans, LA June 5 th – June 9 th, 2011 Irish Deaths Massachusetts: 2008 Method of Identification (Mutually exclusive)Irish Deaths Race/Ethnicity = ‘ Irish' 0 Mother and Father born in Ireland 1,583 Mother born in Ireland 448 Father born in Ireland 302 Decedent, Mother, and Father born in Ireland 289 Decedent and Father born in Ireland 4 Decedent born in Ireland 1 Decedent and Mother born in Ireland 1 Total2,628 Note: 9 decedents were born in Northern Ireland and are not included

33. Continuity of Change: Where We Have Come From, Where We Are Going New Orleans, LA June 5 th – June 9 th, 2011 Puerto Rican Deaths Massachusetts: 2008 Method of Identification (Mutually exclusive) Puerto Rican Deaths Race/Ethnicity = ‘ Puerto Rican' 831 Mother born in Puerto Rico 7 Mother and Father born in Puerto Rico 6 Father born in Puerto Rico 5 Decedent born in Puerto Rico 3 Decedent, Mother, and Father born in Puerto Rico 3 Total 855

34. Continuity of Change: Where We Have Come From, Where We Are Going New Orleans, LA June 5 th – June 9 th, 2011 Analytic Issues

35. Continuity of Change: Where We Have Come From, Where We Are Going New Orleans, LA June 5 th – June 9 th, 2011 How to Use Ethnicity Data? Exploring better denominators from American Community Survey and other data sources Descriptive: numerator-based and proportion of population measures Analytic: numerator-based Standardized odds ratios

36. Continuity of Change: Where We Have Come From, Where We Are Going New Orleans, LA June 5 th – June 9 th, 2011 Standardized Mortality Odds Ratio (SMOR) Often used to study cause specific mortality when population denominators are not available. To estimate an SMOR, one first computes the ratio of deaths from cause A (the cause of interest) to the deaths from cause B (the "control" cause of death) in an exposed sample. This ratio is then compared with an analogous ratio from a standard population.

37. Continuity of Change: Where We Have Come From, Where We Are Going New Orleans, LA June 5 th – June 9 th, 2011 Standardized Mortality Odds Ratio (SMOR) Population of Interest Deaths of all others Injury Deaths ab Non- Injury Deaths cd X 100 SMOR = a b c d

38. Continuity of Change: Where We Have Come From, Where We Are Going New Orleans, LA June 5 th – June 9 th, 2011 Example: Standardized Mortality Odds Ratio (SMOR) Chinese Deaths Deaths of all others ethnicity groups Injury Deaths 202,800 Non- Injury Deaths 33150,190 X 100 a (20) b (2,800) * c (331) d (50,190) = 20 * 50,190 331 * 2,800 = SMOR[Chinese] =108.3

39. Continuity of Change: Where We Have Come From, Where We Are Going New Orleans, LA June 5 th – June 9 th, 2011 Injury Deaths by Race and Ethnicity Massachusetts: 2008 Ethnicity GroupAll Deaths Injury Deaths SMOR ‘American’ White (White Non-Hispanic and Decedent, Mother, AND Father born in US) 23,2811,566165.7 Irish2,62857 38.5* Chinese35120 108.3* Cape Verdean30322140.6 Brazilians9711229.7 Puerto Rican855103 250.9* ‘American’ Black (Black non- Hispanic and Decedent, Mother, AND Father born in US) 1,205115192.8 * Statistically different from White non-Hispanic rate (p<0.05)

40. Continuity of Change: Where We Have Come From, Where We Are Going New Orleans, LA June 5 th – June 9 th, 2011 Cancer Deaths by Race and Ethnicity Massachusetts: 2008 Ethnicity GroupAll Deaths Cancer Deaths SMOR ‘American’ White (White Non-Hispanic and Decedent, Mother, AND Father born in US) 23,2816,401134.9 Irish 2,628535 78.5* Chinese 351119159.8 Cape Verdean 30366 86.4* Brazilians 9718 70.7* Puerto Rican855181 83.1* ‘American’ Black (Black non-Hispanic and Decedent, Mother, AND Father born in US) 1,205308 106.8* * Statistically different from White non-Hispanic rate (p<0.05)

41. Continuity of Change: Where We Have Come From, Where We Are Going New Orleans, LA June 5 th – June 9 th, 2011 Race and Ethnicity by Age Group Massachusetts Deaths: 2008 Age Group ‘Am.’ White IrishChineseCape Verdean BrazilianPuerto Rican ‘Am.’ Black <1135357105528 1-2426735934142 25-646,793114646834410480 65+16,0862,50727721950349655 Age Group WhiteIrishChineseCape Verdean BrazilianPuerto Rican Black < 252%0.2%3%5%13%11%6% 65+69%95%79%72%52%41%54%

42. Continuity of Change: Where We Have Come From, Where We Are Going New Orleans, LA June 5 th – June 9 th, 2011 Injury Deaths by Race and Ethnicity Persons <= 65 Years Massachusetts: 2008 Ethnicity GroupAll Deaths Injury Deaths SMOR ‘American’ White (White Non-Hispanic and Decedent, Mother, AND Father born in US) 7,4671,22785.2 Irish1351664.4 Chinese731076.2 Cape Verdean8016120.4 Brazilians389149.5 Puerto Rican46293122.3* ‘American’ Black (Black non-Hispanic and Decedent, Mother, AND Father born in US) 550105114.3* * Statistically different from White non-Hispanic rate (p<0.05)

43. Continuity of Change: Where We Have Come From, Where We Are Going New Orleans, LA June 5 th – June 9 th, 2011 Cancer Deaths by Race and Ethnicity Persons <= 65 Years Massachusetts: 2008 Ethnicity GroupAll Deaths Cancer Deaths SMOR ‘American’ White (White Non-Hispanic and Decedent, Mother, AND Father born in US) 7,467 2,469144.2 Irish135 50134.4 Chinese73 37235.4 Cape Verdean80 2497.5 Brazilians38 970.6 Puerto Rican4629960.9* ‘American’ Black (Black non- Hispanic and Decedent, Mother, AND Father born in US) 55012968.6* * Statistically different from White non-Hispanic rate (p<0.05)

44. Continuity of Change: Where We Have Come From, Where We Are Going New Orleans, LA June 5 th – June 9 th, 2011 Concluding Thoughts

45. Continuity of Change: Where We Have Come From, Where We Are Going New Orleans, LA June 5 th – June 9 th, 2011 New Mother/Parent Ethnicity

46. Continuity of Change: Where We Have Come From, Where We Are Going New Orleans, LA June 5 th – June 9 th, 2011 NewMother/Parent Race

47. Continuity of Change: Where We Have Come From, Where We Are Going New Orleans, LA June 5 th – June 9 th, 2011 Concluding Thoughts Increased diversity in population requires more thoughtful use of data to monitor disparities and target public health programs-ethnicity can do this. Vitals data are a superb source to provide the needed information Key 1: Training data collectors to ascertain quality information Key 2: Collaboration among Vitals, analysts, and policy makers to develop and use data to address disparities Use what you collect

48. Continuity of Change: Where We Have Come From, Where We Are Going New Orleans, LA June 5 th – June 9 th, 2011 Questions  Contacts:  Bruce Cohen: Bruce.Cohen@state.ma.usBruce.Cohen@state.ma.us  To access data via MassCHIP (DPH ’ s Internet based public health information service): Website: http://masschip.state.ma.us Telephone: 1-888-MASCHIP (Mass only (617) 624-5629

49. Continuity of Change: Where We Have Come From, Where We Are Going New Orleans, LA June 5 th – June 9 th, 2011

50. Continuity of Change: Where We Have Come From, Where We Are Going New Orleans, LA June 5 th – June 9 th, 2011 Additional Slides

51. Continuity of Change: Where We Have Come From, Where We Are Going New Orleans, LA June 5 th – June 9 th, 2011 REFERENCE ONLY: Calculating Confidence Intervals for the SMOR