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PubMed2000

The development of Māori primary care services.

This paper provides a broad overview of the development of Māori primary care services over the last decade and an outline of the current scope of Māori primary care services. The paper also récognizes the number of challenges and opportunities that face Māori providers and will briefly discuss three that are relevant to all providers: frameworks, information and effectiveness. Developing frameworks for contract specification and performance criteria that reflect Māori models of health and well-being, intersectoral approaches and the use of kaupapa and tikanga Māori in service development and delivery is a major challenge. Current approaches, while acknowledging these areas, for example in contracts, are based within the frameworks of a Western medical model. We have yet to clearly identify how we can meaningfully incorporate these philosophical and practical approaches to providing services into contractual arrangements. Providers have identified a need for information. The providers pass significant amounts of information to the funding agency, however many feel that very little information is returned from the funding agencies to the provider organizations. These providers could well use information feedback from the funding agency when they are reviewing and developing their services. There are also other types of information, for example having access to detailed local epidemiological and demographic information, that would be very useful to providers who are reviewing existing programs and developing new services. The third 'universal' challenge is the need to begin to collect information about how effective current Māori health strategies are, and how effectively services are caring for Māori clients. Developing information on effectiveness could utilize a multi-faceted approach, with information being collected at the provider level as well as at population level. Other questions relate to the effectiveness of our health promoting, disease preventing or disease management interventions. These points are relevant to all providers, but information on the effectiveness of mainstream health services is just as limited. The disparity between Māori and non-Maori health status however, suggests that these services (both public and personal health services) have not been as effective as they could have been.

Attitude to Health↗

PubMed2002

Does patient educational level affect office visits to family physicians?

Significant disparities in health care based on patient socioeconomic status have been documented. The extent to which physician behavior accounts for these differences is not known. We examined the impact of patient socioeconomic status, measured by years of education, on physician behavior assessed by direct observation of office visits, chart audits, and patient reports among 138 family physicians in 84 practices. Outcomes included time use measured with the Davis Observation Code, delivery of preventive services recommended by the US Preventive Services Task Force, satisfaction assessed with the MOS 9-item Visit Rating Scale, and delivery of attributes of primary care measured by the Components of Primary Care Index. After controlling for patient characteristics among 2538 visits by adult patients who returned questionnaires, a high school education or less was associated with slightly greater proportion of time spent on physical examination and providing nutrition counseling, and less time on patient questions, assessing patient health knowledge, negotiation, and exercise counseling. This indicates that physicians adopt a more directive style with less educated patients. Screening tests were provided at lower rates among less educated patients, but there were no differences in rates of health habit counseling or immunization services delivered and no differences in delivery of patient-reported components of primary care. Less educated patients had similar overall visit satisfaction, but were slightly less likely to have their expectations met. These show that patients' education has relatively small, but potentially important, effects on the outpatient delivery of primary care.

Cross-Sectional Studies↗

PubMed2003

The black cloud over the Sunshine State: health disparities in south Florida.

Florida, the "Sunshine State", is paradise for international tourists and has been adopted as seasonal or permanent home by many wealthy individuals and celebrities. However, Florida is not paradise for the growing number of residents who suffer from poverty, health problems, and a lack of access to health care and social services. The purpose of this paper is to present data on health care problems and disparities throughout the state of Florida and in select south Florida counties. Flaskerud and Winslow (1998) have provided a framework which can be used to analyze disparities in resource availability, relative risk, and health status indicators and suggests areas in which nursing and other health professionals can ethically intervene through research, practice, and political action.

Adolescent↗

PubMed2005

The relationship of racism to appraisals and coping in a community sample.

Ethnicity-related maltreatment (racism) is a significant stressor for many Americans and may contribute to racial disparities in health. Mechanisms linking this stressor to health status are not yet understood. This study tests the hypothesis that lifetime exposure to racism influences individuals' appraisals of and coping responses to new episodes of maltreatment. Participants included 420 Black and Latino patients and staff of community primary care practices in New York City. Participants completed the Brief Perceived Ethnic Discrimination Questionnaire--Community Version. They also completed measures of appraisals and anger coping modified to inquire about responses to new episodes of ethnicity-related maltreatment. Individuals who had higher levels of lifetime exposure to discrimination were more likely to experience new episodes as threatening and potentially harmful. Exposure to ethnic discrimination was also positively related to the use of anger coping styles, but the magnitude of the relationship varied depending on the type of discrimination. Individuals who had been exposed to higher levels of workplace discrimination were more likely to suppress anger in new situations. Those who were exposed to ethnicity-related social exclusion or harassment were more likely to confront others and aggressively express their feelings. The significance of the relationship held even when controlling for mood and personality variables that might account for both racism and coping. No differences were found between Blacks and Latinos in the relationship of racism to appraisals and coping. These findings add to the growing empirical literature on strategies for coping with racism.

Adaptation, Psychological↗

PubMed2002

Racial/ethnic variation in asthma status and management practices among children in managed medicaid.

OBJECTIVE: Racial/ethnic disparities in hospitalization rates among children with asthma have been documented but are not well-understood. Medicaid programs, which serve many minority children, have markedly increased their use of managed care in recent years. It is unknown whether racial/ethnic disparities in health care use or other processes of care exist in managed Medicaid populations. This study of Medicaid-insured children with asthma in 5 managed care organizations aimed to 1) compare parent-reported health status and asthma care processes among black, Latino, and white children and 2) test the hypothesis that racial/ethnic variations in processes of asthma care exist after adjusting for socioeconomic status and asthma status. METHODS: This cross-sectional study collected data via telephone interviews with parents and computerized records for Medicaid-insured children with asthma in 5 managed care organizations in California, Washington, and Massachusetts. The American Academy of Pediatrics (AAP) Children's Health Survey for Asthma was used to measure parent-reported asthma status. We used multivariate models to evaluate associations between race/ethnicity and asthma status while controlling for other sociodemographic variables. We evaluated racial/ethnic variations in selected processes of asthma care while controlling for other demographic variables and asthma status. RESULTS: The response rate was 63%. Of the 1658 children in the respondent group, 38% were black, 19% were Latino, and 31% were white. Black children had worse asthma status than white children on the basis of the AAP asthma physical and emotional health scores, symptom-days, and school days missed in the past 2 weeks. Latino children had equivalent AAP scores but missed more school days than white children. On the basis of the AAP asthma physical health score, the black-white disparity persisted after adjusting for other sociodemographic variables. After adjusting for sociodemographic variables and asthma status, black and Latino children were less likely to be using inhaled antiinflammatory medication than white children (relative risk for blacks: 0.69; relative risk for Latinos: 0.58). They were more likely to have home nebulizers. Other processes of asthma care, including ratings of providers and asthma care, use of written management plans, use of preventive visits and specialists, and having no pets or smokers at home, were equal or better for minority children compared with white children. CONCLUSIONS: Black and Latino children had worse asthma status and less use of preventive asthma medications than white children within the same managed Medicaid populations. Most other processes of asthma care seemed to be equal or better for minorities in the populations that we studied. Increasing the use of preventive medications is a natural focus for reducing racial disparities in asthma.

Black or African American↗

PubMed2006

Improving access to health care among New Zealand's Maori population.

The health status of indigenous peoples worldwide varies according to their unique historical, political, and social circumstances. Disparities in health between Maoris and non-Maoris have been evident for all of the colonial history of New Zealand. Explanations for these differences involve a complex mix of components associated with socioeconomic and lifestyle factors, availability of health care, and discrimination. Improving access to care is critical to addressing health disparities, and increasing evidence suggests that Maoris and non-Maoris differ in terms of access to primary and secondary health care services. We use 2 approaches to health service development to demonstrate how Maori-led initiatives are seeking to improve access to and quality of health care for Maoris.

Community Participation↗

PubMed1996

Progress towards the year 2000: assessing the health status of minorities in Texas.

In 1991, the Centers for Disease Control and Prevention released a consensus set of 18 health status indicators to help communities assess their general health status and focus local, state, and national efforts on tracking the year 2000 objectives. States and local communities were encouraged also to analyze the indicators for each major racial and ethnic population in their jurisdictions. This article presents an update of trends in Texas for the health status indicators for the total population, along with comparisons by race and Hispanic origin for the most recent data. Analysis of these data reveals that the health status for the total population is improving as we approach the year 2000. Yet despite these overall gains, significant disparities exist between the total population and the racial and ethnic minorities in Texas. Further efforts are needed to reduce these health disparities.

Adult↗

PubMedDate not supplied

Disparities in oral health and access to care: findings of national surveys.

In this background paper, sociodemographic variables, including age, race, family income, sex, parental education, and geographic location, have been used to characterize the dental status of US children and their access to dental services. Because tooth decay, or dental caries, remains the preeminent oral disease of childhood and national data is available on dental office visits, tooth decay has been used as the primary marker for children's oral health, and visits to the dentist is the marker for care. In general, children from low-income families experience the greatest amount of oral disease, the most extensive disease, and the most frequent use of dental services for pain relief. Yet these children have the fewest overall dental visits. Paradoxically, children in poverty-those living in households with annual gross incomes under $16 500 for a family of 4-or near poverty-those in family households with incomes between $16 500 and $33 000-also have the highest rates of dental insurance coverage, primarily through Medicaid and SCHIP. For those most affected, dental disease is consequential for their growth, function, behavior, and comfort. The twin disparities of poor oral health and lack of dental care are most evident among low-income preschool children, who are twice as likely to have cavities as are higher income children. Medicaid-eligible children who have cavities have twice the numbers of decayed teeth and twice the number of visits for pain relief but fewer total dental visits, compared to children coming from families with higher incomes. Fewer preventive visits for services such as sealants increase the burden of disease in low-income children. These disparities continue into adolescence and young adulthood, but to a lesser degree. Disparities in oral health status and access to dental care are also evident when comparing black, Hispanic, and Native American children to white children and when comparing children of parents with low educational attainment to children of parents with higher educational attainment. The fastest growing populations of children are those that currently have the highest disease rates and the lowest amount of dental care. If the strong correlation between these subpopulations and dental diseases continues, caries rates are likely to rebound after longstanding declines, and the stress on publicly financed dental care will likely increase.

Adolescent↗

PubMed2004

Inter-state disparities in health care and financial burden on the poor in India.

Over five decades of independence, India has made rapid strides in various sectors. However, its performance in social sectors and particularly the healthcare sector has not been too rosy. Being the State's responsibility the healthcare has traditionally been influenced by individual State's budgetary allocation. Consequently inter-state disparity in availability and utilization of health services and health manpower are distinctly marked. This has implications for achievement of Health for All for the nation as a whole. Keeping in view the significance of studying inter-state variations in healthcare, this study focuses on the performance of healthcare sector in 15 major States in India. This is attempted through a comparative analysis of various parameters depicting availability of health services, their utilization and health outcomes. Our analysis depicts the prevalence of considerable inequity favoring high income group of States. In terms of healthcare resources, for instance, it indicates that the high income States hold a superior position in terms of: per capita government expenditure on medical and public health, total number of hospitals and dispensaries, per capita availability of beds in hospitals and dispensaries and health manpower in rural and urban areas. These parameters of availability have an impact on utilization levels and health outcomes in these States. A comparative profile of high and low income States as well as middle and low income States, both in rural and urban areas, reaffirms a greater financial burden in availing treatment at OPD and inpatient in low income States. In line with the higher financial burden and low per capita health expenditure, the health outcome indicators also depict a disconcerting situation in regard to low income States. These States are marked by lower life expectancy and higher incidence of diseases as well as high mortality rates. In this regard, demand as well as supply side constraints are observed which restrain the optimum utilization of existing health services. Among the low income States the main constraints on the demand side include illiteracy, malnutrition, and lack of infrastructure in accessing the facilities. Certain state specific supply side factors add significantly to under-utilization in low income States. In some of the States, however, corrective actions have been initiated to overcome the problem of the quality and low utilization of health facilities. In due course of time, it is likely that proper implementation of these measures may result in improved utilization level of existing health services, which may be useful to improve health status indicators. Nonetheless, overcoming the current levels of regional disparities in healthcare across three income groups of States may also require additional resources. The latter could be mobilized through assistance of donor agencies and appropriate mix of social and private insurance. Ultimately mitigating the problem of regional disparities in healthcare and protecting the poor and vulnerable from financial burden may require establishing and maintaining proper linkages between socio-economic development and healthcare planning.

Cost of Illness↗

PubMed2005

The future (history) of socioeconomic measurement and implications for improving health outcomes among African Americans.

Socioeconomic status (SES) has powerful and complex impacts on health, and understanding the relationship between SES and health is essential for long-term improvements in the health of populations. In addition, in the United States, the impact of SES on health is inextricably intertwined with racial and ethnicity status and the historical development and maintenance of health disparities. Most of the literature documenting this relationship has focused on individual-level socioeconomic factors. There are sound theoretical reasons and some empirical support to suggest that socioeconomic resources at both individual and neighborhood levels have strong influences on health outcomes such as disease, disability, and mortality. However, these relationships have been inadequately examined to date. In this article, the term "ecological SES" will be used to denote SES at geographic group levels. As the United States attempts to achieve the goals of the Department of Health and Human Services' Healthy People 2010 program, understanding ecological SES and its impacts on health will be crucial. We review the theory, some of the empirical evidence, and likely future for the measurement and use of a broader approach to SES and offer a specific research paradigm for examining these issues. We focus in particular on one racial-ethnic group that experiences health disparity, that is, African Americans. We use our ongoing project investigating physical frailty in urban African Americans to illustrate the importance of a multilevel approach to understanding the impacts of socioeconomic resources on health and the potential implications for efforts to prevent or reverse frailty.

Black or African American↗

PubMed2003

Comparison of lower urinary tract symptom severity and associated bother between community-dwelling black and white men: the Olmsted County Study of Urinary Symptoms and Health Status and the Flint Men's Health Study.

OBJECTIVES: To determine the magnitude of racial disparity in lower urinary tract symptom (LUTS) severity and bother by combining two large comparable epidemiologic studies of community-dwelling white and black men, thereby avoiding many of the referral biases present in previous studies. Prior studies evaluating racial differences in benign prostatic hyperplasia have been hampered by selection bias, because nearly all have used surgical treatment as a marker for benign prostatic hyperplasia. METHODS: Data from the Olmsted County Study of Urinary Symptoms and Health Status and the Flint Men's Health Study were combined for a total study sample of 2480 men. We examined LUTS severity and associated bother as measured by the self-administered American Urological Association Symptom Index and Symptom Problem Index. RESULTS: Overall 34% of white men reported moderate/severe LUTS compared with 41% of black men (P <0.001). These patterns were consistent across age and persisted after adjustment for age and other sociodemographic factors. The relationship between LUTS severity and bother differed by race in that black men reported less bother for each unit increase in LUTS (P <0.001). CONCLUSIONS: In contrast to studies based on clinical populations, our community-based study demonstrated greater LUTS severity in black men compared with white men but black men reported less bother for any given level of LUTS severity. Although these findings suggest a racial disparity in benign prostatic hyperplasia, additional studies of anatomic, physiologic, and molecular factors may clarify whether these racial differences are real or due to sociocultural differences in reporting symptom morbidity.

Adult↗

PubMed2005

Prostate cancer among African-American males: understanding the current issues.

Prostate cancer affects African-American males within the United States in a disproportionate number compared to White males. African-American males are 1.7 times more likely to develop and 2-3 times more likely to die from prostate cancer than White males. Numerous reasons for this disparity exist, including low socioeconomic status, distrust, conflicting cultural beliefs, and past health-care experiences. Controversies surrounding this topic and perhaps contributing to the disparity include cancer-screening recommendations, cancer-related myths, and potential prevention modalities. Nursing research must focus on cancer-related issues among African-Americans to increase the awareness and knowledge of health-care professionals and the public to help decrease morbidity and mortality within African-Americans and other minority populations, and particularly among more vulnerable sections of at-risk minority populations. This article focuses on current issues related to African-American men and prostate health.

Black or African American↗

PubMed2005

Eliminating disparities in cardiovascular health: six strategic imperatives and a framework for action.

Disparities in cardiovascular health are among the most serious public health problems in the United States today. Despite the remarkable declines in cardiovascular mortality observed nationally over the last 3 decades, many population subgroups defined by race, ethnicity, gender, socioeconomic status, educational level, or geography show striking, and often widening, disparities in cardiovascular health. The pervasive nature of these disparities and compelling evidence of the adverse impact they have on clinical outcomes and quality of life have been well documented. The elimination of these disparities is 1 of the 2 overarching goals of the Healthy People 2010 national public health agenda; however, few publications provide guidance on what actions to take. In this review, 6 strategic imperatives within a framework for action are presented. Other key elements of the framework include 10 focal areas and 6 major settings within which the framework calls for accelerated interventions to eliminate disparities in cardiovascular health. Success in this endeavor will require innovative and comprehensive interventions built on a foundation of sound clinical and public health science. Strategic partnerships with communities, community-based organizations, state and local governments, and public and private partners from both health and nonhealth sectors are essential. Additionally, investment in local-level disparities surveillance, community-based participatory research, and development of a diverse clinical and public health workforce will be invaluable.

Attitude of Health Personnel↗

PubMed2004

Racial similarities and differences in predictors of mobility change over eighteen months.

OBJECTIVES: To define racial similarities and differences in mobility among community-dwelling older adults and to identify predictors of mobility change. DESIGN: Prospective, observational, cohort study. PARTICIPANTS: Nine hundred and five community-dwelling older adults. MEASURES: Baseline in-home assessments were conducted to assess life-space mobility, sociodemographic variables, disease status, geriatric syndromes, neuropsychological factors, and health behaviors. Disease reports were verified by review of medications, physician questionnaires, or hospital discharge summaries. Telephone interviews defined follow-up life-space mobility at 18 months of follow-up. RESULTS: African Americans had lower baseline life-space (LS-C) than whites (mean 57.0 +/- standard deviation [SD] 24.5 vs. 72.7 +/- SD 22.6; P < .001). This disparity in mobility was accompanied by significant racial differences in socioeconomic and health status. After 18 months of follow-up, African Americans were less likely to show declines in LS-C than whites. Multivariate analyses showed racial differences in the relative importance and strength of the associations between predictors and LS-C change. Age and diabetes were significant predictors of LS-C decline for both African Americans and whites. Transportation difficulty, kidney disease, dementia, and Parkinson's disease were significant for African Americans, while low education, arthritis/gout, stroke, neuropathy, depression, and poor appetite were significant for whites. CONCLUSIONS: There are significant disparities in baseline mobility between older African Americans and whites, but declines were more likely in whites. Improving transportation access and diabetes care may be important targets for enhancing mobility and reducing racial disparities in mobility.

Black or African American↗

PubMedDate not supplied

Pathways to access: health insurance, the health care delivery system, and racial/ethnic disparities, 1996-1999.

We examine the roles that insurance coverage, the delivery system, and external factors play in explaining persistent disparities in access among racial and ethnic groups of all ages. Using data from the 1996-1999 Medical Expenditure Panel Surveys and regression-based decomposition methods, we find that our measures of health care system capacity explain little and that while insurance clearly matters, external factors are equally important. Employment, job characteristics, and marital status are key determinants of disparities in access to insurance but are difficult for health policy to affect directly. Much of existing disparities remains unexplained, presenting a challenge to developing policies to eliminate them.

Black or African American↗

PubMed2001

Race: a major health status and outcome variable 1980-1999.

Based on the latest available data, African Americans are faced with persistent, or worsening, wide and deep, race-based health disparities compared to the white or general population as we enter the new millennium. These disparities are a 382-year continuum. There have been two periods of health reform specifically addressing the correction of race-based health disparities. The first period (1865-1872) was linked to Freedmen's Bureau legislation and the second (1965-1975) was a part of the Black Civil Rights Movement. Both had dramatic and positive effects on black health status and outcome, but were discontinued too soon to correct the "slave health deficit." Although African-American health status and outcome is slowly improving, black health has generally stagnated or deteriorated compared to whites since 1980. There is a compelling need for a third period of health reform accompanied by a cultural competence movement to address and correct persistent, often worsening, race-based health disparities.

Black or African American↗

PubMed2005

Reducing and eliminating health disparities: a targeted approach.

Health disparities have dominated recent discourse among public health and medical researchers. Ever since the United States began to compile health statistics, differences in health status have been noted between majority and non-majority populations. Myriad approaches have been undertaken in an attempt to reduce or eliminate racial and ethnic disparities in health. However, the disparities continue to persist. We are at a point in our history where innovative strategies must be explored that will be more effective in addressing racial and ethnic disparities in health. In large part, health disparities exist as a result of inequitable distribution of goods, resources, services and power in America. We have learned that improvements in health cannot come about solely through primary and secondary interventions but rather through an examination of the availability of resources that would allow individuals to improve their health. The goal of this paper is to provide an overview of the contextual factors that affect health disparities, to integrate theory to address disparities and to provide recommendations to encourage systematic changes to eliminate health disparities. It is hoped that this paper will bring about a national discussion relating to addressing the real issues we face in reducing and ultimately eliminating health disparities.

Black or African American↗

PubMed2002

Receipt of nutrition and exercise counseling among medical outpatients with psychiatric and substance use disorders.

OBJECTIVE: Mentally ill persons represent a population that is potentially vulnerable to receiving a poorer quality of medical care. This study examines the relationship between mental disorders and the likelihood of receiving recommended nutrition and exercise counseling. DESIGN: Cross-sectional study combining chart-review data and administrative database records. SETTING: One hundred forty-seven Veterans Affairs (VA) medical centers nationwide. PATIENTS/PARTICIPANTS: The sample included 90,240 patients with obesity and/or hypertension who had >/=3 medical outpatient visits in the previous year. MEASUREMENTS AND MAIN RESULTS: The outcomes of interest were chart-documented receipt of nutrition counseling and receipt of exercise counseling in the past 2 years. This chart information was merged with VA inpatient and outpatient administrative databases, which were used to identify persons with diagnosed mental disorders. Most patients received nutrition counseling (90.4%), exercise counseling (88.5%), and counseling for both (85.7%) in the past 2 years. The rates of counseling differed significantly but modestly by mental health status. The lowest rates were found among patients dually diagnosed with comorbid psychiatric and substance use disorders; however, the magnitude of the disparities was small, ranging from 2% to 4% across outcomes. These results were unchanged after controlling for demographics, health status, and facility characteristics using multivariable generalized estimating equation modeling. CONCLUSIONS: Among patients engaged in active medical treatment, rates of nutrition and exercise counseling were high at VA medical centers, and the diagnosis of mental illness was not a substantial barrier to such counseling. More work is needed to determine whether these findings generalize to non-VA settings and to understand the potential role that integrated systems such as the VA can play in reducing disparities for vulnerable populations.

Aged↗