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African Americans: Disparities in Health Care Access and Utilization

Posted on: Wednesday, 10 August 2005, 03:01 CDT

Despite remarkable improvements in the overall health of our nation during the past two decades, compelling evidence suggests that our nation's racial and ethnic minority Americans suffer increasing disparities in the incidence, prevalence, mortality, and burden of dis eases and adverse health outcomes compared with white Americans. The 1998 Presidential Initiative on Race and Health was the first national commitment to eliminate health disparities between majority and minority population groups. Because racial and ethnic minority groups will increase to nearly 40 percent of the U.S. population by 2030 (U.S. Department of Health and Human Services [HHS] 2000), a stronger commitment to better understand health disparities and develop new diagnostic, treatment, and prevention strategies for their elimination is a sound investment. Only rigorous population and epidemiologic research can discern where these disparities exist, define the scope of the problem, and identify and evaluate new interventions to reduce and eliminate them. Sources of these disparities are multivariate, complex, and rooted in an inequitable health care system. Contributing factors include lack of access to health care; barriers to care; increased risk of disability and disease resulting from occupational exposure; biological, socioeconomic, ethnic, and family factors; cultural values and education; social relationships between majority and minority population groups; autonomous institutions within ethnic minority group populations; and culturally insensitive health care systems (Geronimus, 2000; HHS, 2000; HHS, 2001b;Jackson et al., 2001 ; Smedley.Stith, & Nelson, 2003).

The practice implications of disparities in health care deserve the attention of health care professionals, administrators, policymakers, and consumers. Health disparities pose moral and ethical dilemmas in our rapidly changing health care system. They threaten our efforts to improve health outcomes and create problems for a society that continues to struggle with a legacy of racial discrimination and oppression. Because health care resources are tied to social justice, opportunity, and quality of life, the productivity of the workforce is linked to the health status of its - workers. The cost of inadequate health care has a huge impact on overall health care expenditures. In the final analysis, these disparities prompt concerns about the overall quality of health care in the Unites States (Smedley et al., 2003). The professional values of social work practice compel us to participate in the fight for a health care system that is sensitive to the health care needs of all, regardless of race or ethnicity. Service equity is part of our call to social justice.

Having a diverse society is an asset and a challenge for our nation. Racial and ethnic disparities in health care occur among several population and subpopulation groups: American Indians, Alaska Natives, Asian Americans and Pacific Islanders, and Hispanic Americans; rural and urban populations; infants, children, and youths; adults and senior citizens, and so forth. The scope of this column does not permit an in-depth discussion of the relationship between health disparities and cultural and ethnic characteristics unique to each group. Nor is it appropriate to approach the health disparity problem from a racial or an ethnically blind perspective. The focus of this column is African Americans, who have a unique history in the United States, rooted in slavery, emancipation, segregation, racism, and discrimination.

AFRICAN AMERICANS AND HEALTH DISPARITIES

Approximately 12 percent (34.7 million) of the U.S. population is African American (HHS, 1999). Compared with white Americans, they are less likely to have private or employment-based health insurance, more likely to be covered by Medicaid or other publicly funded insurance, and twice as likely to be uninsured, even though eight of 10 are in working families. A disproportionate percentage of African Americans work in jobs that do not provide health insurance. Many African Americans, especially those who are poor and those working without health care benefits, are less likely than white Americans to have a usual source of health care (Smedley et al, 2003; HHS, 2003).

The social environment in which many African Americans live is associated with many of their health problems. Families living in urban areas are confronted with constant challenges of population density, inadequate or unaffordable housing, overcrowding, limited access to resources, and high crime rates (Black & Krishnakumar, 1998). Racial differences in socioeconomic status, neighborhood residential conditions, and medical care all contribute to racial differences in disease (Williams & Jackson, 2005). In part, all of these factors contribute to the manifestation of psychological stress, which also links race to health.The prolonged negative impact of racism, discrimination, poverty, substandard housing and neighborhood conditions, insurance status, and insufficient availability of and access to quality health care, have all been linked to poor health outcomes among African Americans (Chadiha & Brown, 2002; Klonoff, Landrine, & Ullman, 1999; Leventhal & Brooks- Gunn, 2003; Mechanic, 2005; Satcher et al., 2005;Williams & Jackson).

We have witnessed dramatic changes in civil rights, housing, education, and income, but the inequities in health care services continue.These disparities are rooted in the larger social, economic, and political structures of our society. For example, changes in the overall availability of housing have occurred, but for the majority of African Americans, residential segregation continues. In many urban areas, large concentrations of African Americans live in community census tracts that are identifiable by the questionable safety of their neighborhood environments, the low socioeconomic status of the residents, a paucity of health resources in the community, and the absence of ecological resources for promoting positive health behaviors. Black-white differences in socioeconomic status, neighborhood and community conditions, and health and ecological resources are factors that contribute to racial differences in disease and disability (Satcher et al., 2005;Williams & Jackson, 2005).

Using data from the National Center for Health Statistics to examine standardized death rates for African and white Americans across age and gender from 1960 through 2000, Satcher and colleagues (2005) found that even though overall reductions in excess death rates occurred for all age and gender groups, the disparity between African and white Americans changed little. In 1960, before Medicare and Medicaid, the infant mortality rate was 44.3 and 29.2 per 1,000 for African Americans and white Americans, respectively. Medicaid and Medicare have contributed to better health care and health status for many African Americans, yet the overall gap in mortality has not changed dramatically, and the infant mortality rate has worsened (Satcher et al.).

Williams and Jackson (2005), in an examination of the social sources of racial differences in mortality rates, investigated five causes of death with different pathways to present disparities. Persistent racial disparities for black and white Americans were evident in national trends for homicide, heart disease, and cancer. In causes of death linked to pneumonia and flu and suicide there were no disparities. The authors suggested that racial differences in mortality for the five causes are better understood in the context of socioeconomic status as measured by education, income, health practices, and psychosocial stressors; residential segregation, which results from low-income levels, increased exposure to violence; level of health care coverage and access to medical care; homicide; and cancer mortality.

Mechanic (2005) suggested that we focus on health interconnections instead of specific diseases. This makes sense because physical health status results from a system of biospychosocial interconnections. For example, obesity, cancer, diabetes, hypertension, coronary heart disease, and cerebrovascular disease are interrelated risk factors for cancer in African American women (HHS, 2003). Other interconnections to poorer health and lower life expectancy in African Americans are lifestyle habits such as smoking, diet, lack of physical exercise; life stress; occupational conditions; and individual and systemic barriers to preventive health care.

ACCESS AND UTILIZATION

Improving access to and utilization of quality health care services are two of the most notable challenges in eliminating disparities in health care. To address these disparities, an overwhelming body of literature documents structural barriers to care, such as lack of transportation, lack of or inadequate health insurance, scarcity of providers, long waiting lists, and inconvenient health services locations (Anderson, 1995; Beal, 2004; Frist, 2005; HHS, 1999; HHS, 2001a,b; Kennedy, 2005; Owens et al., 2002). After acquiring access to health care services, many African Americans continue to experience poor quality care. Improving health insurance coverage is a strategy for reducing disparities (Beal; Fri\st; Kennedy),but having access to care as a function of insurance coverage will not solve the problem.

Perceptions of Quality of Care

With the exception of the client satisfaction literature, very few investigations examine the perceptions African Americans have about the services they receive. Investigations that focus exclusively on provider perceptions of treatment delivered present a bias that may not represent the perceptions of African American consumers. The health care relationship is a two-way process in which the patient's input is at least as important as that of the provider (Bryan, Dersch, Shumway, & Arredondo 2004; Macran, Ross, Hardy, & Shapiro, 1995; Stiffman, Chen, Elze, Dore, & Cheng, 1997). Whereas research on adult perceptions and satisfaction with health services has increased (Bryan et al.), African Americans perceptions of the care they receive has been examined in only a few studies (Martin, Petr, & Kapp, 2003).

The perceived lack of quality in care, the result of biased, incomplete, and deficient treatment services, may be due to a failure of providers to recognize sociocultural differences between African Americans' and white Americans' illness perception (Dana, 2002).The quality of care may differ in part as a function of where African Americans receive care (Smedley et al., 2003). Other perceptual barriers to African Americans' use of health care services are distrust in the health care system, cultural differences in understanding and explaining illness, history of hospital and medical office segregation, and knowledge of available services.

Patient-Provider Relationship

How patients feel about the quality of the relationship with a health care provider is linked to patient satisfaction, adherence, and health outcomes. If the cultural differences between patients and providers are not recognized, explored, and reflected upon, patients' health may suffer (HHS, 2002). Culture and language have considerable impact on how patients obtain and respond to health care services. African American patients who feel that their provider has been disrespectful may not return to treatment, may try another provider, or may change their health care plans (Copeland, Scholle, & Binko,2003). According to Beal and colleagues (2003), African Americans in their study felt that they would have received better care if their race or ethnicity had been different. Many of these patients were less confident that they would ever receive good quality care. An African father participating in a focus group I facilitated for parents of children receiving behavioral health services suggested that "the type of insurance you have dictates the kind of care you receive...It's the difference between having a Volkswagen and a Cadillac." Many other African Americans attribute the poor care they receive to their race-it has been an ever present dynamic in a country where race matters.

Perceptions of Health and Illness

Research on access to and utilization of health care services tends to focus on barriers and utilization. Little literature exists regarding the personal and nonstructural barriers to access and utilization of services as perceived by racial and ethnic minority consumers (Buston, 2002; Littell, Alexander, & Reynolds, 2001; Snowden, 2003). A barrier that has not been extensively studied is perceptions African Americans have about concepts of health and illness, services received, and treatment outcomes. An individual's perception regarding the seriousness and source of his or her health problems can be a barrier to treatment (Hines-Martin, Malone, Kirn, & Brown-Piper, 2003; Macran et al., 1995). These perceptions are related to interpretations of symptoms of illness; values, knowledge, attitudes, and health beliefs; services received; and a sense of control over their treatment (Davis & Ford, 2004; Hines- Martin et al., 2003). Other factors include social relationships between majority and minority populations and group loyalty to autonomous institutions in the racial or ethnic minority community (Geronimus, 2000; HHS 2000; Jackson et al, 2001).

Perceptions of Care from a Sociocultural Context

To understand the perceptions, rooted in the life circumstances, contributing to health disparities for African Americans and to identify remedies, providers must be aware of the historical and cultural influences on African Americans as a population group. Race is a defining issue in the history of the United States. The history of African Americans has included being disenfranchised, emancipated, enfranchised, and empowered politically.They have engaged in a massive migration from the rural south to the urban north, realized dramatic economic gains, and moved from caste segregation to social desegregation (HHS, 2003). Such events have had a significant influence on their economic, social, political, and health status. An understanding of the sociocultural context of African Americans can facilitate the elimination of bias in the delivery of health care services.

African Americans have been perceived and treated as different from and inferior to other Americans. Their disadvantaged social position is evident from the social indicators reflected in the literature documenting the gaps in their health status. As residents of the United States for more than 400 years (HHS, 2003), African Americans have developed and maintained a unique culture that helps them make sense of and cope with their perceived social status by the larger society. They have developed their own view and judgment of the larger American society and cultural guidelines for interacting with members of the larger society, including health care institutions. Many of the guidelines for functioning in a society where race and class matter emphasize caution, mistrust, and avoidance. The culture of the African American communities can encompass community and social support networks, family and kinship networks, health beliefs and practices related to health and illness, and beliefs about who is likely to be influential in health- related decision making. Perceptions of systemic barriers include clinical bias, personal attitudes health providers have toward African Americans, and their of lack awareness of cultural issues important to African Americans (Davis & Ford, 2004; HHS, 2003).

IMPLICATIONS FOR SOCIAL WORK PRACTICE

How do social workers participate in the elimination of health disparities? First and foremost, we must examine our own biases and understand how these biases permeate our conscious and unconscious practice behaviors. Our individual and collective social identities have to be examined so that the necessary transformation can occur. Before we can scrutinize other systems of care we must begin by increasing our own awareness.

Advocating for system change includes continuing the fight for quality universal health care coverage. Health care should be a basic right for everyone (Kennedy, 2005). Social workers can advocate for policy expansions of Medicaid and the State Children's Health Insurance Program. Because we know that health insurance coverage is not enough, we must continue to develop culturally competent health care systems.We must promote and refine culturally competent social work interventions and research methodologies in social justice; train culturally competent providers for effective clinical care with African Americans; and address the impact of racism, oppression, social injustice, and other human rights violations through social work education. Social workers must learn how to acknowledge, recognize, confront, and address racism in the social work profession at the individual, agency, and institutional levels (NASW, 2005). At every level opportunities exist for us to make an impact on the national agenda for eliminating racial and ethnic disparities in health care. Effective culturally competent providers must be aware of their own culture and the cultural characteristics of the group they are working with to bring about improved health outcomes. We should work to develop diversity in the workplace at all levels (Kennedy) by increasing the number of African Americans to provide quality mental health services, to conduct research investigations on best practices with racial and ethnic minority groups, and to work with groups and organizations in atrisk communities. "Patients who share the same race or ethnic background as their provider report higher levels of satisfaction with their care and greater participation in decisions involving their health" (Kennedy, p. 4). In addition, linguistic barriers between patient and provider are reduced when ethnic matching occurs. Bridging the gap between cultural differences is a challenge. Both the provider and patient bring their biases and attitudes to the health care setting. Many of these biases are rooted in each of their sociocultural identities. Many of these attitudes may be based on experiences with other human services systems for consumers and experiences with consumers for providers. We all bring history to a situation. Biases from both perspectives can inhibit clear communication between patient and provider and lead to adverse health outcomes.Thus, nonstructural contributors to disparities in health care will continue. Success in eliminating disparities in health care access and utilization requires all social work professionals to critically examine their own biases and to adopt the values and behaviors needed for social change. Acts of social injustice against any individual or group dehumanizes us all.

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Value Caff Copeland, PhD, MPH, is associate professor, School of Social Work and Department of Behavioral and Community Health Sciences, Graduate School of Public Health, University of Pittsburgh, 2211 Cathedral of Learning, Pittsburgh, PA 15260; e- mail: sswvcc@pitt.edu. The author thanks Dn. Stephen Gorin and Cynthia Moniz for their feedback on earlier drafts of this column and acknowledges support from the EXPORT Health Project at the Center for Minority Health, Graduate School of Public Health, University of Pittsburgh, NIH/NCMHD grant P60 MD-000-207-02.

Accepted May 17. 2005

Copyright National Association of Social Workers, Incorporated Aug 2005

Source: Health & Social Work

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