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PubMed2001

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↗

PubMed2006

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↗

PubMed2004

Racial and ethnic diversity and organizational behavior: a focused research agenda for health services management.

Initiatives to reduce racial and ethnic disparities are conceptualized as a three-legged stool. Public policy: to ensure a legal and regulatory environment designed to eliminate disparities in access and health status; clinical practice: to ensure patient satisfaction and loyalty and improve treatment outcomes through the cultural competence of clinicians; and organizational behavior: to ensure that leadership, staff, and the culture of the health services organization represents and values the communities they serve. Our review of the health services and general management literature published since 1990 reveals a paucity of research on organizational behavior. Based on our review of health services and general management organizational behavior and racial/ethnic diversity literature, we offer an agenda for future research in this area. Factors that will facilitate or inhibit the pursuit of the proposed research agenda are also identified and discussed. The literature reviewed is mainly from the United States and the proposed research agenda results from that review, which presents a potential limitation to its applicability internationally.

Breast Feeding↗

PubMed2006

Caregiving outside of the home: the effects of race on depression.

OBJECTIVE: This research examines the conditions that determine whether Blacks experience lower or higher levels of depression while caregiving outside of the home, as compared to Whites. Some prior literature has found that African Americans report a lesser caregiver burden despite an increased likelihood that they will acquire this role, and decreased resources to do so. Others have found that African Americans experience the same caregiver burden and distress as Whites. Given these mixed findings, we use the stress process model to examine whether African American caregivers experience lower or higher levels of depression when they provide care outside of the home. DESIGN: A sample of care workers who provide care to others outside of the home was drawn from the 1992-4 National Survey of Families and Households. The final sample included 275 (11%) Blacks, and 2,218 (89%) Whites (not of Hispanic origin). The primary statistical method for predicting differences in caregivers' depressive symptomatology was OLS regression analysis with progressive adjustment. RESULTS: We examined sociodemographics, family structure, resources, and stressors and found that African Americans, those with lower socioeconomic status, the unmarried, spending more weeks caregiving, having a physical impairment, and surprisingly receiving more help from parents are associated with higher depressive symptomatology. Stronger religious beliefs decreased depressive symptomatology for Blacks. The race effect was, in part, explained by family structure, amount of caregiving, and impairment of care worker. CONCLUSION: Contrary to prior literature, we found that Blacks are more depressed than White caregivers in large part because of lower socioeconomic status and greater stressors, and higher levels of physical impairment. Yet, strength in religious belief has a stress-buffering effect for African Americans. We suggest that policies that attempt to eliminate racial disparities in socioeconomic status and health could benefit these caregivers.

Adult↗

PubMedDate not supplied

Survivors of domestic violence: demographics and disparities in visitors to an interdisciplinary specialty clinic.

Although the traditional response to domestic violence has been undertaken by legal and human service agencies, this societal issue has become increasingly recognized as a national public health concern. While identification and intervention in cases of domestic violence are widely recommended, little data exist on intervention outcomes. This retrospective study describes similarities and disparities in sociodemographic variables, health status, referral characteristics, and management strategies among patients referred to a specialty clinic for survivors of domestic violence.

Adult↗

PubMed1999

Health promoting organizations: a systems model for advanced practice.

Nursing and other health care providers are challenged to create the future of health care. Health is synonymous with well-being framed holistically, mind, body, and spirit. Disparities are growing in health status for vulnerable population groups and the percentage of people who are uninsured is rising. New approaches to health care are needed in the current age of uncertainty. A comprehensive health promoting organization (HPO) model within an ecological systems framework is described. An operational example is delineated, Welcome Home Ministries HPO.

Health Maintenance Organizations↗

PubMed2003

Social determinants of tooth loss.

OBJECTIVES: To quantify racial and socioeconomic status (SES) disparities in oral health, as measured by tooth loss, and to determine the role of dental care use and other factors in explaining disparities. DATA SOURCES/STUDY SETTING: The Florida Dental Care Study, comprising African Americans (AAs) and non-Hispanic whites 45 years old or older who had at least one tooth. STUDY DESIGN: We used a prospective cohort design. Relevant population characteristics were grouped by predisposing, enabling, and need variables. The key outcome was tooth loss, a leading measure of a population's oral health, looked at before and after entering the dental care system. Tooth-specific data were used to increase inferential power by relating the loss of individual teeth to the disease level on those teeth. DATA COLLECTION METHODS: In-person interviews and clinical examinations were done at baseline, 24, and 48 months, with telephone interviews every 6 months. PRINCIPAL FINDINGS: African Americans and persons of lower SES reported more new dental symptoms, but were less likely to obtain dental care. When they did receive care, they were more likely to experience tooth loss and less likely to report that dentists had discussed alternative treatments with them. At the first stage of analysis, differences in disease severity and new symptoms explained tooth loss disparities. Racial and SES differences in attitudes toward tooth loss and dental care were not contributory. Because almost all tooth loss occurs by means of dental extraction, the total effects of race and SES on tooth loss were artificially minimized unless disparities in dental care use were taken into account. CONCLUSIONS: Race and SES are strong determinants of tooth loss. African Americans and lower SES persons had fewer teeth at baseline and still lost more teeth after baseline. Tooth-specific case-mix adjustment appears, statistically, to explain social disparity variation in tooth loss. However, when social disparities in dental care use are taken into account, social disparities in tooth loss that are not directly due to clinical circumstance become evident. This is because AAs and lower SES persons are more likely to receive a dental extraction once they enter the dental care system, given the same disease extent and severity. This phenomenon underscores the importance of understanding how disparities in health care use, dental insurance coverage, and service receipt contribute to disparities in health. Absent such understanding, the total effects of race and SES on health can be underestimated.

Black or African American↗

PubMed2003

Ethnic disparities in the prevalence of dental caries and restorative dental treatment in Brazilian children.

AIM: This study assesses disparities in the oral health status of Brazilian black and white children. PARTICIPANTS: 11- and 12-year-old schoolchildren living in 131 cities of the State of São Paulo, Brazil. METHODS: Spatial data analysis of city-level indexes of oral health, socio-economic status and provision of dental services. MAIN OUTCOME MEASURES: Ethnic ratios of the DMFT and the care index. RESULTS: White children had higher indexes of caries in permanent teeth than their black counterparts, concurrent with a higher utilisation of dental attendance. The gap of caries prevalence between black and white children was reduced in cities with a better profile of socio-economic status. Cities with higher per-capita yearly budget, expenditure in health, and provision of public dental services presented reduced indications of ethnic inequality in dental care. CONCLUSION: The knowledge of conditions associated with a lower ethnic discrepancy in the risk of caries and in the incorporation of dental services can be used to design socially appropriate dental services. An improved community dental service, higher public expenditure in health and per-capita municipal yearly budget contribute effectively to reducing inequities in oral health by allowing an incorporation of restorative dental treatment more equitably distributed between black and white children.

Black People↗

PubMed2000

The intersection of socioeconomic variables, oral health, and systemic disease: all health care is cultural.

In the last decade, there has been an increase in the proportion of the American population that lacks health insurance. Additionally, long-term disparities in health access and status for populations of color have continued to exist without major change. A review of the literature in periodontia shows a statistical relationship between the risk of periodontal disease and a range of sociodemographic characteristics (race, income, social class). However, the factors giving rise to this increased risk or how to reduce it are unclear. Cultural competence, an elaboration of biopsychosocial theory, hypothesizes a relationship between the culture of a group and its risk of disease and the kind and quality of services obtained. Four areas of a culturally competent approach are cited as a minimum base of standards for providing services to people of color.

Chronic Disease↗

PubMed2002

Dental care considerations for young children.

Although the majority of America's children enjoy remarkably good oral health, a significant subset of low-income, minority, medically and developmentally compromised, and socially vulnerable children continue to suffer significant and consequential dental and oral disease. Most of this inequitably distributed disease burden is preventable through early and individualized preventive care. Yet the primary-care medical and dental workforce is ill-prepared to manage the oral health needs of young children. Demographic trends suggest that the problem of disparities in both oral health status and access to competent dental services will continue to worsen for young children. Impediments to improving the oral health of young children include barriers between medical and dental systems of care, paucity of private and safety-net facilities and providers in many areas where vulnerable children reside, and dysfunctional Medicaid insurance programs. Barriers are generated by parents, providers, payers, and systems of care as well as by the age-appropriate behaviors of young children. Vulnerable families often do not access the case management services and disease control information needed to effectively address their young children's needs. Approaches to improving the oral health of young children therefore include enhancing public education about oral health, the appropriateness of early and periodic dental care, and primary prevention. Improvements in workforce numbers, distribution, diversity, and competency are needed. Attention to delivery systems and public insurance capacities are also necessary to effectuate improvements. HRSA's Title VII and VIII health professions training programs could potentially address may of these barriers and shortcomings. Training enhancements for predoctoral, postdoctoral, and graduate dentists and hygienists as well as for primary-care medical providers hold the key to marked improvements in the oral health of young children. Enhanced training of health care providers is the necessary if not sufficient condition to children whose daily life experiences are compromised by dental and oral diseases that are overwhelmingly preventable.

Child, Preschool↗

PubMed2004

Clean indoor air policies in Wisconsin workplaces.

OBJECTIVE: To describe the nature and extent of workplace environmental tobacco smoke exposures in Wisconsin. METHODS: Descriptive data and confidence intervals from the Current Population Survey tobacco supplements of 1995-1996 and 1998-1999 are presented. RESULTS: The percent of indoor workers working under a smoke-free policy increased slightly, from 62% in 1995-1996 to 65% in 1998-1999. Respondents with a college degree were more likely to work under a smoke-free policy than those with a high school education or less. Among respondents with a work policy in 1998-1999, a complete ban on smoking reduced any workplace exposure in the past 2 weeks (4%) compared to a partial ban (26%) or an unrestricted policy (30%). CONCLUSION: Wisconsin has seen a small increase in workplace policies that ban smoking in the workplace. These policies are more likely to protect workers of higher socioeconomic status and may increase health disparities in tobacco-related diseases in the future.

Adolescent↗

PubMed1998

Prevalence of caries and edentulousness among 65-74-year-olds in Europe.

Reviewed in this article are epidemiological studies included in the WHO Global Oral Data Bank for noninstitutionalized European adults aged 65-74 years for the period 1986-96. Edentulous percentages, decayed, missing, filled teeth (DMFT) index, and data on the mean number of teeth are presented. At least one representative study had been carried out in 48% of the countries, with the quantity of information from countries with developed market economies being similar to that from countries with economies in transition. The proportion of 65-74-year-olds who were edentulous varied from 12.8% to 69.6%, the mean number of teeth ranged from 15.1 to 3.8, and the DMFT index from 22.2 to 30.2. The observed disparities in the oral health status among older European adults suggest that it may be possible to develop and implement oral health policies that take into account geographical and socioeconomic differences in populations.

Aged↗

PubMed1999

Experience of primary care by racial and ethnic groups in the United States.

OBJECTIVES: The purpose of this study was to examine the experience of primary care by racial and ethnic groups and identify aspects of primary care where significant disparities in experience exist across racial and ethnic groups. METHODS: Data for this study came from the Household Component of the 1997-1998 Medical Expenditure Panel Survey (MEPS), a nationally representative survey of the civilian noninstitutionalized population of the United States. Measures were identified within MEPS that denote race, ethnicity, experience of primary care, and socioeconomic covariates associated with access to care. RESULTS: Racial and ethnic minorities experienced worse primary care, particularly in the first-contact aspect, than did white Americans. Their usual sources of care were more likely to be hospital settings than private clinics. They faced greater barriers accessing their usual source of care (USC), finding it more difficult to get an appointment and waiting longer during an appointment. Many of the significant differences persist after adjustment for sociodemographic and health-status characteristics. CONCLUSIONS: Racial and ethnic disparity in primary care experience is not simply a reflection of sociodemographic and health-status differences across racial/ethnic groups. Efforts must be made to reduce nonfinancial as well as financial barriers to care and ensure that quality primary care is provided in all settings, public as well as private, and to individuals of all colors.

Adolescent↗

PubMed2001

Socioeconomic inequality in voting participation and self-rated health.

OBJECTIVES: This study tested the hypothesis that disparities in political participation across socioeconomic status affect health. Specifically, the association of voting inequality at the state level with individual self-rated health was examined. METHODS: A multilevel study of 279,066 respondents to the Current Population Survey (CPS) was conducted. State-level inequality in voting turnout by socioeconomic status (family income and educational attainment) was derived from November CPS data for 1990, 1992, 1994, and 1996. RESULTS: Individuals living in the states with the highest voting inequality had an odds ratio of fair/poor self-rated health of 1.43 (95% confidence interval [CI] = 1.22, 1.68) compared with individuals living in the states with the lowest voting inequality. This odds ratio decreased to 1.34 (95% CI = 1.14, 1.56) when state income inequality was added and to 1.27 (95% CI = 1.10, 1.45) when state median income was included. The deleterious effect of low individual household income on self-rated health was most pronounced among states with the greatest voting and income inequality. CONCLUSIONS: Socioeconomic inequality in political participation (as measured by voter turnout) is associated with poor self-rated health, independently of both income inequality and state median household income.

Adult↗

PubMed2002

Racism as a source of health disparity in families with children with attention deficit hyperactivity disorder.

Although poverty and health are inextricably linked, one cannot assume that simple poverty and low socioeconomic status are the primary causes of health disparity among racial groups. Examining the roles of racism and discrimination in access to health care and in the health experiences of people of color is fundamental to the goal of eliminating health disparities by 2010. Data from ethnic minority groups on how race influences health and health care services are absent from much of the nursing research literature. This article explores racism as a source of health disparity and discusses methodological implications for research, using attention deficit hyperactivity disorder (ADHD) research as an example.

Adaptation, Psychological↗

PubMed2006

The double burden on safety net providers: placing health disparities in the context of the privatization of health care in the US.

The US Institute of Medicine's (IOM) influential 2003 report has focused attention on disparities in treatment outcomes and health status for American minorities, zeroing in on the role of unconscious bias in the unequal clinical disposition of minority patients. In keeping with the IOM's focus, current examinations of health disparities in the US tend to explore bias in clinical decision-making to the neglect of the political economic trends that buffet health care safety net sites and create the need for financial shortcuts. This paper recontextualizes the study of health disparities in the US by placing it against the backdrop of private sector trends emphasizing fiscal austerity and increased workforce productivity in health care. The social science literature on workers in human service bureaucracies, only recently applied to health care workers, suggests that higher demands for system "accountability" and worker "efficiency" may encourage providers to take shortcuts by treating individuals as mass categories. This ethnography of a Latino mental health clinic in the Northwestern USA shows that new private-sector measures of "productivity" take a toll on both the Latina clinicians whose invisible work subsidizes the system as well as on particular categories of patients--the uninsured and immigrants with serious psychosocial issues. While clinicians attempt to buffer the impacts of such reforms on patients, they also resort to means to increase their productivity such as firing repeated no-show patients and denial of care to the uninsured. This study is relevant for the health care of the poor in all health care systems considering restructuring along managerial principles to increase system 'efficiencies.'

Community Mental Health Services↗

PubMedDate not supplied

Disparities in access to care and satisfaction among U.S. children: the roles of race/ethnicity and poverty status.

OBJECTIVES: The study assessed the progress made toward reducing racial and ethnic disparities in access to health care among U.S. children between 1996 and 2000. METHODS: Data are from the Household Component of the 1996 and 2000 Medical Expenditure Panel Survey. Bivariate associations of combinations of race/ethnicity and poverty status groups were examined with four measures of access to health care and a single measure of satisfaction. Logistic regression was used to examine the association of race/ethnicity with access, controlling for sociodemographic factors associated with access to care. To highlight the role of income, we present models with and without controlling for poverty status. RESULTS: Racial and ethnic minority children experience significant deficits in accessing medical care compared with whites. Asians, Hispanics, and blacks were less likely than whites to have a usual source of care, health professional or doctor visit, and dental visit in the past year. Asians were more likely than whites to be dissatisfied with the quality of medical care in 2000 (but not 1996), while blacks and Hispanics were more likely than whites to be dissatisfied with the quality of medical care in 1996 (but not in 2000). Both before and after controlling for health insurance coverage, poverty status, health status, and several other factors associated with access to care, these disparities in access to care persisted between 1996 and 2000. CONCLUSIONS: Continued monitoring of racial and ethnic differences is necessary in light of the persistence of racial/ethnic and socioeconomic disparities in access to care. Given national goals to achieve equity in health care and eliminate racial/ ethnic disparities in health, greater attention needs to be paid to the interplay of race/ethnicity factors and poverty status in influencing access.

Adolescent↗

PubMedDate not supplied

The community need index. A new tool pinpoints health care disparities in communities throughout the nation.

Catholic Healthcare West, San Francisco (CHW), has developed a national Community Need Index (CNI) in partnership with Solucient, an information products company, to help health care organizations, not-for-profits, and policymakers identify and address barriers to health care access in their communities. The CNI aggregates five socioeconomic indicators long known to contribute to health disparity--income, culture/language, education, housing status, and insurance coverage--and applies them to every zip code in the United States. Each zip code is then given a score ranging from 1.0 (low need) to 5.0 (high need). Residents of communities with the highest CNI scores were shown to be twice as likely to experience preventable hospitalization for manageable conditions--such as ear infections, pneumonia or congestive heart failure--as communities with the lowest CNI scores. The CNI provides compelling evidence for addressing socioeconomic barriers when considering health policy and local health planning. The tool highlights health care disparities between geographic regions and illustrates the acute needs of several notable geographies, including inner city and rural areas.Further, it should enable health care providers, policymakers, and others to allocate resources where they are most needed, using a standardized, quantitative tool. The CNI provides CHW with an important means to strategically allocate resources where it will be most effective in maintaining a healthy community.

Community Health Planning↗