Racial and Ethnic Disparities in Health and Health Care

1
Racial and Ethnic Disparities in Health and
Health Care

• Kevin Fiscella, MD, MPH
• University of Rochester School of Medicine
  Dentistry
• Departments of Family Medicine
• Community Preventive Medicine

2
What is race?

• How we define race strongly affects how we
  conceptualize the relationships between race and
  health and health care.

3
What is race?

• A group of people of common ancestry
  distinguished by physical characteristics such as
  hair type, eye or skin color, etc.
• -Collins English dictionary, 1998
• Geographic origin of ancestry 1997 OMB standards
• Ideology of inequality devised to rationalize
  European attitudes and treatment of the conquered
  and enslaved peoples.- American Anthropological
  Association Statement, 1998

4
What is ethnicity?

• Shared cultural, national, religious or
  linguistic heritage
• Hispanic or non-Hispanic origin 1997 OMB
  standards

5
Racial and ethnic disparities in mortality

• African Americans have the highest age-adjusted
  mortality rate of any group, followed by whites,
  American Indians/Alaska Natives, Hispanics, and
  Asians, Native Hawaiians or other Pacific
  Islanders.
• Deaths for American Indians/Alaska Natives and
  Hispanics tend to be misclassified on death
  certificates, so vital statistics underestimate
  mortality rates for these groups.

6
Disparities in cause-specific mortality

• Blacks have higher death rates than whites from
  all the leading causes of death except suicide
  and chronic lung disease. HIV death rates are 10
  times higher and homicide rates are more than 7
  times higher among blacks than whites.
• Hispanics have 3 times higher rates of death from
  HIV and homicide than whites and higher rates
  from liver disease and diabetes, but lower rates
  than whites for all other major causes including
  heart disease and cancer.

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Disparities in cause-specific mortality

• Asians have lower death rates than whites in all
  categories except homicide.
• American Indians/Alaska Natives have higher death
  rates than whites from liver disease, diabetes,
  HIV, accidents and homicide, but lower death
  rates from heart disease and cancer.

8
Life expectancy for African Americans is nearly
six years less than whites

• Disparities in socioeconomic status explain much
  of this gap.
• Disparities in cardiovascular mortality explain
  nearly one third of the gap.
• Hypertension represents the single largest
  contributor to this gap.

9
Black-white disparities in health begin in utero

• Black infant mortality rate is two and half times
  higher than that of whites.
• Most of this gap is due to racial differences in
  rates of very low birth weight.
• The primary causes of very low birth weight are
  intrauterine infection and hypertensive disorders
  that result in preterm birth.
• Sudden infant death is the major cause of racial
  disparities in post neonatal mortality.

10
Black-white disparities in maternal mortality

• African American women die during pregnancy and
  child birth at five times the rate of whites.
• The primary causes of this gap is disparities are
  vascular and infection related complications and
  homicide.

11
Fundamental causes of racial disparities in
health and well being

• Poverty
• Segregation
• Racism

12
Poverty

• More than one out of three black children under
  the age of 6 lived in poverty in 2000 (twice the
  rate of whites).
• Blacks earn on average 62 of that of whites.
• Among equivalent income or educational levels,
  blacks have far less wealth than whites.

13
Segregation

• African Americans experience greater and more
  persistent residential segregation than any other
  group hypersegregation.
• Massey, 1989
• Residential segregation and confinement to
  impoverished central cities has a devastating
  impact on the economic, educational,
  psychological, and physical well-being of African
  Americans. Williams, 2002
• Segregation undermines social cohesion,
  reinforces individual, institutional, and
  internatalized racism.

14
Racism

• Institutional and individual practices that
  create and reinforce oppressive systems of race
  relations whereby people and institutions
  engaging in discrimination adversely restrict by
  judgment and action, the lives of whom they
  discriminate against. -Krieger 2003

15
Categories of racism

• Individual racism - Ideology of inherent,
  biological superiority of one race over another
  that is used to justify discrimination.
• Institutional racism - Policies and practices
  that systematically reinforce the power and
  privilege of one racial group over another.
• Internalized racism - Introjection of pejorative
  messages by stigmatized racial group regarding
  their capabilities and behavior.

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These categories reinforce each other

• Unconscious racist assumptions (individual
  racism) result in national, state, and local
  policies (institutional racism) that reinforce
  racial stratification. Examples include
  educational, correctional, and economic policies.
• Persistent poverty, despair, stigma, and loss of
  community role models reinforce internalized
  racism.

17
Context matters

• Poverty, segregation, and racism do not operate
  in isolation from each other. It is the
  confluence of these factors that undermines the
  well being of African Americans.
• Current conditions cannot be understood in the
  absence of their historical context.
• The impact of poverty on a black child growing up
  in the inner-city is qualitatively different than
  that of a first generation Mexican or Asian child.

18
Race and genetics

• Race is a social construct without biological
  basis there is far greater genetic diversity
  within racial categories than between them.
• Because race is associated with geographic
  ancestral origin and because differences in
  geographic origin are associated with genetic
  allele frequency, allele frequency occasionally
  differs by race.
• These differences do not negate the social
  construction of race.
• Only a few conditions result from the effects of
  single alleles. Genetic differences by race are
  unlikely to explain most disparities in chronic
  diseases.

19
Causal pathways across the life course

• The pathways through which racism, segregation,
  and poverty affect black well-being are complex.
• Effects early in life may have lasting effects,
  e.g. fetal nutrition, lead toxicity, cognitive
  stimulation.
• Risk factors among disadvantaged groups tend to
  cluster and generate downward trajectories.
• Risk factors tend to have cumulative effects over
  time.

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Specific mediators of disparities

• Intrauterine environment - Fetal origins of
  disease hypothesis suggests that low birth weight
  infants are at higher risk for diabetes,
  hypertension, obesity, renal disease, and heart
  disease.
• Physical environment - Exposure to lead and other
  toxins, violence, availability of food, alcohol,
  and illicit drugs. allergens, passive smoke,
  crowding, infections, and diet.
• Family environment - Presence of two adult age
  parents, early cognitive stimulation, absence of
  abuse, and role models.
• Social environment - Impact of peers,
  expectations of future, risk of violence,
  opportunities for self expression, social
  network and support, and opportunities for
  marriage.

21
Specific mediators of disparities

• Psychological environment - Psychosocial stress
  from discrimination, autonomy/control, stigma,
  and internalized racism.
• Educational environment - Levels of expectations,
  concentration of students at risk, and resources.
• Work environment - Job opportunities, control of
  work, opportunities for advancement, risk of
  physical injury.
• Cultural environment - Norms of health related
  behavior e.g. breast feeding, infant sleeping
  position, douching, attitudes towards
  immunizations and health care.
• Health care environment Large disparities
  documented.

22
Exposure to toxins, allergens, infections
Racism
segregation
Intrauterine effects
Childhood poverty
Cognitive stimulation
Marriage
Family function
Access to health care
Community decline
cognitive and emotional development
Peer effects
Access to social networks
behavior
stress
Educational achievement
employment

• Adult poverty

Health
23
Racial and ethnic disparities in health care

• Disparities differ by type of health care and by
  racial and ethnic group.
• Disparities are best documented and most severe
  for African Americans.

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Disparities in types of health care

• Preventive services
• Medical treatment
• Surgical procedures
• Interpersonal care

25
Disparities in preventive care

• Prenatal care (number of visits and quality)
• Child immunizations
• Well child visits
• Adolescent immunizations
• Pap smear screening
• Breast cancer screening
• Colon cancer screening
• Influenza Pneumococcal immunization
• Smoking cessation advice

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Disparities in medical treatment

• Acute chronic pain
• Asthma
• Chemotherapy
• Congestive heart failure
• Coronary artery disease
• Depression

• Diabetes
• Dialysis
• HIV
• Hypertension
• Myocardial Infarction
• Pneumonia
• Stroke

27
Disparities in surgical or invasive procedures

• Organ transplantation
• Curative cancer surgery
• Cardiovascular procedures/surgery
• Cerebrovascular procedures/surgery
• Hip and knee replacement surgery

28
Disparities in satisfaction and interpersonal care

• Health care satisfaction
• Physician satisfaction
• Physician trust
• Involvement in care
• Perceived discrimination

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Causes of disparities in health care

• Societal factors - Differences in presence and
  type of health insurance and systems of care.
• Patient factors - Literacy, knowledge, beliefs,
  attitudes, language and norms.
• Physician factors - Unconscious stereotyping,
  cultural insensitivity, and poor communication
  skills

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Societal factors

• More than 50 of Hispanics and 40 of African
  Americans lacked health insurance at some point
  during 2001.
• Minorities more likely to be seen by residents.
• Presence and type of health insurance contribute
  to, but do not fully explain, disparities in
  health care.

31
Patient factors

• Patients beliefs, attitudes, knowledge,
  preferences and literacy contribute to
  disparities.
• Patient factors do not fully explain disparities.
• Patient factors are strongly influenced by system
  and provider factors.

32
Physician factors

• Overt prejudice - I wont recommend bypass
  surgery because this patient is black.
• Stereotyping - I wont recommend kidney
  transplantation because most blacks do not adhere
  to treatment.
• Clinical uncertainty - I wont recommend
  angiography because the patients symptoms are
  too dramatic (or not dramatic enough) to warrant
  the risk of this procedure.
• Poor communication - Absence of patient-centered
  care and patient-physician partnership.

33
Patient-centered care

• Represents a core dimension of health quality as
  defined by the IOM.
• Involves a set of core communication skills
  necessary to insure patient involvement in their
  care.
• Skills include obtaining knowledge of the patient
  as a person, eliciting the patients perspective
  on their condition.
• Explaining treatment options in understandable
  terms.
• Eliciting the patients preferences for treatment
• Confirming the patients understanding of the
  specifics of the treatment plan.

34
Minorities receive less patient-centered care

• Physicians adopt a more directive style,
• provide less information, and engage in less
  partnership with minority patients.
• The result is lower rates of adherence and lower
  quality care.

35
Equity is a core dimension of quality

• Equity recognized by the Institute of Medicine in
  2001.
• Quality assurance must include measures of
  disparity.
• Quality Improvement represents an important means
  for addressing disparities in care.
• Recent data suggest that quality improvement
  reduces disparities.

36
Implications for addressing disparities in health
health care

• The Healthy People 2010 goal of eliminating
  disparities in health requires addressing
  fundamental causes of disparities.
• Academic-community partnerships represent an
  important means for addressing fundamental and
  proximate causes of disparities at the local
  level.
• The elimination of disparities in health care
  will require initiatives leverage existing
  quality improvements efforts that address
  physician and patient factors.
• Quality improvements offer the greatest potential
  for change when they are strongly tied to the
  community.
• Disparities in access including insurance must be
  addressed