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Health disparities

Health disparities (also called healthcare inequality in some countries) refer to gaps in the quality of health and health care across racial, ethnic, sexual orientation and socioeconomic groups.[1] 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."[2]

In the United States, health disparities are well documented in minority populations such as African Americans, Native Americans, Asian Americans, and Latinos.[3] When compared to whites, these minority groups have higher incidence of chronic diseases, higher mortality, and poorer health outcomes.[4] 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.[5] In addition, adult African Americans and Latinos have approximately twice the risk as whites of developing diabetes.[6] Minorities also have higher rates of cardiovascular disease, HIV/AIDS, and infant mortality than whites. (See also: Health care in the United States.)[7]

Health disparities are evident in the developing world, where the importance of equitable access to healthcare has been cited as crucial to achieving many of the Millennium Development Goals[8].


[edit] Ethnic and racial disparities

See Ethnicity and health and Race and health.

There is debate about what causes health disparities between ethnic and racial groups.[9] 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.[10]

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. Additionally, attention on health care disparities is largely focused on race and ethnicity; data on racial and ethnic disparities are relatively widely available. In contrast, data on socioeconomic health care disparities are collected less often, often using education as the indicator of socioeconomic status.[11]

The goal of eliminating disparities in health care in the United States remains elusive. Even as quality improves on specific measures, disparities often persist. Addressing these disparities must begin with the fundamental step of bringing the nature of the disparities and the groups at risk for those disparities to light by collecting health care quality information stratified by race, ethnicity and language data. Then attention can be focused on where interventions might be best applied, and on planning and evaluating those efforts to inform the development of policy and the application of resources. A lack of standardization of categories for race, ethnicity, and language data has been suggested as one obstacle to achieving more widespread collection and utilization of these data.[12]

The Institute of Medicine report, Race, Ethnicity, and Language Data[1] identifies current models for collecting and coding race, ethnicity, and language data; ascertains the challenges involved in obtaining these data in health care settings; and makes recommendations for improvement.

A study of 20,000 cancer patients in the United States found that African Americans are less likely than European Americans to survive breast, prostate and ovarian cancer even when given equal care, but that other forms of cancer had equal survival chances, which suggests that biological factors may be at work.[13]

Transplantation rates differ based on race, sex, and income. A study done with patients beginning long term dialysis showed that the sociodemographic barriers to renal transplantation present themselves even before patients are on the transplant list.[14] For example, different groups express definite interest and complete the pretransplant workup at different rates. Previous efforts to create fair transplantation policies had focused on patients currently on the transplantation waiting list.

[edit] LGBT minority group health disparities

See also LGBT issues in medicine.

Often under emphasized are the minority groups that are heavily affected by health disparities in America, UK and all the same worldwide. Health disparities are not just based on race, ethnic, and cultural differences. Such disparities are seen as affecting the sexuality minority groups and observations and surveys show that one's sexual minority status may limit access to health care, with especially bad impact on lesbians [15], which are being discriminated both as females and as homosexual [16].

'Health inequalities exist for lesbian and bisexual women, largely related to experiences of discrimination, homophobia and heterosexism.' [17] This known interference with health care access is a prime example of heterosexual privilege and homosexual prejudice prevalence in Western societies. 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 (being feared of) 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.[18]

[edit] 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.[19]
  • 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.[20]
  • 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.[21]
  • 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.[22]
  • 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.[23]
  • 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.[24]
  • 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.[25]
  • Linguistic barriers. Language differences restrict access to medical care for minorities in the United States who are not English-proficient.[26]
  • 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.[27]
  • 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.[28]
  • 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.[29] This could put older individuals at a disadvantage in terms of accessing valuable information about their health and how to protect it.

[edit] 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.[30] Other type of communication problems are seen in LGBT health care with the spoken heterosexist (conscious or unconscious) attitude on LGBT patients, lack of understanding on issues like having no sex with men (lesbians, gynecologic examinations) and other issues[31].
  • 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 ethnic 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.[32]
  • Lack of preventive care. According to the 2009 National Healthcare Disparities Report, uninsured Americans are less likely to receive preventive services in health care.[33] For example, minorities are not regularly screened for colon cancer and the death rate for colon cancer has increased among African Americans and Hispanic people.

[edit] 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:[34]

  • 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.[35]

[edit] 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. On 11 February 2010 Sir Michael Marmot, an epidemiologist at University College London, published the Fair Society, Healthy Lives report on the relationship between health and poverty. Marmot described his findings as illustrating a "social gradient in health": the life expectancy of the poorest is seven years shorter than the most wealthy, and the poor are more likely to have a disability. In its report on the study, The Economist argued that the causes of this health inequality include lifestyles - smoking remains more common, and obesity is increasing fastest, amongst the poor in Britain.[36]

[edit] See also

[edit] References

  1. ^ 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).
  2. ^ Goldberg, J., Hayes, W., and Huntley, J. "Understanding Health Disparities." Health Policy Institute of Ohio (November 2004), page 3.
  3. ^ Goldberg, J., Hayes, W., and Huntley, J. "Understanding Health Disparities." Health Policy Institute of Ohio (November 2004).
  4. ^ Goldberg, J., Hayes, W., and Huntley, J. "Understanding Health Disparities." Health Policy Institute of Ohio (November 2004), pages 4-5.
  5. ^ American Public Health Association (APHA), Eliminating Health Disparities: Toolkit (2004).
  6. ^ American Public Health Association (APHA), Eliminating Health Disparities: Toolkit (2004).
  7. ^ Goldberg, J., Hayes, W., and Huntley, J. "Understanding Health Disparities." Health Policy Institute of Ohio (November 2004), pages 4-5.
  8. ^ Vandemoortele, Milo (2010) The MDGs and equity Overseas Development Institute
  9. ^ Henry J. Kaiser Family Foundation (KFF), "A Synthesis of the Literature: Racial and Ethnic Differences in Access to Medical Care" (October 1999).
  10. ^ Goldberg, J., Hayes, W., and Huntley, J. "Understanding Health Disparities." Health Policy Institute of Ohio (November 2004), pages 6-7.
  11. ^ Isaacs, J.D., Stephen L. and Steven A. Schroeder. "Class - The Ignored Determinant of the Nation's Health". New England Journal of Medicine 351.11 (Sep 2004), 1137-1142. Retrieved 12 November 2008: http://content.nejm.org/cgi/reprint/351/11/1137.pdf
  12. ^ National Academy of Sciences. 2009. Race Ethniciy, and Language Data: Standardization for Health Care Quality Improvement. Washington, DC: The National Academies Press. Available at: http://www.nap.edu/catalog.php?record_id=12696
  13. ^ Blacks With Equal Care Still More Likely to Die of Some Cancers
  14. ^ Alexander GC, Sehgal AR. Barriers to cadaveric renal transplantation among blacks, women, and the poor. JAMA. 1998;280:1148-1152.
  15. ^ Handbook of health behavior research, David S. Gochman, pp. 145-147
  16. ^ Lesbian perinatal depression and the heterosexism that affects knowledge about this minority population, S. Trettin, E. L. Moses-Kolko, and K. L. Wisner, p. 1
  17. ^ (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.
  18. ^ 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.
  19. ^ Kaiser Commission on Medicaid and the Uninsured (KCMU), "The Uninsured and Their Access to Health Care" (December 2003).
  20. ^ 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.
  21. ^ Commonwealth Fund (CMWF), "Analysis of Minority Health Reveals Persistent, Widespread Disparities," press release (May 14, 1999).
  22. ^ Goldberg, J., Hayes, W., and Huntley, J. "Understanding Health Disparities." Health Policy Institute of Ohio (November 2004), page 10.
  23. ^ Agency for Healthcare Research and Quality (AHRQ), "National Healthcare Disparities Report," U.S. Department of Health and Human Services (July 2003).
  24. ^ Goldberg, J., Hayes, W., and Huntley, J. "Understanding Health Disparities." Health Policy Institute of Ohio (November 2004), page 10.
  25. ^ 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).
  26. ^ 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).
  27. ^ 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).
  28. ^ Goldberg, J., Hayes, W., and Huntley, J. "Understanding Health Disparities." Health Policy Institute of Ohio (November 2004), page 13.
  29. ^ Brodie M, Flournoy RE, Altman DE, et al. Health information, the Internet, and the digital divide. Health Affairs 2000; 19(6):255-65.
  30. ^ Goldberg, J., Hayes, W., and Huntley, J. "Understanding Health Disparities." Health Policy Institute of Ohio (November 2004), page 14.
  31. ^ Handbook of health behavior research, David S. Gochman
  32. ^ B. Smedley, A. Stith, and A. Nelson, "Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care," Institute of Medicine (2002).
  33. ^ Habib JL. Progress lags in infection prevention and health disparities. Drug Benefit Trends. 2010;22(4):112.
  34. ^ 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).
  35. ^ 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.
  36. ^ "In sickness and in health". The Economist. 11 February 2010. http://www.economist.com/world/britain/displayStory.cfm?story_id=15501633. Retrieved 15 February 2010. 

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