In this video from AJMC.com, Dr. Moon S. Chen, Jr., professor of hematology and oncology at UC Davis Comprehensive Cancer Center and principal investigator of The National Center for Reducing Asian American Cancer Health Disparities, responds to the question , “What are some important considerations in designing health interventions for minority populations?” As a part of his answer, Dr. Chen discusses the attitude of humility and the need to work with the community instead of on the community.
The high loan burden associated with medical school can discourage students from underrepresented minority groups or lower-income families from pursuing a career as a physician. This creates a ripple effect of widening health care disparities that disproportionately affect the accessibility of primary care physicians in underserved areas.
Adjusted for inflation, the average medical student graduated in 2014 with a loan burden 3.5 times greater than a medical student in 1978. By 2014, the average loan burden was over $170,000.
Higher interest rates and unsubsidized loans for graduate students mean that they pay off more per dollar owed than undergraduate students. The Association of American Medical Colleges (AAMC) estimates that, accounting for interest under the Pay As You Earn repayment program, a student with $180,000 in loan burdens could pay almost $380,000 in total repayment. During a three-year residency, the AAMC estimates that total repayment to reach nearly $450,000. This amount increases further if a student pursues a specialty care field.
Those kinds of figures may be enough to intimidate any bright student considering a career in medicine. But students in ethnic and racial minority groups that are underrepresented in medicine, and those from lower-income families, can be particularly daunted by the prospect of six-figure loan burdens. According to the most recent AAMC report, 18.2 percent of black high-school sophomores said they aspired to apply to medical school, but only 6.7 percent actually applied. For Hispanic high-school sophomores, 24.4 percent said they wanted to go to medical school but only 6.8 percent applied.
According to 2014 AAMC data, while 13 percent of the U.S. population was black, they only made up 4.1 percent of the physician workforce. Hispanics accounted for 18 percent of Americans, but only 4.4 percent of the physician workforce. This in turn likely contributes to the lack of physicians making direct efforts to serve these communities. According to research published in JAMA, despite making up less than 30 percent of the physician workforce in 2013, physicians from underserved groups are significantly more likely to see nonwhite patients, and “nonwhite physicians cared for 53.5 percent of minority and 70.4 percent of non-English-speaking patients.”
Additionally, the cost of medical school likely deters applicants from lower-income rural communities as well. This could contribute to the fact that while 20 percent of Americans live in rural areas, only 10 percent of physicians practice where people in rural communities can access them. With a shortage of about 4,000 primary care physicians, 77 percent of rural U.S. counties are designated as health professional shortage areas.
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For African-Americans, the isolation of living in a racially segregated neighborhood may lead to an important health issue: higher blood pressure.
A study published Monday in JAMA Internal Medicine suggested blacks living in such areas experienced higher blood pressure than those living in more diverse communities. Moving to integrated areas was associated with a decrease in blood pressure, and those who permanently stayed in localities with low segregation saw their pressure fall on average nearly 6 points.
Kiarri Kershaw, assistant professor of preventive medicine at Northwestern University in Chicago and lead author of the study, said the findings reinforce the close relationship between social policy and community health outcomes.
“It lends credence to the notion that we should bring public health practitioners and health policy officials to the table to make these decisions,” she said. Researchers used data from a long-term study that has followed 2,280 African-Americans over the course of 25 years, checking in every three to seven years to track blood pressure.
Heart disease is the leading cause of death in the United States, and African-Americans are disproportionately affected by the condition. According to the American Heart Association, 46 percent of non-Hispanic black men and nearly 48 percent of non-Hispanic black women live with a form of heart disease, while about 36 percent of non-Hispanic white men and 32 percent of non-Hispanic white women do.
Georges Benjamin, executive director of the American Public Health Association, said the burden to address such disparities falls on society at large.
“It doesn’t just hurt African-Americans or people of color. This hurts everybody,” he said. “Because everyone pays not just in terms of humanity, but in terms of dollars.”
Doctors generally record two numbers for blood pressure: the diastolic pressure — the blood’s force inside the veins when the heart is at rest — and the systolic pressure, which gauges the blood’s force when the heart beats. Blood pressure is measured in millimeters of mercury, or mmHg (using mercury’s chemical element symbol), with systolic pressure reported first, such as 115 mmHg over 75 mmHg.
Researchers found residential segregation was associated with changes in systolic blood pressure, which is tied to adverse cardiovascular events, such as a heart attack. The findings did not show any changes in diastolic blood pressure.
The scientists also collected data on a variety of other social indicators including level of education, poverty and marriage status. They ranked the level of segregation in participants’ neighborhoods as “low,” “medium” and “high” based on the number of African-Americans in the larger area.
When compared to African-Americans living in highly segregated locations, participants living in medium-segregation neighborhoods recorded blood pressure that was on average 1.33 mmHg lower. Those residing in low-segregation areas were an average 1.19 mmHg lower.
Blood pressure for black residents who permanently moved into medium segregation locations decreased on average 3.94 mmHg. African-Americans who stayed in low-segregation locales saw an average decrease of 5.71 mmHg.
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Humans frequently make automatic decisions at a subconscious level. The human brain’s capacity for reflexive decisionmaking is what Nobel Laureate Daniel Khaneman calls “System 1” (as opposed to the more analytical, thoughtful, deliberate decision making of “System 2”) in the best-selling “Thinking, Fast and Slow.” This evolutionary adaptation was, and is, sometimes necessary for survival. However, these automatic responses occur via the rapid processing of new information through existing patterns of thought. Thus, because our automatic responses are shaped by our lived experiences and the broader social contexts in which we live and work, a pervasive byproduct of reflexive decisionmaking is unconscious bias (UB), which is also referred to as implicit bias or implicit social cognition.
Specifically, UB is the phenomenon in which stereotypes, positive or negative, influence decisions and behaviors without the individual consciously acting on the stereotype or being aware that he or she is doing so. Moreover, UB can occur even when individuals know or believe the stereotype to be false.
The insidiousness of UB is that it can create self-fulfilling prophecies that create and perpetuate inequities between in- and out-groups, even when the initial stereotype was incorrect (and there was no pre-existing difference between in- and out-group members). This post outlines some promising interventions we identify in a recent report, commissioned by Google’s Computer Science Education Research Division, that can short-circuit the recursive processes and self-fulfilling prophecies triggered by UB.
In this report, we argue that the consequences of UB may be particularly salient in the hierarchical environments of schools. Specifically, UB likely perpetuates socio-economic, gender, and racial gaps in educational outcomes such as academic performance, engagement with school, course and major choice, and persistence in higher education, particularly among historically disadvantaged and underrepresented groups such as low-income and racial-minority students. These gaps in educational outcomes then manifest in corresponding workplace disparities in pay, promotions, and employment.
Indeed, there is ample evidence of UB in educational settings, both in experimental labs and “in the field” with real individuals who were unaware of their participation in an experiment. For example, Moss-Racusin and colleagues conducted a lab experiment in which science faculty at research universities reviewed fictitious applications for a hypothetical lab assistant position and systematically rated male “applicants” higher than otherwise-identical female “applicants.” In a similar field experiment, Milkman and colleagues emailed meeting requests from fictitious prospective doctoral students to professors and found that white male “students” received more, and faster, responses than female and non-white students, particularly in higher-paying STEM careers like computer science and engineering. A recent field experiment conducted by one of us and colleagues found that the instructors of online courses were nearly twice as likely to respond to discussion-forum comments placed by students who were randomly assigned white-male names. Consistent with a UB interpretation, the pro-male bias was observed among both male and female faculty in these studies. The K-12 context is also ripe with suggestive, quasi-experimental evidence of pervasive UB in the form of systematic grading biases and student-teacher racial match effects.
Additionally, individuals from stereotyped out-groups themselves react negatively to seemingly innocuous environmental factors, such as the demographic composition of a classroom, the race or sex of an instructor or proctor, and even the design and decoration of the classroom. One example of this is the phenomenon of stereotype threat, whereby the mere threat of being stereotyped by a white (male) instructor, even when no outright bias is expressed, may distract black (female) students, ultimately leading to poor performance on exams and even disengagement from school.
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A new qualitative study has shown that previous bias and fear of black men likely result in them not getting the same healthcare as white male patients.
Published by the Journal of Racial and Ethnic Health Disparities, the study by Marie Plaisime, a 2014 graduate of Drexel University’s Dornsife School of Public Health and current Howard University student, found that health providers largely perceive black male patients with bias, fear and discomfort.
These findings in “Healthcare Providers’ Formative Experiences with Race and Black Male Patients in Urban Hospital Environments” back up past quantitative studies that found that black men are less likely to receive cardiac medical procedures such as cardiac catheterizations and coronary angioplasties compared to white men presenting with identical symptoms.
Plaisime’s work on this study was conducted under Jennifer Taylor, PhD, associate professor in the Dornsife School of Public Health.
“Racial bias in healthcare is worrying because one of the higest values of medical practice is to ‘do no harm,'” Taylor said. “Whether explicit or implicit, our racial biases can direct patients to different and unequal treatments that do not make them whole. No one goes into medicine wanting this to happen, so we must look at both our personal and professional socialization to check in on how those experiences may influence our actions as caregivers.”
Participants in the study included physicians, nurses and medical students from two urban university hospitals in the United States. Interviews were conducted with them to gather qualitative data on how formative childhood, personal and professional experiences with race and black men influences interactions with male, black patients today.
Plaisime and her team found themes across the interviews that were reflective of personally-mediated racism and concluded with findings of how the perception of black males and cognitive dissonance appear to influence providers’ approaches with black male patients.
Both black and white medical providers who were interviewed described examples when black male patients were treated differently based on race.
For example, one physician noted, “I’ve had … a black patient who I think had not been offered a procedure because of either where he was economically or where he was assumed to be economically because of his race. He clearly needed to be catheterized for his presentation and it was suggested that we do medical management. I spoke with the cardiologist and as soon as we started talking, he said, ‘Oh well, of course, we’ll cath’ him.’ And so, like that, it changed… certainly have enough anecdotal experience to think that people are probably [being] treated differently based on race.”
Furthermore, white providers described experiencing a sense of fear or discomfort and discussed their lack of exposure to black males. In contrast, black providers shared their frustration with media portrayal of black men, the pressure they feel to avoid confirming negative stereotypes associated with black culture, and instances of patients discriminating against them.
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Rural African Americans are disproportionately exposed to numerous stressors, such as poverty, racism, and discrimination, that place them at risk for experiencing elevated levels of depressive symptoms. Elevated levels of depressive symptoms can lead to a host of negative outcomes, including poor management of chronic illnesses (e.g., hypertension, diabetes), poor social and occupational functioning, and development of clinical depression. Although effective treatments for decreasing depressive symptoms exist, structural barriers (e.g., lack of available services, transportation) and perceptual barriers (e.g., stigma, fear of misdiagnosis) impede the use of traditional mental health services within these communities, resulting in a significant unmet psychiatric need. Failure to develop culturally appropriate strategies to provide adequate, timely care to rural African Americans can result in a significant public health crisis.
African American churches have been identified as potential venues for providing depression education and treatment for rural African Americans. Within the African American rural community, churches represent a key portal through which as much as 85% of the community can be reached. Churches have been used to address physical health outcomes in those communities, but few have focused primarily on addressing mental health outcomes. Through the NIMHD-funded project entitled “Faith Academic Initiatives to Transform Health (FAITH) in the Delta,” our partnership, consisting of faith community leaders and University of Arkansas for Medical Science researchers, conducted formative work in the Arkansas Delta. Data suggested that community members consider elevated depressive symptoms to be a significant unmet need. Furthermore, community members suggested that attempts to improve depressive symptoms should do the following:
- Provide education about depressive symptoms. Recognizing when depressive symptoms become a clinical problem is the first step toward receiving adequate treatment. However, rural African Americans report difficulties in differentiating between normal sadness and clinically significant depressive symptoms. Providing education about depressive symptoms allows rural African Americans to make informed treatment decisions.
- Address the role that stress from social inequities plays in the development and maintenance of depressive symptoms. Rural African Americans correctly realize that prolonged exposure to stress caused by social inequities is a significant factor in the development and maintenance of depressive symptoms. Treatments that conceptualize depressive symptoms as normal reactions to stress are more culturally acceptable in rural African American communities.
- Find ways to increase social support for those experiencing depressive symptoms. Stigma is a significant concern in rural communities. Rural African Americans experiencing depressive symptoms tend to socially isolate themselves, which, in turn, can worsen depressive symptoms.
- Provide mental health interventions in community-based settings. Residents suggest that offering mental health services in community settings, such as churches, would allow residents to receive treatment in less stigmatizing places and improve access to mental health care.
Read the full article.
Americans today live shorter, sicker lives than people in other developed countries, and, across the nation, health varies by income, education, race and ethnicity, and geography. Warning that the United States will pay the high price in lost lives, wasted potential and squandered potential resources until these gaps are closed, a comprehensive report from the National Academies of Sciences, Engineering, and Medicine (NASEM) calls for leaders across sectors to make health equity a priority for the nation.
Why Does Health Equity Matter?
When health equity is achieved, “everyone has the opportunity to attain full health potential, and no one is disadvantaged from achieving this potential because of social position or any other socially defined circumstance,” the report says. And ensuring that opportunity is crucial not just for individuals, but also for the nation’s economic and growth prospects, for its national security and for its communities’ well-being and vibrancy.
Data show the costs of current health inequities: The report estimates that racial health disparities alone are projected to cost health insurers $337 billion between 2009 and 2018. The impact on national security is also high, with some 26 million young adults unqualified to serve in the U.S. military because of persistent health problems, or because they are poorly educated or have been convicted of a felony.
…The Cost of Inequality
- In 2015, the percentage of low-birthweight infants in the U.S. rose for the first time in seven years.
- Racial health disparities alone are projected to cost health insurers $337 billion between 2009 and 2018.
- Health care spending accounted for 17.5 percent of GDP in 2014.
- In 2014, VA-enrolled veterans accounted for 17.9 percent of suicide deaths among U.S. adults.
- People with disabilities are more than twice as likely not to receive medical care because of cost.
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During my daily visits to ill patients throughout Durham County, it is staunchly apparent that many low income neighborhoods often predominately high in racial and ethnic minorities, have no proper functional sidewalks. As a nurse practitioner who provides home visits to patients I see a blatant disparity in Durham neighborhoods. My patients who are in dire need of food, transportation and mobility assistance are often the ones living in housing that is not wheelchair or walker friendly, far from grocery stores, without sidewalks and have living environments that even getting in and out of the front door is an overwhelming challenge. In 2016 Thornton et al. published a study identifying low-income neighborhoods and neighborhoods with a high proportion of racial and ethnic minorities had poorer aesthetics, had fewer sidewalks and crosswalks. Sidewalks are needed to get safely to the bus stops, grocery stores, health care appointments and to be connected with social and spiritual support.
Utilizing public transportation may be the only means of transportation for many residents in the low income neighborhoods, however there are limited sidewalks to get to transit access locations, which is a serious crisis for those requiring the use of a cane, walker or wheelchair.
Having access to a suitable grocery store with fresh healthy foods is important for health. In many low income neighborhoods adequate grocery stores are a privilege that is not a reality, so residents need to walk to public transit, then to a grocery store, or succumb to what is available at a smaller store with fewer healthy choices, often which are more expensive. Installing sidewalks could improve health, access to grocery stores as well as improving self-worth.
Healthy lifestyle is nearly impossible when there is no access to sidewalks, parks and ability to safely exercise. As a health care provider, after going into the homes of patients I now realize, if people have limited transportation or a home that is not easily manageable with their physical ability as well as no sidewalks, it is highly unlikely for a person to be able to achieve the exercise health care providers request. It was found by 2016 Thronton et al. that sidewalk quality, crosswalks, and neighborhood aesthetics may affect residents’ physical activity.
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In the the third report from its Race for Results Case Study Series, the Annie E. Casey Foundation describes the use of racial equity impact assessment tools to improve policy making. The report focuses on four areas:
- Why it is critical to measure the impact of any proposed legislation or change in policy on communities of color.
- How racial equity impact assessments can lead to smarter and more targeted public investments.
- How racial equity impact assessments keep decision-making focused on data and facts, not assumptions and long-held subjective beliefs.
- How advocating and using racial equity impact assessments can position leaders and elected officials as strong champions of equity.
Download the report to learn more.
Racial minorities and lower-income people typically fare far worse when it comes to health outcomes. And figuring out why has long been one of health care’s black boxes. Forthcoming research may help shed light on what’s driving those inequities — and how the system can fix them.
What is needed? Better bedside manner, so patients actually trust their doctors. Communication that is easily understood by everyday people. And transparency about what medical care costs, plus a willingness to discuss how price points fit into consumers’ health decisions.
Those ideas were highlighted in a white paper presented recently at a health communication conference sponsored by the Centers for Disease Control and Prevention. The findings, which will be published in full later this fall, are based on interviews with 100 health professionals and 65 “disadvantaged patients,” along with a nationally representative survey of 4,000 consumers. The examination is part of a larger project funded by the Robert Wood Johnson Foundation, a health-focused nonprofit. It was conducted by the Altarum Institute, a research and consulting organization.
The paper suggests that “implicit bias” — doctors and nurses subtly or subconsciously treating some patients differently than others — or patients’ perception of it could have consequences for people’s health. Patients who felt that they had experienced bias based on factors like race, income or insurance were less likely to follow advice about medication, for instance, and ended up sicker in the long run.
“We for a long time have neglected the human element,” said Chris Duke, director of Altarum’s Center for Consumer Choice in Health Care, and the white paper’s author. “The number one predictor of patient satisfaction is if your nurse listened to you. We neglect this at our great peril.”
Duke stressed that the research isn’t enough to draw conclusions about causality — that feeling disrespected causes worse health. But the study builds on years of investigation that suggests implicit bias and how patients perceive it could contribute to differences in health outcomes.
Insurance status was the largest predictor of how patients viewed their doctor-patient interaction, Duke said. People on Medicaid, the state-federal health insurance program for low-income people, or who were uninsured, were more likely to perceive disrespect than those with private insurance or Medicare, which provides coverage for senior citizens and some disabled people. Income was the next predictor for how well people felt they were treated. After that came race.
Meanwhile, racial minorities and low-income people also were more likely to be sensitive to concerns about a doctor’s bedside manner, and to seek out someone they thought would treat them well, Duke noted.
Often, these patients cue in on subtle behaviors, such as the doctor not making eye contact or not asking questions about their symptoms and health conditions, their lifestyle or their preferences on how to manage a disease. But that can be enough, Duke said, to keep people from seeking care, or following through on medical advice.
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