Health disparities

Health disparities (also called healthcare inequality in some countries) refer to gaps in the quality of health and health care across racial (see Race and health), ethnic, and socioeconomic groups. [U.S. Department of Health and Human Services (HHS), Healthy People 2010: National Health Promotion and Disease Prevention Objectives, conference ed. in two vols (Washington, D.C., January 2000).] The Health Resources and Services Administration defines health disparities as "population-specific differences in the presence of disease, health outcomes, or access to health care." [Goldberg, J., Hayes, W., and Huntley, J. "Understanding Health Disparities." Health Policy Institute of Ohio (November 2004), page 3.]

In the United States, health disparities are well documented in minority populations such as African Americans, Native Americans, Asian Americans, and Latinos. [Goldberg, J., Hayes, W., and Huntley, J. "Understanding Health Disparities." Health Policy Institute of Ohio (November 2004).] When compared to whites, these minority groups have higher incidence of chronic diseases, higher mortality, and poorer health outcomes. [Goldberg, J., Hayes, W., and Huntley, J. "Understanding Health Disparities." Health Policy Institute of Ohio (November 2004), pages 4-5.] Among the disease-specific examples of racial and ethnic disparities in the United States is the cancer incidence rate among African Americans, which is 10% higher than among whites. [American Public Health Association (APHA), Eliminating Health Disparities: Toolkit (2004).] In addition, adult African Americans and Latinos have approximately twice the risk as whites of developing diabetes. [American Public Health Association (APHA), Eliminating Health Disparities: Toolkit (2004).] Minorities also have higher rates of cardiovascular disease, HIV/AIDS, and infant mortality than whites. ("See also: Health care in the United States".) [Goldberg, J., Hayes, W., and Huntley, J. "Understanding Health Disparities." Health Policy Institute of Ohio (November 2004), pages 4-5.]

Groups affected by health disparities

Often under emphasized are the groups that are heavily affected by health disparities in America. Health disparities are not just based on race, ethnic, and cultural differences. Observations and surveys show that one’s choice of lifestyle limits or benefit his or her access to health care. “Health inequalities exist for lesbian and bisexual women, largely related to experiences of discrimination, homophobia and heterosexism.” [(2003, August 28). Health care inequalities in the lesbian community need to be addressed. Women's Health Weekly, 53(1), 1. Retrieved 30 March 2008, from Gale: http://find.galegroup.com/ips/start.do?prodId=IPS. ] This known interference with health care access is a prime example of heterosexual privilege and homosexual prejudice prevalence in our society. Just as this lack of health care affects minority races, ethnic groups, and less represented cultural beliefs; lesbian and bisexual women are deteriorating their health by either not seeing or not be attended to by health care professionals. It is important that health care professionals consider the nine cultural competency techniques suggested by the Agency for Healthcare Research and Quality and make an effort to break the barriers put into place through society’s homophobia and heterosexism. [ Brach, C. & Fraser, I. (2000). Can Cultural Competency Reduce Racial and Ethnic Health Disparities? A Review and Conceptual Model. Medical Care Research and Review, 57, 181-217. Retrieved March 31, 2008 from Google Scholar: http://mcr.sagepub.com/cgi/reprint/57/suppl_1/181.pdf.]

Causes of health disparities

There is debate about what causes health disparities between ethnic and racial groups. [Henry J. Kaiser Family Foundation (KFF), "A Synthesis of the Literature: Racial and Ethnic Differences in Access to Medical Care" (October 1999).] However, it is generally accepted that disparities can result from three main areas:

* From the personal, socioeconomic, and environmental characteristics of different ethnic and racial groups (such as how certain racial groups, on average, live in poorer areas with high incidence of lead-based paint, which can harm children). A great deal of research on social determinants of health and the socio-ecological model have also surfaced, which connect economic and social conditions in determining a community's or a population's health.
* From the barriers certain racial and ethnic groups encounter when trying to enter into the health care delivery system; and
* From the quality of health care different ethnic and racial groups receive. [Goldberg, J., Hayes, W., and Huntley, J. "Understanding Health Disparities." Health Policy Institute of Ohio (November 2004), pages 6-7.]

Each of these dimensions have been suggested as possible causes for disparities between racial and ethnic groups. However, most attention on the issue has been given to the health outcomes that result from differences in access to medical care among groups, and the quality of care different groups receive.

Disparities in access to health care

Reasons for disparities in access to health care are many, but can include the following:

* Lack of insurance coverage. Without health insurance, patients are more likely to postpone medical care, more likely to go without needed medical care, and more likely to go without prescription medicines. Minority groups in the United States lack insurance coverage at higher rates than whites. [Kaiser Commission on Medicaid and the Uninsured (KCMU), "The Uninsured and Their Access to Health Care" (December 2003).]
* Lack of a regular source of care. Without access to a regular source of care, patients have greater difficulty obtaining care, fewer doctor visits, and more difficulty obtaining prescription drugs. Compared to whites, minority groups in the United States are less likely to have a doctor they go to on a regular basis and are more likely to use emergency rooms and clinics as their regular source of care. [G. E. Fryer, S. M. Dovey, and L. A. Green, "The Importance of Having a Usual Source of Health Care," American Family Physician 62 (2000): 477.]
* Lack of financial resources. Although the lack of financial resources is a barrier to health care access for many Americans, the impact on access appears to be greater for minority populations. [Commonwealth Fund (CMWF), [http://www.commondreams.org/pressreleases/may99/051499a.htm "Analysis of Minority Health Reveals Persistent, Widespread Disparities,"] press release (May 14, 1999).]
* Legal barriers. Access to medical care by low-income immigrant minorities can be hindered by legal barriers to public insurance programs. For example, in the United States federal law bars states from providing Medicaid coverage to immigrants who have been in the country fewer than five years. [Goldberg, J., Hayes, W., and Huntley, J. "Understanding Health Disparities." Health Policy Institute of Ohio (November 2004), page 10.]
* Structural barriers. These barriers include poor transportation, an inability to schedule appointments quickly or during convenient hours, and excessive time spent in the waiting room, all of which affect a person's ability and willingness to obtain needed care. [Agency for Healthcare Research and Quality (AHRQ), "National Healthcare Disparities Report," U.S. Department of Health and Human Services (July 2003).]
* The health care financing system. The Institute of Medicine in the United States says fragmentation of the U.S. health care delivery and financing system is a barrier to accessing care. Racial and ethnic minorities are more likely to be enrolled in health insurance plans which place limits on covered services and offer a limited number of health care providers. [Goldberg, J., Hayes, W., and Huntley, J. "Understanding Health Disparities." Health Policy Institute of Ohio (November 2004), page 10.]
* Scarcity of providers. In inner cities, rural areas, and communities with high concentrations of minority populations, access to medical care can be limited due to the scarcity of primary care practitioners, specialists, and diagnostic facilities. [K. Collins, D. Hughes, M. Doty, B. Ives, J. Edwards, and K. Tenney, "Diverse Communities, Common Concerns: Assessing Health Care Quality for Minority Americans," Commonwealth Fund (March 2002).]
* Linguistic barriers. Language differences restrict access to medical care for minorities in the United States who are not English-proficient. [National Health Law Program and the Access Project (NHeLP), Language Services Action Kit: Interpreter Services in Health Care Settings for People With Limited English Proficiency (February 2004).]
* Health literacy. This is where patients have problems obtaining, processing, and understanding basic health information. For example, patients with a poor understanding of good health may not know when it is necessary to seek care for certain symptoms. While problems with health literacy are not limited to minority groups, the problem can be more pronounced in these groups than in whites due to socioeconomic and educational factors. [K. Collins, D. Hughes, M. Doty, B. Ives, J. Edwards, and K. Tenney, "Diverse Communities, Common Concerns: Assessing Health Care Quality for Minority Americans," Commonwealth Fund (March 2002).]
* Lack of diversity in the health care workforce. A major reason for disparities in access to care are the cultural differences between predominantly white health care providers and minority patients. Only 4% of physicians in the United States are African American, and Hispanics represent just 5%, even though these percentages are much less than their groups' proportion of the United States population. [Goldberg, J., Hayes, W., and Huntley, J. "Understanding Health Disparities." Health Policy Institute of Ohio (November 2004), page 13.]
*Age. Age can also be a factor in health disparities for a number of reasons. As many older Americans exist on fixed incomes which may make paying for health care expenses difficult. Additionally, they may face other barriers such as impaired mobility or lack of transportation which make accessing health care services challenging for them physically. Also, they may not have the opportunity to access health information via the internet as less than 15% of Americans over the age of 65 have access to the internet. [Brodie M, Flournoy RE, Altman DE, et al. Health information, the Internet, and the digital divide. Health Affairs 2000; 19(6):255-65.] This could put older individuals at a disadvantage in terms of accessing valuable information about their health and how to protect it.

Disparities in quality of health care

Health disparities in the quality of care different ethnic and racial groups receive can include:

* Problems with patient-provider communication. This communication is critical for the delivery of appropriate and effective treatment and care and, regardless of a patient’s race, miscommunication can lead to incorrect diagnosis, improper use of medications, and failure to receive follow-up care. Among non-English-speaking populations in the United States, the linguistic barrier is even greater. Less than half of non-English speakers who say they need an interpreter during health care visits report having one. Additional communication problems stem from a lack of cultural understanding on the part of white providers for their minority patients. For example, patient health decisions can be influenced by religious beliefs, mistrust of Western medicine, and familial and hierarchical roles, all of which a white provider may not be familiar with. [Goldberg, J., Hayes, W., and Huntley, J. "Understanding Health Disparities." Health Policy Institute of Ohio (November 2004), page 14.]
* Provider discrimination. This is where health care providers either unconsciously or consciously treat certain racial and ethnic patients differently than other patients. Some research suggests that minorities are less likely than whites to receive a kidney transplant once on dialysis or to receive pain medication for bone fractures. Critics question this research and say further studies are needed to determine how doctors and patients make their treatment decisions. Others argue that certain diseases cluster by ethnicity and that clinical decision making does not always reflect these differences. [B. Smedley, A. Stith, and A. Nelson, "Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care," Institute of Medicine (2002).]

Ending health disparities

The Commonwealth Fund, in a report on how to eliminate health disparities, says that the following steps should be considered in developing policies to eliminate racial and ethnic disparities: [J. McDonough, B. Gibbs, J. Scott-Harris, K. Kronebusch, A. Navarro, and K. A. Taylor, "State Policy Agenda to Eliminate Racial and Ethnic Health Disparities," Commonwealth Fund (June 2004).]

* Consistent racial and ethnic data collection by health care providers.
* Effective evaluation of disparities-reduction programs.
* Minimum standards for culturally and linguistically competent health services.
* Greater minority representation within the health care workforce.
* Establishment or enhancement of government offices of minority health.
* Expanded access to services for all ethnic and racial groups.
* Involvement of all health system representatives in minority health improvement efforts.

Other methods for ending health disparities or reducing health disparities have been suggested based on research that observes cultural differences within health care systems. According to the Agency for Healthcare Research and Quality and the assisting authors Cindy Brach and Irene Fraserirector, in an effort to reduce disparities between racial and ethnic groups, the health care system should consider the following nine cultural competency techniques:

*Interpreter services. If agencies take an active approach in hiring professional interpreters, for both foreign languages and for the speaking and hearing impaired, communication barriers will begin to decrease.
*Recruitment and Retention. Healthcare systems need to become more conscious of the staff within their facilities. It is essential to the reduction of disparities that most minority groups be represented within the various health care offices and clinics.
*Training. The Agency for Healthcare Research and Quality and its assisting authors emphasized the importance of health care professionals being trained to work with interpreters and minority groups.
*Coordinating with traditional healers. Health care workers should be supportive and able to adjust health care plans according to the patient’s cultural beliefs and traditional health practices.
*Use of Community Health Workers. These individuals could be responsible for bringing in the population of people who rarely seek out health care.
*Culturally competent health promotion. This information can be available through community health workshops, or simply by health care workers taking the necessary measures to promote early detection and treatment and outlining the good and risky health behaviors to all patients.
*Including family and/or community members. The Agency for Healthcare Research and Quality states that this particular cultural competency may be vital to obtaining consent and adherence to treatments.
*Immersion into another culture. Allowing yourself to step outside of your comfort zone will increase your tolerance for another culture as well as raise your awareness to new ideals and beliefs.
*Administrative and Organizational accommodations. These are some aspects of the health care offices that should be considered; they include the location of the healthcare offices, public transportation availability, clinic hours, the physical environment of the clinic, and the rapport built with the patients. [Brach, C. & Fraser, I. (2000). Can Cultural Competency Reduce Racial and Ethnic Health Disparities? A Review and Conceptual Model. Medical Care Research and Review, 57, 181-217. Retrieved March 31, 2008 from Google Scholar: http://mcr.sagepub.com/cgi/reprint/57/suppl_1/181.pdf.]

Health inequalities

Health inequality is the term used in a number of countries to refer to those instances whereby the health of two demographic groups (not necessarily ethnic or racial groups) differs despite comparative access to health care services.

Such examples include higher rates of morbidity and mortality for those in lower occupational classes than those in higher occupational classes, and the increased likelihood of those from ethnic minorities being diagnosed with a mental health disorder.

In Canada, the issue was brought to public attention by the LaLonde report.In UK, the Black Report report was produced in 1980 to highlight inequalities.

References

Further Notes

* Goldberg, J., Hayes, W., and Huntley, J. [http://www.healthpolicyohio.org/publications/healthdisparities.html "Understanding Health Disparities."] Health Policy Institute of Ohio (November 2004).
* McDonough, J., Gibbs, B., Scott-Harris, J., Kronebusch, K., Navarro, A., and Taylor, K. A. "State Policy Agenda to Eliminate Racial and Ethnic Health Disparities," Commonwealth Fund (June 2004).
* Smedley, B., Stith, A., and Nelson, A. " [http://www.nap.edu/openbook/030908265X/html/index.html Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care] ." Institute of Medicine (2002).

See also

*Health and Social Class
* Healthcare inequality
* Public health
* Center for Minority Health
* Population health

External links

* [http://www.iom.edu/CMS/3793/44963.aspx Institute of Medicine Roundtable on Health Disparities] was created to enable diaologue and discussion of issues related to the visibility of racial and ethnic disparities in health and health care as a national problem, the development of programs and strategies to reduce disparities and the emergence of new leadership.
* [http://videos.med.wisc.edu/event.php?eventid=2 Cultural Diversity in Health Care Speaker Series] videos presentations from expert lecturers, University of Wisconsin School of Medicine and Public Health
* [http://videos.med.wisc.edu/event.php?eventid=30 Cultural Diversity in Health Care Research Symposium] video presentations from expert lecturers, University of Wisconsin School of Medicine and Public Health
* [http://www.ncmhd.nih.gov/ National Center on Minority Health and Health Disparities]
*Journal of Health Care for the Poor and Underserved
* [http://www.healthpolicyohio.org/publications/healthdisparities.html Understanding Health Disparities]
* [http://raceandhealth.hhs.gov/ Initiative to Eliminate Racial and Ethnic Disparities in Health] United States government minority health initiative
* [http://www.healthdisparities.net/hdc/html/home.aspx Health Disparities Collaborative]
* [http://www.boston.com/business/articles/2005/07/26/mgh_seeks_to_bridge_healthcares_racial_gap/?page=full Massachusetts General Hospital seeks to bridge healthcare's racial gap]
* [http://www.dhi.gov.au/clearinghouse/ Diversity Health Institute Clearinghouse]
* [http://www.reducedisparity.org/ Case Center for Reducing Health Disparities]
* [http://chua2.fiu.edu/hdrg/ FIU Health Disparity Research Group]
* [http://kaisernetwork.org/daily_reports/rep_disparities.cfm "Kaiser Health Disparities Report: A Weekly Look at Race, Ethnicity and Health"] , News summary report from kaisernetwork.org
* [http://www.moh.govt.nz/moh.nsf/0/523077dddeed012dcc256c550003938b?OpenDocument Health inequality in New Zealand]
* [http://news.bbc.co.uk/1/hi/health/4139440.stm BBC News article regarding health inequalities]
* [http://www.healthdisparity.tuskegee.edu/ EXPORT Project webpage atTuskegee University]
* [http://www.wilsoncenter.org/index.cfm?topic_id=116811&fuseaction=topics.event_summary&event_id=224806 VIDEO: Health Status Disparities in the US] , April 4, 2007, "featuring" Paula Braveman, Gregg Bloche, George Kaplan, Thomas Ricketts, Mary Lou deLeon Siantz, and David Williams
* UK National Health Service Specialist Library for Ethnicity & Health [http://www.library.nhs.uk/ethnicity]
* [http://www.NRHArural.org/ National Rural Health Association]