Disparities in Healthcare

By Claudia Stahl, Special to ADVANCE

Reports of improvements in the overall health of the nation should be celebrated, but cautiously. Significant and persistent disparities in the rates and management of conditions such as cardiovascular disease, diabetes and HIV in racial and ethnic minority populations, compared to those in whites, have raised significant concerns about the ability of health care professionals and health systems to provide effective treatment to an increasingly diverse population.

ADVANCE will explore different angles of this complex issue in a series of articles. The first provides an overview of disparities in health care, focusing on targeted disease states, leading organizations involved in resolving disparities, and the importance of cultural competence. Subsequent stories will examine collaborative efforts to resolve health care disparities, and recommendations for culturally-based professional education and cultural competence in occupational therapy.

When the most thorough battery of tests and examinations failed to reveal the source of an infection in a Latina patient, Ruth Ann Chaffee, RN, reached for a piece of paper and resorted to a primitive diagnostic technique: conversation.

Using a communication tool that the staff had developed for patients who speak Spanish, Chaffee learned that the problem was hidden only by the patient's language barrier and a sock—a gangrenous pinky toe. When she revealed her findings to the surgeon, "he said, 'why didn't she tell me?' I said, 'Doctor, that's the essence of the problem. It would be very difficult for this [Latina] to step out of her cultural bounds and address you, to give you information, to question what you said. This would seem not at all respectful and be counter to everything she's been brought up to believe is correct.'"

Chaffee's is one of several testimonials on Working Together to End Racial and Ethnic Disparities: One Physician at a Time, a DVD produced by the American Medical Association. The program, which includes testimonials from patients, physicians and nurses, was developed to raise awareness of disparities in diagnosis and treatment of disease in racial and ethnic minority patients. The DVD also includes practical resources for health care professionals, such as a discussion guide and fact sheets developed to assist professionals with closing gaps in the care received by racial and ethnic minority patients.

How pervasive are disparities in health care? Compared to whites, ethnic and racial minorities—100 million U.S. citizens, nearly a third of the population—are disproportionately affected by preventable, treatable conditions such as cardiovascular disease, diabetes, asthma, mental illness, cancer and HIV. According to the 4th (2006) National Health Care Disparities Report (NHDR), produced by the Agency for Health care Research and Quality (AHRQ), gaps are evident across multiple clinical conditions, in quality of care and in access to care, and across multiple settings (primary care, home care, hospice care, emergency departments, hospitals and nursing homes).

The frequently cited Institute of Medicine (IOM) report Unequal Treatment: What Healthcare Providers Need to Know about Racial and Ethnic Disparities in Healthcare evaluated more than 100 studies of health care quality for racial and minority groups to conclude that minorities are less likely to receive needed services, including clinically necessary procedures. The report attributes these differences to multiple sources, including health systems, health care providers and patients themselves.

Meet the 'Others'

The fact that the overall health of the American population has improved in the past 20 years punctuates the disparities dilemma, especially when more than 30 percent of the United States population self-identify as members of racial or ethnic minority groups—that's 36 million African Americans, 35 million Hispanics (in the continental United States; add an additional 3.8 million when you factor in Puerto Rico), 12 million Asians, 874,000 Native Hawaiians and Other Pacific Islanders (NHOPI), and over four million Native Americans and Alaska Natives. (Source: U.S. Census Bureau. Profiles of General Demographic Characteristics: 2000. Available at: http://www.census.gov/Press-Release/www/2001/demoprofile.html. Accessed November 1, 2006)

According to Cara James, PhD, senior policy analyst for the Henry J. Kaiser Family Foundation, years of lumping ethnicity into the categories "black, white or other" has impaired the quality and breadth of information about our multicultural nation.

"We have different subgroups within populations and a growing number of populations that identify as being two or more races," James explains. "In the Asian population, for example, the experiences and culture of people who are Chinese are different from those who are Hmong or Indian/Southeast Asian. Similarly, the health status of Hispanics from Mexico and Puerto Rico is different from the health status of Hispanics from Cuba. Data on the experiences of these sub-populations would facilitate more targeted strategies for reducing disparities."

Closing the Cultural Gap

Income and socioeconomic status have long been identified as key sources of health disparities, but culture, it turns out, is an equally important piece of the equation. The "thoughts, communications, actions, customs, beliefs, values and institutions of racial, ethnic, religious or social groups," combined with misunderstandings originating from cultural and language differences, are believed to impact patients' perceptions, behaviors and attitudes, as well as providers' delivery of services, according to the Office of Minority Health (OMH).

The term cultural competence describes the ability of caregivers and health systems "to establish effective interpersonal and working relationships that supersede cultural differences." (Institute of Medicine, 2002) Culturally competent practices include communicating in the patient's native language (or using aides to facilitate communication) and using scenarios during the visit that are relevant—like talking to Indian patients with diabetes about the nutrition of korma and naan instead of burgers and fries.

Elmhurst is one of 11 New York public hospitals providing educational materials in multiple languages, phone-based translation services and population-specific cooking classes as measures to overcome communication barriers and control diabetes. It is likely that more hospitals will adopt these practices as states pass legislation requiring physicians to complete cultural competency training for licensure or relicensure. California, Washington and New Jersey have already instituted these requirements, and similar bills are pending in Arizona, Illinois, Ohio and New York.

The OMH has developed the National Standards for Culturally and Linguistically Appropriate Services (CLAS) and the Web site "Think Cultural Health" (www.thinkculturalhealth.org) to help clinicians adopt culturally competent practices. While resources like these are a significant step forward, resolving the equality gap will be a multi-stepped process requiring continued collection of data (especially in sub-populations), improvements in health care access and financing sources, and integration of public- and private-sector activities such as federal and state agencies, community groups, pharmaceutical companies and insurers. 

James notes it will be equally important to continue to study the social determinants of health: housing, income and education.

Claudia Stahl is manager of communications for Nexus Communications, Inc., www.nexuscominc.com, where she participated in a program focused on decreasing disparities in the diagnosis and treatment of depression (www.i-3d.org). Claudia is also a freelance writer and a former editor for ADVANCE.

This article originally appeared in Advance for Occupational Therapy Practitioners, January 7, 2008; Vol. 24 •Issue 1 • Page 41.