Decrease in the prevalence of environmental tobacco smoke exposure in the home during the 1990s in families with children

OBJECTIVES: This study explored correlates with and changes in the prevalence of environmental tobacco smoke (ETS) exposure of children in the home. METHODS: We used multiple logistic regression to explore ETS exposures as reported in the 1992 and 2000 National Health Interview Survey. RESULTS: ETS exposure in homes with children declined from 35.6% to 25.1% (P <.001) between 1992 and 2000, whereas smoking prevalence declined 26.5% to 23.3%. Home ETS exposures were more prevalent among non-Hispanic Whites than among African Americans (adjusted odds ratio [AOR] = 0.702; 95% confidence interval [CI] = 0.614, 0.802), Asian Americans (AOR = 0.534; 95% CI = 0.378, 0.754), and Hispanics (AOR = 0.388; 95% CI = 0.294, 0.389). Exposures declined across all groups, with greater gains in higher education and income groups. CONCLUSIONS: Home ETS exposure declined sharply between 1992 and 2000, more than would be predicted by the decline in adult smoking prevalence.     

Delivery Complications Associated With Prenatal Care Access for Medicaid-Insured Mothers in Rural and Urban Hospitals

CONTEXT: Pregnancy complications affect many women. It is likely that some complications can be avoided through routine primary and prenatal care of reasonable quality. PURPOSE: The authors examined access to health care during pregnancy for mothers insured by Medicaid. The access indicator is potentially avoidable maternity complications (PAMCs). Potentially avoidable maternity complications are often preventable through routine prenatal care, such as infection screening and treatment. The authors examined the risks of potentially avoidable maternity complications among rural and urban hospital deliveries for groups of mothers defined by race or ethnicity. METHODS: Data are from the year 2000 Nationwide Inpatient Sample (NIS). The stratified sample represents all discharges from 20.5% of community hospitals in the United States. The Nationwide Inpatient Sample identifies hospital locations, but not patients' areas of residence. Analyses, which accounted for the sample design, included calculation of potentially avoidable maternity complication rates by race or ethnicity, chi2, t tests, and multivariate logistic regression. FINDINGS: Within groups defined by race or ethnicity, unadjusted rates for potentially avoidable maternity complications did not differ significantly by hospital location. Holding other factors constant, potentially avoidable maternity complications were less common in rural hospitals than in urban hospitals (odds ratio, 0.78; CI, 0.62 to 0.99). In rural hospitals, African Americans had notably higher risk for potentially avoidable maternity complications than did non-Hispanic whites (odds ratio, 1.72; CI, 1.26 to 2.36). In urban hospitals, risk of potentially avoidable maternity complications was not significantly higher for African Americans. Hispanics and Asians had notably lower risks of potentially avoidable maternity complications in urban hospitals than did non-Hispanic whites. CONCLUSIONS: Providers and policymakers should work to reduce the risks of potentially avoidable maternity complications for African American women in rural areas who are insured by Medicaid.     

Racial and ethnic differences in access to medical care in managed care plans

OBJECTIVE: To examine the extent to which access differences between racial/ethnic minorities and whites in managed care plans are greater than such differences in other types of health plans. DATA SOURCE: A nationally representative sample of 4,811 African American, 3,379 Hispanic, and 33,737 white nonelderly persons with public or private health insurance. STUDY DESIGN/DATA COLLECTION: A cross-sectional survey of households was conducted during 1996 and 1997. Commonly used measures of access to and utilization of medical care were constructed for individuals: (1) percentage of visits with a usual provider, (2) percentage with a regular provider, (3) visit with a physician in the past year, (4) hospital ER use, (5) last visit was to a specialist. PRINCIPAL FINDINGS: Fewer than 74 percent of Hispanics and African Americans had a regular provider compared to more than 78 percent of white Americans. Hispanics were least likely to have had their last doctor visit with a specialist (22 percent) compared to African Americans (26 percent) and whites (28 percent). Differences between ethnic/racial minorities and whites in managed care plans are similar to differences observed in non-managed care plans. Americans of all racial and ethnic backgrounds in managed care plans with gatekeeping are more likely to have a usual source of care, a regular provider, and lower use of specialists compared to persons in plans without gatekeeping. CONCLUSION: Although greater access to primary care was shown among African Americans and Hispanics in managed care plans, the extent of the disparities between racial/ethnic minorities and whites in managed care is similar to disparities in other types of health plans.     

Race, rural residence, and control of diabetes and hypertension

PURPOSE: African Americans are at increased risk for diabetes mellitus and hypertension, and rural residents have historically had decreased access to care. It is unclear whether living in a rural area and being African American confers added risks for diagnosis and control of diabetes and hypertension. The purpose of this study was to examine the prevalence of diagnosed diabetes and hypertension, as well as control of both conditions, among rural and urban African Americans and whites. METHODS: We conducted an analysis of the Third National Health and Nutrition Examination Survey (1988-1994). Non-Hispanic African Americans and non-Hispanic white adults 20 years and older were classified according to rural or urban residence (n = 11,755). Investigated outcomes were previously diagnosed diabetes mellitus and hypertension and control of diabetes and hypertension. RESULTS: The prevalence of diagnosed diabetes was 4.5% for urban whites, 6.5% for rural whites, 6.0% for urban African Americans, and 9.5% for rural African Americans. Among patients with diagnosed diabetes, 33% of rural whites, 43% of urban whites, 45% of urban African American, and 61% of rural African Americans had glycosylated hemoglobin (HbA(1c)) levels of 8% or higher (P < .01). Among patients with diagnosed hypertension, 11% of rural whites, 13% of urban whites, 20% of urban African Americans, and 23% of rural African Americans had diastolic blood pressure greater than 90 mmHg (P < .01). In regression models controlling for relevant variables, including body mass index, health status, access to care, education, income, and insurance, compared with rural African Americans, rural and urban whites were significantly more likely to have better glycemic control and diastolic blood pressure control. Urban African Americans also had better diabetes control than rural African Americans. CONCLUSIONS: In this nationally representative sample, rural African Americans are at increased risk for a lack of control of diabetes and hypertension.     

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.     

Racial/ethnic differences in adult vaccination among individuals with diabetes

OBJECTIVES: This study examined whether differences in access to health care, health coverage, and socioeconomic status (SES) explained racial differences in influenza and pneumococcal vaccination rates in individuals with diabetes. METHODS: We analyzed data on 1906 individuals from the 1998 National Health Interview Survey. We used multiple logistic regression to adjust for race/ethnicity, age, access to care, health insurance, and SES, and used SUDAAN for statistical analyses to yield national estimates. RESULTS: Whites had higher vaccination rates than did African Americans or Hispanics. After adjustment for covariates, race/ethnicity predicted receipt of both vaccines independent of age, access to care, health care coverage, and SES. CONCLUSIONS: Racial disparity in vaccination rates for adults with diabetes is independent of access to care, health care coverage, and SES.     

Influence of Place of Residence in Access to Specialized Cancer Care for African Americans

Context: Disparities in cancer care for rural residents and for African Americans have been documented, but the interaction of these factors is not well understood.
Purpose: The authors examined the simultaneous influence of race and place of residence on access to and utilization of specialized cancer care in the United States.
Methods: Access to specialized cancer care was measured using: (1) travel time to National Cancer Institute (NCI) Cancer Centers, academic medical centers, and any oncologist for the entire continental US population, and (2) per capita availability of oncologists for the entire United States. Utilization was measured as attendance at NCI Cancer Centers, specialized hospitals, and other hospitals in the Surveillance, Epidemiology, and End Results (SEER) program Medicare population from 1998-2004.
Findings: In urban settings, travel times were shorter for African Americans compared with Caucasians for all three cancer care settings, but they were longer for rural African Americans traveling to NCI Cancer Centers. Per capita oncologist availability was not significantly different by race or place of residence. Urban African American patients were almost 70% more likely to attend an NCI Cancer Center than urban Caucasian patients (OR = 1.66; 95% CI 1.51-1.83), whereas rural African American patients were 58% less likely to attend an NCI Cancer Center than rural Caucasian patients (OR = 0.42; 95% CI 0.26-0.66).
Conclusions: Urban African Americans have similar or better access to specialized cancer care than urban Caucasians, but rural African Americans have relatively poor access and lower utilization compared with all other groups.     

Separate and unequal: residential segregation and estimated cancer risks associated with ambient air toxics in U.S. metropolitan areas

This study examines links between racial residential segregation and estimated ambient air toxics exposures and their associated cancer risks using modeled concentration estimates from the U.S. Environmental Protection Agency's National Air Toxics Assessment. We combined pollutant concentration estimates with potencies to calculate cancer risks by census tract for 309 metropolitan areas in the United States. This information was combined with socioeconomic status (SES) measures from the 1990 Census. Estimated cancer risks associated with ambient air toxics were highest in tracts located in metropolitan areas that were highly segregated. Disparities between racial/ethnic groups were also wider in more segregated metropolitan areas. Multivariate modeling showed that, after controlling for tract-level SES measures, increasing segregation amplified the cancer risks associated with ambient air toxics for all racial groups combined [highly segregated areas: relative cancer risk (RCR) = 1.04; 95% confidence interval (CI), 1.01-107; extremely segregated areas: RCR = 1.32; 95% CI, 1.28-1.36]. This segregation effect was strongest for Hispanics (highly segregated areas: RCR = 1.09; 95% CI, 1.01-1.17; extremely segregated areas: RCR = 1.74; 95% CI, 1.61-1.88) and weaker among whites (highly segregated areas: RCR = 1.04; 95% CI, 1.01-1.08; extremely segregated areas: RCR = 1.28; 95% CI, 1.24-1.33), African Americans (highly segregated areas: RCR = 1.09; 95% CI, 0.98-1.21; extremely segregated areas: RCR = 1.38; 95% CI, 1.24-1.53), and Asians (highly segregated areas: RCR = 1.10; 95% CI, 0.97-1.24; extremely segregated areas: RCR = 1.32; 95% CI, 1.16-1.51). Results suggest that disparities associated with ambient air toxics are affected by segregation and that these exposures may have health significance for populations across racial lines.     

Would safety-net expansions offset reduced access resulting from lost insurance coverage? Race/ethnicity differences

This study simulated whether increased community health center (CHC) funding under the Bush administration narrowed racial/ethnic gaps in access to care among low-income people. Expanded CHC funding resulted in small increases in access to care, more so for minorities than for whites. Spanish-speaking Hispanics had the largest improvements in access in the simulation. However, minorities experienced bigger drops in insurance coverage. The net result was no improvements in the access measures for Spanish-speaking Hispanics and slight decreases in access for whites, English-speaking Hispanics, and African Americans. Access gaps either remained the same or worsened slightly for English-speaking Hispanics and African Americans relative to whites.     

Race, ethnicity and hospitalization for six chronic ambulatory care sensitive conditions in the USA

Objectives. Hospitalization for ambulatory care sensitive conditions, also called preventable hospitalization, has been widely accepted as an indicator of access to primary health care, and of the overall success of the primary health care system. Our objective is to examine associations between preventable hospitalization and race and ethnicity in the USA, separately for six major chronic diseases: angina, asthma, chronic obstructive pulmonary disease, congestive heart failure, diabetes and hypertension.

Design. We used the 1997 Nationwide Inpatient Sample, 1997 Current Population Survey and 1997 National Health Interview Survey, to calculate rates of preventable hospitalization, and the prevalence of ambulatory care sensitive conditions, for African Americans, Hispanics and non-Hispanic whites. Rates were calculated for ages 19–64, and 65 and over. Preventable hospitalization rates that accounted for underlying hospitalization patterns were also estimated. A final set of estimations adjusted the preventable hospitalization rates for disease prevalence.

Results. Preventable hospitalization rates were notably higher for African Americans and Hispanics than for non-Hispanic whites for almost all of the conditions, both for women and men and for both age groups. Rates adjusted for underlying hospitalization patterns showed a similar pattern. Adjusted for disease prevalence, rate differences remained notably large for both women and men, and for both age groups. Particularly great, for both African Americans and Hispanics of both sexes, are the risks of preventable hospitalization for asthma, diabetes and hypertension.

Conclusion. African Americans and Hispanics have high preventable hospitalization rates for major chronic conditions, even after disease prevalence and underlying hospital utilization patterns are considered. These rates are particularly high for asthma, diabetes and hypertension, which are amenable to prevention and management interventions. Our results suggest a need to improve access to quality primary health care for African Americans and Hispanics in the USA, and for enhanced support of targeted prevention efforts.     

County-Level Poverty Is Equally Associated With Unmet Health Care Needs in Rural and Urban Settings

Context: Regional poverty is associated with reduced access to health care. Whether this relationship is equally strong in both rural and urban settings or is affected by the contextual and individual-level characteristics that distinguish these areas, is unclear. Purpose: Compare the association between regional poverty with self-reported unmet need, a marker of health care access, by rural/urban setting. Methods: Multilevel, cross-sectional analysis of a state-representative sample of 39,953 adults stratified by rural/urban status, linked at the county level to data describing contextual characteristics. Weighted random intercept models examined the independent association of regional poverty with unmet needs, controlling for a range of contextual and individual-level characteristics. Findings: The unadjusted association between regional poverty levels and unmet needs was similar in both rural (OR = 1.06 [95% CI, 1.04-1.08]) and urban (OR = 1.03 [1.02-1.05]) settings. Adjusting for other contextual characteristics increased the size of the association in both rural (OR = 1.11 [1.04-1.19]) and urban (OR = 1.11 [1.05-1.18]) settings. Further adjustment for individual characteristics had little additional effect in rural (OR = 1.10 [1.00-1.20]) or urban (OR = 1.11 [1.01-1.22]) settings. Conclusions: To better meet the health care needs of all Americans, health care systems in areas with high regional poverty should acknowledge the relationship between poverty and unmet health care needs. Investments, or other interventions, that reduce regional poverty may be useful strategies for improving health through better access to health care.     

Variations of Depression Treatment Among Women With Hypertension

The objective was to examine depression treatment among non-pregnant women, aged 22 and older, with hypertension, utilizing cross-sectional data from the 2006 and 2007 Medical Expenditure Panel Survey. Depression treatment patterns by demographic, socioeconomic, health care access, and health characteristics were analyzed utilizing chi-square tests and logistic and multinomial logistic regressions. Overall, 23.9% had no depression treatment, 56.8% had antidepressant use only, and 19.3% had psychotherapy with or without antidepressants. African Americans (adjusted odds ratio [AOR] = 0.47), Latinas (AOR = 0.46), and uninsured women (AOR = 0.39) were significantly less likely to report any treatment for depression compared with Whites and those with private insurance.     

Preventive services for rural and urban African American adults

BACKGROUND: Studies have shown that African Americans and rural patients receive fewer preventive services than other patients. OBJECTIVE: To compare the use of preventive services by African Americans in urban and rural settings to determine if race and rural residence were additive risks for not obtaining preventive services. METHODS: Three hundred African American patients seeking care in family practices in South Carolina were surveyed about preventive health care. RESULTS: Rural and urban African Americans were equally likely to know about preventive services and be up-to-date on receiving these services. In both practices, those with lower incomes were less likely to be up-to-date. Patients seen in the urban setting were more likely to receive counseling regarding exercise and smoking than those in the rural practice (87% vs 71%, P = .003). CONCLUSIONS: For both urban and rural African American patients with access to primary care physicians, preventive service use is high. The best predictor of poor compliance with preventive service recommendations was low income, suggesting that a lack of access to care is the primary reason why rural and African American populations do not receive adequate preventive health care.     

Primary care for low-income populations: comparing health care delivery systems

Amidst recent policy discussions about the health care safety net there has been relatively little information about whether the actual site of care affects care quality. We therefore used National Health Interview Survey data to describe low-income adults seeking primary care at different types of sites and the quality of access and preventive care at these sites. After adjusting for sociodemographic characteristics and illness burden, hospital-outpatient- department patients were more likely to receive vaccinations for influenza (adjusted odds ratio [AOR] 1.3, 95% confidence interval [CI] 1.0-1.6) and pneumococcus (AOR 1.4, 95% CI 1.1-1.8) than were those at clinics or health centers. Hospital-clinic patients were more likely to report delays in care due to office administrative difficulties (AOR 1.3, 95% CI 1.1-1.7) and more likely to have more than one emergency room visit (AOR 1.9, 95% CI 1.5-2.3). Physicians' office or HMO patients were less likely to report administrative delays in care than those at clinics or health centers, but there were no other differences in quality between these two site types. Policymakers and health care services analysts and providers must monitor quality as they decide how best to deliver care to vulnerable populations.     

Racial and spatial relations as fundamental determinants of health in Detroit

African Americans in the United States have a higher than average risk of morbidity and mortality, despite declining mortality rates for many causes of death for the general population. This article examines race-based residential segregation as a fundamental cause of racial disparities, shaping differences in exposure to, and experiences of, diseases and risk factors. The spatial distribution of racial groups, specifically the residential segregation of African Americans in aging urban areas, contributes to disparities in health by influencing access to economic, social, and physical resources essential to health. Using the Detroit metropolitan area as a case study, this article looks at the influences of the distribution of African American and white residents on access to these resources and discusses the implications for urban policies to reduce racial disparities in health status.     

Factors underlying variation in receipt of physician advice on diet and exercise: applications of the behavioral model of health care utilization

PURPOSE: To identify factors associated with receipt of physician advice on diet and exercise, including patient sociodemographic characteristics, health-related needs, and health care access, using Andersen's model of health care utilization. DESIGN: A cross-sectional analysis was performed using data from the 2000 National Health Interview Survey (NHIS). SETTING: NHIS data were collected through personal household interviews by Census interviewers. The overall response rate for the 2000 NHIS adult sample was 82.6%. SUBJECTS: Subjects were a representative sample of the American civilian, noninstitutionalized population aged 18 and older. After eliminating missing data and respondents who reported they did not see a doctor in the past 12 months, sample sizes for physician advice on diet and exercise were n = 26,255 and n = 26,158, respectively. MEASURES: Using the 2000 NHIS, the prevalence of receipt of physician advice on diet and exercise was assessed. Multiple logistic regression analyses were performed to examine the associations between receipt of physician advice on diet and exercise and potential predictors, adjusting for all covariates. RESULTS: By self-report, 21.3% and 24.5% of respondents received physician advice on diet and exercise, respectively. Being middle-aged (adjusted odds ratio [AOR] = 1.14, 95% confidence interval [CI], 1.0-1.29 for diet; AOR = 1.55, 95% CI = 1.33-1.79 for exercise) and having a baccalaureate degree or higher (AOR = 1.78, 95% CI = 1.52-2.08 for diet; AOR = 1.75, 95% CI = 1.47-2.07) were associated with a higher likelihood of receiving physician advice on diet and exercise. African-Americans (AOR = .78, 95% CI = .67-.92) and foreign-born immigrants (AOR = .57, 95% CI = .38-.86) were less likely to receive physician advice on exercise. The prevalence of physician advice was higher for persons who chose hospital outpatient departments as a usual source for care (AOR = 2.36, 95% CI = 1.66-3.36 for diet; AOR = 2.39, 95% CI = 1.68-3.4 for exercise) than for adults with other types of usual care sites. Poorer self-rated health status (AOR = 5.2, 95% CI = 4.12-6.57 for diet; AOR = 2.63, 95% CI = 2.04-3.38 for exercise) and obesity (AOR = 2.32, 95% CI = 2.02-2.66 for diet; AOR = 3.01, 95% CI = 2.46-3.69 for exercise) was positively associated with the likelihood of receiving physician advice on diet and exercise. CONCLUSIONS: Effective strategies to increase receipt of physician advice should include efforts to improve access to regular source of care and patient-physician communication. Sociodemographic factors remain independent and important predictors of who obtains such advice.     

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.     

Limited English Proficiency Is a Barrier to Receipt of Advice about Physical Activity and Diet among Hispanics with Chronic Diseases in the United States

The prevalence of obesity, diabetes, and cardiovascular disease is reaching epidemic proportions among Hispanics in the United States. Health care providers play an important role in motivating patients to make healthful lifestyle changes to reduce the burden of such conditions. Data from the US 2000 National Health Interview Survey was analyzed to determine differences in report of physician-provided physical activity and/or dietary advice by level of English proficiency among obese Hispanics or those who reported having diabetes or cardiovascular disease and who contacted a physician during the past year (n=1,186). Only one third of the sample reported receiving advice to increase their physical activity or to improve their dietary habits; one fifth reported receipt of advice about both. English-proficient Hispanics were about 50% more likely to report receiving advice on physical activity (adjusted odd ratio [AOR]=1.5; 95% confidence interval [CI]: 1.1 to 2.1), diet (AOR=1.5; 95% CI: 1.1 to 2.2) or both (AOR=1.6; 95% CI: 1.1 to 2.3), as compared with limited English-proficient Hispanics, after controlling for health insurance coverage and number of visits to a physician during the last year. Sex, age, region of residence, level of education, annual family income, and smoking status were not significantly associated with receiving physical activity and/or dietary advice. In order to address racial health disparities, and lower the burden of chronic illness, culturally sensitive strategies must be implemented to enhance delivery of effective health-promotion messages by physicians, particularly among at-risk communities.     

Breastfeeding Laws and Breastfeeding Practices by Race and Ethnicity

ObjectivesWe sought to examine breastfeeding practices by race and ethnicity in areas with and without eight specific breastfeeding laws.MethodsThe 2003 through 2010 National Health and Nutrition Examination Survey provides national breastfeeding practice information. We assessed eight breastfeeding laws before and after legislation was enacted and linked to population-based estimates of breastfeeding initiation and duration for children between birth and age one.FindingsRelative to Whites, Mexican-American infants were 30% more likely to breastfeed for at least 6 months in areas with laws protecting break-time from work to pump, and 20% more likely to breastfeed for at least 6 months in areas with pumping law enforcement provisions. Unexpectedly, five laws with the intention of supporting breastfeeding duration were significantly less helpful for African-American women relative to White women. African-American women were nearly half as likely to breastfeed for at least 6 months, relative to Whites in areas with provisions to provide break-time from work (adjusted odds ratio [AOR], 0.6; 95% confidence interval [CI], 0.5–0.8), private areas to pump at work (AOR, 0.6; 95% CI, 0.4–0.8), exemption from jury duty (AOR, 0.6; 95% CI, 0.4–0.9), awareness education campaigns (AOR, 0.5; 95% CI, 0.3–0.8), and pumping law enforcement provisions (AOR, 0.6; 95% CI, 0.5–0.8).ConclusionsBreastfeeding laws influence African Americans and Mexican Americans differently than Whites. Examination of specific laws in conjunction with the interaction of known specific barriers for African-American mothers could help to achieve the Healthy People 2020 goals for breastfeeding.     

Effect of race on patient expectations regarding their primary care physicians

BACKGROUND: Fulfilment of patients' expectations has been associated with greater patient satisfaction with care and greater adherence to medical advice. However, little is know about how race influences patient expectations. OBJECTIVE: To determine the association between patient race and patient expectations of their primary care physician. METHODS: The design was a cross-sectional study. Setting and participants were sample of 709 primary care patients from four clinic sites at the Philadelphia Veterans Affairs Medical Center and the University of Pennsylvania Health System. The measures were an expectations instrument asking patients to rate the necessity of the physician performing 13 activities during the index visit, self-reported race, demographics, the Rapid Estimate of Adult Literacy in Medicine, the Charlson Comorbidity Index and SF-12. RESULTS: After adjusting for age, sex, education, clinic site, comorbidity, health literacy and health status, African Americans were more likely to report it was absolutely necessary for the physician to refer them to a specialist [AOR 1.55 (95% confidence interval, CI, 1.09-2.21), P = 0.01], order tests [AOR 1.59 (95% CI 1.11-2.27), P = 0.01] and conduct each of the six physical exam components. CONCLUSIONS: African American race is associated with greater expectations of the primary care physicians. More research is needed to confirm the differential expectations by race and determine the reasons for the differential expectations.