Health Disparities Among Under-served Populations: Implications for Research, Policy and Praxis: Volume 9

Health Disparities Among Under-served Populations: Implications for Research, Policy and Praxis is a volume widely anticipated, focusing on a topic of national concern. Moreover, it is a volume that is entirely fitting for the series Advances in Education in Diverse Communities: Research, Policy and Praxis. In this series, education is not limited to the formal institutional processes of schooling, but education is defined as a way of knowing and learning, as a means to become better informed about the profound challenges affecting humankind. Because of our aging populations, there are few social welfare issues more daunting than health care, not only in the United States, but globally as well. For those who are fortunate, America affords some of the best health care in the world. For those less fortunate, the corrosive impact of race, class, and gender, that is the combined social stratification effects on health and illness, are often insurmountable. From a humane perspective, the issue of caring for the sick and infirmed should be a part of any advanced nation's social welfare safety net. Health Disparities Among Under-served Populations: Implications for Research, Policy and Praxis illustrates compellingly and literally the status of health and health care of African Americans, Latinos, and American Indians, with particular focus on children and adolescents. In so doing, this volume boldly paints a vivid portrait of diverse communities who are “down and out,” as they strive to cope in the midst of unimaginable circumstances. Do read this gripping, yet illuminating volume and become informed. Then, I challenge you to act, to overcome the dire social, political, and economic consequences of ignoring the welfare and basic provisions of health care for those less fortunate in our society.

The interventions in section one (e.g., public policy initiatives, community-based intervention programs) discuss ways to reduce or alleviate health disparities among ethnic populations and provide careful descriptions of factors that increased or decreased the success of these interventions (e.g., barriers, resiliency, protective factors, and cultural competence).

Purpose – The purpose of this chapter is to provide a comprehensive overview of the substance use disparities among American Indian/Alaska Native (AI/AN) youth, the contributing factors to these disparities, proven and promising approaches through strengths-based methods, barriers to implementation of prevention and treatment efforts, and future recommendations for effective programs and research.

Approach – We have conducted a thorough literature review of relevant research studies, as well as a review of government, tribal, and community-based curricula and resources. This review of programs is not exhaustive but provides several examples of best practices in the field and suggestions for future directions.

Social implications – We strongly advocate that to accurately explore the true etiology of substance abuse and to respond to the concerns that AI/AN have prioritized, it is necessary to utilize a strengths-based approach and draw upon traditional AI/AN perspectives and values, and active community participation in the process. More specifically, prevention and treatment programs should use methods that incorporate elders or intergenerational approaches; foster individual and family skills-building; promote traditional healing methods to recognize and treat historical, cultural, and intergenerational and personal trauma; focus on early intervention; and tailor efforts to each Native nation or community.

Value – Ultimately, to reduce substance abuse disparities in AI/AN youth, we must find better ways to merge traditional Native practices with western behavioral health to ensure cultural competency, as well as to develop mechanisms to effect system- and policy-level changes that reduce barriers to care and promote the well-being of AI/AN youth, families, and communities.

Purpose – To synthesize the literature on coping among adolescents of color in the U.S., we examine normative and circumstantial stressors, describe coping strategies, and summarize the literature on coping for the promotion of well-being among adolescents of color, including descriptive and intervention studies.

Methods/approach – We conducted an extensive review of the literature in four scientific databases (medline, CINAHL, ERIC, and PyschInfo) between July 2010 and June 2011 (key words: (minority) adolescent(s) (of color), cope/coping, stress (ors), and adaptation/psychological). Studies included in our review were peer-reviewed articles published between 2000 and June 2011 that presented original data on the coping strategies and outcomes of adolescents of color (e.g., studies including a majority from underrepresented racial/ethnic communities) between the ages of 12 and 18.

Findings – We identified a total of 91 articles for inclusion, including 83 descriptive and 8 intervention studies. We use a matrix approach to compare descriptive studies by their purpose, study design, sample, targeted stressors, and outcomes. We then discuss the eight interventions we identified, highlighting the targeted population, intervention protocol/adaptation, feasibility/acceptability, and study outcomes.

Implications – The breadth and depth of research on coping among adolescents of color has improved significantly over the past decade, yet our review reveals several areas where further exploration is needed, including research on intra-group differences, validation of coping measures in diverse groups, measurement of the effectiveness of coping strategies over time, and most importantly, the translation of available knowledge on effective coping into culturally relevant, multifaceted interventions for adolescents and their families.

Purpose – This chapter discusses the promise of and challenges to providing effective and culturally responsive trauma-focused mental health services to immigrant and refugee youth and their families within school settings.

Design/methodology/approach – This chapter utilizes “practice-based evidence” to outline successes and address the barriers associated with the implementation of school-based, trauma-focused, evidence-based interventions in four immigrant or refugee-dense cities: Los Angeles, Chicago, Minneapolis, and Boston.

Findings – Making cultural adaptations to identified trauma interventions that were consistent with community priorities, cultural norms, and values resulted in more accessible programs and greater engagement in treatment services.

Practical implications – The strategies tested in these real-world settings contribute to the development of culturally competent trauma-informed services for immigrant and refugee youth and their families. Mental health providers and program developers will better understand the need for multilevel engagement strategies and for culturally driven modifications when employing evidence-based programs with immigrant and refugee youth.

Originality/value – This chapter adds to the scarce evidence about useful methods to engage immigrant and refugee youth and families in treatment and to increase the likelihood of positive outcomes.

Purpose – This chapter discusses health disparities among African Americans living in urban spaces within the United States.

Approach – This chapter provides an overview of health disparities in morbidity and mortality related to maternal and child health (maternal mortality rate, infant mortality, and low birth weight).

Practical implications – This chapter describes research and interventions that strive to increase our ability to understand and reduce health disparities. Eliminating health disparities not only is beneficial to these affected groups but also offers the opportunity to improve the health of the entire U.S. population.

Originality/value – This chapter adds to our understanding of the correlates of health disparities for African American women and children as well as successful interventions that have proven effective in ameliorating these disparities.

Purpose – To provide an overview of racial/ethnic disparities in human papillomavirus (HPV) infection, HPV vaccination, and cervical cancer on domestic and international levels.

Design/methodology/approach – The literature, cervical cancer prevention guidelines, and Centers for Disease Control and Prevention resources were culled to aggregate information on epidemiology, racial/ethnic disparities, and knowledge and attitudes related to HPV, HPV vaccination, and cervical cancer. Original data supplement information about HPV and HPV vaccination knowledge and attitudes.

Findings – Cervical cancer is among the leading causes of female death worldwide, with substantial racial/ethnic and geographic disparities. In the United States, African American and Hispanic women suffer disproportionate cervical cancer incidence and mortality compared to their Caucasian counterparts. Globally, the greatest burden of cervical cancer (and HPV infection) is shouldered by developing regions. Prevention efforts, such as HPV vaccination and adaption of screening programs to resource-poor areas, have the potential to reduce such disparities, but cultural context is critical to successful development and implementation of such interventions.

Research limitations/implications – As this is not a systematic review, but rather a viewpoint on issues related to disparities in cervical cancer, the literature review is not exhaustive.

Practical implications – This chapter provides a context for examining cervical cancer disparities domestically and globally and serves as a starting point for formulating future research.

Originality – This perspective on HPV and cervical cancer presents disparities both within the United States and worldwide. The chapter supplements the literature with new data that provide additional insight into knowledge and attitudes about these health issues.

Purpose – We designed a community-based participatory research project to investigate a perceived cluster of lupus in a historically contaminated African-American neighborhood. The purpose of the Buffalo Lupus Project was to investigate the high prevalence of lupus in the East Buffalo area and whether cases of disease were linked to chemicals found at a nearby New York State Superfund site.

Methods – The project's research activities consisted of a registry to assess the city-wide prevalence of lupus and other autoimmune diseases and a survey to investigate common environmental factors. Lupus prevalence in the area of concern corresponded to seven times greater risk of the disease compared with the general population. The majority of survey participants were African-American women. Almost all survey participants reported some type of potentially harmful residential exposure.

Results – The Buffalo Lupus Project identified an excessive number of people with lupus and other autoimmune diseases residing in an area plagued with multiple sources of toxic waste exposure.

Social implications – As shown by this project, engaging the community in research and involving the community members in actions to improve their neighborhood can positively impact environmental quality. This study also played a leadership role in advocating for site cleanup and continuing legislation to support lead screening.

Purpose – This chapter describes the “Teen Alliance for Prepared Parenting–SPIN” (TAPP-SPIN) unwanted pregnancy prevention intervention for pregnant/parenting adolescents and their adult parent(s) in primarily African American and Latino communities in the District of Columbia (DC).

Methodology/approach – We augment TAPP services with SPIN Video Home Training (VHT)11Called Video Interaction Guidance in the United Kingdom., an intervention to build Parent–Child Connectedness (PCC). SPIN VHT aims to (1) improve adult–teen interaction to strengthen the supports teen parents need to continue to progress toward life success and (2) build the teen's ability to engage in warm, attuned, and skillful parenting of her child.

SPIN VHT uses a guided, strengths-based analysis of videotaped parent–child interactions to identify examples of the parent's competencies that support the child's well-being and optimal development. Collaborative review of an edited collection of video helps guide participants to integrate what has been effective into their daily patterns of interaction and communication.

Findings – The randomized experiment compares TAPP to TAPP-SPIN with a sample of 400 15- to 18-year-olds and their parents (dyads). After a baseline survey, we collect follow-up data at 6, 12, 18, and 24 months post-baseline. We collect outcome data on health information-seeking, pregnancy prevention communication, cognitions related to parenting and subsequent pregnancy, improved parenting, and clinical outcomes including subsequent pregnancy.

Social implications – The TAPP-SPIN intervention aims to advance the state of pregnancy prevention research in a population facing multiple health disparities.

Originality/value of chapter – This chapter describes the first ever randomized controlled trial of the SPIN approach to improving PCC.

Purpose – This chapter discusses a study that examined outcomes between homeless sexual minority youths and their heterosexual counterparts regarding family, peer behaviors, school, mental health (suicide risk and depression), stigma, discrimination, substance use, and sexual risk behaviors.

Methodology – Structured interviews were conducted with individuals ages 16–24 at three drop-in programs serving homeless youths in downtown Toronto (N=147).

Findings – Bivariate analyses indicate statistically significant differences between homeless sexual minorities (n=66) and their heterosexual counterparts (n=81) regarding all parameters except school engagement, including family communication, peer behaviors, stigma, discrimination, mental health, substance use, and sexual risk behaviors. Specifically, homeless sexual minority youths fared more poorly than their heterosexual counterparts.

Implications – Improving family communication may be a worthwhile intervention for the youths who are still in contact with their families. Future research should focus on victimization in the context of multiple systems.

Purpose – To examine and critique the research on HIV/AIDS health disparities among Black Americans.

Methodology – A selective investigation of quantitative research on HIV/AIDS health disparities from the 1980s to the present. Prevalence and incidence of HIV/AIDS in Black American communities and research targeting individual-level behaviors and their outcomes are presented. The impact of racialized discourses related to Black sexuality and its impact on research are discussed. Future policy and practice directions are offered.

Findings – This chapter notes the preponderance of studies at the individual level even in the face of null findings.

Research limitations/implications – This work is not an exhaustive examination of all the studies on HIV racial health disparity.

Practical implications – This chapter contributes to the literature that redirects HIV/AIDS research from focus on individual behaviors in the face of a population-level epidemic.

Social implications – This chapter demonstrates how research goals may be diverted by unacknowledged racialized assumptions.

Originality/value of chapter – This study is one of the few critiques of HIV/AIDS research on Black Americans.

Purpose – For many African American college students, the pursuit of a college education has both rewards and risks. Oftentimes, African American students are faced with the decision to leave the comforts of their home communities in order to realize the American dream through the mechanism of higher education. The majority attend predominately White institutions (PWIs) where successful negotiation of this process not only has academic consequences, but psychological and cultural consequences as well. This chapter examines the psychological and phenomenological experience of African American students at PWIs of higher education.

Design/methodology/approach – The present day manifestation of historical and sociopolitical foundations of exclusion, racism, and discrimination in higher education are explored. There is a focus on how these latter themes relate to “campus culture” and institutions, with implications for psychological coping and educational success. Conclusions also focus on ways to begin to bring about change in this culture.

Findings – The successful negotiation of the collegiate environment, ultimately leading to the awarding of one's degree requires more than just passing classes; matriculation and retention in college also involves engaging one's social and cultural environment as well, particularly outside of the classroom.

Originality/value – As discussions of multiculturalism and inclusiveness in higher education find themselves anchored to abstract and theoretical conceptualization, or linked to an approach which focuses on “numbers” and “percentages” among student bodies, both of these approaches provide little indication that we are ultimately talking about the lived experiences of real people.

Purpose – This chapter will explore the link between health disparities and cultural competence and demonstrate the importance of helping providers to understand how their personal biases can result in care that is inequitable and unsafe.

Methodology/approach – This chapter provides a literature review as well as case studies to illustrate the association between culture competence and health disparities.

Findings – Research has shown that racial and ethnic minorities experience more negative health outcomes as compared to Caucasians. Many of these health disparities are associated with communication difficulties created by language, cultural barriers, and low health literacy. These barriers often result in ethnic and racial minority patients having longer hospital stays for common medical and surgical conditions and more adverse events with greater consequences than Caucasians; moreover, minorities are more likely to be readmitted to the hospital after discharge.

Practical implications – Empowering health care providers with skills and techniques in cultural competence can reduce health disparities. Intentionally using cultural competence as an intervention to address health disparities can lead to more effective, patient-centered care, with improved health care outcomes.

Originality/value – This chapter will provide practical knowledge to help health care providers deliver culturally competent and patient-centered care.

Purpose – The purposes of this chapter are to describe both the within-group and between-group variance in Black Americans’ (Blacks’) prevalence of mental illness. This chapter also comments on the impact that poorer mental health has on this group's subsequent social mobility and explores recommendations for the reduction of these inequities.

Methodology/approach – This chapter reviews Black's history in America. It also outlines the influence of this history and related factors on Black Americans' current rates of illness and subsequently vulnerable upward mobility.

Research implications – The history of Blacks in America is tumultuous and has contributed to their vulnerable state. Blacks, on average, are poorer and sicker than Whites, and Blacks’ higher rates of illness are due to a number of factors. As a result, Blacks’ social mobility is precarious. Future research should continue to explore mental health care programs that are specifically designed to address Blacks’ unique culture and worldview.

Social implications – In addition to culturally competent and culturally responsive health care, future initiatives should focus on improving the accessibility and quality of health care, and alleviating socioeconomic disparities, racism, and racism-related stress. These initiatives, in conjunction, are the best approach to improving Blacks’ rates of mental illness.

Will our society continue to tolerate differential health outcomes based on race, class, gender, and income? Does the political will exist to change the current patterns of disproportionate health status, disease, and mortality? Will our government decide that there is a basic right to health and then make the investment to turn this promise into a reality? If not now, then when? Those committed to addressing these inequities, such as the contributors to this volume, must ask these questions, publish the research that documents health disparities, and create and disseminate interventions that will improve the health and thereby the quality of life for us all. For it is indeed the case that the health status of the most vulnerable members of our communities serve as a canary in the mines for our entire society.