Jacqueline C. Wiltshire

Separate and Unequal: Clinics Where Minority and Nonminority Patients Receive Primary Care

BACKGROUND Few studies have examined the influence of physician workplace conditions on health care disparities. We compared 96 primary care clinics in New York, New York, and in the upper Midwest serving various proportions of minority patients to determine differences in workplace organizational characteristics. METHODS Cross-sectional data are from surveys of 96 clinic managers, 388 primary care physicians, and 1701 of their adult patients with hypertension, diabetes mellitus, or congestive heart failure participating in the Minimizing Error, Maximizing Outcome (MEMO) study. Data from 27 clinics with at least 30% minority patients were contrasted with data from 69 clinics with less than 30% minority patients. RESULTS Compared with clinics serving less than 30% minority patients, clinics serving at least 30% minority patients have less access to medical supplies (2.7 vs 3.4, P < .001), referral specialists (3.0 vs 3.5, P < .005) on a scale of 1 (none) to 4 (great), and examination rooms per physician (2.2 vs 2.7, P =.002) . Their patients are more frequently depressed (22.8% vs 12.1%), are more often covered by Medicaid (30.2% vs 11.4%), and report lower health literacy (3.7 vs 4.4) on a scale of 1 (low) to 5 (high) (P < .001 for all). Physicians from clinics serving higher proportions of minority populations perceive their patients as frequently speaking little or no English (27.1% vs 3.4%, P =.004), having more chronic pain (24.1% vs 12.9%, P < .001) and substance abuse problems (15.1% vs 10.1%, P =.005), and being more medically complex (53.1% vs 39.9%) and psychosocially complex (44.9% vs 28.2%) (P < .001 for both). In regression analyses, clinics with at least 30% minority patients are more likely to have chaotic work environments (odds ratio, 4.0; P =.003) and to have fewer physicians reporting high work control (0.2; P =.003) or high job satisfaction (0.4; P =.01). CONCLUSION Clinics serving higher proportions of minority patients have more challenging workplace and organizational characteristics.

African American men and women's attitude toward mental illness, perceptions of stigma, and preferred coping behaviors.

Background:Although research focused on African Americans with mental illness has been increasing, few researchers have addressed gender and age differences in beliefs, attitudes, and coping. Objective:The aim of this study was to examine African Americans’ beliefs about mental illness, attitudes toward seeking mental health services, and preferred coping behaviors and whether these variables differ by gender and age. Methods:An exploratory, cross-sectional survey design was used. Participants were 272 community-dwelling African Americans aged 25–72 years. Data analysis included descriptive statistics and general linear regression models. Results:Depression was the most common mental illness, and there were no gender differences in prevalence. Both men and women believed that they knew some of the symptoms and causal factors of mental illness. Their attitudes suggested they are not very open to acknowledging psychological problems, are very concerned about stigma associated with mental illness, and are somewhat open to seeking mental health services, but they prefer religious coping. Significant gender and age differences were evident in attitudes and preferred coping. Discussion:Our findings have implications for gender- and age-specific psychoeducation interventions and future research. For instance, psychoeducation or community awareness programs designed to increase openness to psychological problems and reduce stigma are needed. Also, exploration of partnerships between faith-based organizations and mental health services could be helpful to African Americans.

Trust, Medication Adherence, and Hypertension Control in Southern African American Men

We examined the relationship between trust in the medical system, medication adherence, and hypertension control in Southern African American men. The sample included 235 African American men aged 18 years and older with hypertension. African American men with higher general trust in the medical system were more likely to report better medication adherence (odds ratio [OR] = 1.06), and those with higher self-efficacy were more likely to report better medication adherence and hypertension control (OR = 1.08 and OR = 1.06, respectively).

Disentangling the influence of socioeconomic status on differences between African American and White women in unmet medical needs.

OBJECTIVES We sought to disentangle the relationships between race/ethnicity, socioeconomic status (SES), and unmet medical care needs. METHODS Data from the 2003-2004 Community Tracking Study Household Survey were used to examine associations between unmet medical needs and SES among African American and White women. RESULTS No significant racial/ethnic differences in unmet medical needs (24.8% of Whites, 25.9% of African Americans; P = .59) were detected in bivariate analyses. However, among women with 12 years of education or less, African Americans were less likely than were Whites to report unmet needs (odds ratio [OR] = 0.57; 95% confidence interval [CI] = 0.42, 0.79). Relative to African American women with 12 years of education or less, the odds of unmet needs were 1.69 (95% CI = 1.24, 2.31) and 2.18 (95% CI = 1.25, 3.82) among African American women with 13 to 15 years of education and 16 years of education or more, respectively. In contrast, the relationship between educational level and unmet needs was nonsignificant among White women. CONCLUSIONS Among African American women, the failure to recognize unmet medical needs is related to educational attainment and may be an important driver of health disparities, representing a fruitful area for future interventions.

The Effects of Socioeconomic Status on Participation in Care Among Middle-Aged and Older Adults

Objective: This study assesses the effects of socioeconomic status (education and poverty) on seeking health information and subsequent use of this information during the medical encounter. Method: Data on 19,944 adults (aged 45 and older) were drawn from the 2000-2001 Household Component of the Community Tracking Study, a nationally representative survey of non-institutionalized individuals. Results: Higher levels of education were associated with a greater likelihood of seeking health information and mentioning information to physicians. The poor and near poor were less likely to seek health information, but only the near poor were significantly less likely to mention information to the physician. Discussion: These findings underscore the importance of education in the acquisition and use of health information among middle-aged and older adults.

Gender differences in financial hardships of medical debt.

Women are more likely than men to forgo, delay, and ration medical care because of medical debt. Using 2003–04 Community Tracking Study Household Survey data, this study examined gender differences in five financial hardships associated with medical debt. Regression analyses accounting for predisposing, enabling, and need factors of health services use indicated women were less likely to report being contacted by a collection agency (b=−0.15, p<.05), using savings (b=−0.23, p<.005), or having any financial hardships associated with medical debt (b=−0.24, p<.05). There were no significant gender differences in putting off major purchases, borrowing money, and problems paying for necessities. Similarly, there were positive and negative relationships between medical debt financial hardships and income, insurance, and health status. Findings suggest that making health care affordable and equitable is critically important for both men and women. Research is needed to understand the differential impact of medical debt, especially among disadvantaged populations.

Medical Debt and Related Financial Consequences Among Older African American and White Adults

OBJECTIVES To evaluate African American-White differences in medical debt among older adults and the extent to which economic and health factors explained these. METHODS We used nationally representative data from the 2007 and 2010 US Health Tracking Household Survey (n = 5838) and computed population-based estimates of medical debt attributable to economic and health factors with adjustment for age, gender, marital status, and education. RESULTS African Americans had 2.6 times higher odds of medical debt (odds ratio = 2.62; 95% confidence interval = 1.85, 3.72) than did Whites. Health status explained 22.8% of the observed disparity, and income and insurance explained 19.4%. These factors combined explained 42.4% of the observed disparity. In addition, African Americans were more likely to be contacted by a collection agency and to borrow money because of medical debt, whereas Whites were more likely to use savings. CONCLUSIONS African Americans incur substantial medical debt compared with Whites, and more than 40% of this is mediated by health status, income, and insurance disparities. Public health implications. In Medicare, low-income beneficiaries, especially low-income African Americans with poor health status, should be protected from the unintended financial consequences of cost-reduction strategies.

How Do African American Men Rate Their Health Care? An Analysis of the Consumer Assessment of Health Plans 2003-2006

African American (AA) men remain one of the most disconnected groups from health care. This study examines the association between AA men’s rating of health care and rating of their personal physician. The sample included 12,074 AA men aged 18 years or older from the 2003 to 2006 waves of the Consumer Assessment of Healthcare Providers and Systems Adult Commercial Health Plan Survey. Multilevel models were used to obtain adjusted means rating of health care systems and personal physician, and the relationship of ratings with the rating of personal physician. The adjusted means were 80 (on a 100-point scale) for most health ratings and composite health care scores: personal physician (83.9), specialist (83.66), health care (82.34), getting needed care (89.57), physician communication (83.17), medical staff courtesy (86.58), and customer service helpfulness (88.37). Physician communication was the strongest predictor for physician rating. AA men’s health is understudied, and additional research is warranted to improve how they interface with the health care system.

African American women perceptions of physician trustworthiness: A factorial survey analysis of physician race, gender and age

Background/Objective Physical concordance between physicians and patients is advocated as a solution to improve trust and health outcomes for racial/ethnic minorities, but the empirical evidence is mixed. We assessed womens perceptions of physician trustworthiness based on physician physical characteristics and context of medical visit. Methods A factorial survey design was used in which a community-based sample of 313 African American (AA) women aged 45+ years responded to vignettes of contrived medical visits (routine versus serious medical concern visit) where the physicians race/ethnicity, gender, and age were randomly manipulated. Eight physician profiles were generated. General linear mixed modeling was used to assess separately and as an index, trust items of fidelity, honesty, competence, confidentiality, and global trust. Trust scores were based on a scale of 1 to 5, with higher scores indicating higher trust. Mean scores and effect sizes (ES) were used to assess magnitude of trust ratings. Results No significant differences were observed on the index of trust by physician profile characteristics or by medical visit context. However, the white-older-male was rated higher than the AA-older-female on fidelity (4.23 vs. 4.02; ES = 0.215, 95% CI: 0.001–0.431), competence (4.23 vs. 3.95; ES = 0.278, 95% CI: 0.062–0.494) and honesty (4.39 vs. 4.19, ES = 0.215, 95% CI: 0.001–0.431). The AA-older male was rated higher than the AA-older-female on competence (4.20 vs. 3.95; ES = 0.243, 95% CI: 0.022–0.464) and honesty (4.44 vs. 4.19; ES = 0.243, 95% CI: 0.022–0.464). The AA-young male was rated higher than AA-older-female on competence (4.16 vs. 3.95; ES = 0.205, 95% CI: 0.013–0.423). Conclusions Concordance may hold no salience for some groups of older AA women with regards to perceived trustworthiness of a physician. Policies and programs that promote diversity in the healthcare workforce in order to reduce racial/ethnic disparities should emphasize cultural competency training for all physicians, which is important in understanding patients and to improving health outcomes.

Disparities in Confidence to Manage Chronic Diseases in Men

Background Chronic diseases are highly prevalent among men in the United States and chronic disease management is problematic for men, particularly for racial and ethnic minority men. Objectives This study examined the association between health information seeking and confidence to manage chronic diseases among men. Methods Study data were drawn from the 2007 Health Tracking Household Survey and analyzed using multiple binary logistic regressions. The analytical sample included 2,653 men, 18 years and older with a chronic illness. Results: Health information seeking was not associated with confidence to manage chronic illnesses. African-American men had lower odds than White men to agree to take actions to prevent symptoms with their health. Hispanic men had lower odds than White men to agree to tell a doctor concerns they have, even when not asked. Conclusions Racial and ethnic minority men with a chronic condition appear to be less confident to manage their health compared to white men. Chronic disease management needs greater exploration to understand the best ways to help racial and ethnic minority men successfully manage their chronic condition.