Self-Reported Racial Discrimination and Substance Use Among Asian Americans in Arizona

We examined associations between different forms of self-reported racial discrimination and current substance use (i.e., smoking, alcohol use, and controlled substance use) among Asian Americans living in Arizona. The data are from 271 Asian American adults participating in the 2008 Asian Pacific Arizona Inititative (APAZI) Survey, which is part of a larger collaboration between community members, organizational leaders, and researchers. Asian Americans treated like they were not American because of their race were at increased risk of tobacco use, after controlling for covariates, including age, gender, education, family income, health insurance, nativity status, and language, and other types of racial discrimination. Also, individuals treated differently because of their race were at increased risk of alcohol use and controlled substance use, after controlling for covariates and other types of racial discrimination. The results indicate that Asian Americans experience a wide range of racial discrimination types and some forms of racial discrimination may have greater associations with tobacco, alcohol, and controlled substance use than others.     

Equity in access to zero-fees and low-cost Primary Health Care in Aotearoa New Zealand: Results from repeated waves of the New Zealand Health Survey, 1996-2016

Primary Health Care in Aotearoa New Zealand is mainly funded through capitation-based funding to general practices, supplemented by a user co-payment. Funding is designed in part to keep the costs of care low for key groups in the population who have higher health needs. We investigated changes in the socio-demographic determinants of no-cost and low-cost access to Primary Health Care using data from sequential waves of the New Zealand Health Survey (1996/97–2016/17). Fees paid were self-reported and inflated using CPI-adjustment to the value of the 2018NZD.Over the 20-year study period, there was an increase in the population accessing low-cost care. Access to low-cost care was particularly high for Pacific people, but also higher for Māori and Asian people compared to Other/New Zealand European ethnicities. Area-level deprivation was a stronger predictor of access to low-cost care for non-Māori than for Māori. Although Māori were more likely than non-Māori to access low-cost care at all levels of deprivation, this was less evident in more deprived compared to more affluent areas. Given ongoing reported inequity for Māori being less able to afford primary health care, we suggest that future policies to improve access should be fully aligned with the articles of Te Tiriti o Waitangi and should focus on equity.     

Racial/Ethnic Differences in the Self-Reported Use of Screening Mammography

The efficacy of mammography in reducing breast cancer mortality among women 50–69 years of age has been demonstrated in randomized controlled studies, but many women, especially ethnic minorities, have not been receiving regular mammographic screening. The current study investigated racial/ethnic differences in mammography use and their association with demographic characteristics and other factors. The study population consisted of 4,444 women aged 40 years and older who participated in the1996 Medical Expenditure Panel Survey. Outcome measures studied included the self-reporting of mammography within the past two years and past year. Multivariate logistic regression modeling was used to examine the effect of race while controlling for other factors. In the univariate analysis, there was virtually no difference between white, black, and Hispanic women in mammography rates within either one or two years. However, multivariate logistic regression suggested that both blacks and Hispanics were more likely than whites to have received recent mammography, as black women were 31% and Hispanic women were 43% more likely than white women to have had a mammogram within the previous two years. Our results suggest that white women are no longer more likely to receive periodic screening mammography than black and Hispanic women, and in fact, might even be less likely to undergo the procedure. This reversal might indicate, at least in part, that programs and other activities to promote screening mammography among ethnic minority women have been successful and should now be expanded to include other women.     

Self-Reported Pregnancy and Access to Primary Health Care Among Sexually Experienced New Zealand High School Students

Purpose

To determine the prevalence of self-reported pregnancy among sexually experienced high school students, and the association between teenage pregnancy and access to primary health care.

Methods

Between March and October 2007, 96 high schools throughout New Zealand participated in Youth'07, a cross-sectional Health and Wellbeing survey. The dataset included 2,620 (1,217 females and 1,403 males) year 9 through 13 students who reported ever having sexual intercourse and responded to a question about whether they had ever been pregnant or ever caused a pregnancy.

Results

Nationwide, 10.6% of sexually experienced high school students self-reported that they had been pregnant (11.6%) or caused a pregnancy (9.9%). Māori (15.3%) and Pacific Island (14.1%) students had the highest self-reports of pregnancy. Foregone health care was reported by 24.2% of sexually experienced students. Students who self-reported pregnancy reported greater difficulty accessing health care (41.7% vs. 20.6%; odds ratio: 2.6); however, when they accessed care, the majority received confidential care (67.4%) as compared with pregnancy-inexperienced peers (51.6%). Concern about privacy was the most common reason for not accessing health care. Other barriers included uncertainty about how to access care and lack of transportation (all p values < .05).

Conclusions

Self-reported pregnancy among sexually active high school students in New Zealand is high and ethnic disparities exist. Being pregnant or causing a pregnancy is associated with difficulty accessing health care. Further research is needed to identify drivers for ethnic differences and determine what the cause-and-effect relationship between teenage pregnancy and access to health care looks like.     

The State of Research on Racial/Ethnic Discrimination in The Receipt of Health Care

Objectives. We conducted a review to examine current literature on the effects of interpersonal and institutional racism and discrimination occurring within health care settings on the health care received by racial/ethnic minority patients.Methods. We searched the PsychNet, PubMed, and Scopus databases for articles on US populations published between January 1, 2008 and November 1, 2011. We used various combinations of the following search terms: discrimination, perceived discrimination, race, ethnicity, racism, institutional racism, stereotype, prejudice or bias, and health or health care. Fifty-eight articles were reviewed.Results. Patient perception of discriminatory treatment and implicit provider biases were the most frequently examined topics in health care settings. Few studies examined the overall prevalence of racial/ethnic discrimination and none examined temporal trends. In general, measures used were insufficient for examining the impact of interpersonal discrimination or institutional racism within health care settings on racial/ethnic disparities in health care.Conclusions. Better instrumentation, innovative methodology, and strategies are needed for identifying and tracking racial/ethnic discrimination in health care settings.Racial/ethnic minorities suffer disproportionate morbidity and mortality from chronic diseases, including cancer, heart disease, diabetes, and stroke. US racial/ethnic health disparities are a consequence of several factors including the disproportionate prevalence of less healthy lifestyles, low socioeconomic status, resource-poor neighborhood environments, and poorer access to care. Another factor is the poorer care received by minority patients after they enter the health care system. The 2005 National Healthcare Disparities Report indicated that White patients receive better quality of care than 53% of Hispanic, 43% of African American, 38% of American Indian/Alaska Native, and 22% of Asian and Pacific Islander patients.1 An updated report in 2010 showed no changes in disparities in 30 of 41 quality core measures for Hispanics, 40 of 47 measures for African Americans, 13 of 19 measures for Asians, and 15 of 22 measures for American Indian or Alaska Natives compared with Non-Hispanic Whites.2 Efforts to eliminate these disparities are hampered by the lack of a full understanding of all proximal causes including any role that racial/ethnic discrimination within the health care system might play.Racial discrimination is defined as “(1) differential treatment on the basis of race that disadvantages a racial group and, (2) treatment on the basis of inadequately justified factors that disadvantage a racial group,”^3(p39) and has been linked to racial/ethnic disparities in health outcomes. Not all discrimination occurs at the individual level or is intended. Seemingly benign policies, practices, structures, and regulations also have the potential to be discriminatory and are collectively referred to as institutional racism. Individual level discrimination and institutional racism may compound the negative effects of other health determinants,4 thereby placing racial/ethnic minorities in double jeopardy.Results of a recent nationwide poll of the United States showed that 74% of African Americans, 69% of other non-Whites, and 30% of Whites report personally experiencing general race-based discrimination.5 Research studies have shown that general experiences with racial/ethnic discrimination are associated with a variety of adverse health outcomes including higher mortality6; lower use of cancer screening7; elevated blood pressure8,9; higher levels of C-reactive protein10; substance use11,12; mental and physical health13,14 including mood, anxiety, and psychiatric disorders12; increased depressive symptoms15; weight gain16; high body mass index17; and smoking.18 Not all studies, however, have found a significant association between general race/ethnicity-based discrimination and health.19,20 Although racial/ethnic discrimination within health care settings and health systems has also been implicated in health disparities,21 little is known about the empirical evidence supporting its prevalence or the association with poor health outcomes.We provide a review of the scientific literature on the prevalence, perception of and effect of racial/ethnic discrimination and institutional racism within health care settings. Our specific objectives were to examine the extent to which recent literature addressed the following research questions:

1. What research methods are currently being used to measure receipt of discriminatory health care?
2. What is the current prevalence of racial/ethnic discrimination in health care settings?
3. Has the perception of or receipt of discriminatory health care changed over time?
4. How does racial/ethnic discrimination influence health in health care settings?
5. How do system level factors, such as institutional practices, policies and regulations contribute to discriminatory health care services?

This review summarizes results of recent research, identifies currently used instrumentation and methodology, and identifies areas where additional research is needed and is a resource for researchers with interest in working in this topic area.     

Change in Health Status and Access to Care in Young Adults With Special Health Care Needs: Results From the 2007 National Survey of Adult Transition and Health

BackgroundDespite over 500,000 adolescents with special health care needs transitioning to adulthood each year, limited information is available on their health status or their access to care after transition.ObjectiveTo describe the change in health status and access to care of a nationally sampled, longitudinal cohort of young adults with special health care needs (ASHCN).MethodsWe analyzed follow-up data collected in the 2007 Survey of Adult Transition and Health on young adults who were 14–17 years of age when their parents participated in the 2001 National Survey of Children with Special Health Care Needs. We describe changes in access to care and health status over time, and used logistic regression to identify characteristics that were associated with declining health status in this cohort.Results1,865 participants, aged 19–23 years, completed the Survey of Adult Transition and Health. Between 2001 and 2007, there was a 3.6 fold increase in the proportion experiencing delayed or forgone care; 10% reported a decline in health status. There was a 7.7-fold increase in the proportion reporting no insurance. In regression analysis, factors associated with declining health status between 2001 and 2007 included underlying disease severity and delayed or forgone care in young adulthood.ConclusionsWe found significant deterioration in insurance coverage, usual source of care and receiving timely health care as ASHCN aged into adulthood, and that this was associated with decline in health status. Our findings suggest that further population-based analyses of health outcomes are needed to plan for interventions to assist this vulnerable population.     

Experience of racism and associations with unmet need and healthcare satisfaction: the 2011/12 adult New Zealand Health Survey

Objective: Racism may affect health through differential access to, and quality of, healthcare. This study examined associations between experience of racism and unmet need and satisfaction with healthcare. Methods: Cross‐sectional analysis of the 2011/12 adult New Zealand Health Survey (n=12,596) was undertaken. Logistic regression was used to examine associations between experience of racism (by a health professional and other experiences of racism [ever]) and unmet need for a general practitioner and satisfaction with a usual medical centre in the past year. Results: Experience of racism by a health professional and other forms of racism were higher among Māori, Pacific and Asian groups compared to European/Other. Both racism measures were associated with higher unmet need (health professional racism adjusted OR 3.52, 95%CI 2.42–5.11; other racism OR 2.21, 95%CI 1.78–2.75) and lower satisfaction with a usual medical centre (health professional racism adjusted OR 0.25, 95%CI 0.15–0.34; other racism OR 0.60, 95%CI 0.45–0.79). Conclusions: Racism may act as a barrier to, and influence the quality of, healthcare. Implications for public health: Addressing racism as a public health issue and major driver of inequities in healthcare and health outcomes is required within the health sector and wider society.     

Latina Self-Reported Mental Health and Delay in Health Care in a New Latino Destination

Understanding how depression and/or anxiety affects use of health care among Latinas in rapidly growing new Latino destinations, population where the growth rate of the Latino population exceeds the national average, may enhance community engagement efforts. Using community-based participatory research, a questionnaire assessing health care use was administered to 289 Latinas. Most (70%) reported delaying healthcare, and self-reported depression/anxiety was associated with a 3.1 fold (95% CI: 1.6–5.9) increase in delay, after adjusting for current health status, acculturation, age, education, and place of birth. Mental health disparities exist among Latinas, which are related to delays in use of health care. A gap exists regarding health education interventions for Latinas. More research is needed to identify successful models, especially in new Latino destinations as they may be particularly vulnerable to delay care.     

Quality of Hospital Communication and Patient Preparation for Home Health Care: Results From a Statewide Survey of Home Health Care Nurses and Staff

Objectives

To evaluate the quality of communication between hospitals and home health care (HHC) clinicians and patient preparedness to receive HHC in a statewide sample of HHC nurses and staff.

Experiences of Transgender-Related Discrimination and Implications for Health: Results From the Virginia Transgender Health Initiative Study

Objectives. We examined relationships between social determinants of health and experiences of transgender-related discrimination reported by transgender people in Virginia.Methods. In 2005 through 2006, 387 self-identified transgender people completed a statewide health needs assessment; 350 who completed eligibility questions were included in this examination of factors associated with experiences of discrimination in health care, employment, or housing. We fit multivariate logistic regression models using generalized estimating equations to adjust for survey modality (online vs paper).Results. Of participants, 41% (n = 143) reported experiences of transgender-related discrimination. Factors associated with transgender-related discrimination were geographic context, gender (female-to male spectrum vs male-to-female spectrum), low socioeconomic status, being a racial/ethnic minority, not having health insurance, gender transition indicators (younger age at first transgender awareness), health care needed but unable to be obtained (hormone therapy and mental health services), history of violence (sexual and physical), substance use health behaviors (tobacco and alcohol), and interpersonal factors (family support and community connectedness).Conclusions. Findings suggest that transgender Virginians experience widespread discrimination in health care, employment, and housing. Multilevel interventions are needed for transgender populations, including legal protections and training for health care providers.Transgender is an umbrella term used to describe people whose gender identity or expression does not conform to that typically associated with the sex they were born as or assigned to at birth.1 The Virginia Transgender Health Initiative Study was a multiyear project that sought to assess the health care and social service needs of transgender people in Virginia and elucidate the social correlates of health among this population.2 The study was conducted using a conceptual model that viewed the social stigma of being transgender as a root cause of poor health status, producing societal factors such as discrimination that accumulate over the life course. We examined the prevalence of experiences of perceived transgender-related discrimination in health care, employment, and housing; explored factors associated with perceived transgender-related discrimination, including how those who experienced discrimination differed from those who had not; and investigated barriers to accessing health services in Virginia, with an eye toward increased access to and use of services for transgender populations.Cross-sectional and community-based convenience samples have shown that transgender people report high rates of discrimination across multiple areas, including health care, employment, and housing.3–11 A needs assessment of 182 transgender people in Philadelphia, Pennsylvania, found that 26% had been denied medical care because they were transgender, and 52% had difficulty accessing 1 or more health services in the past year.5 Data from the San Francisco Transgender Community Project (n = 515) revealed that 39% of female-to-male (FTM) respondents reported being denied health care or having difficulties obtaining health care compared with 13% of male-to-female (MTF) respondents.12 In a Chicago, Illinois, study that sampled 111 transgender people, 12% were refused routine health care, 3% were refused mental health care, and 14% reported difficulty getting emergency health care because they were transgender.6The impact of the social stigma of transgenderism on employment and housing discrimination has also been measured. In a national sample of 402 transgender people, 37% reported employment-related discrimination and were nearly 5 times more likely to experience some form of violence than were those who had not experienced such discrimination.8 In studies conducted in Washington, DC; Philadelphia; and San Diego, Los Angeles, and San Francisco, California, employment discrimination was reported to range from 14% to 60%.9,12–16 A San Francisco study of 515 transgender people found that 62% had experienced discrimination in employment, housing, or health care;4 almost half (46%) of MTF participants reported employment discrimination, and 27% reported housing discrimination.12 Among FTM participants, 57% reported employment discrimination and 20% reported housing discrimination. In a Washington, DC, study of 252 transgender people (69% Black, 22% Hispanic), 15% reported job loss as a result of being transgender.15 Although just 4% of participants reported housing discrimination, 19% of the sample was homeless.10 A 2009 review of US data highlighted persistent reporting and negative impact of physical violence against transgender individuals.17The decision to conduct the Virginia Transgender Health Initiative Study was based on growing evidence that the social determinants of health, including experiences of violence and discrimination, may result in broad negative psychological and physiological changes with important implications for health across populations.4,18–28 If the study found that transgender-related discrimination in health care, employment, and housing were prevalent in Virginia, public health strategies could be developed to intervene and ameliorate social and environmental influences that negatively affected the population’s health.