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September 29, 2011

Disparities in health care:

Institutional or personal?


Jeannette South-Paul

Jeannette South-Paul, professor and chair of the Department of Family Medicine, launched the Center for Race and Social Problems fall speaker series with a Sept. 19 lecture, “Disparities in Healthcare for Minorities: Institutional or Personal?”

“When we talk about disparities, it’s really what happens when things aren’t equal. All things are not equal in America,” South-Paul said, displaying a Newsweek photo of victims of Hurricane Katrina.

“Katrina was probably one of the most in-your-face examples … to see that when a disaster hits and you don’t have resources, you are disproportionately affected,” she said, emphasizing the desperation and destitution that follows “when something happens that wasn’t targeted at that particular group of people but has disproportionately affected that group.”

Disparities have existed for decades, she said. They occur across the lifespan, involve both physical and behavioral health and encompass a variety of clinical and scientific disciplines.

But are they patient-centered, institution-centered, provider-centered or community-centered? “Yes,” she said.

The solution to such a complicated situation will require a diverse, well-trained workforce that comes from a variety of areas. Everyone will need to address the issues, she said. “We have to be culturally proficient in order to manage it well.”

Teen pregnancy

Teen pregnancy is a factor in disparities, she said, noting that a greater percentage of teen births occur among minorities, particularly in the African-American population.

Teen mothers are more likely to have additional pregnancies as a teen, more likely to be depressed and more likely to have prenatal complications, South-Paul said. They’re also more likely to have poor school performance and higher dropout rates, which lead to a greater likelihood that they will have limited job opportunities and will live in poverty. “This is not a pathway that leads to success in general,” she said.

Infant mortality

Disparities can be found in infant mortality rates, she added, noting that there is wide variation within ethnic groups in rates of infant mortality. Among Hispanic women in America, why does a mother of Puerto Rican heritage have a higher infant mortality rate than does a Cuban-American mother? Why would similar disparities be found in Asian Americans of Southeast Asian heritage than in those of Japanese descent?

Local disparities in infant mortality rates between 1998 and the mid-2000s were broader than in the national population, with the rate of infant mortality for African Americans in Allegheny County two-three times greater than for non-Hispanic whites.

Is prenatal care a factor? South-Paul said studies find that early prenatal care is more likely for majority mothers than minority mothers, but Allegheny County Health Department data on the availability of services for teen mothers show that 70-90 percent of them were able to get early prenatal care, and essentially all received some prenatal care. Some, perhaps unsure whether they wanted to continue the pregnancy, didn’t get care in the first trimester, but care is available.

“There are other issues taking place,” she said.

Is education a factor in these disparities? A 1995 study that looked at infant mortality rates by education level as well as by race and ethnic origin for mothers in their 20s found disparities even in women of color who were educated: African-American mothers with a college education still had higher rates than non-Hispanic white mothers who had only a high school diploma.

Community support

South-Paul noted that in 1991 the Healthy Start program targeted six Pittsburgh communities in response to infant mortality concerns, raising awareness of the contributing factors. The program provided case management and support to pregnant women, resulting in a 30 percent decrease in infant mortality and reductions in the teen pregnancy rate and in sexually transmitted diseases. In addition, the program increased the number of women who received early prenatal care and cut behavioral risk factors such as smoking or substance use.

Another initiative, the Department of Family Medicine’s Maikuru program, named for the Shona language of Zimbabwe’s term for the wise woman of the village, aimed to pair teen mothers with older women who could provide support.

South-Paul said she noticed that pregnant teens rarely came to their appointments accompanied by an older woman or partner. Instead, they were alone, or with a classmate who often was another pregnant teenager.

In weekly meetings the program tackled issues such as good and bad relationships, the importance of education, juggling school with pregnancy and parenting, spirituality, STDs and stress management. A mentorship component matched teens with older mothers who could provide them with support.

At the end of the eight-week program, participants demanded it continue. It’s now running monthly and data still are being analyzed, South-Paul said.

Some of the major issues the teens face include a lack of parental support and a dearth of positive male role models, she said. Financial insecurity and an unsupportive legal environment — particularly with getting child support — also are factors. In addition, the girls tended to struggle with unhealthy communication styles that didn’t yield positive results either in personal or professional encounters, and had limited educational backgrounds — either as poor students or dropouts.

Logistical issues such as a lack of transportation and a lack of understanding about other barriers that impact teen mothers also were problematic.

“They result in significant disparities,” South-Paul said.

Societal/community issues

Disparities in major health indicators in children and adults seem to be most pronounced in the lowest-income and least-educated groups. “They’re patterned along not just racial and ethnic lines but also along socioeconomic lines,” South-Paul said, adding that people of color are disproportionately represented in those lower socioeconomic groups.

New research is showing that populations in high- and medium-poverty level tracks are rising — areas in which African Americans, Hispanic Americans and Native Americans are more heavily represented than white Americans. Movement to low-poverty neighborhoods, a trend that had been on the upswing for decades, now has stalled, she said.

If you are a person of color, you are disproportionately more likely to live in a high-poverty neighborhood, South-Paul said.

In such neighborhoods, there are no places for young people to find part-time jobs. Amenities such as grocery stores, banks or even bus stops may not exist.

“Place matters,” she said. “When you are in a more segregated neighborhood, nothing goes nearly as well for you in all aspects of your life as if you were in a more integrated neighborhood.”

Health status measures can be equated with both racial composition and the poverty level of neighborhoods. “You find that race is important but poverty level is also equally important,” she said.

Neighborhood poverty is not just individual poverty, but a community level of disadvantage that can directly impact a person’s health.

“Everybody suffers in poverty but people of color seem to suffer more,” she said, adding that when addressing issues of health and race, the socioeconomic framework in which these disparities occur also must be taken into account.

Language barriers

“If you are not English-speaking, you are significantly disadvantaged,” she said, noting that in some situations she has an interpreter to help her communicate with patients, but often times must rely on family members, which is less than ideal.

Low language skills can result in fewer health care choices. “You can’t necessarily go to anybody. You have to go to the place where you think they will understand you.”

Continuity of care

People of color are less likely to have a regular source of health care, she said. Those who rely instead on emergency rooms or urgent care facilities tend to be less likely to obtain preventive care.

And where a person chooses to receive care matters, she said. Some hospitals in urban centers — even those with strong affiliations — had varying quality levels, she said.

Factors including the lack of care, unavailability of care and poor chronic disease management can add up to higher mortality rates for people of color, she said.

Provider issues

Sometimes biases in health care providers contribute to disparities. Research on long bone fractures — an obviously painful condition — found that people of color were less likely to be offered and administered adequate pain control.

Another study found proposed treatment of standardized coronary artery disease patients differed by race, ethnicity and gender. When different “patient” photos were attached to a standardized case description, the proposed handling of the case varied.

“You didn’t want to be a woman of color, because we were right at the bottom,” she said, noting that group was much “less likely to have a definitive diagnostic procedure or even  be recommended for the intervention that was supposed to provide you the best result.” In addition, discussion of secondary precautions such as avoiding smoking, exercising, taking baby aspirin and keeping diabetes under control “were less likely to be had in patients of color than they were in majority patients,” she said.

Socioeconomic status also impacts clinical management, she said, noting that some doctors see little point in prescribing follow-up visits, additional care such as physical therapy or multiple medications to patients they believe won’t comply anyway.

The matter of trust

Race and gender can influence perceptions about doctor-patient relationships, she said, with research finding that patients of color report they were less likely to be talked to in a collegial, participatory fashion by a clinician who didn’t look like them. “They may tell us what to do, but they don’t ask us what’s possible, they don’t ask us what issues might be barriers. Or they just sort of mandate what we need to do,” she said.

“We really need more diversity among providers so there is better understanding of what the issues are that relate to those diverse patient populations,” she said.

Patients from minority groups also say they have greater difficulty in communicating with doctors. Patients may choose not to say anything if they don’t know the “professional” way to describe symptoms or they may clam up if their descriptions elicit a shocked look from their care providers.

“It’s not just the look, but how do you come across to the patient,” she said.

Also, patients may not trust the health system, she said, noting that research has found patients’ trust can be eroded by the lack of time and attention by health care professionals, by a perceived lack of empathy or by the belief that providers hold negative stereotypes of minority patients.

They also may lose trust if they believe that the profit motive drives medical decision-making or hold the perception that managed-care plans are not designed to protect patients’ interests.

Resolving the disparities

“This is not a soloist enterprise,” she said. The community, the health system and the patient all play a role in narrowing the gap. Information systems that educate and inform patients so they can play an active role in their own care, combined with a prepared, proactive practice team are necessary. Everyone needs to have a patient-centered medical home and clinicians need to value cultural proficiency, integrating the individual into what they know about managing diseases, she said. “We’re not taking care of diseases, we’re taking care of illnesses. The difference between a disease and illness is that illnesses occur in people. We can’t divorce the person from the disease.”

Education is paramount, South-Paul said — education for doctors, for patients and for communities.

“And we absolutely have to address poverty,” she said. “If someone has to decide between buying medicine or putting food on the table, what choice do you think they’re going to make?”

—Kimberly K. Barlow

Editor’s note: A link to South-Paul’s presentation can be found at

Filed under: Feature,Volume 44 Issue 3

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