Moving beyond the status quo in reducing racial and ethnic disparities in children's health.
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Adolescent↗
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Economic status over the life course and racial disparities in health.
OBJECTIVES: Racial and socioeconomic disparities in health have become a prominent feature of American society, though our understanding of the processes leading to such persistent disparities is still relatively limited. In this study, we focus on the impact of social and economic advantages and disadvantages over the life course on health disparities at older ages. In particular, we look at the roles of both cumulative and current financial resources and financial strains as determinants of a range of subjective and objective health assessments of physical conditions, functional impairment, and mental health. METHODS: Our data come from the 2001 Aging, Stress, and Health Study, which interviewed over 1,100 White and African American adults aged 65 years and older living in the Washington, D.C., metropolitan area. RESULTS AND DISCUSSION: Our results show that although racial and socioeconomic disparities in health do not follow a simple explanation, we do provide strong support for the fundamental importance of social and economic resources. Unlike previous studies that emphasize the role of financial resources such as income and wealth, we show that the lack of these resources, as indicated by high levels of financial strain, provides an important clue to how economic resources influence health.
Black or African American↗
Closing the gap: effect of diabetes case management on glycemic control among low-income ethnic minority populations: the California Medi-Cal type 2 diabetes study.
OBJECTIVE: Disparities exist in the diabetes health status of ethnic minority and/or low-income populations relative to other groups. A primary objective of diabetes management is to improve glycemic control. The feasibility of implementing intensive diabetes case management in disparate populations remains largely untested. RESEARCH DESIGN AND METHODS: Clinical sites in three southern California counties serving low-income, ethnic minority populations participated in our study. We randomized 362 Medicaid (called Medi-Cal in California) recipients with type 2 diabetes for at least 1 year to intervention (diabetes case management) or control (traditional primary care treatment) groups. Fifty-five percent of participants were minorities. Participants with HbA(1c) levels less than 7.5%, serious diabetes-related complications, or other serious medical conditions were excluded. We assessed the effect of the intervention (ongoing diabetes case management added to primary care) on glycemic control using serial HbA(1c) measurements over several years. RESULTS: The mean duration of follow-up was 25.3 months. HbA(1c) decreased substantially in both groups from an average of 9.54-7.66% (a reduction of 1.88%) in the intervention group and from an average of 9.66-8.53% (a reduction of 1.13%) in the control group. This improvement was sustained throughout the study. The reduction in HbA(1c) was consistently greater in the intervention group at each time point (P < 0.001), ranging between 0.65 at 6 months and 0.87 at study end. CONCLUSIONS: Diabetes case management, added to primary care, substantially improved glycemic control compared with the control group. Diabetes case management can help reduce disparities in diabetes health status among low-income ethnic populations.
Blood Glucose↗
Racial/ethnic disparities in health: the interplay between discrimination and socioeconomic status.
In the past decade, racial/ethnic discrepancy in health status has drawn increased attention from academicians, policy makers and planners, service providers, and community advocates. While the field has witnessed a growth in research projects and intervention programs, the gap in health status among racial/ethnic groups persists, which suggests that future research should incorporate a focus on one neglected area, ie, the health implications of discrimination. Using the National Survey of Functional Health (N=1,659), a nationally representative sample of English-speaking persons 18 years of age and older living in non-institutional arrangements within the United States, we analyzed how self-perceived unfairness (discrimination due to racial identity or to low socioeconomic status [SES]) was linked to self-assessed health status. The study found that racial and class discrimination were rather pervasive in the United States. Experiences of discrimination tended to have a strong negative association with health and accounted for some racial/ethnic differences in health status. The study also revealed a complex relationship between experiences of discrimination and social class, suggesting that future research should focus on specifying the social distribution of discrimination and assessing its subsequent association with health.
Adult↗
Directions for unraveling the issue of alcohol and health disparities: findings from the Postmenopausal Health Disparities study.
The Postmenopausal Health Disparities Study (PHD Study) is a model for unraveling the underlying factors that may play a role in the health status and life expectancy disparities among racial and ethnic groups, with particular attention to effects of alcoholic beverage consumption. The study is bioepidemiologic; underlying mechanisms, rather than end points per se, are evaluated. The design is cross-sectional with historical prospective elements. Data were collected from responses to three questionnaires and examination findings from a clinic visit. There were significant differences among racial and ethnic groups in patterns of alcoholic beverage consumption and selected demographic factors, body mass index, measures of physical activity and fitness, and nutritional factors. Predictors of body mass index included both moderate drinking and hormonal factors. To address the current controversy about risks and benefits of hormone replacement therapy (HRT) we examined the predictors of control-based categories of estradiol among treated women; predictors included drinking of alcohol, hormonal variables, and being Caucasian. In addition, a substantial proportion of the variables examined differed significantly between alcohol drinkers and abstainers. The significant differences between alcohol drinkers and abstainers, and among racial and ethnic groups, demonstrate the value of studying multiple racial and ethnic groups simultaneously. The PHD Study provides a unique and productive model that can be used in other populations.
Alcohol Drinking↗
[Health indicators in Tunisia, trends in regional disparities over the last thirty years].
The measure of health indicators on a regional-scale seems more interesting then the measure on a national-scale. It allows us to study differences between regions and their evolution. In order to know the time trend's disparities between regions, we have studied seven indicators, concerning different types of the World Health Organisation's classification, using data from yearly statistics and results of decennial census. Regional disparities are evaluated by a ratio between the highest regional value and the lowest regional value. This study showed us a global trend to the decline of regional disparities about indicators that we have studied. The improvement of health care resources indicators and socioeconomic's indicators, in the process of time, is associated with the improvement of health status indicators. The study of regional disparities makes possible to target actions for health in order to promote health's equity between regions.
Delivery of Health Care↗
Income inequality and infant mortality in New York City.
A series of studies have demonstrated that people who live in regions where there are disparities in income have poorer average health status than people who live in more economically homogeneous regions. To test whether such disparities might explain health variations within urban areas, we examined the possible association between income inequality and infant mortality for zip code regions within New York City using data from the 1990 census and the New York City Department of Health. Both infant mortality and income inequality (percentage of income received by the poorest 50% of households) varied widely across these regions (range in infant mortality: 0.6-29.6/1,000 live births; range in income inequality: 12.7-27.3). An increase of one standard deviation in income inequality was associated with an increase of 0.80 deaths/1,000 live births (P <.001), controlling for other socioeconomic factors. This finding has important implications for public health practice and social epidemiological research in large urban areas, which face significant disparities both in health and in social and economic conditions.
Censuses↗
Racial segregation and health disparities between Black and White older adults.
OBJECTIVES: In this study, we examined whether racial segregation is associated with poorer self-rated health among older adults, and whether racial segregation helps explain race disparities in self-rated health between Black and White older adults. METHODS: We used multilevel data at the individual, neighborhood (tract), and county levels, from two national surveys-the Americans' Changing Lives (ACL) survey and the National Survey of Families and Households (NSFH). We used hierarchical linear models in order to regress self-rated health on county-, neighborhood-, and individual-level racial and socioeconomic variables. RESULTS: In the NSFH, there was an association between county racial segregation and poorer self-rated health among White but not Black older adults (net of county percent Black and percent poverty). In the ACL, there was no statistically significant association between racial segregation and self-rated health. In the NSFH, there was some indication that Black older adults had better self-rated health when living in neighborhoods with a higher percentage of Black residents than the county percentage. DISCUSSION: Although aggregate-level studies demonstrate associations between racial segregation and mortality rates, our multilevel analyses with two national data sets suggest only weak associations between racial segregation and self-rated health. However, socioeconomic status at multiple levels contributes to race disparities in health.
Aged↗
Social conditions and self-management are more powerful determinants of health than access to care.
Professional organizations advocate universal access to medical care as a primary approach to improving health in the population. Access to medical services is critical to outcomes of acute processes managed in an inpatient hospital, the setting of most medical education, research, and training, but seems to be limited in its capacity to affect outcomes of outpatient care, the setting of most medical activities. Persistent and widening disparities in health according to socioeconomic status provide evidence of limitations of access to care. First, job classification, a measure of socioeconomic status, was a better predictor of cardiovascular death than cholesterol level, blood pressure, and smoking combined in employed London civil servants with universal access to the National Health Service. Second, disparities in health according to socioeconomic status widened between 1970 and 1980 in the United Kingdom despite universal access (similar trends were seen in the United States). Third, in the United States, noncompletion of high school is a greater risk factor than biological factors for development of many diseases, an association that is explained only in part by age, ethnicity, sex, or smoking status. Fourth, level of formal education predicted cardiovascular mortality better than random assignment to active drug or placebo over 3 years in a clinical trial that provides optimal access to care. Increased recognition of limitations of universal access by physicians and their professional societies may enhance efforts to improve the health of the population.
Educational Status↗
Disparities in cancer care among racial and ethnic minorities.
The 2005 National Health Disparities Report found disparities related to race, ethnicity, and socioeconomic status in the United States health-care system. While varying in magnitude, disparities were observed in almost all aspects of health care including cancer. Disparities were noted across quality and access to health care, levels and types of health care, various health-care settings, and within many subpopulations. In this review, we explore the disparities in cancer care among racial and ethnic minorities. In particular we consider numerous factors that may influence health care for racial and ethnic minority groups including socioeconomic issues, access, cultural beliefs, risk factors, and comorbidities. Although there are extensive confounding factors that vary with each subgroup, trends that may help individual practitioners better understand this complex issue become evident through closer evaluation of available data.
Comorbidity↗
Socioeconomic status and dissatisfaction with health care among chronically ill African Americans.
Addressing differences in social class is critical to an examination of racial disparities in health care. Low socioeconomic status is an important determinant of access to health care. Results from a qualitative, in-depth interview study of 60 African Americans who had one or more chronic illnesses found that low-income respondents expressed much greater dissatisfaction with health care than did middle-income respondents. Low socioeconomic status has potentially deadly consequences for several reasons: its associations with other determinants of health status, its relationship to health insurance or the absence thereof, and the constraints on care at sites serving people who have low incomes.
Adult↗
The impact of ethnicity, family income, and parental education on children's health and use of health services.
OBJECTIVES: This study characterized ethnic disparities for children in demographics, health status, and use of services; explored whether ethnic subgroups (Puerto Rican, Cuban, and Mexican) have additional distinctive differences; and determined whether disparities are explained by differences in family income and parental education. METHODS: Bivariate and multivariate analyses of data on 99,268 children from the 1989-91 National Health Interview Surveys were conducted. RESULTS: Native American, Black, and Hispanic children are poorest (35%, 41% below poverty level vs 10% of Whites), least healthy (66%-74% in excellent or very good health vs 85% of Whites), and have the least well educated parents. Compared with Whites, non-White children average fewer doctor visits and are more likely to have excessive intervals between visits. Hispanic subgroup differences in demographics, health, and use of services equal or surpass differences among major ethnic groups. In multivariate analyses, almost all ethnic group disparities persisted after adjustment for family income, parental education, and other relevant covariates. CONCLUSIONS: Major ethnic groups and subgroups of children differ strikingly in demographics, health, and use of services; subgroup differences are easily overlooked; and most disparities persist even after adjustment for family income and parental education.
Adolescent↗
Racial/ethnic variations in women's health: the social embeddedness of health.
This article provides an overview of the magnitude of and trends in racial/ethnic disparities in health for women in the United States. It emphasizes the importance of attending to diversity in the health profiles and populations of minority women. Socioeconomic status is a central determinant of racial/ethnic disparities in health, but several other factors, including medical care, geographic location, migration and acculturation, racism, and exposure to stress and resources also play a role. There is a need for renewed attention to monitoring, understanding, and actively seeking to eliminate racial/ethnic disparities in health.
Acculturation↗
Effect of difficulty affording health care on health status after coronary revascularization.
BACKGROUND: An objective of the United States' Healthy People 2010 Initiative is to eliminate disparities based on socioeconomic status. We assessed the effect of difficulty affording health care on the health status (symptoms, function, and quality of life) of patients treated with percutaneous coronary intervention or CABG. METHODS AND RESULTS: A consecutive, single-center cohort of 480 patients undergoing coronary revascularization received the Seattle Angina Questionnaire at the time of their procedure and at subsequent monthly intervals for 6 months. At baseline, patients who reported somewhat of a burden to a severe burden in affording health care had significantly lower scores on the Seattle Angina Questionnaire (mean+/-SD) with respect to angina (55+/-29 versus 68+/-25, P<0.0001), physical limitation (55+/-26 versus 72+/-24, P<0.0001), and quality of life (46+/-22 versus 56+/-22, P<0.0001) than those who did not perceive healthcare costs to be burdensome. Although both groups of patients improved after revascularization, poorer health status persisted among those with difficulty affording health care after percutaneous coronary intervention (6-month mean+/-SE: angina 79+/-2.5 versus 88+/-1.9, P=0.002; physical function 61+/-2.7 versus 80+/-2.0, P<0.0001; quality of life 67+/-2.4 versus 82+/-1.8, P<0.0001) but not after CABG (angina 91+/-2.5 versus 93+/-1.6, P=0.47; physical function 75+/-3.4 versus 81+/-2.2, P=0.13; quality of life 84+/-3.1 versus 84+/-2.0, P=0.81). Similar differences remained after adjustment for demographic and clinical characteristics. CONCLUSIONS: Patients reporting difficulty affording health care have worse health status at the time of coronary revascularization. A persistent disparity exists after percutaneous but not surgical revascularization. Additional inquiry into the mechanism of this disparity is needed so that the goals of equitable health care, irrespective of treatment strategy, can be achieved.
Aged↗
Racism and health inequity among Americans.
UNLABELLED: Research reports often cite socioeconomic status as an underlying factor in the pervasive disparities in health observed for racial/ethnic minority populations. However, often little information or consideration is given to the social history and prevailing social climate that is responsible for racial/ethnic socioeconomic disparities, namely, the role of racism/racial discrimination. Much of the epidemiologic research on health disparities has focused on the relationship between demographic/clinical characteristics and health outcomes in main-effects multivariate models. This approach, however, does not examine the relationship between covariate levels and the processes that create them. It is important to understand the synergistic nature of these relationships to fully understand the impact they have on health status. PURPOSE: A review of the literature was conducted on the role that discrimination in education, housing, employment, the judicial system and the healthcare system plays in the origination, maintenance and perpetuation of racial/ethnic health disparities to serve as background information for funding Program Announcement, PA-05-006, The Effect of Racial/ Ethnic Discrimination/Bias on Healthcare Delivery (http:// grants.nih.gov/grants/ guide/pa-files/PA-05-006.html). The effect of targeted marketing of harmful products and environmental justice are also discussed as they relate to racial/ethnic disparities in health. CONCLUSION: Racial/ethnic disparities in health are the result of a combination of social factors that influence exposure to risk factors, health behavior and access to and receipt of appropriate care. Addressing these disparities will require a system that promotes equity and mandates accountability both in the social environment and within health delivery systems.
Black or African American↗
Health status in an invisible population: carnival and migrant worker children.
One goal of Healthy People 2010 (2003) is to close the gap of disparities in access to care and health. The purpose of this descriptive exploratory study was to evaluate health status indicators in the children of itinerant carnival and migrant farmworkers aged birth to 12 years. Health status outcomes (immunization records, well-child examinations, dental health status, and growth parameters) were compared between the two groups and to national averages to identify health disparities. All forms were available in Spanish and English. A total of 97 children were recruited for this study: 45 carnival children and 52 migrant farmworker children.
Agriculture↗
Testing relationships among determinants of health, health policy, and self-assessed health status in Quebec.
By removing financial barriers, the Canada Health Act (1984) equalized access to health care services in Canada. Yet class, educational, and geographical disparities in individual and population health status persist. Recent health reform policies in Quebec assert that health and well-being are a function of income, educational level, housing conditions, employment, and other socioeconomic factors. They suggest that health policy should encompass social policies that influence individual and community socioeconomic factors which in turn affect health. Against the backdrop of these reforms, this study tests the importance of socioeconomic factors as a determinant of health--while controlling for other known determinants through a logistic regression model--with data from the Santé Quebec health surveys 1987 and 1992-93. The results confirm the importance of economic security as a determinant of individual health. This effect appears to operate through an individual income variable and through the community-level variable of regional unemployment. The importance of the income effect declined between 1987 and 1992-93. This may indicate that an increased focus on the socioeconomic determinants of health has reduced inequalities in health. It may also mean that health inequalities appear inevitable until health care policy merges completely with broader health and social policies. But such integration may well conflict with economic (and political) imperatives of the post-Fordist capitalist system.
Adolescent↗
Exploring racial and ethnic disparities in prescription drug spending and use among Medicare beneficiaries.
BACKGROUND: Little is known about why minority Medicare beneficiaries spend less on and use fewer prescription drugs than white Medicare beneficiaries. OBJECTIVE: We explored whether population differences in demographic characteristics, socioeconomic status, and health status were associated with observed disparities by race and ethnicity in the prescription drug spending and use of noninstitutionalized elderly Medicare beneficiaries. METHODS: We used a nationally representative sample of 8101 white, 816 black, and 642 Hispanic Medicare beneficiaries from the 1999 Medicare Current Beneficiary Survey Cost and Use files. For each of these groups, we calculated total prescription drug spending, out-of-pocket spending, and number of prescriptions. We then used the Oaxaca-Blinder decomposition method to separate the impact of race and ethnicity on disparities in spending and use from the impact of differences in population characteristics across racial and ethnic groups. RESULTS: Much of the disparity in spending between whites and blacks and some of the disparity between whites and Hispanics can be attributed to race/ethnicity. Because of race/ethnicity, total spending for whites was 8.9% more than for blacks and 5.4% more than for Hispanics. Similarly, total out-of pocket spending for whites was 28.8% more than for blacks and 10.7% more than for Hispanics. Race/ethnicity also influenced the amount of prescription drug use. Whites used 2.3 more prescriptions than blacks and 1.6 more than Hispanics. However, these differences in use were offset by the impact of differences in population characteristics. CONCLUSIONS: Differences in factors identified in the Andersen model of access to care do not fully explain observed disparities in prescription drug use and spending. The portion of the disparities due to race and ethnicity may reflect patients' skepticism about medicine and medical care in general, patients' adherence to medical advice, patient-physician communication, physicians' prescribing habits, and usual source of care. Future research should explore whether these and other unobserved factors associated with race and ethnicity are responsible for disparities in drug spending and use.
Black or African American↗