Mechanisms for Explaining Mechanisms for Explaining Health and Health Care Health and Health Care

Disparities: Disparities: Implications for Implications for Measures and MethodsMeasures and Methods

Eliseo J. PEliseo J. Pérez-Stable, MDérez-Stable, MD

EPI 222 Clinical Research in EPI 222 Clinical Research in Diverse CommunitiesDiverse Communities

1 May 20081 May 2008

ObjectivesObjectives

• To identify mechanisms that explain the differential distribution of health and health care by race and ethnicity

• Specify individual and contextual constructs that may exp0lain variance

• Describe emerging measures and methods in studies of health disparities

• Provide methods for clarifying concepts to enable their application

Deconstructing Race/Ethnicity Deconstructing Race/Ethnicity and Social Classand Social Class

• Identify more specific variables that mediate the effects of race/ethnicity on health outcomes

• Developing more specific indicators is necessary for developing effective interventions to decrease disparities

• Constructs may be missing or poorly defined for an ethnic group

Institutional Racism FrameworkInstitutional Racism Framework

Deconstructing the impact of race on health

Culture

(lifestyle, values)

Socio-political power

(institutional power)

Social class

(income, education)

Discrimination

King, G. 1996 Ethn & Dis;6:30-46

Promising Constructs for Health Promising Constructs for Health Disparities ResearchDisparities Research

• Physiological or Clinical

• Psychological

• Social environment

• Physical environment

• Social class

• Community resources

• Health care

Physiological or ClinicalPhysiological or Clinical

• Co-morbidity: more burden• Stress reactivity: Anger,

inflammation• Allostatic load-weathering

hypothesis• SNP sequences: genetics• Risk factors with different effects by

group

Allostatic LoadAllostatic Load

• Weathering hypothesis: effects of social inequality on health compound with age leading to growing gaps

• Magnitude of black/white disparity in neonatal mortality widens with increasing maternal age

Geronimus A 1996 Soc Sci med;42:589

Nicotine Metabolism by Nicotine Metabolism by Race/EthnicityRace/Ethnicity

• Metabolic clearance of nicotine and cotinine in Latinos was similar to Whites, lower among Chinese, and higher among Blacks

• Intake of nicotine per cigarette:– Chinese: 0.73 mg (0.53 to 0.94)– Latinos: 1.05 mg (0.85 to 1.25)– Whites 1.10 (0.91 to 1.30)– Blacks 1.41 (1.22 to 1.60)

• Nicotine intake = tobacco smoke

Psychological and BehavioralPsychological and Behavioral

• Control, fatalism, helplessness

• Optimism

• Self-efficacy

• Self-esteem

• Risk Taking

• Substance Use

PsychologicalPsychological

• Knowledge about prevention, clinical Knowledge about prevention, clinical conditions and treatmentsconditions and treatments

• Health beliefs (and knowledge) Health beliefs (and knowledge) affects behavioraffects behavior

• Trust in clinicians: communicationTrust in clinicians: communication

• Role expectations by gender, age Role expectations by gender, age groupsgroups

Optimism and FatalismOptimism and Fatalism

• Optimists show quicker recovery from coronary bypass surgery and have less angina

Fitzgerald TE 1993 J Behav Med;16:25

• Fatalistic beliefs scale was an independent predictors of Pap smear use and interval mammography among Latinas but not White women

Chavez LR 1997 Am J Prev Med;13:418

Social EnvironmentSocial Environment

• Social opportunitiesSocial opportunities

• Family environmentFamily environment

• Social supportSocial support

• Perceived discriminationPerceived discrimination

• Religious involvementReligious involvement

• Participation in groups: NetworksParticipation in groups: Networks

Physical EnvironmentPhysical Environment

• Neighborhood safetyNeighborhood safety

• Quality of housingQuality of housing

• TrafficTraffic

• SegregationSegregation

• Hazardous materialsHazardous materials

• Occupational hazardsOccupational hazards

Social ClassSocial Class

• Social stratificationSocial stratification• Perceived inequalityPerceived inequality• EducationEducation• Language ability and literacyLanguage ability and literacy• Income per capita Income per capita • WealthWealth• Documentation status: ImmigrationDocumentation status: Immigration

Community ResourcesCommunity Resources

• TransportationTransportation

• Exercise venuesExercise venues

• Neighborhood stability Neighborhood stability

• Political leveragePolitical leverage

• Community organizationsCommunity organizations

• Faith-based institutionsFaith-based institutions

• Social servicesSocial services

Health CareHealth Care

• AccessAccess

• Continuity and specialty careContinuity and specialty care

• Quality: Process and OutcomesQuality: Process and Outcomes

• Cultural and linguistic competenceCultural and linguistic competence

• DiscriminationDiscrimination

• SatisfactionSatisfaction

Disparities in UtilizationDisparities in Utilization

• 50-70% of disparities would remain if disparities in income and insurance coverage were eliminated (Weinick et al.2000 MCR&R;57 suppl 1:36-54.

• Care with safety net clinicians, hospital outpatient and ED–more organizational barriers

• Low-income neighborhoods with fewer medical and health resources

Mechanisms: Individual LevelMechanisms: Individual Level

• Lifestyle factorsLifestyle factors

• Self-efficacySelf-efficacy

• Sense of controlSense of control

• Cultural normsCultural norms

Mechanisms: Self-efficacyMechanisms: Self-efficacy

• Self-efficacy is critical to people’s ability to initiate and maintain positive health habits, e.g. exercise, breast self-exam, smoking cessation and control of alcohol consumption (Taylor SE. 1999 Health Psychology)

Mechanisms – ContextMechanisms – ContextSocial environmentSocial environment

• Collective efficacy-index of informal social control and social cohesion

• “Collective efficacy” predicted rates of violence in 300 Chicago neighborhoods after controlling for poverty, residential stability, immigrant concentration, and individual-level age, sex, SES, race, home ownership (Sampson et al. Science, 1997:277:918-24)

• Longitudinal studies that focus on person-environment interactions

Research Methods: Research Methods: Cultural EpidemiologyCultural Epidemiology

• Combination of methodological approaches

• Qualitative methods - individual belief systems, cultural norms and cognitions about health

• Epidemiology – social and economic causes (Angel and Williams. Cultural models of health and illness in

Handbook of Multicultural Mental Health, 2000)

Recommendation 1Recommendation 1

• Use qualitative methods to explore relevance and adequacy of constructs

• By expanding the definitions of constructs, can develop better measures that are meaningful across groups

• May identify constructs with increased explanatory power

Recommendation 2Recommendation 2

• Use qualitative and quantitative methods in iterative manner

• Qualitative before administer or develop questionnaire to explore concepts

• Quantitative to assess reliability, validity and explanatory power of measures across groups

• Qualitative to diagnose why measures or interventions failed

Concept ClarificationConcept Clarification

What does CultureWhat does Culturemean to you in Health Care?mean to you in Health Care?

Poorly defined construct: culture Poorly defined construct: culture and the medical encounterand the medical encounter

• Most studies of cultural influences on medical encounter focus on SES, gender, language and racial concordance

• Culture-difficult to operationalize

• Core cultural competencies lack clear definitions and evidence base

Difficult to operationalizeDifficult to operationalize

• Multi-dimensional

• Multi-directional

• Cultural factors operate at the individual and group levels

• Encompasses behaviors, attitudes and values

14 CLAS Standards14 CLAS Standards

• 4 of 14 are mandates (not guidelines 4 of 14 are mandates (not guidelines or recommendations) for language or recommendations) for language capacity, not culturecapacity, not culture

• How do we develop measures of How do we develop measures of cultural competence?cultural competence?

• Can you ask patients “what is Can you ask patients “what is cultural competence?”cultural competence?”

Meanings of culture and its Meanings of culture and its impact on medical visitsimpact on medical visits

• 19 focus groups stratified by ethnicity (AA, L, WH) and age (<50, >50)

• Open-ended questions with probes• What does the word “culture” mean to

you?• What do or don’t your doctors

understand about your culture or health beliefs that might affect your visits?

Meanings of CultureMeanings of Culture

• Varied definitions reflecting historical, social, economic and political contexts

• Themes: values, manifest customs, self-identified ethnicity, shared experiences, nationality, discrimination, language

Meanings of CultureMeanings of Culture

DiscriminationDiscrimination“Sometimes being a minority as they call it, is not so good…you get treated different. You know what I’m saying, even by other minorities.” (AA male < age 50)

Shared experiencesShared experiences“Our culture is staying clean…it means staying away from an addiction that could or will eventually kill us..We don’t have a religion or ethnicity. All we have is we’ve been through the school of hard knocks and come out alive.” (WH male < age 50)

Culture and the Medical VisitCulture and the Medical Visit

• CAMCAM• LanguageLanguage• Health insurance Health insurance

discriminationdiscrimination• Ethnic Ethnic

discriminationdiscrimination• Social class Social class

discriminationdiscrimination• Ethnicity of the Ethnicity of the

physicianphysician• ModestyModesty

• Immigration

• Age discrimination

• Nutrition

• Spirituality

• Family

• Submissiveness to MD

• Doctor culture

Culture and the Medical VisitCulture and the Medical Visit

Ethnicity-based discriminationEthnicity-based discrimination“You get some type of bad vibe, or it’s the way a doctor treats you or might pick up something that you’ve touched. Sometimes…jumpy; when I moved the doctor sort of made sure he was a slight distance from me. It’s a doctor that’s prejudiced.” (AA woman < age 50)

Culture and the Medical VisitCulture and the Medical Visit

Social-class based discriminationSocial-class based discrimination“In order for me to feel more comfortable with a doctor, I would like it if they didn’t assume so much. He assumed that I didn’t - actually that I COULD not understand some scientific principles.” (AA woman < age 50)

Culture and the Medical VisitCulture and the Medical Visit

Doctor cultureDoctor culture“One of the strongest cultures in the room is the doctor culture in the sense that they have been trained to think certain ways, consider certain treatments for ailments. Relating to that culture is one of the big challenges in terms of the relationship. The doctor looks at a problem as a very objective thin, whereas we look at it as very personal.” (WH man < age 50)