Lebrun LA, LaVeist TA. Black/White Racial Disparities in Health: A Cross-Country Comparison of Canada and the United States. Arch Intern Med. 2011;171(17):1591-1593. doi:10.1001/archinternmed.2011.408
Author Affiliations: Department of Health Policy, Bloomberg School of Public Health (Drs Lebrun and LaVeist) and Hopkins Center for Health Disparities Solutions (Dr LaVeist), Johns Hopkins University, Baltimore, Maryland.
Research on health disparities in the United States has consistently reported poorer health outcomes among racial/ethnic minorities relative to whites, particularly among African Americans.1,2 In Canada, there are limited studies on racial/ethnic groups, presumably because of concerns about small samples, confidentiality, and an emphasis on socioeconomic inequalities.3 The body of literature regarding black Canadians, which compose 2.5% of the nation, is beginning to emerge.
The existing literature indicates that the burden of disease may be greater for black Canadians compared with their white counterparts, and that black Canadians face a number of barriers to achieving good health, including poverty, difficulty accessing health care, discrimination, and poor health behaviors.4- 8
We obtained nationally representative estimates of health indicators among native-born black Canadians, and compared these estimates with those of native-born white Canadians. We replicated the analyses using a US sample of African Americans and white Americans to compare racial disparities in health in Canada vs the United States.
Individual-level data came from the Canadian Community Health Survey (CCHS) and the National Health Interview Survey (NHIS). For both data sets, we pooled data from 4 survey cycles (2003-2008) into a single sample to increase sample size. Analyses in both countries were limited to native-born adults to isolate the effect of race from that of nativity. Final sample sizes were 729 blacks and 280 672 whites (CCHS) and 14 211 blacks and 64 625 whites (NHIS).
Outcomes included smoking status, body mass index (BMI), general health status, and various chronic conditions (ie, asthma, hypertension, diabetes, heart disease, cancer). Self-reported race was categorized as black vs white (respondents reporting multiple races were excluded). Sociodemographic characteristics were considered as covariates, including age, sex, marital status, education, annual household income, employment status, and health insurance coverage status (in the United States).
We compared health outcomes across black and white respondents in each country. Logistic regressions assessed associations between race and health outcomes. Estimates were adjusted for various sociodemographic factors. Sampling weights were incorporated to account for complex sampling. Adjustments were made for multiple comparisons, with P < .01 considered statistically significant.
In Canada, native-born whites had higher rates of current (25%) or former smoking (45%), while native-born blacks had higher rates of smoking abstinence (52%; P < .001). Whites had higher rates of hypertension (21% vs 9%), diabetes (6% vs 2%), heart disease (5% vs 0.6%), and cancer (6% vs 1%) compared with blacks (P < .001 for all).
In the United States, blacks had higher rates of never smoking than whites (63% vs 53%; P < .001) but also higher rates of obesity (34% vs 24%; P < .001) and lower rates of excellent/very good health status (52% vs 64%; P < .001). Blacks had higher rates of asthma (9% vs 8%), hypertension (35% vs 28%), and diabetes (11% vs 8%) but lower rates of heart disease (6% vs 9%) and cancer (4% vs 9%) compared with whites (P < .001 for all).
The Table provides results of logistic regression models. In adjusted analyses for Canada, blacks had lower odds of current or former smoking, heart disease, or cancer compared with whites. In the United States, blacks had higher adjusted odds of obesity, hypertension, diabetes, and fair/poor health relative to whites. Blacks had better outcomes than whites for current smoking, former smoking, heart disease, and cancer.
Native-born black Canadians generally reported comparable or better health outcomes than their white counterparts in contrast to the findings in the United States, where African Americans fared worse than white Americans on many health indicators.
The study had several limitations. Multiple cycles of the CCHS were pooled to produce larger samples of native-born blacks, yet despite these efforts the sample remained small, raising questions concerning generalizability. This study also examined self-reported responses rather than medical records. Recall bias is possible if blacks and whites remembered or perceived their health differently.
Another consideration is the diverging country histories: a much larger proportion of the black population in Canada comes from recent immigration flows, compared with the black population in the United States, which predominantly consists of multiple generations dating back to slavery. The United States has a long history of slavery, which was much more limited in Canada. Thus, African Americans faced a dramatically more disadvantaged social and economic trajectory compared with Canadian counterparts. These differences might contribute to our findings. Finally, there were important sociodemographic differences in the black populations across Canada and the US black Canadians were younger, had higher education and income, and were more frequently employed compared with African Americans (results not shown). And of course, Canada provides universal health coverage while the US health care system is fragmented and employment based, leaving many individuals uninsured. Our adjusted analyses may not have adequately accounted for these differences, which might explain some of the disparate health findings across countries.
Correspondence: Dr LaVeist, Hopkins Center for Health Disparities Solutions, Johns Hopkins University, 624 N Broadway, Room 441, Baltimore, MD 21205 (firstname.lastname@example.org).
Author Contributions: Dr Lebrun had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Lebrun and LaVeist. Acquisition of data: Lebrun. Analysis and interpretation of data: Lebrun and LaVeist. Drafting of the manuscript: Lebrun and LaVeist. Critical revision of the manuscript for important intellectual content: Lebrun and LaVeist. Administrative, technical, and material support: Lebrun and LaVeist. Study supervision: Lebrun and LaVeist. Ethical committee review: Lebrun.
Financial Disclosure: None reported.
Funding/Support: Funding for this study was provided by the National Center on Minority Health and Health Disparities, National Institutes of Health.
Disclaimer: While the research and analysis are based on data from Statistics Canada and the National Center for Health Statistics, the opinions expressed do not represent the views of either of these organizations.
Previous Presentations: Preliminary findings from this study were previously presented at the American Public Health Association annual meeting, November 8, 2010, Denver Colorado; Academy for Health Equity conference, August 18, 2010, Littleton, Colorado; and the Canadian Public Health Association conference, June 13, 2010, Toronto, Ontario, Canada.
Additional Contributions: This analysis is based on Statistics Canada's Canadian Community Health Survey Microdata File, which contains “anonymized” data collected in the 2003, 2005, 2007, and 2008 CCHS, as well as the Centers for Disease Control and Prevention, National Center for Health Statistics' NHIS datasets from the same years.