Causes of Health Disparities

Income and educational attainment on average are lower for ethnic/racial minority groups.

• Whites lead both African Americans and Hispanics in educational attainment at the high school and college level.
• The percentage of African Americans and Hispanics earning a bachelor's degree or more is about half that of Whites.⁸

A link between poverty, low educational attainment and poorer health outcomes with increased morbidity and mortality is well established. Heart disease, diabetes, obesity, elevated blood lead level, and low birth weight are more prevalent among individuals with low income and low educational attainment.

Additionally, higher socioeconomic groups have recently achieved greater improvements in health status than lower socioeconomic groups.⁷

Federal initiatives have acknowledged the importance of the relationship of socioeconomic inequalities to health.

Healthy People 2000 noted income disparities in health status and acknowledged that eliminating the disparities would require more than enhancing access to medical care including education, job training and social services.⁹

While 26% of Whites and 29% of Asians are considered low-income (below 200% of poverty), the rate is 49% for Blacks, 54% for Native Americans, and 61% for Hispanics. At the state level, poverty rates for Blacks and Hispanics vary widely.¹

More than three times as many Black and Hispanic adolescents live in poverty than White adolescents.

Poverty rates vary greatly among various subgroups of Hispanic children. Puerto Rican children (43.5%) are most likely to live in poverty, followed by Mexican American (35.4%), Central and South American (26.6%), and Cuban (16.4%).⁴

Culture

Culture plays an important role in determining health related beliefs and practices.

Effective health care delivery requires the application of knowledge of cultural health related beliefs, practices and health risks.

For example, individuals from specific cultures may require screening for diseases that are more prevalent in that culture, react differently to a medication, or use traditional healing practices. Health care delivery organizations are legally required to respond to the language and cultural needs of their service area by becoming "linguistically and culturally competent."

Cultural competence is defined as "a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or amongst professionals and enables that system, agency, or those professionals to work effectively in cross-cultural situations."¹⁰

Thus, cultural competence goes beyond awareness and sensitivity by requiring that health care providers apply an understanding and respect for different cultures when working with clients from cultures different from their own. Culturally competent health providers could help reduce disparities.¹⁰

Techniques that health care agencies could use to become more culturally competent include¹⁰

• Interpreter services
• Recruitment and retention of minority staff
• Training programs to increase cultural awareness, knowledge, and skills, leading to changes in staff behavior and patient-staff interactions
• Coordination with traditional healers
• Use of community health workers
• Including family and/or community members
• Immersion in another culture
• Administrative and organizational accommodations

African American Culture and Health

In a study of African American health attitudes, beliefs, and behaviors, 30% believed that their health was dependent upon fate or destiny and only about 50% felt health was a high priority in their life. Participants in this study also stated that they believed health talks and other health information were helpful in preventing disease.¹¹

In another study, caregivers of obese or super-obese children do not always believe the child's weight is a potential health problem. Reasons for lack of concern include a culturally based greater acceptance of a large body size, lack of knowledge about the connection between childhood obesity and future health risk, and feeling invulnerable.¹²

Hispanic Culture and Health

Some common cultural-based Hispanic health beliefs and practices include:

• Placing little value on early detection and preventative health care
• Lack of knowledge of the benefits of early detection and prevention
• Infrequent medical visits and delayed treatment when symptoms occur
• Fatalisimo, a cultural norm that combines negative expectations with a relinquishment of power to God
• A need for confianza (trust) and personalismo (personalized caring) in medical interactions¹³

Access to and Utilization of Health Care

Several different factors both nonfinancial and financial impact minority children's access to and utilization of health care services.^13,4

Inequalities in use of preventive and primary care services have been documented with respect to vision screening, prescription medicines, equipment for the management of asthma, and access to and use of mental health services,⁴ The result places these children at risk for inadequate preventive care, more lost school days and health problems as adults.⁴

Nonfinancial utilization factors may include:

• Caregivers are unaware of services
• Caregivers feel uncomfortable with providers
• Health provider attitudes
• Unavailability of translators
• Long waiting times
• Inconvenient location ^11,4

Health Insurance

Minorities are far less likely than Whites to have private coverage and far more likely to be uninsured. In 1996 nonelderly minorities made up 25% of the population and 40% of the uninsured.¹³

When racial and ethnic minorities had insurance, they were more likely to be covered by public rather than private insurance. Hispanics were most likely to be uninsured (35.4%), followed by American Indians (27.3%), Blacks (25.6%) and Asians (21.2%).¹⁴

Health insurance coverage has declined over the past decade due to fewer employers offering health insurance and increasing health premiums. ^13,14

Minorities face more difficulties obtaining health insurance coverage, especially through employers, than White Americans. Minorities also are less likely to accept offers of health insurance from their employers. Public insurance does not close the insurance gap between minorities and White Americans.¹⁵

Individuals with low income and educational attainment are less likely to have health insurance. Individuals with low education were less likely to enroll in a health insurance program even if eligible.

Hispanic children are more likely than any other racial/ethnic group to be uninsured, with the Mexican American subgroup most likely to be uninsured.^4,14,16

Contributing factors include parents working in economic sectors that lack employment linked health benefits and multiple and persistent barriers experienced by Latinos in accessing health care.

The older the Latino child, the more likely he or she is to have no medical contact compared to his or her African American and non-Hispanic White peers.⁴

• African American children are most likely to be covered by Medicaid.
• Children under six years of age are more likely to be covered than children age 6-17 years

Other factors impacting health insurance coverage are:

• Parental education: Children of parents with a higher level of education are most likely to privately insured and least likely to be uninsured.
• Employment of parents: children living with two employed parents are most likely to be privately insured and least likely to be uninsured.
• Residence: Children living in metropolitan statistical areas are more likely to privately insured and least likely to be uninsured.¹⁶

Federal regulations require that states provide health care coverage for:

• children through age 5 in families who live with incomes below 133% of the federal poverty level
• children ages 6-13 in families with incomes at or below the federal poverty level
• children ages 14-18 only if they would have been eligible under the Aid to Families with Dependent children program rules

Many states have expanded health care coverage beyond the federal requirements.

In 1995 10 million children under age 18, or 13.8% of children, were uninsured. This led to the Balanced Budget Act of 1997, creating the State Children's Health Insurance Program to extend health insurance coverage for children in families with incomes below 200% of the federal poverty level.¹⁷

However, public health insurance coverage has not reduced disparities in health insurance coverage due to race/ethnicity, income, and area of residence. Furthermore, public coverage competes with other state spending priorities such as education and social services which also impact health.¹⁴

Utilization of Preventive Care

Many minority or disadvantaged children are not receiving recommended well child care. African American and Hispanic Infants were 70% less likely than White infants to receive complete well child care during the first six months of life according to results of the 1988 National Maternal and Infant Health Survey and its 1991 provider follow-up.¹⁸

Controlling for socioeconomic status did not decrease the difference. Poor maternal education and low income added to the risk of incomplete well child care despite availability of Medicaid.¹⁸

Lack of a usual source of care decreases continuity and may adversely affect health outcomes. White children are more likely to have a usual source of care and more likely to have an office based source of care than Black or Hispanic children.

Additionally, for Hispanic children, limited knowledge of English can make it difficult for parents to find a provider with whom they can clearly and comfortably communicate and who understands their knowledge and beliefs about health care.

The children least likely to have a usual source of health are

• Hispanic or Black youth
• Teenagers living with parents who have less than a high school education
• Live in the South (10.5%) and West (12.4%) rather than the Northeast (5.8%) and Midwest (4.9%)¹⁶

Racial and ethnic disparities are still present after adjusting for differences in health insurance, income, and other individual characteristics. Equalizing the income and health insurance status of African Americans and Hispanics to that of whites eliminates 33% to 45% of the disparities in usual source of care and use of ambulatory care.¹⁹

Children lack a usual source of health care for a variety of reasons:

Children with a usual source of health care often face other barriers to receiving needed health care

Access to Dental Care

Millions of children have little to smile about. For them the daily reality is persistent dental pain, endurance of dental abscesses, inability to eat comfortably or chew well, embarrassment at discolored and damaged teeth, and distraction from play and learning.²⁰

Extent of the Problem

• Four to five million children experience untreated dental disease sufficiently extensive and severe enough to cause chronic dental pain.
• Nearly 1 in 5 preschoolers have experienced some visually evident tooth decay increasing to more than 50% by middle childhood and 80% by late adolescence
• Once dental caries have been established, future decay is likely, as the process stabilizes within the oral cavity
• Certain children are more vulnerable; In permanent teeth, 80% of all cavities occur in 25% of children.
• Decayed teeth in youth from lower-income households are more likely to remain untreated at all ages.^21,22

Substantial disparities in the prevalence, severity, and consequence of oral health problems exist among American youth. Children from low income families, who are a racial or ethnic minority, and whose parents have limited education experience higher caries rates.²²

• Preschoolers living in poverty have twice the odds of having decayed teeth, twice the extent of decay when they have disease, and twice the pain experience of their more affluent peers.

Additionally, they are half as likely to have a dental visit. This occurs despite the fact that low income children are eligible for comprehensive dental coverage through Medicaid.²²

• Poor adolescents were less likely to have had a dental visit in the past year than near-poor and non-poor adolescents (64% vs. 80%)²³
• Low-income adolescents, particularly those living near poverty are less likely to have dental insurance (51%) than adolescents with higher family incomes (65%) or those living below the poverty level (60%)²³
• 2-4 times as many Black and Mexican American children and adolescents and Asian/Pacific Islander children have untreated dental caries as white children and adolescents⁷
• 20% fewer nonwhite children had a dental visit in 1996 compared to White children²²

Reasons for Disparities:

Practitioner Supply

The supply of dentists available to treat young children is inadequate and decreasing; There are only 3500 pediatric dentists nationwide

Inadequate numbers of dentists treat Medicaid eligible children (only 10% of dentists participate nationwide). Most dental care is provided in practices with only 1 to 2 dentists who have limited ability to offset low Medicaid fees or costs of missed appointments

Public Health Infrastructure

The number and distribution of providers participating in programs to reach underserved children is inadequate to meet the need. Only 58% of federally qualified health center grantees provide dental services. Thus, nearly half of the 4 million children who obtain their routine health care in community health care centers have no access to dental care in their health center. ^22,23

Water fluoridation is the most cost effective measure for preventing caries, yet only 62% of community water supplies are fluoridated.²²

Insurance Coverage

Insurance coverage can facilitate provision of care. Children who have no dental coverage are three-fold more likely to have an unmet dental need than are children with dental coverage. ²³

Inadequate reimbursement rates that often do not cover costs

Burdensome provider and administrative barriers to enrollment, procedure prior-authorization and claims filing requirements

Behavioral and cultural disjunctions between dentists and patients'knowledge and expectations that are expressed as missed appointments or lack of compliance

Transportation

Language barriers ^22,23

Racism

Racism provides another reason for the health disparities of minorities. In fact, negative stereotypes of minority racial/ethnic groups are common.

According to national data 45% of Whites believe that most Blacks are lazy, 51% that most Blacks are prone to violence, 29% that most Blacks are not intelligent, and 56% that Blacks prefer to live off welfare.

Whites also are reluctant to acknowledge positive stereotypes of Blacks.

Only 17% of Whites indicated that most Blacks are hard-working, 15% that most Blacks are not prone to violence, 21% that most Blacks are intelligent and 12% that most Blacks prefer to be self-supporting.

Whites possess negative views of all minority racial groups, with Blacks being viewed more negatively than any other group.²⁴

Racism provides one explanation for the low socioeconomic attainment of minorities. Minorities live in areas of concentrated poverty with poor schools that limit educational and employment opportunities. High paying low skill jobs have followed WhiteÕs migration from cities to suburbs resulting in higher rates of job losses for African Americans. In addition, impoverished segregated communities contain many barriers that impact employment and socioeconomic status.²⁴

Individuals who perceive themselves experiencing racism are more likely to suffer psychological distress, depressive symptoms, substance use, and physical health problems.²⁴

The high rates of hypertension among African Americans may be explained in part by exposure to chronic stressors such as perceived racism.²⁵ Dark-skinned Blacks have significantly higher rates of hypertension than their lighter-skinned counterparts and are ¹¹ times more likely to experience frequent racial discrimination when compared to their light-skinned counterparts.²⁶ African American youth exhibit greater cardiovascular reactivity to various stressors compared with Whites.²⁷ This effect was buffered by family socioeconomic status.²⁸

Conclusion

In summary, the problem of racial disparities is complex and no one causative factor or magic bullet to resolve the problem can be identified.

Reducing racial disparities will require addressing nonfinancial barriers to accessing health care such as the cultural and linguistic competency of health providers and institutions, the lack of health care providers where minority groups reside, both intentional and unintentional discrimination within the health care system, and perception of discrimination on the part of members of various racial and ethnic groups.¹⁹