The Impact of Demographics on Health and Health Care: Race, Ethnicity and Other Social Factors: Volume 28

This chapter provides an introduction to Volume 28, The Impact of Demographics on Health and Health Care: Race, Ethnicity and Other Social Factors. This chapter introduces the topic of demographic factors leading to differences and disparities in health and health care by reviewing more recent literature within sociology addressing social factors leading to differences in health and health. This chapter also serves as an introduction to the volume. As such, the chapter explains the organization of the volume and briefly comments on each of the chapters included in the volume.

Hepatitis C virus (HCV) is highly prevalent in the United States, yet is largely culturally invisible. This study examines what people know about their illness, both before and after diagnosis, and the relationship to race. The data are from in-depth interviews in 2004 with 53 persons, mostly white or African American, with HCV in the southeastern United States. The respondents have varying educational backgrounds, family incomes, and possible modes of transmission of HCV. Regardless of whether the diagnosis of HCV came as a surprise, respondents had a range of reactions including fear, shock, sadness, and ambivalence. Knowledge of the disease postdiagnosis varies as some people have expert knowledge, moderate knowledge, or inaccurate to no knowledge of the disease. Minority respondents have less knowledge of HCV than whites. This racial disparity in knowledge has profound implications for people with HCV and the larger society.

As the size of the U.S. population age 65 and older continues to grow, racial disparities within this population persist despite near universal insurance coverage provided through Medicare. Reform of the government administered program in 2003 has the potential to influence racial disparities due to increased privatization. This study compares racial disparities in health service utilization between Medicare fee-for-service and managed care, the two drastically different ways Medicare administers health care. Data was analyzed from the National Health Interview Survey (NHIS), a nationally representative study of the U.S. civilian, noninstitutionalized, household population. Included in this study were African American and white respondents aged 65 and older who participated in the NHIS in any year from 2004 to 2008 (N=22,364). Small differences were found in regard to the number of medical office visits, with African Americans reporting fewer visits. However, these differences were significant in only 25% of the analyses conducted. Across both types of Medicare, significant differences between African Americans and whites regarding consultations with a medical specialist and having surgery were found in 75% of analyses. In all analyses, African Americans were less likely to have interacted with a specialist or have surgery. The greatest difference in racial disparity between fee-for-service and managed care for all three health service use indicators was observed among those who were chronically ill and poor, and the smallest difference was observed among those who were chronically ill and very poor. These racial disparities in health service use may be linked to earlier life disparities in access to health care, higher out-of-pocket costs in Medicare fee-for-service, and the for-profit structure of managed care plans.

We use data from the American Time Use Survey (ATUS) to investigate racial differences in the amount of time individuals spend traveling to, waiting for, and receiving outpatient healthcare services on a randomly selected survey interview day. Of the 60,674 participants in the 2003–2006 waves of the ATUS, 2.67% (n=1,621) reported a clinical encounter on their designated day; this proportion did not differ significantly by race. Among those reporting a clinical encounter, blacks reported spending 30 more minutes than whites in receiving services, and this race gap persisted net of socioeconomic, health, and geographic factors. Hispanics also reported significantly longer visits than whites; yet, this difference was partially accounted for by Hispanics’ relatively poorer health status. Hispanics and persons of other ethnicity reported significantly longer wait times than whites, whereas blacks and Hispanics reported significantly longer travel times than did whites; these significant differences did not attenuate in the fully adjusted models. The results show that ethnic minorities spend far more time than whites when traveling to, waiting for, or receiving outpatient services, revealing another aspect of health care where stark racial inequities exist. We suggest that the relatively long wait and transportation times reported by ethnic minorities may reflect overcrowded care sites and the lack of quality care in neighborhoods inhabited largely by blacks and Hispanics, thus impeding the delivery of timely and “patient-centered” medical care.

Immigrants’ access to health services is a widely researched topic, yet few studies examine immigrants’ use of complementary and alternative medicine (CAM). This study uses the Behavioral Model to compare overall CAM use and use of acupuncture, chiropractic, herbs, yoga, and relaxation by immigrant status (nativity and time in the United States). It then explains the nativity gap in use by assessing knowledge, cost, and need as potential reasons for not using these modalities. Results show that controlling for predisposing, enabling, and need factors, recent immigrants use CAM less than the U.S.-born. Lack of knowledge of CAM modalities partially explains why some recent immigrants do not use acupuncture, chiropractic, or relaxation, while established immigrants cite lack of need as a reason for not using yoga. Cost does not explain immigrants’ lower use of these five modalities. Finally, ethnicity moderates the association between immigrant status and reasons for not using CAM.

Researchers have spent considerable time studying how racial-ethnic minorities experience poorer health than whites [Townsend, P., & Davidson, N. (Eds). (1990). Inequalities in health: The black report. England: Penguin Press; Platt, L. (2006). Assessing the impact of illness, caring and ethnicity on social activity. STICERD Research Paper No. CASE108 London England), and how low socioeconomic status (SES) can negatively influence health status (Lynch, J., & Kaplan, G. (2000). Socioeconomic position. In: L. F. Berkman & I. Kawachi (Eds), Social epidemiology (pp. 13–55). New York: Oxford University Press]. This research investigates the relationship between class and race and perceived health status among patients with chronic conditions. More specifically, we apply the concept of social capital to assess whether the quantity of health information seeking behaviors (HISB) via social networks mediates the relationship between race and health status, and between SES and health status. Regression, t-test and ANOVA analyses of 305 surveys completed at a chronic illness management clinic in a Northwest research hospital reveal three important findings: first, that social class affects perceived health status more strongly than race; second, that frequency and amount of HISB do not play a significant role in perceived health status, regardless of race or SES; and third, that an interaction effect between frequency and amount of HISB suggests that the way that patients seek health information, and the quality of that information, may be more useful indicators of the role of social capital in HISB than our study can provide.

Blacks are more likely than white, in the United States, to experience a stillbirth. In this study, I use a structural perspective of race to create a heuristic model that combines medical and social epidemiological explanations to understand the racial disparity in stillbirths. Using data from the National Maternal and Infant Health Survey 1988 (NMIHS), I examine whether racial disparities in stillbirths can be explained by medical and social epidemiological variables. My findings show that medical and social epidemiological explanations do little to reduce the racial disparity. However, many medical model variables were important predictors of stillbirths including multiple gestations, being overweight, obesity, vaginal bleeding, advanced maternal age, and parity.

Using data on children under three years of age from the 2003 National Survey of Children's Health (n=16,953), this study uses logistic regression to identify the presence of disparities in the use of habilitative therapy (physical therapy, occupational therapy, and speech therapy) among all children, strong candidates for therapy due to physical or developmental issues, and children for whom there is a parental concern about speech. Region of residence emerges as a source of disparity: (1) Children in the South exhibit consistently low levels of therapy use, and (2) children with speech concerns in all regions of the country outside the Northeast are less likely to use therapists than children in the Northeast. Other variables gaining significance include age of child, gender, race, presence in a nuclear family, and insurance status, though the influence of these variables is not consistent.

Consumer-Directed Health Plans (CDHPs) are proposed as an option to control healthcare costs. No research has addressed their applicability in rural settings. This study analyzes three years (2003–2005) of healthcare expenditure and utilization incurred by two employers and a national carrier providing data from a rural state, Kentucky. The study included two measures of expenditures (health care and prescription drugs) and three measures of utilization (physician visits, hospital admissions, and hospital inpatient days). In general, the CDHP successfully controlled the growth of medical costs. These findings suggest that CDHPs may be a viable alternative benefit structure for rural employers.

An estimated 50 million people in the United States do not speak the same language as their healthcare provider, and 23 million are considered limited English proficient (LEP). Federal and state laws mandate language assistance services, such as interpreting, to all LEP patients at all points of medical care. Despite longtime and widespread use of interpreting in healthcare, efforts to assure interpreting access and quality are now slowly emerging. An interpreter may be a family member or friend, a bilingual staff member, or professional interpreter. As with trends in other ancillary staff in medicine, the majority of interpreters are female. Research is not available to clarify how gender may influence the process and outcomes of care during an interpreted medical visit. This chapter draws from the results of a brief qualitative study on medical interpreting and published standards on medical interpreting to critically reflect on the role of gender during an interpreted healthcare visit. Recommendations for research and practice are offered to raise awareness of the interpreting process and how it may be influenced by gender. Attention to the role of gender during interpreted medical visits is important to improving healthcare and health for persons with LEP.

Inequalities in health and health care by gender for older adults are often hidden because much data concerning the older adult are not disaggregated by gender. Older women are more likely to have chronic diseases that disable but do not kill. Older men are more likely to have chronic diseases that kill but do not disable for long periods of time. A gender analysis is used to elaborate inequalities by gender in two situations. The first is that of post-hospital care under Medicare. The second is a detailed analysis of living arrangements men and women over 85 years in the community based on the U.S. Census data for 2000. Combined with a population health model, a gender analysis indicates unequal access to health care and well-being by gender as well as unequal control over the provision of necessary care.

Purpose – Despite growing efforts to treat depression, engaging low-income and minority mothers continues to challenge providers. To address this issue, we conducted focus groups to identify responsive strategies for improving engagement of low-income and racially diverse mothers at high risk for depression.

Methods – Three focus group discussions (one prenatal, two postpartum) with 21 low-income and racially diverse mothers were held to determine their definition of depression, attitudes about depression treatment, and perceived barriers to treatment. Discussions took approximately 60 minutes and were audio-recorded. Detailed notes were taken during the discussions. The notes and audio recordings were analyzed using qualitative methods.

Results – Identification of the source of distress, assessing women's perception of treatment and their related costs and benefits, and addressing cultural and financial barriers to treatment emerged as key themes for improving engagement among participants.

Conclusion – To be responsive to women's depression care needs, treatments should be informed by patient perceptions and needs, while addressing barriers to care.

A primary impetus of the modern hospice movement was the disparity, during the later 20th century, between the care provided to persons with illnesses considered “curable” and the treatment – or lack of it – accorded the incurably or terminally ill. In its transformation from a reform-oriented, interdisciplinary response to the needs of the dying to an integrated component of the American healthcare system, hospice care's original mission, target population, and modality of service delivery were all significantly altered in ways that generated new disparities in access to “death with dignity.” This chapter attempts to trace the political, economic, and institutional dimensions of this transformation as reflected in the experiences of one Northeastern hospice during a 6-month period in 2001. Using an analytic approach known as institutional ethnography (IE), the authors focus on the work of the Hospice's Interdisciplinary Group (IDG) to uncover the linkages between local problems in the delivery of hospice care and extra-local sites of power and constraint at the mezzo- and macrolevels of the American healthcare system. The significance of these linkages for patients, frontline workers, and other stakeholders are interpreted from several perspectives. Implications for change are discussed.