Challenging Dogma


...Using social sciences to improve the practice of public health

Wednesday, April 25, 2007

Disadvantaged From Birth: Why The Initiative To Eliminate Racial And Ethnic Health Disparities Is Failing Miserably – Norma Ojehomon

Disparities in morbidity and mortality continue to be experienced more by African Americans, Hispanic Americans, Asian Americans/Pacific Islanders, and American Indians/Alaska Natives, as compared to the US population as a whole (1). It is clear that socio-economic status (SES), which is often the clear distinction between whites and minority groups, plays a major role. However, even when data is adjusted for SES, many of these groups tend to have poorer health outcomes (2, 3). Minor genetic and biological difference also cannot explain this (4, 5). Clearly, the experts are missing something. There must be other combinations of environmental factors, health behaviors, and differences in health care quality and access that play a role. This disproportionate toll of certain diseases on various racial and ethnic minority populations calls to attention the need for prevention, treatment and improving resources toward reducing the loss of life(5) .

Such statistics have led to the launch of several campaigns that have committed to eliminating these differences, the best known of which might be Healthy People 2010. Another such campaign, The “Closing the Health Gap Campaign,” is an educational campaign that was designed to inform racial and ethnic minority populations, about the rate at which they are disproportionately affected by serious diseases and health conditions when compared to Caucasians. It was initiated by the Office of Minority Health Resource Center (OMRHC), specifically to target African-American and Hispanic populations (7).

Two of the program’s main components: Know What to Do for Life and Take a Loved One for a Checkup Day are particularly interesting. The former is designed to help reduce the infant mortality rate among African Americans by reducing the risks of Sudden Infant Death Syndrome (SIDS), preterm birth, and low birth weight. Statistics show that African-American infants are twice as likely and Native-Americans one and a half times as likely to die in their first year as their white counterparts (5, 8). Data, adjusted for SES, shows as many as 14.2 deaths per 1000 live births, placing African-American babies on par with some developing countries(8). Take a Loved One for a Checkup Day encourages individuals to make an appointment for a health screening, attend a health event in the community, or help a friend, neighbor or family member do the same. It focuses on major areas in which racial and ethnic minorities experience serious disparities in health access and outcomes, such as diabetes, heart disease and stroke, cancer, infant mortality, child and adult immunization, and HIV/AIDS. While having good intentions, the Closing the Health Gap campaign is destined to fail if officials do not stop to take into account several key social behavioral aspects in analyzing the problem.

But wait… what more do you need?

The Closing the Health Gap campaigns fail to take into account Maslow’s hierarchy of needs. This theory contends that as humans meet 'basic needs', such as food, they will move up the ranks and seek to satisfy successively 'higher needs' needs, such as safety, employment, love and belonging, and esteem before which they can finally reach the peak which is self-actualization(9). Once an individual has moved past a level, those needs will no longer be prioritized. However, if a lower set of needs is continually unmet for extended periods of time, the individual will temporarily re-prioritize those needs, dropping down to in levels until those lower needs are reasonably satisfied again(9). Among many minority populations, basic needs are unmet; therefore, it is not a priority for them to move up the Maslow’s hierarchy (10). Starting from the bottom of the scale moving up there is evidence that many minority communities are lacking in the safety component. For example, many urban areas are notoriously underserved when it comes to transportation (10, 11). It is then very unlikely that a mother will chose to take herself, and her children or family members to the hospital for screening after waiting for the bus for several hours. More than likely the only time she will be forced to go is during an emergency.

If you move up the hierarchy to love and belonging, it is difficult to feel that you are cared for or wanted in an urban setting, when homes are falling apart and everything looks worn down (12). Experiences of racism and discrimination tear down self-esteem, causing a person to feel unworthy of treatment, or mistrust the system because of it, and avoid treatment (13). Growing up in this type of environment, it is easy to see why you would never reach the top of the pyramid. Even among the wealthier minority populations, who have these elementary needs met, more complex issues, such as racism and belonging to a given community, may still come into play (14 -17).

All men are created equal

SES also plays an important role in looking at the campaigns. More minorities are likely to be poor (12). Know What to Do for Life and Take A Loved One For A Checkup Day rely heavily on the Health Belief Model, based on the belief that once perceived susceptibility, and severity are made clear, then people will seek treatment. This model relies heavily on the individual making a rational decision to change behavior once informed, but this does not necessarily occur. Once a person is aware of a problem, they may not be able to or willing to change it.

The first aspect, ability, is often tied with economic barriers since in many minority communities, the nearest hospital is very difficult to reach and residents will often have to wait a long time for public transportation (11). These hospitals are often crowded, understaffed and undersupplied, resulting in a further delay before being seen by a physician (18 -21). Both the Take a Loved One to Check up Day and Know What to Do for Life campaign fail to consider other important demands in a patient’s life. For example, if a patient has to worry about child care because paid babysitters are not affordable or the child cannot accompany the patient, then it really is not a simple matter of going to the hospital just because care is provided. Also, since not every element of the care is free, there is a possibility that a patient will go to the doctor for a screening, be prescribed medication and not get it because they are unable to afford it, which would defeat the whole purpose of having gone in the first place.

Other than the visible economic barriers to better health, there may be cultural or social aspects which play a part. Again, awareness of the importance of screening does not dictate whether a person will seek the available services. Many people might be afraid to get screened, especially if they have been living unhealthy lifestyles, because they are afraid of what they will find especially if they have put it off so long. There is evidence to show that African-American men are more likely to be screened for and diagnosed with colorectal cancer much later than their Caucasian counterparts (22). Among the many reasons cited as to why this occurs is that there is simply a mistrust of the system. Some women are from cultures where women do not go in to see a doctor, or cannot go without a male present (23). If no one is available to go with her, then whether or not she is educated about the dangers is irrelevant, she will choose not to go.

Preterm and low-birth rates, which play a factor in infant mortality, have been known to be linked with alcohol consumption and cigarette smoke (14). However, many minorities are living in communities where the probable daily reality of life is gunshot wounds and racism is experienced continually (12). Even though the knowledge that these things are bad during pregnancy is present, many women might to chose to self-medicate with these to escape the harsh reality of their world.

It’s all you fault!

The Closing the Health Gap campaign frames the issue as if once access to knowledge and health care are provided, and then the problems will be solved. The program fails to take into account that in addition to poverty and other factors often commonly associated with poor health in minority communities, much research has been done to show that there are many other reasons why minorities experience poorer health outcomes even when adjusting for these factors across racial groups. For example, there have been many reports of discrimination of minorities by health care providers, even when they are able to pay for their healthcare (8, 14, 24). The cause of this has long been a mystery, but some researchers believe that physician training may have played a part (8). Some biases, including the belief that African-Americans are less likely to get a certain disease, may lead to an increase in screening among the African-American population; however, if individuals have not been thoroughly screened and still acquire that particular disease, the news might quickly spread through their community that such screenings are useless (8).

Language creates another formidable barrier for health care providers dealing with minority groups, especially with the growing number of non-English speaking immigrants (24). Often this population will come to health care settings with their young children to translate because there is no one else to come in with them. When Chinese-American women were told about cancer screening in their own language, they were more likely to go in for screening (24). Closely related to this, is medical literacy. Since most adults do not know many medical terms, it is certainly not expected that a child will completely understand and accurately express these terms. This defeats the whole purpose of going in for screening if you live in a community where there are not adequate people to translate. Another inhibitor to seeking care with immigrant populations is the fact that some are illegal aliens, and may fear that they will be required to report their immigration status when going in for screening, which might result in being traced and subsequently deported (25). For many, the possibility of getting deported before their children are born as American citizens may be reason enough to not go in for checkups. This is especially crucial for the Know What to do for Life campaign.

There is another element that plays a part, and that is the broad and often useless terms which are used to describe many cultural groups (8). For example, the term African-American is used to describe people who have been living in the US for several generations, as well as recent immigrants from several African and Caribbean countries. Likewise, the term Hispanic-American is used to describe people from Cuba, Mexico, Puerto-Rico, the Dominican Republic, Brazil, and many other nations. A program targeted to one of these broad groups, may not be effective in reaching all populations included in the umbrella terms Hispanic and African American (26). For example, reports show not much difference in infant mortality when Hispanic Americans are compared to whites, yet the average daily infant mortality rates for people of Puerto-Rican descent were 50% higher than those for Mexican-Americans, highlighting a marked difference in rates (8). This shows that the lumping together of categories and cultures based a single common characteristic is virtually useless in delivering effective interventions, since there is often as much variation across groups as among groups(8).

These cultural factors make it difficult to solve any health care problem with one specific intervention. The need to be flexible and adaptable is a feature many programs often lack but is necessary due to the difference in prevalence of certain health outcomes in various minority groups. For example, the incidence of colorectal cancer in African-Americans is not the same as that in Hispanics (24 -26). As long as these programs continue to ignore certain social and behavioral principles, and leave behind their one size-fits-all models, the data will continue to be disparaging.

Do not give up hope

In the end, overall, the Closing the Health Gap Campaign has good intentions and has begun with a great start in calling attention to a problem and laying out plans for a solution. It is crucial to get the news out about racial disparities in health and let people know what exactly is affecting them. It is difficult to begin any sort of changing process without the knowledge to back up and proper venues where you can begin. Until social and behavioral needs are taken into consideration, it will be a long and difficult process to produce much change.

References

1. Carter-Pokras, O and Baquet, C. What is a Health Disparity? Public Health Reports. 2002, 17, 426 -434.

2. Agency for Healthcare Research and Quality Addressing Racial and Ethnic Disparities in Health Care Fact Sheet, Rockville, MD. http://www.ahrq.gov/research/disparit.htm. 2000.

3. Fiscella K et. al. Inequality in Quality, Addressing socioeconomic, racial. And ethnic disparities in health care. JAMA 283, 19 2579 -2583. 2000

4. Mays, VM et al. Classifications of Race and Ethnicity. Implications for Public Health. Annu. Rev. Public Health 2003. 24:83–110

5. US Department of Health and Human Services. HHS Fact Sheet. The Initiative to Eliminate Racial and Ethnic Disparities in Health. http://raceandhealth.hhs.gov/glance.htm, 2004.

6. Sankar, P et al. Genetic Research and Health Disparities. JAMA, 2004; 291 24: 2985 -2989.

7. Department of Health and Human Services. Closing the Health Gap Campaign. http://www.omhrc.gov/healthgap/. Washington, DC.

8. The Association of Health Care Journalists. Why it matters: Communities are changing; inequities endure. Covering the Quality of Health Care – A Resource Guide for Journalists.

9. Maslow, A. H. (1943). A Theory of Human Motivation. Psychological Review, 50, 370–96.

10. National Consumers Council. Every day essentials, Meeting basic needs. http://www.ncc.org.uk/access/essentialsfindings.pdf. London

11. US department of Transportation. Public Involvement Techniques for Transportation Decision-Making. Ethnic, Minority, And Low-Income Groups. https://www.fhwa.dot.gov/reports/pittd/ethmin.htm

12. Alcevedo-Garcia, D. Children left behind. How Metropolitan Areas are Failing America’s Children. http://diversitydata.sph.harvard.edu/

13. National Health Service. Meeting the needs of black and minority ethnic groups. The New NHS: Commentaries on the White paper. Specialist Services to Special Groups. United Kingdom.

14. Satcher, D. Our commitment to eliminate racial and ethnic health disparities. Yale Journal of Health Policy, Law, and Ethics.

15. Koenig, B. 54’s impact on health, http://daily.stanford.edu/article/2003/10/7/54sImpactOnHealth. 2003

16. Thomas, SB; Benjamin, GC, Almario, D and Lathan, MJ. Historical and Current Policy Efforts to Eliminate Racial and Ethnic Health Disparities in the United States: Future Opportunities for Public Health Education Research. Health Promotion Practice. 2006;7, 3: 324-330

17. American Medical Association Minority Affairs Consortium. Report on Racial and Ethnic Disparities in Health Care. http://www.ama-assn.org/ama/pub/category/6925.html. 2003.

18. Schulte, B. Herald Washington Bureau The health gap disparities are matters of life, death: Part 1. Miami Herald - Tuesday, August 4, 1998

19. Green, A. The Human Face of Health Disparities. Public Health Reports July–August 2003, 118: 303 – 309.

20. Centers for Disease Control and Prevention. About Minority Health. Atlanta, GA. Office of Minority Health.http://www.cdc.gov/OMH/AMH/AMH.htm

21. The Centers for Disease Control. Racial and Ethnic Approaches to Community Health (REACH) U.S. Finding Solutions to Health Disparities. At A Glance. http://www.cdc.gov/nccdphp/publications/aag/reach.htm. Atlanta, GA. 2007

22. Cancer Research and Prevention Foundation. Minorities and Colorectal Cancer. Alexandria, VA. http://www.preventcancer.org/colorectal/facts/minorities.cfm.htm

23. Campinha-Bacote, J., “Many Faces: Addressing Diversity in Health Care" Online Journal of Issues in Nursing. 2003: 8, 1: 2. Available at: http://nursingworld.org/ojin/topic20/tpc20_2.htm

24. Public Health Special Report. Public Health – Seattle and King County. Racial and Ethnic Discriminations in Health Care Settings. 2001

25. Washington State Department of Health Office of Environmental Health Assessments. Summary Results of Yakima Farm worker focus groups about pesticides in health care. http://www5.doh.wa.gov/ehp/oehas/publications_pdf/focus_group_summary_030922final.pdf. 2003

26. Stirland H. et al Cervical Cancer Screening in Inner Cities. Is the opportunistic approach still worthwhile? BMJ 1996;313:600

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