Epidemiologic evidence makes clear that the likelihood of exposure to environmental contaminants increases in most poor and underserved communities. Despite progress in reducing a number of environmental risk factors for disease, serious environmental problems persist, and those remaining problems are highly complex. Their solution requires meaningful community engagement as well as a diverse environmental health workforce. Demographic data, and related social and economic developments, strongly indicate that such a workforce must include underrepresented minorities. While the problem has not been solved, select programs have made impressive contributions to meeting this need, an example of which is described in this paper.
While reducing racial/ethnic and socioeconomic disparities in cancer mortality has been identified as a national goal, current policies are unlikely to achieve it. In order to advance the development of policies for the primary prevention of cancer and cancer disparities, we propose that the practices of the tobacco, alcohol, and food industries be considered as modifiable social determinants of health. We review evidence that the practices of these industries in product design, marketing, retail distribution, and pricing contribute to cancer risk behavior, incidence, and disparities, then examine public health strategies designed to reduce health-damaging practices of these industries and encourage healthier alternatives. We conclude with recommendations for research, practice, and policy that could contribute to the development of less carcinogenic corporate practices.
No studies have evaluated the quality of anticoagulation control among populations characterized by low socioeconomic status, diverse racial and ethnic backgrounds, or limited English proficiency. We conducted a retrospective cohort study to evaluate the effects of race/ethnicity and language on anticoagulation outcomes among patients (N=864) receiving continuous anticoagulation services at a university-affiliated public hospital. White/non-Hispanic patients made up 24%, Asian/Pacific Islanders 33%, Hispanics 22%, African Americans 18%. English (63%), Spanish, (14%), and Cantonese (13%) were the most common languages. Mean time in therapeutic range (TTR) was 43%. After adjustment, TTR was lower for African Americans than for Whites (absolute difference, 28.7%, p,.001) and for Spanish-speaking than for English-speaking Hispanics (absolute difference, 27.2%, p,.05). There were no differences between Asian/Pacific Islanders and Whites, nor between Cantonese-speaking and English-speaking Asian/Pacific Islanders. Future research should examine mechanisms by which race/ethnicity and language affect quality of anticoagulation and evaluate programs to improve treatment in diverse communities.
Low-income and minority women are less likely to be screened for breast and cervical cancer and less likely than others to be diagnosed at an early stage in the cancer's growth. We consulted women and providers to understand how social, economic, and health care environments affect screening among African American, Amish, Appalachian, and Latina women, and to outline possible solutions. Women participated in 31 focus groups. Providers completed a mail survey (n=168) and follow-up interviews (n=12). We identified barriers women face: not always following recommendations; feeling intimidated during appointments; having incorrect information about risks, screening guidelines, and programs; and receiving information in ways they cannot understand or accept. Women indicated a strong desire for accurate information and, like the providers, identified strategies for reducing barriers to screening. In the terms of a social ecological model, our results point to three avenues along which to approach cultural competence: 1) policy, 2) health care provision, and 3) clinical care.
Smoking is a major risk factor for many chronic diseases. Nearly all studies collecting smoking data use self-reports, which are very rarely validated. We identified 15,182 adults 18 years or older in the Third National Health and Nutrition Examination Survey. Denying smoking, the main outcome, was defined as cotinine-determined smokers self-reporting non-smoking. Multiple logistic regression modeling took into account the complex survey design and sample weights. Age and race/ethnicity-gender categories predicted denying smoking. Smokers denying smoking ranged from 0.0% for elderly (75 years and older) Mexican-American women to 67.8% for elderly non-Hispanic Black women. Among elderly smokers, non-Hispanic Black women were more likely to deny smoking than both non-Hispanic White women (odds ratio (OR) 5 8.9, 95% confidence interval (CI): 2.1–38.3) and non-Hispanic Black men (OR521.4 95% CI: 4.3–107.2). This U.S. population-based study of age-specific race/ethnicity-gender predictors of denying smoking suggests caution in interpreting smoking-related survey data.
Little is known about barriers to care experienced by Latino children with chronic kidney disease (CKD). We conducted a qualitative study with children with CKD and their families to elucidate conceptions about disease process, expression, and treatment; perceived access to care barriers; and potential for treatment non-adherence. Semi-structured interviews were conducted with 42 individuals from 28 family units treated for CKD in San Diego, California. Transcripts were analyzed by coding consensus, co-occurrence, and comparison. Latino patients cited pre-diagnosis barriers in accessing primary and subspecialty care not mentioned by non-Latino Whites. Whites described a pro-active style of interacting with the health care system not mentioned by Latinos. There were no differences apparent in reports of medication adherence, but both groups emphasized the importance of extended social networks in adhering to treatment regimens. Families' perspectives provide valuable information that can serve future studies and interventions for improving care for children with CKD.
Background. Medicare implemented reimbursement for screening mammography in 1991. Main Findings. Post-implementation, breast cancer mortality declined faster (p=.0001) among White than among Black elderly women (65+ years). No excess breast cancer deaths occurred among Black elderly compared with White elderly through 1990; over 2,459 have occurred since. Contextual socioeconomic status does not explain differences between counties with lowest Black breast cancer mortality/post-implementation declines in disparity and counties with highest Black breast cancer mortality/widened disparity post-implementation. Conclusions. The results lead to these hypotheses: (a) Medicare mammography reimbursement was causally associated with declines in elderly mortality and widened elderly Black:White disparity from breast cancer; (b) the latter reflects inherent Black-White differences in risk of breast cancer death; place-specific, unaddressed inequalities in capacity to use Medicare benefits; and/or other factors; (c) previous observations linking poverty with disparities in breast cancer mortality are partly confounded by factors explained by theories of human capability and diffusion of innovation.
Although population-based studies report lower rates of cancer screening among racial/ethnic minorities than among Whites in the U.S., few studies have examined predictors of screening among low-income Hispanic, Black, and Chinese primary care patients. We examined utilization of mammography, Pap smear, digital rectal examination, fecal occult blood testing, sigmoidoscopy/colonoscopy, and prostate-specific antigen testing in 833 patients from 2 community health centers in New York City, ascertaining relationships between use of screening and race/ethnicity, income, education, years in the U.S., insurance, cancer risk perception, family disease history, and physician recommendation. Despite similar access to primary care, Hispanics and Blacks reported higher utilization rates of all screening tests than Chinese (p=.01). Physician recommendation and more years in the U.S. were associated with greater use of all screening services (p=.001), with physician recommendation most strongly associated with screening. Interventions to enhance screening by at-risk groups should emphasize both physician recommendation and culturally-sensitive patient education.
We investigated whether self-reported racial/ethnic and gender discrimination were associated with lower rates of diabetes management. Analyses focused on 524 respondents with diabetes from the 2001 Commonwealth Health Care Quality Survey. Probit models estimated the marginal effect of self-reported racial/ethnic and gender discrimination on diabetes management, adjusting for racial/ethnic and gender concordance of the patient and physician, as well as a variety of health and sociodemographic indicators. Self-reported racial/ethnic discrimination was associated with a roughly 50% lower marginal probability of receiving a hemoglobin A1c test, foot exam, and blood pressure exam, when accounting for racial/ethnic and gender physician-patient concordance and other factors. Self-reported gender discrimination was associated with 22% lower marginal probability of conducting a hemoglobin test but not associated with the other management indicators. Evidence from this study suggests that racial/ethnic discrimination is an important barrier to diabetes management.
Objective. To determine the compliance rate for treatment recommendations consistent with expectant management of inner-city men with prostate cancer. Methods. Twenty-seven out of 560 men who underwent biopsy of the prostate were found to harbor cancer and opted for expectant management. Clinic and hospital records were reviewed for adherence to follow-up schema. Results. Of the 27 men on expectant management, 22 men (82%) adhered to strict follow-up schema. At 6-month follow-up, there were no significant changes in clinicopathologic features (e.g., prostate specific antigen (PSA), Gleason score, and stage). With a median follow-up of 12 months, only 2 men demonstrated a rise of more than 30% from baseline PSA (repeat biopsy demonstrated persistent low grade, low stage disease). Conclusions. Our findings imply that expectant management may be feasible in inner-city settings. Thus, in subsequent expectant management trials, inner-city men should be actively recruited.
Purpose. To report the reach of Take Charge Lite (TCL), a lifestyle weight management program. Methods. Eight months of data were used to determine prescription reach (number of patients receiving a TCL prescription divided by total eligible), visit reach (number of patients with a TCL visit divided by total receiving a prescription), and total reach (number of patients with a TCL visit divided by total eligible). Results. TCL prescription reach was 42.3% (1,071 prescriptions/2,528 eligible). There were 411 TCL first visits for an average visit reach of 38% (411/1,071). Total reach for the full period was 16% (411/2,528). Total reach was highest among female, middle-aged, and Black patients. Conclusion. There is potential for public health impact from such efforts but issues of reach require further planning and evaluation.
Background. Obesity and diabetes are epidemic in the predominantly minority Harlem community. To address them, a coalition of community and academic leaders tested the effectiveness of a peer-led weight loss course. Methods. The coalition developed Project HEAL: Healthy Eating, Active Lifestyles through extensive collaboration with community members and experts in nutrition, exercise, and peer education. We piloted the course in a local church and assessed its impact through pre and post course weights, self-reported behaviors and quality of life. Results. Twenty-six overweight and obese African American adults lost a mean of 4.4 pounds at 10 weeks, 8.4 pounds at 22 weeks, and 9.8 pounds at 1 year. Participants reported decreased fat consumption and sedentary hours, and improved health related quality of life. Conclusions. A peer-led, community-based course can lead to weight loss and behavior change. The minority communities most affected by obesity and diabetes may benefit from this low-cost, culturally appropriate intervention.
The roles religious and health promoting behaviors may play in bolstering positive physical and emotional health were assessed using structured, face-to-face interviews conducted using a non-random community sample of 105 adult African American, Protestant Christians in a small city in a rural state in the Midwest. The interview measured health promotion, health locus of control beliefs, emotional health, physical health, religious practices, and demographics. Health promotion, church attendance, or both were related to decreased prevalence of loneliness, depression, trouble sleeping, and family problems. More than 80% of those interviewed ascribed healing power to God and prayer. There was an apparent lack of connection between respondents' attitudes about faith and healing and their actual experiences.
Objectives. To evaluate longitudinal changes in disease-specific health-related quality of life (HRQOL) among a cohort of low-income men treated for prostate cancer. Methods. Three hundred fifty-seven participants in a state-funded program that provides free prostate cancer treatment to uninsured, low-income men completed written surveys and telephone interviews containing validated measures of general and disease-specific HRQOL. Assessments were made at study enrollment and at subsequent times. Determinants of change were identified with repeated-measures analyses. Results. We found a significant interaction between the acute surgical treatment effects and time of assessment. Men exposed longer to the program's supportive and educational interventions reported less severe declines in post-operative urinary and bowel HRQOL than others. Conclusions. Demographic covariates predicted general and disease-specific domains of HRQOL. Among patients treated with surgery, longer duration of pre-treatment program enrollment was associated with better outcomes.
Objectives. To assess the effectiveness of breast health promoting messages administered by salon stylists to clients in the salon setting. Methods. Forty salons in an urban, minority area were randomly assigned to provide messages to clients or to serve as controls. Pre-intervention surveys were completed by 1,185 salon clients. Following program initiation, assessments of 1,210 clients were conducted. Results. Among women completing surveys at control salons, 10% reported exposure to breast health messages, as opposed to 37% at experimental salons (OR 5.4, 95% CI 3.7–7.9). Self-reported exposure to stylist-delivered messages was associated with improved breast self-examination rates (OR 1.6, 95% CI 1.2–2.1) and with greater intentions to have a clinical breast examination (OR 1.9, 95% CI 1.1–3.3). Conclusion. Hair salons are a potentially important venue for promotion of health behaviors related to breast cancer detection.
Asthma is the most common chronic illness among children in the United States. Poverty and asthma are tightly related, with poor children having higher rates of asthma than non-poor children. To document how poor parents with asthmatic children cope with health care-related barriers on a day-to-day basis, the author conducted 38 in-depth interviews with central city Phoenix (Arizona) parents. Barriers facing parents include a lack of health insurance and/or personal transportation, the expense of using private insurance, treatment delays, and language/communication. Instances of parents overcoming barriers are highlighted and offered as opportunities for designing capacity building interventions and policies that build on parents' strengths.
This study examines racial/ethnic disparities in children's mental health and the receipt of mental health services, and whether those disparities differ between urban and rural areas. We find no significant difference between racial/ethnic groups in the prevalence of child mental health problems in either urban or rural areas. However, there are disparities in the use of mental health services. Hispanic children and Black children in urban areas receive less mental health care than their White counterparts, and the disparity persists for Hispanic children in rural areas, even after controlling for other relevant factors. Initiatives to improve access to mental health care for racial/ethnic minorities should recognize these disparities, and address the lack of culturally appropriate services in both urban and rural areas. In addition, outreach should raise awareness among parents, teachers, and other community members concerning the need for mental health services for minority children.
In this pilot study for evaluating equity in services at a hospital in rural Haiti, we investigated whether topography, walking time to dispensary, and presence of a mobile clinic were related to disparities in prenatal care utilization, using quantitative hospital record data on 100 women pregnant in 2002. We also assessed whether additional factors contributed to prenatal care disparities using qualitative key informant interviews with local health agents in Haiti.
In logistic regression analyses, we found that walking time to the dispensary was associated with disparities in prenatal care utilization (p=.039). Health agent responses demonstrated lack of acknowledgment of disparities and attribution of underutilization to women undervaluing educational messages. Reducing disparities in prenatal care utilization will require attention to walking time to a point of care, though attitudes and experiential factors should not be overlooked. Similar multi-method approaches should be explored in future studies of health inequities in other communities.
The Prenatal Risk Overview (PRO) was designed to screen for 13 psychosocial risk factors associated with poor birth outcomes. This study describes the development and implementation of the PRO in 4 community health centers. The study also examines the prevalence, co-occurrence, and inter-correlations of psychosocial risks in their prenatal populations. The study sample included 1,386 prenatal patients screened between November 2005 and April 2007; 95% were women of color; 77% were not married. The PRO classified 48% at moderate or high risk for housing instability; 32% for food insecurity; 75% for lack of social support; 7% for intimate partner violence; 9% for other physical/sexual abuse; 18% for depression; 23% for cigarette use, 23% for alcohol use, and 25% for drug use. Systematically assessing and quantifying psychosocial risks are essential activities for evaluating the extent to which appropriate and timely responses to identified risks reduce infant mortality, preterm births, and low birth weights.
African American adolescents are a vulnerable population, overrepresented in the juvenile justice system and underserved by mental health providers. Consequently, a disproportionate number of African American youth in the juvenile justice system have diagnosable mental health problems. This study investigates whether, among African American adolescents, the effects of attitude towards deviance, self-efficacy, and exposure to delinquent peers on antisocial behavior are moderated by anxiety sensitivity. A sample of 238 African American adolescents ages 13–19 from 3 public housing developments participated in this study. Results indicated that 40% of the adolescents reported no involvement in antisocial behaviors. Gender, anxiety sensitivity, and attitudes towards deviance were significant correlates of antisocial behavior. Interaction effects indicate that the relative impact of attitudes towards deviance and exposure to delinquent peers on antisocial behaviors is contingent upon adolescents' level of anxiety sensitivity. Implications for practice and future research are discussed.
This qualitative study explored perceptions and experiences of HIV-positive rural African American women regarding availability, accessibility, and quality of health care and social services. Twenty-two women residing in rural areas of South Carolina were recruited to participate in one of three focus groups. A conceptual model of health services utilization was used to guide the study and served as a framework for coding data. Verbatim transcripts of group discussions were analyzed using content analysis to code and identify data categories. Data revealed common perceptions of lack of services and inferior quality of available services to meet some of their most important needs. Overall, findings provide a picture of women whom the health care/social services system fails to serve. The findings have significant implications for increasing resources and designing interventions that empower these women and enhance their quality of life.
Objective. Budgetary pressures have led some states to limit Medicaid eligibility. We evaluated access to care for all low-income adults by the extent of state Medicaid coverage. Methods. Current Population Survey data compiled by the Kaiser Commission on Medicaid and the Uninsured were used to rank the 48 continental states by the extent of Medicaid coverage for low-income non-elderly adults during 2000–2003. Data from the Behavioral Risk Factor Surveillance System for 2000–2003 were used to assess indicators of access to care, including being unable to see a physician due to cost, not obtaining routine checkups, and four preventive services for appropriate age groups by state. Access gaps were calculated between low-income (under $25,000/year) and high-income ($50,000 or more/year) adults within each state to control for unmeasured economic and health system differences between states. Results. Access gaps between high and low-income people who could not see physicians due to cost were significantly smaller in states with the broadest Medicaid coverage compared with states with the narrowest coverage (19.2% vs. 23.7%, p=.003). Significantly smaller access gaps also occurred in states with broader Medicaid coverage for cholesterol testing (16.0% vs. 18.7%, p=.01), and Pap testing (6.0% vs. 10.8%, p=.002), but not colorectal cancer screening (13.3% vs. 12.5%, p=.28), mammography (14.3% vs. 19.7%, p=.07), and routine checkup within two years (8.0% vs. 9.3%, p=.10). Conclusions. A state's level of Medicaid coverage was associated with access to physicians' services, cholesterol testing, and cervical cancer screening for low-income adults. Broad Medicaid coverage may be an effective strategy for states to improve access to care and preventive services for low-income adults.