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Factors associated with patients' perceptions of health care providers' communication behavior.

We examined patients' ratings of communication with health care providers by sociodemographic characteristics, health care access, and health status. Data were from a national, population-based survey, the 2003 Health Information National Trends Survey (HINTS). The survey was administered to 6,369 adults from a representative sample of U.S. households. Linear regression analysis was conducted using SUDAAN. None of the sociodemographic variables were significantly associated with patients' ratings of providers' communication behavior in the linear model. Ratings of health care providers' communication behavior, however, were significantly higher among respondents with health insurance (p = 0.007) and those with a usual source of health care from whom they consistently sought care (p < 0.001). Ratings of provider communication were significantly lower among respondents who perceived their general health to be fair or poor (p < 0.001) and among those respondents with greater depressive symptoms (p < 0.001). Differences in patient ratings of health care providers' communication by health care access and health status suggest the potential for disparities in health outcomes.

Adolescent↗

Informal care and the empowerment of minority communities: comparisons between the USA and the UK.

This paper examines informal care and the empowerment of minority communities with respect to health care and health promotion in the USA and the UK based upon work prepared for the workshop, 'Involving Black and Minority Ethnic Users in Delivery of Services and Empowering Communities' presented during the bi-national 1997 USA, UK. Conference, 'Health Gain for Black and Minority Ethnic Communities' and the information gained from that Conference. 'Informal care' is operationally defined as 'the practice of alleviating distressful physiological and psychological dysfunctions through all others (e.g. traditional healers, family members, self, etc.) using measures that do not require a physician's prescription or intervention (e.g. lifestyle modifications) typically outside of formal, institutionally based care mechanisms (e.g. homes and communities). Informal care is a significant force in health maintenance, health promotion, and disease prevention. In the USA, at least one-third of the population is estimated to engage in unconventional medical practices, and perhaps, one-half of racial/ethnic populations use informal care. An enormous potential exists to better utilize informal care because informal care is culturally more compatible, relatively low cost, and flexible. The policy of the Indian Health Service in accepting the use of traditional medicine was cited. The US Congress recognized the potential of alternative medicine by establishing such an Office within the National Institutes of Health. 'Empowerment of racial/ethnic minority communities is the right for minority populations to determine their own destinies. In the USA, racial/ethnic minority populations are Blacks, Hispanics, Asians or Pacific Islanders, and American Indian/Alaska Native. These classifications are based upon self-report; in the UK, the black and minority classifications are based upon countries of birth rather than self-reported racial/ethnic identities. Empowerment of these communities is important both demographically and historically. In demographic terms, racial/ethnic minority populations are increasing at higher rates than the majority population in the USA and hence, the health status of minorities will become the health status of the nation in the next half century. Historically, racial/ethnic minorities have not been empowered. As a consequence of the 1985 Secretary's Task Force Report on Black and Minority Health Federal measures to address disparities in the health status of minorities were initiated. In March 1994, the UK Government initiated the Ethnic Health Unit within the National Health Service. These measures are not mature enough to evaluate their impact. However, progress in implementing measures to empower minorities in the UK have begun and are illustrated by the work reported by Dr Pui-Ling Li, the UK counterpart to the workshop, 'Involving Black and Minority Ethnic Users in Delivery of Services and Empowering Communities'. Recommendations are made to increase use of informal care and the empowerment for racial/ethnic minority communities and to build upon the works in progress in both the USA and the UK.

Complementary Therapies↗

Perceived social status, language and identified dental home among Hispanics in Florida.

BACKGROUND: The authors conducted a study to examine the extent to which perceived social status in communities and in U.S. society in general and primary language are associated with having a dental home among four Hispanic groups. METHODS: The authors used random-digit-dialing technology to select a probability sample of Hispanic adults in Miami-Dade County, Fla., for a telephone-based survey. Trained interviewers administered the pretested survey instrument in Spanish or English. The authors used bivariate contingency tables and multiple logistic regression modeling to analyze the data. RESULTS: Eight hundred ten adults participated, and their nationality groups were as follows: Cuba (n = 450), Nicaragua (n = 139), Colombia (n = 132) and Puerto Rico (n = 89). After controlling for nationality group, the authors found that respondents who perceived themselves to be at a higher social status in the United States than in their own community were significantly more likely to have a dental home; those who reported having a higher community status were significantly less likely to have a dental home compared with respondents who perceived their national and community social status to be equal. Respondents who primarily spoke a language other than English at home were less likely than those who primarily spoke English to have a dental home. Female respondents were more likely than male respondents to have a dental home. Respondents with dental insurance were more likely to have a dental home than were those without dental insurance. CONCLUSIONS: Perceived social status and acculturation may influence whether Hispanics have a dental home. However, because of the sample design, the findings may not be generalizable to all Hispanic populations in Florida or the United States. CLINICAL IMPLICATIONS: Reducing disparities in oral health status and in use of dental services among Hispanics relative to non-Hispanic whites may require attention to cultural factors such as language, community structure and immigrants' degree of acculturation.

Acculturation↗

Structure and content of chronic kidney disease information on the World Wide Web: barriers to public understanding of a pandemic.

Chronic kidney disease (CKD) is a pandemic and the need to inform those at risk has never been more important. The World Wide Web (WWW) is no w considered a key source of health information, but the quality and utility of this information has been challenged. In this article, we assess structural, content, and linguistic barriers to accessed CKD information and discuss the implications of limited Internet access to communicating health. Technical (number of hyperlinks), content (number of six core CKD and risk factor information domains included), and linguistic (readability and variation in readability) barriers were assessed for websites offered by 12 kidney disease associations. The Flesch Reading Ease Index method was used to estimate readability scores, and variation in the readability of information was assessed. Eleven websites met inclusion criteria. Six of 11 websites provided information in all 6 domains of CKD information. A mean of 4 hyperlinks (range 3-5) was clicked before CKD information was available and a mean of 6 hyperlinks (range 4-12) was clicked to access all available CKD information. Mean readability scores for all six domains of CKD information exceeded national average literacy skills and far exceeded the 5th grade level readability desired for informing vulnerable populations. Information about CKD and diabetes consistently had higher readability scores. The WWW currently has little utility for informing populations at greatest risk for CKD. Barriers to accessing CKD information on the WWW are socioeconomic, technical, and linguistic. Having lower socioeconomic status, less access to computers and the WWW, multiple website hyperlinks, incomplete information, difficult readability, and significant variation in readability of CKD information on the WWW are social, structural, and content barriers to communicating CKD information. This may contribute to the growing epidemics of diminished public understanding about CKD, and disparities in CKD health status experienced by racial/ethnic minority populations globally.

Computer Literacy↗

The need for diversity in the health professions.

The Surgeon General's Report on Oral Health remains a baseline document for addressing the issues of oral health disparities in America. With the problems of access to care and quality of care, cultural differences, history of discrimination, and ongoing severity of poverty, today there are many disturbing disparities in oral health status between people of color and the majority population. While the number of people of color is increasing, the number being prepared to provide quality oral health care is declining. The nation, the dental profession, and dental schools have not made adequate progress in the effort to develop a workforce that can address the disparities in oral health problems based on race and ethnicity. The Office of the Surgeon General is developing a National Oral Health Action Plan to help address these problems, but the role of dental schools is critical. Building a pipeline that will bring diverse people to the dental workforce must be a high priority for all involved. A substantial improvement in the diversity of the oral health student body and eventual workforce is a critical and essential element to achieving the goals of improving oral health and quality of life and eliminating health disparities.

Black or African American↗

Primary malignant brain tumor incidence and Medicaid enrollment.

BACKGROUND: The relationship between socioeconomic status and health care disparities in the incidence of brain tumors is unclear. OBJECTIVE: To identify the associations between age, sex, and Medicaid enrollment and the incidence of primary malignant brain tumors in Michigan in 1996 and 1997. METHODS: Records were obtained from the Michigan Cancer Surveillance Program on the 1,006 incident cases during this period and cross-checked with Medicaid enrollment files. RESULTS: Persons enrolled in Medicaid were more likely than non-enrolled persons to develop a malignant brain tumor of any type, a glioblastoma multiforme, and an astrocytoma for certain subgroups. In addition, incidence rates for malignant brain tumors in persons enrolled in Medicaid peaked at a younger age. CONCLUSION: Sociodemographic status may be associated with cerebral malignancy and should be considered when targeting treatment and educational interventions at persons at risk.

Adult↗

Mapping and measuring social disparities in premature mortality: the impact of census tract poverty within and across Boston neighborhoods, 1999-2001.

The identification and documentation of health disparities are important functions of public health surveillance. These disparities, typically falling along lines defined by gender, race/ethnicity, and social class, are often made visible in urban settings as geographic disparities in health between neighborhoods. Recognizing that premature mortality is a powerful indicator of disparities in both health status and access to health care that can readily be monitored using routinely available public health surveillance data, we undertook a systematic analysis of spatial variation in premature mortality in Boston (1999-2001) across neighborhoods and sub-neighborhoods in relation to census tract (CT) poverty. Using a multilevel model based framework, we estimated that the incidence of premature mortality was 1.39 times higher (95% credible interval 1.09-1.78) among persons living in the most economically deprived CTs (>/=20% below poverty) compared to those in the least impoverished tracts (<5% below poverty). We present maps of model-based standardized mortality ratios that show substantial within-neighborhood variation in premature mortality and a sizeable decrease in spatial variation after adjustment for CT poverty. Additionally, we present maps of model-based direct standardized rates that can more readily be compared to externally published rates and targets, as well as maps of the population attributable fraction that show that in some of Boston's poorest neighborhoods, the proportion of excess deaths associated with CT poverty reaches 25-30%. We recommend that these methods be incorporated into routine analyses of public health surveillance data to highlight continuing social disparities in premature mortality.

Adolescent↗

Compiling the evidence: the National Healthcare Disparities Reports.

Disparities in health care have been described extensively in the literature. The next step in resolving this national problem is to develop the necessary infrastructure for monitoring and tracking disparities. The congressionally mandated National Healthcare Disparities Report begins to build this infrastructure. The 2003 report addressed many of the methodological challenges inherent in measuring disparities. The recently released 2004 report continues the process by summarizing the status of U.S. health care disparities and beginning to track changes over time. Both reports emphasize the need to integrate activities to reduce disparities and to improve the quality of health care.

Data Collection↗

The Bulgarian country profile: the dynamics of some inequalities in health.

The Bulgarian health-care system was based on the concept of equal access and treatment. In its early stages health improved and disparities between urban and rural areas and districts diminished. New problems, institutional rigidities and policy reversals led later to the concentration of health resources in the towns and cities and to a deterioration in rural health. Sharp disparities in reported health status exist between occupational, educational and income groups. Life expectancy has fallen. Some health problems arise from urbanization, industrialization and heavy internal migration. Others clearly derive from dysfunction in the health system itself, its narrow concept of health, the inability of health plans to adapt to changing problems and needs and the emergence of privilege in access and quality of care.

Adolescent↗

Public policy analysis of Indiana's minority health initiatives.

Similar to national health trends in the US, racial/ethnic minorities in the state of Indiana continue to experience disparities in poor health status from preventable health conditions. To address this problem, people from minority communities across the state mobilized a broad base of individuals and organizations to facilitate the successful legislative enactment of a statewide minority health initiative. A case study of the initiative is presented for public policy analysis. The theoretical framework for the study is Etzioni's Societal Guidance Theory. The findings show that minority health advocates were able to impact favorably on public policy formulation and funding of the initiative by increasing knowledge about minority health status among grass-roots people, generating public consensus for public policy intervention, setting mutual goals via a 5-year strategic minority health plan, creating organizational structures to implement the plan and utilizing power to push the initiative through the legislative process. The weaknesses of the initiative efforts include a limited infrastructure development of minority health coalitions, restricted effective use of the legislative process and varying degrees of linkages among other advocacy groups. Improvements in these areas are discussed and recommendations are made for the implementation phase of the initiative.

Health Knowledge, Attitudes, Practice↗

Developing cultural competence in health care settings. National Center for Cultural Competence.

Increasing cultural and linguistic competence in health care settings is important for several reasons, including: responding to current and projected demographic changes in the United States; eliminating long-standing disparities in the health status of people of diverse racial, ethnic, and cultural backgrounds; improving quality of both services provided and health outcomes; meeting legislative, regulatory, and accreditation mandates; gaining a competitive edge in the market place; and decreasing the likelihood of liability/malpractice claims. Changes in policies, structures, practices, and procedures are often needed to bring about improvements in this arena. To support the process of change, The National Center for Cultural Competence (NCCC) was funded to increase the capacity of health care and mental health systems, institutions, programs, and providers to design, implement, and evaluate service delivery systems for cultural and linguistic competence. Several checklists developed by the NCCC are presented here for use by individual practitioners, programs, and institutions in assessing aspects of cultural competence.

Child↗

Professional motivation and career plan differences between African-American and Caucasian dental students: implications for improving workforce diversity.

Vast disparities in oral health status coupled with projected decreases in African Americans enrolling in and graduating from dental school have heightened concern about the underrepresentation of African Americans in the dental profession. The purpose of this study was to explore differences between African-American and white American students regarding demographics, professional motivations, and career plans. African-American (n = 104) and white American (n = 226) dental students completed a biographical data survey instrument, which included information about family background and professional motivations and plans, and rated descriptions of three practice arrangements. African-American students were more motivated to become a dentist to serve the public, plan to specialize, work in an urban area, and work part-time. White American students were more motivated to become a dentist based on factors related to family commitments. Race was a significant predictor for student ratings for both solo and employee practice. Study results have implications for health professions educators, administrators, and policy makers in their efforts to improve the recruitment and retention of African-American students, shape dental curricula to meet diverse student needs, and implement loan forgiveness programs to enhance minority student recruitment.

Black or African American↗

Many faces: addressing diversity in health care.

DIVERSITY: The changing demographics and economics of our growing multicultural world, and the long-standing disparities in the health status of people from culturally diverse backgrounds has challenged health care providers and organizations to consider cultural diversity as a priority. The purpose of this article is to present a model that will be helpful in providing culturally competent care. The concept of cultural competence is discussed, "The Process of Cultural Competence in the Delivery of Healthcare Services Model" is described, and a mnemonic to guide in providing culturally competent care is presented.

Cultural Diversity↗

The Minnesota Oral Health Care Solutions Project: implications for people with special needs.

Disparities in oral health status and access to dental care are major problems for people with special needs in Minnesota and across the country. The current delivery system for people with special needs is failing. Patients, community leaders, private dentists, safety net clinics, and state agencies are frustrated with the Medicaid program that funds the current system; and everyone is looking for new solutions. What would an improved oral health care system and Medicaid model look like? This paper describes Minnesota's Oral Health Care Solutions Project that seeks to answer this question and highlights the implications of a new model for people with special needs. The low reimbursements and administrative burdens of Minnesota's Medicaid program have led many dentists to reduce or stop seeing public program patients. As a result, many people with special needs have been unable to obtain routine dental care and therefore seek treatment in emergency rooms.

Delivery of Health Care↗

Eliminating oral health disparities: Ethics workshop reactor comments.

Oral health encompasses dentistry and is broader in concept. Dentistry alone appears insufficient to ensure oral health for the population at large. Troubling disparities in oral health status and access to care have been documented. The segment of the population that has little or no access to care is growing; aging baby-boomers are adding to this problem. As suggested in Oral Health in America: A Report of the Surgeon General, partnerships and collaboration are essential to improving oral health. The ethics of dental practice and the profession are being called into question. Who will provide the necessary leadership to address and resolve these issues, so that oral health is attainable by all?

Aged↗

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↗