Race, ethnicity, and the health care system: public perceptions and experiences

Predictors of Organ Donation Behavior among Hispanic Americans

Context

Hispanic Americans have a substantial need for organ transplants and are underrepresented among organ donors, yet little is known about predictors of organ donation outcomes in this population.

Objective

To assess factors that may function as significant predictors of organ donation behavior among Hispanic Americans.

Design

A random-digit-dial computer-assisted telephone-interview survey.

Setting

Pima and Maricopa counties in Arizona.

Participants

1200 Hispanic Americans.

Main Outcome Measures

Family discussion of organ donation and willingness to be an organ donor.

Results

Significant predictors of family discussion of organ donation include knowing someone willing to be an organ donor and disagreeing that carrying a donor card results in inadequate medical care. Willingness to be a donor is also predictive of family discussion. Significant predictors of willingness to be an organ donor are knowing someone willing to be an organ donor, being female, and disagreeing that thoughts about donation leads to thoughts about one's own mortality. Having a family discussion about organ donation is also predictive of willingness to be an organ donor.

Conclusion

The data provide a springboard for larger studies encompassing the diversity and geographical dispersion of Hispanic Americans. The data also highlight the importance of educational efforts to make Hispanic Americans aware of people in their community who have donated in the past or who are now potential donors.

The Pain Experience of Hispanic Americans: A Critical Literature Review and Conceptual Model

Although the Hispanic population is a burgeoning ethnic group in the United States, little is known about their pain-related experience. To address this gap, we critically reviewed the existing literature on pain experience and management among Hispanic Americans (HAs). We focused our review on the literature on nonmalignant pain, pain behaviors, and pain treatment seeking among HAs. Pain management experiences were examined from HA patients' and health care providers' perspectives. Our literature search included variations of the term "Hispanic" with "AND pain" in PubMed, Embase, Web of Science, ScienceDirect, and PsycINFO databases. A total of 117 studies met our inclusion criteria. We organized the results into a conceptual model with separate categories for biological and/or psychological and sociocultural and/or systems-level influences on HAs' pain experience, response to pain, and seeking and receiving pain care. We also included information on health care providers' experience of treating HA patients with pain. For each category, we identified future areas of research. We conclude with a discussion of limitations and clinical implications.

PERSPECTIVE

In this critical review of the literature we examined the pain and management experiences of the HA population. We propose a conceptual model, which highlights findings from the existing literature and future areas of research.

Racial and Ethnic Disparities in Health and Health Care: an Assessment and Analysis of the Awareness and Perceptions of Public Health Workers Implementing a Statewide Community Transformation Grant in Texas

INTRODUCTION

Little is known about the awareness of public health professionals regarding racial and ethnic disparities in health in the United States of America (USA). Our study objective was to assess the awareness and perceptions of a group of public health workers in Texas regarding racial health disparities and their chief contributing causes.

METHODS

We surveyed public health professionals working on a statewide grant in Texas, who were participants at health disparities' training workshops. Multivariable logistic regression was employed in examining the association between the participants' characteristics and their perceptions of the social determinants of health as principal causes of health disparities.

RESULTS

There were 106 respondents, of whom 38 and 35 % worked in health departments and non-profit organizations, respectively. The racial/ethnic groups with the highest incidence of HIV/AIDS and hypertension were correctly identified by 63 and 50 % of respondents, respectively, but only 17, and 32 % were knowledgeable regarding diabetes and cancer, respectively. Seventy-one percent of respondents perceived that health disparities are driven by the major axes of the social determinants of health. Exposure to information about racial/ethnic health disparities within the prior year was associated with a higher odds of perceiving that social determinants of health were causes of health disparities (OR 9.62; 95 % CI 2.77, 33.41).

CONCLUSION

Among public health workers, recent exposure to information regarding health disparities may be associated with their perceptions of health disparities. Further research is needed to investigate the impact of such exposure on their long-term perception of disparities, as well as the equity of services and programs they administer.

Lay perceptions of health and environmental inequalities and their associations to mental health

Health inequalities are very well documented in epidemiological research: rich people live longer and have fewer diseases than poor people. Recently, a growing amount of evidence from environmental sciences confirms that poor people are also more exposed to pollution and other environmental threats. However, research in the social sciences has shown a broad lack of awareness about health inequalities. In this paper, based on data collected in Portugal, we will analyze the consciousness of both health and environmental injustices and test one hypothesis for this social blindness. The results show, even more clearly than before, that public opinion tends to see rich and poor people as being equally susceptible to health and environmental events. Furthermore, those who have this equal view of the world present lower levels of depression and anxiety. Following cognitive adaptation theory, this "belief in an equal world" can be interpreted as a protective positive illusion about social justice, particularly relevant in one of the most unequal countries in Europe.

Educating Patients about CKD: The Path to Self-Management and Patient-Centered Care

Patient education is associated with better patient outcomes and supported by international guidelines and organizations, but a range of barriers prevent widespread implementation of comprehensive education for people with progressive kidney disease, especially in the United States. Among United States patients, obstacles to education include the complex nature of kidney disease information, low baseline awareness, limited health literacy and numeracy, limited availability of CKD information, and lack of readiness to learn. For providers, lack of time and clinical confidence combine with competing education priorities and confusion about diagnosing CKD to limit educational efforts. At the system level, lack of provider incentives, limited availability of practical decision support tools, and lack of established interdisciplinary care models inhibit patient education. Despite these barriers, innovative education approaches for people with CKD exist, including self-management support, shared decision making, use of digital media, and engaging families and communities. Education efficiency may be increased by focusing on people with progressive disease, establishing interdisciplinary care management including community health workers, and providing education in group settings. New educational approaches are being developed through research and quality improvement efforts, but challenges to evaluating public awareness and patient education programs inhibit identification of successful strategies for broader implementation. However, growing interest in improving patient-centered outcomes may provide new approaches to effective education of people with CKD.

Disaggregating ethnoracial disparities in physician trust

Past research yields mixed evidence regarding whether ethnoracial minorities trust physicians less than Whites. Using the 2002 and 2006 General Social Surveys, variegated ethnoracial differences in trust in physicians are identified by disaggregating a multidimensional physician trust scale. Compared to Whites, Blacks are less likely to trust the technical judgment and interpersonal competence of doctors. Latinos are less likely than Whites to trust the fiduciary ethic, technical judgment, and interpersonal competence of doctors. Black-Latino differences in physician trust are a function of ethnoracial differences in parental nativity. The ways ethnoracial hierarchies are inscribed into power-imbalanced clinical exchanges are discussed.

Perceptions of racism in healthcare among patients with systemic lupus erythematosus: a cross-sectional study

Background

Racial disparities in the clinical outcomes of systemic lupus erythematosus (SLE) exist. Perceived racial discrimination may contribute to disparities in health.

Objectives

To determine if perceived racism in healthcare differs by race among patients with SLE and to evaluate its contribution to racial disparities in SLE-related outcomes.

Methods

163 African–American (AA) and 180 white (WH) patients with SLE were enrolled. Structured interviews and chart reviews were done to determine perceptions of racism, SLE-related outcomes (Systemic Lupus International Collaborating Clinics (SLICC) Damage Index, SLE Disease Activity, Center for Epidemiologic Studies-Depression (CES-D)), and other variables that may affect perceptions of racism. Serial hierarchical multivariable logistic regression models were conducted. Race-stratified analyses were also performed.

Results

56.0% of AA patients compared with 32.8% of WH patients had high perceptions of discrimination in healthcare (p<0.001). This difference remained (OR 4.75 (95% CI 2.41 to 8.68)) after adjustment for background, identity and healthcare experiences. Female gender (p=0.012) and lower trust in physicians (p<0.001) were also associated with high perceived racism. The odds of having greater disease damage (SLICC damage index ≥2) were higher in AA patients than in WH patients (crude OR 1.55 (95% CI 1.01 to 2.38)). The odds of having moderate to severe depression (CES-D ≥17) were also higher in AA patients than in WH patients (crude OR 1.94 (95% CI 1.26 to 2.98)). When adjusted for sociodemographic and clinical characteristics, racial disparities in disease damage and depression were no longer significant. Among AA patients, higher perceived racism was associated with having moderate to severe depression (adjusted OR 1.23 (95% CI 1.05 to 1.43)) even after adjusting for sociodemographic and clinical variables.

Conclusions

Perceptions of racism in healthcare were more common in AA patients than in WH patients with SLE and were associated with depression. Interventions aimed at modifiable factors (eg, trust in providers) may reduce higher perceptions of race-based discrimination in SLE.

Perceived discrimination in U.S. healthcare: Charting the effects of key social characteristics within and across racial groups

This article employs an original empirical analysis to contribute to scientific understandings of the relationship between social characteristics and perceptions of discrimination in healthcare encounters within and across racial categories in the U.S. Our analysis focuses on a diverse sample of 43,020 adults aged 18 to 85 drawn from the California Health Interview Survey (CHIS). We use a series of weighted descriptive statistics and logistic regression models to parse out factors associated with perceived discrimination and chart how they vary by race and ethnicity. Members of racial minorities were more likely to report perceptions of discrimination, and while the effect was somewhat mitigated by introducing patient and health-care system factors into our models, the race effects remained both statistically significant and of substantial magnitude (particularly for African Americans and Native Americans). Poor self-reported health and communication difficulties in the clinical encounter were associated with increased perceptions of discrimination across all groups. Further, among non-whites, increased education was associated with increased perceptions of discrimination net of other factors. These findings suggest efforts to reduce disparities in medical care should continue to focus on expanding the depth and quality of patient–provider interactions for disadvantaged racial groups, while also being attentive to other factors that affect perceived racial discrimination in healthcare encounters within and across racial groups.

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Race shapes perceived discrimination net of other factors.

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Some of the race effect can be accounted for by individual and system level factors.

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Interactions with providers have a powerful effect on perceptions of discrimination.

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The effect of factors such as education varies between racial groups.

Reports of insurance-based discrimination in health care and its association with access to care

OBJECTIVES

We examined reports of insurance-based discrimination and its association with insurance type and access to care in the early years of the Patient Protection and Affordable Care Act.

METHODS

We used data from the 2013 Minnesota Health Access Survey to identify 4123 Minnesota adults aged 18 to 64 years who reported about their experiences of insurance-based discrimination. We modeled the association between discrimination and insurance type and predicted odds of having reduced access to care among those reporting discrimination, controlling for sociodemographic factors. Data were weighted to represent the state's population.

RESULTS

Reports of insurance-based discrimination were higher among uninsured (25%) and publicly insured (21%) adults than among privately insured adults (3%), which held in the regression analysis. Those reporting discrimination had higher odds of lacking a usual source of care, lacking confidence in getting care, forgoing care because of cost, and experiencing provider-level barriers than those who did not.

CONCLUSIONS

Further research and policy interventions are needed to address insurance-based discrimination in health care settings.

Gender, race, and variation in the evaluation of microscopic hematuria among Medicare beneficiaries

BACKGROUND

Female gender and black race are associated with delayed diagnosis and inferior survival in patients with bladder cancer.

OBJECTIVE

We aimed to determine the association between gender, race, and evaluation of microscopic hematuria (an early sign of bladder cancer).

DESIGN AND PARTICIPANTS

This was a cohort study using a 5 % random sample of fee-for-service Medicare beneficiaries diagnosed with incident hematuria (International Classification of Diseases, Ninth Revision [ICD-9] code 599.7x) between January 2009 and June 2010 in a primary care setting. Beneficiaries with pre-existing explanatory diagnoses or genitourinary procedures were excluded.

MAIN MEASURES

The main endpoint was completeness of the hematuria evaluation in the 180 days after diagnosis. Evaluations were categorized as complete, incomplete, or absent based on receipt of relevant diagnostic procedures and imaging studies.

KEY RESULTS

In all, 9,211 beneficiaries met the study criteria. Hematuria evaluations were complete in 14 %, incomplete in 21 %, and absent in 65 % of subjects. Compared to males, females were less likely to have a procedure (26 vs. 12 %), imaging (41 vs. 30 %), and a complete evaluation (22 vs. 10 %) (p < 0.001 for each comparison). Receipt of a complete evaluation did not differ by race. Controlling for baseline characteristics, a complete evaluation was less likely in white women (OR, 0.40 [95 % CI, 0.35-0.46]) and black women (OR, 0.46 [95 % CI, 0.29-0.70]) compared to white men; no difference was found between black and white men.

CONCLUSIONS

Women are less likely than men to undergo a complete and timely hematuria evaluation, a finding likely relevant to women's more advanced stage at bladder cancer diagnosis. System-level process improvement between providers of urologic and primary care in the evaluation of hematuria may benefit women harboring malignancy.

Propensity score matching to measure the effect of survey mode on reports of racial and ethnic discrimination in health care

OBJECTIVE

To examine the effect of survey mode (mail vs. telephone) on the likelihood of reporting health care-related discrimination based on race, ethnicity, or nationality.

METHODS

We use data from a mixed-mode, mail and telephone survey of public health care program enrollees (N=2807), including Somali, Hmong, African American, American Indian, and Latino populations. Self-reported discrimination was measured as the experience of unfair treatment by health care providers due to race, ethnicity, or nationality. We use propensity score matching to create exchangeable groups of phone and mail respondents based on the probability of completing the survey by phone.

RESULTS

Overall, 33.1% of respondents reported having experienced discrimination in health care, but only 23.6% of telephone respondents reported discrimination compared with 36.8% of mail respondents. After matching phone and mail respondents based on probability of responding by telephone, all observable significant differences between respondents that were brought about by differential self-selection into mode were erased, allowing us to estimate the effect of survey mode on report of discrimination. Even after matching, the mode effect remains, where report of health care discrimination for telephone respondents would have been 12.6 percentage points higher had they responded by mail (22.6% vs. 35.2%).

CONCLUSIONS

Survey mode has a significant effect on report of discrimination. Respondents may be more willing to disclose experiences of discrimination in a mail survey than to a telephone interviewer. Findings have substantial policy and clinical significance as variation in report of discrimination based on mode may lead to underestimation of the extent of the problem.

Who leaves the hospital against medical advice in the orthopaedic setting?

BACKGROUND

Patients who leave the hospital against medical advice are at risk for readmission and for a variety of complications and are likely to consume more healthcare resources. However, little is known about which factors, if any, may be associated with self-discharge (discharge against medical advice) among orthopaedic inpatients.

QUESTIONS/PURPOSES

We studied the frequency and factors associated with self-discharge in patients hospitalized for orthopaedic trauma and musculoskeletal infection.

METHODS

Using discharge records from the Nationwide Inpatient Sample (2002-2011), we identified approximately 7,067,432 patient hospitalizations for orthopaedic trauma and 5,488,686 for musculoskeletal infection. We calculated the proportions of admissions that ended in self-discharge for both trauma and infection patients; then, we examined patient demographics, diagnoses, and hospital factors. Multivariable logistic regression models were constructed to determine independent predictors of self-discharge.

RESULTS

Approximately one in 333 (0.3%) patients hospitalized for an isolated fracture and one in 47 (2.1%) patients with musculoskeletal infection left against medical advice. Patient characteristics associated with self-discharge included age < 75 years (trauma: odds ratio [OR] 2.7, 95% confidence interval [CI] 2.5-2.8, p < 0.001; infection: OR 3.9, 95% CI 3.8-4.1, p < 0.001), male sex (trauma: OR 1.7, 95% CI 1.7-1.8, p < 0.001; infection: OR 1.4, 95% CI 1.3-1.4, p < 0.001), black race/ethnicity (trauma: OR 1.5, 95% CI 1.4-1.6, p < 0.001; infection: OR 1.1, 95% CI 1.1-1.1, p < 0.001), low household income (trauma: OR 1.5, 95% CI 1.4-1.5, p < 0.001; infection: OR 1.4, 95% CI 1.4-1.4, p < 0.001), nonprivate insurance (Medicare [trauma: OR 1.7, 95% CI 1.6-1.8, p < 0.001; infection: OR 2.5, 95% CI 2.4-2.5, p < 0.001] and Medicaid [trauma: OR 2.6, 95% CI 2.5-2.7, p < 0.001; infection: OR 3.2, 95% CI 3.2-3.3, p < 0.001]), and no insurance coverage (trauma: OR 3.0, 95% CI 2.9-3.1, p < 0.001; infection: OR 3.5, 95% CI 3.4-3.5, p < 0.001), less medical comorbidity (trauma: OR 0.94 per one-unit increase in the number of comorbidities, 95% CI 0.93-0.95, p < 0.001; infection: OR 0.88, 95% CI 0.87-0.88, p < 0.001), alcohol (trauma: OR, 2.3, 95% 2.2-2.4, p < 0.001; infection: OR 1.5, 95% CI 1.5-1.5, p < 0.001), opioid (trauma: OR 2.9, 95% CI 2.7-3.1, p < 0.001; infection: OR 4.4, 95% CI 4.3-4.4, p < 0.001) and nonopioid drug abuse (trauma: OR, 2.0, 95% CI 1.9-2.1, p < 0.001; infection: OR 2.8, 95% CI 2.8-2.9, p < 0.001), psychosis (trauma: OR 1.3, 95%CI 1.2-1.3, p < 0.001; infection: OR 1.3, 95% CI 1.3, 1.4, p < 0.001), and AIDS/HIV infection (trauma: OR 1.5, 95% CI 1.2-1.8, p < 0.001; infection: OR 1.3, 95% CI 1.3-1.4, p < 0.001). Patients with upper extremity fractures (OR 1.9, 95% CI 1.8-1.9, p < 0.001) or fractures of the neck and trunk (OR 2.1, 95% CI 2.0-2.2, p < 0.001) were more likely to leave against medical advice than patients with lower extremity fractures. Among infection hospitalizations, patients with cellulitis had the highest odds of self-discharge compared with carbuncle/furuncle (OR 1.3, 95% CI 1.2-1.5, p < 0.001). Self-discharges were more likely to occur at hospitals of larger size (trauma: OR 1.2, 95% CI 1.1-1.2, p < 0.001; infection: nonsignificant), located in urban settings (trauma: OR 1.3, 95% CI 1.2-1.4, p < 0.001; infection: OR 1.6, 95% CI 1.5-1.6, p < 0.001), and in the Northeast (trauma: OR 1.7, 95% CI 1.6-1.8, p < 0.001; infection: OR 1.6, 95% CI 1.6-1.6, p < 0.001) than at small, rural hospitals in the South.

CONCLUSIONS

Our data can be used to promptly identify orthopaedic inpatients at higher risk of self-discharge on admission and target interventions to optimize treatment adherence. Strategies to enhance physician communication skills among patients with low health literacy, improve cultural sensitivity, and proactively address substance abuse issues early during hospital admission may aid in preventing discharge dilemmas and merit additional study.

LEVEL OF EVIDENCE

Level III, prognostic study. See the Instructions for Authors for complete description of levels of evidence.

What do patients take into account when they choose their dentist? Implications for quality improvement

BACKGROUND

From dental care providers' perspective, it is vital to put efforts into improving the quality of services delivered. Therefore, the exploration of patients' satisfaction with dental services and their preferences with regard to the factors involved in their dental care choices should be one of the main areas of focus in a dental care office, by focusing on the quality management.

AIMS

The aim of this research was to determine the factors that patients consider important when choosing a dentist, and bring evidence on the importance of implementing a quality management system for dental care.

METHODS AND PARTICIPANTS

The data analysis was conducted on a national representative sample of patients who had visited a dentist at least once in the last 12 months, in Romania. Using a survey which explored patients' satisfaction with their dental care visits, data were collected between October and November 2012 with the help of computer-assisted telephone interviews. Information about socio-demographics, frequency of accessing dental care, factors associated with choosing a dentist, and the level of patients' satisfaction were collected.

RESULTS

Out of the 1,650 people who agreed to participate in the study, 724 respondents (43.8%) represented the sample who visited a dentist at least once in the last 12 months and whose responses were analyzed in this article. The majority of the respondents were satisfied with the quality of dental services received, with 85.91% of them rating their satisfaction with 5, on a scale from 1 to 5. According to a high majority of the patients (n=680, 93.92%), the communication with their dentist was extremely easy. The most frequently mentioned factors that respondents took into account when choosing a dentist were the dentist's competence (22.22%), the recommendation from someone known (20.56%), and the overall quality of the service provided (19.72%). Among the other factors mentioned were patience and respect.

CONCLUSION

The factors patients consider important when choosing a dentist are the dentist's competence, the recommendation from someone known, and the overall quality of the service provided, but interpersonal factors such as patience and respect are also valued. Our results are relevant for dental education providers, who should consider shaping their curricula as to ensure they train future dentists in a manner that will meet patients' expectations and increase patient satisfaction levels.

Considering care-seeking behaviors reveals important differences among HIV-positive women not engaged in care: implications for intervention

We sought to examine characteristics of HIV-positive women with varying levels of engagement in care and care-seeking behaviors. From 2010 to 2013, in a multi-site US-based study of engagement in care among HIV-positive women, we conducted baseline interviews, which included socio-demographic, clinical, and risk behavior characteristics, and barriers to care. We used multinomial logistic regression to compare differences among three distinct categories of 748 women: engaged in care; not engaged in care, but seeking care ("seekers"); and not engaged in care and not seeking care ("non-seekers"). Compared with women in care, seekers were more likely to be uninsured and to report fair or poor health status. In contrast, non-seekers were not only more likely to be uninsured, but, also, to report current high-risk drug use and sexual behaviors, and less likely to report transportation as a barrier to care. Examining care-seeking behaviors among HIV-positive women not engaged in care revealed important differences in high-risk behaviors. Because non-seekers represent a particularly vulnerable population of women who are not engaged in care, interventions targeting this population likely need to address drug use and be community-based given their limited interaction with the health care system.

Guiding the Process of Culturally Competent Care With Hispanic Patients: A Grounded Theory Study

PURPOSE

To explore nursing care actions that lead to culturally competent care for Hispanic patients.

BACKGROUND

Nurses report apprehension when delivering nursing care because of language barriers and a lack of Hispanic cultural understanding. Research is needed to inform culturally aware nursing practice actions for Hispanic patients.

DESIGN

The study used a qualitative, grounded theory design to address the questions: (a) What cultural knowledge should nurses have when caring for Hispanic patients and families and (b) What nursing actions should nurses take to provide culturally competent care? Hispanic lay health promoters and Hispanic community members were interviewed to make recommendations for care.

RESULTS

A model was identified that informs culturally competent nursing care. "Connectedness," the central phenomenon, describes nursing actions and contains subthemes explaining influences on nursing care. "Up to You" and "At the Mercy of the System" are descriptive themes influencing connectedness.

CONCLUSION

Connectedness is central to culturally well-informed nurse-patient interactions.

Primary health care experiences of hispanics with serious mental illness: a mixed-methods study

This mixed-methods study examines the primary health care experiences of Hispanic patients with serious mental illness. Forty patients were recruited from an outpatient mental health clinic. Participants reported a combination of perceived discrimination and stigmatization when receiving medical care. They rated the quality of chronic illness care as poor and reported low levels of self-efficacy and patient activation. These indicators were positively associated with how patients viewed their relationships with primary care providers. A grounded model was developed to describe the structural, social, and interpersonal processes that shaped participants' primary care experiences.

Minorities are less likely to receive autologous blood transfusion for major elective orthopaedic surgery

BACKGROUND

Surgeons commonly arrange for patients to perform autologous blood donation before elective orthopaedic surgery. Understanding sociodemographic patterns of use of autologous blood transfusion can help improve quality of care and cost containment.

QUESTIONS/PURPOSES

We sought to determine whether there were (1) racial disparities, (2) insurance-based disparities, or (3) income-based disparities in autologous blood use. Additionally, we evaluated the combined effect of (4) race and insurance and (5) race and income on autologous blood use, and we compared ratios of autologous with allogeneic blood use.

METHODS

Of the more than 3,500,000 patients undergoing major elective orthopaedic surgery identified in the Nationwide Inpatient Sample between 2008 and 2011, 2.4% received autologous blood transfusion and 12% received allogeneic blood transfusion. Multivariable logistic regression was performed to determine the influence of race, insurance status, and income on autologous blood use.

RESULTS

Compared with white patients, Hispanic patients had lower odds of autologous blood use for elective hip (odds ratio [OR], 0.75; 95% CI, 0.69-0.82) and knee arthroplasties (OR, 0.71; 95% CI, 0.67-0.75). Black patients had lower odds of receiving autologous blood transfusion for hip arthroplasty (OR, 0.78; 95% CI, 0.74-0.83). Compared with the privately insured, uninsured and publicly insured patients were less likely to receive autologous blood for total joint arthroplasty and spinal fusion. Patients with low and medium income were less likely to have autologous blood transfusion for total joint arthroplasty and spinal fusion compared with high-level income earners. Even at comparable income and insurance levels with whites, Hispanic and black patients tended to be less likely to receive autologous blood transfusion. Ratios of autologous to allogeneic blood use were lower among minority patients.

CONCLUSIONS

Historically disadvantaged populations receive fewer autologous blood transfusions for elective orthopaedic surgery. Whether the differential use is attributable to patient preference or unequal access to this practice should be investigated further.

LEVEL OF EVIDENCE

Level II, prognostic study. See the Instructions for Authors for a complete description of levels of evidence.

Racial and insurance disparities in the utilization of supportive care after inpatient admission for proximal humerus fracture

BACKGROUND

Post-discharge supportive services such as home health assistance and rehabilitation or skilled nursing facilities are often utilized after inpatient care for fracture of the proximal humerus. It is unclear whether sociodemographic disparities exist in the utilization of post-hospital supportive care. The present study aimed to evaluate the individual and combined effects of race and insurance status on the utilization of supportive services after hospital admission for fracture of the proximal humerus.

METHODS

Among the more than 40,000 patients with a proximal humerus fracture identified in the Nationwide Inpatient Sample (2008 to 2011), 85% were white, 7.7% were Hispanic and 7.0% were black. More black patients (19%) and Hispanic patients (15%) were uninsured compared to white patients (8.7%). Multivariable logistic regression was performed to determine the effect of race/ethnicity and insurance status on the utilization of post-hospital supportive care.

RESULTS

Sixty-nine percent of patients were discharged home, 13% went to home health care and 15% went to rehabilitation or skilled nursing facilities. Compared to white patients, Hispanic patients [odds ratio (OR) = 0.71; 95% confidence interval (CI) = 0.64 to 0.79] and black patients (OR = 0.79; 95% CI = 0.71 to 0.88) exhibited lower odds for the utilization of specialized post-hospital supportive services. Uninsured patients were significantly less likely to use post-discharge supportive services (OR = 0.38; 95% CI = 0.33 to 0.42) compared to privately insured patients. Even when insured at levels comparable to whites, Hispanic and black patients tended to experience decreased rates of discharge to post-acute supportive care.

CONCLUSIONS

The utilization of post-hospital supportive services varies by race, ethnicity and insurance status after an inpatient admission for proximal humerus fracture.

Explaining racial/ethnic disparities in use of high-volume hospitals: decision-making complexity and local hospital environments

Racial/ethnic minorities are less likely to use higher-quality hospitals than whites. We propose that a higher level of information-related complexity in their local hospital environments compounds the effects of discrimination and more limited access to services, contributing to racial/ethnic disparities in hospital use. While minorities live closer than whites to high-volume hospitals, minorities also face greater choice complexity and live in neighborhoods with lower levels of medical experience. Our empirical results reveal that it is generally the overall context associated with proximity, choice complexity, and local experience, rather than differential sensitivity to these factors, that provides a partial explanation of the disparity gap in high-volume hospital use.

Optimism and Planning for Future Care Needs among Older Adults

Aging is associated with an increase in need for assistance. Preparation for future care (PFC) is related to improved coping ability as well as better mental and physical health outcomes among older adults. We examined the association of optimism with components of PFC among older adults. We also explored race differences in the relationship between optimism and PFC. In Study 1, multiple regression showed that optimism was positively related to concrete planning. In Study 2, optimism was related to gathering information. An exploratory analysis combining the samples yielded a race interaction: For Whites higher optimism, but for Blacks lower optimism was associated with more planning. High optimism may be a barrier to future planning in certain social and cultural contexts.

National disparities in laparoscopic colorectal procedures for colon cancer

INTRODUCTION

Racial disparity in the treatment of colorectal cancer (CRC) has been cited as a potential cause for differences in mortality. This study compares the rates of laparoscopy according to race, insurance status, geographic location, and hospital size.

METHODS

The 2009 Healthcare Cost and Utilization Project: Nationwide Inpatient Sample (HCUP-NIS) database was queried to identify patients with the diagnosis of CRC by the International Classification of Diseases, Ninth Revision (ICD-9) codes. Multivariate logistic regression was performed to look at age, gender, insurance coverage, academic versus nonacademic affiliated institutions, rural versus urban settings, location, and proportional differences in laparoscopic procedures according to race.

RESULTS

A total of 14,502 patients were identified; 4,691 (32.35 %) underwent laparoscopic colorectal procedures and 9,811 (67.65 %) underwent open procedures. The proportion of laparoscopic procedures did not differ significantly by race: Caucasian 32.4 %, African-American 30.04 %, Hispanic 33.99 %, and Asian-Pacific Islander 35.12 (P = 0.08). Among Caucasian and African-American patients, those covered by private insurers were more likely to undergo laparoscopic procedures compared to other insurance types (P ≤ 0.001). The odds of receiving laparoscopic procedure at teaching hospitals was 1.39 times greater than in nonteaching hospitals (95 % confidence interval [CI] 1.29-1.48) and did not differ across race groups. Patients in urban hospitals demonstrated higher odds of laparoscopic surgery (2.24, 95 % CI 1.96-2.56) than in rural hospitals; this relationship was consistent within races. The odds of undergoing laparoscopic surgeries was lowest in the Midwest region (0.89, 95 % CI 0.81-0.97) but higher in the Southern region (1.14, 95 % CI 1.06-1.22) compared with the other regions.

CONCLUSIONS

Nearly one-third of all CRC surgeries are laparoscopic. Race does not appear to play a significant role in the selection of a laparoscopic CRC operation. However, there are significant differences in the selection of laparoscopy for CRC patients based on insurance status, geographic location, and hospital type.

Medical mistrust influences black women's level of engagement in BRCA 1/2 genetic counseling and testing

Clinical evidence supports the value of BRCA1/2 genetic counseling and testing for managing hereditary breast and ovarian cancer risk; however, BRCA1/2 genetic counseling and testing are underutilized among black women, and reasons for low use remain elusive. We examined the potential influence of sociocultural factors (medical mistrust, concerns about genetic discrimination) on genetic counseling and testing engagement in a sample of 100 black women at increased risk for carrying a BRCA1/2 mutation. Eligible participants fell into 1 of 3 groups: (1) healthy women with at least 1 first-degree relative affected by breast and/or ovarian cancer, (2) women diagnosed with breast cancer at age less than or equal to 50 years; and (3) women diagnosed with breast and/or ovarian cancer at age greater than or equal to 50 years with either 1 first-degree relative or 2 second-degree relatives with breast and/or ovarian cancer. Participants were recruited from clinical anid community settings and completed a semistructured interview. Study variable relationships were examined using bivariate tests and multivariate regression analysis. As expected, genetic counseling and testing engagement among this sample was low (28%). After accounting for;sociodemographic factors and self-efficacy (beta=0.37, p<.001), women with higher medical mistrust had lower genetic counseling and testing engagement (beta=-0.26, p<.01). Community-level and individual interventions are needed to improve utilization of genetic counseling and testing among underserved women. Along with trust building between patients and providers, strategies should enhance women's personal confidence. The impact of medical mistrust on the realization of the benefits of personalized medicine in minority populations should be further examined in future studies.

Perceived discrimination and physical health among HIV-positive Black and Latino men who have sex with men

We conducted the first study to examine health correlates of discrimination due to race/ethnicity, HIV-status, and sexual orientation among 348 HIV-positive Black (n = 181) and Latino (n = 167) men who have sex with men. Participants completed audio computer-assisted self-interviews. In multivariate analyses, Black participants who experienced greater racial discrimination were less likely to have a high CD4 cell count [OR = 0.7, 95 % CI = (0.5, 0.9), p = 0.02], and an undetectable viral load [OR = 0.8, 95 % CI = (0.6, 1.0), p = 0.03], and were more likely to visit the emergency department [OR = 1.3, 95 % CI = (1.0, 1.7), p = 0.04]; the combined three types of discrimination predicted greater AIDS symptoms [F (3,176) = 3.8, p < 0.01]. Among Latinos, the combined three types of discrimination predicted greater medication side effect severity [F (3,163) = 4.6, p < 0.01] and AIDS symptoms [F (3,163) = 3.1, p < 0.05]. Findings suggest that the stress of multiple types of discrimination plays a role in health outcomes.

The relationship between perceived discrimination and patient experiences with health care

BACKGROUND

Prior studies have shown that racial/ethnic minorities have lower Consumer Assessments of Healthcare Providers and Systems (CAHPS) scores. Perceived discrimination may mediate the relationship between race/ethnicity and patient experiences with care.

OBJECTIVE

To examine the relationship between perceived discrimination based on race/ethnicity and Medicaid insurance and CAHPS reports and ratings of care.

METHODS

The study analyzed 2007 survey data from 1509 Florida Medicaid beneficiaries. CAHPS reports (getting needed care, timeliness of care, communication with doctor, and health plan customer service) and ratings (personal doctor, specialist care, overall health care, and health plan) of care were the primary outcome variables. Patient perceptions of discrimination based on their race/ethnicity and having Medicaid insurance were the primary independent variables. Regression analysis modeled the effect of perceptions of discrimination on CAHPS reports and ratings controlling for age, sex, education, self-rated health status, race/ethnicity, survey language, and fee-for-service enrollment. SEs were corrected for correlation within plans.

RESULTS

Medicaid beneficiaries reporting discrimination based on race/ethnicity had lower CAHPS scores, ranging from 15 points lower (on a 0-100 scale) for getting needed care to 6 points lower for specialist rating, compared with those who never experienced discrimination. Similar results were obtained for perceived discrimination based on Medicaid insurance.

CONCLUSIONS

Perceptions of discrimination based on race/ethnicity and Medicaid insurance are prevalent and are associated with substantially lower CAHPS reports and ratings of care. Practices must develop and implement strategies to reduce perceived discrimination among patients.

Birth Control Conspiracy Beliefs, Perceived Discrimination, and Contraception among African Americans: An Exploratory Study

We conducted a cross-sectional telephone survey to explore the relationship of birth control conspiracy beliefs and perceived discrimination to contraceptive attitudes and behavior among a sample of African Americans (aged 18-45) in the USA (N = 71). Results indicated that a large percentage of respondents perceived discrimination targeted at African American women and endorsed birth control conspiracy beliefs, and that a significant proportion of female respondents perceived discrimination when getting family planning or contraceptive services. Stronger conspiracy beliefs and greater perceived discrimination were associated with negative attitudes toward contraceptive methods, particularly birth control pills, and with contraceptive behavior and intentions. Our findings suggest that conspiracy beliefs and perceived discrimination may play an important role in African Americans' attitudes toward and use of contraceptive methods.

Differential predictors of medication adherence in HIV: findings from a sample of African American and Caucasian HIV-positive drug-using adults

Modest or even occasional nonadherence to combined antiretroviral therapy (cART) can result in adverse clinical outcomes. African Americans demonstrate lower rates of adherence than Caucasians or Latinos. Identifying factors that influence medication adherence among African Americans is a critical step toward reducing HIV/AIDS disease progression and mortality. In a sample of 181 African American (n=144) and Caucasian (n=37) HIV-positive drug-using individuals [age (M=42.31; SD=6.6) education (M=13.41; SD=2.1)], we examined the influence of baseline drug use, literacy, neurocognition, depression, treatment-specific social support, and patient satisfaction with health care provider on medication adherence averaged over the course of 6 months (study dates 2002-2006). Our findings suggest differential baseline predictors of medication adherence for African Americans and Caucasians, such that patient satisfaction with provider was the strongest predictor of follow-up medication adherence for African Americans whereas for Caucasians depressive symptoms and treatment-specific social support were predictive of medication adherence (after controlling for duration of drug use).

Using social marketing to increase awareness of the African American infant mortality disparity

BACKGROUND

African American infants in San Francisco suffer a mortality rate two to three times higher than Whites, yet prior discussion groups with African American residents suggested they were unaware of this disparity.

METHODS

Social marketing techniques were used to develop and implement three campaigns to increase awareness. The campaign themes were (1) infant mortality disparities, (2) proper infant sleep position, and (3) taking action to reduce disparities. Mediums to carry messages included bus ads, radio ads, church fans, and posters and cards distributed at clinics, daycares, agency waiting rooms, and community organizations. Campaign effectiveness was evaluated using telephone surveys of African Americans.

RESULTS

Almost 62% report some exposure to Campaign 1, 48.5% to Campaign 2, and 48.9% to Campaign 3. Chi-square analyses reveal a statistically ignificant increase in awareness of the disparity (39.6% vs. 62.7%, p < .0005, odds ratio [OR] = 2.5, confidence interval [CI] = 2.1-3.2). Although there was no overall significant increase in knowledge about proper sleep position, respondents who report any exposure to this campaign are more likely to know about sleep position (70.7% vs. 63.8%, p < .0001, OR = 2.2, CI = 1.6-3.2).

CONCLUSIONS

Social marketing is an effective tool to increase disparity awareness, especially among groups disproportionately affected by the disparity.

Medical mistrust and discrimination in health care: a qualitative study of Hmong women and men

Low rates of breast and cervical cancer screening among Hmong women have been documented. Mistrust of Western medicine and the health care system, as well as experiences of discrimination in health care, may be barriers to seeking health care for this population. In this study, we explored medical mistrust among Hmong women and men, their experiences with discrimination in health care, and how these factors may influence Hmong women's breast and cervical cancer screening behavior. We conducted semi-structured, in-depth interviews with women and men who were members of the Hmong community in Oregon. Transcripts of 83 interviews were analyzed using content analysis. Despite personally trusting Western medicine and the health care system, participants shared reasons that some Hmong people feel mistrust including lack of understanding or familiarity, culture, and tradition. Although mistrust was thought to result in delaying or avoiding breast or cervical cancer screening, more frequently trust was described as positively influencing screening. In addition, few participants reported being treated differently during breast or cervical cancer screening because they were Hmong. When discussing health care more broadly, however, some participants described differential (e.g., disrespectful or rude) treatment. Such experiences led to feelings such as anger and sadness and affected behavior, including willingness to seek care and choice of provider. Medical mistrust and perceived discrimination were not major barriers to breast and cervical cancer screening in this study. Additional studies are needed to assess whether our findings reflect the experiences of other Hmong.

How Do Low-Income Urban African Americans and Latinos Feel about Telemedicine? A Diffusion of Innovation Analysis

Introduction. Telemedicine is promoted as a means to increase access to specialty medical care among the urban underserved, yet little is known about its acceptability among these populations. We used components of a diffusion of innovation conceptual framework to analyze preexperience perceptions about telemedicine to assess its appeal among urban underserved African Americans and Latinos. Methods. Ten focus groups were conducted with African American (n = 43) and Latino participants (n = 44) in both English and Spanish and analyzed for key themes. Results. Both groups perceived increased and immediate access to multiple medical opinions and reduced wait time as relative advantages of telemedicine. However, African Americans expressed more concerns than Latinos about confidentiality, privacy, and the physical absence of the specialist. This difference may reflect lower levels of trust in new health care innovations among African Americans resulting from a legacy of past abuses in the US medical system as compared to immigrant Latinos who do not have this particular historical backdrop. Conclusions. These findings have implications for important issues such as adoption of telemedicine, patient satisfaction, doctor-patient interactions, and the development and tailoring of strategies targeted to each of these populations for the introduction, marketing, and implementation of telemedicine.

Predictors of Subjective Life Expectancy Among African Americans

Few researchers examine how long African Americans expect to live. Using the fifth wave of the Harlem Longitudinal Study of Urban Black Youth, 1993-1994, the author explores the extent to which established predictors of subjective life expectancy (SLE), identified in predominantly and exclusively White samples, predict SLE among African Americans living in an urban area. The analyses reveal that some established predictors are associated with how long African Americans expect to live; others are not. Additionally, I examine two unexplored categories of SLE: stress and social network characteristics. Findings suggest that some measures of stress have a negative relationship to SLE, while other forms of stress have a positive relationship to SLE. In general, network characteristics are associated with how long African Americans expect to live.

"No me ponían mucha importancia": care-seeking experiences of undocumented Mexican immigrant women with chronic illness

This interpretive phenomenological study explored the health care-seeking experiences of undocumented Mexican immigrant women. Interviews and observations were conducted with 26 uninsured Mexican immigrant women with a chronic illness residing in California. Participant narratives revealed that their health care seeking experiences were often characterized by a lack of recognition of their human plight and devaluation of their personhood. Both structural and social barriers to care exist for immigrant women. Modifying current policies to allow undocumented immigrants more options to access care could help reduce stigma, reduce suffering, and encourage clinicians to recognize their humanity and their legitimate medical needs.

Risk factors associated with epidural use

Background

Identify variables associated with intrapartum epidural use.

Methods

Odds ratios were calculated to quantify associations between selected variables and epidural use using a population-based case-control study of Washington State birth certificate data from 2009.

Results

Non-Whites had 10 - 45% lower odds of epidural use relative to Whites. Foreign-born women had 25 - 45% lower odds of epidural use compared to their US-born counterparts, except for Asians. Women who smoked or induced labor had higher roughly 2-fold higher odds of epidural use compared with non-smokers or women giving birth spontaneously, respectively. Women without a high school diploma or equivalent had lower odds of epidural use relative to those who graduated. Delivering at perinatal units, rural hospitals, or non-profit hospitals had ~50% lower odds of epidural use compared with secondary/teritiary perinatal units, urban hospitals or for-profit hospitals, respectively. 

Conclusion

Several individual and health service-related variables were associated with epidural use. These findings elucidate the clinical relevance of epidural use, and dispariaties in its utilization and in quality of care during delivery.

Keywords

Epidural use; Foreign birth; Labor; Racial disparities

Untangling the associations among distrust, race, and neighborhood social environment: a social disorganization perspective

Over the past decade, interest in exploring how health care system distrust is associated with individual health outcomes and behaviors has grown substantially, and the racial difference in distrust has been well documented, with African Americans demonstrating higher distrust than whites. However, relatively little is known about whether the individual-level determinants of distrust differ by various dimensions of distrust, and even less is understood regarding whether the race-distrust association could be moderated by the neighborhood social environment. This study used a dual-dimensional distrust scale (values and competence distrust), and applied social disorganization theory to address these gaps. We combined the 2008 Philadelphia Health Management Corporation's household survey (N = 3746 adult respondents, 51% of which are of African American race) with neighborhood-level data (N = 45 neighborhoods) maintained by the 2000 U.S. Census and the Philadelphia Police Department. Using multilevel modeling, we found that first, after controlling for individual- and neighborhood-level covariates, African American residents have greater values distrust than whites, but no racial difference was found in competence distrust; second, competence distrust is more likely to be determined by personal health status and access to health care services than is values distrust; and third, ceteris paribus, the association between race and values distrust was weakened by the increasing level of neighborhood stability. These results not only indicate that different aspects of distrust may be determined via different mechanisms, but also suggest that establishing a stable neighborhood may ameliorate the level of distrust in the health care system among African Americans. As distrust has been identified as a barrier to medical research, the insight provided by this study can be applied to develop a health care system that is trusted, which will, in turn, improve population health.

Problem posing and cultural tailoring: developing an HIV/AIDS health literacy toolkit with the African American community

The rate of HIV infection among African Americans is disproportionately higher than for other racial groups in the United States. Previous research suggests that low level of health literacy (HL) is an underlying factor to explain racial disparities in the prevalence and incidence of HIV/AIDS. The present research describes a community and university project to develop a culturally tailored HIV/AIDS HL toolkit in the African American community. Paulo Freire's pedagogical philosophy and problem-posing methodology served as the guiding framework throughout the development process. Developing the HIV/AIDS HL toolkit occurred in a two-stage process. In Stage 1, a nonprofit organization and research team established a collaborative partnership to develop a culturally tailored HIV/AIDS HL toolkit. In Stage 2, African American community members participated in focus groups conducted as Freirian cultural circles to further refine the HIV/AIDS HL toolkit. In both stages, problem posing engaged participants' knowledge, experiences, and concerns to evaluate a working draft toolkit. The discussion and implications highlight how Freire's pedagogical philosophy and methodology enhances the development of culturally tailored health information.

Satisfaction with health care among Latinas

Despite growing interest in disparities in access to health care, relatively little is known about different facets of care among Latinas, their satisfaction with the care they receive, and the predictors of satisfaction. This study examined whether various health care access and context factors, the quality of the patient-physician interaction, and medical mistrust predict satisfaction with health care among Latina immigrants in New York City. Structured interviews were conducted with 220 Latinas predominantly from the Dominican Republic and aged 40 years or over. Of the access to health care variables examined, greater waiting time predicted dissatisfaction with health care. Greater quality of the patient-physician interaction predicted less dissatisfaction. The effect of the patient-physician interaction on dissatisfaction was mediated, in part, by waiting time. The results illustrate the important role of specific health care factors in satisfaction with care.

Insurance-based discrimination during prenatal care, labor, and delivery: perceptions of Oregon mothers

The purpose of this study was to improve understanding of who experiences insurance-based discrimination during prenatal care, labor, and delivery and how their health care may differ from that of other women. We pooled data from the 1998-1999, 2000, and 2001 Oregon Pregnancy Risk Assessment Monitoring System and conducted univariate, bivariate, and multivariate analyses. The women who perceived that they had been treated differently by health care providers during prenatal care, labor, or delivery based on their insurance status were largely a lower income group. Insurance-based discrimination was significantly associated with lower annual household incomes, being unable to pay bills during pregnancy, and being without employer-sponsored insurance for their baby's delivery, when adjusted for other factors. Insurance-based discrimination was less likely among Hispanic mothers. With respect to the relationship between insurance-based discrimination and receipt of health care, our findings were mixed. Insurance-based discrimination was not significantly associated with the number of topics covered by providers during prenatal care. In contrast, insurance-based discrimination was significantly associated with fewer breastfeeding support actions taken at the hospital and with having had a provider discuss birth control after delivery among women with employer sponsored insurance. These findings draw attention to the need to better understand women's experiences and perceptions of insurance-based discrimination during prenatal care, labor, and delivery.

Adverse birth outcomes in African American women: the social context of persistent reproductive disadvantage

African Americans have the highest rates of infant mortality and adverse birth outcomes of all major racial/ethnic groups in the United States. The long-standing nature of this disparity suggests the need to shift epidemiologic focus from individual-level risk factors to the larger social forces that shape disease risk in populations. In this article, the African American reproductive disadvantage is discussed within the context of American race relations. The review of the literature focuses on racism as a social determinant of race-based disparities in adverse birth outcomes with specific attention to the viability of genetic explanations, the role of socioeconomic factors, the multidimensional nature of racism, and the stress-induced physiologic pathways by which racism may negatively affect pregnancy. Implications for social work research and practice also are discussed.

Provider characteristics desired by African American women in prenatal care

PURPOSE

The purpose of this study was to describe provider characteristics African American pregnant women identified as important when interacting with their prenatal care providers in an outpatient office setting.

STUDY DESIGN

A descriptive qualitative design was used to explore provider characteristics desired by African American women receiving prenatal care at two inner-city hospital-based obstetric clinics. A total of 22 African American women between the ages of 19 and 28 years participated in the study.

FINDINGS

Four major provider characteristic themes emerged from the data: (a) demonstrating quality patient-provider communication, (b) providing continuity of care, (c) treating the women with respect, and (d) delivering compassionate care.

DISCUSSION

An overarching theme revealed by the data analysis was the desire by African American women in this study to have their prenatal providers know and remember them. They wanted their providers to understand the context of their lives from their prenatal interactions. Incorporating findings from this study to improve patient-provider interactions during prenatal care could provide an increased understanding of the many complex variables affecting African American women's lives.

IMPLICATIONS

Prenatal care provides an opportunity for African American women to develop a trusting relationship with a provider. Developing models of prenatal care congruent with the realities of African American women's lives has the potential to improve patient- provider interactions and potentially affect birth outcomes.

The effect of patient race on total joint replacement recommendations and utilization in the orthopedic setting

BACKGROUND

The extent to which treatment recommendations in the orthopedic setting contribute to well-established racial disparities in the utilization of total joint replacement (TJR) in the treatment of advanced knee/hip osteoarthritis has not been explored.

OBJECTIVE

To examine whether orthopedic surgeons are less likely to recommend TJR to African-American patients compared to white patients with similar clinical indications, and whether there are racial differences in the receipt of TJR within six months of study enrollment.

DESIGN

Prospective, observational study.

PARTICIPANTS

African-American (AA; n = 120) and white (n = 337) patients seeking treatment for knee or hip osteoarthritis in Veterans Affairs orthopedic clinics.

MAIN MEASURES

Patients completed surveys that assessed socio-demographic and clinical variables that could influence osteoarthritis treatment. Orthopedic surgeons' notes were reviewed to determine whether patients had been recommended for TJR and whether they underwent the procedure within 6 months of study enrollment.

RESULTS

Rate of TJR recommendation was 19.5%. Odds of receiving a TJR recommendation were lower for AA than white patients of similar age and disease severity (OR = 0.46, 95% CI = 0.26-0.83; P = 0.01). However, this difference was not significant after adjusting for patient preference for TJR (OR = 0.69, 95% CI = 0.36-1.31, P = 0.25). Overall, 10.3% of patients underwent TJR within 6 months. TJR was less likely for AA patients than for white patients of similar age and disease severity (OR = 0.41, 95% CI = 0.16-1.05, P = 0.06), but this difference was reduced after adjusting for whether patients had received a recommendation for the procedure at the index visit (OR = 0.57, 95% CI = 0.21-1.54, P = 0.27).

CONCLUSIONS

In this study, race differences in patient preferences for TJR appeared to underlie race differences in TJR recommendations, which led to race differences in utilization of the procedure. Our findings suggest that patient treatment preferences play an important role in racial disparities in TJR utilization in the orthopedic setting.

Race/ethnicity-based concerns over understanding cancer diagnosis and treatment plan

BACKGROUND

Race/ethnicity and culture influence illness perceptions, health beliefs and behaviors, and communication with health care providers. However, information about the impact of race/ethnicity on the understanding of cancer diagnosis and treatment plan is limited.

METHODS

Nine hundred seventy-three cancer patients completed an information needs-assessment questionnaire prior to starting treatment at 20 geographically distinct clinical cancer sites within the University of Rochester Community Clinical Oncology Program network. Chi2 Test was used to examine the association between race/ethnicity and education, occupation, and perception and use of available information. T test and analysis of covariance were used to examine race/ethnicity-based differences in concerns over understanding cancer diagnosis/treatment plan and the effect of race/ethnicity controlling for demographics.

RESULTS

There were 904 non-Hispanic white and 69 nonwhite (blacks, Latinos, and others) patients in the sample. Whites and nonwhites were comparable in educational attainment and occupation. However, there was a statistically significant race/ethnicity-based difference in concerns over understanding the diagnosis and treatment plan for cancer, even after controlling for sex (male, female), age, education, and occupation (p < .001). More nonwhite patients indicated that additional information would have been helpful in dealing with these concerns (p <.001).

CONCLUSIONS

Nonwhite cancer patients reported more concerns about understanding their diagnosis and treatment plan and were more likely to indicate that additional information would have been helpful. The findings emphasize the need for oncology professionals to confirm patients' understanding and ensure patients' information needs have been met, particularly when working with racial/ethnic minorities.

Validation of the group-based medical mistrust scale among urban black men

BACKGROUND

Socioculturally relevant measures of medical mistrust are needed to better address health disparities, especially among Black men, a group with lower life expectancy and higher death rates compared to other race/gender groups.

OBJECTIVES

The study aim was to investigate the psychometric properties of the Group-Based Medical Mistrust Scale (GBMMS) in a Black male sample.

DESIGN

Data were collected as part of a randomized controlled trial testing educational strategies to support Black men's decisions about prostate cancer screening.

PARTICIPANTS

Participants included 201 Black men ages 40-75 years recruited in New York City during 2006-2007.

MAIN MEASURES

The primary measures included: race-based medical mistrust, health care participation, avoidance of health care, perceived access to health care, health care satisfaction, racial identity, residential racial segregation, attitudes towards prostate cancer screening, and past prostate cancer screening behavior.

KEY RESULTS

An exploratory factor analysis suggested a three-factor structure. Confirmatory factor analysis supported the three-factor model. Internal consistency was high for the total GBMMS and the three sub-scales: Suspicion, Discrimination, and Lack of Support. Construct validity was supported by: significant positive correlations between GBMMS and avoidance of health care and racial identity as well as significant negative correlations with health care access, health care satisfaction, and attitudes about prostate cancer screening. ANOVA showed that the GBMMS was associated with greater residential racial segregation. Higher total GBMMS scores were associated with not visiting a physician in the last year and not having a regular physician.

CONCLUSIONS

The present findings provide strong additional evidence that the GBMMS is a valid and reliable measure that may be used among urban Black men.

African American adolescent males' views on doctors and the health care system

OBJECTIVE

African American adolescent males have disproportionately high rates of morbidity and mortality and low levels of primary care use. To optimize health care for this group, there is a need to understand their views on doctors and health care, reasons for foregone care, and preferences regarding provision of health care.

METHODS

This was a pilot survey of African American adolescent males attending community groups in Chicago.

RESULTS

A majority of respondents agreed with declarative statements about doctors being considerate, truthful, and respectful (63%, 80%, and 80%, respectively). A majority also indicated that the health care system informs them of ways to stay healthy (65%), but fewer agreed that it meets the needs of adolescents and minorities (44% and 33%, respectively). Race/gender concordance with physicians did not seem to be a high priority. Significant reasons for foregone care included conflict with school hours, parents not having time, and lack of transportation. Despite access issues, only a minority of participants wanted health care services co-located with other aspects of their daily lives (school, community centers, church, and barbershops).

CONCLUSION

African American adolescent males may view doctors and the health care system positively. Eliminating barriers to care and ensuring positive interactions may create opportunities to improve health issues afflicting these at-risk adolescents.

Conspiracy beliefs about HIV are related to antiretroviral treatment nonadherence among african american men with HIV

BACKGROUND

Medical mistrust is prevalent among African Americans and may influence health care behaviors such as treatment adherence. We examined whether a specific form of medical mistrust-HIV conspiracy beliefs (eg, HIV is genocide against African Americans)-was associated with antiretroviral treatment nonadherence among African American men with HIV.

METHODS

On baseline surveys, 214 African American men with HIV reported their agreement with 9 conspiracy beliefs, sociodemographic characteristics, depression symptoms, substance use, disease characteristics, medical mistrust, and health care barriers. Antiretroviral medication adherence was monitored electronically for one month postbaseline among 177 men in the baseline sample.

RESULTS

Confirmatory factor analysis revealed 2 distinct conspiracy belief subscales: genocidal beliefs (eg, HIV is manmade) and treatment-related beliefs (eg, people who take antiretroviral treatments are human guinea pigs for the government). Both subscales were related to nonadherence in bivariate tests. In a multivariate logistic regression, only treatment-related conspiracies were associated with a lower likelihood of optimal adherence at one-month follow-up (odds ratio = 0.60, 95% confidence interval = 0.37 to 0.96, P < 0.05).

CONCLUSIONS

HIV conspiracy beliefs, especially those related to treatment mistrust, can contribute to health disparities by discouraging appropriate treatment behavior. Adherence-promoting interventions targeting African Americans should openly address such beliefs.

Psychosocial correlates of medical mistrust among African American men

The current study proposed and tested a conceptual model of medical mistrust in a sample of African American men (N = 216) recruited primarily from barbershops in the Midwest and Southeast regions of the United States. Potential psychosocial correlates were grouped into background factors, masculine role identity/socialization factors, recent healthcare experiences, recent socioenvironmental experiences (e.g., discrimination), and healthcare system outcome expectations (e.g., perceived racism in healthcare). Direct and mediated relationships were assessed. Results from the hierarchical regression analyses suggest that perceived racism in healthcare was the most powerful correlate of medical mistrust even after controlling for other factors. Direct effects were found for age, masculine role identity, recent patient-physician interaction quality, and discrimination experiences. Also, perceived racism in healthcare mediated the relationship between discrimination experiences and medical mistrust. These findings suggest that African American men's mistrust of healthcare organizations is related to personal characteristics, previous negative social/healthcare experiences, and expectations of disparate treatment on the basis of race. These findings also imply that aspects of masculine role identity shape the tone of patient-physician interactions in ways that impede trust building processes.

Perceived discrimination and self-reported quality of care among Latinos in the United States

BACKGROUND

Given the persistence of health and health-care disparities among Latinos in the United States and evidence that discrimination affects health and health care, an investigation of the relationship between perceived discrimination and quality of health care among Latinos is warranted.

OBJECTIVE

To examine the relationship of perceived discrimination (in general and in regard to doctors and medical personnel) with self-reported quality of health care and doctor-patient communication in a nationally representative Latino population sample.

PARTICIPANTS

Participants were 1,067 Latino adults aged >or=18 years living in the US selected via random-digit dialing. Telephone interviews were conducted in 2008 during Wave 2 of the Pew Hispanic Center/Robert Wood Johnson Foundation Hispanic Healthcare Survey.

RESULTS

US-born Latinos were twice as likely to report general discrimination as foreign born: 0.32 SD versus -0.23 SD (P < 0.001) on the Detroit Area Survey (DAS) discrimination scale. Higher DAS discrimination was associated with lower self-reported quality of care in US-born Latinos [OR = 0.5; 95% CI (0.3, 0.9); P = 0.009]. For foreign-born Latinos, report of any doctor or medical staff discrimination was associated with lower quality of care [OR = 0.5; 95% CI (0.3, 0.9); P = 0.03], but the DAS was not. For US-born Latinos, doctor discrimination and higher DAS were jointly associated with worse doctor-patient communication. For foreign-born Latinos, the effect of discrimination on doctor-patient communication was significantly smaller than that observed in US-born Latinos.

CONCLUSIONS

Given the association between perceived discrimination and quality of care, strategies to address discrimination in health-care settings may lead to improved patient satisfaction with care and possibly to improved treatment outcomes.

Patients' perceptions of discrimination during hospitalization

OBJECTIVE

To identify sources of perceived discrimination during hospitalization and examine the relationship of perceived discrimination to patient and hospital stay characteristics, and to patient ratings of care.

BACKGROUND

Patient experiences of discrimination within the health-care system are associated with delays in care seeking, non-adherence to medical advice and poorer health status. Most research to date has focused on race and ethnicity-based discrimination, and few studies have included hospitalized patients.

METHODS

Questions about patients' experiences of discrimination were added to a regular patient opinion survey conducted at the Geneva University Hospitals. Participants were 1537 adult residents of Switzerland discharged from the hospital between 15 February and 15 March 2007.

RESULTS

A total of 171 (11.1%) respondents reported at least one source of discrimination. Most (93, 54.4%) reported a single cause of discrimination. The most frequent causes of discrimination were language, age, nationality and having a disease that is viewed negatively by others. Fifteen percentage of non-European respondents reported at least one of the following types of discrimination: language, nationality, religion and skin colour. Reporting discrimination from any cause was associated with higher Picker Patient Experience problem scores, and patients who reported discrimination were less likely to describe their care as very good or excellent and less likely to recommend the hospital to others.

CONCLUSIONS

Patient experiences of discrimination during hospitalization are relatively frequent and are associated with lower patient ratings of care. Collection of data on patient experiences of discrimination may contribute to the development of interventions aimed at ensuring respectful, quality care for all patients.

Perceived racial discrimination in health care: a comparison of Veterans Affairs and other patients

OBJECTIVES

We compared rates of perceived racial discrimination in health care settings for veteran and nonveteran patients and for veterans who used the Veterans Affairs health care system and those who did not.

METHODS

Data were drawn from the 2004 Behavioral Risk Factor Surveillance System. We used logistic regression to examine whether perceived racial discrimination in health care was associated with veteran status or use of Veterans Affairs health care, after adjusting for patient characteristics.

RESULTS

In this sample of 35,902 people, rates of perceived discrimination were equal for veterans and nonveterans (3.4% and 3.5%, respectively; crude odds ratio [OR] = 1.00; 95% confidence interval [CI] = 0.77, 1.28; adjusted OR = 0.92; 95% CI = 0.66, 1.28). Among veterans (n = 3420), perceived discrimination was more prevalent among patients who used Veterans Affairs facilities than among those who did not (5.4% vs 2.7%; OR = 2.08; 95% CI = 1.04, 4.18). However, this difference was not significant after adjustment for patient characteristics (OR = 1.30; 95% CI = 0.54, 3.13).

CONCLUSIONS

Perceived racial discrimination in health care was equally prevalent among veterans and nonveterans and among veterans who used the Veterans Affairs health care system and those who did not.