HSC 4030 – Disparities among minority populations persist

| April 14, 2018

Of disparities and diversity: Where are we?Gloria Sarto, MD, PhD,Show moredoi:10.1016/j.ajog.2004.12.065Get rights and contentThere has been remarkable improvement in the health of women over the past century;however, disparities among minority populations persist. While the reasons for thedisparities, usually poorer health, are many and complex, such disparities areunacceptable. Because the reasons for disparities are multiple and complex, eliminatinghealth disparities will require a multifaceted approach. Increasing research into healthdisparities, biologic, sociologic, and health services research, transforming the healthcare system into a culturally sensitive system, eliminating unequal treatment provided tominority populations, increasing diversity in the health care workforce, and assuring thathealth care providers provide culturally competent health care are needed.Key wordsHealth disparities;Cultural competency;Diversity;Unequal treatment;Women’s healthIn the past century, we experienced a remarkable transformation in the health ofwomen. Life expectancy at the beginning of the century was 47 years, today it is 78years. In the past 50 years, maternal mortality decreased from 73 per 100,000 livebirths in 1950, to 8.8 per 100,000 live births. 1 Infant mortality decreased from 58.1 perthousand live births in 1933, the first year in which all states were included in thecollection of death certificates, to 7.0 per thousand live births in 2002. 2 In spite of theimprovements in the overall health of women, persistent disparities in the health ofracial and ethnic minorities exist.Racial and ethnic disparities in health status have existed for centuries; however, from anational perspective, the poor health status and poor health outcomes experienced byminority populations, especially blacks, was not appreciated until Secretary of Healthand Human Services Margaret Heckler issued the Report of the Task Force on Blackand Minority Health (Malone-Heckler Report) in 1985-1986. 3 Starting in the late 80s andthroughout the 90s, reports were appearing in the literature describing the disparities inhealth status and health outcomes among our minority populations. An example of thisis the higher rates of chronic and disabling illnesses and mortality that minoritypopulations experience when compared with white Americans. The mortality rate forAfrican Americans is about 60% higher than that for whites, essentially unchanged since1950.4,5, 6 and 7 Likewise, attention was brought to the limited access to health services forminority populations. Almost 35% of Hispanic and black individuals in the US have nohealth insurance.8All of this has brought increasing attention to health disparities. To quote Dr DavidSatcher, recognizing that “the health of an individual is almost inseparable from thehealth of a community and …the health of every community in every state and territorydetermines the overall health status of the nation.” David Satcher, MD, PhD, SurgeonGeneral, prompted a national initiative, Healthy People 2010. The goal of this initiative isto eliminate disparities in health status and health outcomes by 2010. 9Reviewing evidence for disparitiesWhen reviewing evidence for disparities in health outcomes among minority populationsand making comparisons over time, several caveats have to be considered.First, to accurately explore health status and health outcomes among minoritypopulations requires that data collection be impeccable and analyses consistent. Hereinlies a problem.While the race of the population has been collected in every decennial beginning withthe first US census in 1790, racial categories, as well as the wording of questionsincluded on census questionnaires, have changed over time. The racial categories weredefined by social attitudes and political considerations that existed at that time.Until 1850, enumeration of race was white and black. African Americans were classifiedas either “slave” or “free colored,” reflecting the attitude of society at the time. Even aslate as 1900, codification of race was by color: white or Caucasian; yellow or Mongolian;red or Indian; black or African American. 10 The 1940 census was the first to includeethnicity. In 1976, the population was categorized into these 4 races: white, yellow, red,and black, while individuals of Hispanic origin were classified as white. Finally, the 1997standards defined 5 racial groups: American Indian or Alaskan Native; Asian; black orAfrican American; Native Hawaiian or Pacific Islander; and white. Respondents now canselect more than one classification. Whether one is of Hispanic origin reflects anotherdimension. The US Census Bureau classifies Hispanic as an ethnicity, not a race.Therefore, individuals of Hispanic origin may be of any race. 11 Recent reports in theliterature document these recent classifications.Second, another factor that makes it difficult to follow outcomes over time, and to makecomparisions, is the change in assignment of race at birth that has occurred. Before1980, assignment of race of a newborn infant was determined by the race of the father,but if parents were of different races, and one parent was white, the child was classifiedaccording to the race of the other parent. Since 1989, the race of newborn infants hasbeen tabulated according to race of the mother.12Third, most reports in the literature on health disparities compare black with whitepopulations. Only recently have reports on the health status of Hispanic, AmericanIndian, and other racial and ethnic categories appeared.Last, differences of study design exist. Sometimes odds ratios are used, and at othertimes, risk ratios are used, making comparisions difficult. Not all studies control forconfounding factors, such as patient compliance and preferences, availability ofservices, insurance coverage, environment, and socioeconomic status.In spite of these vagaries, however, distinguishing racial and ethnic groups from oneanother is useful for epidemiologic research, health services research, and determiningdisease rates. Perhaps more important, information applicable to distinct groups isimportant in directing biomedical research, focusing health promotion, changingscreening procedures and therapies, and tracking health status and health outcomes.Examples of disparities in healthOf the nearly 140 million women living in the US, women of racial and ethnic minoritiescomprise almost 40 million, or about 28% of the population. 13 and 14One need look at any one of several collections of health data, such as the Women ofColor Data Book,15 the National Center for Health Statistics,16 the Kaiser FamilyFoundation,17 Commonwealth Foundation,18 and, most recently, the National HealthcareDisparities Report,19 to know that disparities in health status and health outcomes exist.Upon reviewing such data over time, it is apparent that not only has the health gapbetween minority and nonminority women persisted for decades, in some cases it hasincreased.Cardiovascular disease is the leading cause of death for all women, except for Asianwomen, for whom it is second. African American women have the highest mortality ratefrom heart disease (147.6 per 100,000). In contrast, the mortality rate from heartdisease for non-Hispanic white women is 90 per 100,000. Lung cancer, the leadingcause of cancer deaths for women, is on the rise. For women of color, the rate ishighest among American Indian/Alaskan Native women, 58 deaths per 100,000, and thelowest among Asian American/Pacific Islander, 11.5 and 8.9 deaths per 100,000,respectively.In the US, age-adjusted breast cancer mortality rates among white and AfricanAmerican women have been diverging over the last 20 years—that is, the gap has beenwidening. Even though the incidence of breast cancer among African American womenis lower than that of white women, African American women have the highest rate ofdeath from breast cancer, 31 per 100,000. The mortality rate for black women in 2000was 31% higher than white women; by 2001, this had increased to 34%. 20 Although theincidence of endometrial cancer is lower among African American women than whitewomen, the mortality rate is nearly twice as high for African American women than forany other racial or ethnic group.21 and 22Maternal mortality and infant mortality are added examples of marked disparities inhealth outcomes. Although both maternal and infant mortality have declined remarkably,maternal mortality among black women is 4 times that of white women, and representsone of the largest racial disparities among major public health indicators. Moreimportantly, there has been no improvement in the gap between black and white womenin the last 20 years.23 Black women have a higher risk of dying from every pregnancyrelated cause of death, including the 3 leading causes, hemorrhage, pregnancy-inducedhypertension, and embolism.23Between 1950 and 2000, the infant mortality rate declined by more than 75%. In spite ofthis, large disparities remain. The infant mortality rate for black infants has remainedabout 2.5 times that of white infants for the past 50 years. Although not as marked,infant mortality rates for American Indian/Alaskan Native (9.0 for 2000), Hawaiian (8.7),and Puerto Rican (8.1) also are higher than for all births (7.0 deaths per 1000 livebirths).24Sources for disparities in health status and health outcomesAn immediate response to why disparities in health status exist is to invoke geneticpredisposition and biologic factors as the cause, even though these same factors existamong all populations. Therefore, while there may be genetic and biologic factors thatcontribute to diseases associated with health disparities, such as HLA genotype withhuman papillomavirus and cervical cancer, and p53 mutations with more aggressivebreast cancer,25 and 26 one cannot dismiss the fact that the onset or severity of diseaseresults from a complex interaction of genetic, social, and environmental factors. It is thelatter about which we can have an impact.It is clear that access to health care is important to maintain health and prevent disease,and barriers to access, whether perceived or actual, result in adverse health outcomes.Insurance status, more than any other demographic or economic factor, determines thetimeliness and quality of health care received. More than 45 million Americans do nothave health insurance,27 and minorities are disproportionately represented in theuninsured population. Uninsured individuals are less likely to have a usual source ofmedical care, which is so helpful in navigating the health care system. The uninsuredare also less likely to have routine screening, less likely to receive the recommendedimmunizations, and less likely to be exposed to prevention programs such as smokingcessation, importance of exercise, lifestyle changes, and diet management. The result isthat uninsured children suffer worse health and die sooner than those with insurance,and uninsured adults have a higher risk of dying before age 65 than do insured adults.Socioeconomic status, likewise, is correlated with health status. Individuals with lowerincomes not only cannot afford to purchase insurance, they are also more likely to workin jobs that do not offer subsidized health insurance. Minority populations aredisproportionately represented in this group. Many minorities with low or poor incomeslive in segregated areas where there are fewer economic opportunities, worse physicalenvironments, fewer public resources, and experience more environmental pollutionand violence. Additionally, they live in communities where the quality of health care maybe lower.6 and 28 This is supported by a recent report of Bach et al.29 Regardless of race,clinicians caring for black patients were less likely to be board certified, less likely to saythey could provide high-quality subspecialist care, and less likely to say they had accessto high quality diagnostic imaging and other ancillary services. 30Geographic availability of health care services and other factors within the healthsystem, including cultural and linguistic barriers, time pressures, and cost-controlmeasures also are potential sources of disparities. Clearly, caring for a patient withlanguage barriers and cultural differences requires more provider time, yet the financialincentives to move the patient in and out in 15 minutes disproportionately andnegatively affect such individuals. Additionally, structural barriers, including poortransportation and inability to communicate well enough to schedule appointments,interfere with a person’s ability to get care. Fragmentation of health care financing anddelivery likewise occurs more commonly in minority populations. Once insurancecoverage is interrupted, reestablishing health care with another provider almostroutinely takes several months to a year. 31 Certainly, this negatively impacts individualswith chronic disorders, common in underrepresented minorities.Improving equality in income and health insurance coverage for minorities alone will noteliminate disparities in health. It has been estimated that one half to three quarters ofthe disparities are not explained by differences in access and utilization. 32 Instead,improving cultural and linguistic competency among health care providers and thehealth care system may be key to reducing minority health disparities. 33There is increasing evidence that beyond access-related issues and system-levelfactors, patient/provider factors during clinical encounters contribute to disparities inhealth. Although complex, patient trust and doubts about medical care, their own values,fears, and hopes, a greater reluctance to accept physician recommendations, andpersonal preferences can contribute to health disparities. However, the health caresystem or provider may play a larger role in health disparities. An increasing body ofevidence documents racial and ethnic disparities in quality of care. 32Many racial and ethnic minority Americans experience language barriers, which presentsignificant challenges to patients and the providers. According to the US Census, 21million people living in the US have no, or limited, English skills. Nearly 12 millionindividuals live in linguistically isolated households, that is, households in which noperson over the age of 14 speaks English “very well.” 34 It is understandable, therefore,that in our relatively monolingual society, non–English-speaking patients report havingdifficulty accessing appropriate health care services. In a study of providers caring fornon–English-speaking patients, slightly over half of the providers believed that theirpatients did not adhere to medical treatments because of cultural or linguistic barriers. 35Sociocultural differences between patient and provider have been implicated ascontributing to inequality of health care. I marvel at the ability of physicians, residentphysicians, and medical students to encounter a patient for the first time, take a history,do a physical examination, and pull together a vast array of information presented bythe patient and obtained by diagnostic tests—and most often, make a correct diagnosis.Additionally, this is often done under severe time constraints. To do this, we makecertain assumptions. It is here where sociocultural differences between provider andpatient may influence decision making and eventual outcomes. As a consequence, it ishere where differences in care may result from unconscious biases on the part ofphysicians and other health care providers.What is the evidence that physician biases and stereotyping may exist and, therefore,influence a clinical encounter and subsequent care? In examining health caredisparities, the IOM committee addressing inequalities in health care reviewed over 600publications describing disparities in the quality of health care. 33 While many of thestudies focused on cardiovascular care, they are good examples of how socioculturaldifferences affect care. Schulman et al 36 assessed physicians’ recommendations formanagement of chest pain after they viewed vignettes of patients, actually actors, whocomplained of symptoms of coronary artery disease. The “patients” varied in race, theywere either black or white, varied in age, they were either 55 or 70 years of age, andgender. The physicians in this study were 40% less likely to recommend cardiaccatheterization for African Americans compared to whites. The group that faired theworst was the older African American women. White men were more likely to bereferred for cardiac catheterizations, followed by white women, and then black men, andthen black women. Another study by Van Ryn and Burke 37 surveyed 193 physicians’perceptions of behavior and attitudes of 842 patients, 57% of whom were white, and43% of whom were African American, during a post-angiogram hospital visit. Thephysicians rated the patients on a variety of personal characteristics, such asintelligence, self control, education level, and pleasantness. They also rated theirperceptions of the patient’s degree of social support and tendencies to exaggeratediscomfort, likelihood of complying with medical advice, likelihood of drug or alcoholabuse, as well as other characteristics. The results again support the hypothesis thatpatient race and socioeconomic background influence the physician’s perceptions, evenwhen controlling for degree of illness. African American patients were rated as lessintelligent, less educated, more likely to abuse drugs and alcohol, more likely to lacksocial support, and less likely to participate in cardiac rehab than white patients. Blackpatients were rated as less pleasant and less rational than whites at the samesocioeconomic levels. Although the influences on care may be complex, these andother studies lend support to the hypothesis that diagnostic and treatment decisions areinfluenced by patient race. However, to what degree attitudes of both the patient and theprovider affect health outcomes requires further study.InterventionsIncreasing diversity in the health care workforce, increasing research into healthdisparities, and emphasizing the incorporation of culturally competent curriculum inmedical education have been proposed as a strategies to reduce disparities in healthand decrease inequalities in health care.ResearchContinued biologic and genetic research is needed to decrease disparities in health.Encouragingly, the NIH funding classified as supporting health disparities, approached$3 billion dollars in 2003. While biomedical and genetic research is needed, how weapproach research to reduce disparities will require a new framework. To this end, Irefer to the NIH Roadmap: “Biomedical research traditionally has been organized muchlike a series of cottage industries—lumping researchers into broad areas of scientificinterest and grouping them into distinct, departmentally based specialties.” 38 In order toadequately understand and address health disparities, it will be necessary for scientiststo approach scientific questions from a multidisciplinary perspective, and with anunderstanding of the influence of behavioral, social science, and environmental factorson health and illness. While there has been an unprecedented accumulation ofinformation about the human genome and variations therein that may predisposecertain disorders, this knowledge alone will not suffice. There is a need to understandthe influence of the interaction of genetic predisposition with environmental/behavioralfactors on the onset and severity of disease.Minority communities must be participants in the research endeavor in order forresearch to be effective in the effort to reduce disparities. To accomplish this,introducing the concept of community-based participatory research (CBPR) is essential.CBPR requires that research conducted in communities includes community members,especially individuals affected by the disorder, to be studied, as well as other keycommunity stakeholders, in the design, conduct, analysis, interpretation, anddissemination of results. This is a concept that is new to most researchers.Increase diversitySeveral groups of studies provide a strong rationale for increasing diversity amonghealth professionals to influence care. Racial and ethnic minority health careprofessionals are more likely than their white peers to practice in minority and medicallyunderserved communities, care for poor patients and patients with Medicaid insuranceor no health insurance.39, 40 and 41 Underrepresented minority physicians are more likely totreat patients of color.39, 42 and 43 Minority patients are more likely to select health careprofessionals of their own racial and ethnic background, and are more satisfied with thecare they receive from minority professionals. Minority patients rate their health caregenerally higher when cared for in racially concordant settings compared to discordantsettings.44, 45 and 46 While increasing diversity among professional health care providersmay provide racial and ethnic minorities with choices and better experiences with theirhealth care, because they are cared for by a physician with similar racial or ethnicbackground, there still are too few studies that link physician-provider racial and ethnicconcordance with improved health outcomes.Before 1960, the number of minorities admitted to medical schools remained relativelylow, about 2% to 3%. While in the late 1960s to mid 1970s, reflecting the heightenedsensitivity to racial injustice spurred by the civil rights movement, there was an increasein the number of minorities admitted to medical schools. However, during the periodfrom the mid 1970s to 1990, there was little change. Underrepresentation of minoritiesin 1990 mirrored that which existed 15 years earlier. An American Association of MedicalColleges (AAMC) initiative to enroll 3000 students from underrepresented minoritygroups annually in US Medical Schools by the year 2000 was introduced in 1994. 47Although an array of approaches to achieve “3000 by 2000” was described, the initiativefailed to reach its goal. In 2000, underrepresented minorities, defined as black, NativeAmerican, including Alaskan and Hawaiian Natives, Mexican American, and mainlandPuerto Rican, accounted for 13% of all applicants to medical schools. The total numberof underrepresented minorities admitted to medical schools in 2002 was 1906, or 11.6%of the total number of matriculants. Among the black students, two thirds were women. 48Once admitted, retaining underrepresented minorities becomes an issue. Enhancing theracial and ethnic diversity of faculty and research scientists can provide support forunderrepresented minorities in the form of mentors and role models. However,excluding historically black and Puerto Rican medical schools, underrepresentedminorities make up only 1.3% of Professors, 2.5% of Associate Professors, 4.7% ofAssistant Professors, and 5.4% of Instructors.49Culturally competent curriculaIn order to address disparities in health care and eventual health outcomes, the need toprovide “culturally competent” health care has evolved as one of the strategies. AMEDLINE search for “culturally competent health care” results in a multitude ofreferences describing cultural competence and its effect on health outcomes. But, it isnot entirely clear what is meant by culturally competent health care and why it isimportant. The Center for Linguistic and Cultural Competence in Health Care 50 definesculturally competent health care quite simply as “health care services that are respectfulof and responsive to the health beliefs and practices, and cultural and linguistic needs ofdiverse patient populations.” Culture in this context refers to patterns of human behaviorthat include language, thoughts, communication, actions, customs, and beliefs, andvalues of an individual or specific population. Competence implies the ability to providecare, either as an individual or organization, tailored to the beliefs, behaviors, and needspresented by individual patients and their communities. 50 and 51Most practicing physicians, irrespective of their own cultural backgrounds, seldom havehad much intercultural contact with others who are substantially unlike themselves. Thisis almost always true for those born and raised in the US, no matter where they mayhave spent most of their years. A culturally competent curriculum is designed to bridgethe provincial gaps between health care providers and their patients, so that they canrecognize, understand, and effectively deal with the intercultural differences that exis…

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