HEALTH CARE DISPARITIES
| ELIMINATING HEALTH DISPARITIES FACING THE FUTURE —Jeannette E. South-Paul, MD, Professor and
Chair, Department of Family Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
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| Background: changing demographics—aging population; increasing number of women as patients, in workforce,
and in higher education; racial issues—growing racial and ethnic diversity; 2000 census showed fewer white Americans
and greater percentage of individuals from underrepresented minorities; changes in family structure—more
single-parent families, especially among ethnic minorities; ≥25% of children come from single-parent households;
most single-parent families headed by women; children born into single-parent households more likely to be at lower
socioeconomic level; socioeconomic level and ethnicity—median family income varies among racial and ethnic
groups, with white and Asian families having higher median household incomes than black or Hispanic families;
when net worth considered, income disparity even greater; perceived health status—varies dramatically with median
family income; ≥20% of individuals from families with median family income <$15,000 per year described
their perceived health status as fair to poor; those with better socioeconomic status more likely to describe health as
good; perceptions tend to be accurate
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 | Lack of health insurance: today, more Americans of working age do not have health insurance; individuals who do not
have health insurance more likely to receive too little medical care too late, be sicker, and die sooner; uninsured—
receive poorer care; even when in hospital for acute illness or event, quality of care lower than that given to insured patients;
go without preventive screenings, resulting in delayed diagnoses and premature death; do not receive recommended
care for chronic diseases, eg, eye and foot examinations in diabetes; lack regular access to medications to
manage conditions, eg, hypertension, HIV infection
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| Women’s health care: annual income directly reflects likelihood of receiving regular preventive healthcare, eg, Papanicolaou
(Pap) test, mammograms; annual income level also corresponds to likelihood of diagnosis of high blood pressure
(BP), arthritis, heart disease, diabetes, or cancer
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| Areas of disparity: mortality rate—differences in health care use only partly explained by income differences
among whites and ethnic minorities; health care gap between whites and minorities not changed in 50 yr, despite technologic
advances and drug developments; gap widened for leading causes of death, eg, heart disease, cancer, diabetes,
cirrhosis; poor management of chronic disease translates to persistently higher mortality rates during entire lifespan of
blacks, Hispanics, and American Indians; leading causes of death in whites heart disease, cancer, stroke, chronic lower
respiratory disease, and unintentional injury; 10 leading causes of death among blacks show increasing incidence of
death from diabetes, unintentional injury and homicide, and HIV infection; blacks and Hispanics less likely to get immunizations
against infectious diseases (eg, influenza, pneumonia); depression—depression often underdiagnosed,
misdiagnosed, and undertreated in blacks; blacks more likely to get tricyclic antidepressants (TCAs; have lower compliance
rate than selective serotonin reuptake inhibitors [SSRI]); hypertension—racial and ethnic minorities have
higher rate of hypertension, develop hypertension at earlier age, and less likely to have adequate control of BP; different
rate of hypertension among men and women, blacks and Hispanics; variations in treatment, diagnosis, and in level
of control in different age groups (undertreatment 28% in persons <25 yr of age); study looking at incidence of hypertension
in foreign-born Asian Americans found conflicts between Western and traditional care and unavailability of
health care providers of similar ethnic background; 48% of these patients diagnosed with hypertension did not know
they were hypertensive (BP not checked); infant mortality rate—national average 7 per 1000 live births; >14 per 1000
births in blacks; wide variations within and among ethnic groups, with some relationship to socioeconomic or educational
level and whether individual new to United States; infant mortality rate varies according to mother’s educational
level
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| Factors influencing health: environmental factors—minority populations more likely to be exposed to toxic waste,
violence, and disease (eg, tuberculosis [TB], HIV); communities where people of color live more likely to contain commercial
hazardous waste dumps; 17% of American children <5 yr of age suffer from lead toxicity (children disproportionately
Mexican-American, Puerto Rican-American, and black); social factors—consider family and kinship networks, communication
preferences, role of religion or church, indigenous beliefs about medicine, gender roles, and community stability;
institutional factors—access to care, availability of similar ethnic providers, and availability of providers that speak patient’s
language
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| Health disparities: require attention to environmental hazards and social conditions; psychosocial stressors key to differential
susceptibility to disease; disparities result from individual factors that influence patients at multiple levels; many
factors affecting health of patients overlap (eg, sociocultural factors, social class, social environment, race, education
level, socioeconomic status, unmeasured biologic factors); race—not anthropologically or biologically sound concept,
but governs many aspects of how patients treated, eg, Schulman et al showed that physicians make different choices about
diagnostic tests and ultimate care of coronary artery disease (CAD), depending on whether patient man or woman, black
or white; stress-exposure disease framework—describes relationship between stress, race, environmental conditions,
and health; residential location and access to transportation affects ability to access health care, eg, patient who must take
several buses to get to clinic, patient living in area where fresh fruits and vegetables not readily available; segregation—
still exists in communities; individuals of lower socioeconomic level in certain neighborhoods; individuals of similar cultural,
racial, or immigrant backgrounds in other communities; availability of health care in these communities not equal to
others
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| Use of health care system: affected by social isolation, family and/or community disorganization, language and cultural
barriers, illegal residence status, and shortage of ethnic physicians; minority physicians—studies show minority
patients >4 times more likely to receive care from minority physicians than white patients; patients who are low income,
uninsured, or covered by Medicaid more likely to receive care from minority physicians; minority physicians appeared to
care for sicker patients than white physicians; study of 718 primary care practices in 51 communities found black physicians
practiced in areas with 5 times as many black residents as communities where nonblack physicians practiced; physician-patient
partnerships—study found patients of color less likely to feel they could participate in health care
decision making if their physician not of same racial/ethnic background
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| Unequal treatment: perception of quality of care—black or Hispanic patients believe they get lower quality of care
from white physicians than white counterparts; study data—people of color less likely to get counseling and patient education
materials once their CAD diagnosed; white women presenting to emergency department (ED) with osteoporotic
fractures counseled more frequently as to exercise, calcium injections, and other therapies than women of color; Institutes
of Medicine (IOM) report—found racial and ethnic disparities in health care exist and associated with worse outcomes;
disparities occur in context of broader historic and contemporary social and economic inequality; patients do not
trust physicians and health care system; disparities exist from person to person, up to institutional level; physicians need
to recognize that bias and stereotyping occur and act to decrease effects
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| Patient trust: focus groups demonstrate treatment disparities due to health insurance differences, age, sex, and location
of residence; these disparities foremost on minds of consumers and result in distrust of health care system in United
States; trust in physician eroded when patients perceive—lack of time and attention given by physician; lack of concern
and empathy for patient’s life circumstances; desire for profit driving medical decision making; managed care
plans not putting patient interests first; that many health care providers hold negative stereotypes of minority patients;
reduction in Medicare benefits perceived as physician not caring about patient; result of eroded trust—patients become
more aggressive and do own research to ensure that physician’s recommendations serve patient’s best interests
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| Addressing health care disparities: need more diverse physician population, starting with medical training programs;
need culturally competent physicians; increase access to health care for underserved populations; ensure that
medical community and policy makers adequately informed about special needs of minority population; partner with
public health and social science colleagues to research issues; expand cultural competence curricula at all levels of
medical training; work closely with communities to understand needs
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| Question on Medicaid: patients on Medicaid fare better in areas of disease prevention and management of chronic disease,
but not treated same as patients with commercial insurance
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| HEALTH CARE DISPARITIES, CULTURAL SENSITIVITY, AND LINGUISTICS —Elisabeth Wilson, MD, MPH,
Assistant Clinical Professor, Department of Family and Community Medicine, University of California, San Francisco,
School of Medicine and San Francisco General Hospital
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| Health disparities: definition—differences in health that systematically and adversely affect groups who have historically
suffered discrimination, marginalization, or exclusion, and put those already economically disadvantaged at further
disadvantage with respect to health, and could be influenced by policy; socioeconomic status—large contributor to
health disparity; high socioeconomic status associated with better health
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| Health care disparities: includes quality or process of care and refers to inequities within health care system (excluding
access, clinical need, patient preferences, and appropriateness of treatment); multiple national reports; Unequal
Treatment: Confronting Racial and Ethnic Disparities in Health Care, 2002 report—found disparities persist, even
when other factors controlled for (eg, access, insurance), and these extend across range of illnesses and health care services;
racial and ethnic factors—clinical appropriateness, clinical need, and patient preferences not necessarily disparities
but can lead to disparities if not correctly addressed; discrimination because of biases, stereotyping, and
uncertainty called health care disparity when they lead to unequal treatment
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| Causes of disparities: care process level—studies show that as medical students progress through training, they become
less altruistic, more sociopolitically conservative, and less likely to perceive disparities as unfair; studies found
physicians more likely to ascribe negative racial stereotypes to minority patients and make negative comments when discussing
minority patients’ cases; Schulman study found women less frequently referred than men for cardiac catheterization,
and blacks less frequently referred than whites for cardiac catheterization; also found black women referred
significantly less often than white men; system level—barriers include language and literacy issues; language barriers
associated with poor access, impaired comprehension, decreased adherence, poor satisfaction, and adverse outcomes; literacy
barriers associated with poor self-rated health and impaired comprehension; study—looked at professional vs ad
hoc (untrained) interpreters in pediatric outpatient clinic; found interpretation errors common (31 per clinical encounter),
and clinically significant errors more common with ad hoc interpreter (eg, not describing how to take medication, not explaining
about dosages)
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| Solutions: involve increasing and improving communication, system changes, and improving civil rights; patient-level
interventions—elicit preferences, encourage shared decision making, and earn respect and trust; care process-level
interventions—understand and recognize evidence for disparities; recognize own bias and stereotypes and exclude
them from patient encounters and decision-making process; acquire cultural competence skills
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| Cultural sensitivity and competence: cultural sensitivity refers to recognizing that differences exist and respecting
them; cultural competence requires tools for listening to patients’ perspectives, explaining physician’s perspective, discussing
differences and similarities, and recommending and negotiating plan for change; system-level interventions—
identify barriers to access and quality care; assess English proficiency and literacy levels; ensure system linguistically
and culturally competent; create access to professional interpreters; provide appropriate handouts; increase diversity in
workforce; identify patients with limited English proficiency (closely connected to literacy); ask patients to repeat instruction
or advice (proficiency limited if patient not able to explain concepts); use of interpreters—speak with patient,
not interpreter; introduce interpreter and patient at beginning of visit; after interpreter explains to patient, ask patient to
repeat information using interpreter to make sure patient understands; health literacy—consider health literacy in patients
who ask staff for help in understanding information given by physician; also includes numeric issues and issues negotiating
health care system; consider literacy issue in patient who postpones decision until they can take it home to
person who translates for them; consider that noncompliant patient may be illiterate; avoid using medical terms to explain
complex concepts; show or demonstrate information; use anatomic models; limit information to essential points;
have patient repeat information to you; African American Heart Failure Trial (A-HeFT)—found decrease in rate of
congestive heart failure in black patients taking combination of isosorbide dinitrate and hydralazine (Bidil); suggests different
pathophysiology associated with heart failure in blacks and need for different treatment strategy; approved in 2005
as race-specific treatment for heart failure; look for more race-specific treatments in future
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Educational Objectives
| The goal of this activity is to provide the listener with an understanding of disparities in the health care system. After hearing
and assimilating this program, the clinician will be better able to:
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| 1. Cite background issues related to ethnicity- and gender-based health care disparities in the United States.
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| 2. Explain how use of the health care system and treatment within the system differs with ethnicity, gender, and socioeconomic
status.
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| 3. Discuss some possible solutions to the problem of health care disparities.
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| 4. Examine issues of cultural sensitivity and competence relevant to physicians and other health care providers.
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| 5. Describe the correct use of interpreters in encounters with patients whose health care is affected by language and linguistic
barriers.
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Discussed on This Program
Isosorbide dinitrate and hydralazine hydrochloride [BiDil]
Sources of Information
http://spiral.tufts.edu
http://www.aafp.org/fpm/20020600/39achi.html
http://www.familydocs.org/assests/Publications/Toolkits/AddressingLanguageAccessToolkit.pdf
http://depts.washington.edu/pfes/cultureclues.html
http://www.awesomelibrary.org/multiculturaltoolkit.html
http://medstat.med.utah.edu/24languages/
http://babelfish.altavista.com
http://gucchd.georgetown.edu/nccc/sidsdvd.html
Suggested Reading
Armstrong K et al: Patient preferences can be misleading as explanations for racial disparities in health care.
Arch Intern Med. 166:950, 2006; Asch SM et al: Who is at greatest risk for receiving poor-quality health care? N Engl
J Med. 354:1147, 2006; Chen FM et al: Patients' beliefs about racism, preferences for physician race, and satisfaction
with care. Ann Fam Med. 3:138, 2005; Chen E et al: Understanding health disparities: the role of race and socioeconomic
status in children's health. Am J Public Health. 96:702, 2006; Correa-de-Araujo R: Women, gender, and
health care disparities. Womens Health Issues. 16:40, 2006; Das AK et al: Depression in African Americans: breaking
barriers to detection and treatment. J Fam Pract. 55:30, 2006; Dayton E et al: Racial and ethnic differences in patient
assessments of interactions with providers: disparities or measurement biases? Am J Med Qual. 21:109, 2006; Gregg J et
al: Losing Culture on the Way to Competence: The Use and Misuse of Culture in Medical Education. Acad Med. 81:542,
2006; Kirby JB et al: Explaining racial and ethnic disparities in health care. Med Care. 44:I64, 2006; Kuller LH:
Trends in racial disparities in care. N Engl J Med. 353:2081, 2005; Rutten LJ et al: Factors associated with patients'
perceptions of health care providers' communication behavior. J Health Commun. 11 Suppl 1:135, 2006; Shavers VL et
al: Racism and health inequity among Americans. J Natl Med Assoc. 98:386, 2006; South-Paul JE: Cross-cultural issues
concerning sexuality, fertility, and childbirth. J Am Board Fam Pract. 16:180, 2003; South-Paul JE: Racism in the
examination room: myths, realities, and consequences. Fam Med. 33:473, 2001; Wilson E et al: Effects of limited english
proficiency and physician language on health care comprehension. J Gen Intern Med. 20:800, 2005; Wilson E et
al: Medical student, physician, and public perceptions of health care disparities. Fam Med. 36:715, 2004.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial relationship
with the manufacturer or provider of any commercial product or service discussed. For this issue, the faculty reported
nothing to disclose.
Dr. South-Paul was recorded in San Francisco, CA, September 28-October 1, 2005, at the American Academy of
Family Practice Annual Scientific Assembly. Dr. Wilson was recorded in San Francisco, CA, March 5-7, 2005, at the
Annual Review in Family Medicine, sponsored by the University of California, San Francisco, School of Medicine.
The Audio-Digest Foundation thanks the speakers and the sponsors for their cooperation in the production of this program.
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