Racial & Ethnic Inequalities
in American Healthcare:
Information & Implications
John R. Stone, MD, PhD
September 2011
Center for Health Policy and Ethics
Creighton University School of Medicine
402.280.2207; [email protected]
Learning Objectives
Summarize health & healthcare
inequalities
Explain professional & institutional
factors in unequal healthcare
Explain strategies for addressing
health disparities
Center for Health Policy and Ethics
Major Disparities Categories
Race/ethnicity
Socio-economic status
Gender
Mental health status
Age
Language
Center for Health Policy and Ethics
“Health Disparities” Literature
Articles/Year*
Center for Health Policy and Ethics
*April 1-April 1
Unequal Health & Healthcare
“Unnatural Causes”*
Racial/Ethnic minorities, Native Americans
Diseases
– Diabetes
– Infant mortality  maternal health
– Cardiovascular (HPT, MI, CHF)
– Cerebrovascular (Stroke)
– Obesity
– Cancer
* http://www.unnaturalcauses.org/about_the_series.php (Accessed 11Oct2009)
Center for Health Policy and Ethics
Ethics and Health/Healthcare
Inequalities
Sufficient Level of
Health for All*
Human
Flourishing/Well-being
6
*Powers M, Faden R. Social Justice: The Moral Foundations of Public
Health and Health Policy. New York: Oxford Univ. Press, 2006.
Center for Health Policy and Ethics
Physicians’ Social Responsibilities
Physicians’ are individually and
collectively obligated to work toward
elimination of unjust root social inequalities
that adversely affect health.
Moral foundations: respect, justice, social
contract, reciprocity
See the argument.
Stone, Cambridge Quarterly of Healthcare Ethics, 2010
Center for Health Policy and Ethics
DeLancey JO, Thun MJ, Jemal A, Ward EM. Recent trends in black-white disparities in
cancer mortality. Cancer Epidemiol Biomarkers Prev. 2008; 17(11):2908-2912.
Center for Health Policy and Ethics
DeLancey JO, Thun MJ, Jemal A, Ward EM. Recent trends in black-white disparities in
cancer mortality. Cancer Epidemiol Biomarkers Prev. 2008; 17(11):2908-2912.
Center for Health Policy and Ethics
Center for Health Policy and Ethics
Breast Ca Incidence/100k: B/W
Baquet, C. R., Mishra, S. I., Commiskey, P., Ellison, G. L., & DeShields, M. (2008). Breast cancer epidemiology in
blacks and whites: Disparities in incidence, mortality, survival rates and histology. Journal of the National Medical
Association, 100(5), 480-488.
Center for Health Policy and Ethics
Breast Cancer B/W
Spread 
Benefits from advances  (Dx, Rx)
Mortality 
Center for Health Policy and Ethics
65, Breast Ca, AA Woman
Excisional biopsy
Breast conserving surgery
Radiotherapy
– Are AA as likely to receive as Whites?
– No (significant difference)
Smith, G. L., Shih, Y. C., Xu, Y., Giordano, S. H., Smith, B. D., Perkins, G. H., . . . Buchholz, T. A. (2010). Racial
disparities in the use of radiotherapy after breast-conserving surgery: A national medicare study. Cancer, 116(3), 734741. doi: 10.1002/cncr.24741
Breast Cancer-USA B/W 1980-2005
Black & Hispanic
Black Non-Hispanic
White & Hispanic
White Non-Hispanic
Whitman, S., Ansell, D., Orsi, J., & Francois, T. (2011). The racial disparity in breast
cancer mortality. Journal of Community Health, 36(4), 588-596. doi: 10.1007/s10900010-9346-2
Open diamonds represent Black data that includes Hispanics and closed circles represent White data that
includes Hispanics (1980–1989). Closed Diamonds represents Non-Hispanic Blacks and open circles
represents Non-Hispanic Whites (1990–2005)
Center for Health Policy and Ethics
Breast Cancer Disparities B/W
Reasons 1
 Access: screening, diagnosis, treatment
Inferior institutions
Environment  biology
Socio-economic disadvantages
– Transportation
– Navigation
– Social support
– Education & understanding
Center for Health Policy and Ethics
Breast Cancer Disparities B/W
Reasons 2
 Access: screening, diagnosis, treatment
– Mammograms
–  Quality of mammograms
–  Quality of treatment
Whitman, S., Ansell, D., Orsi, J., & Francois, T. (2011). The racial disparity in breast cancer mortality.
Journal of Community Health, 36(4), 588-596. doi: 10.1007/s10900-010-9346-2
Center for Health Policy and Ethics
“Social Patterning”
Patient-Doctor
Lower social class
– More directive, less participatory
Ethnic Minority
– less expression of empathy or rapport
Forde I, Raine R. Placing the individual within a social determinants approach
to health inequity. Lancet. 2008; 372(9650):1694-1696.
Center for Health Policy and Ethics
Omaha Experiences
AA Women with Breast Cancer
Breast Cancer Treatment, Symptom
Management and Invitation to Participate
in Clinical Trials: The Experience of
African American Women
– Amy Haddad, PhD and Jacqueline Hill, MSN
– Center for Health Policy and Ethics
From: Amy Haddad, PhD and Jacqueline Hill, MSN. Breast Cancer Treatment, Symptom
Management and Invitation to Participate in Clinical Trials: The Experience of African American
Women. Center for Health Policy and Ethics. Poster.
Center for Health Policy and Ethics
Omaha Experiences
AA Women with Breast Cancer
Purpose: Explore survivors’ experience
Re: received information about
– treatment options,
– symptom management
– participation in clinical trials
From: Amy Haddad, PhD and Jacqueline Hill, MSN. Breast Cancer Treatment, Symptom
Management and Invitation to Participate in Clinical Trials: The Experience of African American
Women. Center for Health Policy and Ethics. Poster.
Center for Health Policy and Ethics
Omaha Experiences
AA Women with Breast Cancer
4 focus groups, 21 participants, 31-68
Survivorship <1 - >5 years
90% health insurance
Treatment
– 90% surgery
– 76% chemotherapy
– 66% radiotherapy
From: Amy Haddad, PhD and Jacqueline Hill, MSN. Breast Cancer Treatment, Symptom
Management and Invitation to Participate in Clinical Trials: The Experience of African American
Women. Center for Health Policy and Ethics. Poster.
Center for Health Policy and Ethics
Omaha Experiences
AA Women with Breast Cancer
Themes grouping
– Things patients should know
– Things health care providers should know
Other needs
– Ways to record relevant information (patients)
– Culturally appropriate info materials
– Community dissemination
From: Amy Haddad, PhD and Jacqueline Hill, MSN. Breast Cancer Treatment, Symptom
Management and Invitation to Participate in Clinical Trials: The Experience of African American
Women. Center for Health Policy and Ethics. Poster.
Center for Health Policy and Ethics
Omaha Experiences
AA Women with Breast Cancer
Specific ideas
– Booklet: focus group key points
– Diagnosis and treatment history card
– Key talking points to effectively utilize media
opportunities
From: Amy Haddad, PhD and Jacqueline Hill, MSN. Breast Cancer Treatment, Symptom
Management and Invitation to Participate in Clinical Trials: The Experience of African American
Women. Center for Health Policy and Ethics. Poster.
Center for Health Policy and Ethics
Ecology
Social
determinants
Healthcare
Health
Center for Health Policy and Ethics
Braveman P, Egerter S, Williams DR. The social
determinants of health: Coming of age.
Annu Rev Public Health. 2011; 32:381-398.
Center for Health Policy and Ethics
Annual Reviews
Maternal
Health
Adult
Health
Fetal
Health
Stress
HPT
Diabetes
Stroke
Kidney Dis
Preterm birth
Low birth wt
Higher infant
mortality
Infant
Health
Childhood
Health
Adapted from: Gravlee CC. How race becomes biology: Embodiment of social
inequality. Am J Phys Anthropol. 2009; 139(1):47-57
Center for Health Policy and Ethics
Ecology & Physician
Physician
Social
determinants
Healthcare
Health
Center for Health Policy and Ethics
Healthcare Equity Reports: An “Action
Step”
Aim:  unequal care: race, ethnicity,
language, socio-economic status
Measures
– Distribution: where seen, what conditions
– Utilization & process
Do children receive advised # well-child visits?
How often & long are asthma patients in hospital?
Do qualified patients preventive screening tests?
Robin M.Weinick, Katherine Flaherty, and Steffanie J. Bristol. Creating Equity Reports:A Guide for
Hospitals.The Disparities Solutions Center, Massachusetts General Hospital, 2008.
http://www.massgeneral.org/disparitiessolutions/resources.html.
Center for Health Policy and Ethics
Healthcare Equity
Eliminating Inequalities: Structures
Measure outcomes
Require publishing outcomes
Assess structures
Include communities: all levels and roles
Change structures
Implement & evaluate strategies
Nicole Lurie. Health Disparities — Less Talk, More Action.
NEJM 2005; 353:727-729
Center for Health Policy and Ethics
Evolution of Cultural Competence
“Cultural competence is the ability of health care
professionals to communicate with and
effectively provide high-quality care to patients
from diverse sociocultural backgrounds; aspects
of diversity include—but go beyond—race,
ethnicity, gender, sexual orientation, religion,
and country of origin.”
Previous “categorical approach”: “attitudes,
values, beliefs, and behaviors of specific cultural
groups”
Betancourt 2010
Center for Health Policy and Ethics
Evolution of Cultural Competence
General community/cultural background is
helpful.
Learning sets of attributes  stereotyping
and oversimplification.
Current model: skills and framework for
individual assessment: “what sociocultural
factors might affect that patient's care”
Betancourt 2010
Center for Health Policy and Ethics
Cross-cultural/Multi-cultural
System Level
Leadership
Cultural competency/proficiency/humility
Institutional journey
Trust through trustworthiness
Community partnering & collaboration
Center for Health Policy and Ethics
Teaching about R/E Disparities
Learning Objectives
“Understand your own racial and cultural
background”
“Understand cultural diversity and the
relationship between racial and cultural attitudes
and quality of care”
“Understand U.S. racial and ethnic population
trends and the prevalence and severity of racial
and ethnic health disparities”
Smith WR et al. Recommendations for Teaching about Racial and Ethnic Disparities in Health and
Health Care. Annals of Internal Medicine. 2007;147(9):654-665
Center for Health Policy and Ethics
Teaching about R/E Disparities
Learning Objectives
“Use a patient-centered approach to clinical
encounters”
“Negotiate conflict resulting from differences
between patient explanatory models of illness
and treatment and physician models”
“Learn and apply skills to combat racial, ethnic,
and cultural barriers to effective care” [Add:
language barriers]
Smith WR et al. Recommendations for Teaching about Racial and Ethnic Disparities in Health and
Health Care. Annals of Internal Medicine. 2007;147(9):654-665
Center for Health Policy and Ethics
Limited English Proficiency
(LEP)
24 million people in the USA
[Anonymous]. Ending racial and ethnic health disparities
in the USA. Lancet. 2011; 377(9775):1379.
Center for Health Policy and Ethics
Ecology
Social
determinants
Healthcare
Health
Center for Health Policy and Ethics
CU Center for Promoting Health
and Health Equality (CPHHE)
A community-academic partnership
http://www.creighton.edu/health/cphhe/
Center for Health Policy and Ethics
CBPR
Community-Based Particpatory
Research
Stone, JR. Ethics and Community-Based Participatory Research. Focus. Spring 2011.
http://chpe.creighton.edu/publications/focus/spring-2011/CBPR.htm.
Center for Health Policy and Ethics
CBPR Model
Study
Center for Health Policy and Ethics
CBPR Rationale-1*
Knowledge & skills: local, investigators
No “value-free” science
Builds capacities
Builds cultural bridges
*Israel et al. 1998
Center for Health Policy and Ethics
CBPR Rationale-2*
Enhances community opportunities
Community health primary
Vitally involves marginalized
*Israel et al. 1998
Center for Health Policy and Ethics
Insights Driving CBPR
Upstream health influences
Interactive social determinants
Inadequate knowledge paradigms
Respect for persons
Justice
Beneficence/harm minimization
Humility (cultural, epistemological, conflict)
Stone, JR. Ethics and Community-Based Participatory Research. Focus. Spring 2011.
http://chpe.creighton.edu/publications/focus/spring-2011/CBPR.htm.
Center for Health Policy and Ethics
CBPR Challenges*
Distrust
Power/control inequalities
Conflicts: priorities, loyalties,
assumptions, values, beliefs, funding
Time
Community: defining, representation
Political/social in community
Tenure/promotion
*Israel et al. 1998
Center for Health Policy and Ethics
Healthcare Equity
Robin M.Weinick, Katherine Flaherty, and Steffanie J. Bristol.
Creating Equity Reports: A Guide for Hospitals. The
Disparities Solutions Center, Massachusetts General
Hospital, 2008. The model and many related documents and
information is available at
http://www2.massgeneral.org/disparitiessolutions/resources.ht
ml. At that site see:
Resources Produced by the Disparities Solutions Center
Improving Quality and Achieving Equity: A Guide for Hospital
Leaders
Assuring HealthCare Quality: A Healthcare Equity Blueprint
Creating Equity Reports: A Guide for Hospitals
Center for Health Policy and Ethics
Health/Healthcare Inequalities
& Culture
Adler NE, Stewart J. Health disparities across the lifespan: Meaning, methods, and
mechanisms. Ann N Y Acad Sci. 2010; 1186:5-23.
Ashing-Giwa KT, Gonzalez P, Lim JW, et al. Diagnostic and therapeutic delays
among a multiethnic sample of breast and cervical cancer survivors. Cancer. 2010;
116(13):3195-3204.
Ayanian JZ. Racial disparities in outcomes of colorectal cancer screening: Biology or
barriers to optimal care? J Natl Cancer Inst. 2010; 102(8):511-513.
Betancourt JR, Green AR. Commentary: Linking cultural competence training to
improved health outcomes: Perspectives from the field. Acad Med. 2010; 85(4):583585.
Tervalon M, Murray-Garcia J. Cultural humility versus cultural competence: A critical
distinction in defining physician training outcomes in multiculural education. J of
Health Care for the Poor and Underserved. 1998; 9(2):117-125.
Center for Health Policy and Ethics
Health/Healthcare Inequalities
Bleich, S. N., Jarlenski, M. P., Bell, C. N., & LaVeist, T. A. (2012). Health inequalities:
Trends, progress, and policy. Annual Review of Public Health, 33, 7-40. doi:
10.1146/annurev-publhealth-031811-124658
Braveman, P. (2012). Health inequalities by class and race in the US: What can we
learn from the patterns? Social Science & Medicine (1982), 74(5), 665-667. doi:
10.1016/j.socscimed.2011.12.009
Clark-Hitt, R., Malat, J., Burgess, D., & Friedemann-Sanchez, G. (2010). Doctors' and
nurses' explanations for racial disparities in medical treatment. Journal of Health Care
for the Poor and Underserved, 21(1), 386-400. doi: 10.1353/hpu.0.0275
Cohen, M. G., Fonarow, G. C., Peterson, E. D., Moscucci, M., Dai, D., Hernandez, A.
F., . . . Smith, S. C.,Jr. (2010). Racial and ethnic differences in the treatment of acute
myocardial infarction: Findings from the get with the guidelines-coronary artery
disease program. Circulation, 121(21), 2294-2301. doi:
10.1161/CIRCULATIONAHA.109.922286
Krieger, N. (2012). Methods for the scientific study of discrimination and health: An
ecosocial approach. American Journal of Public Health, 102(5), 936-944. doi:
10.2105/AJPH.2011.300544
Center for Health Policy and Ethics
Health/Healthcare Inequalities
Leeper, B., & Centeno, M. (2012). Disparities in cardiac care for patients with
complex cardiovascular care needs. The Journal of Cardiovascular Nursing, 27(2),
114-119. doi: 10.1097/JCN.0b013e318239f4c1
Lunn, M. R., & Sanchez, J. P. (2011). Prioritizing health disparities in medical
education to improve care. Academic Medicine : Journal of the Association of
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Peterson, E., & Yancy, C. W. (2009). Eliminating racial and ethnic disparities in
cardiac care. The New England Journal of Medicine, 360(12), 1172-1174. doi:
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American Journal of Public Health, 102(5), 933-935. doi: 10.2105/AJPH.2011.300643
Weinick, R. M., & Hasnain-Wynia, R. (2011). Quality improvement efforts under
health reform: How to ensure that they help reduce disparities--not increase them.
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Center for Health Policy and Ethics
Ethics & Health/Healthcare
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Center for Health Policy and Ethics
Community-Based Research
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Center for Health Policy and Ethics