Health status measurement performance and health status differences by age, ethnicity, and gender: assessment in the medical outcomes study

The comparative measurement performance of self-reported health status instruments for African American and Hispanic elderly has rarely been studied, despite evidence of their poor health status. This study examined psychometric performance and health status differences by age, ethnicity, and gender among 10,569 ethnically diverse patients who completed the Short-Form General Health Survey in the Medical Outcomes Study (MOS). Hispanics and African Americans tended to have slightly lower measurement performance than other ethnic groups. Compared with whites, health status scores for African American and Hispanic women were slightly but significantly lower. The small differences in health status by ethnicity may be due to the MOS sampling strategy, which excluded low-socioeconomic status minorities with poor education and no regular medical care. The psychometric performance of MOS health status measures should be examined in studies of ethnically diverse, community-dwelling, elderly populations who have poor access to care, poor education, and/or low socioeconomic status.     

Interpersonal Processes of Care Survey: Patient-Reported Measures for Diverse Groups

Objective. To create a patient-reported, multidimensional physician/patient interpersonal processes of care (IPC) instrument appropriate for patients from diverse racial/ethnic groups that allows reliable, valid, and unbiased comparisons across these groups.
Data Source/Data Collection. Data were collected by telephone interview. The survey was administered in English and Spanish to adult general medicine patients, stratified by race/ethnicity and language (African Americans, English-speaking Latinos, Spanish-speaking Latinos, non-Latino whites) ( N =1,664).
Study Design/Methods. In this cross-sectional study, items were designed to be appropriate for diverse ethnic groups based on focus groups, our prior framework, literature, and cognitive interviews. Multitrait scaling and confirmatory factor analysis were used to examine measurement invariance; we identified scales that allowed meaningful quantitative comparisons across four race/ethnic/language groups.
Principal Findings. The final instrument assesses several subdomains of communication, patient-centered decision making, and interpersonal style. It includes 29 items representing 12 first-order and seven second-order factors with equivalent meaning (metric invariance) across groups; 18 items (seven factors) allowed unbiased mean comparison across groups (scalar invariance). Final scales exhibited moderate to high reliability.
Conclusions. The IPC survey can be used to describe disparities in interpersonal care, predict patient outcomes, and examine outcomes of quality improvement efforts to reduce health care disparities.     

Improving Disparity Estimates for Rare Racial/Ethnic Groups with Trend Estimation and Kalman Filtering: An Application to the National Health Interview Survey

Objective. Single-year estimates of health disparities in small racial/ethnic groups are often insufficiently precise to guide policy, whereas estimates that are pooled over multiple years may not accurately describe current conditions. While collecting additional data is costly, innovative analytic approaches may improve the accuracy and utility of existing data. We developed an application of the Kalman filter in order to make more efficient use of extant data.
Data Source. We used 1997–2004 National Health Interview Survey data on the prevalence of health outcomes for two racial/ethnic subgroups: American Indians/Alaska Natives and Chinese Americans.
Study Design. We modified the Kalman filter to generate more accurate current-year prevalence estimates for small racial/ethnic groups by efficiently aggregating past years of cross-sectional survey data within racial/ethnic groups. We compared these new estimates and their accuracy to simple current-year prevalence estimates.
Principal Findings. For 18 of 19 outcomes, the modified Kalman filter approach reduced the error of current-year estimates for each of the two groups by 20–35 percent—equivalent to increasing current-year sample sizes for these groups by 56–135 percent.
Conclusions. This approach could increase the accuracy of health measures for small groups using extant data, with virtually no additional cost other than those related to analytical processes.     

Mobilizing women for minority health and social justice in california

Women's Health Leadership is building the leadership capacity of diverse community leaders in California committed to promoting health and social justice in their communities. This program provides opportunities for cross-cultural exchanges of ideas, resources, and expertise. Graduates continue to receive technical support and to engage in peer learning via an alumnae network. The network is dedicated to advancing social justice issues and to addressing health disparities. It is also a way to mobilize trained grassroots leaders to provide expertise to influence policy decisions, to provide technical support and resources to local communities, and to foster new partnerships across the state.     

State-specific prevalence of disability among adults--11 states and the District of Columbia, 1998

Disability is a large public health problem in the United States (1), affecting an estimated 54 million persons who report disabling conditions (2). One of the national health goals for 2010 is to eliminate health disparities among different segments of the population, including among persons with disabilities (3). Although the development and implementation of public health policy and services relating to disability would be aided by public health surveillance (4), the lack of a brief case definition of disability limits efforts to obtain state-level prevalence to define the magnitude of disability. To assess state-level prevalence based on uniform criteria, CDC analyzed data from the Disability Module of the 1998 Behavioral Risk Factor Surveillance System (BRFSS). This report summarizes the results of the analyses, which indicated an overall prevalence consistent with national surveys and demonstrated wide variation in disability prevalence in states.     

A summary measure of health disparity

OBJECTIVES: Eliminating health disparities is a goal of Healthy People 2010. In order to track progress toward this goal, we need improved methods for measuring disparity. The authors present the Index of Disparity (ID) as a summary measure of disparity. METHODS: The ID, a modified coefficient of variation, was used to measure disparity across populations defined on the basis of race/ethnicity, income, education, and gender. Disparity was also assessed for a diverse range of health indicators and over time to monitor trends. RESULTS: Disparity in cardiovascular disease deaths decreased based on gender from 1989 to 1998 but was largely unchanged based on race/ethnicity. The magnitude of disparities in cervical cancer and cholesterol screening, smoking, exercise, and health insurance ranged from 1.9% to 78.6%. The largest disparities for health indicators were not associated with any particular population classification, whether defined on the basis of race/ethnicity, education, or income. CONCLUSIONS: To eliminate disparities, we need a means to assess disparities across many types of health indicators. Furthermore, for a given health indicator, disparities may differ for populations defined on the basis of race/ethnicity, education, income, and so on. The ID is a simple method for summarizing disparities across groups within a population that can be applied across health indicators regardless of magnitude, over time to monitor trends, and across different populations.     

Disparities in indigenous health: a cross-country comparison between New Zealand and the United States

OBJECTIVES: We compared the health statuses of the indigenous populations of New Zealand and the United States with those of the numerically dominant populations of these countries. METHODS: Health indicators compared included health outcome measures, preventive care measures, modifiable risk factor prevalence, and treatment measures. RESULTS: In the case of nearly every health status indicator assessed, disparities (both absolute and relative) were more pronounced for Maoris than for American Indians/Alaska Natives. Both indigenous populations suffered from disparities across a range of health indicators. However, no disparities were observed for American Indians/Alaska Natives in regard to immunization coverage. CONCLUSIONS: Ethnic health disparities appear to be more pronounced in New Zealand than in the United States. These disparities are not necessarily intractable. Although differences in national health sector responses exist, New Zealand may be well placed in the future to evaluate the effectiveness of new strategies to reduce these disparities given the extent and quality of Maori-specific health information available.     

Problems of focus group methods in cross-cultural research: a case study of beliefs about sudden infant death syndrome

Over the past decade there has been increasing interest in using focus group methods in public health research. Focus group discussions have become particularly popular, in part because they are commonly perceived to be a less time-consuming and less expensive way of collecting qualitative data than the more traditional ethnographic methods. However, little attention has been given to methodological issues when the locus group method is applied in cross-cultural settings. This paper discusses a number of these concerns, illustrated through the use of the focus groups to explore mothers' beliefs about sudden infant death syndrome (SIDS) in an ethnically diverse sample in Victoria. We found that some methodological difficulties were related to cultural factors. This has led us to use caution when considering the use of focused group discussions as a research method in cross-cultural contexts. We urge public health researchers to take a critical look at the appropriateness of focus groups before applying this method in cross-cultural public health research. (Aust J Public Health 1995; 19: 257–63)     

An overview of methods for monitoring social disparities in cancer with an example using trends in lung cancer incidence by area-socioeconomic position and race-ethnicity, 1992-2004

The authors provide an overview of methods for summarizing social disparities in health using the example of lung cancer. They apply four measures of relative disparity and three measures of absolute disparity to trends in US lung cancer incidence by area-socioeconomic position and race-ethnicity from 1992 to 2004. Among females, measures of absolute and relative disparity suggested that area-socioeconomic and race-ethnic disparities increased over these 12 years but differed widely with respect to the magnitude of the change. Among males, the authors found substantial disagreement among summary measures of relative disparity with respect to the magnitude and the direction of change in disparities. Among area-socioeconomic groups, the index of disparity increased by 47% and the relative concentration index decreased by 116%, while for race-ethnicity the index of disparity increased by 36% and the Theil index increased by 13%. The choice of a summary measure of disparity may affect the interpretation of changes in health disparities. Important issues to consider are the reference point from which differences are measured, whether to measure disparity on the absolute or relative scale, and whether to weight disparity measures by population size. A suite of indicators is needed to provide a clear picture of health disparity change.     

Community based participatory approaches to address health disparities in Hawai'i: recent applications in cancer prevention, detection and treatment programs

Assessment of recent trends in the prevalence and incidence of cancer, and its associated risk and protective factors in the State of Hawai'i illustrate that there are definite ethnic, socio-economic, and geographic health disparities. Disparities in access to health care are reflected in decreased and under utilization of all types of preventive cancer screening tests and decreased proportions of people with health insurance coverage. Increases in obesity mirror U.S. national trends and disproportionately affect certain ethnic groups and those with low income. Tobacco use has increased among at-risk populations including: certain ethnic groups, those with low-income and/or low education and those in rural areas. Data that reveal continuing or worsening health disparities imply that either the old methods have not been effective and/or resources are not available or are not being applied to address such disparities. Promising methodologies and programmatic focuses to reduce health disparities are needed as mechanisms for improving the circumstances of at-risk populations. Community based participatory approaches are described here for cancer prevention, detection, and treatment programs that utilize culturally appropriate methods.     

Conceptualizing and Categorizing Race and Ethnicity in Health Services Research

Objectives. Veterans Affairs (VA) patient populations are becoming increasingly diverse in race and ethnicity. The purpose of this paper is to (1) document the importance of using consistent standards of conceptualizing and categorizing race and ethnicity in health services research, (2) provide an overview of different methods currently used to assess race and ethnicity in health services research, and (3) suggest assessment methods that could be incorporated into health services research to ensure accurate assessment of disease prevalence and incidence, as well as accounts of appropriate health services use, in patients with different racial and ethnic backgrounds.
Design. A critical review of published literature was used.
Principal Findings. Race is a complex, multidimensional construct. For some individuals, institutionalized racism and internalized racism are intertwined in the effects of race on health outcomes and health services use. Ethnicity is most commonly used as a social–political construct and includes shared origin, shared language, and shared cultural traditions. Acculturation appears to affect the strength of the relationships among ethnicity, health outcomes, and health services use.
Conclusions. Improved and consistent methods of data collection need to be developed for use by VA researchers across the country. VA research sites with patients representing specific population groups could use a core set of demographic items in addition to expanded modules designed to assess the ethnic diversity within these population groups. Improved and consistent methods of data collection could result in the collection of higher-quality data, which could lead to the identification of race- and ethnic-specific health services needs. These investigations could in turn lead to the development of interventions designed to reduce or eliminate these disparities.     

Development of the Patient Activation Measure (PAM): Conceptualizing and Measuring Activation in Patients and Consumers

Background. Controlling costs and achieving health care quality improvements require the participation of activated and informed consumers and patients.
Objectives. We describe a process for conceptualizing and operationalizing what it means to be "activated" and delineate the process we used to develop a measure for assessing "activation," and the psychometric properties of that measure.
Methods. We used the convergence of the findings from a national expert consensus panel and patient focus groups to define the concept and identify the domains of activation. These domains were operationalized by constructing a large item pool. Items were pilot-tested and initial psychometric analysis performed using Rasch methodology. The third stage refined and extended the measure. The fourth stage used a national probability sample to assess the measure's psychometric performance overall and within different subpopulations.
Study Sample. Convenience samples of patients with and without chronic illness, and a national probability sample ( N =1,515) are included at different stages in the research.
Conclusions. The Patient Activation Measure is a valid, highly reliable, unidimensional, probabilistic Guttman-like scale that reflects a developmental model of activation. Activation appears to involve four stages: (1) believing the patient role is important, (2) having the confidence and knowledge necessary to take action, (3) actually taking action to maintain and improve one's health, and (4) staying the course even under stress. The measure has good psychometric properties indicating that it can be used at the individual patient level to tailor intervention and assess changes.     

Ethnic and racial health disparities research: issues and problems.

Racial and ethnic disparities in health and health care are pervasive. A number of research and policy issues have been raised in the examination of disparities. This article analyzes some methodological, conceptual, and political issues that underlie disparities research. Specifically examined are the research challenges posed by the different ways of defining disparities, heterogeneity within racial or ethnic groups, measurement issues, conceptual levels of analyses, and financial/political factors. It is suggested that research funding for disparities research be substantially supported and encouraged and that researchers more adequately address methodological and conceptual difficulties that are associated with disparities research.     

Implementing the Institute of Medicine definition of disparities: an application to mental health care

OBJECTIVE: In a recent report, the Institute of Medicine (IOM) defines a health service disparity between population groups to be the difference in treatment or access not justified by the differences in health status or preferences of the groups. This paper proposes an implementation of this definition, and applies it to disparities in outpatient mental health care. DATA SOURCES: Health Care for Communities (HCC) reinterviewed 9,585 respondents from the Community Tracking Study in 1997-1998, oversampling individuals with psychological distress, alcohol abuse, drug abuse, or mental health treatment. The HCC is designed to make national estimates of service use. STUDY DESIGN: Expenditures are modeled using generalized linear models with a log link for quantity and a probit model for any utilization. We adjust for group differences in health status by transforming the entire distribution of health status for minority populations to approximate the white distribution. We compare disparities according to the IOM definition to other methods commonly used to assess health services disparities. PRINCIPAL FINDINGS: Our method finds significant service disparities between whites and both blacks and Latinos. Estimated disparities from this method exceed those for competing approaches, because of the inclusion of effects of mediating factors (such as income) in the IOM approach. CONCLUSIONS: A rigorous definition of disparities is needed to monitor progress against disparities and to compare their magnitude across studies. With such a definition, disparities can be estimated by adjusting for group differences in models for expenditures and access to mental health services.     

Measuring culture: a critical review of acculturation and health in Asian immigrant populations

The number of studies examining how acculturation affects the health of Asian immigrants has increased in recent years. The proliferation of studies reflects the growing size and heterogeneity of Asian immigrant populations in the United States, Canada, Australia, New Zealand, and the United Kingdom. This paper compares various approaches to acculturation within the health literature on Asian immigrants by reviewing the literature in three-health domains (1) mental health (2) physical health and (3) health services use. The review critically examines the conceptualizations and measures of acculturation in these three domains and presents major findings. We observe that measurement difficulties posed by the experiences of heterogeneous Asian groups compound theoretical and disciplinary disparities between acculturation instruments. The extent to which conceptual and methodological critiques of acculturation studies in Hispanic populations apply to studies of Asian populations is also discussed. The critical review thus provides insights into the diverse ways that the relationship between culture and health is measured in this complicated and growing literature.     

Critical review of the international assessments of health-related quality of life

This paper reviews the international adaptation and use of generic health quality of life measures over the last several years, including the Nottingham Health Profile (NHP) the Sickness Impact Profile (SIP), the Medical Outcomes Short-Form 36 (MOS SF-36), the EuroQol, and Dartmouth COOP Charts. International work with disease or condition specific HRQL measures is exemplified with the European Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire (QLQ), and the Spitzer Quality of Life (QL) Index. Progress towards cross national measurement equivalence in HRQL measures reported in the literature has been uneven. Results show that the development of language-adapted versions of HRQL measures to date have mostly concerned translation issues, within the context of independently conducted studies. Substantially less focus has been placed on psychometric equivalence across language versions necessary for coordinated international studies, such as multi-national clinical trials. However, this picture is rapidly changing with recent projects underway to develop and refine new or existing HRQL measures. Overall, the lack of prominent differences found between countries in ranking of health states in major HRQL measures supports the feasibility of developing internationally applicable HRQL instruments. Recommendations are made for additional data needed to better ascertain the degree of measurement equivalence developed in the various versions of each instrument reviewed.Preparation of this document was supported by a grant from the Burroughs Wellcome Foundation and by the Bowman Gray School of Medicine.     

Health care disparities in disadvantaged Medicare beneficiaries: a national project review

The wealth of literature documenting differences in health care utilization by race and ethnicity underscores the need to develop a system to effectively measure health care related disparities. The Centers for Medicare & Medicaid Services has taken the first steps toward detailing the quality of care for fee-for-service (FFS) Medicare beneficiaries. Using data collected for the two-period 1997-1999 on a cross-section of beneficiaries from all states and territories of the U.S., quality was measured using a set of 24 indicators of care. The results of this effort were reported in the October 4, 2000 issue of the Journal of the American Medical Association. This article reports similar measures of quality but focuses specifically on disparities in the indicators among five disadvantaged Medicare beneficiary groups: African-American, American Indian/Alaska Natives, Asian/Pacific Islanders, Hispanics, and Medicare beneficiaries enrolled in Medicaid (dually enrolled). These indicators serve as a baseline for tracking quality improvement within disadvantaged populations and evaluating the success of efforts to reduce health care disparities at the national level. The findings suggest that patterns of disparities exist in both the inpatient and outpatient settings for disadvantaged beneficiaries. Over the next decade, the composition of Medicare beneficiaries will become more diverse. This increasing diversity makes it imperative to identify and monitor the existence and extent of health care disparities. The consistent and ongoing evaluation of racial, ethnic, and socioeconomic disparities should provide an incentive to create effective preventive programs tailored to specific community needs.     

The riskscape and the color line: examining the role of segregation in environmental health disparities

Environmental health researchers, sociologists, policy-makers, and activists concerned about environmental justice argue that communities of color who are segregated in neighborhoods with high levels of poverty and material deprivation are also disproportionately exposed to physical environments that adversely affect their health and well-being. Examining these issues through the lens of racial residential segregation can offer new insights into the junctures of the political economy of social inequality with discrimination, environmental degradation, and health. More importantly, this line of inquiry may highlight whether observed pollution--health outcome relationships are modified by segregation and whether segregation patterns impact diverse communities differently. This paper examines theoretical and methodological questions related to racial residential segregation and environmental health disparities. We begin with an overview of race-based segregation in the United States and propose a framework for understanding its implications for environmental health disparities. We then discuss applications of segregation measures for assessing disparities in ambient air pollution burdens across racial groups and go on to discuss the applicability of these methods for other environmental exposures and health outcomes. We conclude with a discussion of the research and policy implications of understanding how racial residential segregation impacts environmental health disparities.     

Measuring Racial/Ethnic Disparities across the Distribution of Health Care Expenditures

Objective. To assess whether black–white and Hispanic–white disparities increase or abate in the upper quantiles of total health care expenditure, conditional on covariates.
Data Source. Nationally representative adult population of non-Hispanic whites, African Americans, and Hispanics from the 2001–2005 Medical Expenditure Panel Surveys.
Study Design. We examine unadjusted racial/ethnic differences across the distribution of expenditures. We apply quantile regression to measure disparities at the median, 75th, 90th, and 95th quantiles, testing for differences over the distribution of health care expenditures and across income and education categories. We test the sensitivity of the results to comparisons based only on health status and estimate a two-part model to ensure that results are not driven by an extremely skewed distribution of expenditures with a large zero mass.
Principal Findings. Black–white and Hispanic–white disparities diminish in the upper quantiles of expenditure, but expenditures for blacks and Hispanics remain significantly lower than for whites throughout the distribution. For most education and income categories, disparities exist at the median and decline, but remain significant even with increased education and income.
Conclusions. Blacks and Hispanics receive significantly disparate care at high expenditure levels, suggesting prioritization of improved access to quality care among minorities with critical health issues.