Racial/ethnic disparities in the use of mental health services in poverty areas

OBJECTIVES: This study examined racial/ethnic disparities in mental health service access and use at different poverty levels. METHODS: We compared demographic and clinical characteristics and service use patterns of Whites, Blacks, Hispanics, and Asians living in low-poverty and high-poverty areas. Logistic regression models were used to assess service use patterns of minority racial/ethnic groups compared with Whites in different poverty areas. RESULTS: Residence in a poverty neighborhood moderates the relationship between race/ethnicity and mental health service access and use. Disparities in using emergency and inpatient services and having coercive referrals were more evident in low-poverty than in high-poverty areas. CONCLUSIONS: Neighborhood poverty is a key to understanding racial/ethnic disparities in the use of mental health services.     

Awareness of racial and ethnic health disparities has improved only modestly over a decade

Documented disparities exist in the United States between the majority white population and various racial and ethnic minority populations on several health and health care indicators, including access to and quality of care, disease prevalence, infant mortality, and life expectancy. However, awareness of these disparities-a necessary first step toward changing behavior and compelling action-remains limited. Our survey of 3,159 adults age eighteen or older found that 59 percent of Americans in 2010 were aware of racial and ethnic disparities that disproportionately affect African Americans and Hispanics or Latinos. That number represents a modest increase over the 55 percent recorded in a 1999 survey. Meanwhile, in our survey, 89 percent of African American respondents were aware of African American and white disparities, versus 55 percent of whites. Yet the survey also revealed low levels of awareness among racial and ethnic minority groups about disparities that disproportionately affect their own communities. For example, only 54 percent of African Americans were aware of disparities in the rate of HIV/AIDS between African Americans and whites, and only 21 percent of Hispanics or Latinos were aware of those disparities between their group and whites. Policy makers must increase the availability and quality of data on racial and ethnic health disparities and create multisectoral partnerships to develop targeted educational campaigns to increase awareness of health disparities.     

Person and place: the compounding effects of race/ethnicity and rurality on health

Rural racial/ethnic minorities constitute a forgotten population. The limited research addressing rural Black, Hispanic, and American Indian/Alaska Native populations suggests that disparities in health and in health care access found among rural racial/ethnic minority populations are generally more severe than those among urban racial/ethnic minorities. We suggest that disparities must be understood as both collective and contextual phenomena. Rural racial/ethnic minority disparities in part stem from the aggregation of disadvantaged individuals in rural areas. Disparities also emerge from a context of limited educational and economic opportunity. Linking public health planning to the education and economic development sectors will reduce racial/ethnic minority disparities while increasing overall well-being in rural communities.     

Historical and current policy efforts to eliminate racial and ethnic health disparities in the United States: future opportunities for public health education research

In the summer of 2005, the Society for Public Health Education convened a meeting, Health Disparities and Social Inequities, with the task of setting the minority health disparities research agenda for public health educators. The article provides a history of minority health efforts beginning with the Negro Health Improvement Week in 1915 and an overview of National Institutes of Health's (NIH) current 5-year strategic research plan to eliminate health disparities. The plan's goals represent a significant investment in minority health research and the emergence of NIH as the leading federal agency funding health disparity research. Understanding the history of minority health efforts and current health disparity research offers a perspective that will help guide public health educators in reaching the Healthy People 2010 goal of eliminating racial and ethnic health disparities.     

Factors influencing the effectiveness of interventions to reduce racial and ethnic disparities in health care

Reducing racial and ethnic disparities in health care has become an important policy goal in the United States and other countries, but evidence to inform interventions to address disparities is limited. The objective of this study was to identify important dimensions of interventions to reduce health care disparities. We used qualitative research methods to examine interventions aimed at improving diabetes and/or cardiovascular care for patients from racial and ethnic minority groups within five health care organizations. We interviewed 36 key informants and conducted a thematic analysis to identify important features of these interventions. Key elements of interventions included two contextual factors (external accountability and alignment of incentives to reduce disparities) and four factors related to the organization or intervention itself (organizational commitment, population health focus, use of data to inform solutions, and a comprehensive approach to quality). Consideration of these elements could improve the design, implementation, and evaluation of future interventions to address racial and ethnic disparities in health care.     

Racial/ethnic variations in veterans' ambulatory care use

OBJECTIVES: We assessed racial/ethnic variations in patterns of ambulatory care use among Department of Veterans Affairs (VA) health care-eligible veterans to determine if racial/ethnic differences in health care use persist in equal-access systems. METHODS: We surveyed 3227 male veterans about their health and ambulatory care use. RESULTS: Thirty-eight percent of respondents had not had a health care visit in the previous 12 months. Black (odds ratio [OR] = 0.5), Hispanic (OR = 0.4), and Asian/Pacific Islander veterans (OR=0.4) were less likely than White veterans to report any ambulatory care use. Alternately, Whites (OR=2.2) were more likely than other groups to report ambulatory care use. Being White was a greater predictor of health care use than was having fair or poor health (OR=1.4) or functional limitations (OR=1.5). In non-VA settings, racial/ethnic minorities were less likely to have a usual provider of health care. There was no VA racial/ethnic variation in this parameter. CONCLUSIONS: Racial/ethnic disparities in health and health care use are present among VA health care-eligible veterans. Although the VA plays an important role in health care delivery to ethnic minority veterans, barriers to VA ambulatory care use and additional facilitators for reducing unmet need still need to be investigated.     

Children's mental health care: differences by race/ethnicity in urban/rural areas

This study examines racial/ethnic disparities in children's mental health and the receipt of mental health services, and whether those disparities differ between urban and rural areas. We find no significant difference between racial/ethnic groups in the prevalence of child mental health problems in either urban or rural areas. However, there are disparities in the use of mental health services. Hispanic children and Black children in urban areas receive less mental health care than their White counterparts, and the disparity persists for Hispanic children in rural areas, even after controlling for other relevant factors. Initiatives to improve access to mental health care for racial/ethnic minorities should recognize these disparities, and address the lack of culturally appropriate services in both urban and rural areas. In addition, outreach should raise awareness among parents, teachers, and other community members concerning the need for mental health services for minority children.     

Racial/ethnic variation in functional and self-reported health

OBJECTIVES: We investigated whether racial/ethnic health disparities exist in Canada and whether socioeconomic or behavioral differences between racial/ ethnic minorities and nonminorities account for such disparities. METHODS: We used data from the National Population Health Survey, conducted by Statistics Canada in 1996 and 1997. We used regression models to examine differences in functional and self-reported health. RESULTS: Our study found no association between socioeconomic or behavioral differences and racial/ethnic health disparities. There was no clear pattern between racial/ethnic minority status and health. CONCLUSIONS: The state can play an important role in health outcomes, and public commitment to accessible health care may explain why socioeconomic status and health behaviors are weak indicators of racial/ethnic health variation in Canada.     

A plan for action: key perspectives from the racial/ethnic disparities strategy forum

CONTEXT: Racial and ethnic disparities in health care in the United States have been well documented, with research largely focusing on describing the problem rather than identifying the best practices or proven strategies to address it. METHODS: In 2006, the Disparities Solutions Center convened a one-and-a-half-day Strategy Forum composed of twenty experts from the fields of racial/ethnic disparities in health care, quality improvement, implementation research, and organizational excellence, with the goal of deciding on innovative action items and adoption strategies to address disparities. The forum used the Results Based Facilitation model, and several key recommendations emerged. FINDINGS: The forum's participants concluded that to identify and effectively address racial/ethnic disparities in health care, health care organizations should: (1) collect race and ethnicity data on patients or enrollees in a routine and standardized fashion; (2) implement tools to measure and monitor for disparities in care; (3) develop quality improvement strategies to address disparities; (4) secure the support of leadership; (5) use incentives to address disparities; and (6) create a message and communication strategy for these efforts. This article also discusses these recommendations in the context of both current efforts to address racial and ethnic disparities in health care and barriers to progress. CONCLUSIONS: The Strategy Forum's participants concluded that health care organizations needed a multifaceted plan of action to address racial and ethnic disparities in health care. Although the ideas offered are not necessarily new, the discussion of their practical development and implementation should make them more useful.     

Asthma prevalence and control characteristics by race/ethnicity--United States, 2002

During 1980-1999, asthma prevalence, morbidity, and mortality increased among U.S. adults. These annual rates were higher among certain racial/ethnic minority populations than among whites. In addition, racial/ethnic minority populations reported higher use of emergency departments (EDs) and doctors' offices for asthma treatment than whites. To assess asthma prevalence and asthma-control characteristics among racial/ethnic populations, CDC analyzed 2002 data from the Behavioral Risk Factor Surveillance System (BRFSS). This report summarizes the results of that analysis, which indicated that among the estimated 16 million (7.5%) U.S. adults with asthma, self-reported current asthma prevalence among racial/ethnic minority populations ranged from 3.1% to 14.5%, compared with 7.6% among whites. Comprehensive state-specific asthma surveillance data are necessary to identify disparities in asthma prevalence and asthma-control characteristics among racial/ethnic populations and to develop targeted public health interventions.     

Racial/ethnic variations in women's health: the social embeddedness of health

This article provides an overview of the magnitude of and trends in racial/ethnic disparities in health for women in the United States. It emphasizes the importance of attending to diversity in the health profiles and populations of minority women. Socioeconomic status is a central determinant of racial/ethnic disparities in health, but several other factors, including medical care, geographic location, migration and acculturation, racism, and exposure to stress and resources also play a role. There is a need for renewed attention to monitoring, understanding, and actively seeking to eliminate racial/ethnic disparities in health.     

Disparities in health: perspectives of a multi-ethnic, multi-racial America

This 2006 survey of 4,157 randomly selected U.S. adults compared perceptions of health care disparities among fourteen racial and ethnic groups to those of whites. Findings suggest that many ethnic minority groups view their health care situations differently and, often, more negatively than whites. A substantial proportion perceived discrimination in receiving health care, and many felt that they would not receive the best care if they were sick. Most differences remained when socioeconomic characteristics were controlled for. The variety of responses across racial groups demonstrates the importance of examining ethnic subgroups separately rather than combined into a single category.     

Challenges in understanding disparities in drug use and its consequences

Racial/ethnic disparities in health have long been documented in a broad range of medical conditions in the United States. For example, Blacks have higher HIV incidence and AIDS-related mortality than do Whites., This article summarizes racial/ethnic differences in drug use and its consequences in the United States and proposes three key challenges to the study of disparities in drug use and its consequences. These are (a) patterns of drug use and misuse are complex, with different patterns of use of different drugs in different racia,/ethnic groups; (b) racial/ethnic differnces in use of drugs are not always associated with comparable differences in the consequences of drug use; and (c) the consequences of drug use are associated with drug use itself and other social/economic circumstances. Each of these challenges is discussed, and suggestions offered for future research that may help overcome them.     

Medicare as a catalyst for reducing health disparities

As the nation's largest purchaser and regulator of health care, Medicare is positioned to be a leader in reducing racial and ethnic health disparities. Its leverage was demonstrated in 1966-the year of Medicare's inception-when hospitals desegregated as a condition for receiving Medicare reimbursement. Since then, Medicare has contributed to dramatic improvement in the health of the elderly and disabled minority population, although disparities between minority and white beneficiaries remain. A National Academy of Social Insurance study panel is exploring how Medicare could use its leverage to reduce disparities, for both its beneficiaries and the rest of the nation.     

Racial/Ethnic Disparities in Nursing Home End-of-Life Care: A Systematic Review

ObjectiveHealth disparities are pervasive in nursing homes (NHs), but disparities in NH end-of-life (EOL) care (ie, hospital transfers, place of death, hospice use, palliative care, advance care planning) have not been comprehensively synthesized. We aim to identify differences in NH EOL care for racial/ethnic minority residents.DesignA systematic review guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses and registered in PROSPERO (CRD42020181792).Setting and ParticipantsOlder NH residents who were terminally ill or approaching the EOL, including racial/ethnic minority NH residents.MethodsThree electronic databases were searched from 2010 to May 2020. Quality was assessed using the Newcastle-Ottawa Scale.ResultsEighteen articles were included, most (n = 16) were good quality and most (n = 15) used data through 2010. Studies varied in definitions and grouping of racial/ethnic minority residents. Four outcomes were identified: advance care planning (n = 10), hospice (n = 8), EOL hospitalizations (n = 6), and pain management (n = 1). Differences in EOL care were most apparent among NHs with higher proportions of Black residents. Racial/ethnic minority residents were less likely to complete advance directives. Although hospice use was mixed, Black residents were consistently less likely to use hospice before death. Hispanic and Black residents were more likely to experience an EOL hospitalization compared with non-Hispanic White residents. Racial/ethnic minority residents experienced worse pain and symptom management at the EOL; however, no articles studied specifics of palliative care (eg, spiritual care).Conclusions and ImplicationsThis review identified NH health disparities in advance care planning, EOL hospitalizations, and pain management for racial/ethnic minority residents. Research is needed that uses recent data, reflective of current NH demographic trends. To help reduce EOL disparities, language services and cultural competency training for staff should be available in NHs with higher proportions of racial/ethnic minorities.     

Quality improvement efforts under health reform: how to ensure that they help reduce disparities--not increase them

Despite persistent evidence of continued racial and ethnic disparities in health care, little explicit attention has been paid to how quality improvement activities might affect disparities. As the nation focuses on the practical realities of implementing health care reform and concurrent quality improvement provisions under the Affordable Care Act of 2010, it is important to recognize that overall improvements in the US health care system might not automatically benefit all segments of the population equally. In this article we highlight challenges to ensuring that quality improvement efforts reduce racial and ethnic disparities. These include making certain that quality improvement efforts measure disparities and improvements in them, notwithstanding providers' reputational concerns; that such efforts not create perverse incentives for providers to avoid serving minority patients; that they be applied to institutions where minority patients are most likely to receive care; and that they fully engage minority patients despite language or other barriers. To assist in these efforts, we argue for the development of disparities impact assessments to measure the effect that the Affordable Care Act's quality provisions will have on reducing disparities.     

Establishing centers to address treatment effectiveness in diverse ethnic groups: the MEDTEP experience

Objective. To investigate racial ethnic and socioeconomic disparities in health outcomes amenable to improvement through more effective delivery of health care services. Design. The Medical Treatment Effectiveness Program (MEDTEP) Research Centers on Minority Populations were a group of centers in the USA funded to improve the effectiveness of medical diagnosis and treatment to provide technical assistance to ethnic minority health researchers to train new researchers and to disseminate information to help ethnic minority patients and their health care providers. Results. Centers often provided many specific findings related to assessment of the magnitude of disparities in health outcomes and to approaches for eliminating these outcomes. The Centers were able to build community partnerships using an approach now defined as community-based participatory research. Centers changed the culture of their institutions by making them more aware of the need to train diverse investigators and do more to eliminate health disparities. Conclusions. A key to the success of the Centers has been the unification of a cadre of committed investigators dedicated to the mentoring of minority health researchers and to the elimination of ethnic and socioeconomic disparities in health. The MEDTEP Centers provide a model but there remains a need for continued work.     

In Brief: Southern Medical Assn. Meeting

Healthcare organizations suffer from a disparate distribution of racial and ethnic minority employees in professional positions. Although the percentage of racial and ethnic minorities in the workforce continues to grow, the percentage of racial and ethnic minorities who compose the professional ranks, nursing and managerial positions, lags far behind the percentage of White individuals in similar positions. This gap has implications for organizational performance as research indicates organizations with more diverse workforces enjoy better outcomes. A more diverse workforce also has broader societal consequences directly tied to healthcare such as positively impacting health disparities. The authors posit that recruitment is critical to developing a diverse workforce.     

Defining cultural competence: a practical framework for addressing racial/ethnic disparities in health and health care

OBJECTIVES: Racial/ethnic disparities in health in the U.S. have been well described. The field of "cultural competence" has emerged as one strategy to address these disparities. Based on a review of the relevant literature, the authors develop a definition of cultural competence, identify key components for intervention, and describe a practical framework for implementation of measures to address racial/ethnic disparities in health and health care. METHODS: The authors conducted a literature review of academic, foundation, and government publications focusing on sociocultural barriers to care, the level of the health care system at which a given barrier occurs, and cultural competence efforts that address these barriers. RESULTS: Sociocultural barriers to care were identified at the organizational (leadership/workforce), structural (processes of care), and clinical (provider-patient encounter) levels. A framework of cultural competence interventions--including minority recruitment into the health professions, development of interpreter services and language-appropriate health educational materials, and provider education on cross-cultural issues--emerged to categorize strategies to address racial/ethnic disparities in health and health care. CONCLUSIONS: Demographic changes anticipated over the next decade magnify the importance of addressing racial/ethnic disparities in health and health care. A framework of organizational, structural, and clinical cultural competence interventions can facilitate the elimination of these disparities and improve care for all Americans.