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

Unintended effects of emphasizing disparities in cancer communication to African-Americans

Little is known about how minority groups react to public information that highlights racial disparities in cancer. This double-blind randomized study compared emotional and behavioral reactions to four versions of the same colon cancer (CRC) information presented in mock news articles to a community sample of African-American adults (n = 300). Participants read one of four articles that varied in their framing and interpretation of race-specific CRC mortality data, emphasizing impact (CRC is an important problem for African-Americans), two dimensions of disparity (Blacks are doing worse than Whites and Blacks are improving, but less than Whites), or progress (Blacks are improving over time). Participants exposed to disparity articles reported more negative emotional reactions to the information and were less likely to want to be screened for CRC than those in other groups (both P < 0.001). In contrast, progress articles elicited more positive emotional reactions and participants were more likely to want to be screened. Moreover, negative emotional reaction seemed to mediate the influence of message type on individuals wanting to be screened for CRC. Overall, these results suggest that the way in which disparity research is reported in the medium can influence public attitudes and intentions, with reports about progress yielding a more positive effect on intention. This seems especially important among those with high levels of medical mistrust who are least likely to use the health care system and are thus the primary target of health promotion advertising.

Discrimination, distrust, and racial/ethnic disparities in antiretroviral therapy adherence among a national sample of HIV-infected patients

OBJECTIVE

Although discriminatory health care experiences and health care provider distrust have been shown to be associated with health care disparities, little is known about their contribution to racial/ethnic disparities in antiretroviral therapy adherence. We therefore sought to assess the extent to which discriminatory health care experiences and health care provider distrust influence treatment-related attitudes, beliefs, and self-reported adherence in a national sample of HIV-infected patients.

STUDY DESIGN

This secondary analysis used data from the HIV Cost and Services Utilization Study. We used structural equation modeling to identify pathways from minority status to adherence through discrimination, distrust, and treatment-related attitudes and beliefs.

PARTICIPANTS

The sample was the 1886 participants who completed the baseline and 2 follow-up interviews and were prescribed antiretroviral therapy at the second follow-up interview (54% white, 28% black, 14% Hispanic, and 3% others).

RESULTS

Minorities were less likely to report perfect adherence than whites (40% vs. 50%, P < or = 0.001). Over one third (40%) of all participants reporting ever having discriminatory health care experiences since having HIV, and 24% did not completely or almost completely trust their health care providers. The effect of minority status on adherence persisted in the full model. More discrimination predicted greater distrust, weaker treatment benefit beliefs, and, in turn, poorer adherence. Distrust affected adherence by increasing treatment-related psychological distress and weakening treatment benefit beliefs.

CONCLUSIONS

The relationship between minority status and adherence was not fully explained by patient-level factors. Future studies should consider conceptualizing minority status as a contextual factor rather than predictor.

Perceptions of race/ethnicity-based discrimination: a review of measures and evaluation of their usefulness for the health care setting

BACKGROUND

To assess discrimination in health care, reliable, valid, and comprehensive measures of racism/discrimination are needed.

OBJECTIVE

To review literature on measures of perceived race/ethnicity-based discrimination and evaluate their characteristics and usefulness in assessing discrimination from health care providers.

METHODS

Literature review of measures of perceived race/ethnicity-based discrimination (1966-2007), using MEDLINE, PsycINFO, and Social Science Citation Index.

RESULTS

We identified 34 measures of racism/discrimination; 16 specifically assessed dynamics in the health care setting. Few measures were theoretically based; most assessed only general dimensions of racism and focused specifically on the experiences of African American patients. Acceptable psychometric properties were documented for about half of the instruments.

CONCLUSIONS

Additional measures are needed for detailed assessments of perceived discrimination in the health care setting; they should be relevant for a wide variety of racial/ethnic groups, and they must assess how racism/discrimination affects health care decision making and treatments offered.

Perceived discrimination in health care and health status in a racially diverse sample

BACKGROUND

Despite the surge of recent research on the association between perceived discrimination and health-related outcomes, few studies have focused on race-based discrimination encountered in health care settings. This study examined the prevalence of such discrimination, and its association with health status, for the 3 largest race/ethnic groups in the United States.

METHODS

Data were drawn from the 2004 Behavioral Risk Factor Surveillance System survey. The primary variables were perceived racial discrimination in health care and self-reported health status. Multivariable logistic regression was used to compare the prevalence of perceived discrimination for whites, African Americans, and Hispanics, and to examine the association between perceived discrimination and health status, controlling for sex, age, income, education, health care coverage, affordability of medical care, racial salience, and state.

RESULTS

Perceived discrimination was reported by 2%, 5.2%, and 10.9% of whites, Hispanics, and African Americans, respectively. Only the difference between African Americans and whites remained significant in adjusted analyses [odds ratio (OR) = 3.22, 95% confidence interval (CI) = 2.46-4.21]. Racial/ethnic differences in perceived discrimination depended on income, education, health care coverage, and affordability of medical care. Perceived discrimination was associated with worse health status for the overall sample (OR = 1.71, 95% CI = 1.35-2.16). Stratified analyses revealed that this relationship was significant for whites (OR = 2.00, 95% CI = 1.45-2.77) and African Americans (OR = 1.95, 95% CI = 1.39-2.73), but not for Hispanics (OR = 0.55, 95% CI = 0.24-1.22).

CONCLUSIONS

Perceived racial discrimination in health care is much more prevalent for African Americans than for whites or Hispanics. Furthermore, such discrimination is associated with worse health both for African Americans and for whites.

Perceived discrimination during prenatal care, labor, and delivery: an examination of data from the Oregon Pregnancy Risk Assessment Monitoring System, 1998-1999, 2000, and 2001

Although recent research has examined discrimination in health care, no studies have investigated women's experiences during prenatal or obstetrical care. Analyses of data from the Oregon Pregnancy Risk Assessment Monitoring System showed that 18.53% of mothers reported discrimination by providers during prenatal care, labor, or delivery, most commonly because of age or insurance status. Perceived discrimination was associated with maternal characteristics such as age, marital status, and type of insurance, but not with number of subsequent well-baby visits.

Effects of poverty and lack of insurance on perceptions of racial and ethnic bias in health care

OBJECTIVE

To investigate whether poverty and lack of insurance are associated with perceived racial and ethnic bias in health care.

DATA SOURCE

2001 Survey on Disparities in Quality of Health Care, a nationally representative telephone survey. We use data on black, Hispanic, and white adults who have a regular physician (N=4,556).

STUDY DESIGN

We estimate multivariate logistic regression models to examine the effects of poverty and lack of health insurance on perceived racial and ethnic bias in health care for all respondents and by racial, ethnic, and language groups.

PRINCIPAL FINDINGS

Controlling for sociodemographic and other factors, uninsured blacks and Hispanics interviewed in English are more likely to report racial and ethnic bias in health care compared with their privately insured counterparts. Poor whites are more likely to report racial and ethnic bias in health care compared with other whites. Good physician-patient communication is negatively associated with perceived racial and ethnic bias.

CONCLUSIONS

Compared with their more socioeconomically advantaged counterparts, poor whites, uninsured blacks, and some uninsured Hispanics are more likely to perceive that racial and ethnic bias operates in the health care they receive. Providing health insurance for the uninsured may help reduce this perceived bias among some minority groups.

Race, racism, and racial disparities in adverse birth outcomes

While the biologic authenticity of race remains a contentious issue, the social significance of race is indisputable. The chronic stress of racism and the social inequality it engenders may be underlying social determinants of persistent racial disparities in health, including infant mortality, preterm delivery, and low birth weight. This article describes the problem of racial disparities in adverse birth outcomes; outlines the multidimensional nature of racism and the pathways by which it may adversely affect health; and discusses the implications for clinical practice.

Factors affecting Latina immigrants' perceptions of maternal health care: findings from a qualitative study

Due to the influx of Latino immigration in the United States, health care services are faced with the challenge of meeting the needs of this growing population. In this qualitative study, we explored Latina immigrants' experiences with maternal health care services. We found that despite enduring language barriers and problems, Spanish-speaking women expressed satisfaction with their care. Factors influencing women's perceptions of care included sociocultural norms (respeto, personalismo, and familismo), previous experiences with care in their countries of origin, having healthy babies, and knowledge about entitlement to interpreter services. We offer recommendations for public health practice and research.

Understanding the role of reactions to race-based treatment in breast and cervical cancer screening

Racial and ethnic disparities in breast and cervical cancer mortality persist despite effective screening methods. We examined associations between race/ethnicity and Pap testing within three years or mammography within two years, controlling for a composite reactions-to-race-based-treatment variable created using data from the 2002 and 2004 Behavioral Risk Factor Surveillance System Reactions to Race module, which assessed respondents experiences based on one's race. We calculated prevalence of Pap testing (for women aged > or = 18) and mammography (for women aged > or = 40) by race, and fit logistic regression models to estimate the strength of association of reactions to race-based treatment with screening and race--before and after controlling for demographics, socioeconomic status, health status, smoking and healthcare access. In the reduced model, black women were more likely (2.03: 95% CI: 1.55-2.65) to be screened for cervical cancer than whites. Reactions to race-based treatment did not impact the odds of black women receiving Pap tests or mammograms. Given current racial and ethnic disparities in breast and cervical cancer mortality, we suggest that more attention needs to be focused on follow-up of abnormal results and state-of-the art treatment for black and Hispanic women.

Clinical and social predictors of application for social security disability insurance by workers' compensation claimants with low back pain

OBJECTIVE

The objective of this study was to identify clinical and social predictors of application for Social Security Disability Insurance (SSDI) in workers' compensation claimants with low back pain.

METHODS

Archival and interview data were analyzed for 1372 Missouri claimants who were, on average, nearly 42 months postinjury.

RESULTS

Two hundred sixty-five (19.3%) claimants were receiving SSDI (8.0%) or had applied for SSDI (11.3%). Logistic regression indicated that black race, older age, herniated disc diagnosis, surgery, and longer time since injury were associated with increased odds of SSDI. Higher preinjury wage, more education, and higher satisfaction with medical treatment and/or treatment by employer were associated with decreased odds of SSDI.

CONCLUSIONS

Application for SSDI among claimants with occupational low back pain is associated with social factors like race, satisfaction, and socioeconomics as well as clinical factors like diagnosis and surgery.

Service Utilization among ethnic minority children with ADHD: a model of help-seeking behavior

Despite a significant increase in the number of children and adolescents who receive clinical services for attention deficit hyperactivity disorder (ADHD), there is still a considerable level of unmet need. Children of ethnic minority status continue to lag well behind their non-minority counterparts in the rate of diagnosis and treatment for the disorder. Racial/ethnic disparities in service use are the result of a combination of access barriers and individual, cultural, and societal factors. The ADHD Help-Seeking Behavior Model is proposed as a framework for understanding factors that may be predictive of service use. Variables specific to ADHD and ethnic-minority populations are integrated within the framework of a four-stage pathway model encompassing problem recognition, decision to seek help, service selection, and service use. The authors argue that by systematically addressing factors related to service use for each ethnic minority group, more effective intervention initiatives can be developed to improve identification and treatment for ADHD among underserved children.

Understanding African Americans' views of the trustworthiness of physicians

BACKGROUND

Many scholars have written about the historical underpinnings and likely consequences of African Americans distrust in health care, yet little research has been done to understand if and how this distrust affects African Americans' current views of the trustworthiness of physicians.

OBJECTIVE

To better understand what trust and distrust in physicians means to African Americans.

DESIGN

Focus-group study, using an open-ended discussion guide.

SETTING

Large public hospital and community organization in Chicago, IL.

PATIENTS

Convenience sample of African-American adult men and women.

MEASUREMENTS

Each focus group was systematically coded using grounded theory analysis. The research team then identified themes that commonly arose across the 9 focus groups.

RESULTS

Participants indicated that trust is determined by the interpersonal and technical competence of physicians. Contributing factors to distrust in physicians include a lack of interpersonal and technical competence, perceived quest for profit and expectations of racism and experimentation during routine provision of health care. Trust appears to facilitate care-seeking behavior and promotes patient honesty and adherence. Distrust inhibits care-seeking, can result in a change in physician and may lead to nonadherence.

CONCLUSIONS

Unique factors contribute to trust and distrust in physicians among African-American patients. These factors should be considered in clinical practice to facilitate trust building and improve health care provided to African Americans.

Preference for same-race health care providers and perceptions of interpersonal discrimination in health care

This article examines black Americans' preference for black health care providers. Using data from a national survey, we assess how blacks 'perceptions of discrimination are related to preference for same-race health care providers. Overall, the belief that discrimination is frequent in different-race doctor-patient dyads is associated with greater preference for a same-race provider However; the belief that discrimination occurs regardless of a doctor's race reduces preference for a same-race provider Finally, general perceptions of discrimination are distinct from concerns about personally being treated unfairly, and low personal concern about unfair treatment reduces preference for a same-race provider among those who believe that interpersonal discrimination occurs frequently. These results suggest a complex picture of how perceptions of discrimination influence preferred race of health care provider among blacks in the United States.

Migraine care among different ethnicities: do disparities exist?

OBJECTIVE

Evaluate whether, in a primary care setting, Caucasians (C) and African Americans (AA) with moderately to severely disabling migraines differed in regards to: utilizing the health-care system for migraine care, migraine diagnosis and treatment, level of mistrust in the health-care system, perceived communication with their physician, and perceived migraine triggers.

BACKGROUND

Research has documented ethnic disparities in pain management. However, almost no research has been published concerning potential disparities in utilization, diagnosis, and/or treatment of migraine. It is also important to consider whether ethnic differences exist for trust and communication between patients and physicians, as these are essential when diagnosing and treating migraine.

METHODS

Adult patients with headache (n = 313) were recruited from primary care waiting rooms. Of these, 131 (AA = 77; C = 54) had migraine, moderate to severe headache-related disability, and provided socioeconomic status (SES) data. Participants completed measures of migraine disability (MIDAS), migraine health-care utilization, diagnosis and treatment history, mistrust of the medical community, patient-physician communication (PPC), and migraine triggers. Analysis of covariance (controlling for SES and recruitment site), chi-square, and Pearson product moment correlations were conducted.

RESULTS

African Americans were less likely to utilize the health-care setting for migraine treatment (AA = 46% vs. C = 72%, P < .001), to have been given a headache diagnosis (AA = 47% vs. C = 70%, P < .001), and to have been prescribed acute migraine medication (AA = 14% vs. C = 37%, P < .001). Migraine diagnosis was low for both groups, and <15% of all participants had been prescribed a migraine-specific medication or a migraine preventive medication despite suffering moderate to severe levels of migraine disability. African Americans had less trust in the medical community (P < .001, eta2 = 0.26) and less positive PPC (P < .001, eta2 = 0.11). Also, the lower the trust and communication, the less likely they were to have ever seen (or currently be seeing) a doctor for migraine care or to have been prescribed medication.

CONCLUSIONS

Migraine utilization, diagnosis, and treatment were low for both groups. However, this was especially true for African Americans, who also reported lower levels of trust and communication with doctors relative to Caucasians. The findings highlight the need for improved physician and patient education about migraine diagnosis and treatment, the importance of cultural variation in pain presentation, and the importance of communication when diagnosing and treating migraine.

Differences in Access to Outpatient Medical Care for Black and White Adults in the Rural South

OBJECTIVES

We compared black and white adults in the rural South on multiple indicators of access to outpatient medical care and assessed whether any differences might be explained by group differences in socioeconomic situations or proximity to medical resources.

DESIGN

Cross-sectional telephone survey.

SUBJECTS

Survey respondents were 1237 black and 2158 white adults from 113 rural counties in 6 southern states.

MEASURES

Blacks and whites were compared on a variety of commonly used survey measures of access, some followed in the Healthy People 2010 Initiative. Access comparisons were adjusted for age, gender, and health status and then reassessed with adjustments for individual socioeconomic indicators and county medical resources: physician-to-population ratios, the presence of hospitals and federally qualified health centers, and urban adjacency.

RESULTS

Compared with whites, blacks reported similar or higher use of outpatient services over the previous year, including the likelihood of having had an outpatient physician visit and regular checkup. Nevertheless, blacks more often reported forgoing needed care, encountering various barriers, and experiencing dissatisfaction with some aspects of care. Adjusting for socioeconomic factors generally reduced but did not eliminate black-white access differences, whereas adjusting for county medical care resources did not affect measured group differences.

CONCLUSIONS

Blacks and whites in the rural South report similar use rates of outpatient medical care, but blacks more often report unmet needs, barriers to care, and dissatisfaction with care. Beyond socioeconomic differences, black versus white differences in sites of care, the quality of care received, the quality of interactions with providers, and expectations for their care may explain group reported access differences.

African American women and family planning services: perceptions of discrimination

OBJECTIVES

The purpose of this study was to examine perceived race-based discrimination in obtaining family planning or contraceptive services among African American women in the U.S.

METHODS

We conducted a 30-minute telephone survey with a random sample of 500 African Americans (aged 15-44), which included questions about race-based discrimination when obtaining family planning services. The present analyses were limited to the 326 women who completed interviews.

RESULTS

The majority (79%) of women reported having seen a health care provider for family planning or birth control services. Of those, 67% reported race-based discrimination when obtaining such services. Half of the women reported more general experiences of discrimination when obtaining family planning services (e.g., poorer service), and 52% reported experiences that reflect stereotypes of African American women (e.g., doctor or nurse assumed they had multiple sexual partners). Most indicated that experiences of discrimination occurred infrequently. Generally, background characteristics were not significantly associated with perceived discrimination. However, in multivariate models, stronger Black identity, younger age, and lower income were associated with reports of discrimination.

CONCLUSION

African American women may be vulnerable to prejudice within reproductive health care contexts, including family planning.

Perceived discrimination in clinical care in a nationally representative sample of HIV-infected adults receiving health care

BACKGROUND

Perceived discrimination in clinical settings could discourage HIV-infected people from seeking health care, adhering to treatment regimens, or returning for follow-up.

OBJECTIVES

This study aims to determine whether HIV-infected people perceive that physicians and other health care providers have discriminated against them.

DESIGN, PARTICIPANTS

Cross-sectional data (1996 to 1997) from the HIV Cost and Services Utilization Study (HCSUS), which conducted in-person interviews with a nationally representative probability sample of 2,466 HIV-infected adults receiving health care within the contiguous U.S.

MEASUREMENTS

Reports of whether health care providers have been uncomfortable with the respondent, treated the respondent as an inferior, preferred to avoid the respondent, or refused the respondent service. Questions also covered the types of providers who engaged in these behaviors.

RESULTS

Twenty-six percent of HIV-infected adults receiving health care reported experiencing at least 1 of 4 types of perceived discrimination by a health care provider since becoming infected with HIV, including 8% who had been refused service. White respondents (32%) were more likely than others (27%) and Latinos (21%) and nearly twice as likely as African Americans (17%) to report perceived discrimination (P < .001). Respondents whose first positive HIV test was longer ago were also more likely to report discrimination (P < .001). Respondents who reported discrimination attributed it to physicians (54%), nurses and other clinical staff (39%), dentists (32%), hospital staff (31%), and case managers or social workers (8%).

CONCLUSIONS

Many HIV-infected adults believe that their clinicians have discriminated against them. Clinicians should make efforts to address circumstances that lead patients to perceive discrimination, whether real or imagined.

Explaining black-white differences in receipt of recommended colon cancer treatment

BACKGROUND

Black-white disparities exist in receipt of recommended medical care, including colorectal cancer treatment. This retrospective cohort study examines the degree to which health systems (e.g., physician, hospital) factors explain black-white disparities in colon cancer care.

METHODS

Data from the Surveillance, Epidemiology, and End Results program; Medicare claims; the American Medical Association Masterfile; and hospital surveys were linked to examine chemotherapy receipt after stage III colon cancer resection among 5294 elderly (> or = 66 years of age) black and white Medicare-insured patients. Logistic regression analysis was used to identify factors associated with black-white differences in chemotherapy use. All statistical tests were two-sided.

RESULTS

Black and white patients were equally likely to consult with a medical oncologist, but among patients who had such a consultation, black patients were less likely than white patients (59.3% versus 70.4%, difference = 10.9%, 95% confidence interval [CI] = 5.1% to 16.4%, P < .001) to receive chemotherapy. This black-white disparity was highest among patients aged 66-70 years (black patients 65.7%, white patients 86.3%, difference = 20.6%, 95% CI = 10.7% to 30.4%, P < .001) and decreased with age. The disparity among patients aged 66-70 years also remained statistically significant in the regression analysis. Overall, patient, physician, hospital, and environmental factors accounted for approximately 50% of the disparity in chemotherapy receipt among patients aged 66-70 years; surgical length of stay and neighborhood socioeconomic status accounted for approximately 27% of the disparity in this age group, and health systems factors accounted for 12%.

CONCLUSIONS

Black and white Medicare-insured colon cancer patients have an equal opportunity to learn about adjuvant chemotherapy from a medical oncologist but do not receive chemotherapy equally. Little disparity was explained by health systems; more was explained by illness severity, social support, and environment. Further qualitative research is needed to understand the factors that influence the lower receipt of chemotherapy by black patients.

Perceived discrimination and reported delay of pharmacy prescriptions and medical tests

BACKGROUND

Access to health care varies according to a person's race and ethnicity. Delaying treatment is one measure of access with important health consequences.

OBJECTIVE

Determine whether perceptions of unfair treatment because of race or ethnicity are associated with reported treatment delays, controlling for economic constraints, self-reported health, depression, and demographics.

DESIGN

Cross-sectional, observational study.

PARTICIPANTS

A randomly selected community sample of 181 blacks, 148 Latinos, and 193 whites in Durham County, NC.

MEASUREMENTS

A phone survey conducted in 2002 to assess discrimination, trust in medical care, quality of care, and access to care. Treatment delays were measured by whether or not a person reported delaying or forgoing filling a prescription and delaying or forgoing having a medical test/treatment in the past 12 months. Perceived discrimination was measured as unfair treatment in health care and as racism in local health care institutions.

RESULTS

The odds of delaying filling prescriptions were significantly higher (odds ratio (OR)=2.02) for persons who perceived unfair treatment, whereas the odds of delaying tests or treatments were significantly higher (OR=2.42) for persons who thought racism was a problem in health care locally. People with self-reported depression and people who reported not working had greater odds of delaying both types of care.

CONCLUSIONS

A prospective cohort study with both personal and macro measures of discrimination, as well as more refined measures of treatment delays, would help us better understand the relationship between perceived discrimination and treatment delays.

Patient satisfaction with health care providers in South Africa: the influences of race and socioeconomic status

OBJECTIVE

The first democratic government elected in South Africa in 1994 inherited huge inequalities in health status and health provision across all sections of the population. This study set out to assess, 4 years later, the influence of race and socioeconomic status (SES) on perceived quality of care from health care providers.

DESIGN

A 1998 countrywide survey of 3820 households assessed many aspects of health care delivery, including levels of satisfaction with health care providers among different segments of South African society.

RESULTS

Fifty-one percent (n = 1953) of the respondents had attended a primary care facility in the year preceding the interview and were retained in the analysis. Both race and SES were significant predictors of levels of satisfaction with the services of the health care provider, after adjusting for gender, age, and type of facility visited. White and high SES respondents were about 1.5 times more likely to report excellent service compared with Black and low SES respondents, respectively.

CONCLUSION

In South Africa, race and SES are not synonymous and can no longer be considered reliable proxy indicators of one another. Each has distinct and significant but different degrees of association with client satisfaction. Any assessment of equity-driven health policy in South Africa should consider the impacts of both race and SES on client satisfaction as one of the indicators of success.

Patients' beliefs about racism, preferences for physician race, and satisfaction with care

PURPOSE

Few studies have attempted to link patients' beliefs about racism in the health care system with how they use and experience health care.

METHODS

Using telephone survey data from a national sample of 1,479 whites, 1,189 African Americans, and 983 Latinos, we explored patients' beliefs about racism, their preferences for the race and ethnicity of their physician, and their satisfaction with that physician. A scale was developed to reflect patients' beliefs about racism. Race-stratified analyses assessed associations between patients' beliefs, racial preferences for physicians, choice of physician, and satisfaction with care.

RESULTS

Among African Americans, stronger beliefs about racial discrimination in health care were associated with preferring an African American physician (P <.001). Whereas only 22% of African Americans preferred an African American physician, those who preferred a African American physician and had an African American physician were more likely to rate their physician as excellent than did African Americans who preferred a African American physician but had a non-African American physician (57% vs 20%, P <.001). Latinos with stronger beliefs about discrimination in health care were more likely to prefer a Latino physician (P <.001). One third of Latinos preferred a Latino physician. Though not statistically significant, those who preferred and had a Latino physician rated their physician higher than Latinos who preferred a Latino physician but had a non-Latino physician (40% vs 29%).

CONCLUSIONS

Many African Americans and Latinos perceive racism in the health care system, and those who do are more likely to prefer a physician of their own race or ethnicity. African Americans who have preferences are more often satisfied with their care when their own physicians match their preferences.

Health law 2005: an agenda

In 2004, the journalHealth Matrixpublished a very interesting symposium volume titled “The Field of Health Law: Its Past and Future. As the title implies, the various commentators took both a retrospective and a prospective look at past trends and future prospects in health law. Some, including Clark Havighurst, Skip Rosoff and Walter Wadlington, wrote thoughtful essays on the development of health law over time and the implications of those trends. Others, including Rob Schwartz, Jim Blumstein, Rand Rosenblatt, and Mark Hall and Carl Schneider, wrote equally thoughtful essays that reflected on the past but focused more on future directions and prospects. And one, Kep Wing, wrote a semi-dyspeptic essay debunking the entire field of health law.

Taken together, these essays present a comprehensive view of how health law has developed so far and where its future might lie. Four themes emerge from the collected writings. First, there is considerable agreement on how and why health law has developed, but little agreement on where it is headed.

Management of occupational back injuries: differences among African Americans and Caucasians

This study examined differences in the case management of occupational low back injuries in a large, racially diverse population of Workers' Compensation claimants in Missouri. Participants were African Americans (N=580) and non-Hispanic whites (N=892) who had filed occupational injury claims that were settled over an 18-month period. Telephone interview data were gathered regarding diagnoses, legal representation, demographics, and socioeconomic status. The Missouri Division of Workers' Compensation also provided information on medical and temporary disability expenditures, claim duration, final disability ratings, and settlement awards. Simultaneous-entry, hierarchical multiple and logistic regression analyses showed significant and substantial effects for injury-related variables, socioeconomic status, and race across all Workers' Compensation variables. Differences remained for both injury and African Americans and lower socioeconomic status workers after controlling for injury, and for African Americans after controlling for both injury and socioeconomic status. Because Workers' Compensation mandates equal access to treatment and disability reimbursement for all injured workers, the differences observed in this study may reflect sociocultural biases in disability management among healthcare providers.

The contribution of insurance coverage and community resources to reducing racial/ethnic disparities in access to care

OBJECTIVE

To examine the extent to which health insurance coverage and available safety net resources reduced racial and ethnic disparities in access to care.

DATA SOURCES

Nationally representative sample of 11,692 African American, 10,325 Hispanic, and 74,397 white persons. Nonelderly persons with public or private health insurance and those who were uninsured.

STUDY DESIGN

Two cross-sectional surveys of households conducted during 1996-1997 and 1998-1999.

DATA COLLECTION

Commonly used measures of access to and utilization of medical care were constructed for individuals. These measures include the following. (1) percent reporting unmet medical needs, (2) percent without a regular health care provider, and (3) no visit with a physician in the past year.

FINDINGS

More than 6.5 percent of Hispanic and African Americans reported having unmet medical needs compared to less than 5.6 percent of white Americans. Hispanics were least likely to see the same doctor at their usual source of care (59 percent), compared to African Americans (66 percent) and whites (75 percent). Similarly, Hispanics were less likely than either African Americans or whites to have seen a doctor in the last year (65 percent compared to 76 percent or 79 percent). For Hispanics, more than 80 percent of the difference from whites was due to differences in measured characteristics (e.g., insurance coverage, income, and available safety net services). Differences in measured characteristics between African Americans and whites explained less than 80 percent of the access disparities.

CONCLUSION

Lack of health insurance was the single most important factor in white-Hispanic differences for all three measures and for two of the white-African American differences. Income differences were the second most important factor, with one exception. Community characteristics generally were much less important, with one exception. The positive effects of insurance coverage in reducing disparities outweigh benefits of increasing physician charity care or access to emergency rooms.

Methods for conducting systematic reviews of the evidence of effectiveness and economic efficiency of interventions to promote healthy social environments

The social and physical surroundings in which people live affect their health. Knowing what basic conditions and opportunities in communities advance or impede improvement of community health can inform public health practice and policy. This article describes the methods for conducting systematic literature reviews of three community interventions to promote healthy social environments: early childhood development programs, programs to promote affordable family housing in safe neighborhoods, and interventions to increase the cultural and linguistic competence of healthcare systems. Existing methods, established for conducting systematic reviews for the Guide to Community Preventive Services, were applied to these interventions to promote healthy social environments.

Culturally competent healthcare systems. A systematic review

Culturally competent healthcare systems-those that provide culturally and linguistically appropriate services-have the potential to reduce racial and ethnic health disparities. When clients do not understand what their healthcare providers are telling them, and providers either do not speak the client's language or are insensitive to cultural differences, the quality of health care can be compromised. We reviewed five interventions to improve cultural competence in healthcare systems-programs to recruit and retain staff members who reflect the cultural diversity of the community served, use of interpreter services or bilingual providers for clients with limited English proficiency, cultural competency training for healthcare providers, use of linguistically and culturally appropriate health education materials, and culturally specific healthcare settings. We could not determine the effectiveness of any of these interventions, because there were either too few comparative studies, or studies did not examine the outcome measures evaluated in this review: client satisfaction with care, improvements in health status, and inappropriate racial or ethnic differences in use of health services or in received and recommended treatment.

Do health care ratings differ by race or ethnicity?

BACKGROUND

There is growing evidence that Asians and Pacific Islanders perceive their health care more negatively than whites and other racial and ethnic subgroups. This study of differences in health care experiences by race and ethnicity was the first to use nationally representative data.

METHODS

Data from the 1998 National Research Corporation Healthcare Market Guide survey were analyzed. A total of 120,855 respondents were included in the study. Four global satisfaction ratings (overall health plan satisfaction, medical care satisfaction, recommend plan to others, and intent to switch plans) and four composite measures (access to care, providers' delivery of care, customer service, and cost/benefits of care) were examined.

RESULTS

Nonwhite survey respondents--particularly those in the other/multiracial and Asian/Pacific Islander groups--rated their health plan coverage and medical care lower than whites.

DISCUSSION

The results of this study are consistent with those of other recent (and comparable) studies in which these racial and ethnic groups are represented. Most strikingly consistent, however, are the lower ratings of Asians/Pacific Islanders and the comparable (and higher) ratings (compared to whites) of African Americans. Why Asians/Pacific Islanders are considerably less satisfied with their medical care than all other racial and ethnic groups in the United States needs to be explored. Access to care and quality of care improvement efforts should be directed at all ethnic minority groups, particularly for limited English-speaking, other/multiracial, Hispanic, and Asian/Pacific Islander subgroups.

Eliminating disparities in perinatal outcomes--lessons learned

The disparity between blacks and whites in perinatal health ranges from a 2.3-fold excess risk among black women for preterm delivery and infant mortality to a 4-fold excess risk among black women for maternal mortality. To stimulate concerted public health action to address such racial and ethnic disparities in health, the national Healthy People objectives call for elimination of all health disparities by the year 2010. Eliminating health disparities requires a greater understanding of the factors that contribute to their development. This commentary summarizes the state of the science of reducing such disparities and proposes a framework for using the results of qualitative studies on the social context of pregnancy to understand, study, and address disparities in infant mortality and preterm delivery. Understanding the social context of African American women's lives can lead to an improved understanding of the etiology of preterm birth, and can help identify promising new interventions to reduce racial and ethnic disparities in preterm delivery.