Journal of Health Care for the Poor and Underserved

Journal of Health Care for the Poor and Underserved
Volume 15, Number 4, November 2004


ACU Column 15.4 (November 2004)

Guest Editorial

    Walker, Bailus.
    Mays, Vickie M.
    Warren, Rueben C.
  • The Changing Landscape for the Elimination of Racial/Ethnic Health Status Disparities
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    Subject Headings:
    • Minorities -- Health and hygiene -- United States.
    • Medical care -- United States.
      The elimination of racial/ethnic health status disparities is a compelling national health objective. It was etched in sharp relief by the 1985 report of the U.S. Department of Health and Human Services Secretary's Task Force on Black and Minority Health and considerable attention has been devoted to the problem since that report. But the problem persists, disparities are not fully explained and effective policies to reduce them have been elusive, a situation presenting both opportunities and challenges. Important advances towards reducing racial/ethnic health disparities may be made by better understanding the complex bidirectional relationship between and among the multiple factors, biological and non-biological, influencing morbidity and mortality. The landscape in which these influences are felt is anything but static. In this paper selected components of the landscape that are critical to the elimination of racial/ethnic health status disparities are reviewed. These factors underscore the importance of adopting and maintaining a perspective on health disparities that encompasses a broad array of health determinants.
      Disparities, racial groups, ethnic groups, minority groups, environment, globalization, socioeconomic status, health literacy, health status.

Bried Communications

    Goepp, Julius G.
    Chin, Nancy P.
    Massad, John.
    Edwards, Lori A.
  • Pediatric Emergency Department Outreach: Solving Medical Problems or Revealing Community Solutions?
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    Subject Headings:
    • Pediatric emergencies -- United States.
    • Primary care (Medicine) -- United States.
    • Health education -- United States.
      Low-acuity (LA) use of emergency departments (EDs) is often viewed as misuse or abuse. We designed a program to help users access services more efficiently. Community health workers (CHWs) functioned as health educators, screeners, and liaisons to care. A participatory curriculum emphasized medical problems. Qualitative ethnographic methods were used for formative evaluation. Ninety families received regular visits from CHWs. Original system-oriented objectives and methods did not fit community needs. Instead, information was gathered regarding service utilization patterns: (1) families mistrusted primary and preventive care, reporting frequent discrimination and humiliation; (2) a primarily biomedical prioritization did not match families' need hierarchies; (3) complex demands of poverty made other uses of the system challenging; (4) primary care services were frequently avoided; and (5) the ED was often preferred. Intangible psychosocial factors and practical complexities of poverty were powerful promoters of LA visits. Families were creative strategists, viewing LA visits as rational use, not misuse, of a challenging system.
      emergency department, primary care, mistrust, access to care, barriers to care, discrimination, health decision making.
    Robbins, Jessica M.
    Webb, David A.
  • Neighborhood Poverty, Mortality Rates, and Excess Deaths Among African Americans: Philadelphia 1999-2001
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    Subject Headings:
    • African Americans -- Pennsylvania -- Philadelphia -- Mortality.
    • Poverty -- Social aspects -- Pennsylvania -- Philadelphia.
    • African Americans -- Pennsylvania -- Philadelphia -- Social conditions.
    • African Americans -- Pennsylvania -- Philadelphia -- Economic conditions.
      We usedvital statistics and census data to determine whether mortality rates in Philadelphia were associated with neighborhood poverty, and to what extent excess mortality among African Americans was associated with neighborhood poverty.Gender-specific, age-adjusted mortality rates for 1999-2001 were strongly associated with neighborhood poverty among both women and men overall, and among both African Americans and non-Hispanic whites. The actual number of deaths among African Americans was 5,305 higher than it would have been if African Americans had had the same gender- and age-specific mortality rates as the average for non-Hispanic whites in Philadelphia, and 1,944 higher than if African Americans had had the same gender- and age-specific rates as non-Hispanic whites in the same neighborhood poverty categories. The excess mortality associated with neighborhood poverty and the socioeconomic factors that force large numbers of African Americans into poverty and high-poverty neighborhoods appear to be major factors in excess mortality among African Americans.
      African Americans, ethnic groups, mortality, Philadelphia, poverty, poverty areas, residence characteristics, socioeconomic factors.
    Soller, Marie.
    Osterberg, Lars.
  • Missed Opportunities for Patient Education and Social Worker Consultation at The Arbor Free Clinic
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    Subject Headings:
    • Patient education -- California -- San Mateo.
    • Medical social work -- California -- San Mateo.
    • Stanford University. Arbor Free Clinic.
      We conducted a cross-sectional survey of 210 patients who came to a free medical clinic for health care over an 8-month period. We (1) measured their satisfaction with care, (2) determined the frequency of missed opportunities for providing health education and social work consultation, and (3) assessed whether patient-specific factors drive the frequency of these missed opportunities. Of the 210 patients surveyed, a total of 168 (80.0%) completed the entire survey. The mean satisfaction rating was high (4.6 on a scale of 1 to 5). A significant number of missed opportunities occurred, with only 28% of patients receiving patient education material, and 32% of patients visiting the social worker. No particular patient groups emerged as most susceptible to these missed opportunities. This study shows both the high degree of patient satisfaction at this free clinic and the many opportunities for improving patient education and social services. Adding health education and social work consultation to the patient encounter could improve the health of these patients.
      patient education, social work, free clinics, survey, satisfaction, social services.

Original Papers

    Reed, Susan C.
    Davis, Nancy.
  • Jane Dent Home: The Rise and Fall of Homes for the Aged in Low-Income Communities
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    Subject Headings:
    • Old age homes -- Illinois -- Chicago -- History.
    • Older people -- Long-term care -- Illinois -- Chicago -- History.
    • Elderly poor -- Medical care -- Illinois -- Chicago -- History.
      The Jane Dent Home was established in 1898 (as the Home for Aged and Infirm Colored People) to serve African American elderly barred from admission to most homes for the aged. Sustained by community leadership through difficult times, the Home finally closed in 1975 after growing and persistent racial and economic segregation of Chicago's low-income neighborhoods combined with pressure from state government to ensure fire safety. This history illustrates the decline of not-for-profit homes for the aged while for-profit nursing homes were capturing market share. In Chicago this trend is strongest in low-income communities of color, which may lead to lower quality of care for such communities. Support for indigenous not-for-profit long-term care may promote the goals of health care equity articulated by Healthy People 2010.
      Medicaid, long-term care, poverty areas, residential facilities, disabled persons.
    Vargas, Roberto B.
    Davis, Roger B.
    McCarthy, Ellen P.
    Li, Donglin.
    Iezzoni, Lisa I.
  • Racial and Ethnic Differences in Utilization of Health Services in Patients with Diabetes Enrolled in Medicaid
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    Subject Headings:
    • Medical care -- Utilization -- United States -- States.
    • Diabetics -- Medical care -- United States -- States.
    • Minorities -- Medical care -- United States -- States.
    • Medicaid.
      We evaluated racial and ethnic differences in use of medical care between patients with diabetes enrolled in Medicaid and explored whether differences varied by state Medicaid program. Using data from 137,006 patients we created a multivariable Poisson regression model to examine the effect of race on ambulatory care visits, emergency ward visits, and hospitalization rates for patients with diabetes mellitus enrolled in three state Medicaid programs. We found significant differences in service use between groups, which varied depending on state. For example, black patients compared with whites had significantly fewer outpatient visits but more hospitalizations in New Jersey; by contrast, blacks had higher outpatient visit rates and lower hospitalization rates in Georgia. Racial and ethnic differences in health service use among Medicaid enrollees were not consistent across states, suggesting that local factors, including varied Medicaid policies, may affect racial and ethnic differences in use of health care services.
      Diabetes, health service utilization, Medicaid, race, ethnic groups, ambulatory care, emergency service, hospitalization, disparities, geographic variation.
    Coronado, Gloria D.
    Thompson, Beti.
    Tejeda, Silvia.
    Godina, Ruby.
  • Attitudes and Beliefs Among Mexican Americans About Type 2 Diabetes
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    Subject Headings:
    • Mexican Americans -- Attitudes.
    • Non-insulin-dependent diabetes -- United States.
      Hispanics in the United States have a disproportionately high risk for non-insulin-dependent diabetes mellitus (type 2 diabetes) compared with non-Hispanic whites. Little is known of the attitudes and beliefs about diabetes in this group. Using data from six focus groups of 42 Mexican Americans (14 men and 28 women), we characterized perceptions about the causes of and treatments for type 2 diabetes. Many participants believed diabetes is caused by having a family history of the disease, eating a diet high in fat or sugar, and engaging in minimal exercise. Experiencing strong emotions such as fright (susto), intense anger (coraje), or sadness and depression (tristeza) was also thought to precipitate diabetes. Nearly all participants expressed the belief that it is important to follow doctors' recommendations for diet and exercise, oral medication or insulin; many also cited herbal therapies, such as prickly pear cactus (nopal) and aloe vera (savila) as effective treatments. These findings may be useful in designing interventions to reduce the burden of diabetes in Hispanic populations.
      diabetes mellitus, Hispanics, Mexican Americans, susto, coraje, tristeza, natural remedies, herbal treatments, health beliefs.
    Erwin, Katherine.
    Blumenthal, Daniel S.
    Chapel, Thomas.
    Richardson, Liana.
    Allwood, L. Vernon.
  • Building an Academic-Community Partnership for Increasing Representation of Minorities in the Health Professions
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    Subject Headings:
    • Universities and colleges -- Curricula -- United States.
    • Community organization -- United States.
    • Medicine -- Study and teaching -- United States.
    • Minorities in medicine -- United States.
      We evaluated collaboration among academic and community partners in a program to recruit African American youth into the health professions. Six institutions of higher education, an urban school system, two community organizations, and two private enterprises became partners to create a health career pipeline for this population. The pipeline consisted of 14 subprograms designed to enrich academic science curricula, stimulate the interest of students in health careers, and facilitate entry into professional schools and other graduate-level educational programs. Subprogram directors completed questionnaires regarding a sense of common mission/vision and coordination/collaboration three times during the 3-year project.

      The partners strongly shared a common mission and vision throughout the duration of the program, although there was some weakening in the last phase. Subprogram directors initially viewed coordination/collaboration as weak, but by midway through the project period viewed it as stronger. Feared loss of autonomy was foremost among several factors that threatened collaboration among the partners. Collaboration was improved largely through a process of building trust among the partners.

      Health occupations, leadership, cooperative behavior, community networks.
    Mott Keis, Rachel.
    Gifford DeGeus, Linda.
    Cashman, Suzanne B.
    Savageau, Judith.
  • Characteristics of Patients at Three Free Clinics
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    Subject Headings:
    • Medically uninsured persons -- Massachusetts.
    • Health services accessibility -- Massachusetts.
      This study examined factors associated with the use of three free clinics located in Central Massachusetts. A total of 248 patients completed a questionnaire during the 2-month study period. Descriptive results showed a majority of free clinic patients are low-income, uninsured, and female. Many patients (62%) do not have a usual source of care, nor do they know where to go if the clinic is not open (61%). Most (82%) report using free clinics because they lack insurance. Patients who had been using the free clinics longer than 1 year are more likely to use the clinic because of inadequate insurance (p = 0.002) and as a way to obtain prescription drugs (p < 0.001). Although they serve an important need, free clinics cannot provide comprehensive, continuous care. Efforts to provide health care to the medically underserved must take these findings into consideration if they are to be successful.
      Free clinic, medically indigent, underserved health care, health service utilization, low-income, uninsured.
    Lu, Ning.
    Samuels, Michael E.
    Wilson, Richard.
  • Socioeconomic Differences in Health: How Much Do Health Behaviors and Health Insurance Coverage Account For?
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    Subject Headings:
    • Health behavior -- Social aspects -- United States.
    • Health behavior -- Economic aspects -- United States.
    • Insurance, Health -- United States.
      As evidence accumulates that both unhealthy behaviors and inadequate access to health care are responsible in part for poor health, there is a tendency to attribute the differences in health status between the poor and the affluent to the higher prevalence of unhealthy behaviors and inadequate access to health care among people of low socioeconomic status (SES). The purpose of this study is to determine quantitatively how much health behaviors and health insurance coverage account for the SES disparity in health. The study employed secondary analysis of data collected through the Kentucky Behavioral Risk Factor Surveillance System for 2000. After adjusting for health behaviors and health insurance coverage, the differences in health among different levels of SES (measured by education and income) remained strong and significant. Health behaviors and health insurance coverage accounted for 10-16% of the socioeconomic differences in health.
      health disparity, health behaviors, health insurance, socioeconomic status, health status.
    Horowitz, Carol R.
    Tuzzio, Leah.
    Rojas, Mary, 1940-
    Monteith, Sharifa A.
    Sisk, Jane E.
  • How do Urban African Americans and Latinos View the Influence of Diet on Hypertension?
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    Subject Headings:
    • African Americans -- Attitudes.
    • Hispanic Americans -- Attitudes.
    • Hypertension -- Diet therapy -- United States.
      Uncontrolled hypertension and its complications continue to be major health problems that disproportionately affect poor minority communities. Although dietary modification is an effective treatment for hypertension, it is not clear how hypertensive minority patients view diet as part of their treatment, and what barriers affect their abilities to eat healthy diets. We conducted nine focus groups with 88 African American and Latino patients treated for hypertension to assess their knowledge, attitudes, behaviors, and beliefs concerning hypertension. Participants generally agreed that certain foods and food additives play an important role in the cause and treatment of hypertension. However, they found clinician-recommended diets difficult to follow in the context of their family lives, social situations, and cultures. These diets were often considered expensive, an unwelcome departure from traditional and preferred diets, socially isolating, and not effective enough to obviate the need for medications. These findings suggest the importance of culturally sensitive approaches to dietary improvements.
      diet, hypertension, focus groups, African American, black, Latino, Hispanic, culture, knowledge, beliefs.
    Lower Mississippi Delta Nutrition Intervention Research Consortium.
  • Self-Reported Health of Residents of the Mississippi Delta
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    Subject Headings:
    • Public health -- Mississippi -- Delta (Region)
    • Public health -- Louisiana -- Mississippi River Delta.
    • Public health -- Arkansas -- Arkansas Delta.
    • Health surveys -- Mississippi -- Delta (Region)
    • Health surveys -- Louisiana -- Mississippi River Delta.
    • Health surveys -- Arkansas -- Arkansas Delta.
      The rural Lower Mississippi Delta of Arkansas, Louisiana, and Mississippi has a large economically and socially disadvantaged population at high risk for health problems. Their health status is poorly understood as they are not well represented in national health surveys. A random-digit-dialing telephone survey was conducted in 2000, with 2,236 respondents representing residents of 36 counties along the Mississippi River. Self-reported chronic conditions, health status, and obesity (derived from weight and height) were compared with the nationally representative Continuing Survey of Food Intake of Individuals. High cholesterol, diabetes, and hypertension were significantly higher than in the national sample. Obesity was strikingly higher in Delta children (27.9% versus 16.2%) of all ages and in Delta adults (33.9% versus 17.3%). Controlling for age, income, and gender, African Americans were at particular risk for obesity, hypertension, and diabetes. A public health crisis appears to exist in the Delta given the high prevalence health problems.
      Key words: diabetes, Mississippi.
    Vassilev, Zdravko P.
    Strauss, Shiela M.
    Astone, Janetta M.
    Friedmann, Peter D.
    Des Jarlais, Don, 1945-
  • Provision of On-Site Medical Care to Patients With Hepatitis C in Drug Treatment Units
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    Subject Headings:
    • Hepatitis C -- Patients -- Medical care -- United States.
    • Hepatitis C -- Chemotherapy -- United States.
      Substance abusers are at high risk for hepatitis C (HCV) infection and also constitute a group that is medically underserved and hard to reach. We conducted a nationwide survey with 445 randomly selected drug treatment units in the United States to determine unit and patient characteristics associated with the provision of on-site medical services for HCV-infected drug users. Eighty-four percent of the 322 units that estimated having at least one HCV-infected patient reported that they provided patients with HCV-related medical care. Drug treatment units were more likely to provide at least some of this care on site if they were residential, part of a network, or affiliated with a hospital; had medical staff; and required that their patients undergo a medical examination before entering treatment. Some organizational factors appear to influence the provision of on-site medical services to HCV-positive patients in drug treatment units. Further research on the role of such factors could inform the development of effective models of care for patients with hepatitis C in drug treatment organizations.
      hepatitis C, medical care, drug abuse treatment, drug users.
    Mullins, C. Daniel.
    Cohen, Leonard A.
    Magder, Laurence S.
    Manski, R. (Richard)
  • Medicaid Coverage and Utilization of Adult Dental Services
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    Subject Headings:
    • Medicaid -- Maryland.
    • Dental care -- Utilization -- Maryland.
      This study evaluated the economic impact of a policy change in adult Maryland Medicaid dental benefits that eliminated reimbursements to dentists. We examined all claims for 2 years before and after the change. Reimbursements to dentists fell to zero from their preenactment period annual rate of $7.6 million; other care settings simultaneously generated an additional $232,470 savings during the postenactment period. Medicaid's goal to reduce costs was achieved; however, disadvantaged patients may have been confused by the policy change and likely suffered poorer health outcomes and paid for treatment out of pocket, found free clinics, or received free care from generous dentists.
      Medicaid, economics, policy, dental.
    Legg, Jeffrey S.
    Clement, Dolores G.
    White, Kenneth R.
  • Are Women With Self-Reported Cognitive Limitations at Risk for Underutilization of Mammography?
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    Subject Headings:
    • Breast -- Radiography -- United States.
    • Preventive health services -- Utilization -- United States.
    • Women with mental disabilities -- Medical care -- United States.
      Functional limitations (namely, limitations in activities of daily living and instrumental activities of daily living) have previously been demonstrated to exert a negative influence on mammography utilization. This study examines self-reported cognitive limitation in addition to sociodemographic, functional, and other health-related factors to determine their relationship with self-reported mammography use in the previous year. Data from the 1998 National Health Interview Survey was analyzed for 6,053 women, ages 50 years and older. Just over 44% of women with self-reported cognitive impairment (n = 351) reported a mammogram in the previous year, compared with 55% of unimpaired women (n = 5,702). Logistic regression analysis indicates that the presence of a cognitive limitation significantly reduced the likelihood of a mammography in the previous year (p < 0.05) after controlling for other sociodemographic, functional, and health-related factors. Women with self-reported cognitive limitations were 30% less likely than unimpaired women to utilize mammography after controlling for various forms of disability and other factors. Thus, women with cognitive impairments may be at risk for underutilization of mammography and therefore at risk for later-stage breast cancer diagnoses.
      mammography, breast cancer, disability, cognitive impairment, preventive care.


    Epps, Anna Cherrie.
  • Affirmative Action in Medicine (Improving Health Care for Everyone) (review)
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    Subject Headings:
    • Curtis, James L., 1922- Affirmative action in medicine (improving health care for everyone)
    • Social medicine.
    Christensen, Richard C.
  • Adapting Your Practice: General Recommendations for the Care of Homeless Patients (review)
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    Subject Headings:
    • Bonin, Edward. Adapting your practice: general recommendations for the care of homeless patients.
    • Homeless persons -- Medical care.
    Lehmann, Susan P.
  • A Shelter Is Not a Home... Or Is It? Lessons from Family Homelessness in New York City (review)
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    Subject Headings:
    • DaCosta Nunez, Ralph. Shelter is not a home... or is it? lessons from family homelessness in New York City.
    • Shelters for the homeless -- New York (State) -- New York.

Recently Received

List of Reviewers 2003-2004

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