Minority Health: Recent Findings
Care for the Elderly/Long-Term Care
- Caring for older family members is especially challenging for Korean Americans.
The researchers conducted eight focus groups with first-generation Korean American adults who were living with and/or providing care to a Korean American relative or nonrelative aged 60 or older. Focus group participants expressed a strong sense of duty to care for ill or frail family members, thereby upholding the traditional value of daughter/son devotion. This duty often competed with other life priorities within immigrant life, such as working extremely long hours and communication difficulties. All of the caregivers were ambivalent about using outside, formal services, which they viewed as a last resort.
Source: Han, Choi, Kim, et al., J Adv Nurs 63(5):517-526, 2008 (AHRQ grant HS13779).
- Greater functional disability among older blacks and Latinos may be due in part to disparities in treatment and care quality.
This study of community-dwelling adults aged 50 and older found that blacks and Latinos with physician visits and hospitalizations were significantly less able than same-aged whites to carry out activities of daily living. In addition, many of the blacks and Latinos in this survey had more mobility limitations than whites. Other predisposing factors (e.g., age and sex, chronic illness, and economic access to care) did not account for the greater disability among blacks and Latinos. These findings suggest that improving economic access to care may not be enough to guarantee equal access to high-quality care.
Source: Bowen and Gonzalez, Gerontologist 48(5):659-667, 2008 (AHRQ grant HS13819).
- Racial disparities in care for the elderly persisted and even worsened for some procedures in the late 1990s.
Researchers analyzed discharge data for New York and Pennsylvania hospitals for elderly patients undergoing three referral-sensitive hospital procedures during 1997 and 2001—coronary angiography, heart bypass surgery, and hip/joint replacement, all high-technology procedures that generally require referral to a specialist. Elderly blacks were 37 percent less likely than elderly whites to have received angioplasty in 1997. This disparity had widened considerably by 2001, to 48 percent. Disparities in hip/joint replacement among other races also increased over time relative to whites.
Source: Basu and Mobley, Med Care Res Rev 65(5):617-637, 2008 (AHRQ Publication No. 08-R074)* (Intramural).
- Viewing patient stories seems to help black patients with hypertension manage their blood pressure.
This study found that watching story segments of patients talking about high blood pressure helped black men and women with hypertension make substantial improvements in their own blood pressure readings. The study involved 299 blacks with hypertension who were recruited from an inner city clinic in the South; 147 of the patients were assigned to the storytelling intervention, and the other 152 were assigned to the usual-care group. Those in the intervention group showed a reduction in blood pressure that persisted through the 9-month followup period.
Source: Houston, Allison, Sussman, et al., Ann Intern Med 154(2):77-84, 2011 (AHRQ grant HS19353).
- Control of high blood pressure can be difficult for blacks and Mexican Americans.
Despite adherence to treatment and lifestyle changes, high blood pressure control is often elusive for blacks and Mexican Americans, according to this study of nearly 5,400 adults with hypertension. Blacks and Mexican Americans were twice as likely as whites to report following advice to exercise, quit smoking, restrict alcohol, and reduce stress. Also, blacks were much more likely to report salt restriction and attempts to lose weight. Despite adherence to medication (which was similar for all three groups) and lifestyle modification, both blacks and Mexican Americans were 40 percent and 50 percent, respectively, more likely than whites to continue to suffer from uncontrolled hypertension.
Source: Natarajan, Santa Ana, Liao, et al., Ann Epidemiol 19:172-179, 2009 (AHRQ grant HS10871).
- Knowledge test validated for Korean Americans with hypertension.
Researchers developed the High Blood Pressure Knowledge Test and assessed its utility, reliability, and validity in a group of Korean Americans. Results showed that the test is sensitive to differences in blood pressure control status and should provide a reliable, standardized measure of high blood pressure with wide relevance.
Source: Han, Chan, Song, et al., J Clin Hypertension 13(10):750-757, 2011. See also Lee, Han, Song, et al., Int J Nurs Stud 47(4):411-417, 2010; Han, Kim, Kim, et al., Patient Educ Counsel 80:130-134, 2010; and Kim, Han, Song. et al., J Clin Hypertension 12(4):253-260, 2010 (AHRQ grant HS13160).
- Study finds low rates of racial/ethnic discrimination by health care providers caring for diabetes patients.
Discrimination has been suggested as one potential explanation for racial/ethnic disparities in health and health care. However, this study of 18,000 patients receiving care in a large group plan in northern California found that just 3 percent of members had reported discrimination from doctors or other providers, compared with 20 percent who reported such discrimination in everyday life. All racial/ethnic minority groups reported discrimination more frequently than whites, with blacks reporting general discrimination most frequently, and Filipinos reporting health care provider discrimination most often.
Source: Lyles, Karter, Young, et al., J Health Care Poor Underserved 22:211-225, 2011 (AHRQ grant HS13853).
- Diabetes testing is declining among poor, minority, and inner-city adults.
According to data presented in the 2010 National Healthcare Disparities Report, the proportion of poor adults aged 40 and older with diabetes that had their blood sugar, eyes, and feet examined at least once a year dropped from 39 percent to 23 percent between 2002 and 2007. Blacks experienced an 11 percent drop in testing, from 43 to 32 percent, while the proportion of Hispanics who had all three exams fell from 34 to 27 percent over the same period. The decline was smallest among whites at 4 percent (from 43 to 39 percent).
Source: Available at http://www.ahrq.gov/research/findings/nhqrdr/nhqrdr10/qrdr10.html (Intramural).
- Health information technology may be instrumental in decreasing disparities among people with diabetes.
This literature review included 18 articles published between 2006 and 2009 on the effectiveness of health care interventions using health information technology to improve diabetes process of care and intermediate diabetes outcomes in black and Hispanic patients in underresourced settings.
Source: Baig, Wilkes, Davis, et al., Med Care Res Rev 67(5 Suppl):163S-197S, 2010. See also Lu, Kotelchuck, Hogan, et al., Med Care Res Rev 67(5):1985-2305, 2010 (AHRQ contract P233200900421P).
- Few diabetes education programs serving American Indians and Alaska Natives meet national standards.
American Indians and Alaska Natives have diabetes rates that are two to three times as high as the general population, and they are four times as likely to die from the disease. Thus, diabetes education is particularly important for these individuals to help them learn to self-manage their disease. According to this study, few diabetes education programs funded by the Indian Health Service met national standards in 2001. Programs were assessed against three levels of care, and only 9 of 86 programs achieved level 2 recognition. Since that time, with increased funding toward staff and training, the number of recognized programs grew to 37 in 2009.
Source: Roubideaux, Noonan, Goldberg, et al., Am J Public Health 98(11):2079-2084, 2008 (AHRQ grant HS10854).
- Use of a uniform treatment algorithm eliminates racial disparities in blood sugar control.
According to this study, differences between blacks and whites in glycemic levels disappear in care settings where treatment is uniform, immediate care is facilitated, and medication is aggressively managed. Patients with type 2 diabetes (3,324 blacks, 218 whites) all made initial and 1-year followup visits; a subset of patients had an additional followup visit at 2 years. Patient adherence to treatment, number of visits, and provider behavior were similar for both groups. Initially, glycemic levels were higher in black patients than in white patients; at 1 year, the difference in glycemic levels had narrowed but remained significant. Among those who returned for a 2-year visit, (1,691 blacks, 114 whites), glycemic levels were no longer different.
Source: Rhee, Ziemer, Caudle, et al., Diabetes Educ 34(8):655-663, 2008 (AHRQ grant HS07922).
- Low-income city-dwelling adults with high blood pressure are reasonably knowledgeable about their condition.
This study of predominantly low-income black women with hypertension found that nearly two-thirds (65 percent) of them were fairly knowledgeable about their condition. Those with less knowledge tended to be at least 60 years of age, have less than a high school education, or be recently diagnosed with the condition. Individuals who were uncomfortable asking questions of their doctors also were less knowledgeable. Nearly one-fourth of the patients did not know that high blood pressure can cause kidney problems, despite the prevalence of kidney problems among blacks with hypertension. The study involved 296 adults being cared for at one urban clinic.
Source: Sanne, Muntner, Kawasaki, et al., Ethn Dis 18:42-47, 2008 (AHRQ grant HS11834).
- Underresourced clinics that treat medically complex patients may partly explain poor chronic disease outcomes among minorities.
Primary care clinics that serve minority patients have less access to medical resources, a chaotic work environment, and more medically challenging patients, compared with clinics that serve predominantly white patients, according to this study. The researchers compared data from 27 clinics with at least 30 percent minority patients with data from 69 clinics with less than 30 percent minority patients.
Source: Varkey, Manwell, Williams, et al., Arch Intern Med 169(3):243-250, 2009 (AHRQ grant HS11955).
- Low health literacy and cultural differences affect screening and management of chronic disease.
The researchers examined the impact of cultural differences and low health literacy on chronic disease outcomes and the use of preventive screening tests and found that many racial/ethnic groups lack an understanding of the idea of chronic disease. For example, the stigma associated with nonnormative sexual behavior may keep unmarried Latinas from seeking out Pap smears. The researchers call for programs to address cultural and linguistic barriers in primary care and prevention settings.
Source: Shaw, Huebner, Armin, et al., J Immigr Minor Health 11:460-467, 2009 (AHRQ grant HS14086). See also Schillinger, Hammer, Wang, et al., Health Educ Behav 35:664-682, 2008 (AHRQ grant HS14864).
- New program helps physicians teach patients how to correctly use asthma inhalers.
Asthma is a chronic illness that disproportionately affects minorities living in major urban areas. Critical to asthma self-management is patients' ability to use inhalers properly, but factors such as low patient health literacy and poor clinician knowledge of new inhalers and their use can make patient education difficult. The Chicago Breathe Project is an intervention designed to improve education for resident physicians on new inhalers and inhaler techniques and ways to assess their use during patient encounters. According to the researchers, the Chicago Breathe Project can be easily replicated in other urban areas to benefit minority communities affected by asthma.
Source: Press, Pincavage, Pappalardo, et al., J Natl Med Assoc 102(7):548-555, 2010 (AHRQ grant HS16967).
- More stress means worse asthma in inner-city adults.
This study found a direct link between an individual's level of stress and the severity of their asthma. Those who perceived higher stress levels were more likely to have increased asthma-related problems compared with those who reported lower stress levels. The study's findings are based on encounters with 326 inner-city residents with asthma; most were either black or Hispanic and of low socioeconomic status. They also had various conditions in addition to asthma, including hypertension (47 percent) and diabetes (25 percent).
Source: Wisnivesky, Lorenzo, Feldman, et al., J Asthma 47:100-104, 2010. See also Ponieman, Wisnivesky, Leventhal, et al., Ann Allergy Asthma Immunol 103:38-42, 2009; Wisnivesky, Kaltan, Evans, et al., Med Care 47(2):243-249, 2009; and Wisnivesky, Lorenzo, Lyn-Cook, et al., Ann Allergy Asthma Immunol 101:264-270, 2008 (AHRQ grant HS13312).
- Study finds racial/ethnic variation in parental perceptions of their children’s asthma.
Researchers interviewed parents of 739 children with persistent asthma in a Medicaid health plan in Massachusetts. Overall, 75 percent of parents believed their children could be symptom-free most of the time (75 percent Latino, 84 percent black, and 89 percent white). Also, 43 percent of Latino parents, 44 percent of black parents, and 55 percent of white parents said their children should have no emergency room visits or hospitalizations for asthma. Black (18 percent) and Latino (23 percent) parents were more likely than white parents (8 percent) to have competing family priorities “all of the time” or “most of the time” in addition to their child’s asthma, even after adjusting for income, education, insurance, and other factors.
Source: Wu, Smith, Bokhour, et al., Ambul Pediatr 8(2):89-97, 2008 (AHRQ grant T32 HS00063).
- Many patients with sickle cell disease self-discharge from the hospital.
This study found that many patients with sickle cell disease leave the hospital against medical advice, which can jeopardize their health. Those who were more distrustful of clinicians and those who reported difficulty in persuading medical staff about sickle cell pain were more likely to self-discharge from the hospital.
Source: Haywood, Lanzkron, Ratanawongsa, et al., J Hosp Med 5:289-294, 2010 (AHRQ grant HS13903). See also Tanabe, Porter, Creary, et al., J Natl Med Assoc 102(11):1033-1041, 2010 (AHRQ grant T32 HS00078); Sobota, Graham, Heeney, et al., Am J Hematol 85(1):24-28, 2010 (AHRQ grant T32 HS00063); and Brousseau, Owens, Mosso, et al., JAMA 303(13):1288-1294, 2010 (AHRQ Publication No. 10-R060)* (Intramural).
- Certain socioeconomic factors increase parental nonadherence to recommendations for managing sickle cell disease.
Infants with sickle cell disease are at greatly increased risk for pneumococcal infection. Treatment with penicillin has been shown to reduce the risk of infection by 64 percent, but this study found that 60 percent of Medicaid-enrolled infants with sickle cell disease did not receive an antibiotic prescription by the age of 12 weeks. Having one or more risk factors—being a single mother, maternal age younger than 20 years, maternal education less than 12 years, very low income, and urban residence—significantly increased nonadherence to recommended treatment.
Source: Warren, Arbogast, Dudley, et al., Arch Pediatr Adolesc Med 164(3):298-299, 2010 (AHRQ grant HS16974).
- Adult drug for sickle cell anemia may be safe for children.
This review of published studies found that the medication hydroxyurea—which is approved for use in adults with sickle cell disease to prevent sudden, painful episodes—may also be useful and safe when taken by children with the disease. A panel of experts found that hydroxyurea did not cause growth delay in children ages 5 to 15, but because the drug affects the reproductive system of male mice, it may have an adverse effect on sperm production after puberty.
Source: Strouse, Lanzkron, Beach, et al., Pediatrics 122(6):1332-1342, 2008 (AHRQ contract 290-02-0018).
- Formal and informal social support networks enhance management of HIV disease.
The advent of improved treatment for HIV infection has changed the nature of the disease from an acute illness to a chronic condition. This has increased the importance of HIV disease management, including regular medical appointments and consistent medication use. Through interviews with HIV-positive adults, this study found that formal support networks (professional support organizations) are critical for engagement in HIV-specific medical care, while informal networks (family, friends) are instrumental in emotional, household-related, and financial support.
Source: George, Garth, Wohl, et al., J Health Care Poor Underserved 20:1012-1032, 2009 (AHRQ grant HS14022).
- Treatment of hepatitis C virus infection is less likely for blacks and those coinfected with HIV.
This study compared treatment of 241 patients with hepatitis C virus (HCV) infection and 158 patients with HCV and HIV coinfection and found that HIV coinfection was an independent predictor of not receiving treatment for HCV. Blacks also were less likely than whites to receive treatment for HCV, most likely because of their reduced likelihood of achieving good treatment responses to HCV medications compared with whites.
Source: Butt, Tsevat, Leonard, et al., Int J Infect Dis 513:449-455, 2009 (AHRQ grant HS13220).
- Sociodemographic factors may predict early discontinuation of HIV therapy.
Antiretroviral therapy (ART) used to treat HIV infection can have severe and debilitating side effects (e.g., nausea, vomiting. diarrhea, dizziness, and intense dreams), yet long-term adherence is critical to halting disease progression. This study found that blacks and young people are more likely than others to stop taking their HIV medication early, and women are more likely than men to stop taking some ART drugs. These use patterns may be due to greater and more severe side effects related to genetic differences among blacks and/or greater susceptibility to drug side effects among women, according to the researchers.
Source: Asad, Hulgan, Raffanti, et al., J Natl Med Assoc 100(12):1417-1424, 2008 (AHRQ grant HS10384).